Socioeconomic position indicators and periodontitis: examining the evidence

Periodontitis and alveolar resorption in human skeletal remains: The relationship between quantitative alveolar bone loss, occlusal wear, antemortem tooth loss, dental calculus and age at death in a low socioeconomic status, modern forensic human collection from Yucatan

OBJECTIVE

This paper assesses the relationship between the distance between the cemento-enamel junction and alveolar crest and risk factors commonly associated with periodontitis.

MATERIALS

Eighty individuals between 28 and 92 years old with known biological sex and age were analyzed from a 20th century forensic human collection from Merida, Yucatan (Mexico).

METHODS

Macroscopic assessment, along with metric analysis, was employed using a probe.

RESULTS

Ante-mortem tooth loss was positively correlated with the distance between the cemento-enamel junction and alveolar crest, as was the presence of root calculus in females.

CONCLUSIONS

Cemento-enamel junction to alveolar crest distance is not a reliable indicator of periodontitis since it is not directly related to periodontitis-causing infectious pathogens, and since ante-mortem tooth loss can affect root exposure.

SIGNIFICANCE

This study demonstrates that a purely quantitative approach to diagnosing periodontitis in archaeological and forensic human remains can be misleading.

LIMITATIONS

The skeletal collection is only representative of the low socioeconomic class of Merida, and its female cohort is underrepresented. In addition, because the Xoclan collection is modern, limitations (particularly with respect to tooth wear) of the applicability of these interpretations to older archaeological remains exist.

SUGGESTION FOR FURTHER RESEARCH

A combination of quantitative and qualitative characteristics of alveolar bone is needed to reliably diagnose periodontitis in skeletal populations.

Smokeless tobacco and periodontitis: A systematic review with meta-analysis

AIM

The present systematic review with meta-analysis aimed to investigate the global association between smokeless tobacco (SLT) use and periodontitis, considering significant effect size variation based on the income levels of countries.

METHODS

We searched seven databases to identify studies that assessed the prevalence of periodontitis in adult SLT users compared to non-users. The quality of studies was evaluated using the 10-item risk-of-bias tool, and publication bias was addressed through the trim-and-fill method. Sensitivity analysis utilized the leave-one-out approach. Meta-analysis and meta-regression, stratified by country income, SLT type, and smoking status, employed robust variance estimation.

RESULTS

From an initial pool of 484 studies, 29 studies met the selection criteria and were subjected to qualitative synthesis. Subsequently, data from 19 studies were included in the meta-analysis. SLT users exhibited a nearly threefold greater likelihood of periodontitis compared to non-users (OR = 2.99; 95% CI: 2.10, 4.27; p < .01). The pooled estimate did not vary significantly based on the type of SLT used or concurrent smoking. However, the odds of periodontitis varied according to the economic level of the country; the pooled estimate was higher in high-income countries (OR = 1.69; 95% CI: 1.20, 2.37; p < .01) and even higher in lower-middle-income and lower-income countries (OR = 3.91; 95% CI: 2.66, 5.77; p < .01).

CONCLUSIONS

Smokeless tobacco users have a higher likelihood of developing periodontitis. This study underscores global disparities in the SLT-periodontitis relationship, highlighting the need for targeted interventions, particularly in economically challenged areas where SLT use is largely unregulated.

The economic and societal impact of periodontal and peri-implant diseases

Periodontal and peri-implant diseases result from a chronic inflammatory response to dysbiotic microbial communities and are characterized by inflammation in the soft tissue and the ensuing progressive destruction of supporting bone, resulting in tooth or implant loss. These diseases' high prevalence, multifactorial etiology, extensive treatment costs, and significant detriment to patients' quality-of-life underscore their status as a critical public health burden. This review delineates the economic and sociocultural ramifications of periodontal and peri-implant diseases on patient welfare and healthcare economics. We delve into the implications of diagnosis, treatment, supportive care, and managing destructive tissue consequences, contrasting these aspects with healthy patients.

Systemic racism and racial inequities in periodontal health: The long journey from upstream determinants to downstream treatment

Racial disparities in the prevalence of periodontal disease are consistent and persistent. The epidemiology of periodontal disease demonstrates racial inequities: non-Hispanic Black (14.7%), Mexican American (13.4%), and other Hispanic adults (7.8%) experience a higher prevalence of severe periodontal disease than non-Hispanic White adults (5.9%). Epidemiologic and clinical research on periodontal health suffers from the same problem that has plagued the health equity movement, an over emphasis on describing racial inequities coupled with few interventions that reduce racial health inequity. Over the decades that racial inequities in periodontal disease have been observed, many have argued that systemic racism is the fundamental driver of racial health inequity. This paper interrogates the roles of systemic racism, dental education, clinical treatment, and patient behavior in periodontal disease. We describe how, together, these mechanisms contribute to racial disparities in periodontal outcomes. However, it is insufficient for oral health equity scientists to only describe and discuss the negative effects of systemic racism. The imperative is to create antiracist strategies designed to eliminate systemic racism. Health equity scientists must also specify how dental systems operate in a racist manner and create effective clinical strategies designed to reduce racial disparities in periodontal disease.

Association of cardiovascular health and periodontitis: a population-based study

BACKGROUND

There is a strong association between cardiovascular disease (CVD) and periodontitis. This study utilized the Life Essentials 8 (LE8) score, a composite measure of cardiovascular health (CVH), to elucidate the relationship between CVH and periodontitis.

METHODS

Data from 8,649 nationally representative participants in the National Health and Nutrition Examination Survey (NHANES) were analyzed. The independent variable in our study was the CVH score (a higher CVH score indicates better cardiovascular health), and the dependent variable was the presence or absence of periodontitis. The association between CVH and periodontitis was investigated using weighted multivariable logistic regression models and restricted cubic spline (RCS). We controlled for potential confounders such as age, sex, race, education, and socioeconomic status to minimize bias.

RESULTS

There was a negative association between the total CVH score and the odds of periodontitis. After adjusting for all covariates, a 10-point increase in total CVH score was associated with a 10% lower in the odds of periodontitis [0.90 (0.87, 0.93)]. Participants with a higher CVH had 40% lower odds of periodontitis compared with those with a lower CVH. Socioeconomic status (education and income) modified this association (P for interaction < 0.05).

CONCLUSION

Our study suggests that better cardiovascular health, as indicated by higher CVH scores, is associated with a reduced likelihood of periodontitis among US adults. The relationship between CVH and periodontitis appears to be influenced by socioeconomic status, emphasizing the need for targeted interventions in populations with lower socioeconomic status.

The Potential of Cochlospermum tinctorium, Flueggea virosa, and Waltheria indica Traditional Plants From Burkina Faso in Treating Periodontitis: A Systematic Review

Periodontitis is a chronic, infectious, and inflammatory oral disease with a high prevalence in developing countries, where limited access to modern dental care curtails its treatment. This review is dedicated to examining three indigenous botanical species frequently recommended by traditional therapists for the treatment of periodontal disease, namely, Cochlospermum tinctorium, Flueggea virosa, and Waltheria indica, with the aim of elucidating their chemical constituents and pharmacological properties that may support their empirical use. This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines extension for scoping reviews. An electronic search was conducted in three databases (PubMed, Science Direct, and Google Scholar) up to July 2022. Out of 700 articles initially identified, only 11 were deemed eligible for inclusion; a substantial majority (80%) of these comprised in vitro studies. Among the trio of botanicals considered, Waltheria indica emerged as the most extensively investigated (65% of the studies). The administration of these plants was predominantly in the form of decoctions or macerations, with extraction methods employing alcoholic agents (ethanolic and methanolic), hydroalcoholic solutions, or aqueous solvents. The selected plants exhibited notable richness in polyphenolic compounds, particularly flavonoids, and demonstrated anti-inflammatory effects, as indicated in 60% of the studies, along with antibacterial properties (against Streptococcus aureus and Helicobacter pylori). None of the studies reported antibacterial activity against periodontal pathogens. The pharmacological properties of these plants may hold promise for the management of oral inflammatory and infectious conditions. Nevertheless, further comprehensive investigations are imperative to establish their safety and efficacy for periodontitis treatment before conclusive recommendations can be formulated.

Demystifying the connection between periodontal disease and chronic kidney disease - An umbrella review

Chronic kidney disease (CKD) and poor oral health are inter-related and their significant impact on each other is well established in the literature. Many systematic reviews and meta-analyses have demonstrated a strong relationship between CKD and periodontitis, where periodontal treatment has shown potential in improving CKD outcomes. However, the quality of the studies and heterogeneity of the results show variation. The aim of this umbrella review was to review the quality of the current systematic reviews on the relationship between CKD and oral health with an emphasis on periodontal disease and to generate clinically relevant guidelines to maintain periodontal health in patients with CKD. This umbrella review was conducted and reported in alignment with the Joanna Briggs Institute and the PRISMA 2020 guidelines. The review protocol was established prior to commencing the review and registered on JBI and PROSPERO (CRD42022335209). Search strings were established for PubMed, Embase, Web of Science, Cochrane Database of Systematic Reviews, and Dentistry & Oral Science Source up to April 2022. All systematic reviews and meta-analyses that considered the relationship between CKD and periodontitis or periodontal treatment were included. Of 371 studies identified through the systematic search, 18 systematic reviews met the inclusion criteria. Ten studies assessed the relationship between oral health status and CKD with a focus on periodontitis and CKD, five reviewed the impact of periodontal treatment on CKD outcomes, two included both relationship and effectiveness of periodontal treatment and one qualitatively reviewed oral health-related quality of life in patients with kidney failure. Findings indicate there is a bidirectional relationship between CKD and periodontal disease. In view of the heterogeneity of the existing literature on CKD and periodontal disease, specific recommendations for the management of periodontitis among patients with CKD are proposed for medical professionals, dental professionals, and aged care workers based on the evidence collated in this review.

