Influence of CPITN partial recordings on estimates of prevalence and severity of various periodontal conditions in adults

Association Between Periodontitis and Adverse Pregnancy Outcomes: Two-Sample Mendelian Randomisation Study

AIM

This Mendelian randomisation (MR) study endeavoured to delineate the causal relationship between periodontitis and adverse pregnancy outcomes (APOs), encompassing low birthweight (LBW), pre-term birth (PTB), stillbirth, miscarriage, and gestational hypertension (GH).

METHODS

Utilising genetic instruments for periodontitis (acute and chronic periodontitis) from the Genome-Wide Association Study (GWAS) database among individuals of European descent, this study explored the causal relationship with adverse pregnancy outcomes, and vice versa. The Inverse Variance Weighted (IVW) method was employed as the primary analytical approach to assess causality, with MR-Egger serving as a sensitivity analysis method.

RESULTS

The primary analytical method employed in this study, IVW, did not reveal any impact of periodontitis (acute and chronic periodontitis) on PTB, stillbirth, miscarriage, and gestational hypertension, and vice versa. Heterogeneity testing using the MR-Egger method confirmed the null causal hypothesis, with odds ratios (OR) approximating 1, and P-values exceeding 0.05. Notably, the results from the IVW analysis (OR 1.410, CI 1.039-1.915, P-value 0.028) indicate statistically significant evidence supporting a causal relationship between chronic periodontitis and LBW. However, caution is advised in interpreting the causal relationship, considering the non-significant P-values obtained from other methods.

CONCLUSION

Within the limitations of this MR study, the findings do not support the influence of periodontitis on LBW, PTB, stillbirth, miscarriage, and GH, nor vice versa.

Vitamin D, periodontitis and tooth loss in older Irish adults

The aim of this study is to investigate whether 25-hydroxyvitamin D (25(OH)D) is associated with periodontitis and tooth loss in older adults. A total of 2346 adults underwent a detailed dental examination as part of the health assessment of a national population study - The Irish Longitudinal Study of Ageing. 25(OH)D analysis was performed on frozen non-fasting total plasma using LC-MS. The analysis included both multiple logistic regression and multinominal logistic regression to investigate associations between 25(OH)D concentration, periodontitis and tooth loss, adjusting for a range of potential confounders. Results of the analysis found the mean age of participants was 65·3 years (sd 8·2) and 55·3 % of the group were female. Based on the quintile of 25(OH)D concentration, participants in the lowest v. highest quintile had an OR of 1·57 (95 % CI 1·16, 2·13; P < 0·01) of having periodontitis in the fully adjusted model. For tooth loss, participants in the lowest v. highest quintile of 25(OH)D had a RRR of 1·55 (95 % CI 1·12, 2·13; P < 0·01) to have 1-19 teeth and a RRR of 1·96 (95 % CI 1·20, 3·21; P < 0·01) to be edentulous, relative to those with ≥ 20 teeth in the fully adjusted models. These findings demonstrate that in this cross-sectional study of older men and women from Ireland, 25(OH)D concentration was associated with both periodontitis and tooth loss, independent of other risk factors.

A Systematic Review and Meta-Analysis of the Association Between Periodontal Disease and Severe Mental Illness

BACKGROUND

Periodontal disease represents a global public health concern, with a disproportionate burden being borne by vulnerable populations. One such group is people with severe mental illness (SMI), and this study examined whether periodontal health is poorer in people with SMI than the general population.

METHODS

We conducted a systematic search for studies published before March 2021 on the periodontal health of people with SMI using the following databases: PubMed, PsycINFO, EMBASE, China National Knowledge Infrastructure, and Chongqing VIP. Outcomes were periodontitis, periodontal disease, and shallow and deep periodontal pockets. Results were compared with the general population.

RESULTS

Seventeen studies had sufficient data for a random-effects meta-analysis, consisting of 4404 psychiatric patients and 95,411 controls. SMI was associated with an increased prevalence of periodontitis (odds ratio = 1.97, 95% confidence interval [CI] = 1.15-3.35) compared with the general population. People with SMI had 4.28 the odds of having periodontal disease compared with controls (95% CI = 2.54-7.21). They also had 3.65 the odds of shallow pockets (95% CI = 1.80-7.42) and 2.76 the odds of deep pockets (95% CI = 1.10-6.93).

CONCLUSIONS

Our findings highlight the increased prevalence and severity of periodontal disease in people with SMI. Oral health is often considered the gateway to overall health and should be a public health priority for this population.

Relationship between periodontitis and psoriasis: A two-sample Mendelian randomization study

AIM

Observational research suggests that periodontitis affects psoriasis. However, observational studies are prone to reverse causation and confounding, which hampers drawing causal conclusions and the effect direction. We applied the Mendelian randomization (MR) method to comprehensively assess the potential bi-directional association between periodontitis and psoriasis.

MATERIALS AND METHODS

We used genetic instruments from the largest available genome-wide association study of European descent for periodontitis (17,353 cases, 28,210 controls) to investigate the relationship with psoriasis (13,229 cases, 21,543 controls), and vice versa. Causal Analysis Using Summary Effect (CAUSE) estimates and inverse variance-weighted (IVW) MR analyses were used for the primary analysis. Robust MR approaches were used for sensitivity analyses.

RESULTS

Both univariable methods, CAUSE and IVW MR analyses, did not reveal any impact of periodontitis on psoriasis (CAUSE odds ratio [OR] = 1.00, p = 1.00; IVW OR = 1.02, p = .6247), or vice versa (CAUSE OR = 1.01, p = .5135; IVW OR = 1.00, p = .7070). The null association was corroborated by pleiotropy-robust methods with ORs close to 1 and p-values >.59. Overall, MR analyses did not suggest any effect of periodontitis on psoriasis. Similarly, there was no evidence to support an effect of psoriasis on periodontitis.

CONCLUSIONS

Within the limitations of this MR study, the outcomes supported neither periodontitis affecting psoriasis nor psoriasis affecting periodontitis.

