Periodontal diseases in adult Kenyans

Prevalence of JP2 and Non-JP2 Genotypes of Aggregatibacter actinomycetemcomitans and Oral Hygiene Practice of Kenyan Adolescents in Maasai Mara

Aggregatibacter actinomycetemcomitans is implicated in the etiology of periodontitis that affects adolescents. The monitoring and mapping of the geographic dissemination pattern of JP2 and non-JP2 genotypes of A. actinomycetemcomitans are of interest. In Africa, the highly leukotoxic JP2 genotype is known to be prevalent, particularly in north-west Africa. The aims of this study were to determine the prevalence of JP2 and non-JP2 genotypes and investigate the oral hygiene practices among adolescents living in Maasai Mara, Kenya. A total of 284 adolescents (mean age: 15.0 yrs; SD 1.1) were interviewed regarding their age, gender, medical history, and oral hygiene practice, and the number of teeth present was recorded. One subgingival pooled plaque sample from all the first molars of each participant was analyzed by conventional PCR. The mean number of permanent teeth present was 27.9 (SD: 2.0; range: 22–32; 95% CI: 27.7–28.1). Sixteen (5.6%) and two (0.7%) adolescents were positive for non-JP2 and JP2 genotypes, respectively. For the vast majority of the adolescents, the use of a toothbrush (99.3%) and toothpaste (80.1%), as well as some kind of toothpick (>60.2%), were part of their oral hygiene practice, with dental floss (0.4%) and/or mouth rinses (0.4%) rarely being used. We have, for the first time, identified Kenyan adolescents colonized with the JP2 genotype. The prevalence of the JP2 genotype of A. actinomycetemcomitans is low, a possible indicator that spreading through human migration from North and West Africa to East Africa is a rare occasion.

A public health approach for prevention of periodontal disease

Upwards of 1 in 10 adults worldwide may be affected by severe periodontitis, making the disease more prevalent than cardiovascular disease. Despite its global scope, its impact on pain, oral function, and the wellbeing of individuals, and the disproportionate burden of disease and the socioeconomic impact on communities, the perception that periodontal disease is a public health problem remains low. Although there have been substantial improvements in our understanding of the etiology of periodontal disease and how we can prevent and control it, these advances have been primarily focused on individual, patient-focused approaches. The prevention of periodontal disease depends on improving currently available individual interventions and on determining what public health interventions can be effective and sustainable under real-life conditions. Currently, public health approaches for periodontal disease prevention and control are lacking. This review traces the historical strategies for prevention of periodontal disease in an epidemiologic transition context, using a modified model developed for cardiovascular disease, and presents a possible public health approach. Improving periodontal disease prevention and control will need to take into consideration the core activities of a public health approach: assessment, policy development, and assurance.

Current concepts and an alternative perspective on periodontal disease

BACKGROUND

Epidemiological data from countries worldwide show a consistent pattern implying that a fraction of around 10% of those over 40-50 years in all populations will exhibit severe periodontitis with the potential risk of losing teeth during their life-time. The subgingival microbiota shows striking similarities between populations irrespective of disease severity and can only marginally explain the clinical pattern. It is also difficult to explain this pattern by genetic and acquired risk factors such as systemic disease (e.g. diabetes) or habits (e.g. smoking) even if they may have a confounding effect on the disease.

MAIN TEXT

Inflammation of the gingiva appears to be a normal and physiological response to the presence of commensal bacteria along the gingival crevice and in the dental biofilm. Over many years of exposure to the dental biofilm, the chronic inflammation in the gingiva gradually results in a loss of attachment and bone loss. Numerous laboratory and clinical studies have provided insight into the potential role of determinants that are associated with periodontitis. However, it has been difficult to relate the findings to the pattern of the distribution of the disease observed in epidemiological studies. We propose a simple and parsimonious model that considers all the multitude of potential determinants as creating effectively random noise within the dental biofilm to which the tissues react by accumulating the effects of this noise.

CONCLUSIONS

We suggest that such a model can explain many of the epidemiological features of periodontal breakdown over time, and we discuss its clinical implications.

Declassifying Mobility Classification

INTRODUCTION

Tooth mobility is often discussed among dental health care providers according to a numerical scale (ie, 1, 2, or 3) without a clear understanding of the definition of each category. Thus, a comprehensive review to examine and discuss the various classifications is needed. The aim of this comprehensive review was to discuss the main clinical classifications of tooth mobility.

METHODS

The authors conducted electronic searches in MEDLINE, Scopus, and PubMed. Additionally, the authors manually searched the textbooks, gray literature, and bibliographies of all relevant articles.

RESULTS

The most commonly referenced clinical index for mobility was the Miller index; yet, many other mobility classifications exist as well as modifications of those indexes. The literature has been very inconsistent and at times inaccurate when classifying mobility; using various stages of mobility using grades, classes, and scores interchangeably and not defining the meaning of the actual numerical scores/terminologies are common problems.

CONCLUSIONS

In order to avoid ambiguity and provide clarity regarding the impact of degrees of mobility when used clinically, this review comprehensively discusses different classifications and definitions of tooth mobility with attention to the importance of using them consistently and accurately. There is a need to standardize 1 classification for mobility.