Periodontitis and risk of immune-mediated systemic conditions: A systematic review and meta-analysis

INTRODUCTION

The aim of this review is to examine and quantify the long-term risk of immune-mediated systemic conditions in people with periodontitis compared to people without periodontitis.

METHODS

Medline, EMBASE and Cochrane databases were searched up to June 2022 using keywords and MeSH headings. The 'Risk of Bias in Non-Randomised Studies of Interventions' tool was used to assess bias. Cohort studies comparing incident metabolic/autoimmune/inflammatory diseases in periodontitis to healthy controls were included. Meta-analysis and meta-regression quantified risks and showed impact of periodontitis diagnosis type and severity.

RESULTS

The search retrieved 3354 studies; 166 studies were eligible for full-text screening, and 30 studies were included for review. Twenty-seven studies were eligible for meta-analysis. The risks of diabetes, rheumatoid arthritis (RA) and osteoporosis were increased in people with periodontitis compared to without periodontitis (diabetes-relative risk [RR]: 1.22, 95% CI: 1.13-1.33; RA-RR: 1.27, 95% CI: 1.07-1.52; osteoporosis-RR: 1.40, 95% CI: 1.12-1.75). Risk of diabetes showed gradient increase by periodontitis severity (moderate-RR = 1.20, 95% CI = 1.11-1.31; severe-RR = 1.34, 95% CI = 1.10-1.63).

CONCLUSION

People with moderate-to-severe cases of periodontitis have the highest risk of developing diabetes, while the effect of periodontal severity on risk of other immune-mediated systemic conditions requires further investigation. More homologous evidence is required to form robust conclusions regarding periodontitis-multimorbidity associations.

Chronic Periodontitis and the Potential Likelihood of Gastric Cancer: A Nested Case-Control Study in the Korean Population Utilizing a National Health Sample Cohort

There is limited information regarding the potential association between chronic periodontitis (CP) and gastric cancer, especially in the Korean population. This study aimed to explore this relationship. This nested case-control study analyzed data from 10,174 patients with gastric cancer and 40,696 controls from the Korean National Health Insurance Service-National Sample Cohort using propensity score matching. Standardized differences were used to compare baseline characteristics between study groups. Logistic regression analyses adjusted for confounders were conducted to assess the association between history of CP and gastric cancer occurrence. CP histories and comprehensive subgroup analyses in the 1- and 2-year periods preceding the index date were evaluated. Individuals with a history of CP within the 1-year and 2-year periods showed an increased likelihood of developing gastric cancer. Subgroup analyses consistently supported these findings in male participants aged <65 years and individuals with various income levels or living in residential areas. However, no significant associations were observed among participants aged ≥65 years. In conclusion, CP may be a potential risk factor for gastric cancer development in the Korean population. Regular screening for gastric cancer may be necessary for high-risk individuals, specifically men aged <65 years with a history of CP.

Predictors of Caries Risk among Egyptian Children Attending Pediatric Dental Clinics at a University Hospital

Background

Dental caries is the most prevalent dental disease. The external validity of the available caries risk assessment (CRA) tools is not established, especially among pediatric population.

Objectives

To assess caries risk using the caries management by risk assessment (CAMBRA) protocol among Egyptian children aged 3-12 years and suggest variables that could potentially be used to develop a simpler CRA model.

Materials and Methods

For this cross-sectional study, we recruited 320 children aged 3 to <6 years (Group I) and 320 children aged 6-12 years (Group II). CAMBRA was used to collect data about disease indicators, biological and environmental factors, and protective factors among study participants. Each child was examined clinically to collect data about past caries experiences and to measure plaque scores.

Results

The risk of caries was high in 92.5% of Group I and 83.4% of Group II participants. The overall dmft was 5.71 ± 3.18 for Group I and 4.78 ± 2.53 for Group II. In Group I, a significant positive relation was found between the overall mean caries risk score and past caries experience (dmft; r = 0.344, P < 0.001) and mean plaque index (r = 0.463, P < 0.001). In Group II, a significant positive relation was found between the overall mean caries risk score and dmft score (r = 0.511, P < 0.001), S. mutans count (r = 234, P < 0.001), Lactobacilli count (r = 0.316, P < 0.001), and plaque index (r = 0.463, P < 0.001). Participants' age, parents' education, and parents' occupation had a negative significant effect on the overall mean caries risk score.

Conclusion

This study suggests predictors that can be used in the development of a new CRA model for children aged 3-12 years.

Identification of microbiological factors associated with periodontal health disparities

The present study aimed at identifying risk factors associated with periodontitis development and periodontal health disparities with emphasis on differential oral microbiota. The prevalence of periodontitis is recently rising dentate adults in the US, which presents a challenge to oral health and overall health. The risk of developing periodontitis is higher in African Americans (AAs), and Hispanic Americans (HAs) than in Caucasian Americans (CAs). To identify potentially microbiological determinations of periodontal health disparities, we examined the distribution of several potentially beneficial and pathogenic bacteria in the oral cavities of AA, CA, and HA study participants. Dental plaque samples from 340 individuals with intact periodontium were collected prior to any dental treatment, and levels of some key oral bacteria were quantitated using qPCR, and the medical and dental histories of participants were obtained retrospectively from axiUm. Data were analyzed statistically using SAS 9.4, IBM SPSS version 28, and R/RStudio version 4.1.2. Amongst racial/ethnic groups: 1) neighborhood medium incomes were significantly higher in the CA participants than the AA and the HA participants; 2) levels of bleeding on probing (BOP) were higher in the AAs than in the CAs and HAs; 3) Porphyromonas gingivalis levels were higher in the HAs compared to that in the CAs; 4) most P. gingivalis detected in the AAs were the fimA genotype II strain that was significantly associated with higher BOP indexes along with the fimA type IV strain. Our results suggest that socioeconomic disadvantages, higher level of P. gingivalis, and specific types of P. gingivalis fimbriae, particularly type II FimA, contribute to risks for development of periodontitis and periodontal health disparities.

Association between skull bone mineral density and periodontitis: Using the National Health and Nutrition Examination Survey (2011-2014)

BACKGROUND AND OBJECTIVE

Bone mineral density (BMD) and periodontitis have been the subject of many studies. However, the relationship between skull (including mandible) BMD and periodontitis has not been extensively studied. An objective of this cross-sectional study was to examine the relationship between skull BMD and periodontitis using data from the National Health and Nutrition Examination Surveys (NHANES) for 2011-2012 and 2013-2014.

MATERIALS AND METHODS

From NHANES 2011-2014, 3802 participants aged 30-59 were selected. We divided the skull BMD level into quartiles to check the distribution of variables. Periodontitis was defined by the Centers for Disease Control and Prevention (CDC) and the American Association of Periodontology (AAP) in 2012. Multivariate logical regression analysis was used to explore the independent relationship between skull BMD and periodontitis. The generalized additive model (GAM), smooth curve fitting (penalty spline) and threshold effect analysis was used to evaluate dose-response relationship between skull BMD and periodontitis and the potential nonlinear relationship between skull BMD and periodontitis. Finally, subgroup analysis and interaction test were conducted to determine the role of covariates between skull BMD and periodontitis.

RESULTS

The overall average skull BMD of 3802 participants was 2.24g/cm2, the average age was 43.94 years, and the prevalence of periodontitis was 41.03%. In the fully adjusted logistic regression model, skull BMD and periodontitis showed an independent negative correlation (OR 0.73, 95% CI 0.59-0.90, P = 0.0032) and a linear relationship. Compared with the lowest quartile array (Q1:1.22-1.98) of skull BMD, the highest quartile array(Q4: 2.47-3.79) had a significantly lower risk of periodontitis (OR 0.70,95% CI 0.56-0.87, P = 0.0014). Subgroup analysis showed a highly consistent negative correlation between skull BMD and periodontitis. In the interaction test, people with moderate poverty income ratio (1.57-3.62) and those who had more than 12 alcohol drinks in the past year had a lower risk of periodontitis.

CONCLUSIONS

This result suggested that periodontal disease can be related to low skull BMD, for those people, oral hygiene and health care should be more closely monitored. Validation of our findings will require further research.

Does Oral Health-Related Quality of Life Differ by Income Group? Findings from a Nationally Representative Survey

OBJECTIVES

Clarify the association between income group and oral health-related quality of life.

METHODS

Data were used from a nationally representative online survey with n = 3075 individuals. It was conducted in late Summer 2021. The established Oral Health Impact Profile (OHIP-G5) was used to measure oral health-related quality of life. The income group (household net income) was used as key independent variable. It was adjusted for several covariates. Full-information maximum likelihood was used to address missing values.

RESULTS

Individuals in the lowest income decile had a lower oral health-related quality of life (Cohen's d = -0.34) compared to individuals in the second to ninth income deciles. Individuals in the highest income decile had a higher oral health-related quality of life (Cohen's d = 0.20) compared to individuals in the second to ninth income deciles. Consequently, there was a medium difference (Cohen's d = 0.53) between individuals in the lowest income decile and individuals in the highest income decile. Additionally, multiple linear regressions showed significant differences between individuals in the lowest income decile and individuals in the second to ninth income deciles (β = 0.72, p < 0.01). In contrast, only marginal significant differences were identified between individuals in the second to ninth income deciles and individuals in the highest income decile (β = -0.28, p < 0.10).

CONCLUSIONS

The current study particularly stressed the association between low income and low oral health-related quality of life in the general adult population. Increasing oral health-related quality of life in individuals with low income is a major issue which should be targeted.