Metabolic syndrome and severe periodontitis were associated in Thai adults: A cross-sectional study

BACKGROUND

Studies support the relationship between metabolic syndrome (MetS) and periodontitis. However, age is the major confounding factor for both conditions. Therefore, this cross-sectional study was performed to investigate the relationship between MetS and severe periodontitis in different Thai adult age groups.

METHODS

Data on the medical history, medical examination, and full mouth oral examination of 5,690 Electricity Generating Authority of Thailand employees aged 25 to 77 years were collected. The prevalence ratio (PR) between risk variables, MetS, and periodontitis was determined using Poisson regression analysis. Moreover, the subgroup analysis and effect modification by age on severe periodontitis were performed.

RESULTS

Overall, MetS was significantly associated with severe periodontitis compared with non-severe periodontitis (adjusted PR, 1.11; 95% confidence interval [CI], 1.01 to 1.13). The association was modified by age, with negative effect modification observed on the multiplicative and additive scales. The subgroup analysis revealed a significant relationship between MetS and severe periodontitis only in participants aged <45 years with an adjusted PR of 1.69 (95% CI, 1.29 to 2.21). All MetS components, except hypertension, were associated with severe periodontitis in this group.

CONCLUSIONS

There is a significant relationship between MetS and severe periodontitis in adults aged <45 years. Therefore, attempts to control the risk of MetS and periodontitis should be emphasized for early adults to reduce the incidence of these conditions and related complications when they become elderly.

Accuracy of a 7-Item Patient-Reported Stand-Alone Tool for Periodontitis Screening

Periodontitis is interrelated with various other chronic diseases. Recent evidence suggests that treatment of periodontitis improves glycemic control in diabetes patients and reduces the costs of diabetes treatment. So far, however, screening for periodontitis in non-dental settings has been complicated by a lack of easily applicable and reliable screening tools which can be applied by non-dental professionals. The purpose of this study was to assess the diagnostic accuracy of a short seven-item tool developed by the German Society for Periodontology (DG PARO) to screen for periodontitis by means of patient-reported information. A total of 88 adult patients filled in the patient-reported Periodontitis Risk Score (pPRS; range: 0 points = lowest periodontitis risk; 20 points = very high periodontitis risk) questionnaire before dental check-up at Heidelberg University Hospital. Subsequent clinical assessments according to Periodontal Screening and Recording (PSR®) were compared with pPRS scores. The diagnostic accuracy of pPRS at different cutoff values was assessed according to sensitivity, specificity, positive, and negative predictive values, as well as Receiver-Operator-Characteristic curves, Area Under the Curve (AUC), and logistic regression analysis. According to combined specificity and sensitivity (AUC = 0.86; 95%-CI: 0.76-0.95), the diagnostic accuracy of the pPRS for detecting periodontal inflammation (PSR® ≥ 3) was highest for a pPRS cutoff distinguishing between pPRS scores < 7 vs. ≥ 7. Patients with pPRS scores ≥ 7 had a 36.09 (95%-CI: 9.82-132.61) times higher chance of having a PSR® ≥ 3 than patients with scores < 7. In conclusion, the pPRS may be considered an appropriately accurate stand-alone tool for the screening for periodontitis.

Effectiveness of a family-centered behavioral and educational counselling approach to improve periodontal health of pregnant women: a randomized controlled trial

BACKGROUND

Poor oral hygiene and high hormone levels during pregnancy can lead to a deterioration in periodontal health. This study assessed the effectiveness of a family-centered behavioral and educational counselling program on improving the periodontal health of women during pregnancy and postpartum.

METHODS

A randomized controlled trial was conducted among pregnant women (10th-22nd gestational week) and their husbands. Participating families were randomized into test and control groups. Intervention in the test group included explanation of oral health education (OHE) pamphlets, oral hygiene instruction, individualized feedback, and proposed solutions to overcome barriers in self-care. Reinforcements were implemented in the 3rd trimester of pregnancy and six months postpartum. In the control group, only OHE pamphlets were distributed. The assessed outcomes were bleeding on probing (BOP), periodontal pocket (Poc), loss of clinical attachment (LoA), and Visible Plaque Index (VPI). The data collection was carried out at baseline (T₀), in the 32nd gestational week (T₁), and 12 months postpartum (T₂).

RESULTS

Altogether 589 pregnant women were recruited, and 369 attended all three visits (test:188; control:181). In the test group, the mean VPI score at T₀ was 0.19, which decreased to 0.14 at T₁ and 0.15 at T₂. In the control group, the mean VPI decreased from 0.19 at T₀ to 0.16 at T₁, but increased to 0.22 at T₂. A main effect of time and intervention and an interaction between time and intervention were detected (all p < 0.05), indicating that the intervention effect differed between T₁ and T₂. The test group showed a significantly greater decrease over time than the control group did. Similarly, the mean BOP% decreased more significantly over time in the test group (T₀:57%, T₁:46%, T₂:35%) than in the control group (T₀:58%, T₁:52%, T₂:46%). For Poc and LoA, there were improvements in both study groups at 12 months postpartum, compared with during pregnancy (p < 0.001).

CONCLUSIONS

Providing family-centered, behavioral, and educational counselling to pregnant women at an early stage of pregnancy and with reinforcements can improve their oral hygiene and reduce gingival inflammation. The effect can be sustained over an extended period and is greater than that of distributing oral health leaflets alone.

TRIAL REGISTRATION

Clinicaltrials.gov , #NCT02937194. Registered 18 October 2016. Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02937194?cond=Family-centered+oral+health+promotion+for+new+parents+and+their+infants&draw=2&rank=1.

The 2018 periodontitis case definition improves accuracy performance of full-mouth partial diagnostic protocols

We aimed to compare the accuracy performance of the new 2018 periodontitis case definition by the European Federation of Periodontology (EFP)/ American Association of Periodontology (AAP) with Centers for Disease Control (CDC)/AAP 2012 in full-mouth partial recording protocols (PRP). Retrospective data from NHANES 2011-2012 and 2013-2014 were analyzed. For each case definition, full-mouth diagnostic was defined as the reference standard. Patients were diagnosed for the presence of periodontitis and staging for each PRP. Sensitivity, specificity, accuracy and precision, through several indicators, were determined. Performance measurement was assessed through binary and multiclass ROC/AUC analyses. Our performance analysis shows that the new 2018 classification outperforms the 2012 classification regarding the diagnosis and staging of periodontitis on full-mouth PRPs. This recent case definition has strengthened the utility of PRPs and its improvements certainly explain the observed findings. Also, our findings contribute to the reliability of PRPs and its use in future worldwide epidemiological surveys.

