Risk assessment and periodontal prevention in primary care

Contesting the conventional wisdom of periodontal risk assessment

Over the years, several reviews of periodontal risk assessment tools have been published. However, major misunderstandings still prevail in repeated attempts to use these tools for prognostic risk prediction. Here we review the principles of risk prediction and discuss the value and the challenges of using prediction models in periodontology. Most periodontal risk prediction models have not been properly developed according to guidance given for the risk prediction model development. This shortcoming has led to several problems, including the creation of arbitrary risk scores. These scores are often labelled as 'high risk' without explicit boundaries or thresholds for the underlying continuous risk estimates of patient-important outcomes. Moreover, it is apparent that prediction models are often misinterpreted as causal models by clinicians and researchers although they cannot be used as such. Additional challenges like the critical assessment of transportability and applicability of these prediction models, as well as their impact on clinical practice and patient outcomes, are not considered in the literature. Nevertheless, these instruments are promoted with claims regarding their ability to deliver more individualized and precise periodontitis treatment and prevention, purportedly resulting in improved patient outcomes. However, people with or without periodontitis deserve proper information about their risk of developing patient-important outcomes such as tooth loss or pain. The primary objective of disseminating such information should not be to emphasize assumed treatment efficacy, hype individualization of care, or promote business interests. Instead, the focus should be on providing individuals with locally validated and regularly updated predictions of specific risks based on readily accessible and valid key predictors (e.g. age and smoking).

Data-driven prediction model for periodontal disease based on correlational feature analysis and clinical validation

Objectives

This study aimed to investigate the performance and reliability of data-driven models employing correlational feature analysis and clinical validation for predicting periodontal disease.

Methods

The 7th Korea National Health and Nutrition Examination Survey (n = 10,654) was used for correlation analysis to identify significant risk factors for periodontitis. Periodontal prediction models were developed with the selected factors and database, followed by internal validation with 5-fold cross-validation and 1000 bootstrap resampling. External validation was conducted with clinical data (n = 120) collected through self-reported questionnaires, clinical periodontal parameters, and radiographic image analysis. Predictive performance was assessed for logistics regression, support vector machine, random forest, XGBoost, and neural network algorithms using the area under the receiver operating characteristic curves (AUC) and other performance metrics.

Results

Correlation analysis identified 16 features from over 1000 potential risk factors for periodontitis. The best data-driven model (XGBoost) showed AUC values of 0.823 and 0.796 for internal and external validations, respectively. Modeling with clinical data revealed those same measures to be 0.836 and 0.649, respectively. In addition, the data-driven model could predict other clinical periodontal parameters including severe bone loss (AUC = 0.813), gingival bleeding (AUC = 0.694), and tooth loss (AUC = 0.734). A patient case study about prognostic predictions revealed that the probability of periodontitis can be reduced by 6.0 % (stop smoking) and 0.6 % (stop drinking) on average.

Conclusions

Data-driven models for predicting periodontitis and other periodontal parameters were developed from 16 risk factors, demonstrating enhanced prediction performance and reproducibility in internal-external validations.

CCL5's Role in Periodontal Disease: A Narrative Review

Persistent host inflammatory and immune responses to biofilm play a critical role in the mechanisms that govern soft and hard tissue destruction in periodontal disease. Among the less explored facets of these mechanisms are chemokines, including CCL5 (C-C motif chemokine ligand 5), also known as RANTES (regulated on activation, normal T cell expressed and secreted), a proinflammatory CC subfamily chemokine synthesized by T lymphocytes. Despite its importance, there is currently no comprehensive review of the role of CCL5 in periodontitis in the literature. Therefore, this paper aims to fill this gap by summarizing the existing knowledge on the involvement of CCL5 in the onset and progression of periodontitis. In addition, we aim to stimulate interest in this relatively overlooked factor among periodontitis researchers, potentially accelerating the development of drugs targeting CCL5 or its receptors. The review examines the association of CCL5 with periodontitis risk factors, including aging, cigarette smoking, diabetes, and obesity. It discusses the involvement of CCL5 in pathological processes during periodontitis, such as connective tissue and bone destruction. The data show that CCL5 expression is observed in affected gums and gingival crevicular fluid of periodontitis patients, with bacterial activity contributing significantly to this increase, but the reviewed studies of the association between CCL5 expression and periodontal disease have yielded inconclusive results. Although CCL5 has been implicated in the pathomechanism of periodontitis, a comprehensive understanding of its molecular mechanisms and significance remains elusive, hindering the development of drugs targeting this chemokine or its receptors.