Cross-sectional associations between effort-reward imbalance at work and oral diseases in Japan

Background

Psychological stress is a potential risk factor for oral diseases. However, evidence for the association between work stress and oral diseases is scarce. We aimed to examine the associations of work stress, according to the effort-reward imbalance model, with dental caries, periodontal status, and tooth loss.

Methods

This cross-sectional study included 184 regular employees at a medical university and 435 registrants of a web research company. Work stress was assessed using the effort-reward imbalance (ERI) ratio. Dental caries and tooth loss were assessed according to the number of decayed, filled, and missing teeth (DMFT) among the set of 28 teeth. Periodontal status was assessed using a self-administered questionnaire. For the DMFT, a linear regression model was used to estimate the unstandardised coefficients. A Poisson regression model was used to estimate the prevalence ratios (PRs) of poor periodontal status.

Results

Among medical university employees and employees enrolled from among the registrants of an online research company, a one-unit increase in the ERI ratio was associated with -2.81 (95% CI [-4.70 to -0.92]; p-value = 0.004) and -0.84 (95% CI [-1.80 to 0.12]; p-value = 0.085) changes in the DMFT from adjusted linear regression models, respectively. In employees enrolled from among the registrants of an online research company, a one-unit increase in the ERI ratio was also associated with 1.55 (95% CI [1.04-2.32]; p-value = 0.032) of the PR for poor periodontal status based on Poisson regression models.

Conclusion

ERI at work was associated with an increased risk of poor periodontal status.

Self-esteem and oral health-related quality of life of women with periodontal disease - A cross-sectional study

Aim

The aim of this study is to assess the effect of periodontal disease on self-esteem and oral health-related quality of life (OHRQoL) in women.

Materials and Methods

A cross-sectional study was conducted among 522 women (mean age - 38.92 ± 14.3 years). Oral hygiene status, plaque level, gingival inflammation, probing depth, and periodontal status were assessed. The self-esteem was assessed using a Rosenberg Self-esteem Scale, and the OHRQoL was measured using a 14-item oral health impact profile (OHIP-14) questionnaire.

Results

Younger, employed women with higher income had significantly better OHRQoL and self-esteem. Women with healthy periodontium had better OHRQoL. Probing depth and community periodontal index scores were found to have a significant positive correlation with most of the sub-scale items and total OHIP-14 score in women with low self-esteem. Women with good OHRQoL and normal self-esteem were seen to be maintaining significantly better oral hygiene. No such statistically significant difference was observed in women with low self-esteem. Multiple regression analysis for the prediction of OHIP-14 score indicated that the best model included probing depth as the only statistically significant predictor (P = 0.002).

Conclusion

Periodontal disease has a significant negative impact on self-esteem and OHRQoL in women.

Upstream interventions to promote oral health and reduce socioeconomic oral health inequalities: a scoping review protocol

INTRODUCTION

Improving oral health and reducing oral health inequalities is an important global health priority. 'Upstream interventions' are a vital part of the collective effort to reduce oral disease burdens, however it is a rather nebulous term. Furthermore, there is little evidence on the effectiveness, impact and sustainability of upstream interventions that have focused on oral health and wider public health measures that impact on oral health. The aim of this scoping review is to systematically map and synthesise evidence on the effectiveness, impact and sustainability of upstream interventions on population oral health and reducing socioeconomic oral health inequalities.

METHODS AND ANALYSIS

This scoping review will be conducted in accordance with the Joanna Briggs Institute methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist. A detailed search strategy will be used to conduct a comprehensive search of electronic databases: Scopus, Embase and MEDLINE, PsycINFO and CINAHL, ASSIA and Cochrane Database of Systematic Reviews. A search of grey literature will also be completed to identify relevant dissertations, governmental reports and evaluations of implemented policies. Identification and extraction of data will be performed by two pairs of reviewers. Oversight and feedback will be provided by an independent expert advisory group.

ETHICS AND DISSEMINATION

This study will review published and available grey literature and does not require an ethics review. The scoping review protocol has been registered with the Open Science Framework. The final report will be circulated and disseminated through publication and feed into the work of the ongoing Lancet Commission on Oral Health. Due to the policy relevance of this work, discussions will take place with key stakeholders regarding the implications of the findings for future policy development.

Prevalence and Risk Factors for Periodontal Disease Among Women Attending Antenatal Care in Public Hospitals, Southwest Ethiopia, 2022: A Multicenter Cross-Sectional Study

Background

Periodontal disease is characterized by the inflammation of all tissues that surround and support the teeth, and it is the most common public health problem worldwide. It has many different contributing factors, such as poor oral hygiene, smoking, anemia, bacterial plaque, poor economic status, and nutritional deficiency. It also causes different feto-maternal complications like preeclampsia, gestational diabetes, preterm labor, low birth weight, and early abortion. Thus, this study aimed to assess the prevalence and associated factors of periodontal disease among pregnant women.

Methods

A cross-sectional study was conducted among 618 women at public hospitals in the Southwest Ethiopia. Data were collected using a systematic random sampling method and a structured interviewer administered questionnaire. The data were entered into Epi-Data Manager 4.2 and then transferred to a statistical package for social science (SPSS) version 21 for analysis. The logistic regression analysis was done to see the significant association between each predictor with periodontal disease by considering a p-value of <0.05 and a CI of 95%.

Results

A total of 618 women attending ANC with a 100% response rate were enrolled in this study. The mean and standard deviation of the age of the study participants was 31.07 ± 7.8 years. The periodontal disease was observed among 240 (38.8%) of the total participants with 95% C.I of (35%, 43%). Predictors like rural residency, women who could not read and write, women with poor wealth index, nutritional status of underweight, had no information about periodontal disease, depression, history of diabetes mellitus, self-perceived halitosis, no history of ANC, and lower gestational age were found to be significantly associated with periodontal disease.

Conclusion

In this study, the prevalence of periodontal disease was found to be significantly higher. Therefore, in order to minimize the burden of periodontal disease among pregnant women, oral, medical, and mental health education should be promoted.

Cardiovascular Diseases and Periodontitis

Periodontitis is a chronic inflammatory disease of the tooth-supporting connective tissue and alveolar bone that is initiated by a bacterial biofilm in periodontal pockets. It affects about half of adults in the Western world, and is associated with a range of systemic comorbidities, e.g., cardiovascular disease (CVD), diabetes and rheumatoid arthritis, and these diseases share overlapping systemic and target tissue inflammatory mechanisms. Indeed, mounting evidence has indicated that their association is causal and built on the presence of systemic low-grade inflammation (LGI). Prior research linking periodontitis to CVD has mainly been derived from experimental studies, observational data, and small interventional trials with surrogate markers of CVD, e.g., endothelial dysfunction. However, recent data from randomised studies have demonstrated that intensive treatment of periodontitis can reduce blood pressure in patients with hypertension in conjunction with reduction of systemic inflammatory markers. Furthermore, targeted anti-inflammatory therapy has been shown to reduce recurrent events in patients with established CVD and LGI. Along this line, the concept of residual inflammatory risk has emerged as an independent new risk factor for atherothrombotic CVD. The present review summarizes translational evidence indicating that periodontitis is a risk factor for CVD dependent on LGI, and we conclude that treatment of periodontitis is likely to contribute importantly to reduction of residual inflammatory risk.

Association between oral health and cardiovascular outcomes in patients with hypertension: a nationwide cohort study

OBJECTIVE

Studies on the association of oral hygiene indicators with cardiovascular disease in hypertensive patients have been lacking. Oral hygiene is directly or indirectly associated with systemic inflammation, one of the essential mechanisms of cardiovascular disease. Therefore, we hypothesized that oral hygiene would be related to the risk of cardiovascular diseases in hypertensive patients.

METHODS

We included 52 677 hypertensive participants who completed oral health checkups from the Korean National Health Insurance Service-National Health Screening Cohort between 2003 and 2004. We collected data on periodontitis diagnosis and treatment history, number of teeth loss, number of dental caries, and frequency of tooth brushing from medical records of health claims and oral health examination. The primary outcome was defined as composite outcomes of stroke and myocardial infarction. Follow-up was done until the date of primary outcome, or 31 December 2015.

RESULTS

During the 11.26 ± 2.39 years (mean ± standard deviation) of the study follow-up, 3292 participants developed primary outcomes [stroke (n = 2430), myocardial infarction (n = 862)]. In multivariable Cox regression analyses, participants with dental caries (≥ 5) were independently associated with occurrence of a primary outcome [adjusted hazard ratio: 1.37; 95% confidence interval (CI):1.10-1.72; P = 0.006]. Frequent tooth brushing (≥ 2 times/day) was significantly related to lower risk of primary outcomes (adjusted hazard ratio: 0.88; 95% CI: 0.81-0.96; P = 0.002).

CONCLUSION

Our study demonstrated that multiple dental caries were related to the risk of cardiovascular diseases in hypertensive patients. Better oral hygiene may attenuate the risk of cardiovascular events in hypertensive patients.

Understanding the consequences of educational inequalities on periodontitis: Mendelian randomization study

AIM

Higher educational attainment is associated with a lower risk of periodontitis, but the extent to which this association is causal and mediated by intermediate factors is unclear.

METHODS AND MATERIALS

Using summary data from genetic association studies from up to 1.1 million participants of European descent, univariable and multivariable Mendelian randomization analyses were performed to infer the total effect of educational attainment on periodontitis and to estimate the degree to which income, smoking, alcohol consumption, and body mass index mediate the association.