Dental fluorosis and oral health in the African Esophageal Cancer Corridor: Findings from the Kenya ESCCAPE case-control study and a pan-African perspective

There are no studies of oral health in relation to esophageal cancer in Africa, or of Eastern Africa's endemic dental fluorosis, an irreversible enamel hypo-mineralization due to early-life excessive fluoride intake. During 2014-18, we conducted a case-control study of squamous cell esophageal cancer in Eldoret, western Kenya. Odds ratios (AORs (95% confidence intervals)) were adjusted for design factors, tobacco, alcohol, ethnicity, education, oral hygiene and missing/decayed teeth. Esophageal cancer cases (N = 430) had poorer oral health and hygiene than controls (N = 440). Compared to no dental fluorosis, moderate/severe fluorosis, which affected 44% of cases, had a crude OR of 20.8 (11.6, 37.4) and on full adjustment was associated with 9.4-fold (4.6, 19.1) increased risk, whilst mild fluorosis (43% of cases) had an AOR of 2.3 (1.3, 4.0). The prevalence of oral leukoplakia and tooth loss/decay increased with fluorosis severity, and increased cancer risks associated with moderate/severe fluorosis were particularly strong in individuals with more tooth loss/decay. Using a mswaki stick (AOR = 1.7 (1.0, 2.9)) rather than a commercial tooth brush and infrequent tooth brushing also independently increased risk. Geographic variations showed that areas of high esophageal cancer incidence and those of high groundwater fluoride levels have remarkably similar locations across Eastern Africa. In conclusion, poor oral health in combination with, or as a result of, high-altitude susceptibility to hydro-geologically influenced dental fluorosis may underlie the striking co-location of Africa's esophageal cancer corridor with the Rift Valley. The findings call for heightened research into primary prevention opportunities of this highly fatal but common cancer.

Secular trends over 40 years of periodontal health and disease in individuals aged 20-80 years in Jönköping, Sweden: Repeated cross-sectional studies

AIM

To assess trends over 40 years regarding prevalence and severity of periodontitis in a Swedish adult population.

MATERIALS AND METHODS

Cross-sectional examinations using the same clinical protocol have been repeated every 10 years (1973-2013) in a Swedish city with focus on periodontal disease in adults. Periodontal recordings included all teeth, excluding 3rd molars. Periodontal disease experience was classified (no/minor, moderate and severe).

RESULTS

The no/minor group increased from 43% in 1983 to 60% in 2013. There was a non-significant trend for a decrease of the severe group. Over the 40-year period, the number of teeth increased significantly and at the examination 2013, the severe group accounted for this increase. More than 60% of the study population in 2013 had no periodontal pockets (PD) ≥6 mm. The number of PD ≥4 mm and ≥6 mm were unaltered between 2003 and 2013 in all age groups, except for the 20-year old individuals. This group showed a statistically significant increase of ≥4 mm PD.

CONCLUSIONS

The periodontal health has improved in the population over the 40 years. The number of teeth increased significantly in the population, and in 2013, this increase occurred entirely in the severe group. Finally, there was a trend toward diminished prevalence of severe periodontitis.

Caries and Periodontitis: Contesting the Conventional Wisdom on Their Aetiology

We review the literature on the oral microbiome and the role of the microbiota in the development of dental caries and periodontitis. While most research has been focused on identifying one or more specific determinants of these diseases, the results have provided limited predictive value and have not been able to explain the variation in the distribution of these diseases observed in epidemiological or clinical studies. Drawing on existing knowledge about the nature of the oral microbiota, we suggest that a stochastic model based on the Weiner process provides simple and parsimonious explanations for the pathogenesis of both caries and periodontitis, making few assumptions, and providing explanations for phenomena that have hitherto proved difficult, or have required complex arguments, to explain. These diseases occur as the result of the dental hard tissues and periodontal tissues integrating the random "noise" caused by normal metabolic activities of commensal microorganisms in the dental biofilm. The processes that result in the progression and regression of caries and periodontitis may be considered as "natural," rather than pathological, even if, when left unchecked over long periods of time, they can result in the development of pathologies. The likelihood of progression or regression can be influenced by other determinants, but these processes will nevertheless occur in the absence of such influences. The distributional characteristics of the model approximate the findings of epidemiological studies indicating that, for both caries and periodontitis, there will be few sites affected in the early period after the eruption of the permanent dentition, but in those older there is an almost linear relationship with increasing age; furthermore, the longer a site survives without being affected, the less likely that it will be affected. We discuss the clinical and public health importance of these findings.

Assessment of periodontal bone level revisited: a controlled study on the diagnostic accuracy of clinical evaluation methods and intra-oral radiography

OBJECTIVES

The accuracy of analogue and especially digital intra-oral radiography in assessing interdental bone level needs further documentation. The aim of this study was to compare clinical and radiographic bone level assessment to intra-surgical bone level registration (1) and to identify the clinical variables rendering interdental bone level assessment inaccurate (2).

MATERIALS AND METHODS

The study sample included 49 interdental sites in 17 periodontitis patients. Evaluation methods included vertical relative probing attachment level (RAL-V), analogue and digital intra-oral radiography and bone sounding without and with flap elevation. The latter was considered the true bone level. Five examiners evaluated all radiographs.

RESULTS

Significant underestimation of the true bone level was observed for all evaluation methods pointing to 2.7 mm on average for analogue radiography, 2.5 mm for digital radiography, 1.8 mm for RAL-V and 0.6 mm for bone sounding without flap elevation (p < 0.001). Radiographic underestimation of the true bone level was higher in the (pre)molar region (p ≤ 0.047) and increased with defect depth (p < 0.001). Variation between clinicians was huge (range analogue radiography 2.2-3.2 mm; range digital radiography 2.1-3.0 mm).

CONCLUSION

All evaluation methods significantly underestimated the true bone level. Bone sounding was most accurate, whereas intra-oral radiographs were least accurate. Deep periodontal defects in the (pre)molar region were most underrated by intra-oral radiography.

