牙周病治療前後兩種牙齒測量診斷方式之量化分析

Quantitative analysis of two diagnostic methods for tooth measurement before and after periodontal initial therapy

吳仲平(Chung-Ping Wu)

指導教授 ： 呂炫&803

臺北醫學大學/口腔醫學院/牙醫學系碩博士班/碩士(2017年)

摘要

背景 :
牙周炎是源自細菌的發炎反應，會造成牙齦、結締組織等牙周組織持續性破壞，導致牙周齒槽骨喪失，牙齒動搖度增加。若置之不理，牙齒甚至可能自動脫落。牙齒動搖度增加是嚴重牙周炎常見的徵兆也是一般大眾到牙周病科求診的主要原因。
目的 :
本次研究的目標是評估單牙根前牙(門齒與犬齒)之牙齒動搖度Periotest value (PTV) ，Miller mobility index(MMI)，在非手術牙周病治療前與治療後兩種測量方式之量性改變，並且分析與各個牙周參數彼此之間的客觀相關性以及對於牙周病診斷的敏感度(sensitivity)，特異性(specificity)，陽性預測值(positive predictive value ，PPV)，陰性預測值(negative predictive value ，NPV)，接收者操作特徵曲線(ROC curve )，曲線下面積值(area under curve ,AUC value)
材料和方法 :
30位受試者是由到台北醫學大學附設醫院與雙和醫院牙周專科門診求診的病患取樣，分別在起始治療之前 和完成全口非手術性牙周治療後第1個月回診與第3個月回診，記錄臨床牙周參數 。臨床牙周參數包含:牙周囊袋深度，臨床附連水平，牙齦萎縮，探測出血，牙菌斑指數， Miller mobility index ， Periotest value 。非手術性牙周治療包含 :口腔衛生指導及牙齦下根面整平，齲齒控制，移除不良贗復物，拔除預後無望的牙齒。
結果 :
PTV 在非手術性牙周病治療前和第一個月回診的變化有顯著性差異，而第一個月與第三個月回診的變化則無顯著性。MMI動搖度零級的牙齒數量在第一個月回診已由40% 增加為66.27%，第三個月回診比第一個月回診只增加2.67% 。Spearman correlation coefficient 分析PTV 與臨床牙周附連水平是高度相關性(r=0.71)，PTV和 MMI高度相關性(r=0.71)，PTV與牙周探測深度是中度相關性(r=0.59) ， 而PTV與牙菌斑指數及探測出血陽性皆是低度相關性。然而，MMI與臨床牙周附連水平是極高度相關性(r=0.92)，MMI與牙周探測深度是高度相關性(r=0.76)。當我們匯總臨床附連水平3-4mm和大於5mm的牙齒為一組中重度牙周炎時，其PTV 的ROC curve AUC值是0.87，並且PTV ≧7 之後其PPV皆達100% ；MMI的ROC curve AUC值是0.81，MMI grade ≧1 級之後，其PPV 也皆達100%。此外當我們匯總牙周探測深度5-7mm 和大於7mm的牙齒為另一組中重度牙周炎時，PTV 的ROC curve AUC值 是0.81，PTV ≧23 之後其PPV 皆呈100% ；MMI的ROC curve AUC值 是0.80，MMI grade1 的 PPV是98.8 %，MMI grade2的 PPV是99% ，MMI grade3的 PPV是100%。
結論:
本研究再次印證非手術性牙周治療之重要性，在第一個月回診獲得統計學顯著性的牙齒動搖度改善。PTV和CAL是高度相關性，PTV和PD是中度相關性。MMI和CAL是極高度相關性，MMI和PD是高度相關性。PTV和MMI之中重度牙周炎 ROC curve AUC值皆大於 0.8，對於疾病有優良鑑別力，而且兩者於PPV也有高度表現。因此我們認為PTV與 MMI 都有資格當作中重度牙周炎診斷理想的參數。根據美國牙周病醫學會專家會議牙周疾病定義2015年更新版建議，將來臨床牙醫師或許會普遍使用牙周探測深度(PD)當作橫斷面研究診斷標準，不同于測量臨床附連水平(CAL)，使我們在比較各種臨床研究資料相當困難。基於本次研究結果，我們建議在中重度牙周炎可以利用PTV和MMI做為CAL 和PD不同的牙周炎定義之診斷工具。而且MMI分類方法操作較為方便，牙醫師只要經過適當訓練，MMI是很適合用於臨床中重度牙周炎的常規檢查與診斷。

