Periodontal health in Europe: future trends based on treatment needs and the provision of periodontal services--position paper 1

This review gives an update on recent epidemiologic data on periodontal diseases and a description of current periodontal services in Europe. A Medline search of articles published within the last decade with the keywords epidemiology, prevalence, periodontitis, tooth loss, and Europe was performed. Data on provision of dental services originated from international databases. Epidemiologic data on the prevalence of edentulism, the number of missing teeth, the prevalence of probing depth (Community Periodontal Index - CPI >or= 3 or Pocket Depth - PD >or= 4 mm), and clinical attachment loss (CAL >or= 4 mm) displayed a fragmentary picture within Europe. With respect to the limited data on periodontal health, Spain, Sweden, and Switzerland ranked as the healthiest among European countries in contrast to Germany where increased tooth loss and the highest prevalence of CAL >or= 4 mm were reported. The role of dental auxiliaries especially of dental hygienists and/or the medico-legal framework in which they work, appears to be an important factor in provision of effective periodontal care. Actual epidemiologic data on periodontal diseases are non-homogeneous and absent from several European countries. This emphasises the need for more national representative epidemiological studies with a uniform design to permit comparability between different nations. Merging actual epidemiologic data with former data on provision of periodontal care may help to explain differences in periodontal parameters on a population basis and to define future provision of dental care.

The factors associated with body mass index in adults from the study of health in Pomerania (SHIP-0), Germany

OBJECTIVE

To investigate the relation between dental status, BMI and systemic diseases and to evaluate the risk factors for having a higher BMI.

MATERIALS AND METHODS

Apopulation based cross sectional study of 6248 subjects aged 18-80 years (response of 68.8%, n=4310) was conducted in the Study of Health in Pomerania (SHIP-0). Socio-demographic, medical and oral health information was recorded by 5 dentists at two similarly equipped medical/dental services in the cities of Greifswald and Stralsund. Bivariate statistics, multivariate statistics, linear and logistic regression models were performed to assess the relationship between following covariates: gender, educational level, family status, social activities, income, quality of life (SF-12), smoking, alcohol abuse, diabetes, renal disease, high blood pressure, dental status and high physical activity.

RESULTS

Significant risk factors for subjects having a higher BMI were: high blood pressure (OR=2.28), diabetes (OR=2.10), educational level (low: OR=1.49; medium OR=1.27), male (OR=1.32) and former smoker (OR=1.20). whereas young age, being single and being dentate (natural teeth, replaced teeth or fixed teeth) was shown to be protective for having a "high" BMI.

CONCLUSION

The most important predictors of BMI were shown to be social and medical factors. Dental factors are most significantly influenced by social factors and also exhibit an important impact on BMI.

[Gastrointestinal stromal tumor (GIST): imaging findings and differential diagnosis]

We report the preoperative imaging findings of a 75 year old man with a large tumor of the lower abdomen. Computed tomography showed a large intraabdominal mass. In the differential diagnosis a gastrointestinal stromal tumor (GIST) or a metastasis of an unknown primary neoplasia were considered. Histology confirmed the diagnosis of a gastrointestinal stromal tumor (GIST).

Incidence of clinical pulmonary embolism after laparoscopic surgery

Background

This study aimed to determine the incidence of pulmonary embolism (PE) following laparoscopic surgery and its potential risk factors.

Methods

Data concerning 44 453 patients from 114 surgical institutions were collected by the Swiss Association of Laparoscopic and Thoracoscopic Surgery. The incidence of postoperative PE despite thromboprophylaxis was evaluated and potential risk factors were assessed singly, and then in a consecutive stepwise logistic multiple regression analysis.

Results

Among 44 453 patients assessed, 55·8 per cent were female and 44·2 per cent were male. Interventions included cholecystectomy (52·8 per cent), hernia repair (17·7 per cent), appendicectomy (12·4 per cent), colonic surgery (4·6 per cent) and oesophageal surgery (5·5 per cent). Postoperative PE occurred in 86 patients (0·2 per cent), and the incidence tended to decrease during this study (P = 0·016). A total of 149 patients died (0·3 per cent) of which nine (6·0 per cent) were due to PE. Significant predictive risk factors were female sex (P < 0·001), age (P < 0·001), weight above 90 kg (P < 0·001), emergency procedure (P < 0·001) and operating time exceeding 150 min (P < 0·001).