CLINICAL RELEVANCE

Bone sounding had the highest accuracy in assessing interdental bone level.

Epidemiology of Oral and Maxillofacial Infections

Dental caries and periodontal disease are the most common dental infections and are constantly increasing worldwide. Distribution, occurrence of dental caries, gingivitis, periodontitis, odontogenic infections, antibiotic resistance, oral mucosal infections, and microbe-related oral cancer are important to understand the public impact and methods of controlling such disease. Distribution of human papilloma virus and human immunodeficiency virus -related oral cancers in the US population is presented.

Effects of adhesion promoter on orthodontic bonding in fluorosed teeth: A scanning electron microscopy study

Introduction:

The objectives of the present study were to elucidate the effects of fluorosis in orthodontic bonding and to evaluate the efficiency of an adhesion promoter (Assure Universal Bonding Resin) in bonding to fluorosed teeth.

Materials and Methods:

Extracted premolars were divided into two groups on the basis of Thylstrup and Fejerskov Index. Ten samples from each group were etched and evaluated for etching patterns using scanning electron microscope (SEM). The remaining samples were subdivided into four groups of 20 each on the basis of adhesives used: IA, IIA - Transbond XT and IB, IIB - Transbond XT plus Assure Universal Bonding Resin. Shear bond strength (SBS) was measured after 24 h using the universal testing machine. Adhesive remnant index (ARI) scores were recorded using SEM. Statistical analysis was conducted using a two-way analysis of variance, and Tukey's post hoc test was performed on SBS and ARI scores.

Results:

Similar etching patterns were observed in both fluorosed and nonfluorosed teeth. No significant differences were found in the SBS values observed in both groups (8.66 ± 3.19 vs. 8.53 ± 3.44, P = 1.000). Increase in SBS was observed when Assure Universal Bonding Resin was used. Higher ARI scores were observed when adhesion promoter was used for bonding.

Conclusions:

Mild-moderately fluorosed teeth etch in a manner similar to the nonfluorosed teeth. Similar bond strengths were achieved in fluorosed and nonfluorosed teeth when conventional composite was used. Use of adhesion promoter increases the bond strengths in both groups of teeth.

Assessment of oral health status and treatment needs of Santhal tribes of Dhanbad District, Jharkhand

AIMS AND OBJECTIVES

India has an assortment of tribal population living in isolated pockets, and the Santhals are numerically predominant in Jharkhand. This study was aimed at assessing the oral health status and treatment needs of Santhals residing in Dhanbad, Jharkhand.

MATERIALS AND METHODS

A cross-sectional survey of 921 Santhals of Topchanchi Block was conducted. A modified World Health Organization (WHO) Oral Health Assessment Form (1997) was utilized and examined according to the WHO methodology (1997). The recorded data was statistically analyzed using the Statistical Package for the Social Sciences version 15.

RESULTS

Based on the occupation, it was seen that 620 (67.3%) participants practiced agriculture and 206 (22.4%) worked as laborers. The mean decayed missing filled tooth (score was 3.56 ± 1.93 in 2-5-year-old participants. In the higher age groups of 35-44 and 65-74 years, the scores were 5.21 ± 2.34 and 7.42 ± 4.29, respectively. Participants with bleeding gums were predominantly seen in the age group of 35-44 years (0.91 ± 0.08). Approximately 138 (54.1%) participants had a loss of attachment of 4-5 mm in the 35-44 year age group. In the 13-15-year-old age group, 0.14 ± 0.05 teeth needed two surfaces fillings. A total of 118 (12.8%) participants needed one-unit prosthesis in the upper jaw.

CONCLUSION

This study showed that a majority of Santhal tribals used twigs to routinely clean their teeth. Poor oral hygiene and periodontal status was seen among the tribes.

Generalized, severe, chronic periodontitis is associated with anemia of chronic disease: a pilot study in urban, Indian males

AIM

Anemia of chronic disease, a cytokine-mediated anemia, is a frequent complication of many chronic inflammatory conditions. The present case-control study was aimed to evaluate levels of systemic hematological markers indicative of anemia in patients with generalized, severe, chronic periodontitis.

METHODS

A convenience quota sample of 30 systemically-healthy, urban, male patients comprised two groups, based on full mouth periodontal examination: group A patients (n=15) were diagnosed with generalized, severe, chronic periodontitis, and group B patients comprised the control group (n=15), which included patients with a clinically-healthy periodontium. Laboratory blood investigations included hemoglobin (g%), total number of erythrocytes (red blood cells), hematocrit/packed cell volume, erythrocyte sedimentation rate, mean corpuscular volume of erythrocytes, and mean corpuscular hemoglobin concentration. An analysis of covariance using age as a covariate was done to compare the mean values of hematological parameters within groups.

RESULTS

The mean values of hemoglobin, red blood cells, packed cell volume, and mean corpuscular hemoglobin concentration were significantly lower, while the mean corpuscular volume of erythrocytes and erythrocyte sedimentation rate were significantly higher in group A patients compared to those in group B, indicating mild anemia.

CONCLUSIONS

Severe periodontal disease can be linked with anemic status.

Screening for periodontal disease in research dogs - a methodology study

Background

It has been shown that the prevalence of both clinical attachment loss (CAL) ≥1 mm and pocket probing depth (PPD) ≥4 mm is relatively high even in younger dogs, but also that only a minority of the dogs have such clinical signs of periodontal disease (PD) in more than a few teeth. Hence, a minority of dogs carry the major PD burden. These epidemiological features suggest that screening for PD in larger groups of dogs, allowing for rapid assessment of treatment planning, or for the selection of dogs with or without PD prior to be included in experimental trials, should be possible. CAL is the central variable in assessing PD extent and severity while PPD is the central variable used in treatment planning which make these two variables obvious in a screening protocol with the dual aim of disease identification and treatment planning. The main purpose of the present study in 98 laboratory Beagle dogs was to construct a fast, simple and accurate screening tool, which is highly sensitive for the identification of dogs with PD.

