Validation of School Nurses to Identify Severe Gingivitis in Adolescents

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. TABLE 1 —Visual Periodontal Index and Visual Oral Hygiene Index Criteriaa This project addressed 3 issues: (1) agreement of the nurse and dentist in the outcome of the visual examination, (2) effectiveness of the screening tool in detecting marked gingival disease, and (3) effectiveness of the screening process determined by referral for treatment. Of the 84 seventh-grade students who were screened, 92.8% were Hispanic and 56.6% were female. One third of the students presented with edematous gingival tissue with gross loss of contour and bleeding along the gingival margin corresponding to a Visual Periodontal Index of 2. 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 κ 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. TABLE 2 —Kappa Statistic Comparing the Accuracy of the School Nurse and Dentist With Visually Identified Gingival Disease To determine whether the visual screening examination could accurately identify those individuals who were diagnosed as requiring treatment, the nurse's visual examination was compared with referrals. Both of the nurse's scores were associated with referral (odds ratio [OR] for Visual Periodontal Index = 5.94; P = .00; OR for Visual Oral Hygiene Index = 5.75; P = .05). 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.