Environmental tobacco smoke and periodontal disease in the United States

The influence of periodontitis case definition on the association between periodontal disease and glycaemic status

OBJECTIVE

The association between periodontitis and glycaemic control is complex, and often described as 'bidirectional'. Although epidemiological studies have examined this relationship extensively, a disagreement on periodontitis case definition still exists. This study aimed to assess the influence of case definition on the association between periodontal disease and glycaemic status.

METHODS

The study is a secondary analysis of data from the United States National Health and Nutrition Examination Survey (NHANES), 2009-2014 cycles. The association between periodontitis and glycated haemoglobin (HbA1c) was assessed using different periodontitis case definitions: the definition by the Centers for Disease Control and Prevention and the American Academy of Periodontology (CDC/AAP), Community Periodontal Index (CPI), ≥1 site with ≥3 mm clinical attachment loss (CAL) and ≥4 mm probing depth (PD), ≥1 site with ≥4 mm CAL and ≥4 mm PD, the 5th European Workshop definitions, Machtei et al. 'established periodontitis', the 2017 World Workshop classification, and self-reported periodontitis. The associations between periodontitis and HbA1c were compared across the case definitions.

RESULTS

There was substantial variability in prevalence estimates of periodontitis, and in the strength of association between periodontitis and HbA1c when different case definitions were applied. The CDC/AAP and stage III/IV periodontitis were consistently significantly associated with elevated HbA1c. For stage III/IV, the adjusted odds ratios of prediabetes and diabetes HbA1c were 1.19 and 1.76, respectively.

CONCLUSION

Comprehensive periodontitis case definitions that account for CAL and PD, such as the CDC/AAP and the 2017 classification, seem to better detect the association between periodontal disease and HbA1c.

Differences in Oral Health and Generalized Anxiety Disorder According to Secondhand Smoke Exposure in Public Places

BACKGROUND

This study aims to provide basic data for minimizing exposure to secondhand smoke (SHS) by confirming the relationship between exposure to SHS and generalized anxiety disorder (GAD).

METHODS

Using the third year data of the eighth National Health and Nutrition Examination Survey, 3874 people were selected as subjects. Complex sampling analysis was applied to all analyses, and 307 people were exposed to the SHS group (SHSG) and 3567 people were not exposed to the SHS group (NSHSG). Complex sample linear regression analysis was conducted to confirm the effect of exposure to SHS on oral health and GAD.

RESULTS

Among oral-health-related factors, exposure to SHS in Korean adults was related to the presence of implants. Additionally, exposure to SHS had a significant effect on GAD despite adjusting for sociodemographic characteristics and oral-health-related factors (p < 0.05).

CONCLUSIONS

In this study, the relationship between passive smoking and GAD was confirmed. Therefore, to reduce GAD, oral health management is necessary and exposure to SHS should be minimized.

The role of cigarette smoking in periodontal disease and treatment outcomes of dental implant therapy

Tobacco smoking has been implicated in periodontal pathology through various mechanisms, including perturbations of the inflammatory and host responses to putative periodontal pathogens, alterations in the subgingival microbial communities, and a compromised healing potential of the tissues leading to imbalance of tissue homeostasis. This review provides the evidence for the relationship between cigarette smoking and periodontal disease in an attempt to explain possible mechanisms of how tobacco smoking may exert its negative effects on the periodontal tissues via systemic and localized pathways. Early and more recent studies explore cigarette smoking-induced changes in periodontal clinical indices; in subgingival microbial flora by employing traditional detection methods for selected microorganisms, in addition to modern techniques such as deep sequencing and bioinformatics analyses that are able to fully characterize the microbial communities; and in inflammatory and immune responses critically appraising study limitations and differences in study protocol designs. Periodontal treatment outcomes and implant therapy outcomes are reviewed in an attempt to shed light on possible mechanisms for the inferior treatment outcome noted in smokers. The potential harmful effects of passive smoking are also reviewed, providing evidence for the advantages of smoking cessation. Quitting cigarette smoking should be recommended by the dentist, and effort should be made to inform smokers about the negative effects of smoking on the periodontal status and implant therapy outcomes.

Association between exposure to secondhand smoking at home and tooth loss in Japan: A cross-sectional analysis of data from the 2016 National Health and Nutrition Survey

INTRODUCTION

Tooth loss affects oral health and physical and social functions. With widespread population aging, its prevalence is increasing. Secondhand smoking is a risk factor for oral diseases; however, in Japan, there are currently no regulations restricting exposure to secondhand smoke at home. This cross-sectional study examined the association between secondhand smoking at home and tooth loss among Japanese adults.

METHODS

The study examined secondary data from the 2016 National Health and Nutrition Survey, Japan. The self-reported responses of 18812 non-smokers aged ≥20 years were analyzed. The association between exposure to secondhand smoke at home and number of teeth was examined through multiple linear regression with multiple imputation. To obtain a more normal distribution, logarithmic transformation was applied to the number of teeth that deviated substantially from a normal distribution. Adjustments were made for sex, age, occupation, household size, dental check-up within the past year, and exposure to secondhand smoke outside the home.

RESULTS

Overall, 8.4% of the respondents were exposed to secondhand smoking at home almost every day; this percentage was larger among younger respondents, who also had more teeth than the older respondents. Although the univariate linear regression did not show a positive association between exposure to secondhand smoke and tooth loss, the multivariate-adjusted analysis revealed that respondents who were exposed to secondhand smoke at home almost every day had fewer teeth (β= -0.04; 95% CI: -0.07 – -0.01).

CONCLUSIONS

The present results suggest that exposure to secondhand smoke at home increases the risk of tooth loss.

Collins J, Jones T, Brache M, Toro M, Tumanyan S, Walters C, White S, Elias-Boneta A. The SmoCar Study: A Caribbean-Based Multicenter Study on the Prevalence and Disparities Linked to Smoking and Gingival Health

The aim of the SmoCar (Smoking in the Caribbean) study was to estimate the prevalence of smoking and the disparities in the smoking practices of three regions in the Caribbean: Jamaica, Dominican Republic, and Puerto Rico. The secondary objective was to assess the prevalence and severity of gingivitis in relation to the smoking practices. The study population comprised 1,847 (weighted N = 1,830) individuals (18 years and older) who were volunteer participants from the capitals of Jamaica, Dominican Republic, and Puerto Rico. A structured interview was used to assess the participants’ smoking behaviors. The gingival index was used to determine the extent of gingival inflammation. Polytomous regression was used to estimate the adjusted odds ratios (aORs) for smoking status (current, past, or never), according to risk factors (sex, age-group, education, marital status, tooth-brushing frequency, and city of residence). Logistic regression models were used to assess the associations between different smoking status variables and mild to moderate/severe gingivitis. The majority of the participants were never-smokers, with current smokers being found most commonly in Kingston (33.22%), followed by San Juan (12.76%) and Santo Domingo (8.8%). Both current (aOR = 2.22, 95% confidence interval [1.45, 3.40]) and past (aOR = 1.87, 95% confidence interval [1.19, 2.93]) smoking (vs. never smoking) was strongly associated with severe gingivitis. Smoking was the most prevalent in Jamaicans and the least prevalent in Dominicans. The study population of current smokers was found to have a fourfold increased risk of severe gingivitis and a twofold increased risk of moderate gingivitis.