RESULTS

The odds ratio of periodontitis per one standard deviation increment in genetically predicted education was 0.78 (95% CI: 0.68-0.89). The proportions mediated of the total effect of genetically predicted education on periodontitis were 64%, 35%, 15%, and 46% for income, smoking, alcohol consumption, and body mass index, respectively.

CONCLUSIONS

Using a genetic instrumental variable approach, this study triangulated evidence from existing observational epidemiological studies and suggested that higher educational attainment lowers periodontitis risk. Measures to reduce the burden of educational disparities in periodontitis risk may tackle downstream risk factors, particularly income, smoking, and obesity.

Psychopathologies and socioeconomic status as risk indicators for periodontitis: a survey-based investigation in German dental practices

OBJECTIVES

Periodontitis is a highly prevalent multifactorial disease associated with various mental disorders. However, study results about this association are still contradictory. One methodological reason could be the neglect of potential confounders, such as socioeconomic factors or mental comorbidity. Our study examined a wide range of potential psychosocial risk indicators to identify those with relevant associations to periodontitis.

MATERIALS AND METHODS

In a cross-sectional study, 111 patients with periodontitis (PERIO) (> 30% teeth with approximal attachment loss ≥ 5 mm) and 110 patients without periodontitis (NON-PERIO) were recruited in four dental practices in Germany. Clinical attachment loss, pocket depth, plaque, bleeding on probing, and DMFT were measured. Psychopathologic symptoms and socioeconomic status were recorded using self-report questionnaires (DAS, PHQ-8, GAD-7, CTS, SCOFF, AUDIT, FTND, SSS-8, SES).

RESULTS

The PERIO group reported significantly lower socioeconomic status (Cohen's d = 0.49) and higher psychopathological symptom burden than the NON-PERIO regarding dental anxiety (d = 0.86) and avoidance behavior, nicotine dependency (d = 0.84), depressiveness (d = 0.46), general anxiety (d = 0.45), somatic symptoms (d = 0.42), and childhood traumatization (d = 0.34). No significant group differences existed for alcohol abuse and eating disorders. Dental anxiety was the strongest predictor of periodontitis and showed significant correlations with other psychopathologies and social status.

CONCLUSIONS

Out of all psychosocial factors, socioeconomic status and dental anxiety showed the greatest association with periodontitis.

CLINICAL RELEVANCE

Dentists should encourage socially disadvantaged and dentally anxious patients in the utilization of prevention and dental care. Furthermore, physicians and psychotherapists can contribute to the early detection of dental anxiety, oral diseases, and avoidance behavior.

Socio-behavioral factors, oral hygiene level and periodontitis prevalence in a 35-44-year-old Greek adult population: A cross-sectional survey

Background

Sub-optimal oral hygiene is considered as a primary risk factor for periodontitis occurrence. Various socio-behavioral determinants may contribute either independently or by influencing adversely the oral hygiene (OH) level. The aim of the present study was to examine the periodontal status of 35-44-year-old Greek adults and determine the contribution of risk indicators, including the socio-behavioral aspects and the population’s oral hygiene level, on disease prevalence.

Material and Methods

In 1218 participants, Community Periodontal Index (CPI), Loss of Attachment (LoA) and simplified Oral Hygiene Index (OHI-S) were calculated. Multivariable regression models examined the effect of socio-behavioral factors with/without the inclusion of OHI-S level on pocket depth (PD)≥4mm and LoA≥4mm presence.

Results

11.8% of the participants had healthy periodontium, whereas 37.3% and 5.6% presented with shallow and deep pocketing, respectively. 60.4%, 28.8%, and 10.8.% of the adults demonstrated LoA≤3mm, 4-5mm, and ≥6mm, accordingly. Fair and poor oral hygiene significantly increased the likelihood for PD≥4mm (OR=4.8-20.3) and LoA≥4mm (OR=3.3-6.0) presence. ‘Emergency-oriented dental visiting pattern’ significantly elevated the chance for PD≥4mm presence (OR=1.7). ‘Lower education level’ ‘urban location’, and ‘using an interdental brush’ were significantly independently linked to LoA≥4mm occurrence (OR=1.7-2.1, 1.5, and 2.0, respectively). Lower educated individuals demonstrated inferior oral hygiene status, which in turn elevated significantly the chances of PD≥4mm presence. Smoking more than 10 cigarettes/day, emergency-oriented dental attendance pattern and not flossing were linked to worse oral hygiene levels, which consequently increased significantly the likelihood of LoA≥4mm occurrence.

Conclusions

Fair and poor oral hygiene contribute strongly to periodontitis occurrence. Various socio-behavioral factors may influence adversely oral hygiene maintenance, leading to periodontitis manifestations.

Key words:Community periodontal index, periodontal attachment loss, oral hygiene, adults 35-44, cross-sectional survey, socio-behavioral indicators.

The Intersections of Ethnicity, Nativity Status and Socioeconomic Position in Relation to Periodontal Status: A Cross-Sectional Study in London, England

The role of migration as a social determinant of periodontitis has been overlooked. Intersectionality theory could help understand how immigration status interacts with other social determinants of health to engender inequalities in periodontitis. The objective of the present study was to evaluate whether ethnicity, nativity status and socioeconomic position intersect to structure social inequalities in periodontal status. Data from 1936 adults in a deprived and multi-ethnic area of London were analysed. The numbers of teeth with probing depth and clinical attachment loss were determined from clinical examinations. A matrix with 51 intersectional strata, defined according to ethnicity, nativity status and education, was created. A cross-classified multilevel analysis, with participants clustered within intersectional social strata, was performed to assess the extent to which individual differences in periodontal measures were at the intersectional strata level. A complex pattern of social inequalities in periodontal status was found, which was characterised by high heterogeneity between strata and outcome-specificity. The variance partition coefficient of the simple intersectional model, which conflated additive and interaction effects, indicated that 3-5% of the observed variation in periodontal measures was due to between-stratum differences. Moreover, the percentual change in variance from the simple intersectional to the intersectional interaction model indicated that 73-74% of the stratum-level variance in periodontal measures was attributed to the additive effects of ethnicity, nativity status and education. This study found modest evidence of intersectionality among ethnicity, nativity status and education in relation to periodontal status.

Tooth wear and socioeconomic status in childhood and adulthood: Findings from a systematic review and meta-analysis of observational studies

OBJECTIVES

To evaluate the association and level of evidence between socioeconomic status (SES) and tooth wear (TW) in children, adolescents, and adults.

DATA

Eligibility criteria comprised population-based observational studies assessing the association between SES and TW in permanent dentition of adolescents and adults. Interventional and descriptive studies or those without an internal comparison between exposed and nonexposed groups were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were applied where applicable. Risk of bias (RoB) was assessed using the Newcastle-Ottawa scale. Meta-analyses were conducted to estimate the pooled effect measures. Q-statistic, I²statistic, subgroup and sensitivity analyses assessed study heterogeneity.

SOURCES

PubMed/Medline, Embase, Scopus, Web of Science, LILACS, SciELO, Cochrane Library, and Google Scholar databases were searched for articles published in English between 1st January 1980 and 31st March 2021.

RESULTS

Sixty-five studies were included, involving 63,893 participants in over 30 countries. A positive association was found between TW and education (OR=1.25 [0.96; 1.62]), family income (OR=1.18 [0.91; 1.53]), and private school (OR= 1.24 [0.90; 1.72]) among adolescents. Higher educated adults had a lower risk for TW (OR=0.70 [0.52; 0.93]). Most included studies had a moderate RoB. Limitations relating to population representation and assessment methodologies were identified in the included studies.

CONCLUSIONS

SES was associated with TW with its direction depending on the individuals' age. The overall quality of evidence was moderate.

CLINICAL SIGNIFICANC

SES should be included as part of the routine screening and risk assessment for tooth wear.

Periodontal diseases: is it possible to prevent them? A populational and individual approach

Periodontal diseases are infectious inflammatory chronic diseases of a multifactorial nature. They are primarily caused by dysbiotic ecological changes in dental biofilm, which may be influenced by risk factors. The prevention of periodontal diseases may involve different strategies focused on reducing distal, intermediate, and proximal risk factors at both the population and individual levels. Effective prevention depends on interdisciplinary and common risk factor approaches. Also, patient-centered preventive models are more effective than professional-centered models in the management of periodontal diseases. Regular and periodic control of dental biofilm is an essential measure for the different levels of prevention of periodontal diseases. The effectiveness of periodontal disease prevention largely depends on positive modifications of behavior, knowledge, health literacy, patient empowerment, motivation, and compliance.

Inequalities in Periodontal Disease According to Insurance Schemes in Thailand

Few studies have considered the effects of insurance on periodontal disease. We aimed to investigate the association between insurance schemes and periodontal disease among adults, using Thailand's National Oral Health Survey (2017) data. A modified Community Periodontal Index was used to measure periodontal disease. Insurance schemes were categorized into the Universal Coverage Scheme (UCS), Civil Servant Medical Benefit Scheme (CSMBS), Social Security Scheme (SSS), and "others". Poisson regression was applied to estimate the prevalence ratios (PRs) of insurance schemes for periodontal disease, with adjustment for age, gender, residential location, education attainment, and income. The data of 4534 participants (mean age, 39.6 ± 2.9 years; 2194 men, 2340 women) were analyzed. The proportions of participants with gingivitis or periodontitis were 87.6% and 25.9%, respectively. In covariate adjusted models, lowest education (PRs, 1.03; 95% CI, 1.01-1.06) and UCS (PRs, 1.05; 95% CI, 1.02-1.08) yielded significantly higher PRs for gingivitis, whereas lowest education (PRs, 1.20; 95% CI, 1.05-1.37) and UCS (PRs, 1.17; 95% CI, 1.02-1.34) yielded substantially higher PRs for periodontitis. Insurance schemes may be social predictors of periodontal disease. For better oral health, reduced insurance inequalities are required to increase access to regular dental visits and utilization in Thailand.

