A hidden periodontitis epidemic during the 20th century?

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.

Oral Osteomicrobiology: The Role of Oral Microbiota in Alveolar Bone Homeostasis

Osteomicrobiology is a new research field in which the aim is to explore the role of microbiota in bone homeostasis. The alveolar bone is that part of the maxilla and mandible that supports the teeth. It is now evident that naturally occurring alveolar bone loss is considerably stunted in germ-free mice compared with specific-pathogen-free mice. Recently, the roles of oral microbiota in modulating host defense systems and alveolar bone homeostasis have attracted increasing attention. Moreover, the mechanistic understanding of oral microbiota in mediating alveolar bone remodeling processes is undergoing rapid progress due to the advancement in technology. In this review, to provide insight into the role of oral microbiota in alveolar bone homeostasis, we introduced the term “oral osteomicrobiology.” We discussed regulation of alveolar bone development and bone loss by oral microbiota under physiological and pathological conditions. We also focused on the signaling pathways involved in oral osteomicrobiology and discussed the bridging role of osteoimmunity and influencing factors in this process. Finally, the critical techniques for osteomicrobiological investigations were introduced.

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

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

Global epidemiology of dental caries and severe periodontitis - a comprehensive review

BACKGROUND

Dental caries and periodontitis are the most common oral diseases and major causes of tooth loss.

AIM

To perform a review of global prevalence and incidence of dental caries and periodontitis.

METHODOLOGY

Inclusion and exclusion criteria were developed. MEDLINE database and EMBASE database were used to search for eligible publications using keywords and MeSH terms. Additionally, WHO databank was used for obtaining dental caries information and PUBMED for a search on trends of dental caries prevalence and severity.

RESULTS

Over the last four decades, the prevalence and severity of dentine carious lesions among 5- and 12-year-olds have declined; the decay-component is very high, with the lowest prevalence among 12-year-olds in high-income countries, which also had the lowest prevalence among 35- to 44-year-olds; and the number of retained teeth has increased around the globe. The prevalence of periodontitis is high, with approximately 10% of the global population affected by severe periodontitis. Study heterogeneity and methodological issues hamper comparisons across studies and over time.

CONCLUSION

While the prevalence of dental caries has decreased, the disease is prevalent in all age groups. The prevalence of periodontitis is high. There is insufficient evidence to conclude that the prevalence of periodontitis has changed over time.

Smokeless Tobacco and Severe Active Periodontal Disease, NHANES III

Whereas smoking is a major risk factor for periodontal disease, the role of smokeless tobacco is unclear. The purpose of this US population-based study of 12,932 adults participating in the Third National Health and Nutrition Examination Survey was to evaluate the association between smokeless tobacco use and severe active periodontal disease. Univariable and multivariable logistic regression modeling quantified the associations between tobacco use and severe active periodontal disease. All adults and never-smokers who currently used smokeless tobacco were twice as likely to have severe active periodontal disease at any site [respective odds ratios (ORAdj) and 95% confidence intervals: ORAdj = 2.1; 1.2–3.7 and ORAdj = 2.1; 1.0–4.4] or restricted to any interproximal site [respective ORAdj = 2.1; 1.0–4.2 and ORAdj = 2.3; 0.9–6.3], simultaneously adjusted for smoking, age, race, gender, diabetes, and having a dental visit in the past year. These results indicate that smokeless tobacco may also be an important risk factor for severe active periodontal disease.

The prevalence of periodontal disease in a Romano-British population c. 200-400 AD

Describes the prevalence of periodontal and other dental disease in an ancient British population from the examination of dried skulls.

Estimates that the prevalence of established periodontitis in this population was around 5%, considerably lower than prevalence estimates for modern humans.

Objective The aim of this study was to investigate the prevalence of moderate to severe periodontitis in an ancient British cohort c. 200-400 AD.

Design Observational study to assess periodontal and other oral disease parameters.

Setting Natural History Museum, London.

Subjects and methods 303 skulls from a Romano-British burial site in Poundbury, Dorset were examined for evidence of dental disease.

Main outcome measures The primary outcome measure was presence of moderate to severe periodontitis. Secondary outcomes included: amount of horizontal bone loss; prevalence of ante-mortem tooth loss; and presence of other dental pathologies.

Results The overall prevalence of moderate to severe periodontitis was just greater than 5%. The prevalence rate remained nearly constant between ages 20 to 60, after which it rose to around 10%. The number of affected teeth increased with age. Horizontal bone loss was generally minor. Caries was seen in around 50% of the cohort, and evidence of pulpal and apical pathology was seen in around 25%.

Conclusions The prevalence of moderate to severe periodontitis was markedly decreased when compared to the prevalence in modern populations, underlining the potential importance of risk factors such as smoking and diabetes in determining susceptibility to progressive periodontitis in modern populations.

The tobacco-using periodontal patient: role of the dental practitioner in tobacco cessation and periodontal disease management

Although the prevalence of tobacco use has declined in some parts of the world, tobacco use remains a persistent and, in some cases, growing problem that will continue to be a fundamental challenge facing dental practitioners in the decades ahead. Dental practitioners have a unique opportunity and professional obligation to be a positive influence in reducing the economic and social burden inflicted by tobacco use on dental and general health. In this article, the current noninvasive, evidence-based approaches are presented for dental practitioners to help patients avoid initiating tobacco use, to encourage and assist patients in ceasing tobacco use and to address tobacco-induced damage to periodontal supporting tissues.