Effect of tobacco smoking on the risk of developing community acquired pneumonia: A systematic review and meta-analysis

AIM

To summarise and quantify the effect of tobacco smoking on the risk of developing community acquired pneumonia (CAP) in adults.

METHODS

We systematically searched MEDLINE, Embase, CINAHL, PsychINFO and Web of Science, from inception to October 2017, to identify case-control and cohort studies and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. The review protocol was registered with the PROSPERO database (CRD42018093943). Study quality was assessed by the Newcastle-Ottawa Scale. Pooled odds ratios (ORs) or hazard ratios (HRs) were estimated using a random-effects model.

RESULTS

Of 647 studies identified, 27 studies were included (n = 460,592 participants) in the systematic review. Most of the included studies were of moderate quality with a median score of six (IQR 6-7). Meta-analysis showed that current smokers (pooled OR 2.17, 95% CI 1.70-2.76, n = 13 studies; pooled HR 1.52, 95% CI 1.13-2.04, n = 7 studies) and ex-smokers (pooled OR 1.49, 95% CI 1.26-1.75, n = 8 studies; pooled HR 1.18, 95% CI 0.91-1.52, n = 6 studies) were more likely to develop CAP compared to never smokers. Although the association between passive smoking and risk of CAP in adults of all ages was not statistically significant (pooled OR 1.13, 95% CI 0.94-1.36, n = 5 studies), passive smoking in adults aged ≥65 years was associated with a 64% increased risk of CAP (pooled OR 1.64; 95% CI 1.17-2.30, n = 2 studies). Dose-response analyses of data from five studies revealed a significant trend; current smokers who smoked higher amount of tobacco had a higher risk of CAP.

CONCLUSION

Tobacco smoke exposure is significantly associated with the development of CAP in current smokers and ex-smokers. Adults aged > 65 years who are passive smokers are also at higher risk of CAP. For current smokers, a significant dose-response relationship is evident.

Salivary LL-37 and periodontal health in children exposed to passive smoking

BACKGROUND

Antimicrobial peptides play an important role in the local defence of oral cavity. Cigarette smoke has detrimental effects on immune defence mechanisms. The effect of passive smoking on salivary LL-37, as an antimicrobial peptide, in children has not yet been reported.

AIM

The aims of this study were to evaluate salivary LL-37 levels in PS-exposed and PS-unexposed children and to investigate the association between salivary LL-37 levels and periodontal clinical parameters.

DESIGN

Unstimulated salivary samples were collected from 180 children (90 PS-exposed [38 girls and 52 boys; mean age: 9.36 ± 1.60 years] and 90 PS-unexposed [43 girls and 47 boys; mean age: 9.02 ± 1.71 years]) in this study. Periodontal clinical parameters, including plaque index (PI), gingival index (GI), probing depth (PD), and clinical attachment level (CAL), were recorded in all children. Salivary cotinine and LL-37 levels were measured by enzyme-linked immunosorbent assay.

RESULTS

PI and GI values in PS-exposed children were significantly higher than those in PS-unexposed children. The mean salivary cotinine concentration was significantly higher in PS-exposed children than in control subjects. The mean salivary LL-37 concentration of PS-exposed children was significantly lower (100.71 ± 72.14 pg/mL) than that of PS-unexposed children (151.84 ± 107.89 pg/mL).

CONCLUSION

Passive smoking could suppress salivary LL-37 concentrations in children.

Prevalence of periodontal status among nicotine dependent individuals of 35-44 years attending community dental camps in Ghaziabad district, Uttar Pradesh

Background:

Tobacco is the second driving reasons for mortality worldwide and its broad utilization in the smoking and smokeless form have added to the expanding weight of non-communicable disease.

Aim:

To study the prevalence of periodontal status among nicotine dependent individuals of 35-44 years attending community dental camps in Ghaziabad District, Uttar Pradesh.

Methods:

A cross-sectional study was conducted on 800 individuals with the age range of 35-44 years. A pre-tested questionnaire was used to gather information about the sociodemographic profile and the pattern of substance use. Fagerstrom Test for Nicotine Dependence-Smokeless Tobacco (FTND-ST) and for smokers; Fagerstrom Test for Nicotine Dependence (FTND) for testing dependence. Periodontal status was assessed by Community Periodontal Index (Modified CPI WHO 2013) and loss of attachment (LOA). Statistical analysis was done by the Statistical Package for Social Sciences (SPSS) version 20.0.

Result:

The prevalence of periodontal disease was found to be 78.5% with maximum disease prevalence among males of 42-44 age. Majority of male consumed a smokeless form of tobacco (50.23%), followed by smoke (14.19%) form whereas females predominantly consumed smokeless form (37.36%). The mean number of teeth with pocket (3.37 ± 1.86) and mean of loss of attachment of more than 9 mm (0.67 ± 0.88) was higher among smokeless form of tobacco users as compared to other habit groups

Conclusion:

Higher prevalence of periodontal disease was seen among nicotine dependent individuals. A model for a comprehensive program in the dental office including the five A's and five R's for tobacco counseling must be applied at every institute.

Influence of involuntary cigarette smoke inhalation on osseointegration: a systematic review and meta-analysis of preclinical studies

There are no studies that have systematically reviewed the influence of involuntary cigarette smoke inhalation (ICSI) on the stability of implants. The aim of the present study was to perform a systematic review and meta-analysis of preclinical studies that assessed the influence of involuntary cigarette smoke inhalation ICSI on osseointegration. Indexed databases (PubMed, Google-Scholar, Scopus, EMBASE, and Web of Knowledge) were searched till September 2017. Titles and abstracts of studies identified using the above-described protocol were independently screened by 2 authors. Full-texts of studies judged by title and abstract to be relevant were independently evaluated for the stated eligibility criteria. Nine studies were included. Six studies showed that ICSI compromised bone area contact around implants. In 4 studies, peri-implant bone mineral density was significantly higher in the control group than among subjects exposed to ICSI. For the effects of ICSI on the osseointegration of dental implants, significant differences could be observed for bone-to-implant contact for test subjects in cancellous (Z=-4.08, p<0.001) and cortical bone (Z=-4.31, p<0.001) respectively. ICSI may negatively influence osseointegration of dental implants. It is imperative to educate patients about the negative effects of passive smoking on dental and systemic health.