Results

Examination of the maxillary P4, P3, P2, I1 and C would, in this population, result in the identification of 85.5% of all dogs and 96% of all teeth positive for CAL ≥1 mm, and 58.9% of all dogs and 82.1% of all teeth positive for PD ≥4 mm.

Examination of tooth pairs, all C’s, maxillary I2, M2 and the mandibular P4 would, in this population result in identification of 92.9% of all dogs and 97.3% of all teeth positive for PD ≥4 mm, and 65.5% of all dogs and 83.2% of all teeth positive for CAL ≥1 mm. The results presented here only pertain to the present study population.

Conclusions

This screening protocol is suitable for examination of larger groups of laboratory Beagle dogs for PD and our findings indicate that diseased dogs are identified with a high degree of sensitivity. Before this screening can be used in clinical practice, it has to be validated in breeds other than Beagle dogs and in populations with larger age variation.

[Periodontal disease in pediatric rheumatic diseases]

Gingivitis and periodontitis are immunoinflammatory periodontal diseases characterized by chronic localized infections usually associated with insidious inflammation This narrative review discusses periodontal diseases and mechanisms influencing the immune response and autoimmunity in pediatric rheumatic diseases (PRD), particularly juvenile idiopathic arthritis (JIA), childhood-onset systemic lupus erythematosus (C-SLE) and juvenile dermatomyositis (JDM). Gingivitis was more frequently observed in these diseases compared to health controls, whereas periodontitis was a rare finding. In JIA patients, gingivitis and periodontitis were related to mechanical factors, chronic arthritis with functional disability, dysregulation of the immunoinflammatory response, diet and drugs, mainly corticosteroids and cyclosporine. In C-SLE, gingivitis was associated with longer disease period, high doses of corticosteroids, B-cell hyperactivation and immunoglobulin G elevation. There are scarce data on periodontal diseases in JDM population, and a unique gingival pattern, characterized by gingival erythema, capillary dilation and bush-loop formation, was observed in active patients. In conclusion, gingivitis was the most common periodontal disease in PRD. The observed association with disease activity reinforces the need for future studies to determine if resolution of this complication will influence disease course or severity.

Risk factors for periodontal disease

Risk factors play an important role in an individual's response to periodontal infection. Identification of these risk factors helps to target patients for prevention and treatment, with modification of risk factors critical to the control of periodontal disease. Shifts in our understanding of periodontal disease prevalence, and advances in scientific methodology and statistical analysis in the last few decades, have allowed identification of several major systemic risk factors for periodontal disease. The first change in our thinking was the understanding that periodontal disease is not universal, but that severe forms are found only in a portion of the adult population who show abnormal susceptibility. Analysis of risk factors and the ability to statistically adjust and stratify populations to eliminate the effects of confounding factors have allowed identification of independent risk factors. These independent but modifiable, risk factors for periodontal disease include lifestyle factors, such as smoking and alcohol consumption. They also include diseases and unhealthy conditions such as diabetes mellitus, obesity, metabolic syndrome, osteoporosis, and low dietary calcium and vitamin D. These risk factors are modifiable and their management is a major component of the contemporary care of many periodontal patients. Genetic factors also play a role in periodontal disease and allow one to target individuals for prevention and early detection. The role of genetic factors in aggressive periodontitis is clear. However, although genetic factors (i.e., specific genes) are strongly suspected to have an association with chronic adult periodontitis, there is as yet no clear evidence for this in the general population. It is important to pursue efforts to identify genetic factors associated with chronic periodontitis because such factors have potential in identifying patients who have a high susceptibility for development of this disease. Many of the systemic risk factors for periodontal disease, such as smoking, diabetes and obesity, and osteoporosis in postmenopausal women, are relatively common and can be expected to affect most patients with periodontal disease seen in clinics and dental practices. Hence, risk factor identification and management has become a key component of care for periodontal patients.

Is human immunodeficiency virus (HIV) stage an independent risk factor for altering the periodontal status of HIV-positive patients? A South African study

BACKGROUND

The immunosuppresion in HIV patients makes them highly susceptible to microbial infections. The aim of the study was to establish whether HIV stage (as depicted by CD4+ T lymphocyte counts) could independently be associated with periodontal status (as revealed by the measurement of clinical indices).

METHODS

One hundred and twenty HIV-infected patients attending an infectious diseases clinic in the Western Cape, South Africa were included in the study. The periodontal clinical indices such as plaque index, gingival index, pocket probing depth and clinical attachment levels were measured on the mesial aspect of the six Ramfjord teeth. The CD4 + T cell counts were taken from the patients' medical records and patients' HIV stage determined and grouped according to their CD4+ T cell counts into A (<200 cells /mm3), B (200-500 cells /mm3) and C (>500 cells /mm3).

RESULTS

The mean age of 120 HIV-positive patients was 33.25 years and the mean CD4 + T cell count was 293.43 cells/mm3. The probing depth and clinical attachment loss were found to be significantly associated with the total CD4 + T cell counts but not with HIV stage. Significant correlations were found between age and all clinical indices except for clinical attachment loss. No correlation was found between age and HIV stage of the patients. The use of antiretroviral therapy was significantly associated with probing depth and clinical attachment loss, but not with plaque nor gingival index. Significant associations were observed between smoking and all of the clinical indices except for the gingival index. A significant association was observed between the use of interdental aids and all the clinical indices except for probing depth, while brushing was significantly associated with plaque index only. CD4 + T cell counts were significantly associated with brushing frequency (p = 0.0190) and the use of interdental aids (p = 0.0170).