Raman microspectroscopy/micro-optical coherence tomography approach for chairside diagnosis of periodontal diseases: A pilot study

BACKGROUND

Our objective was to develop and test a combined Raman microspectroscopy (RMS) and micro-optical coherence tomography (μOCT) approach for chairside quantification of gingival collagen, DNA, epithelium, and connective tissue. We hypothesized that a high-resolution RMS/μOCT can characterize healthy and inflamed periodontal tissues for diagnosis and disease activity monitoring.

METHODS

A prototype instrument was developed, tested ex vivo on gingival specimens and optimized for in vivo intraoral use. The primary outcome measures were the ratios of oral epithelium to connective tissue thickness (OE:CT) and the amount of DNA to collagen type I (DNA/Col 1), and the thickness of sulcular epithelium (SE). For ex vivo testing, eight subjects with healthy periodontal tissues or with Stage II to IV periodontitis were included in the study and underwent crown-lengthening or periodontal surgical procedures, respectively. Gingival biopsies were scanned by RMS/μOCT and histometric analyses were performed. The proof-of-concept study included OE/CT, DNA/Col 1, and SE assessed in six volunteers with or without signs of gingival inflammation (n = 3/group).

RESULTS

The spatially co-registered RMS spectra revealed opposing changes in the collagen and DNA peaks of inflamed compared with healthy tissues (P <0.05). Combined RMS/μOCT analysis showed that OE/CT, DNA/Col, and SE are significantly different between healthy and inflamed sites (P <0.05). Histological assessments confirmed the differences detected by RMS/μOCT. Qualitative analysis of DNA/Col 1 ratios indicated Col I content as the main distinguishing feature for health and DNA content for periodontitis.

CONCLUSION

Results suggest that combined RMS/μOCT chairside imaging may distinguish between healthy and diseased sites by evaluating marginal periodontal morphological and biochemical features.

Developing and testing a prediction model for periodontal disease using machine learning and big electronic dental record data

Despite advances in periodontal disease (PD) research and periodontal treatments, 42% of the US population suffer from periodontitis. PD can be prevented if high-risk patients are identified early to provide preventive care. Prediction models can help assess risk for PD before initiation and progression; nevertheless, utilization of existing PD prediction models is seldom because of their suboptimal performance. This study aims to develop and test the PD prediction model using machine learning (ML) and electronic dental record (EDR) data that could provide large sample sizes and up-to-date information. A cohort of 27,138 dental patients and grouped PD diagnoses into: healthy control, mild PD, and severe PD was generated. The ML model (XGBoost) was trained (80% training data) and tested (20% testing data) with a total of 74 features extracted from the EDR. We used a five-fold cross-validation strategy to identify the optimal hyperparameters of the model for this one-vs.-all multi-class classification task. Our prediction model differentiated healthy patients vs. mild PD cases and mild PD vs. severe PD cases with an average area under the curve of 0.72. New associations and features compared to existing models were identified that include patient-level factors such as patient anxiety, chewing problems, speaking trouble, teeth grinding, alcohol consumption, injury to teeth, presence of removable partial dentures, self-image, recreational drugs (Heroin and Marijuana), medications affecting periodontium, and medical conditions such as osteoporosis, cancer, neurological conditions, infectious diseases, endocrine conditions, cardiovascular diseases, and gastroenterology conditions. This pilot study demonstrated promising results in predicting the risk of PD using ML and EDR data. The model may provide new information to the clinicians about the PD risks and the factors responsible for the disease progression to take preventive approaches. Further studies are warned to evaluate the prediction model's performance on the external dataset and determine its usability in clinical settings.