Conclusion

The low incidence of PE after laparoscopy, with a further decrease over the past decade, suggests a tendency towards improved perioperative thromboembolic risk management.

Analysis of stapling versus endoloops in appendiceal stump closure

BACKGROUND

The effectiveness of various appendiceal stump closure methods has not been evaluated systematically. The aim of this study was to compare the morbidity of stump closure by stapling or use of endoloops.

METHODS

A non-concurrent cohort study of prospectively acquired data was performed. The primary outcome variable was the rate of intra-abdominal surgical-site infection. Secondary outcome measures were complications, duration of intervention, hospital stay, rate of readmission to hospital and the difference in direct costs of the operation.

RESULTS

Staples were used in 60.5 per cent and endoloops in 39.5 per cent of 6486 patients operated on for suspected appendicitis between January 1995 and December 2003. Among 4489 patients with acute appendicitis the rate of intra-abdominal surgical-site infection was 0.7 per cent in the stapler group and 1.7 per cent in the endoloop group (P = 0.004). The rate of readmission to hospital was 0.9 and 2.1 per cent respectively (P = 0.001).

CONCLUSION

Application of a stapler for transection and closure of the appendiceal stump in patients with acute appendicitis lowered the risk of postoperative intra-abdominal surgical-site infection and the need for readmission to hospital.

Inverse association between periodontitis and respiratory allergies

BACKGROUND

Periodontitis is an infection with systemic effects and a high prevalence among adults. In the aetiology of allergic diseases the hygiene hypothesis claims that infections in early infancy may protect against allergic diseases.

OBJECTIVE

The aim of the present analyses was to investigate the independent relation between periodontitis and respiratory allergies such as hayfever, house dust mite (HDM) allergy and asthma.

METHODS

From the Study of Health in Pomerania (SHIP) a total number of 2837 subjects aged 20 to 59 years were included in the analysis. In our study population 326, 111 and 114 subjects were classified as suffering from hayfever, HDM allergy or asthma, respectively. The attachment loss (AL) were measured. Periodontitis was defined according to the percentage of surfaces which exceeded 3 mm AL [healthy: 0-7.7%, mild: 7.8-28.6%, moderate: 28.7-63.9%, severe: >63.9%]. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression.

RESULTS

After adjustment for confounding factors these analyses revealed inverse associations between periodontitis and hayfever as well as periodontitis and HDM allergy. For increasing AL, a trend of decreasing risk could be observed for hayfever (healthy: reference; mild AL: OR 0.87 [95%-CI 0.6-1.2]; moderate AL: OR 0.80 [95% CI 0.6-1.2]; server AL: OR 0.53 [95% CI 0.3-0.9]; P(trend)=0.01) and for HDM allergy (healthy: reference; mild AL: OR 0.80 [95% CI 0.5-1.3]; moderate AL: OR 0.64 [95% CI 0.3-1.2]; server AL: OR 0.39 [95% CI 0.2-0.9]; P(trend)=0.02). Furthermore, for asthma were observed a slightly inverse association in the full-adjusted model (healthy: reference; mild AL: OR 1.10 [95% CI 0.6-2.0]; moderate AL: OR 0.96 [95% CI 0.5-1.8]; server AL: OR 0.48 [95% CI 0.2-1.0]; P(trend)=0.11).

CONCLUSION

There is an inverse association between periodontitis and respiratory allergies. Our results might support the hygiene hypothesis.

[Characteristics of risk groups with an insufficient demand for dental services - results of the study of health in Pomerania (SHIP)]

AIM

The purpose of this study was to identify risk groups for low dental care utilisation and to highlight adequate determinants for necessary action.

METHODS

The database was the "Study of Health in Pomerania" (SHIP), a cross-sectional sample drawn from the adult population (20 - 79 years) in a northeast region of Germany. 4310 of 7008 randomly selected inhabitants participated in the examinations (response rate 68.8 %). The use of dental care in the last year was analysed using logistic regression according to the conceptual model by Andersen and Newman.