CONCLUSION

The findings of this study conclude that HIV stage, ART and age are not independent risk factors for changes in the periodontal status of HIV-positive subjects but rather that smoking and oral hygiene habits determine their susceptibility to disease.

Periodontal diseases in an Omani adult population: a preliminary study

BACKGROUND

Data on the periodontal status of the adult population in the Arab world are scarce. The aim of this pilot study is to assess the prevalence, extent, and severity of periodontal diseases in an adult group from Oman.

METHODS

This is a cross-sectional study of 319 teachers who were randomly sampled from the list of teachers from the Muscat region schools in Oman. Dental caries, tooth loss, and periodontal attachment loss (AL) were recorded for each of the participants. A questionnaire collected data on participants' sociodemographic characteristics, dental-care characteristics, self-rated periodontal status, and self-rated well-being.

RESULTS

A total of 99% of participants had at least one site with probing depth (PD) or clinical AL of ≥ 3 mm. More than one third (36%) of participants had at least one site with AL ≥ 5 mm, and 12% had at least one site with AL ≥ 6 mm; for PD, the prevalence estimates were 26% and 8%, respectively, and a gradient by age group was evident across the different thresholds. Regarding the extent of disease, 17.6% of sites had PD ≥ 3 mm, and 21% of sites had AL ≥ 3 mm.

CONCLUSIONS

The prevalence, extent, and severity of periodontitis were higher than estimates reported from industrialized countries, such as Australia, New Zealand, and the United States. This is of concern, especially when considering the relatively young age of the study population. Because of this high prevalence, investigation of periodontitis in a national sample of Omanis is desirable to confirm the findings of this study.

Destructive periodontal disease in adult Indians from Northeast Brazil: cross-sectional study of prevalence and risk indicators

AIM

The aim of this cross-sectional study was to evaluate the prevalence of destructive periodontal disease and its risk indicators in adult Kiriri Indians from Northeast Brazil.

MATERIALS AND METHODS

Full-mouth periodontal examinations were performed on a sample of 215 Indians (≥19 years). Bivariate analyses and logistic models were applied to assess associations between periodontitis and its putative risk factors.

RESULTS

Prevalence of clinical attachment loss of ≥3, ≥5 and ≥7 mm was 97.8%, 63.8% and 30.8% respectively. Percentage of teeth per individual showing clinical attachment loss of ≥3, ≥5 and ≥7 mm was 49.8%, 18.4% and 8.0% respectively. After adjustment for covariates, individuals aged ≥35 years (OR = 5.83, 95% CI: 3.09-11.00; p < 0.001), men (OR = 2.18, 95% CI: 1.15-4.11; p = 0.02) and diabetics (OR = 3.92, 95% CI 1.03-14.99; p = 0.05) had a higher risk for destructive periodontitis, classified according to the CDC/AAP case definition.

CONCLUSION

Though periodontitis was highly prevalent in Kiriri Indians, only few teeth showed advanced disease, and periodontitis was associated with higher age, male sex and diabetes. A public health action that includes programs of prevention and treatment targeting high-risk groups is vital to improve the periodontal status of this population.

Metastatic tumors to the gingiva and the presence of teeth as a contributing factor: a literature analysis

BACKGROUND

Gingiva that is prone to inflammation may serve as a pre-metastatic niche for the attraction of circulating malignant cells. The aim of this study is to analyze cases of metastatic lesions to the gingiva compared with cases metastasizing to other oral mucosal sites. The pathogenesis of gingival metastases is discussed, with emphasis on the role of inflammation.

METHODS

The English-language literature between 1916 and 2011 was searched for cases of metastatic lesions to the oral mucosa; only cases metastasizing in the oral mucosa, gingiva, and periodontium were included.

RESULTS

Two hundred seven cases were included. The gingiva was the most common site (60.4%), followed by tongue and tonsil. The most common primary sites were lung (24.2%), kidney (13.5%), skin (10.6%), and breast (8.7%). In 27%, the oral lesion was the first sign of a malignant disease. In most cases, the lesion appeared as an exophytic mass (96%) diagnosed clinically as a reactive gingival lesion. The presence of teeth was significantly associated with the development of gingival metastases: in 108 of 125 gingival metastases, the lesion was found adjacent to teeth (P <0.001; odds ratio = 8.2). The average life expectancy after diagnosis of the metastasis was 3.7 months.

CONCLUSIONS

The gingiva is the most common site for metastases to oral soft tissues, with strong association with the presence of teeth. This finding may be related to the role of inflammation in the attraction of metastatic cells to chronically inflamed gingiva.

New attempts to modify periodontal risk assessment for generalized aggressive periodontitis: a retrospective study

BACKGROUND

Periodontal risk assessment (PRA) model was designed for risk evaluation of treated patients with periodontal disease. However, its use on generalized aggressive periodontitis (GAgP) had been scarcely reported. This study aims to investigate the association of original PRA/modified PRA (MPRA) and compliance of periodontal maintenance with long-term treatment outcomes of Chinese patients with GAgP.

METHODS

Eighty-eight patients from a GAgP cohort, who completed active periodontal treatment (APT) and accepted reevaluation 3 to 11 years (mean of 5.5 years) afterward, were enrolled. PRA was modified (three strategies involving replacement of bleeding on probing with bleeding index >2, counting sites with probing depth ≥6 mm and changing method of bone loss [BL] calculation) to classify patients into different risk groups based on data at the first recall after APT. PRA and three MPRA models were investigated regarding long-term association with tooth loss (TL) and alteration of bone level (∆BL).