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.

Do Lasers Have an Adjunctive Role in Initial Non-Surgical Periodontal Therapy? A Systematic Review

(1) Background: dental lasers have numerous applications for periodontal therapy which include surgical procedures of soft tissue and osseous structures, and non-surgical treatments such as pathogen reduction, removal of surface accretions, and photobiomodulation. The aim of this review was to evaluate the scientific literature to ascertain whether lasers have a beneficial role when used adjunctively in initial non-surgical periodontal therapy. (2) Methods: A PubMed search was performed specifically for randomized clinical trials where a dental laser was used adjunctively for initial periodontal therapy on human patients published from January 2010–April 2020. The first search identified 1294 eligible studies. After additional criteria and filters were applied, 20 manuscripts were included in this review. (3) Results: The chosen manuscripts reported on investigations into initial therapy for patients diagnosed with chronic periodontitis. After periodontal charting, conventional instrumentation such as hand and ultrasonic scaling was performed on all patients in the studies, and then a test group or groups of patients were treated adjunctively with a laser. That adjunctive laser group’s periodontal findings showed various degrees of improved health compared to the group treated with only conventional methods. (4) Conclusion: This systematic review found that 70% of the included studies reported significantly better outcomes in certain clinical parameters, but no improvement in others. The remaining 30% of the manuscripts reported no significant difference in any of the measurements. With consideration to correct parametry, lasers have an adjunctive role in initial non-surgical periodontal therapy.

Alveolar bone level at deciduous molars in Flemish children: A retrospective, radiographic study

AIM

The aim of this retrospective radiographic study in Flemish children was to examine the bone level and bone loss around deciduous molars and factors influencing this.

MATERIALS AND METHODS

Two thousand eight hundred ninety six digital intra-oral radiographs of children younger than 18 years old were screened for eligibility. The distance from the cementoenamel junction to the alveolar bone crest was measured, and tooth surfaces were screened for local risk factors that are presumably related to changes in the bone level. A distance >2 mm was defined as bone loss based on previous literature. All measurements were performed by two examiners.

RESULTS

One thousand four hundred ninety one radiographs of 796 patients (mean age 6.46 ± 2.38 years) were included. The distance between the cementoenamel junction and the alveolar bone crest ranged from 0.07 to 2.88 mm, and the mean distance was 0.93 ± 0.37 mm. This distance was positively correlated with age (p < .001). In 3.5% of patients, bone loss was diagnosed. Caries, fillings and pulp pathology were associated with bone loss and higher cementoenamel junction-alveolar bone crest distances (p < .05).

CONCLUSION

This study found a low prevalence of alveolar bone loss in the primary dentition. Both the bone level and bone loss were strongly correlated with local factors.