Dental caries and periodontal diseases in the ageing population: call to action to protect and enhance oral health and well-being as an essential component of healthy ageing - Consensus report of group 4 of the joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases

BACKGROUND

Over the last two decades, progress in prevention and treatment of caries and periodontal diseases has been translated to better oral health and improved tooth retention in the adult population. The ageing population and the increasing expectations of good oral health-related quality of life in older age pose formidable challenges to clinical care and healthcare systems.

AIMS

The objective of this workshop was to critically review scientific evidence and develop specific recommendations to: (i) prevent tooth loss and retain oral function through prevention and treatment of caries and periodontal diseases later in life and (ii) increase awareness of the health benefits of oral health as an essential component of healthy ageing.

METHODS

Discussions were initiated by three systematic reviews covering aspects of epidemiology of caries and periodontal diseases in elders, the impact of senescence on caries and periodontal diseases and the effectiveness of interventions. Recommendations were developed based on evidence from the systematic reviews and expert opinion.

RESULTS

Key messages included: (i) the ageing population, trends in risk factors and improved tooth retention point towards an expected increase in the total burden of disease posed by caries and periodontal diseases in the older population; (ii) specific surveillance is required to monitor changes in oral health in the older population; (iii) senescence impacts oral health including periodontitis and possibly caries susceptibility; (iv) evidence indicates that caries and periodontal diseases can be prevented and treated also in older adults; (v) oral health and functional tooth retention later in life provides benefits both in terms of oral and general quality of life and in terms of preventing physical decline and dependency by fostering a healthy diet; (vi) oral healthcare professionals and individuals should not base decisions impacting tooth retention on chronological age but on level of dependency, life expectancy, frailty, comfort and quality of life; and (vii) health policy should remove barriers to oral health care for vulnerable elders.

CONCLUSIONS

Consensus was reached on specific actionable priorities for public health officials, oral healthcare professionals, educators and workforce planners, caregivers and relatives as well as for the public and ageing patients. Some priorities have major implications for policymakers as health systems need to adapt to the challenge by systemwide changes to enable (promote) tooth retention later in life and management of deteriorating oral health in increasingly dependent elders.

Association between Chronic Periodontitis and Oral/Oropharyngeal Cancer

The aim of this case control study was to assess the association between the extent and severity of chronic periodontitis and oral cavity and/or oropharyngeal cancer. The case group comprised 35 patients (mean age 56.1±8.4), diagnosed for oral and/or oropharyngeal cancer. The control group comprised 40 individuals (mean age 55.4±9.4) without diagnostic of cancer. All individuals were subjected to a periodontal examination, including bleeding on probing, plaque index, gingival index, probing pocket depth (PPD), clinical attachment loss (CAL), and decayed, extracted and filled teeth index (DMFT). The case group had significantly more sites with plaque. GI and BOP had similar values in both groups. The median PPD and CAL values were significantly higher for the case group. Chronic generalized periodontitis was predominant in 80% of patients with oral and/or oropharyngeal cancer. Eighty nine percent of the patients in the case group presented severe chronic periodontitis. There was no significant difference between groups for median values of DMFT. The extent and severity of chronic periodontitis remained as risk indicators for oral cavity and/or oropharyngeal cancer even after the adjustments for traditional confound factors, i.e. smoking and alcohol consumption.

Oral health status in relation to cognitive function among older Japanese

Epidemiologic data examining the relationship between oral health status and cognitive status are sparse, especially in Asian populations. This study aimed to assess whether periodontal disease and tooth loss were related to cognitive impairment among older Japanese. Study participants were 291 Japanese (101 men and 190 women, average age: 80.9 years), classified into three groups based on a clinical examination of oral health status: no periodontal disease, periodontal disease, and edentulous. Periodontal disease was defined using criteria recommended in the consensus report of the European Workshop in Periodontology with a modification. Cognitive impairment was defined using the results of the Mini-mental State Examination (MMSE) and Hasegawa Dementia Scale-Revised (HDS-R) scores. Multivariable logistic regression analyses assessed the relationship of the three-category oral health status variable (reference category = no periodontal disease) with low MMSE score (≤23) and low HDS-R score (≤20). Age, gender, years of education, body mass index, smoking status, drinking behavior, and history of cardiovascular disease were tested as potential confounders in the multivariable models. Periodontal disease and edentulous were significantly associated with greater odds of low cognitive performance after controlling for potential confounders. The multivariable adjusted odds ratios (ORs) (95% confidence intervals [CIs]) for low MMSE score associated with periodontal disease and edentulous were 2.21 (1.01-4.84) and 2.28 (1.06-4.90), respectively. The multivariable adjusted ORs (95% CIs) for low HDS-R score associated with periodontal disease and edentulous were 4.85 (1.29-18.15) and 3.86 (1.05-14.20), respectively. Poor oral health status was significantly associated with cognitive impairment among community-dwelling older Japanese. Additional well-controlled longitudinal studies are needed to elucidate whether there may be a possible cause-and-effect relationship between oral health status and cognitive function.