關鍵字

牙齒動搖度；非手術性牙周治療 ； Periotest；Miller 動搖度指數；敏感度 ； 特異性 ； 陽性預測值 ； 陰性預測值 ； 接收者操作特徵曲線

並列摘要

Background: Periodontitis is an inflammatory disease of bacterial origin that results in the progressive destruction of the gingival and connective tissue and lead to alveolar bone loss finally. If left untreated, the teeth could be exfoliated spontaneously. The increased tooth mobility is a common symptom of severe periodontitis and it is the main reason of people visit the periodontal clinic department for consultations.
Purpose: To assess tooth mobility of anterior single–root teeth (Incisor and Canine teeth) with Periotest value (PTV) and Miller mobility index (MMI) and analyze the quantitative variation of two diagnostic methods before and after completing non-surgical periodontal therapy. To evaluate the correlations between PTV, MMI and the other periodontal parameters. To assess the validity of PTV and MMI on the diagnosis of periodontitis including sensitivity, specificity, positive predictive value, negative predictive value, receiver operating characteristic curve, area under curve value.
Materials and methods: 30 subjects who visited the periodontal clinic department of the TMU Hospital and Shuang Ho Hospital for the first time were included for this study. PTV and MMI and clinical periodontal parameters were recorded at initial time and the first and the third month follow-up visit following non-surgical periodontal therapy. The periodontal parameters included: probing depth, clinical attachment level, gingival recession, bleeding on probing, plaque index, Miller Mobility Index, Periotest Value. Non-surgical periodontal therapy included: oral hygiene instruction, subgingival scaling and root planing, caries control, remove the ill-fitting prostheses, remove hopeless teeth.
Results: The variation of PTV was significantly different between the first month follow-up visit and before non-surgical periodontal therapy. However, there was no significant difference of PTV between the first and third month follow-up visit. The percentage of teeth classified as MMI grade 0 increased from 40% to 66.27% by the first month follow-up visit, but the increase from the first to the third month follow-up visit was only 2.67%. Spearman correlation coefficient was used to analyze the correlation between PTV, MMI, and other periodontal parameters. Strong correlations were observed between PTV, CAL (r=0.71). Medium correlation was observed between PTV, PD (r=0.59). Low correlations were observed between PTV, and PI, BOP. Strong correlations were observed between MMI, CAL (r=0.92), and PD (r=0.76). When we pool teeth with CAL 3 to 4 mm and CAL >5 mm as moderate to severe periodontits, the AUC was 0.87 for PTV, and when PTV>7 the PPV was 100%; the AUC for MMI was 0.81, and the PPV was 100% when MMI grade >1. Besides, when we pool teeth with PD>5 to <7mm and >7mm as moderate and severe periodontitis, the AUC for PTV was 0.81, and when PTV>23 the PPV was 100%; the AUC for MMI was 0.8, the PPV of MMI grade 1 was 98.8%, grade2 was 99%, grade 3 was 100% respectively.
Conclusion: The results of this study reconfirmed the importance of non-surgical periodontal therapy, and the significant improvement of tooth mobility can be approached at the first month follow-up visit. PTV, CAL and MMI, CAL and MMI, PD were highly correlated. PTV, PD was medium correlated. The AUC values for PTV and MMI of moderate to severe periodontitis were more than 0.8 which meant excellent discrimination, and the PPV of both were highly expressed. Therefore, we thought PTV and MMI could be ideal parameters for the diagnosis of moderate to severe periodontitis. According the guidelines of AAP Task Force Report 2015 update, in the future, most general practitioners may use PD as the diagnostic criteria for the cross-sectional researches. The differences between CAL and PD measurements made us hardly to compare the clinic researches data. Base on the results of this present study, we suggested the PTV and MMI could be the diagnostic methods for moderate and severe periodontitis. Thereafter the dentists had been well-trained, the MMI classification was more clinical convenient. The MMI was suitable for the dental routine examination and diagnosis of moderate to severe periodontitis.

並列關鍵字

Tooth mobility ； Miller mobility index ； receiver operating characteristic curve ； positive predictive value ； negative predictive value ； non-surgical periodontal therapy

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