RESULTS

Multivariate analysis revealed that participation in the bonus scheme system of the statutory sickness funds (OR = 8.2) and participation in the bonus system of the private health insurance companies (OR = 2.6) as "enabling resources" predicted dental care use in the last year. "Objektive need" (OR = 1.02) is weaker associated with dental care utilisation than "subjective need", for instance the attitude towards need of regular dental checkups. Presence of own teeth is a significant predictor for dental care utilization (OR = 3.3), whereas edentulous persons, those with complete denture prosthesis, don't think about possible oral problems and don't visit the dentist at least once a year. Among "predisposing factors" only gender and education were significant determinats for dental care utilization.

CONCLUSIONS

The conclusions concerning the significant influence of subjective need and promotional impact of the bonus scheme are important for health care. Financial incentives and motivation for regular prevention should be continued and upgraded. Measures to improve preventive dental care utilization should focus on persons with low educational levels and on men with inadequate dental care utilisation. The mental anchorage of the term "oral health" rather than the conventional term "dental health" is important, so that edentulous persons become conscious of regular prevention pointers to maintain a high quality of life.

Epidemiological evaluation of the multifactorial aetiology of abfractions

The purpose of this study was to determine risk indicators for the aetiology of abfractions (cervical wedge-shaped defects) on teeth using dental and medical variables obtained in a population-based sample of the cross-sectional epidemiological 'Study of Health in Pomerania' (SHIP). Medical history, dental, and sociodemographic parameters of 2707 representatively selected subjects 20-59 years of age with more than four natural teeth were checked for associations with the occurrence of abfractions using a two-level logistic regression model on a tooth and a subject level. The estimated prevalence of developing abfractions generally increased with age. The following independent variables were associated with the occurrence of abfractions: buccal recession of the gingiva, odds ratio (OR) = 6.7; occlusal wear facets of scores 1, 2 and 3, OR = 1.5, 1.9, 1.9; tilted teeth, OR = 1.4; inlays, OR = 1.6; toothbrushing behaviour, OR = 1.9 to 2.0 (two and three times a day versus once a day). First premolars had the highest estimated risk for developing abfractions, followed by the second premolars. Maxillary and mandibular teeth behaved similarly in terms of abfractions, with the exception of mandibular canines, which had a much lower estimated risk of incurring abfractions than did maxillary canines. The results of this analysis indicated that abfractions are associated with occlusal factors, like occlusal wear, inlay restorations, altered tooth position and tooth brushing behaviour. This study delivers further evidence for a multifactorial aetiology of abfractions.

The effect of a dexibuprofen mouth rinse on experimental gingivitis in humans

OBJECTIVES

The pharmacodynamic properties of ibuprofen are related nearly exclusively to the S(+)enantiomer (dexibuprofen). This study investigated the effect of a 1.5% dexibuprofen mouth rinse in an experimentally induced gingivitis.

MATERIALS AND METHODS

The trial was a randomized, double-blinded, placebo-controlled, two-period and two-sequence parallel group cross-over study in 24 healthy volunteers aged 21-30 years (16 males, eight females). Customized guards were worn during tooth brushing to prevent any plaque removal from the experimental area (first and second pre-molars and molars in one upper quadrant). After 22 days of plaque accumulation, the mouth rinses (1.5% dexibuprofen and placebo) were administered under supervision three times daily (rinsing for 1 min. with 15 ml) for 8 days. The wash-out time between the two study periods was 14 days. Parameters evaluated at days 0, 7, 14, 22, and 30 were the Löe & Silness gingival index (GI) and the Quigley & Hein plaque index (QHI). Data were tested for treatment, period, and carry-over effects (parametric cross-over analysis).

RESULTS

There was no statistically significant difference (p=0.240) in GI between placebo and dexibuprofen. However, the decrease in QHI was significantly greater (p=0.019) with dexibuprofen as compared with the placebo.

CONCLUSION

In the present study, a 1.5% dexibuprofen mouth rinse had no effect on gingivitis whereas an anti-plaque effect was demonstrated.

Lipoprotein-associated phospholipase A2 and plasma lipids in patients with destructive periodontal disease

OBJECTIVES

Periodontitis is believed to be an independent risk factor of cardiovascular disease (CVD) and to be associated with a moderate systemic inflammatory reaction and hyperlipidaemia. Lipoprotein-associated phospholipase A(2) (Lp-PLA(2)) is an enzyme that has been shown to be a risk factor of CVD and that is involved in the degradation of the phospholipid mediator platelet-activating factor (PAF), a potent mediator of inflammation.