RESULTS

Based on original PRA, 87 patients (98.8%) had a high-risk profile. According to three MPRA models, annual TL per patient values were greater in high-risk groups than in low-to-moderate risk groups (MPRA-1, 0.20 ± 0.33 versus 0.04 ± 0.14; MPRA-2, 0.18 ± 0.32 versus 0.05 ± 0.14; MPRA-3, 0.17 ± 0.32 versus 0.05 ± 0.15; P <0.05). By MPRA-1, irregular compliers with low-to-moderate risk profile had greater ∆BL (0.027 ± 0.031, indicating bone increment) than those with high risk (-0.012 ± 0.064, tendency for BL). For regular compliers, no significant differences of annual TL or ∆BL were found between risk groups.

CONCLUSIONS

MPRA models could be used for evaluating the long-term outcomes of Chinese patients with severe GAgP, especially irregular compliers. High-risk patients of MPRAs exhibited more TL and less bone fill than low-to-moderate risk ones.

Microbiological basis for periodontal therapy

The search for the etiologic agents of periodontal diseases started in the Golden Era of medical bacteriology, when the etiologic agents of many bacterial infections were isolated and characterized. After the initial enthusiasm in establishing the infectious nature and the true agents of periodontal diseases, this concept was virtually ignored for the next four decades. Until the early 1970s treatment regimens based on the non-specific plaque hypothesis were directed towards a non-specific reduction in plaque amount. Later, the specific plaque hypothesis established the role of some microorganisms such as A. actinomycetemcomitans, P. gingivalis, T. forsythensis, T. denticola, P. intermedia and F. nucleatum in different forms of periodontal diseases. It was recently suggested that these suspected periodontal pathogens seem to not act alone and interactions between species, especially the balance between pathogenic and beneficial species affect both progression of disease and response of tissues to periodontal therapy. Nowadays it is well established that one of the goals of therapy is to control such periodontal pathogens. Among the most commonly used therapies to treat periodontal infections are scaling and root planing (SRP), supragingival plaque control and periodontal surgeries. Many studies confirmed the reduction of "red complex" species by SRP, and apically repositioned flap can lead to an additional beneficial effect in the subgingival microbiota by decreasing levels of "red" and "orange complexes" species. Furthermore, the level of plaque control maintained by the patients has been considered a crucial step in preventing recurrence of destructive periodontitis.

Assessment of periodontal status and treatment needs among 12 and 15 years old school children in Udaipur, India

AIM

To assess and compare the periodontal status and treatment needs among school children aged 12 and 15 years in public and private schools of Udaipur, India and to provide baseline data for planning and evaluation of oral health care promotion programmes.

STUDY DESIGN

A cross-sectional descriptive survey.

METHODS

A survey was conducted on 900 school children aged 12 and 15 years in Udaipur. The data were collected by means of clinical examination using the CPITN index.

STATISTICS

Data was analysed using Pearson's Chi-square and student's t-test.

RESULTS

Children aged 15 years had higher scores of healthy gingiva compared with 12 years old. Gender difference of females having better gingival health than males was seen in both age groups. Amongst the schools, children in private schools had good periodontal status in comparison to public schools. A statistically significant association between frequency of tooth brushing and CPITN scores was found among children of the 15 year old group.

CONCLUSION

There is a need for a long term school oral health promotion program to sustain the healthy tissues of this growing Indian population.

MAPK usage in periodontal disease progression

In periodontal disease, host recognition of bacterial constituents, including lipopolysaccharide (LPS), induces p38 MAPK activation and subsequent inflammatory cytokine expression, favoring osteoclastogenesis and increased net bone resorption in the local periodontal environment. In this paper, we discuss evidence that the p38/MAPK-activated protein kinase-2 (MK2) signaling axis is needed for periodontal disease progression: an orally administered p38α inhibitor reduced the progression of experimental periodontal bone loss by reducing inflammation and cytokine expression. Subsequently, the significance of p38 signaling was confirmed with RNA interference to attenuate MK2-reduced cytokine expression and LPS-induced alveolar bone loss. MAPK phosphatase-1 (MKP-1), a negative regulator of MAPK activation, was also critical for periodontal disease progression. In MPK-1-deficient mice, p38-sustained activation increased osteoclast formation and bone loss, whereas MKP-1 overexpression dampened p38 signaling and subsequent cytokine expression. Finally, overexpression of the p38/MK2 target RNA-binding tristetraprolin (TTP) decreased mRNA stability of key inflammatory cytokines at the posttranscriptional level, thereby protecting against periodontal inflammation. Collectively, these studies highlight the importance of p38 MAPK signaling in immune cytokine production and periodontal disease progression.