Streptococcus pneumoniae Colonization Is Required To Alter the Nasal Microbiota in Cigarette Smoke-Exposed Mice

Smokers have nasal microbiota dysbiosis, with an increased frequency of colonizing bacterial pathogens. It is possible that cigarette smoke increases pathogen acquisition by perturbing the microbiota and decreasing colonization resistance. However, it is difficult to disentangle microbiota dysbiosis due to cigarette smoke exposure from microbiota changes caused by increased pathogen acquisition in human smokers. Using an experimental mouse model, we investigated the impact of cigarette smoke on the nasal microbiota in the absence and presence of nasal pneumococcal colonization. We observed that cigarette smoke exposure alone did not alter the nasal microbiota composition. The microbiota composition was also unchanged at 12 h following low-dose nasal pneumococcal inoculation, suggesting that the ability of the microbiota to resist initial nasal pneumococcal acquisition was not impaired in smoke-exposed mice. However, nasal microbiota dysbiosis occurred as a consequence of established high-dose nasal pneumococcal colonization at day 3 in smoke-exposed mice. Similar to clinical reports on human smokers, an enrichment of potentially pathogenic bacterial genera such as Fusobacterium, Gemella, and Neisseria was observed. Our findings suggest that cigarette smoke exposure predisposes to pneumococcal colonization independent of changes to the nasal microbiota and that microbiota dysbiosis observed in smokers may occur as a consequence of established pathogen colonization.

Accuracy of cotinine serum test to detect the smoking habit and its association with periodontal disease in a multicenter study

Background

The validity of the surveys on self-reported smoking status is often questioned because smokers underestimate cigarette use and deny the habit. It has been suggested that self-report should be accompanied by cotinine test. This report evaluates the usefulness of serum cotinine test to assess the association between smoking and periodontal status in a study with a large sample population to be used in studies with other serum markers in epidemiologic and periodontal medicine researches.

Material and Methods

578 patients who were part of a multicenter study on blood biomarkers were evaluated about smoking and its relation to periodontal disease. Severity of periodontal disease was determinate using clinical attachment loss (CAL). Smoking was assessed by a questionnaire and a blood sample drawn for serum cotinine determination.

Results

The optimal cut-off point for serum cotinine was 10 ng/ml. Serum cotinine showed greater association with severity of CAL than self-report for mild-moderate CAL [OR 2.03 (CI95% 1.16-3.53) vs. OR 1.08 (CI95% 0.62-1.87) ] advanced periodontitis [OR 2.36 (CI95% 1.30- 4.31) vs. OR 2.06 (CI95% 0.97-4.38) ] and extension of CAL > 3 mm [ OR 1.78 (CI95% 1.16-1.71) vs. 1.37 (CI95% 0.89-2.11)]. When the two tests were evaluated together were not shown to be better than serum cotinine test.

Conclusions

Self-reported smoking and serum cotinine test ≥ 10ng/ml are accurate, complementary and more reliable methods to assess the patient’s smoking status and could be used in studies evaluating serum samples in large population and multicenter studies. Clinical Relevance: The serum cotinine level is more reliable to make associations with the patient’s periodontal status than self-report questionnaire and could be used in multicenter and periodontal medicine studies.

Key words:Biological markers, serum, cotinine, periodontitis, smoking.

Environmental Tobacco Smoke and Periodontitis in United States Non-Smokers, 2009 to 2012

BACKGROUND

Epidemiologic studies using half-mouth designs for assessment of periodontal disease prevalence have reported that environmental tobacco smoke (ETS) exposure of non-smokers is associated with a two- to three-fold increase in the odds of developing periodontitis. In response to the possibility of under-reporting of periodontitis, the Centers for Disease Control updated periodontal examination procedures in 2009 for the National Health and Nutritional Examination Survey (NHANES), including full-mouth, six-site periodontal probing, and attachment loss assessment. Aims of this study are to estimate prevalence of periodontitis among United States non-smoking adults exposed to ETS, report the values of the improved methods for estimating disease prevalence, and evaluate the predictive contribution of ETS exposure to periodontitis.

METHODS

A cross-sectional study was conducted using NHANES data from the 2009 to 2012 examination cycle. To address these aims, oral examination data were used to determine prevalence of periodontitis among United States non-smoking adults and to test the influence of ETS exposure on occurrence of periodontitis.

RESULTS

There was a 28% increase in the odds of periodontitis for those with any ETS exposure compared with those with no measurable exposure (Wald χ2 test statistic [df] = 6.58 [1], P = 0.01; 95% confidence interval = 1.06 to 1.55).

CONCLUSION

ETS exposure increases the risk of an individual developing periodontitis.

Environmental tobacco smoke exposure and periodontitis prevalence among nonsmokers in the hispanic community Health Study/Study of Latinos

OBJECTIVE

To describe self-reported exposure to environmental tobacco smoke (ETS) and its association with periodontitis prevalence in a diverse group of Hispanics/Latinos.

METHODS

Data came from 8675 lifetime nonsmokers in the 2008-2011 Hispanic Community Health Study/Study of Latinos. Exposure to ETS was self-reported, while periodontitis was defined using the Centers for Disease Control and Prevention-American Academy of Periodontology criteria and the proportion of sites affected by clinical attachment level of ≥3 mm or pocket depth of ≥4 mm. Survey logistic regression estimated prevalence odds ratios (POR) and 95% confidence intervals (CI). In addition, we assessed whether greater hours of exposure to ETS in the past year was associated with greater periodontitis prevalence, and lastly, we conducted a simple sensitivity analysis of ETS misclassification.

RESULTS

Age-standardized prevalence estimates (95% CI) for ETS exposure and periodontitis were 57.6% (55.9, 59.4) and 39.8% (38.1, 41.4), respectively. After adjusting for confounders and periodontitis risk factors, we estimated an overall adjusted POR (95% CI) for the ETS-periodontitis association as 1.09 (0.95-1.26) with a confidence limit ratio (CLR) of 1.34. This association varied in magnitude by Hispanic/Latino background, ranging from 1.04 (0.75, 1.43 with a CLR = 1.91) among Central Americans to 1.76 (1.16, 2.66 with a CLR = 2.29) in Puerto Ricans.

CONCLUSIONS

Previously reported associations between ETS and periodontitis appear weak in this study. However, the magnitude of the association differs according to Hispanic/Latino background.

Prevalence and risk factors of periodontal disease among pre-conception Chinese women

BACKGROUND

Periodontal disease is one of the most common chronic infectious diseases. It has been reported that periodontal disease is associated with various adverse pregnancy outcomes including preterm birth, low birth weight, and gestational diabetes mellitus. Given the fact that the treatment for periodontal disease during pregnancy was ineffective in improving pregnancy outcomes by most of studies, the pre-conception period has been put forward as a more optimal time. However, very few studies have reported the prevalence of periodontal disease among pre-conception women. This study aimed to examine the prevalence and risk factors of periodontal disease among Chinese pre-conception women.

METHODS

A survey was conducted among pre-conception women at the Maternal and Child Health Hospital, Changzhou, China between January 2012 and December 2014. A total of 987 pre-conception women were recruited for a full-mouth dental examination after providing informed consent. A dental examination was carried out by probing six sites per tooth using a manual UNC-15 probe and a recording form.