Detection and diagnosis of periodontal conditions amenable to prevention

Gingivitis and chronic periodontitis are highly prevalent chronic inflammatory diseases. Gingivitis affects the majority of people, and advanced periodontitis is estimated to affect 5-15% of adults. The detection and diagnosis of these common diseases is a fundamentally important component of oral health care. All patients should undergo periodontal assessment as part of routine oral examination. Periodontal screening using methods such as the Basic Periodontal Examination/Community Periodontal Index or Periodontal Screening Record should be performed for all new patients, and also on a regular basis as part of ongoing oral health care. If periodontitis is identified, full periodontal assessment is required, involving recording of full mouth probing and bleeding data, together with assessment of other relevant parameters such as plaque levels, furcation involvement, recession and tooth mobility. Radiographic assessment of alveolar bone levels is driven by the clinical situation, and is required to assess bone destruction in patients with periodontitis. Risk assessment (such as assessing diabetes status and smoking) and risk management (such as promoting smoking cessation) should form a central component of periodontal therapy. This article provides guidance to the oral health care team regarding methods and frequencies of appropriate clinical and radiographic examinations to assess periodontal status, to enable appropriate detection and diagnosis of periodontal conditions.

The interaction between beta-3 adrenergic receptor polymorphism and obesity to periodontal disease in community-dwelling elderly Japanese

OBJECTIVES

The purpose of this study was to elucidate whether the association between beta-3 adrenergic receptor polymorphism and periodontal disease is modified by body weight.

MATERIAL AND METHODS

We enrolled 332 postmenopausal women and determined their HbA1C levels (%) and beta-3 adrenergic receptor (rs4994) genotypes. Periodontal parameters including clinical attachment level (CAL) were measured. After selecting subjects for each body mass index (BMI) level, the prevalence rate ratio (PRR) by multiple Poisson regression analysis was calculated to evaluate the relationship between periodontal disease and beta-3 adrenergic receptor polymorphism. The number of sites with CAL≥6 mm was used as a dependent variable, and beta-3 adrenergic receptor genotype [categorized as Arg non-carriers (reference) or Arg carriers], age (y) and HbA1C (%) were adopted as independent variables. We converted the number of probing sites (n) to an offset variable.

RESULTS

The PRR of the beta-3 adrenergic receptor genotype for the number of sites of CAL≥6 mm showed a positive association in subjects with BMI≥25.0 and increased markedly with BMI. The PRR in subjects with BMI≥30 was 3.10 (p < 0.0001).

CONCLUSION

This study indicates a positive association between periodontal disease and the beta-3 adrenergic receptor genotype in obese individuals.

Cystatin C-based estimated glomerular filtration rate and periodontitis

BACKGROUND AND OBJECTIVE

Accumulating evidence suggests that decreased kidney function characterised by low estimated glomerular filtration rate (eGFR) may be associated with periodontitis. Recent studies have suggested that the use of cystatin C strengthens the association between the eGFR and the risks of adverse outcomes in decreased kidney function. The aim of this cross-sectional study was to investigate the association of cystatin C-based eGFR (eGFRcys) and creatinine-based eGFR (eGFRcreat), the commonly used method to assess kidney function, with periodontitis in 502 Japanese women (average age, 68.6 years).

MATERIALS AND METHODS

GFR was estimated from serum cystatin C and serum creatinine, respectively, using the Japanese equation for GFR. Participants were classified into five groups according to their eGFRcys and eGFRcreat values. Poisson regression models with robust error variance assessed the associations of eGFRcys and eGFRcreat with periodontitis. Tests for trends were performed by fitting the five-category eGFR variables in their continuous form to the regression models.

RESULTS

Participants with eGFRcys < 50 ml/min/1.73 m(2) were at significantly higher risk of periodontitis compared with the reference group (≥90 ml/min/1.73 m(2) ) (adjusted relative risk = 2.12, 95% confidence interval = 1.12 to 4.02). Additionally, there was a trend towards a higher risk of periodontitis among participants with lower eGFRcys values (p for trend in the multivariable model = 0.008). In contrast, eGFRcreat did not show a significant association with periodontitis.

CONCLUSION

The findings of this study of Japanese older women showed that eGFRcys had a stronger and more linear association with periodontitis than eGFRcreat.

The role of partial recording protocols in reporting prevalence and severity of dental fluorosis

OBJECTIVES

To evaluate the role of partial recording protocols (PRPs) in reporting prevalence and severity of dental fluorosis and assess whether prevalence/severity estimates derived from PRPs differ by race/ethnicity.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) for the years 1999-2004 were analyzed with Stata(®) v.11. Prevalence of dental fluorosis obtained from a full-mouth examination (28 teeth gold standard) was compared with estimates derived from four subsets of teeth (maxillary canine-to-canine; maxillary first-premolar-to-first-premolar; all-premolars; all-molars). Sensitivity, negative predictive value (NPV), absolute bias, and correction factors were calculated against gold standard estimate. Analysis was stratified according to race/ethnicity to assess differences in estimates derived from PRPs.

RESULTS

All subsets underestimated prevalence albeit to varying degrees. Two subsets (all-premolars and all-molars) had prevalence and severity estimates closest to gold standard estimates. The all-molars subset (eight teeth) recorded the highest sensitivity (84.5%) and the lowest absolute bias (3.5%) of all subsets relative to gold standard. Subsets derived from esthetically relevant teeth produced the lowest fluorosis prevalence. For instance, the maxillary canine-to-canine subset underestimated prevalence by 9.5%; incorporating the maxillary first premolars in the span improved prevalence estimate by 31%. Among non-Hispanic Whites, the all-premolars subset produced estimates closest to gold standard while the all-molars subset produced estimates closest to the gold standard among non-Hispanic Blacks and Hispanics.

CONCLUSION

While the majority of dental fluorosis in the United States is very mild, concerns regarding its growing prevalence underscore the need for careful monitoring. The use of PRPs offers an alternative method of assessment, with validity of reported prevalence and severity dependent on choice of subset.

Assessing periodontitis in populations: a systematic review of the validity of partial-mouth examination protocols

OBJECTIVE

To estimate bias associated with partial-mouth periodontal examination (PMPE) protocols regarding estimates of prevalence, severity and extent of clinical attachment loss (CAL), pocket depth (PD) and gingival recession (REC).

MATERIAL AND METHODS

A search was made for articles published in English, from 1946 to 2012, which compared PMPE versus full-mouth periodontal examination protocols for CAL or PD ≥ 4 mm or REC ≥3 mm thresholds. PMPE protocols were evaluated for sensitivity of estimates of periodontitis prevalence, relative biases for severity and extent estimates.