The Effects of Prednisone/Ketoprofen Administration in Association with Amoxicillin Clavulanate Following Periodontal Surgical Therapy in Patients with Severe Chronic Periodontitis

Background and Objectives: The aim of this study was to evaluate and compare the effects of two different anti-inflammatory drugs (ketoprofen and prednisone) combined with an antibiotic (amoxicillin + clavulanic acid) and periodontal surgery on dental and periodontal parameters in patients with severe chronic periodontitis. In addition, salivary stress expressed by cortisol levels was assessed. Materials and Methods: An interventional study was performed on 22 periodontal subjects and 19 clinical healthy controls. The patients were divided in four groups, depending on treatment planning, as follows: eight patients received prednisone and antibiotherapy, associated with surgical periodontal therapy; seven patients received ketoprofen and antibiotherapy, associated with surgical periodontal therapy (group II); seven patients received only prednisone. Periodontal healthy patients underwent routine scaling and polishing. Bleeding on probing (BOP), dental mobility and salivary cortisol (ng/mL) were assessed before and after treatment. The means and standard deviations for the salivary cortisol levels (SCLs), dental and periodontal parameters were calculated for all groups using each patient as a unit of analysis. Results: Data analyses showed that the two different anti-inflammatory drugs associated with or without surgical therapy were efficient on inflammation periodontal parameters (BOP, dental mobility). Prednisone treatment alone was associated with a significant decrease of SCLs between pretreatment and post-treatment. Conclusions: In the present study, the effects of either of the anti-inflammatory drugs on inflammation evolution and salivary stress were comparable in patients undergoing antibiotherapy and surgical periodontal therapy.

Prediagnostic Antibody Responses to Fusobacterium nucleatum Proteins Are Not Associated with Risk of Colorectal Cancer in a Large U.S. Consortium

BACKGROUND

The association between prediagnostic antibody responses to Fusobacterium nucleatum (F. nucleatum) and subsequent risk of colorectal cancer is not established.

METHODS

We conducted a nested case-control study of 8,126 participants in a consortium of 10 prospective cohorts in the United States.

RESULTS

Higher seroprevalence of any F. nucleatum antibody was observed among non-White participants (51.1%) compared with White participants (31.2%). We did not find any statistically significant association between seropositivity to any of the eight F. nucleatum proteins and colorectal cancer risk.

CONCLUSIONS

Prediagnostic antibody responses to F. nucleatum proteins were not associated with the risk of colorectal cancer.

IMPACT

Future studies may consider a more specific detection of the immunoglobulin isotypes or focus on examining F. nucleatum in stool or tissue samples.

Clustering by periodontitis-associated factors: A novel application to NHANES data

BACKGROUND

Unsupervised clustering is a method used to identify heterogeneity among groups and homogeneity within a group of patients. Without a prespecified outcome entry, the resulting model deciphers patterns that may not be disclosed using traditional methods. This is the first time such clustering analysis is applied in identifying unique subgroups at high risk for periodontitis in National Health and Nutrition Examination Surveys (NHANES 2009 to 2014 data sets using >500 variables.

METHODS

Questionnaire, examination, and laboratory data (33 tables) for >1,000 variables were merged from 14,072 respondents who underwent clinical periodontal examination. Participants with ≥6 teeth and available data for all selected categories were included (N = 1,222). Data wrangling produced 519 variables. k-means/modes clustering (k = 2:14) was deployed. The optimal k-value was determined through the elbow method, formula = ∑ (x_i ² ) - ((∑ x_i )2 /n). The 5-cluster model showing the highest variability (63.08%) was selected. The 2012 Centers for Disease Control and Prevention/American Academy of Periodontology (AAP) and 2018 European Federation of Periodontology/AAP periodontitis case definitions were applied.

RESULTS

Cluster 1 (n = 249) showed the highest prevalence of severe periodontitis (43%); 39% self-reported "fair" general health; 55% had household income <$35,000/year; and 48% were current smokers. Cluster 2 (n = 154) had one participant with periodontitis. Cluster 3 (n = 242) represented the greatest prevalence of moderate periodontitis (53%). In Cluster 4 (n = 35) only one participant had no periodontitis. Cluster 5 (n = 542) was the systemically healthiest with 77% having no/mild periodontitis.

CONCLUSION

Clustering of NHANES demographic, systemic health, and socioeconomic data effectively identifies characteristics that are statistically significantly related to periodontitis status and hence detects subpopulations at high risk for periodontitis without costly clinical examinations.

Severe COVID-19 Lung Infection in Older People and Periodontitis

Periodontal bacteria dissemination into the lower respiratory tract may create favorable conditions for severe COVID-19 lung infection. Once lung tissues are colonized, cells that survive persistent bacterial infection can undergo permanent damage and accelerated cellular senescence. Consequently, several morphological and functional features of senescent lung cells facilitate SARS-CoV-2 replication. The higher risk for severe SARS-CoV-2 infection, the virus that causes COVID-19, and death in older patients has generated the question whether basic aging mechanisms could be implicated in such susceptibility. Mounting evidence indicates that cellular senescence, a manifestation of aging at the cellular level, contributes to the development of age-related lung pathologies and facilitates respiratory infections. Apparently, a relationship between life-threatening COVID-19 lung infection and pre-existing periodontal disease seems improbable. However, periodontal pathogens can be inoculated during endotracheal intubation and/or aspirated into the lower respiratory tract. This review focuses on how the dissemination of periodontal bacteria into the lungs could aggravate age-related senescent cell accumulation and facilitate more efficient SARS-CoV-2 cell attachment and replication. We also consider how periodontal bacteria-induced premature senescence could influence the course of COVID-19 lung infection. Finally, we highlight the role of saliva as a reservoir for both pathogenic bacteria and SARS-CoV-2. Therefore, the identification of active severe periodontitis can be an opportune and valid clinical parameter for risk stratification of old patients with COVID-19.

Management of periodontal disease in patients with diabetes- good clinical practice guidelines: A joint statement by Indian Society of Periodontology and Research Society for the Study of Diabetes in India

There is a huge body of literature suggesting an association and a bidirectional relationship between periodontal disease and diabetes. Diabetes and periodontal diseases are both chronic diseases with a high prevalence. Dentists/periodontists, in their daily clinical practice, very often attend to diabetes patients with diverse oral health conditions and cater to their dental treatment needs. Safe and effective periodontal therapy in this population requires a broad understanding of diabetes, medical management of diabetes, and essential modifications to dental/periodontal therapy that may be required. This paper describes a joint statement put forth by the Indian Society of Periodontology and the Research Society for the Study of Diabetes in India aiming to provide expert consensus and evidence-based guidelines for optimal clinical management of periodontal conditions in diabetes patients or patients at risk for diabetes. Although this paper is not envisioned to be a comprehensive review of this topic, it intends to provide the guidelines for dental professionals and periodontists.

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.

Education and income-based inequality in tooth loss among Brazilian adults: does the place you live make a difference?

BACKGROUND

Socioeconomic inequalities in tooth loss might be minimized or potentialized by the characteristics of the context where people live. We examined whether there is contextual variation in socioeconomic inequalities in tooth loss across Brazilian municipalities.

METHODS

Data from the 2010 National Oral Health Survey of 9633 adults living in 157 Brazilian municipalities were used. The individual socioeconomic indicators were education and household income. At the municipal level, we used the Municipal Human Development Index (HDI) as our contextual indicator of socioeconomic status (low:< 0.699 versus high: > 0.70). The Relative (RII) and Slope (SII) Indexes of Inequality, Relative (RCI), and Absolute (ACI) Concentration Indexes were calculated to compare the magnitude of education and income-based inequalities among municipalities with low versus high HDI. Multilevel Poisson regression models with random intercepts and slopes were developed.

RESULTS

At the individual level, adults with lower education & income reported more tooth loss. The mean number of missing teeth was 9.52 (95% CI: 7.93-11.13) and 6.95 (95% CI: 6.43-7.49) in municipalities with low and high HDI, respectively. Municipalities with high HDI showed higher relative and absolute education-based inequality. For income-based inequalities, higher SII and RCI was observed in municipalities with lower HDI. A significant cross-level interaction indicated that high-education adults reported fewer missing teeth when they lived in municipalities with high HDI compared to adults with the same education level living in low HDI municipalities. For individuals with the lowest education level, there was no difference in the number of teeth between those from municipalities with high and low HDI.

CONCLUSIONS

There was a social gradient in tooth loss by education and income. Living in disadvantaged municipalities cannot overcome the risk associated with low schooling. The protective effect of higher education can be reduced when people live in disadvantaged areas.

Tobacco Products, Periodontal Health and Education Level: Cohort Study from Sweden

Background: The aim of this study is to investigate if using tobacco products (including snuff, smoking tobacco and dual-using) associates with periodontal health, education level and mortality in a Swedish cohort, hypothesizing that tobacco products affect periodontal health, associate with lower education and increase the risk of death. Method: Study cohort of 1080 subjects aged 31–40 years (528 men, 552 women) was clinically examined and interviewed in 1985 and followed for mortality until 2015. Subjects were classified into two groups: “tobacco users” and “non-users”. Associations between periodontal health parameters, tobacco products, education level and age of death were analysed. SPSS was used for analyses. Results: Tobacco products, as well as education level associated, with poor periodontal health. Tobacco users and lower education was linked to higher plaque-, calculus- and gingival-index scores than non-users (p < 0.001). They also had significantly higher prevalence of deep periodontal pockets (≥5 mm) (p < 0.001 and 0.010, respectively), missing teeth (p = 0.010 and 0.003, respectively) and lower education level (p < 0.001) compared with non-users. However, tobacco product users did not die significantly earlier than non-users. Conclusion: Tobacco products had a negative impact on periodontal health. Tobacco product users were less educated. However, using tobacco products may not cause premature death.