RESULTS

The overall rate of periodontal disease among participants was 73.9% (729/987) (95% confidence interval (CI): 71.0-76.6%). Among women with periodontal disease, 48.0% of cases were mild, 50.9% were moderate and 1.1% were severe. Self-reported bleeding during tooth brushing was the only significant predictive factor for overall periodontal disease (adjusted odds ratio (aOR): 3.71, 95% CI: 2.24, 6.15, P < 0.001) and moderate/severe periodontal disease (aOR: 5.17, 95% CI: 3.05, 8.79, P < 0.001).

CONCLUSION

A high prevalence of periodontal disease was found in pre-conception Chinese women. Women who have bleeding during tooth brushing could be at increased risk of periodontal disease, and might require further oral health care.

Relationship between Obstructive Sleep Apnea and Self-assessed Oral Health Status: An Internet Survey

The purpose of this study based on a cross-sectional internet survey was to investigate the relationship between risk of obstructive sleep apnea (OSA) and self-assessed oral health status. The participants, who comprised individuals registered with an online research company, were required to complete a self-reported questionnaire. Those answering in the affirmative to both of the following two questions were placed in the OSA-risk group, while those answering in the negative were assigned to the control group: 'Have other people noticed pauses in your breathing while you are sleeping?' and 'Do you feel excessively sleepy during the daytime?'. A total of 493 were included in the OSA-risk group and 2,560 in the control group. Among the total 3,053 respondents, the highest prevalence for OSA risk in men was in the 50-59-year age range, although this tended to level off after age 60 years. No such trend was observed in women, however. Multiple logistic regression analysis was performed to identify the relationship between risk of OSA and self-assessed oral health status. Significant correlations were observed with the following parameters: difficulty in opening mouth (odds ratio [OR]: 2.66; 95% confidence interval [CI]: 1.647-4.311), dry mouth (OR: 2.11; CI: 1.544-2.876), bad breath (OR: 1.69; CI: 1.309-2.186), gingival bleeding (OR: 1.48; CI: 1.134-1.932), and gingival swelling (OR: 1.44; CI: 1.046-1.981). These results suggest a relationship between risk of OSA and self-assessed oral health status, indicating that treating OSA might improve oral health status. Further study is needed to demonstrate a causal relationship between OSA and self-assessed oral health status, however.

Estimating the Economic Impact of Secondhand Smoke on the Health of a Community

Purpose.

This study provides a model to estimate the health-related costs of secondhand smoke exposure at a community level.

Model Development.

Costs of secondhand smoke–related mortality and morbidity were estimated using national attributable risk values for diseases that are causally related to secondhand smoke exposure for adults and children. Estimated costs included ambulatory care costs, hospital inpatient costs, and loss of life costs based on vital statistics, hospital discharge data, and census data.

Application of the Model.

The model was used to estimate health-related costs estimates of secondhand smoke exposure for Marion County, Indiana. Attributable risk values were applied to the number of deaths and hospital discharges to determine the number of individuals impacted by secondhand smoke exposure.

Results.

The overall cost of health care and premature loss of life attributed to secondhand smoke for the study county was estimated to be $53.9 million in 2000—$10.5 million in health care costs and $20.3 million in loss of life for children compared with $6.2 million in health care costs and $16.9 million in loss of life for adults. This amounted to $62.68 per capita.

Conclusions.

This method may be replicated in other counties to provide data needed to educate the public and community leaders about the health effects and costs of secondhand smoke exposure.

Systematic Review and Meta-analysis of the Association Between Exposure to Environmental Tobacco Smoke and Periodontitis Endpoints Among Nonsmokers

OBJECTIVE

A systematic review was conducted to summarize the epidemiological evidence on environmental tobacco smoke (ETS) exposure and prevalent periodontitis endpoints among nonsmokers.

METHODS

We searched PubMed, EMBASE, Web of Science, Pro-Quest dissertations, and conference proceedings of a dental research association. We included studies from which prevalence odds ratios (POR) could be extracted for periodontitis determined by examiner measurements of clinical attachment level (CAL) and/or probing pocket depth (PD) or self-report of missing teeth. Studies determined ETS exposure by self-report or biomarker (cotinine) levels.

RESULTS

For studies reporting CAL and/or PD (n = 6), associations were stronger with cotinine-measured exposure (n = 3; random effects POR [95% prediction interval] = 1.63 (0.90, 2.96)) than self-reported exposure (n = 3; random effects POR = 1.15 (0.68, 1.96)). There was no meaningful difference in summary estimate for studies reporting CAL and/or PD endpoint (n = 6; random effects POR = 1.34 (0.93, 1.94)) as opposed to tooth loss (n = 2; random effects POR = 1.33 (0.52, 3.40)).

CONCLUSIONS

There appears to be a positive association between exposure to ETS and prevalent periodontitis endpoints among nonsmokers, the magnitude of which depended mostly on the method of ETS assessment.

IMPLICATIONS

The notoriety of ETS is often discussed in terms of its associations with cancer, chronic conditions like cardiovascular diseases, and respiratory illnesses in children. However, very little attention is paid to its association with oral diseases, especially periodontitis. Periodontitis affects a large proportion of the population and is a major cause of tooth loss. This study summarized the epidemiologic association between exposure to ETS and periodontitis among nonsmokers. Although the findings are consistent with a positive association, methodological weaknesses relating to study design, assessment of ETS, periodontitis, and adjustment covariates were highlighted and recommendations for improvement in future studies provided.

Periodontal disease classifications revisited

An American Academy of Periodontology Task Force has recently published a report on the Update to the 1999 Classification of Periodontal Diseases and Conditions, which is a focused update outlining changes to be included in a comprehensive update planned for 2017. We discuss the proposed changes, and their rationales, and conclude that the periodontal classification carousel will continue to spin until it is realized that the only way forward is a profound reconsideration of what we hope to achieve with classifications.

Smoking and inflammation: evidence for a synergistic role in chronic disease

Tobacco smoking is the most important preventable risk factor for periodontitis; however, the underlying biological mechanisms responsible for the detrimental effects of smoking on periodontal health remain largely unclear. It is also well established that smoking has a negative impact on several inflammatory diseases, including rheumatoid arthritis, multiple sclerosis and inflammatory bowel disease. The aim of this paper was to review smoking-related changes in local and systemic host responses with a focus on cellular and molecular effects that could explain a hyperinflammatory response leading to periodontal destruction. Biological mechanisms that may be common to periodontal disease and other chronic inflammatory diseases were also explored, together with gene-smoking interactions. An epidemiologic perspective on the burden of smoking on periodontal health and the potential for smoking cessation is also presented. Tobacco smoking seems to induce changes ranging from decreased leukocyte chemotaxis to decreased production of immunoglobulins. Smoking also seems to cause a stronger inflammatory reaction with an increased release of potentially tissue-destructive substances (e.g. reactive oxygen species, collagenase, serine proteases and proinflammatory cytokines). These findings support a hypothesis that periodontitis is a hyperinflammatory condition rather than a hypo-inflammatory condition.

Evaluation of the Effect of Passive Smoking on Lactoferrin and AST on 12 - 15 Years Old Children and Adolescents

BACKGROUND

Passive smokers are involuntarily exposed to cigarette or tobacco smoke and as known, inhalation of environmental tobacco smoke is a serious threat. There is little information about the effect of passive smoking on salivary markers and periodontal indices.