RESULTS

A review of the literature identified 12 studies which reported 32 PMPE protocols. Three PMPE protocols which had sensitivities ≥85% and relative biases ≤0.05 in absolute values for severity and extent estimates were as follows: (1) half-mouth six-sites, (2) diagonal quadrants six-sites and (3) full-mouth mesiobuccal-midbuccal-distobuccal (MB-B-DB). Two other PMPE protocols (full-mouth and half-mouth mesiobuccal-midbuccal-distolingual) performed well for prevalence and severity of periodontitis; however, their performance in estimates of extent was unknown.

CONCLUSIONS

Among the 32 PMPE protocols listed, the half-mouth six-sites and full-mouth MB-B-DB protocols had the highest sensitivities for prevalence estimates and lowest relative biases for severity and extent estimates.

Recording and surveillance systems for periodontal diseases

This paper describes tools used to measure periodontal diseases and the integration of these tools into surveillance systems. Tools to measure periodontal diseases at the surveillance level have focussed on current manifestations of disease (e.g. gingival inflammation) or disease sequelae (e.g. periodontal pocket depth or loss of attachment). All tools reviewed in this paper were developed based on the state of the science of the pathophysiology of periodontal disease at the time of their design and the need to provide valid and reliable measurements of the presence and severity of periodontal diseases. Therefore, some of these tools are no longer valid. Others, such as loss of periodontal attachment, are the current de-facto tools but demand many resources to undertake periodical assessment of the periodontal health of populations. Less complex tools such as the Community Periodontal Index, have been used extensively to report periodontal status. Laboratory tests for detecting putative microorganisms or inflammatory agents present in periodontal diseases have been used at the clinical level, and at least one has been tested at the population level. Other approaches, such as self-report measures, are currently under validation. In this paper, we do not review indices designed to measure plaque or residual accumulation around the tooth, indices focussed only on gingival inflammation or radiographic approaches with limited applicability in surveillance systems. Finally, we review current case-definitions proposed for surveillance of periodontal disease severity.

Change in bone mineral density and tooth loss in Japanese community-dwelling postmenopausal women: a 5-year cohort study

The aim of this longitudinal study was to investigate the association between the change in bone mineral density (BMD) and tooth loss in Japanese community-dwelling postmenopausal women. The subjects were 404 women. At baseline (2005) and follow-up (2010), BMDs of the lumbar spine and right femoral neck were measured using dual-energy X-ray absorptiometry (QDR4500a) and participants were classified by tertiles of the annual percentage change in BMD. The number of teeth was counted at the baseline and follow-up to calculate the number of lost teeth over 5 years. Poisson regression analysis was conducted with tertiles of the changes in BMDs of the lumbar spine and femoral neck as the main exposures to estimate their influence on the number of lost teeth. Participants in the tertile with a greater decrease in BMD at each skeletal site (lumbar spine and femoral neck, respectively) had a larger number of lost teeth, controlling for possible confounders. The adjusted relative risks (95% confidence interval) for the mean number of lost teeth in the first, second, and third tertiles were 1.00, 1.15 (0.91-1.45), and 1.38 (1.11-1.72) for the lumbar spine and 1.00, 1.17 (0.93-1.47), and 1.27 (1.01-1.59) for the femoral neck, respectively. In conclusion, a significant relationship exists between a change in BMD and the number of lost teeth during 5-year study period in Japanese community-dwelling postmenopausal women.

Association between periodontitis and systemic bone mineral density in Japanese community-dwelling postmenopausal women

OBJECTIVE

The purpose of this cross-sectional study was to evaluate the association between loss of attachment (LA) which is clinical index of periodontitis and bone mineral density (BMD) of the lumbar vertebrae and femur measured with dual energy X-ray absorptiometry (DXA) in Japanese community-dwelling postmenopausal women.

SUBJECTS AND METHODS

Subjects were 374 [corrected] women aged 55-74. The oral cavity was divided into 6 areas according to the WHO's method for the determination of the clinical attachment level score (CALscore); the LA was measured at 6 sites using a WHO probe in 17, 16, 11, 26, 27, 37, 36, 31, 46, and 47, and the values were recorded in mm. Then, we assessed BMD of the lumbar vertebrae (L2-L4) and femur (femoral neck, proximal part) by DXA. Based on these data, analysis of covariance was used to estimate relation between periodontitis and systemic BMD status excluding effect of age. Multiple linear regression analysis was used to estimate relation between periodontitis and BMD adjusted for 17 variables.

RESULTS

Significant differences were observed in the mean value between the mean CALscore=0 and CALscore≥1 groups in the Z value in lumbar vertebrate (106.9±18.7 vs. 102.3±1.0, p<0.05, t-test). Multiple regression analysis was conducted using the mean LA as dependent variable. Lumbar vertebral BMD (regression coefficient: B=-1.039±0.379, p=0.007), femoral neck BMD (B=-1.332±0.627, p=0.034), and proximal femoral BMD (B=-1.329±0.536, p=0.014) all exhibited a significant negative correlation with the mean LA.

CONCLUSION

A significant negative correlation was observed between periodontal disease and truncal bone BMD in this study.

Effect of desquamative gingivitis on periodontal status: a pilot study

OBJECTIVE

Desquamative gingivitis (DG) represents the gingival manifestation associated with several mucocutaneous disorders and systemic conditions. Little is known of whether or not DG could influence the onset or progression of plaque-related periodontitis. In this study, the potential impact of DG on plaque-related attachment loss and pocket formation has been evaluated.

METHODS

A cross-sectional evaluation of 12 patients with DG [eight oral lichen planus (OLP), four mucous membrane pemphigoid (MMP)], never treated for DG lesions or plaque-related periodontitis, was carried out. Probing depth (PD), clinical attachment loss (CAL), full-mouth plaque (FMPS), and bleeding (FMBS) scores were evaluated at six sites per tooth. Clinical parameters of sites with DG lesions were compared with that of DG unaffected sites.