MATERIAL AND METHODS

In the present study, we measured concentrations of plasma lipids and plasma activity of Lp-PLA(2) in 32 patients (mean age 43+/-11 years) with moderate-to-severe periodontitis before and 3 months after local treatment.

RESULTS

Periodontal therapy resulted in a significant reduction of local inflammation and tissue destruction as reflected in reduced pocket depths and reduced bleeding indices. Pre- and post-treatment plasma lipid levels were (median and range, mmol/l): total cholesterol (C) 5.01 (3.94-7.15) and 4.91 (3.32-8.01); low-density lipoprotein-cholesterol (LDL-C) 3.14 (2.40-4.84) and 2.96 (1.39-5.04); HDL-C 1.27 (0.73-2.17) and 1.25 (0.74-2.55); triglycerides 1.37 (0.48-5.11) and 1.14 (0.38-792). Using the Wilcoxon's rank test, neither parameter showed a significant change. In contrast to the lacking response of plasma lipids, we observed a significant reduction in the activity of Lp-PLA(2). Local treatment lowered the enzyme activity by about 10% from 3.61+/-0.99 to 3.29+/-0.94 micromol/ml/h (mean+/-SD; p<0.001). The pre-treatment values of Lp-PLA(2) and LDL-C significantly correlated with clinical parameters of inflammation and periodontal destruction.

CONCLUSION

This study indicates that treatment of periodontitis significantly reduces the serum activity of Lp-PLA(2), which is believed to be an independent cardiovascular risk factor.

Pain during prophylaxis treatment elicited by two power-driven instruments

BACKGROUND

Sonic scalers have an elliptical and piezoceramic ultrasonic scalers a linear oscillation pattern. Thus, a sonic scaler "hammers" the tooth surface, irrespective of its alignment to the tooth, whereas a piezoceramic ultrasonic scaler may oscillate parallel to the tooth surface and gently remove calculus if the alignment is correct. The aim of this study was to measure pain on a visual analogue scale (VAS) during removal of supragingival calculus on mandibular incisors with a sonic or an ultrasonic scaler.

MATERIAL AND METHODS

Seventy-four periodontally healthy subjects with supragingival calculus on the mandibular incisors were treated with both a sonic and a piezoceramic ultrasonic scaler in a split-mouth design. The sequence of instrument application and allocation of instruments to jaw side were randomized. Patient comfort was assessed with a VAS after treatment.

RESULTS

The VAS results did not show any difference between the two instrumentation modalities.

CONCLUSION

For calculus removal during prophylaxis the type of power-driven instrument does not seem to have an impact on perceived pain. This means that the oscillation pattern does not influence the pain experience.

Long-term outcomes of breast cancer patients after endoscopic axillary lymph node dissection: a prospective analysis of 52 patients

BACKGROUND

Reports on long-term outcomes after endoscopic axillary lymph node dissection (ALND) of breast cancer patients are still lacking in the medical literature. The objective of this prospective study was to assess the oncological and functional outcomes in breast cancer patients after endoscopic ALND.

METHODS

Fifty-five breast cancer patients were prospectively enrolled, of whom 52 were available for follow-up with a median of 71.9 months (range 11-96). The following oncological and functional endpoints were evaluated during follow-up at several time points: occurrence of local, axillary and distant metastases, seroma or infection, shoulder mobility (range of motion), numbness, pain, presence of lymphoedema as well as restriction in activities of daily living.

RESULTS

In 52 patients endoscopic ALND of level I and II was successfully performed. Two port-site metastases (2/52, 4%) occurred, one of which in a patient with negative axillary lymph nodes. The same patient suffered from the only axillary recurrence (1/52, 2%). Three patients (3/52, 6%) developed lymphoedema. No other functional adverse events (shoulder mobility, pain, numbness, hypertrophic scar) were noticed at the end of the observation period.

CONCLUSION

The present investigation with long-term follow-up after endoscopic ALND--the first one in the literature--reveals minor morbidity, good functional and cosmetic results. In contrary to conventional surgery, the endoscopic procedure is associated with the occurrence of port-site metastases, not seen in the open approach. Axillary recurrences do not appear more frequently when compared with results after conventional ALND. In the meantime the less invasive sentinel lymph node (SLN) biopsy is the established standard technique in evaluating the axillary lymph node status.