OBJECTIVES

This study investigated the effect of passive smoking on lactoferrin and AST in 12 - 15 years old children and adolescents.

PATIENTS AND METHODS

This case-control analytic correlation type study with no-convenience random sampling method was performed on 160 children aged 12 - 15 who had smokers in their families. The eligible children were divided into two equal groups; 80 cot(+) children as case group and 80 cot(-) children as control group, matched according to age, sex and plaque index. Plaque index was obtained from all subjects. 2 cc unstimulated salivary samples were collected by spitting method. The collected specimens were tested by lactoferrin and AST kits in biochemistry were measured on the day of sampling laboratory. Gingival index Loe and Silness (GI) and Probing Pocket Depth (PPD).

RESULTS

Mean and Standard Deviation of PPD and GI was 2.01 ± 0.077 and 1.53 ± 0.055 in experimental group and 1.93 ± 0.073 and 1.49 ± 0.046 in control group respectively (P < 0.001). The Mean and Standard Deviation parameters of lactoferrin and AST, in the experimental group was 38.66 ± 25.15 and 13.45 ± 6.33 and in the control group 10.18 ± 6.82 and 6.53 ± 2.65 group, respectively (P < 0.001).

CONCLUSIONS

Passive smoking can be effective on inflammatory process of periodontal and salivary biomarkers related to inflammation. Lactoferrin was 11 - 104 in case group and 0.5 - 38 in control group. Aspartat aminotransferase in case group was 2.64 - 30.43 and in control group it was 2.16 - 12.02.

The association of active and secondhand smoking with oral health in adults: Japan public health center-based study

Background

Smoking is one of the major risk factors for oral diseases, and many studies have found that active smoking is closely associated with the prevalence or severity of periodontal disease and fewer remaining teeth. In contrast to the established association between active smoking and oral health, there have been very few studies investigating the effects of secondhand smoking on oral health, and whether secondhand smoking deteriorates oral health has not been fully clarified. The purpose of the present study was to examine whether active and secondhand smoking were associated with the prevalence of severe periodontal disease and number of teeth among Japanese adults.

Methods

Subjects were 1,164 dentate adults aged 55–75 years as of May 2005 who participated in both the Japan Public Health Center-Based Study Cohort I in 1990 and a dental survey in 2005. The dental survey was implemented in the Yokote health center jurisdiction, Akita Prefecture. Participating subjects completed a self-administered questionnaire and a clinical oral examination. The association of smoking status with prevalence of periodontal disease was analyzed using a logistic regression, and with number of teeth or functional tooth units of natural teeth (n-FTUs) using a generalized linear model.

Results

After adjusting for age, education level, history of diabetes, BMI, alcohol consumption, perceived mental stress, presence of a family dentist, and oral hygiene, the odds ratio (OR) of risk for periodontal disease in male subjects was significantly increased in non-smokers with secondhand smoking only at home (OR = 3.14, 95 % CI: 1.08−9.12, p = 0.036), non-smokers with secondhand smoking both at home and other places (OR = 3.61, 95 % CI: 1.33−9.81, p = 0.012) and current smokers (OR = 3.31, 95 % CI: 1.54−7.08, p = 0.002), compared to non-smokers without secondhand smoking. Further in men, current smokers had significantly fewer numbers of teeth (19.7 ± 6.82) and n-FTUs (4.92 ± 4.12) than non-smokers without secondhand smoking (22.2 ± 6.92, p = 0.014 and 6.56 ± 4.18, p = 0.007). Such significant relationships of smoking status with periodontal disease and dentition were not observed in women.

Conclusions

The present study indicates that active smoking as well as secondhand smoking may have harmful effects on periodontal health in men. Therefore, it is imperative for health and oral health professionals to enlighten people about the negative influence of smoking, not only on their own health but also on others’ health.

Update on Prevalence of Periodontitis in Adults in the United States: NHANES 2009 to 2012

BACKGROUND

This report describes prevalence, severity, and extent of periodontitis in the US adult population using combined data from the 2009 to 2010 and 2011 to 2012 cycles of the National Health and Nutrition Examination Survey (NHANES).

METHODS

Estimates were derived for dentate adults, aged ≥30 years, from the US civilian non-institutionalized population. Periodontitis was defined by combinations of clinical attachment loss (AL) and periodontal probing depth (PD) from six sites per tooth on all teeth, except third molars, using standard surveillance case definitions. For the first time in NHANES history, sufficient numbers of non-Hispanic Asians were sampled in 2011 to 2012 to provide reliable estimates of their periodontitis prevalence.

RESULTS

In 2009 to 2012, 46% of US adults, representing 64.7 million people, had periodontitis, with 8.9% having severe periodontitis. Overall, 3.8% of all periodontal sites (10.6% of all teeth) had PD ≥4 mm, and 19.3% of sites (37.4% teeth) had AL ≥3 mm. Periodontitis prevalence was positively associated with increasing age and was higher among males. Periodontitis prevalence was highest in Hispanics (63.5%) and non-Hispanic blacks (59.1%), followed by non-Hispanic Asian Americans (50.0%), and lowest in non-Hispanic whites (40.8%). Prevalence varied two-fold between the lowest and highest levels of socioeconomic status, whether defined by poverty or education.

CONCLUSIONS

This study confirms a high prevalence of periodontitis in US adults aged ≥30 years, with almost fifty-percent affected. The prevalence was greater in non-Hispanic Asians than non-Hispanic whites, although lower than other minorities. The distribution provides valuable information for population-based action to prevent or manage periodontitis in US adults.

Generalized Estimating Equations in Longitudinal Data Analysis: A Review and Recent Developments

Generalized Estimating Equation (GEE) is a marginal model popularly applied for longitudinal/clustered data analysis in clinical trials or biomedical studies. We provide a systematic review on GEE including basic concepts as well as several recent developments due to practical challenges in real applications. The topics including the selection of “working” correlation structure, sample size and power calculation, and the issue of informative cluster size are covered because these aspects play important roles in GEE utilization and its statistical inference. A brief summary and discussion of potential research interests regarding GEE are provided in the end.

Polymorphisms in Glutathione S-Transferase M1, T1, and P1 in Patients with Chronic Periodontitis: A Pilot Study

Background. Although the direct cause of chronic periodontitis is bacterial infection, the progression of this disease depends on genetic and environmental factors, and smoking is a known risk factor in the development and severity of the disease. An individual's susceptibility may be influenced by polymorphisms in the glutathione S-transferase genes. These genes encode enzymes that metabolize xenobiotic compounds. The aim of this study was to determine the frequency of GSTM1, GSTT1, and GSTP1 polymorphisms in Mexicans with chronic periodontitis. Methods. 60 Mexicans with chronic periodontitis (30 smokers and 30 nonsmokers) were studied. A peripheral blood sample was taken for subsequent DNA extraction. The genetic material was PCR-amplified followed by restriction fragment length polymorphism with the aim of identifying GST polymorphisms. Results. Polymorphisms in the GSTT1 and GSTP1 genes were not significantly different between the smokers and nonsmokers. However, there were significant differences (P = 0.05) between groups in polymorphisms in the GSTM1 gene. The patients with chronic periodontitis have a higher frequency of null and mutant polymorphisms in GSTM1, GSTT1, and GSTP1 compared with historical data from a healthy Mexican population. Conclusions. The presence of these polymorphisms may be a risk factor for the development of chronic periodontitis.