RESULTS

Median PD and CAL, as well as FMPS and FMBS, were not significantly different (P > 0.05 Mann-Whitney test) for both OLP and MMP patients. However, a negative association between DG lesions and PD < 4 mm (OLP: OR = 0.26; MMP: OR = 0.47), and a positive association with PD 4-6 mm (OLP: OR = 3.76; MMP: OR = 2.68) and with PD > 6 mm (only for OLP: OR = 3.83) were found to be significant.

CONCLUSIONS

The potential interference between DG lesions and periodontitis needs further prospective investigation; nonetheless, a higher level of attention might be prudent.

Trends in periodontal health among 35-year-olds in Oslo, 1973?2003

AIM

The aim of the present study was to describe trends in periodontal health and oral hygiene using data available from four epidemiological studies on 35-year-olds in Oslo performed from 1973 to 2003.

MATERIAL AND METHODS

Periodontal status of randomly selected 35-year-olds was assessed clinically and radiographically. Clinical registrations were based on the Community Periodontal Index of Treatment Needs (CPITN) and the Simplified Oral Hygiene Index. In addition, the proportion of individuals with marginal bone loss was assessed using available orthopantomograms.

RESULTS

The proportion of persons with CPITN score 4 (one or more pockets > or = 6 mm) decreased from 21.8% in 1984 to 8.1% in 2003. In addition, the mean number of sextants with deep pockets per person was considerably lower in 2003 than previously. The proportion of persons without recorded bone loss increased from 46% in 1973 to 76% in 2003. An improvement in oral hygiene scores was also observed during this period.

CONCLUSIONS

The results suggest that periodontal health and oral hygiene have been improving among 35-year-olds in Oslo during the last 30 years.

Validity of the "Community Periodontal Index of Treatment Needs" (CPITN) for population periodontitis screening

The aim of the present study was to validate two versions of CPITN for periodontitis diagnosis. A sample of 400 individuals underwent full mouth periodontal examination including Clinical Attachment Loss, Periodontal Pocket Depth, and Sub-gingival Calculus. Full and partial CPITN versions were derived from this exam (gold standard). Contingency tables were constructed and operational characteristics obtained, as well as ROC curves. The results show 58% sensitivity for full CPITN and 80.6% specificity. Positive and negative predictive values were 87% and 46.3%, respectively. According to the test, estimated periodontitis prevalence was 46%, while the figure obtained with the gold standard was 69%. The partial version of the CPITN showed 50% sensitivity and 87.1% specificity. Positive and negative predictive values were 89.6% and 43.9%, respectively. Estimated periodontitis prevalence, through partial CPITN, was 30.5%. Adjusted global agreement (kappa) for partial and full CPITN was 0.32 and 0.29, respectively. Both CPITN versions disagreed significantly with gold standard results (chi-square p < 0.001). As a conclusion, both total and partial CPITN failed to reflect the real periodontal status of the sample.

The relationship between selected measures of periodontal status and demographic and behavioural risk factors

OBJECTIVE

To assess differences between selected periodontal measures by demographic and behavioural factors in a nationally representative sample of the United States.

METHODS

Data for 11,347 person's ages 20-79 years from the third National Health and Nutrition Examination Survey (NHANES III) were used. Indices and measures constructed from NHANES III data used for this study were: derived community periodontal index (dCPI), attachment loss extent index (ALEI), attachment loss (AL) scores, and a Periodontal Status Measure (PSM) developed for this study.

RESULTS

The influence of demographic and behavioural factors varied across the four indices examined in multivariate cumulative logistic models. Moreover, there was significant effect modification by cigarette smoking with age in the ALEI and AL models. The odds ratio (OR) of increasing periodontal disease status among 20-39 year olds as measured by AL or ALEI for current smokers compared with non-smokers were OR=6.2 (95% confidence interval (CI)=4.1, 8.7) and OR=5.6 (95% CI=3.7, 8.7), respectively. In a similar comparison, the OR for dCPI was 2.6 (95% CI=1.7, 3.8). Furthermore, Mexican American ethnicity was generally not significant in any models using dCPI, PSM, AL, or ALEI and prior dental visit was more likely to be significant only in the dCPI and PSM models.

DISCUSSION

Among the well-known demographic and behavioural influences on periodontal health status, some, such as race/ethnicity and prior dental visit status have different relationships with differing periodontal measures employed to assess periodontal status. Moreover, potential interactions among cofactors also are dependent upon the measure selected. Periodontal research findings may be influenced significantly by periodontal measure selection and its affect on measurement validity. This may have particular relevance to issues concerning disease surveillance and assessing reduction of disparities in oral health. Consequently, a renewed approach to developing appropriate measures for periodontal epidemiology is needed.

Effect of Partial Recording Protocols on Estimates of Prevalence of Periodontal Disease

BACKGROUND

The aim of this study was to assess the degree of underreporting in the estimates of prevalence of periodontal attachment loss due to different partial recording protocols (PRP) in epidemiological studies, and to derive a correction factor to adjust for this bias.

METHODS

The study sample included 1,460 dentate persons 14 to 103 years old who were examined clinically to assess the clinical attachment loss at six sites per tooth. Seven PRP based on full-mouth or half-mouth designs were assessed, and the bias and sensitivity in the assessment of attachment loss prevalence for these protocols were assessed.

RESULTS

All partial protocols underestimated the prevalence of attachment loss. Bias estimates for any full-mouth PRP were smaller than those for the corresponding site-combination PRP for the half-mouth design. The PRP using the mesio-buccal (MB), mid-buccal (B), and disto-lingual (DL) sites of teeth in all four quadrants showed the smallest bias and highest sensitivity of prevalence estimates among the seven PRP evaluated, uniformly across the range of attachment loss severity level. The three site PRP incorporating the DL site produced less bias than the three site PRP including the disto-buccal (DB) site. There was a 3% to 12% gain in sensitivity for 2 to 5 mm attachment loss thresholds for the three site half-mouth PRP compared with the two site MB, B half-mouth PRP.