Contemporary approaches for identifying individual risk for periodontitis

Key breakthroughs in our understanding of the etiology and principles of predictable treatment of patients with chronic periodontitis first emerged in the late 1960s and carried on into the mid-1980s. Unfortunately, some generalizations of the evidence led many to believe that periodontitis was a predictable result of exposure to bacterial plaque accumulations over time. For a brief period, the initial plaque concept was translated by some to implicate specific bacterial infections, with both concepts (plaque exposure and specific infection) being false assumptions that led to clinical outcomes which were frustrating to both the clinician and the patient. The primary misconceptions were that every individual was equally susceptible to periodontitis, that disease severity was a simple function of magnitude of bacterial exposure over time, and that all patients would respond predictably if treated based on the key principles of bacterial reduction and regular maintenance care. We now know that although bacteria are an essential initiating factor, the clinical severity of periodontitis is a complex multifactorial host response to the microbial challenge. The complexity comes from the permutations of different factors that may interact to alter a single individual's host response to challenge, inflammation resolution and repair, and overall outcome to therapy. Fortunately, although there are many permutations that may influence host response and repair, the pathophysiology of chronic periodontitis is generally limited to mild periodontitis with isolated moderate disease in most individuals. However, approximately 20%-25% of individuals will develop generalized severe periodontitis and probably require more intensive bacterial reduction and different approaches to host modulation of the inflammatory outcomes. This latter group may also have serious systemic implications of their periodontitis. The time appears to be appropriate to use what we know and currently understand to change our approach to clinical care. Our goal would be to increase our likelihood of identifying those patients who have a more biologically disruptive response combined with a more impactful microbial dysbiosis. Current evidence, albeit limited, indicates that for those individuals we should prevent and treat more intensively. This paper discusses what we know and how we might use that information to start individualizing risk and treat some of our patients in a more targeted manner. In my opinion, we are further along than many realize, but we have a great lack of prospective clinical evidence that must be accumulated while we continue to unravel the contributions of specific mechanisms.

Personalized periodontal treatment for the tobacco- and alcohol-using patient

The use of various forms of tobacco is one of the most important preventable risk factors for the incidence and progression of periodontal disease. Tobacco use negatively affects treatment outcomes for both periodontal diseases and conditions, and for dental implants. Tobacco-cessation programs can mitigate these adverse dental treatment outcomes and may be the most effective component of a personalized periodontal treatment approach. In addition, heavy alcohol consumption may exacerbate the adverse effects of tobacco use. In this review, the microbiology, host/inflammatory responses and genetic characteristics of the tobacco-using patient are presented as a framework to aid the practitioner in developing personalized treatment strategies for these patients. These personalized approaches can be used for patients who use a variety of tobacco products, including cigarettes, cigars, pipes, smokeless tobacco products, e-cigarettes and other tobacco forms, as well as patients who consume large amounts of alcohol. In addition, principles for developing personalized tobacco-cessation programs, using both traditional and newer motivational and pharmacological approaches, are presented.

A Survey About Dental Instruments at the Primary Health Care in Brazil

Abstract This study describes the structure of oral health services in primary health care in Brazil and the instruments available for the provision of oral health care and to compare the number of instruments according to organizational characteristics of health services and among the macroregions. Of the 23,251 oral health teams (OHTs) in the Public Health System, 17,513 (75.3%) participated in this study. Trained researchers observed the structures of the health services and determined the presence of and whether a sufficient quantity of 36 dental instruments existed. The score of each oral health service was determined by the sum of the number of dental instruments present in sufficient quantity (0 to 36). Central tendency measures were compared along with the variability in these scores according to the organizational characteristics of the services and according to the Brazilian macroregion. No instrument was found to be present in all evaluated services. Basic, surgical and restorative instruments were the most frequently found. Periodontal, endodontic and prosthetic instruments exhibited the lowest percentages. The mean and median numbers of dental instruments were higher for teams that operated over more shifts, those with an oral health technician and those in the South and Southeast regions. The oral health services were equipped with basic, surgical and restorative instruments. Instruments designed for periodontal diagnosis, emergency care and denture rehabilitation were less frequently found in these services. The worst infrastructure conditions existed in the OHTs with the worst forms of care organization and in regions with greater social issues.