Do salivary and serum collagenases have a role in an association between obstructive sleep apnea syndrome and periodontal disease? A preliminary case-control study

OBJECTIVES

Despite increasing evidence for an association of obstructive sleep apnea syndrome (OSAS) and periodontal disease, the pathophysiological linking mechanisms remain unclear. This study aims to evaluate the salivary and serum matrix metalloproteinase-2, -8, -9 (MMP-2, -8, -9), tissue inhibitor of matrix metalloproteinase-1 (TIMP-1), myeloperoxidase (MPO), neutrophil elastase (NE), neutrophil gelatinase-associated lipocalin (NGAL), as well as degree of activation of MMP-2, -9 of patients with and without OSAS.

DESIGN

A total of 50 individuals were included in the study. There were 13, 17 and 20 individuals, respectively in the control (non-OSAS) group, mild-to-moderate OSAS and severe OSAS groups. Saliva, serum samples and clinical periodontal parameters were collected. Biofluid samples were analysed by immunofluorometric assay (IFMA), enzyme-linked immunosorbent assay (ELISA), western immunoblotting and gelatine zymography. Statistical analyses were performed using D'Agostino-Pearson omnibus normality test, Kruskal-Wallis test and Spearman rho rank correlation analysis.

RESULTS

There were no statistically significant differences in clinical periodontal parameters between the study groups. Salivary NE and proMMP-2 levels were significantly lower in the OSAS groups than the control group (p<0.05). Serum proMMP-9 concentration and the degree of MMP-9 activation in saliva were significantly lower in the severe OSAS group than the control group (p<0.05). There were significant correlations between salivary and serum proMMP-9 and -2 concentrations (p<0.05). Serum proMMP-2, NE and salivary proMMP-9 and -2 negatively correlated with indicators of OSAS severity (p<0.05).

CONCLUSIONS

The present findings do not support a pathophysiological link between the severity of OSAS and clinical periodontal status via neutrophil enzymes or MMPs.

Association between environmental tobacco smoke and periodontal disease: a systematic review

The aim of the present study was to systematically review the association between environmental tobacco smoke (ETS) and periodontal disease. The addressed focused question was "Is there a relationship between ETS and periodontal disease?" PubMed/MEDLINE and Google-Scholar databases were searched from 1987 up to March 2014 using different combinations of the following keywords: "Environmental tobacco smoke", "passive", "periodontal disease", "secondhand" and "smoking". Letters to the Editor, review articles, commentaries, case-reports and articles published in languages other than English were excluded. Thirteen studies were included. Nine studies were clinical and 4 studies were performed in-vitro. Five studies reported the odds ratios for periodontal disease to be significantly higher among individuals exposed to ETS than controls (non-smoking individuals unexposed to ETS). In 2 studies, ETS exposure showed no association with periodontal disease. In 2 studies, salivary aspartate aminotransferase, lactoferrin and albumin levels were reported to be significantly higher in individuals exposed to ETS than controls. In one study, levels of salivary interleukin-1β were reported to be significantly higher in individuals exposed to ETS than controls. The in-vitro studies reported ETS exposure to enhance the production of proinflammatory proteins and phagocytic activity of salivary polymorphonuclear leukocytes thereby contributing to periodontal disease. The association between ETS and periodontal disease remains debatable and requires further investigations.

Salivary cytokines and the association between obstructive sleep apnea syndrome and periodontal disease

BACKGROUND

A higher prevalence of periodontal disease has been reported in patients with obstructive sleep apnea syndrome (OSAS), and these two chronic conditions may be linked via inflammatory pathways. The aim of the present study is to evaluate the salivary interleukin (IL)-1β, IL-6, IL-21, IL-33, and pentraxin-3 (PTX3) concentrations in patients with and without OSAS.

METHODS

A total of 52 patients were included in the study. Thirteen individuals were in the control (non-OSAS) group, 17 were in the mild/moderate OSAS group, and 22 were in the severe OSAS group. Clinical periodontal measurements were recorded, and saliva samples were obtained before initiation of periodontal intervention. Enzyme-linked immunosorbent assay was used to determine salivary cytokine concentrations. Data were statistically analyzed using D'Agostino-Pearson omnibus normality, Spearman ρ rank, Kruskal-Wallis, and Dunn tests.

RESULTS

Salivary IL-6 and IL-33 concentrations were similar in the two OSAS groups (P >0.05), which were statistically higher than the control group (P <0.05). IL-1β, IL-21, and PTX3 concentrations were similar in the study groups. The only significant correlation between clinical periodontal parameters and salivary cytokines was found between clinical attachment level (CAL) and IL-21 (P = 0.02). Highly significant correlations were found between probing depth, CAL measures, and indicators of OSAS severity (P <0.01).

CONCLUSIONS

The present findings suggest that OSAS may have an increasing effect on salivary IL-6 and IL-33 concentrations regardless of OSAS severity. Additional investigation is required to elucidate a potential bidirectional relationship between OSAS and periodontal disease.

Community-acquired pneumonia among smokers

Recent studies have left absolutely no doubt that tobacco increases susceptibility to bacterial lung infection, even in passive smokers. This relationship also shows a dose-response effect, since the risk reduces spectacularly 10 years after giving up smoking, returning to the level of non-smokers. Streptococcus pneumoniae is the causative microorganism responsible for community-acquired pneumonia (CAP) most frequently associated with smoking, particularly in invasive pneumococcal disease and septic shock. It is not clear how it acts on the progress of pneumonia, but there is evidence to suggest that the prognosis for pneumococcal pneumonia is worse. In CAP caused by Legionella pneumophila, it has also been observed that smoking is the most important risk factor, with the risk rising 121% for each pack of cigarettes smoked a day. Tobacco use may also favor diseases that are also known risk factors for CAP, such as periodontal disease and upper respiratory viral infections. By way of prevention, while giving up smoking should always be proposed, the use of the pneumococcal vaccine is also recommended, regardless of the presence of other comorbidities.

State cigarette excise tax, secondhand smoke exposure, and periodontitis in US nonsmokers

OBJECTIVES

We assessed the relationship of state cigarette excise tax with cigarette sales, secondhand smoke (SHS) exposure, and periodontitis among US lifetime nonsmokers.

METHODS

Cigarette excise tax and per capita sales data from 1983 to 1998 were obtained for 50 states and the District of Columbia. Periodontal data were analyzed for 3137 adults in 28 states from 3 National Health and Nutrition Examination Survey cycles (1999-2004). Measures of periodontal pocket depth and attachment level were used to classify people with moderate or severe periodontitis. SHS exposure was classified according to gender- or race/ethnicity-specific thresholds of serum cotinine concentration. Statistical analysis adjusted for the complex survey design.