Dental nomograms for benchmarking based on the study of health in Pomerania data set

AIM

Benchmarking is a means of setting goals or targets. On an oral health level, it denotes retaining more teeth and/or improving the quality of life. The goal of this pilot investigation was to assess whether the data generated by a population-based study (SHIP 0) can be used as a benchmark data set to characterize different practice profiles.

MATERIAL AND METHODS

The data collected in the population-based study SHIP (n=4310) in eastern Germany were used to generate nomograms of tooth loss, attachment loss, and probing depth. The nomograms included twelve 5-year age strata (20-79 years) presented as quartiles, and additional percentiles of the dental parameters for each age group. Cross-sectional data from a conventional dental office (n=186) and from a periodontology unit (n=130, Greifswald) in the study region as well as longitudinal data set of a another periodontology unit (n=135, Kiel) were utilized in order to verify whether the given practice profile was accurately reflected by the nomogram.

RESULTS

In terms of tooth loss, the data from the conventional dental office agree with the median from the nomogram. For attachment loss and probing depth, some age groups yielded slight but not uniform deviations from the median. Cross-sectional data from the periodontology unit Greifswald showed attachment loss higher than the median in younger but not in older age groups. The probing depth was uniformly less than the median and tended toward the 25th percentile with increasing age. The longitudinal data of the Unit of Periodontology in Kiel showed a pronounced trend towards higher percentiles of residual teeth, meaning that the patients retained more teeth.

CONCLUSION

The profile of the Pomeranian dental office does not deviate noticeably from the population-based nomograms. The higher attachment loss of the Unit of Periodontology in Greifswald in younger age strata clearly reflects their selection because of periodontal disease; the combination of higher attachment loss and decreased probing depth may reflect the success of the treatment. The tendency of attachment loss towards the median with increasing age may indicate that the Unit of Periodontology in Greifswald does not fulfill its function as a special care unit in the older subjects. The longitudinal data set of the Unit of Periodontology in Kiel impressively reflects the potential of population-based data sets as a means for benchmarking. Thus, nomograms can help to determine the practice profile, potentially yielding benefits for the dentist, health insurance company, or--as in the case of the special care unit--public health research.

Risk determinants of periodontal disease - an analysis of the Study of Health in Pomerania (SHIP 0)

BACKGROUND

In this study, risk determinants were determined for periodontal disease in the representative population sample (n=3146) of the Study of Health in Pomerania.

METHODS

After examining the net random sample (response 69%) and exclusion of edentulous cases and those with missing values, 2595 subjects remained. Using a multivariate, fully adjusted logistic regression, different definitions of "periodontally diseased/healthy" were examined as the dependent variable (extent of attachment loss (AL> or =4 mm, combined AL and tooth loss). The independent variables used were sociodemographic factors (age, gender, income, education), medical factors (systemic diseases, drugs), behavioral factors (regular dental checkup, smoking), and oral factors (presence of supragingival calculus and plaque).

RESULTS

The following risk determinants were found for AL: male gender, presence of supragingival plaque and calculus, smoking, low educational level. For the combination of AL and tooth loss, risk determinants were female gender, supragingival plaque, smoking, and low educational level. Consumption of antiallergic medications and regular dental checkups proved to be protective. Smoking was the most influential risk determinant. These parameters explained approximately 43-55% of the variation.

CONCLUSION

These results concur with those of the literature. In order to explain disease status further, host-response and microbiological factors must also be examined.

[Laparoscopic splenectomy: first experiences with a 3-trocar-technique and the 'hanging-spleen-maneuver']

AIMS

Laparoscopic splenectomy has been established as standard procedure for elective splenectomy and is performed for a variety of haematological diseases. However, different techniques have been used and a four- to five trocar technique is applied in most instances. We report our experience with a three-trocar technique using the triangular liver retractor and the so-called "hanging spleen" maneuver.

METHODS

Data were obtained from a prospectively collected computer database of all patients who underwent elective laparoscopic splenectomy between April 2001 and July 2003.