Preventive healthcare policies in the US: solutions for disease management using Big Data Analytics

Data-driven healthcare policy discussions are gaining traction after the Covid-19 outbreak and ahead of the 2020 US presidential elections. The US has a hybrid healthcare structure; it is a system that does not provide universal coverage, albeit few years ago enacted a mandate (Affordable Care Act-ACA) that provides coverage for the majority of Americans. The US has the highest health expenditure per capita of all western and developed countries; however, most Americans don't tap into the benefits of preventive healthcare. It is estimated that only 8% of Americans undergo routine preventive screenings. On a national level, very few states (15 out of the 50) have above-average preventive healthcare metrics. In literature, many studies focus on the cure of diseases (research areas such as drug discovery and disease prediction); whilst a minority have examined data-driven preventive measures-a matter that Americans and policy makers ought to place at the forefront of national issues. In this work, we present solutions for preventive practices and policies through Machine Learning (ML) methods. ML is morally neutral, it depends on the data that train the models; in this work, we make the case that Big Data is an imperative paradigm for healthcare. We examine disparities in clinical data for US patients by developing correlation and imputation methods for data completeness. Non-conventional patterns are identified. The data lifecycle followed is methodical and deliberate; 1000+ clinical, demographical, and laboratory variables are collected from the Centers for Disease Control and Prevention (CDC). Multiple statistical models are deployed (Pearson correlations, Cramer's V, MICE, and ANOVA). Other unsupervised ML models are also examined (K-modes and K-prototypes for clustering). Through the results presented in the paper, pointers to preventive chronic disease tests are presented, and the models are tested and evaluated.

Global Prevalence of Periodontal Disease and Lack of Its Surveillance

BACKGROUND

Periodontal disease is a public health problem and is strongly associated with systemic diseases; however, its worldwide distribution is not fully understood.

OBJECTIVE

To evaluate global data of periodontal disease: (1) among adolescents, adults, and older population and (2) in low-, middle-, and high-income countries.

METHODS

This ecological study included data of periodontal disease from the World Health Organization's data bank which are based on the Community Periodontal Index of Treatment Needs (CPITN code: 0 = no disease; 1 = bleeding on probing; 2 = calculus; 3 = periodontal pocket (PD) 4-5 mm; 4 = PD (6+ mm). Age- and income-related periodontal disease inequalities were evaluated across the globe.

RESULTS

Compared with 9.3% of adults and 9.7% of older persons, 21.2% of adolescents had no periodontal disease (P = 0.005). Nearly 18.8% of adolescents compared with 8.9% of adults and 5% of older persons had bleeding on probing (P ≤ 0.001). Similarly, 50.3% of adolescents, 44.6% of adults, and 31.9% older persons demonstrated the occurrence of calculus (P = 0.01). On the other hand, older persons had the highest prevalence of PD 4-5 mm and PD 6+ mm than adults and adolescents (P ≤ 0.001). The distribution of periodontitis (CPITN code 3 + 4) in adults differed significantly in low- (28.7%), lower-middle- (10%), upper-middle- (42.5%), and high-income countries (43.7%) (P = 0.04). However, no significant differences in periodontitis (CPITN code 3 + 4) were observed in adolescents and older persons in low- to high-income countries.

CONCLUSIONS

Within the limitations of data, this study found that the distribution of periodontal disease increases with age. Periodontitis was the most common in older persons and in population from high-income countries.

Periodontal health in an indigenous Sámi population in Northern Norway: a cross-sectional study

Background

The aim of the study was to describe prevalence, severity and distribution of periodontal disease as well as associated risk factors in an indigenous Sámi population in Northern Norway, and to investigate differences between the indigenous Sámi and the non-Sámi population.

Methods

This cross-sectional study included data from the Dental Health in the North study (N = 2078; 18–75 years). Data on Ethnicity, household income, education, smoking habits, dental attendance, and tooth brushing habits were collected by a questionnaire. Periodontal conditions were assessed by clinical examination. A modified version of the new AAP/EFP classification system of periodontal disease was used to estimate the severity of periodontitis. Three stages were used: ‘Non-severe periodontitis’, ‘Stage II’, and stage ‘III/IV’.

Results

Of the total study population 66.5% reported Sámi affiliation. The total prevalence of periodontitis was 49.7%, with 20.1% in Stage III/IV, but no differences between Sámi and non-Sámi. When controlled for sex, age, education, smoking and dental attendance the Sámi had higher probability of having more severe stages of periodontitis; Odds Ratio_{Stage II} (OR) = 1.3; 95% CI: 1.1–1.7; and OR_{Stage III/IV} (OR) = 1.6; 95% CI: 1.1–2.2) compared to non-Sámi. The Sámi had higher prevalence of periodontal pocket depth (PD) ≥ 4 mm (t = 1.77; p <  0.001) and PD ≥ 6 mm (t = 1.08; p = 0.038) than the non-Sámi.

Conclusions

The prevalence of periodontitis was high in communities in the core area of Sámi settlement in Northern Norway, regardless of ethnicity. People with Sámi ethnicity had more deep periodontal pockets and an increased odds of having severe stages of periodontitis. Future studies should address possible explaining factors behind the potential higher risk of having more severe periodontitis among indigenous people in Sámi settlements.

Age-Specific Predictive Models of the Upper Quintile of Periodontal Attachment Loss

A practical method to identify people who are most affected by periodontitis in their age group is currently unavailable. We focused on individuals with mean clinical attachment loss (CAL) above the 80th percentile within each of 10 age groups (5-y intervals between 30 and 74 y as well as ≥75 y). We developed predictive models using combined data from 2 cohorts (2009 to 2010 and 2011 to 2012) from the NHANES (National Health and Nutrition Examination Survey; development cohort [DC], n = 6,757), and we carried out external validation using data from a third NHANES cohort (2013 to 2014; validation cohort [VC], n = 3,447). We used 1) age-specific logistic regression models with stepwise selection to identify significant demographic variables, habits, medical conditions, and selected clinical periodontal parameters (proportion of teeth with probing depth ≥4 mm at incisors and molars and with visible [≥2 mm] recession) and to calculate propensity scores (PSs); 2) Youden's J statistic to select optimum PS cutoffs to maximize diagnostic performance using receiver operating characteristic curves; and 3) bootstrap resampling with 1,000 replicates to validate the age-specific models and adjust the PS and optimal PS cutoffs for overfitting. The bootstrap-adjusted PSs were used as single predictors of mean CAL over the 80th percentile in the VC. The age-specific upper quintiles of mean CAL ranged between 1.63 and 3.24 mm in the DC and between 1.87 and 3.20 mm in the VC. The area under the curve of the models exceeded 0.85 in all age groups in the DC and 0.84 in the VC, indicating well-validated diagnostic performance. In the DC, sensitivity values ranged between 0.75 and 0.97 and exceeded 0.83 in 8 of 10 age groups. Corresponding values in the VC ranged between 0.56 and 0.89 and exceeded 0.68 in 8 of 10 age groups. We conclude that modeling that incorporates readily obtainable variables through a brief patient interview and an abbreviated periodontal examination accurately identifies individuals who are most affected by periodontitis in different ages.

The relation between teeth loss and cognitive decline among Saudi population in the city of Riyadh: A pilot study

Background

Teeth are necessary for sensory input to the brain during the chewing process, but how the decrease in this sensory input, due to loss of teeth, may cause weak memory and lead to cognitive decline is not well understood. This pilot public survey aiming to assess the correlation between the number of missing teeth, periodontal disease, and cognitive skill in the city of Riyadh.

Material& Methods

A multicenter cross-sectional survey, targeting geriatric population aged ≥60 years, was performed in Riyadh City, Saudi Arabia. The Montreal Cognitive Assessment (MoCA) was conducted to all participants to assess their cognitive function. Assessment of oral health status was carried out, including the number of present dentation and their periodontal status. Community periodontal-index (CPI) was used to assess the periodontal condition. The primary variables were number of missing teeth, periodontal disease and MoCA test scores. Chi-square test and Pearson’s correlation coefficients were computed and the significant P- value was set at <0.05.

Results

Of 95 participants, overall, 57 (60%) and 38 (40%) were male and female, respectively, with a mean age of 65.67 ± 6.32 years. Females showed more significant cognitive decline than males (P < 0.001). Cognitive decline was significantly high in participants with low educational level 19 (95%), unemployment 41 (79%), and lower income people 26 (79%), while being cognitive intact was significantly higher in highly educated 13 (87%), retired 21 (62%), and higher income people 28 (74%) at (P < 0.001). An advanced age and greater number of missing teeth are associated with lower MoCA test scores. No statistical significant correlation with regard to periodontal disease and MoCA test scores.

Conclusion

Based on the preliminary data, positive correlation was confirmed when the number of missing teeth and cognitive skill were assessed. Therefore, larger, multi-center regional surveys are needed to investigate further this relationship.

SES and correlated factors do not explain the association between periodontal disease, edentulism, and cancer risk

PURPOSE

Severe periodontal disease and edentulism have been previously reported to be significantly associated with cancer risk and mortality, including in the Atherosclerosis Risk in Communities study (2018); however, complex sources of confounding by socioeconomic status (SES), and characteristics correlated with SES, could have been present in earlier analyses.

