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David Cappelli, DMD, MPH and John P. Brown, PhD, BDS

The authors are with The University of Texas Health Science Center at San Antonio, Department of Community Dentistry.

Correspondence: Requests for reprints should be sent to David Cappelli, DMD, MPH, The University of Texas Health Science Center at San Antonio, Department of Community Dentistry, 7703 Floyd Curl Dr, San Antonio, TX 78229-3900 (e-mail: cappelli{at}uthscsa.edu).

This project created a mechanism to identify adolescents with marked gingival disease with a visual screening instrument that can be administered by a school nurse or health care worker. The prevailing paradigm in management of periodontal disease is that plaque removal controls gingivitis,¹ and gingival inflammation is a prerequisite for development of destructive periodontal disease.² Prior investigation³ of a similar population in San Antonio, Tex, showed a high prevalence of severe gingival inflammation. Because school-based interventions are effective in oral health promotion,⁴ establishment of an intervention strategy focused on (1) identification of the health problem; (2) referral for diagnosis, treatment, and follow-up; (3) education and counseling about risk behaviors and impediments to access to care; and (4) evaluation of the intervention methods.

Examinations were conducted in a mobile dental van at a middle school located in a predominantly Hispanic and dentally underserved community in the greater San Antonio area. Following a training session in which dentist and nurse were in agreement on the indices, a school nurse visually screened each student with a penlight, tongue depressor, and photographic reference that pictorially identified each visual index category to score the gingival health of each student. Descriptions of the Visual Periodontal Index and the Visual Oral Hygiene Index categories are presented in Table 1. The dentist screened each student independently of the school nurse and conducted a routine dental diagnostic examination. For this study, supragingival plaque,⁵ gingival index,¹ and probing depth data were collected on Ramjford teeth⁶ with a mirror and Michigan ‘O’ probe.

For the Visual Periodontal Index, the level of agreement was 83.33% (P = .00), and for the Visual Oral Hygiene Index, the level of agreement was 87.70% (P = .00), and both values indicated good reproducibility (Visual Periodontal Index = 0.5794, P < .00; Visual Oral Hygiene Index = 0.5006, P < .00), despite the subjectivity of the indexes (Table 2). Comparison of the dentist's visual screening to the clinical examination (Visual Periodontal Index to gingival index¹; Visual Oral Hygiene Index to supragingival plaque⁵) showed a high level of sensitivity (Visual Periodontal Index = 96.23%; Visual Oral Hygiene Index = 98.44%) but less specificity (Visual Periodontal Index = 50.00%; Visual Oral Hygiene Index = 40.00%). Positive predictive value (Visual Periodontal Index = 80%; Visual Oral Hygiene Index = 66.67%) and negative predictive value (Visual Periodontal Index = 86.44%; Visual Oral Hygiene Index = 95.45%) indicated that this test was effective in detecting gingivitis in this population. False-negative findings were low (Visual Periodontal Index = 3.77%; Visual Oral Hygiene Index = 1.56%). The strength of the sensitivity of both visual tests increased the inclusion of cases, although individuals without gingival disease were being referred. Because the outcome of the screening was referral to a dental professional, maximization of the sensitivity at the expense of the specificity was considered an optimal end point.

Of the 25 students referred for emergent needs, 5 (20%) either had scheduled an appointment or were seen by a dental professional after 4 months. Seven of the parents or guardians did not intend to schedule a dental visit, and the remainder were lost to follow-up.

Ultimately, the referral of patients with disease is a primary criterion determining the success of any screening program. Correlation to referral suggested that this visual screening examination was successful in the identification of patients with plaque accumulation resulting in gingivitis. The response rate of the parent or guardian to seek additional treatment was low because of the lack of oral health education of both adolescents and parents associated with the screening and other barriers but consistent with previous studies indicating that between 19% and 22% of referred patients seek treatment after screening.⁷ Almost all of the parents who did not seek treatment noted access to and availability of a dentist and finances as primary reasons to not obtain treatment. These barriers are high for Mexican American populations.⁸ Although a list of low-cost clinics was provided, access for the working parent was problematic because most clinics operate during daytime hours and have prolonged waiting times for appointments.

This screening tool provides the school nurse with defined criteria to identify students with severe gingival inflammation. The surgeon general's report cited disparities in oral health care among minority groups and recommended that nondental professionals participate in oral health promotion.⁹ Screening and successful referral, not only for caries but also for early-onset gingival disease, can eliminate progression to frank periodontal disease. With demonstrable associations between periodontal disease and diabetes¹⁰ and the increased prevalence of diabetes in adolescent Hispanic populations, this tool may be even more significant in maintaining overall health into adulthood.

	Acknowledgments

 
This research was supported by a grant from the Health Education Training Center at Texas.

Appreciation is expressed to Julia Garcia, RN, District Health Officer/Edgewood Independent School District, and Rose Garcia, RN, Brentwood Middle School, for their cooperation and support in the accomplishment of this project and the administration of the Edgewood Independent School District, San Antonio, Tex, for their unwavering dedication to the health of their children. Jane Steffensen, MPH, CHES, and Karen Holt, RDH, MS, The University of Texas Health Science Center at San Antonio, are acknowledged for their input and advice, as is Diana Saenz, who assisted with the implementation of this project. Dennis MacMahon, MS, provided statistical advice.

	Footnotes

 
D. Cappelli organized the study, conducted the research, analyzed the data, and wrote the paper. J. P. Brown provided administrative and scientific support.

Peer Reviewed

Accepted for publication January 10, 2002.

	References

TOP References

 
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This Article Extract Full Text (PDF) Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Cappelli, D. Articles by Brown, J. P. Search for Related Content PubMed PubMed Citation Articles by Cappelli, D. Articles by Brown, J. P. Related Collections Dental/Oral Health Adolescent Health Hispanics/Latinos Screening