Recession defects associated with scraped roots treated with subepithelial connective tissue graft

The objective of the current study was to assess histomorphometrically the healing process of recession defects associated with scraped roots treated with subepithelial connective tissue graft (SCTG). Six dogs were used. Bone dehiscence defects (6 × 8 mm) and root planing were carried out on maxillary canine teeth. Following a split-mouth model, according to the treatment, left canines (control) were covered with coronally positioned flap (CPF). Right canines were submitted to treatments with SCTG. After a 3-month postoperative period, the animals were killed, and the blocks processed for the histomorphometric assessment. Data assessment demonstrated that the CPF group showed parameters of a new connective tissue attachment, length of new cement (NC), length of new bone (mean ± SD: 0.95 ± 0.53, 2.44 ± 1.97, and 1.96 ± 2.29 mm, respectively), which were higher than those of SCTG group (mean ± SD: 0.71 ± 0.36, 2.21 ± 1.28, and 1.52 ± 1.31 mm, respectively), although not significantly (P > 0.05). The length of both epithelial tissue and connective tissue apposition in the SCTG group (mean ± SD: 1.70 ± 0.53 and 2.62 ± 1.52 mm, respectively) were higher than those of the CPF group (mean ± SD: 1.18 ± 0.49 and 2.03 ± 1.03 mm, respectively), although showing no significant differences (P > 0.05). Within the limits of the current study, it was possible to conclude that there were no significant differences between the groups according to the histologic parameters assessed.

Periodontal status of a given population of West Bengal: An epidemiological study

Background:

This paper presents the prevalence and severity of periodontal disease in a given population of West Bengal and its relationship with their age, sex, socioeconomic status, educational background, and dietary habits. Also, the treatment needs on the basis of Community Periodontal Index of Treatment Needs (CPITN), which might be helpful for future planning of dental services.

Materials and Methods:

A sample of 22,452 individuals aged 15 years and above was selected using a random cluster sampling from the population. All the subjects sampled were weighed by age, sex, community, income group, educational level, diet pattern, and habitation. The WHO CPITN was used to assess the levels of periodontal condition and treatment needs.

Results:

Score 2 was most prevalent in all the groups. Periodontal disease is widespread in West Bengal and a positive relation appears to exist between age, sex, socio-economic status, education level, and dietary habits with periodontal status. Comprehensive oral hygiene instruction and dental prophylaxis need to be initiated.

Conclusion:

The data on periodontal conditions presented in this study are similar to data available from WHO on global oral health. These estimates are important for the future planning of dental services in the state.

Periodontal disease in relation to smoking and the use of Swedish snus: epidemiological studies covering 20 years (1983-2003)

AIM

The aim of the present study was to examine how deleterious current smoking and the use of Swedish moist snuff (snus) is for periodontal health compared with non-tobacco users.

MATERIALS AND METHODS

The studies comprised three epidemiological cross-sectional studies, in 1983, 1993 and 2003, of stratified random samples aged 20, 30, 40, 50, 60 and 70 years. The numbers of dentate participants were 550, 552 and 523, respectively. The participants were examined clinically and radiographically. Diagnostic criteria were the number of teeth, plaque, gingival status, probing pocket depth (PPD) ≥ 4 mm, height of the alveolar bone level and classification by periodontal disease experience. In addition, participants were asked about their tobacco habits.

RESULTS

Multiple logistic regression shows, after adjusting for age, gender and sociodemographic variables, that relative to non-tobacco users, cigarette smokers had statistically significant less gingivitis, a higher frequency of PPD ≥ 4 mm and a higher incidence of severe periodontitis. There was no significant association between gingivitis, frequency of PPD ≥ 4 mm and periodontal disease experience and snus use.

CONCLUSIONS

Cigarette smokers were found to have a statistically significant higher risk of severe periodontitis than non-tobacco users and users of snus. Using snus did not seem to be a risk factor for periodontitis.

Sex differences in destructive periodontal disease: a systematic review

BACKGROUND

Sexual dimorphisms exist in the prevalence and severity of many human conditions and diseases. Models of risk assessment for periodontitis, however, are inconsistent with respect to the inclusion of sex as a risk factor. A systematic review of the literature and meta-analyses estimates sex-related differences in the prevalence of periodontitis.

METHODS

MEDLINE, EMBASE, and SCOPUS databases were searched for population surveys (sample size >500, half-mouth minimum, clinical attachment level) containing prevalence data on destructive periodontal disease in males and females.

RESULTS

Data were stratified by disease thresholds (3, 4, 5, and 7 mm) representing 50,604 subjects from 12 population surveys meeting selection criteria. Using a ≥ 5-mm clinical attachment loss threshold, seven studies provided data, permitting computation of mean-weighted sex differences in prevalence. Four studies provided data enabling a meta-analysis of prevalence rates. Sex exhibited a significant association with prevalence, reflecting a 9% difference between males and females (37.4% versus 28.1%, respectively), although the overall effect of sex in the meta-analysis was comparatively small (d = 0.19; 95% confidence interval, 0.16 and 0.22). This mean difference in prevalence between males and females was similar regardless of severity of disease threshold and after adjustment for other risk factors.

CONCLUSIONS

Men appear at greater risk for destructive periodontal disease than women; however, men do not appear at higher risk for more rapid periodontal destruction than women.

Clinical status and detection of periodontopathogens and Streptococcus mutans in children with high levels of supragingival biofilm

Knowledge about the presence of some important oral pathogens is an important step in better identifying children at risk for periodontal and/or caries diseases in later life. The purpose of this study was to detect the presence of Streptococcus mutans (Sm), Aggregatibacter actinomycetemcomitans (Aa), Campylobacter rectus (Cr), Porphyromonas gingivalis (Pg), Prevotella intermedia (Pi), and Tannerella forsythia (Tf) in gingival biofilm samples from 196 children, and to assess whether any of these pathogens are more associated with gingival inflammation extension and the Decayed/Missing/Filled teeth (DMFT/dmft) index. The subjects presented plaque index greater than 80% and were divided in 3 groups according to the bleeding index (BI): I) Low bleeding (< 30%), II) Medium bleeding (31 - 59%) and III) High bleeding (> 60%). The presence of each pathogen was determined by PCR. The prevalence of Sm was 71.9% and the mean dmft/DMFT was 6.68. The prevalence in low, medium and high bleeding groups was 43.5%, 34.5% and 46.7% for Aa; 43.5%, 37.9%, and 36.7% for Cr; 99.1%, 100%, and 96.7% for Pg; 56.5%, 56.9%, and 66.7% for Pi; and 58.3%, 60.3%, and 56.7% for Tf, respectively. Pg (99.0%) was the most prevalent periodontal pathogen detected followed by Tf (58.7%), Pi (58.2%), Aa (41.3%) and Cr (40.8%). Our study indicated that in this high plaque index population studied, a high prevalence of Sm and high mean DMFT were observed. In addition, the presence of Pi was associated with the presence of inflammation (P < 0.05) whereas Cr was associated with periodontal health (P < 0.05).

