Gingival bleeding on brushing as a sentinel sign of gingival inflammation: A diagnostic accuracy trial for the discrimination of periodontal health and disease

Ke Deng, George Pelekos, Lijian Jin, Maurizio S Tonetti, Ke Deng, George Pelekos, Lijian Jin, Maurizio S Tonetti

Abstract

Aim: To assess the accuracy of self-reported gingival bleeding on brushing (GBoB) for differentiating between periodontal health and disease and explore the optimal haemoglobin concentration that enables visual detection of GBoB.

Materials and methods: Self-assessment of GBoB was conducted in supervised sessions for 408 consecutive adults. The haemoglobin levels in saliva/toothpaste slurry (TPS) were analysed, followed by a full-mouth periodontal examination. Periodontal diagnoses were made based on the 2017 classification of periodontal diseases. Gingival inflammation was defined as presence of at least 10% of sites with bleeding on probing (BOP). Logistic regression and area under the receiver operating characteristic curve (AUROC) analyses were applied to assess the accuracy of GBoB.

Results: Overall, 37.1% of the subjects claimed self-reported GBoB, and they had higher values of BOP (median: 25.0%; interquartile range (IQR): 16.0%-37.5%) than those without GBoB (median: 13.5%; IQR: 8.0%-24.8%, p < .001). The concentration/total amount of haemoglobin in TPS was positively correlated with the number of bleeding sites (r = .409/r = .520, p < .001). Haemoglobin concentration of 90.58 μg/ml or 0.51 μl blood volume enabled visual detection of GBoB with an AUROC of 0.848. Self-reported GBoB exhibited significantly increased values of diagnostic odds ratios (3-8) for varying degrees of gingival inflammation and periodontal disease (gingivitis and periodontitis). It showed low to moderate accuracy for discriminating periodontitis and gingivitis from periodontal health, with a sensitivity of 37.1% and 61.3% and a specificity of 84.8% and 84.4%, respectively. Absence of self-reported GBoB and low levels of haemoglobin had 93%-98% predictive values for periodontal health.

Conclusions: Despite its low sensitivity for the discrimination of periodontitis, self-reported GBoB is a promising sentinel sign for periodontal health and disease, and gingival inflammation in particular. It is visually detectable after minor blood loss. After validation in an independent population, identification of GBoB may promote earlier detection and better prevention and treatment of periodontal disease, thereby eventually reducing the global burden of the disease.

Trial registration: ClinicalTrials.gov NCT03928080.

Keywords: diagnosis; gingival inflammation; periodontal disease; screening; sensitivity and specificity.

Conflict of interest statement

The authors declare no conflicts of interest.

© 2021 The Authors. Journal of Clinical Periodontology published by John Wiley & Sons Ltd.

Figures

FIGURE 1
FIGURE 1
Standards for Reporting Diagnostic Accuracy (STARD) flow diagram of the study for various periodontal conditions
FIGURE 2
FIGURE 2
Relation of self‐reported GBoB to Hb concentrations in the TPS samples. (a) Distribution of Hb concentrations in subjects with or without self‐reported GBoB. Each point denotes the value for a participant. The horizontal bars display the medians and interquartile ranges (IQR). The horizontal green line denotes the threshold value for GBoB being self‐detected (Hb ≥90.58 μg/ml). (b) ROC analysis of Hb, comparing concentrations in subjects with self‐reported GBoB to those without GBoB
FIGURE 3
FIGURE 3
Pearson's correlation coefficient analyses of the concentration and total amount of Hb with periodontal clinical parameters. (a) Concentration and total amount of Hb with the number of bleeding sites. (b) Concentration and total amount of Hb with number of periodontal pockets ≥4 mm. (c) Concentration and total amount of Hb with number of deep pockets ≥6 mm. (d) Concentration and total amount of Hb with number of bleeding pockets ≥4 mm. (e) Concentration and total amount of Hb with number of bleeding pockets ≥6 mm. Each point denotes a subject in the population (n = 408); r, correlation coefficient
FIGURE 4
FIGURE 4
Distribution of the concentration and total amount of Hb among different periodontal statuses. (a) Concentration and total amount of Hb with periodontal case definitions. (b) Concentration and total amount of Hb with different stages of periodontitis. (c) Concentration and total amount of Hb with gingival inflammatory status. Each dot represents one participant; the horizontal bars in each graph display the medians and interquartile ranges (IQR). Kruskal–Wallis tests were used to assess differences among groups. **p < .01, ***p < .001; ns, not significant; Stage I, Stage I periodontitis; Stage II, Stage II periodontitis; Stage III, Stage III periodontitis; Stage IV, Stage IV periodontitis

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