METHODS

To capture life course SES and its correlates, we generated a propensity score and included it, along with other potential confounders such as smoking and obesity, into a Cox regression model to examine the association between periodontal disease and cancer risk. In addition, we stratified the model with the propensity score by low and high SES. All statistical tests were two-sided.

RESULTS

Compared with our previous study, the associations for severe periodontitis and cancer incidence remained comparable after weighting by the propensity score (e.g., for total cancer: before weighting, hazard ratio = 1.24, 95% confidence interval = 1.07-1.42 vs. after weighting, hazard ratio = 1.23, 95% confidence interval = 1.05-1.44 when comparing severe periodontitis to no or mild periodontitis). Associations were comparable in low and high SES strata and statistically significant among participants with high SES.

CONCLUSIONS

Complex sources of confounding by SES and its correlates are unlikely to fully account for the positive associations observed for periodontal disease and edentulism and cancer risk.

Periodontal Health and Use of Oral Health Services: A Comparison of Germans and Two Migrant Groups

A cross-sectional study was performed with 251 individuals, consisting of 127 Germans, 68 migrants from Turkey, and 56 resettlers (migrants from the former Soviet Union with German ancestors) to compare periodontal health status, with a special focus on associations with lifestyle and anthropometric factors, and use of dental health services. Maximal pocket depth was used as a clinical surrogate marker for periodontitis. Other variables were obtained by questionnaires administered by a Turkish or Russian interpreter. The age- and sex-adjusted prevalence of periodontitis was significantly higher in Turks (odds ratio (OR) 2.84, 95% CI = 1.53–5.26) and slightly higher in resettlers (OR = 1.33, 95% CI = 0.71–2.49). These differences are partly explained by a differential distribution of known risk factors for periodontitis. A full model showed a higher prevalence of maximal pocket depth above 5 mm in Turks (OR = 1.97, 95% CI = 0.99–3.92). Use of oral health services was significantly lower in the two migrant groups. Individuals who reported regular visits to a dentist had significantly less periodontitis, independent of migrant status. A reasonable conclusion is that, since oral health causes major chronic diseases and has a major effect on total health system expenditures, public health efforts both generally and specifically focused on migrant groups are warranted.

The use of an interdental brush mitigates periodontal health inequalities: the Korean National Health and nutrition examination survey (KNHANES)

Background

The purpose of this study was to evaluate the mitigating effect of the use of interdental brushes on periodontal health inequality.

Methods

This study was based on the data acquired in the Sixth Korea National Health and Nutrition Examination Survey (KNHANES VI; 2013–2015). A total of 17,583 participants (7,633 males and 9,950 females)) aged 19 years or older completed the KNHANES VI between 2013 and 2015. Multivariable logistic regression analysis was performed using socioeconomic characteristics (sex, age, level of education, individual income), personal health practice (smoking, toothbrushing, dental flossing, interdental brushing, dental clinic visiting), systematic medical factors (diabetes mellitus, hypercholesterolemia, hypertension, obesity) and the community periodontal index. We confirmed differences in the prevalence of periodontal disease with the use of an interdental brushes stratified according to individual income.

Results

Three logistic regression models adjusted for covariates hierarchically. In all models, individuals who used an interdental brush were not significantly different from individuals who did not use an interdental brush. The adjusted odds ratio (OR) for interdental brushing was 0.918 with a 95% confidence intervals (CIs) of 0.797–1.057. When periodontal disease was the outcome of the model, the lowest income group had 1.266 (95% CIs 1.066 to 1.502) times the odds of having periodontal disease than the highest income group. In interdental brush nonusers, the lowest income group had 1.276 (95% CI 1.061–1.533) times the odds of having periodontal diseases than the highest income group. However, in the interdental brush users, there were no significant differences in periodontal disease prevalence among income groups.

Conclusions

The results suggest that the use of interdental brushes could alleviate periodontal health inequality.

The Controlled Direct Effect of Early-Life Socioeconomic Position on Periodontitis in a Birth Cohort

This study used data from the 1982 Pelotas Birth Cohort Study, Brazil, to estimate the controlled direct effect of early-life socioeconomic position (SEP) on periodontitis at age 31 years, controlling for adulthood income and education, smoking, and dental hygiene. Sex was included as a covariate. Early-life SEP was measured at participant birth based on income, health services payment mode, maternal education, height, and skin color (lower versus middle/higher SEP). Periodontitis was assessed through clinical examination at age 31 years (healthy, mild periodontitis, or moderate-to-severe disease). Adulthood behaviors (smoking, dental hygiene) were the mediators, and adulthood SEP (education and income) represented the exposure-induced mediator-outcome confounders. A regression-based approach was used to assess the controlled direct effect of early-life SEP on periodontitis. Multinomial regression models were used to estimate risk ratios and their 95% confidence intervals. The prevalences of mild and moderate-to-severe periodontitis were 23.0% and 14.3%, respectively (n = 539). Individuals from the lowest early-life SEP had a higher risk of moderate-to-severe periodontitis controlled for mediators and exposure-induced mediator-outcome confounders: risk ratio = 1.85 (95% confidence interval: 1.06, 3.24), E value 3.1. We found that early-life SEP was associated with the development of periodontitis in adulthood that was not mediated by adulthood SEP and behaviors.

The Relationship between Income and Oral Health: A Critical Review

In this critical review, we summarized the evidence on associations between individual/household income and oral health, between income inequality and oral health, and income-related inequalities in oral health. Meta-analyses of mainly cross-sectional studies confirm that low individual/household income is associated with oral cancer (odds ratio, 2.41; 95% confidence interval [CI], 1.59-3.65), dental caries prevalence (prevalence ratio, 1.29; 95% CI, 1.18-1.41), any caries experience (odds ratio, 1.40; 95% CI, 1.19-1.65), tooth loss (odds ratio, 1.66; 95% CI, 1.48-1.86), and traumatic dental injuries (odds ratio, 0.76; 95% CI, 0.65-0.89). Reviews also confirm qualitatively that low income is associated with periodontal disease and poor oral health-related quality of life. Limited evidence from the United States shows that psychosocial and behavioral explanations only partially explain associations between low individual/household income and oral health. Few country-level studies and a handful of subnational studies from the United States, Japan, and Brazil show associations between area-level income inequality and poor oral health. However, this evidence is conflicting given that the association between area-level income inequality and oral health outcomes varies considerably by contexts and by oral health outcomes. Evidence also shows cross-national variations in income-related inequalities in oral health outcomes of self-rated oral health, dental care, oral health-related quality of life, outcomes of dental caries, and outcomes of tooth loss. There is a lack of discussion in oral health literature about limitations of using income as a measure of social position. Future studies on the relationship between income and oral health can benefit substantially from recent theoretical and methodological advancements in social epidemiology that include application of an intersectionality framework, improvements in reporting of inequality, and causal modeling approaches. Theoretically well-informed studies that apply robust epidemiological methods are required to address knowledge gaps for designing relevant policy interventions to reduce income-related inequalities in oral health.

WITHDRAWN: Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults

BACKGROUND

Effective oral hygiene is a crucial factor in maintaining good oral health, which is associated with overall health and health-related quality of life. Dental floss has been used for many years in conjunction with toothbrushing for removing dental plaque in between teeth, however, interdental brushes have been developed which many people find easier to use than floss, providing there is sufficient space between the teeth.

OBJECTIVES

To evaluate the effects of interdental brushing in addition to toothbrushing, as compared with toothbrushing alone or toothbrushing and flossing for the prevention and control of periodontal diseases, dental plaque and dental caries.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 7 March 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 2), MEDLINE via OVID (1946 to 7 March 2013), EMBASE via OVID (1980 to 7 March 2013), CINAHL via EBSCO (1980 to 7 March 2013), LILACS via BIREME (1982 to 7 March 2013), ZETOC Conference Proceedings (1980 to 7 March 2013) and Web of Science Conference Proceedings (1990 to 7 March 2013). We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the metaRegister of Controlled Trials (http://www.controlled-trials.com/mrct/) for ongoing trials to 7 March 2013. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (including split-mouth design, cross-over and cluster-randomised trials) of dentate adult patients. The interventions were a combination of toothbrushing and any interdental brushing procedure compared with toothbrushing only or toothbrushing and flossing.

DATA COLLECTION AND ANALYSIS

At least two review authors assessed each of the included studies to confirm eligibility, assessed risk of bias and extracted data using a piloted data extraction form. We calculated standardised mean difference (SMD) and 95% confidence interval (CI) for continuous outcomes where different scales were used to assess an outcome. We attempted to extract data on adverse effects of interventions. Where data were missing or unclear we attempted to contact study authors to obtain further information.

MAIN RESULTS

There were seven studies (total 354 participants analysed) included in this review. We assessed one study as being low, three studies as being high and three studies as being at unclear risk of bias. Studies only reported the clinical outcome gingivitis and plaque data, with no studies providing data on many of the outcomes: periodontitis, caries, halitosis and quality of life. Three studies reported that no adverse events were observed or reported during the study. Two other studies provided some data on adverse events but we were unable to pool the data due to lack of detail. Two studies did not report whether adverse events occurred.Interdental brushing in addition to toothbrushing, as compared with toothbrushing aloneOnly one high risk of bias study (62 participants in analysis) looked at this comparison and there was very low-quality evidence for a reduction in gingivitis (0 to 4 scale, mean in control): mean difference (MD) 0.53 (95% CI 0.23 to 0.83) and plaque (0 to 5 scale): MD 0.95 (95% CI 0.56 to 1.34) at one month, favouring of use of interdental brushes. This represents a 34% reduction in gingivitis and a 32% reduction in plaque.Interdental brushing in addition to toothbrushing, as compared with toothbrushing and flossingSeven studies provided data showing a reduction in gingivitis in favour of interdental brushing at one month: SMD -0.53 (95% CI -0.81 to -0.24, seven studies, 326 participants, low-quality evidence). This translates to a 52% reduction in gingivitis (Eastman Bleeding Index). Although a high effect size in the same direction was observed at three months (SMD -1.98, 95% CI -5.42 to 1.47, two studies, 107 participants, very low quality), the confidence interval was wide and did not exclude the possibility of no difference. There was insufficient evidence to claim a benefit for either interdental brushing or flossing for reducing plaque (SMD at one month 0.10, 95% CI -0.13 to 0.33, seven studies, 326 participants, low-quality evidence) and insufficient evidence at three months (SMD -2.14, 95% CI -5.25 to 0.97, two studies, 107 participants very low-quality evidence).