Methodological issues in epidemiological studies of periodontitis--how can it be improved?

Background

This position paper was commissioned by the European Association of Dental Public Health, which has established six working groups to investigate the current status of six topics related to oral public health. One of these areas is epidemiology of periodontal diseases.

Methods

Two theses "A systematic review of definitions of periodontitis and the methods that have been used to identify periodontitis" [1] and "Factors affecting community oral health care needs and provision" [2] formed the starting point for this position paper. Additional relevant and more recent publications were retrieved through a MEDLINE search.

Results

The literature reveals a distinct lack of consensus and uniformity in the definition of periodontitis within epidemiological studies. There are also numerous differences in the methods used. The consequence is that data from studies using differing case definitions and differing survey methods are not easily interpretable or comparable. The limitations of the widely used Community Periodontal Index of Treatment Need (CPITN) and its more recent derivatives are widely recognized. Against this background, this position paper reviews the current evidence base, outlines existing problems and suggests how epidemiology of periodontal diseases may be improved.

Conclusions

The remit of this working group was to review and discuss the existing evidence base of epidemiology of periodontal diseases and to identify future areas of work to further enhance it.

Characteristics of inflammation common to both diabetes and periodontitis: are predictive diagnosis and targeted preventive measures possible?

Diabetes and periodontitis are chronic inflammatory disorders that contribute to each others' severity and worsen each others' prognosis. Studies have shown that patients with diabetes are at increased risk of developing periodontitis, and that diabetics with untreated periodontitis have more difficulty controlling serum glucose. Periodontal treatment that reduces gingival inflammation aids in the control of hyperglycemia. Periodontitis is accompanied by gingival bleeding and the production of an inflammatory exudate termed gingival crevicular fluid (GCF) that arises from the inflamed gingival tissues surrounding the teeth. GCF contains byproducts of connective tissue degradation, enzymes from host and bacterial cells, cytokines and other inflammatory mediators, and has been studied for screening blood glucose and for biomarkers of both diabetes and periodontitis. This review focuses on the inter-relationship between diabetes and periodontitis and the biomarkers common to both these diseases that may enable earlier detection, targeted preventive measures and individualized therapeutic intervention of these chronic conditions.

The potential use of gingival crevicular blood for measuring glucose to screen for diabetes: an examination based on characteristics of the blood collection site

BACKGROUND

This study examined conditions under which gingival crevicular blood (GCB) could be used to obtain a useful glucose reading to screen for undiagnosed diabetes during routine dental visits.

METHODS

GCB and capillary finger-stick blood (CFB) glucose readings obtained with a glucometer were compared for 46 patients recruited from an urban university dental clinic. Study participants were divided into two groups based on probing depth or bleeding on probing (BOP) at the site of collection of the GCB sample. Group 1 participants had blood collected from sites with adequate BOP to obtain a sample without touching the tooth or gingival margin, whereas group 2 participants had blood collected from sites with little or no bleeding. For each group, Pearson correlations were calculated for glucose readings obtained using GCB and CFB samples, and the limits of agreement between the two samples were examined.

RESULTS

For group 1 participants, correlations between CFB and GCB glucose readings were high (0.89), and the limits of agreement were acceptable (-27.1 to 29.7). By contrast, for participants in group 2, correlations between the glucose readings were lower (0.78), and limits of agreement were much broader (-25.1 to 80.5).

CONCLUSION

GCB samples were suitable to screen for diabetes in persons with sufficient BOP to obtain a sample without touching the tooth or gingival margin (i.e., in patients having the basic clinical signs of gingivitis or periodontal disease).

Prevalence and distribution of principal periodontal pathogens worldwide

BACKGROUND

Detailed genetic analysis of bacteria has demonstrated an unanticipated genetic diversity within species, which often reveals evolutionary lineages that are disproportionately associated with infection. There is evidence that some evolutionary lineages of bacteria have adapted to particular ethnic groups.

AIM

This review analyzes to what extent observed differences in periodontal disease prevalence among ethnically or geographically distinct populations may be explained by restricted host adaptation of clones of principal periodontal pathogens.

RESULTS

Carriage rates of several putative periodontal pathogens and particular subsets of these species vary between ethnic groups. Few of these differences can, with the limited information available, be directly related to differences in periodontal disease prevalence. Asian populations are regularly colonized with Actinobacillus actinomycetemcomitans serotype c with questionable pathogenic potential. Conversely, the JP2 clone of A. actinomycetemcomitans has enhanced virulence and causes significantly higher prevalence of aggressive periodontitis in adolescents whose descent can be traced back to the Mediterranean and Western parts of Africa. Some genetically distinct types of Porphyromonas gingivalis are more associated with disease than others, but additional work is required to relate this to clinical differences.

CONCLUSIONS

Studies that take into account differences linked to the genetics of both patients and potential pathogens are likely to give better insight into the aetiology of periodontal diseases.