Periodontitis: facts, fallacies and the future

This volume of Periodontology 2000 represents the 25th anniversary of the Journal, and uses the occasion to assess important advancements in periodontology over the past quarter-century as well as the hurdles that remain. Periodontitis is defined by pathologic loss of the periodontal ligament and alveolar bone. The disease involves complex dynamic interactions among active herpesviruses, specific bacterial pathogens and destructive immune responses. Periodontal diagnostics is currently based on clinical rather than etiologic criteria, and provides limited therapeutic guidance. Periodontal causative treatment consists of scaling, antiseptic rinses and occasionally systemic antibiotics, and surgical intervention has been de-emphasized, except perhaps for the most advanced types of periodontitis. Plastic surgical therapy includes soft-tissue grafting to cover exposed root surfaces and bone grafting to provide support for implants. Dental implants are used to replace severely diseased or missing teeth, but implant overuse is of concern. The utility of laser treatment for periodontitis remains unresolved. Host modulation and risk-factor modification therapies may benefit select patient groups. Patient self-care is a critical part of periodontal health care, and twice-weekly oral rinsing with 0.10-0.25% sodium hypochlorite constitutes a valuable adjunct to conventional anti-plaque and anti-gingivitis treatments. A link between periodontal herpesviruses and systemic diseases is a strong biological plausibility. In summary, research during the past 25 years has significantly changed our concepts of periodontitis pathobiology and has produced more-effective and less-costly therapeutic options.

Perceptions and attitudes toward performing risk assessment for periodontal disease: a focus group exploration

Background

Currently, many risk assessment tools are available for clinicians to assess a patient’s periodontal disease risk. Numerous studies demonstrate the potential of these tools to promote preventive management and reduce morbidity due to periodontal disease. Despite these promising results, solo and small group dental practices, where most people receive care, have not adopted risk assessment tools widely, primarily due to lack of studies in these settings. The objective of this study was to explore the knowledge, attitudes, and beliefs of dental providers in these settings toward risk-based care through focus groups.

Methods

We conducted six focus group sessions with 52 dentists and dental hygienists practicing in solo and small group practices in Pittsburgh, PA and New York City (NYC), NY. An experienced moderator and a note-taker conducted the six sessions, each including 8–10 participants and lasting approximately 90 min. All sessions were audio-recorded and transcribed verbatim. Two researchers coded the focus group transcripts. Using a thematic analysis approach, they reviewed the coding results to identify important themes and selected representative excerpts that best described each theme.

Results

Providers strongly believed identifying risk factors could predict periodontal disease and use this information to change their patients’ behavior. A successful risk assessment tool could assist them in educating and changing their patient’s behaviors to adopt a healthy lifestyle, thus enabling them to play a major role in their patients’ overall health. However, to achieve this goal, it is essential to educate all dental providers and not just dentists on performing risk assessment and translating the results into actionable recommendations for patients. According to study participants, the research community has focused more on translating research findings into a risk assessment tool, and less on how clinicians would use these tools during patient encounters and if it affects a patients’ risk or outcome.

Conclusions

Dental practitioners were open to performing risk assessment as routine care and playing a bigger role in their patients’ overall health. Recommendations to overcome major barriers included educating dental providers at all levels, conducting more research about their adoption and use in real-world settings and developing appropriate reimbursement models.

Electronic supplementary material

The online version of this article (10.1186/s12903-018-0550-2) contains supplementary material, which is available to authorized users.

Minimally invasive periodontal therapy for general practitioners

There remains a high prevalence of mild-to-moderate forms of periodontal diseases in both developed and developing countries. Although many periodontal specialty practices currently place strong emphasis on implant surgery, periodontal plastic surgery and esthetics, general dentists and hygienists have often assumed more responsibility than periodontal specialty practices for the diagnosis, treatment, assessment and maintenance, and possible referral, of their patients. To address these current trends and challenges, this volume of Periodontology 2000 presents a series of topics on the basic biological principles of periodontal disease, as well as on approaches to diagnosis, treatment planning and treatment, in what is called 'conservative' or 'noninvasive' periodontal therapy. These topics include risk assessment of the periodontal condition; reduction, elimination and/or control of etiologies and risk factors, including mechanical, antimicrobial and host-modulation approaches; considerations for evaluation of clinical outcomes based on treatment approaches; and selected topics in laser therapy, halitosis and gingival recession.