AUTHORS' CONCLUSIONS

Only one study looked at whether toothbrushing with interdental brushing was better than toothbrushing alone, and there was very low-quality evidence for a reduction in gingivitis and plaque at one month. There is also low-quality evidence from seven studies that interdental brushing reduces gingivitis when compared with flossing, but these results were only found at one month. There was insufficient evidence to determine whether interdental brushing reduced or increased levels of plaque when compared to flossing.

Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries

BACKGROUND

Dental caries (tooth decay) and periodontal diseases (gingivitis and periodontitis) affect the majority of people worldwide, and treatment costs place a significant burden on health services. Decay and gum disease can cause pain, eating and speaking difficulties, low self-esteem, and even tooth loss and the need for surgery. As dental plaque is the primary cause, self-administered daily mechanical disruption and removal of plaque is important for oral health. Toothbrushing can remove supragingival plaque on the facial and lingual/palatal surfaces, but special devices (such as floss, brushes, sticks, and irrigators) are often recommended to reach into the interdental area.

OBJECTIVES

To evaluate the effectiveness of interdental cleaning devices used at home, in addition to toothbrushing, compared with toothbrushing alone, for preventing and controlling periodontal diseases, caries, and plaque. A secondary objective was to compare different interdental cleaning devices with each other.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched: Cochrane Oral Health's Trials Register (to 16 January 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 12), MEDLINE Ovid (1946 to 16 January 2019), Embase Ovid (1980 to 16 January 2019) and CINAHL EBSCO (1937 to 16 January 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared toothbrushing and a home-use interdental cleaning device versus toothbrushing alone or with another device (minimum duration four weeks).

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened searches, selected studies, extracted data, assessed studies' risk of bias, and assessed evidence certainty as high, moderate, low or very low, according to GRADE. We extracted indices measured on interproximal surfaces, where possible. We conducted random-effects meta-analyses, using mean differences (MDs) or standardised mean differences (SMDs).

MAIN RESULTS

We included 35 RCTs (3929 randomised adult participants). Studies were at high risk of performance bias as blinding of participants was not possible. Only two studies were otherwise at low risk of bias. Many participants had a low level of baseline gingival inflammation.Studies evaluated the following devices plus toothbrushing versus toothbrushing: floss (15 trials), interdental brushes (2 trials), wooden cleaning sticks (2 trials), rubber/elastomeric cleaning sticks (2 trials), oral irrigators (5 trials). Four devices were compared with floss: interdental brushes (9 trials), wooden cleaning sticks (3 trials), rubber/elastomeric cleaning sticks (9 trials) and oral irrigators (2 trials). Another comparison was rubber/elastomeric cleaning sticks versus interdental brushes (3 trials).No trials assessed interproximal caries, and most did not assess periodontitis. Gingivitis was measured by indices (most commonly, Löe-Silness, 0 to 3 scale) and by proportion of bleeding sites. Plaque was measured by indices, most often Quigley-Hein (0 to 5).

PRIMARY OBJECTIVE

comparisons against toothbrushing aloneLow-certainty evidence suggested that flossing, in addition to toothbrushing, may reduce gingivitis (measured by gingival index (GI)) at one month (SMD -0.58, 95% confidence interval (CI) -1.12 to -0.04; 8 trials, 585 participants), three months or six months. The results for proportion of bleeding sites and plaque were inconsistent (very low-certainty evidence).Very low-certainty evidence suggested that using an interdental brush, plus toothbrushing, may reduce gingivitis (measured by GI) at one month (MD -0.53, 95% CI -0.83 to -0.23; 1 trial, 62 participants), though there was no clear difference in bleeding sites (MD -0.05, 95% CI -0.13 to 0.03; 1 trial, 31 participants). Low-certainty evidence suggested interdental brushes may reduce plaque more than toothbrushing alone (SMD -1.07, 95% CI -1.51 to -0.63; 2 trials, 93 participants).Very low-certainty evidence suggested that using wooden cleaning sticks, plus toothbrushing, may reduce bleeding sites at three months (MD -0.25, 95% CI -0.37 to -0.13; 1 trial, 24 participants), but not plaque (MD -0.03, 95% CI -0.13 to 0.07).Very low-certainty evidence suggested that using rubber/elastomeric interdental cleaning sticks, plus toothbrushing, may reduce plaque at one month (MD -0.22, 95% CI -0.41 to -0.03), but this was not found for gingivitis (GI MD -0.01, 95% CI -0.19 to 0.21; 1 trial, 12 participants; bleeding MD 0.07, 95% CI -0.15 to 0.01; 1 trial, 30 participants).Very-low certainty evidence suggested oral irrigators may reduce gingivitis measured by GI at one month (SMD -0.48, 95% CI -0.89 to -0.06; 4 trials, 380 participants), but not at three or six months. Low-certainty evidence suggested that oral irrigators did not reduce bleeding sites at one month (MD -0.00, 95% CI -0.07 to 0.06; 2 trials, 126 participants) or three months, or plaque at one month (SMD -0.16, 95% CI -0.41 to 0.10; 3 trials, 235 participants), three months or six months, more than toothbrushing alone.

SECONDARY OBJECTIVE

comparisons between devicesLow-certainty evidence suggested interdental brushes may reduce gingivitis more than floss at one and three months, but did not show a difference for periodontitis measured by probing pocket depth. Evidence for plaque was inconsistent.Low- to very low-certainty evidence suggested oral irrigation may reduce gingivitis at one month compared to flossing, but very low-certainty evidence did not suggest a difference between devices for plaque.Very low-certainty evidence for interdental brushes or flossing versus interdental cleaning sticks did not demonstrate superiority of either intervention.Adverse eventsStudies that measured adverse events found no severe events caused by devices, and no evidence of differences between study groups in minor effects such as gingival irritation.

AUTHORS' CONCLUSIONS

Using floss or interdental brushes in addition to toothbrushing may reduce gingivitis or plaque, or both, more than toothbrushing alone. Interdental brushes may be more effective than floss. Available evidence for tooth cleaning sticks and oral irrigators is limited and inconsistent. Outcomes were mostly measured in the short term and participants in most studies had a low level of baseline gingival inflammation. Overall, the evidence was low to very low-certainty, and the effect sizes observed may not be clinically important. Future trials should report participant periodontal status according to the new periodontal diseases classification, and last long enough to measure interproximal caries and periodontitis.

Macrophage immunomodulation in chronic osteolytic diseases-the case of periodontitis

Periodontitis (PD) is a chronic osteolytic disease that shares pathogenic inflammatory features with other conditions associated with nonresolving inflammation. A hallmark of PD is inflammation-mediated alveolar bone loss. Myeloid cells, in particular polymorphonuclear neutrophils (PMN) and macrophages (Mac), are essential players in PD by control of gingival biofilm pathogenicity, activation of adaptive immunity, as well as nonresolving inflammation and collateral tissue damage. Despite mounting evidence of significant innate immune implications to PD progression and healing after therapy, myeloid cell markers and targets for immune modulation have not been validated for clinical use. The remarkable plasticity of monocytes/Mac in response to local activation factors enables these cells to play central roles in inflammation and restoration of tissue homeostasis and provides opportunities for biomarker and therapeutic target discovery for management of chronic inflammatory conditions, including osteolytic diseases such as PD and arthritis. Along a wide spectrum of activation states ranging from proinflammatory to pro-resolving, Macs respond to environmental changes in a site-specific manner in virtually all tissues. This review summarizes the existing evidence on Mac immunomodulation therapies for osteolytic diseases in the broader context of conditions associated with nonresolving inflammation, and discusses osteoimmune implications of Macs in PD.

Interdental cleaning and periodontal pocketing among finnish adults

AIM

To investigate the relationship between frequency of interdental cleaning and 11-year change in teeth with periodontal pocketing in Finnish adults.

METHODS

Data from 1667 dentate adults, aged 30 to 82 years, who participated in the Health 2000 survey and were re-examined in 2004 and/or 2011 were analysed. Participants reported their frequency of interdental cleaning (either dental floss or interdental brush) at baseline. Teeth with periodontal pocketing (PD) ≥4 mm were counted in every survey and treated as a repeated outcome. The association between the frequency of interdental cleaning and the number of teeth with PD ≥4 mm was evaluated in linear mixed effects models, controlling for demographic factors, socioeconomic position, diabetes, smoking status, toothbrushing frequency, dental attendance and number of teeth.

RESULTS

Twelve per cent of adults reported daily interdental cleaning. Significant inverse linear trends in the number of teeth with PD ≥4 mm were found in every survey according to the frequency of interdental cleaning. However, this association was completely attenuated after adjustment for the full set of confounders. Contrarily, toothbrushing frequency was negatively associated with the baseline number of teeth with PD ≥4 mm and its rate of change over time.

CONCLUSION

Interdental cleaning was not associated with 11-year change in periodontal pocketing after accounting for other established risk factors for periodontal disease.