RESULTS

For each additional $0.10 in excise tax, predicted sales decreased by 0.74 packs per person per month and adjusted odds of moderate or severe periodontitis decreased 22% (odds ratio [OR] = 0.78; 95% confidence interval [CI] = 0.62, 0.97). For each pack sold per person per month, adjusted odds of SHS exposure increased 28% (95% CI = 1.17, 1.40) and adjusted odds of periodontitis increased 15% (95% CI = 1.03, 1.29). Odds of periodontitis for those exposed to SHS were elevated 2-fold relative to those who were unexposed (OR = 2.03; 95% CI = 1.30, 3.20).

CONCLUSIONS

Cigarette excise tax may protect nonsmokers against periodontitis.

Active and passive smoking and prevalence of periodontal disease in young Japanese women

BACKGROUND AND OBJECTIVE

Studies reporting on the association between smoking and periodontal disease have mostly focused on active smoking. The purpose of this study was to examine the relationships between active smoking and exposure to second-hand smoke at home and at work and the prevalence of periodontal disease among young Japanese women.

MATERIAL AND METHODS

Study subjects were 1167 postpartum women with a mean age of 31.5 years. Information on smoking and potential confounding factors was obtained through a self-administered questionnaire. Partial-mouth recording was used to determine probing pocket depth at six sites per tooth for six teeth in the mouth. Periodontal disease was defined as positive if a woman had at least one tooth with a probing pocket depth of 3.5 mm or deeper. Adjustment was made for age, region of residence, household income, education, toothbrushing frequency and use of an interdental brush.

RESULTS

Compared with never smoking, ever smoking was independently positively associated with the prevalence of periodontal disease: the adjusted odds ratio was 1.56 (95% confidence interval: 1.02-2.36). There was a marginally significant positive dose-response relationship between pack-years of smoking and the prevalence of periodontal disease (p for linear trend = 0.08). No material associations were observed between second-hand smoke exposure at home or at work and periodontal disease.

CONCLUSION

Our findings suggest that active smoking, but not passive smoking, might be associated with an increased prevalence of periodontal disease among young women in Japan.

The association between periodontitis and obstructive sleep apnea: a preliminary study

BACKGROUND AND OBJECTIVE

Periodontitis is becoming a highly prevalent disease worldwide. Obstructive sleep apnea (OSA) is a common disorder that is characterized by repeated disruptions in breathing during sleep, and mouth breathing is a common characteristic among patients with OSA. We aimed to assess the hypothesis that OSA is associated with the onset and progression of periodontal disease.

MATERIAL AND METHODS

This is a cross-sectional study of a total of 687 participants (460 men and 227 women), 47-77 years of age, who were examined between August 2009 and September 2010 as part of the Korean Genome and Epidemiology Study. The participants underwent standard polysomnography, clinical periodontal examination and health-screening examinations. Periodontitis was defined as clinical attachment level (CAL) ≥ 6 mm and probing pocket depth ≥ 4 mm. OSA was determined using the apnea-hypopnea index (AHI), and an AHI score of ≥ 5 was the cut-off used to indicate the presence of OSA.

RESULTS

The results showed that 17.5% of the participants had periodontitis, 46.6% had OSA and 60.0% who were diagnosed with periodontitis had OSA. In our study, old age, male gender, current smoking status, mouth breathing during sleep and high AHI were identified as risk factors for periodontitis. OSA was positively associated with periodontitis [odds ratio (OR) = 1.84, 95% confidence interval (CI) = 1.18-2.87], probing pocket depth (OR = 2.22, 95% CI = 1.30-3.77) and CAL (OR = 1.86, 95% CI = 1.07-3.21) in a dose-response manner. Additionally, OSA was positively associated with periodontitis (OR = 2.51, 95% CI = 1.37-4.62) in subjects ≥ 55 years of age, but not in subjects < 55 years of age.

CONCLUSION

There is a significant association between OSA and periodontal disease. Further research is needed to clarify the causal relationship between the two conditions.

Prevalence of periodontitis in adults in the United States: 2009 and 2010

This study estimated the prevalence, severity, and extent of periodontitis in the adult U.S. population, with data from the 2009 and 2010 National Health and Nutrition Examination Survey (NHANES) cycle. Estimates were derived from a sample of 3,742 adults aged 30 years and older, of the civilian non-institutionalized population, having 1 or more natural teeth. Attachment loss (AL) and probing depth (PD) were measured at 6 sites per tooth on all teeth (except the third molars). Over 47% of the sample, representing 64.7 million adults, had periodontitis, distributed as 8.7%, 30.0%, and 8.5% with mild, moderate, and severe periodontitis, respectively. For adults aged 65 years and older, 64% had either moderate or severe periodontitis. Eighty-six and 40.9% had 1 or more teeth with AL ≥ 3 mm and PD ≥ 4 mm, respectively. With respect to extent of disease, 56% and 18% of the adult population had 5% or more periodontal sites with ≥ 3 mm AL and ≥ 4 mm PD, respectively. Periodontitis was highest in men, Mexican Americans, adults with less than a high school education, adults below 100% Federal Poverty Levels (FPL), and current smokers. This survey has provided direct evidence for a high burden of periodontitis in the adult U.S. population.

Secondhand smoke and periodontal disease: atherosclerosis risk in communities study

OBJECTIVES

We investigated the relationship between secondhand smoke and periodontal disease in nonsmokers.

METHODS

We undertook a cross-sectional analysis of the Atherosclerosis Risk in Communities study with 2739 lifetime nonsmokers aged 53-74 years, unexposed to other sources of tobacco, who received a complete periodontal examination at visit 4. Exposure was reported as average hours per week in close contact with a smoker in the preceding year. We defined severe periodontitis as 5 or more periodontal sites with probing pocket depth of 5 millimeters or more and clinical attachment levels of 3 millimeters or more in those sites. Other outcomes were extent of periodontal probing depths of 4 millimeters or more and extent of clinical attachment levels of 3 millimeters or more.

RESULTS

In a binary logistic regression model, adjusted odds of severe periodontitis for those exposed to secondhand smoke 1 to 25 hours per week increased 29% (95% confidence interval = 1.0, 1.7); for those exposed to secondhand smoke 26 hours per week, the odds were twice as high (95% confidence interval = 1.2, 3.4) as for those who were unexposed.

CONCLUSIONS

Exposure to secondhand smoke and severe periodontitis among nonsmokers had a dose-dependent relationship.

n-3 fatty acids and periodontitis in US adults

BACKGROUND

Periodontitis is a common, chronic inflammatory disease. Although n-3 fatty acids have anti-inflammatory properties, it is unclear whether n-3 fatty acids can treat or prevent periodontitis.

METHOD

We studied 9,182 adults aged 20 years and older who participated in the National Health and Nutrition Examination Survey between 1999 and 2004. Periodontitis was assessed by dental exam and was defined as >4 mm pocket depth and >3 mm attachment loss in any one tooth. Intake of n-3 fatty acids was assessed by 24-hour dietary recall. We used multivariable logistic regression to estimate the associations between periodontitis and intakes of docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), and linolenic acid (LNA).