RESULTS

The study population consisted of 26 patients (14 men, 12 women, mean age: 45 years; range: 16-75 years). Median operative time was 140 min (85-310 min). There was one conversion (3.8 %) due to a suspected malignancy, which was finally not confirmed. A fourth trocar had to be placed in two cases (10 %) due to a large left lobe of the liver. In two patients a small midline incision was made to extract the spleen in toto for pathohistological examination due to a splenic metastasis. In the remaining cases the spleen was morcellated in an endobag. Accessory spleens were found in 1 patient (3.8 %). There were two bleedings following operation, which required laparotomy in one patient. There were no deaths (0 %). The median postoperative hospital stay was 7 days (range 3-17).

CONCLUSIONS

Laparoscopic splenectomy can be performed safely in the vast majority of patients. The described technique using three trocars with the so-called "hanging spleen" maneuver can be used in about 90 % of cases.

Signs of temporomandibular disorders in tinnitus patients and in a population-based group of volunteers: results of the Study of Health in Pomerania

The literature has documented a controversial discussion on the possible relationship of otogenous symptoms and craniomandibular dysfunction since the 1920s. Therefore, an investigation was conducted which consisted of two parts: a case study with population-based controls and a cross-sectional study. The aim of the first study was to screen a group of patients suffering from acute or chronic tinnitus for temporomandibular disorders (TMD) in comparison with a population-based group of volunteers without tinnitus. To this end, 30 patients (13 females and 17 males, age 18-71 years) suffering from acute hearing loss associated with tinnitus, isolated acute tinnitus, and chronically transient tinnitus were examined for symptoms of craniomandibular dysfunction. The results were compared with those of clinical functional analysis from 1907 subjects selected representatively and according to age distribution from the epidemiological 'Study of Health in Pomerania' (SHIP); the occurrence of tinnitus was ruled out in these control subjects. Statistical analysis was performed with Chi-square and Mann-Whitney U-tests. Sixty per cent of the tinnitus patients and 36.5% of the control subjects exhibited more than two symptoms of TMD (P = 0.004). Tinnitus patients had significantly more muscle palpation pain (P < 0.001), temporomandibular joint (TMJ) palpation pain (P < 0.001), and pain upon mouth opening (P < 0.001) than the general population group. No statistical differences were found in TMJ sounds, limitation of mandibular movement, or hypermobility of the TMJ. Furthermore, 4228 subjects of the population group examined in the epidemiological study were screened for co-factors of tinnitus with the help of a multivariate logistic regression model which was adjusted for gender, age, and a variety of anamnestic and examined data. Increased odds ratios (OR) were found for tenderness of the masticatory muscles (OR = 1.6 for one to three painful muscles and OR = 2.53 for four or more painful muscles), TMJ tenderness to dorsal cranial compression (OR = 2.99), listlessness (OR = 2.0) and frequent headache (OR = 1.84) A relationship between tinnitus and TMD was established in both examinations. Tinnitus patients seem to suffer especially from myofascial and TMJ pain. A screening for TMD should be included in the diagnostic survey for tinnitus patients.

Laparoscopic cholecystectomy in acute cholecystitis: indication, technique, risk and outcome

BACKGROUND

Laparoscopic cholecystectomy (LC) has become the treatment of choice for symptomatic cholelithiasis. However, the laparoscopic approach has remained controversial for patients with acute cholecystitis (AC) because of technical difficulties that, compared with open cholecystectomy (OC), might lead to higher complication rates, particularly common bile duct (CBD) injuries and infection.

METHODS

We reviewed recent clinical findings on feasibility, safety and potential benefits of LC in patients with AC. An electronic search using the PubMed and MEDLINE databases was performed using the terms laparoscopic cholecystectomy, open cholecystectomy and acute cholecystitis. Pertinent references from articles and books not identified by the search engines were also retrieved. Relevant surgical textbooks were also reviewed.

CONCLUSIONS

The early laparoscopic approach has been shown to be technically feasible and at least equally as safe as the open approach. However, extensive inflammation, adhesions and consequent increased oozing can make laparoscopic dissection of Calot's triangle and recognition of the biliary anatomy hazardous and difficult. Therefore, conversion to OC remains an important treatment option to secure patient safety in such difficult conditions. The question of whether intraoperative cholangiography (IOC) should be used routinely or only selectively has never been resolved. Proponents for each side have put forward compelling arguments.