CONCLUSIONS

The bias in the assessment of attachment loss is influenced by the partial recording design and the type and number of sites assessed, and is also influenced by the severity of attachment loss in the study population. These factors should be considered when selecting a partial recording method in large surveys. Furthermore, inflation factors designed to adjust for the bias due to the use of partial systems should be calculated and reported so that comparisons of results with other surveys are more meaningful.

Periodontal treatment needs of patients with renal disease receiving haemodialysis

AIM/OBJECTIVE

The aim of this study was to perform periodontal assessment, using the CPITN index, on patients undergoing renal dialysis.

METHODS

The periodontal conditions of 342 subjects undergoing renal dialysis from eight renal dialysis centres were examined using CPITN. Subjects were distributed into four age groups, 16-19, 20-34, 35-44 and > or =45 years. The study was conducted during a 6-month period. All clinical examinations were performed by one examiner.

RESULTS

There was a significant positive relationship between the CPITN scores and age (r=0.164, p=0.002) and dialysis duration (r = 0.240, p=0.000). There was no statistically significant difference between male and female patients (p>0.05). None of the age groups had healthy sextants. The 35-44 year-age group had a higher number of sextants with deep pockets (0.19) than the other age groups and edentulous sextants were the highest among the oldest age group (1.89).

CONCLUSION

A very small portion of the renal dialysis population is affected by severe forms of periodontitis requiring complex periodontal treatment. However, all such patients should be given oral hygiene education as a priority.

Multivariate analysis of oral hygiene data from a representative sample

BACKGROUND

This analysis was based on an oral health survey with dental examination and interview by questionnaire.

METHOD

The data set comprised a representative random sample of the over 14-year-old residents of the German Federal State of Saxony (n=714), in which a multivariate logistic regression analysis was conducted. The dependent variable was the debris index (DI) score of the oral hygiene index scoring system. The subjects were split into 2 groups by dividing DI scores into tertiles: those with acceptable oral hygiene (1st tertile, DI 0.00< or =1.20) and unacceptable oral hygiene (2nd and 3rd tertile, DI>1.20). The most important explanatory variable was the community periodontal index of treatment need (CPITN).

RESULTS

The higher the CPITN score, the lower the probability of acceptable oral hygiene. In relation to the reference category score 0, higher CPITN scores were associated with acceptable oral hygiene, with an odds ratio 0.05 (95% confidence interval (CI)=0.01-0.23) for CPITN score 1, and an odds ratio 0.02 (95% CI: 0.01-0.08) for score 4. Further significant variables were: self-evaluation of tooth condition, gender, and the number of missing teeth.

Periodontal conditions in adult Southern Chinese

Periodontal diseases remain a concern in adult populations, but there have been no systematic descriptions of periodontal conditions, which have included periodontal attachment loss, among Southern Chinese. The main aim of this report is to describe the periodontal conditions in adult Chinese and to investigate factors that may have influenced periodontal attachment loss. Subjects were recruited from urban and rural survey sites throughout Guangdong. In total, 1,572 35- to 44-year-old subjects and 1,286 65- to 74-year-old subjects completed a structured interview and underwent a periodontal examination, which included the Community Periodontal Index (CPI) and periodontal Attachment Loss (ALoss) recordings. Calculus was found as the highest CPI score in 61-68% of the 35- to 44-year-old subjects and in 54-57% of the 65- to 74-year-olds. Shallow pockets were found as the highest CPI score in about one-third of both the urban and the rural subjects in both age groups, and deep pockets in 3-7% of the subjects. ALoss was more prevalent than pockets in both age groups. On the basis of the ALoss recordings, about one-third of the subjects in both age groups were categorized as exhibiting considerable ALoss for their age. In both age groups, logistic regression analysis indicated that being male, wearing partial dentures, and reporting less frequent toothbrushing were found to be associated with considerable ALoss.

The influence of partial and full-mouth recordings on estimates of prevalence and extent of lifetime cumulative attachment loss: a study in a population of young male military recruits

BACKGROUND

Previous studies have shown that the use of index teeth may underestimate the prevalence of chronic periodontitis in adults. However, there is little information on the effect of using index teeth to estimate the prevalence of early periodontitis in younger adults and the effect this may have on planning treatment needs and health care resources. The aim of this study was to compare full mouth examination with partial examination using index teeth in a group of young British males.

METHODS

One hundred subjects aged between 16 and 20 years (mean 17 years) on entry to the study were examined at baseline, 12 months later, and 30 months later. Lifetime cumulative attachment loss (LCAL) > or =1 mm was measured on the mesio-buccal, disto-buccal, mesio-lingual, and disto-lingual surfaces of all teeth, excluding third molars. All data were entered into a database. The indices used to express LCAL were prevalence, defined as the percentage of subjects with LCAL > or =1 mm, 2 mm, or 3 mm, and extent, defined as the percentage of sites with LCAL > or =1 mm, 2 mm, or 3 mm. Two sets of index teeth were chosen to compare with full mouth recordings, Ramfjord index teeth and the Periodontal Index for Treatment (PIT) teeth.

RESULTS

The prevalence of LCAL > or =1 mm was similar (approaching 100%) for the full mouth and both partial mouth recordings. However, as LCAL increased from a minimum of 1 to 3 mm, partial mouth recording resulted in an underestimation of the prevalence of disease. LCAL > or =2 mm was underestimated by up to 22% and LCAL > or =3 mm by up to 36%. The extent of LCAL was less affected by partial mouth recording, in that the percentage of sites with no sign of early attachment loss was underestimated by up to 11%. However, the percentage of sites with LCAL > or =1 mm and 2 mm were overestimated by 11% and, 7% respectively.

CONCLUSIONS

These data indicate that the use of index teeth in epidemiological studies which include young adults may result in an underestimation of the prevalence of early periodontitis and an overestimation of the extent.

National oral health survey Zimbabwe 1995: periodontal conditions

Ten years after completion of the first national oral health survey, a second national oral health survey was carried out in 1995. Application of a multi-stage sampling procedure resulted in 3,709 persons being examined. WHO's oral health assessment form and CPITN index was used. The background variables studied were age (15-19, and 35-44-year olds), gender, type of location, socio-economic status and level of education. Results suggest that the periodontal health of adolescents was better in 1985 than in 1995. Overall, the prevalence of periodontal conditions in both age groups was high but its severity was low. The need for complex periodontal treatment was only 4 per cent for adults. The survey has shown that the vast majority of Zimbabweans are not receiving and/or are not seeking periodontal care.