RESULTS

The weighted prevalence and 95% confidence interval (CI) of periodontitis was 8.2% (95% CI 7.0 to 9.4). Compared with the lowest tertiles, the adjusted odds ratios for periodontitis associated with the highest tertiles of dietary n-3 intake were 0.78 (95% CI 0.61 to 1.00; P=0.009) for DHA, 0.85 (95% CI 0.67 to 1.08; P=0.10) for EPA, and 0.86 (95% CI 0.60 to 1.23; P=0.28) for LNA. The associations were little changed by multivariable adjustment or exclusion of individuals reporting use of dietary supplements containing DHA, EPA, or LNA.

CONCLUSIONS

In this nationally representative sample, higher dietary intakes of DHA and, to a lesser degree, EPA, were associated with lower prevalence of periodontitis. Interventional studies are needed to confirm the potential protective effects of n-3 fatty acids on periodontitis.

Accuracy of NHANES periodontal examination protocols

This study evaluates the accuracy of periodontitis prevalence determined by the National Health and Nutrition Examination Survey (NHANES) partial-mouth periodontal examination protocols. True periodontitis prevalence was determined in a new convenience sample of 454 adults ≥ 35 years old, by a full-mouth "gold standard" periodontal examination. This actual prevalence was compared with prevalence resulting from analysis of the data according to the protocols of NHANES III and NHANES 2001-2004, respectively. Both NHANES protocols substantially underestimated the prevalence of periodontitis by 50% or more, depending on the periodontitis case definition used, and thus performed below threshold levels for moderate-to-high levels of validity for surveillance. Adding measurements from lingual or interproximal sites to the NHANES 2001-2004 protocol did not improve the accuracy sufficiently to reach acceptable sensitivity thresholds. These findings suggest that NHANES protocols produce high levels of misclassification of periodontitis cases and thus have low validity for surveillance and research.

Treating chronic periodontitis: current status, challenges, and future directions

Periodontitis affects roughly one-third of the US population. A timely diagnosis of chronic periodontitis at its earliest stage is essential to avoid more challenging severe stages of the disease. Most cases of slight and moderate chronic periodontitis can be successfully managed by mechanical removal and/or reduction of subgingival bacterial biofilms and calculus. However, any factor that affects either the local environment or the host response may contribute to progression of the disease and a poor treatment response. Thus, it is essential that clinicians are aware of etiologic and risk factors associated with disease development and progression in order to plan and execute a successful treatment. This paper reviews a variety of risk factors, both local and systemic, that can impact the successful treatment of chronic periodontitis.

[Effects of smoking on periodontal disease]

INTRODUCTION

Smoking is an independent risk factor for periodontal disease and tooth loss.

STATE OF THE ART

Smoking impairs inflammatory and immune responses to periodontal pathogens, and exerts both systemic and local effects. Periodontal disease is increased both in prevalence and severity in smokers. Smoking is a predisposing factor to acute necrotizing ulcerative gingivitis and is associated with an increased rate of periodontal disease in terms of pocket formation and attachment loss, as well as alveolar bone loss. Cigar, pipe, water-pipe and cannabis smoking have similar adverse effects on periodontal health as cigarette smoking. Passive smoking is also an independent periodontal disease risk factor. Smokeless tobacco is associated with localized periodontal disease. Smokers respond less favourably to both non-surgical and surgical treatments and have higher failure rates and complications following dental implantation. Smoking cessation may halt the disease progression and improve the outcome of periodontal treatment.

CONCLUSION

Smoking cessation counselling should be an integral part of periodontal therapy and prevention.

Evaluation of the Relationship between Passive Smoking and Oral Pigmentation in Children

INTRODUCTION

Melanin pigmentation in the oral mucosa occurs as a result of several reasons one of which is smoking. Cigarette smoke induces numerous side effects in the people who do not smoke, but are in the same environment. The aim of this study was to evaluate the role of parental smoking on pigmentation of their children's oral mucosa.

MATERIALS AND METHODS

This study was carried out as a historical cohort. Participants were 400 healthy children, 10 to 11 years old who did not use any drugs. The passive smoker group included 200 children who at least one member in their family was a smoker. The control group included 200 children who did not have a smoker in their family. Furthermore, two groups were matched in the point of view of skin color. The children in the two groups were examined and oral pigmentation was recorded. Finally, the results were analyzed by the chi- square test.

RESULTS

Pigmentation was seen in 150 children (75%) in the experimental group and 122 children (61%) in the control group (P<0.005). The relative risk of oral pigmentation for children who were exposed to passive smoking was 1.23.

CONCLUSION

Based on the results of this study, passive smoking can induce gingival pigmentation in children.

Periodontal health in children exposed to passive smoking

AIM

To determine (1) the cotinine levels of saliva, urine and gingival crevicular fluid (GCF) of children in families with and without smoking members and (2) a possible association between the periodontal health of the children and exposure to passive smoking.

MATERIAL AND METHODS

The study population comprised of 109 children in the age range 6-12 years. Children were classified as exposed to passive tobacco smoking (PTS-exposed, n=51) and as unexposed controls (PTS-unexposed, n=58). Plaque index, gingival index, bleeding on probing, probing depth and clinical attachment level (CAL) were recorded. GCF, saliva and urine samples were also collected. The levels of cotinine in these fluids were determined by enzyme-linked immunosorbent assay.

RESULTS

The mean salivary cotinine concentration was significantly increased in PTS-exposed children compared with PTS-unexposed children (p<0.05). Further, in a dose-dependent way, the mean salivary concentration was significantly higher in children whose father or mother was a smoker (p<0.05) as compared, respectively, with children whose fathers and mothers were non-smokers. The mean CAL was significantly less in PTS-exposed children compared with non-PTS-exposed children (0.09 mm; p<0.05) and also in children whose father was a smoker (p<0.05), but not in children whose mother was a smoker as compared with non-smoker fathers and mothers, respectively. The GCF cotinine levels were below the detection limits with the assay method that was used.

CONCLUSIONS

We have observed that children who are exposed to passive smoking have elevated cotinine levels in their saliva concomitant with a lowered CAL.

From the American Academy of Pediatrics: Technical report--Secondhand and prenatal tobacco smoke exposure

Secondhand tobacco smoke (SHS) exposure of children and their families causes significant morbidity and mortality. In their personal and professional roles, pediatricians have many opportunities to advocate for elimination of SHS exposure of children, to counsel tobacco users to quit, and to counsel children never to start. This report discusses the harms of tobacco use and SHS exposure, the extent and costs of tobacco use and SHS exposure, and the evidence that supports counseling and other clinical interventions in the cycle of tobacco use. Recommendations for future research, policy, and clinical practice change are discussed. To improve understanding and provide support for these activities, the harms of SHS exposure are discussed, effective ways to eliminate or reduce SHS exposure are presented, and policies that support a smoke-free environment are outlined.