Adjusting estimates of alveolar bone loss for missing observations: developing and testing a general model

The occurrence of missing teeth is a vexing and growing problem in epidemiological studies of dental disease. The number of units of measurement (i.e., teeth/tooth sites) varies between persons and may affect summary statistics in descriptive studies as well as in analytical studies. The purpose of the present study was to develop a general model to adjust summary statistics for missing teeth. The proposed method was applied to alveolar bone loss in current smokers, former smokers, and non-smokers, from 45 to 64 years of age (n = 812). Alveolar bone loss was measured on bitewing radiographs. The adjustment method was based on the assumption that the probability of losing a tooth was an increasing function of alveolar bone loss. The main finding of the present study was that mean alveolar bone loss increased after adjustment for the number of missing teeth. This increase was larger for current smokers than for non-smokers, indicating that the effects of smoking were slightly underestimated when missing sites were ignored. Further research is required for the model to be applied to other data, estimating different types of dental disease with various degrees of disease prevalence and various numbers of missing teeth, and for validating the adjustment method by means of longitudinal data.

The periodontal disease problem. A comparison between industrialised and developing countries

There is no reason to believe that periodontal diseases in industrialised and developing countries are in principle different. That is, not in the sense that the problem is caused by a different set of periodontal diseases, with different micro-organisms and a different natural history, needing a different approach towards prevention and treatment. Indeed, from a public health perspective the relative similarities in periodontal conditions around the world are far more striking than the differences. The view that periodontal diseases are a much more prevalent and a severe problem in the developing countries seems to be true only in terms of poorer oral hygiene and considerably greater calculus retention, already at a young age, but not so clear for periodontal destruction in adults.

Dental calculus: recent insights into occurrence, formation, prevention, removal and oral health effects of supragingival and subgingival deposits

Dental calculus, both supra- and subgingival occurs in the majority of adults worldwide. Dental calculus is calcified dental plaque, composed primarily of calcium phosphate mineral salts deposited between and within remnants of formerly viable microorganisms. A viable dental plaque covers mineralized calculus deposits. Levels of calculus and location of formation are population specific and are affected by oral hygiene habits, access to professional care, diet, age, ethnic origin, time since last dental cleaning, systemic disease and the use of prescription medications. In populations that practice regular oral hygiene and with access to regular professional care, supragingival dental calculus formation is restricted to tooth surfaces adjacent to the salivary ducts. Levels of supragingival calculus in these populations is minor and the calculus has little if any impact on oral-health. Subgingival calculus formation in these populations occurs coincident with periodontal disease (although the calculus itself appears to have little impact on attachment loss), the latter being correlated with dental plaque. In populations that do not practice regular hygiene and that do not have access to professional care, supragingival calculus occurs throughout the dentition and the extent of calculus formation can be extreme. In these populations, supragingival calculus is associated with the promotion of gingival recession. Subgingival calculus, in "low hygiene" populations, is extensive and is directly correlated with enhanced periodontal attachment loss. Despite extensive research, a complete understanding of the etiologic significance of subgingival calculus to periodontal disease remains elusive, due to inability to clearly differentiate effects of calculus versus "plaque on calculus". As a result, we are not entirely sure whether subgingival calculus is the cause or result of periodontal inflammation. Research suggests that subgingival calculus, at a minimum, may expand the radius of plaque induced periodontal injury. Removal of subgingival plaque and calculus remains the cornerstone of periodontal therapy. Calculus formation is the result of petrification of dental plaque biofilm, with mineral ions provided by bathing saliva or crevicular fluids. Supragingival calculus formation can be controlled by chemical mineralization inhibitors, applied in toothpastes or mouthrinses. These agents act to delay plaque calcification, keeping deposits in an amorphous non-hardened state to facilitate removal with regular hygiene. Clinical efficacy for these agents is typically assessed as the reduction in tartar area coverage on the teeth between dental cleaning. Research shows that topically applied mineralization inhibitors can also influence adhesion and hardness of calculus deposits on the tooth surface, facilitating removal. Future research in calculus may include the development of improved supragingival tartar control formulations, the development of treatments for the prevention of subgingival calculus formation, the development of improved methods for root detoxification and debridement and the development and application of sensitive diagnostic methods to assess subgingival debridement efficacy.

CPITN and the epidemiology of periodontal disease

This paper discusses the purposes of collecting epidemiological data on periodontal disease, and concludes that the severe shortcomings of the CPITN makes it unsuited as a tool for assessing the prevalence and severity of periodontal disease.

Periodontal diseases: epidemiology

1. The interpretation of epidemiological data of periodontal disease is difficult, due to inconsistencies in the methodology used. It is not possible, therefore, to accurately assess if the prevalence of the periodontal diseases shows a world-wide decline. As long as the disease is assessed through accumulated clinical attachment loss, retention of the natural dentition in older ages entails increased prevalence in these cohorts. Contemporary epidemiological studies should ideally employ full-mouth examination of the periodontal tissues. Partial recording estimates are generally biased, especially when the prevalence of the disease is low. 2. Early-onset periodontitis is infrequent in all populations. Adult periodontitis is rather prevalent; however, advanced disease affects limited subfractions of the population (probably less than 10 to 15%). Although prevalence figures vary with race and geographic region, in most cases, the progression pattern of the disease seems compatible with the retention of a functional dentition throughout life. 3. Of a plethora of behavioral and environmental risk markers identified by multi-variate analysis, smoking and presence of certain subgingival microorganisms have been proven to be true risk factors. The same holds true for diabetes mellitus, a systemic condition that confers a risk for periodontal disease which is independent of the effect of other significant factors. 4. In certain cases, periodontal infections appear to have a systemic impact on the host. Most recent data indicate that periodontal disease may confer risk for coronary heart disease and pre-term low birth weight.