Association between alcohol consumption and periodontal disease among older Nigerians in plateau state: a preliminary study

OBJECTIVE

To report the periodontal status of older adults in Plateau State, Nigeria, and determine its Association with alcohol consumption.

BACKGROUND

Periodontal disease is common among Nigerians, and the prevalence increases with age. The role that alcohol consumption plays in the occurrence of the disease among Africans is uncertain.

MATERIALS AND METHODS

Sample selection was performed using a multistage cluster sampling technique among older adults in Plateau State, Nigeria. Interviews, using structured questionnaires, were conducted for each of the participants. Clinical examinations were then carried out to determine the occurrence of periodontal disease, assessed by clinical attachment loss and probing depth.

RESULTS

The prevalence of periodontal disease was 79%, being severe in 46% of the population. Almost half of the participants (46.7%) examined were still actively consuming alcohol, among which 48% reported a history of intoxication. There was no statistically significant relationship between periodontal disease and the frequency of alcohol consumption, or quantity consumed on each occasion. However, alcohol consumption was highly correlated with periodontal disease among those who reported intoxication from the drink (r = 0.095; p = 0.033). A history of intoxication with alcohol was the only significant predictor of periodontal disease, after adjusting for age and gender.

CONCLUSION

Periodontal disease was highly prevalent among older Nigerians in this study. Apart from those who reported intoxication from alcohol, there was no statistically significant relationship between the prevalence of periodontal disease and the frequency of alcohol consumption or the quantity consumed on each occasion.

Smoking rate and periodontal disease prevalence: 40-year trends in Sweden 1970-2010

AIM

To investigate the relationship between smoking rate and periodontal disease prevalence in Sweden.

MATERIAL AND METHODS

National smoking rates were found from Swedish National Statistics on smoking habits. Based on smoking rates for the years 1970-2010, periodontal disease prevalence estimates were calculated for the age bracket 40-70 years and smoking-associated relative risks between 2.0 and 20.0. The impact of smoking on the population was estimated according to the concept of population attributable fraction.

RESULTS

The age-standardized smoking rate in Sweden declined from 44% in 1970 to 15% in 2010. In parallel with the smoking decline the calculated prevalence estimate of periodontal disease dropped from 26% to 12% assuming a 10-fold smoking-associated relative risk. Even at more moderate magnitudes of the relative risk, e.g. 2-fold or 5-fold, the prevalence decrease was quite tangible, suggesting that the current prevalence in Sweden is about 20-50% of the level 40 years ago. The population attributable fraction, estimating the portion of the disease that would have been avoided in the absence of smoking, was 80% in 1970 and 58% in 2010 at a ten-fold relative risk.

CONCLUSION

Calculated estimates of periodontal disease prevalence are closely related to real changes in smoking rate. As smoking rate drops periodontal disease prevalence will drop.

Economics of periodontal care: market trends, competitive forces and incentives

The adoption of new technologies for the treatment of periodontitis and the replacement of teeth has changed the delivery of periodontal care. The objective of this review was to conduct an economic analysis of a mature periodontal service market with a well-developed workforce, including general dentists, dental hygienists and periodontists. Publicly available information about the delivery of periodontal care in the USA was used. A strong trend toward increased utilization of nonsurgical therapy and decreased utilization of surgical periodontal therapy was observed. Although periodontal surgery remained the domain of periodontists, general dentists had taken over most of the nonsurgical periodontal care. The decline in surgical periodontal therapy was associated with an increased utilization of implant-supported prosthesis. Approximately equal numbers of implants were surgically placed by periodontists, oral and maxillofacial surgeons, and general dentists. Porter's framework of the forces driving industry competition was used to analyze the role of patients, dental insurances, general dentists, competitors, entrants, substitutes and suppliers in the periodontal service market. Estimates of out-of-pocket payments of self-pay and insured patients, reimbursement by dental insurances and providers' earnings for various periodontal procedures and alternative treatments were calculated. Economic incentives for providers may explain some of the observed shifts in the periodontal service market. Given the inherent uncertainty about treatment outcomes in dentistry, which makes clinical judgment critical, providers may yield to economic incentives without jeopardizing their ethical standards and professional norms. Although the economic analysis pertains to the USA, some considerations may also apply to other periodontal service markets.

Is there a positive effect of smoking cessation on periodontal health? A systematic review

BACKGROUND

Although the detrimental effects of tobacco on the periodontal tissues have been reported extensively, little is known about the potential beneficial effect of smoking cessation on periodontal health. The aim of this systematic review is to evaluate the effect of smoking cessation on periodontitis progression and response to periodontal therapy.

METHODS

Two independent reviewers completed the review process through title (n = 118), abstract (n = 24), and whole-paper selection (n = 5). Sources include Medline and EMBASE databases (up to December 2012) and a reference list of selected studies. Prospective studies comparing progression rates of periodontitis between smokers and quitters and clinical trials evaluating the effect of smoking-cessation programs, alone or in combination with periodontal treatment, were included. At least 1 year of follow-up was required for inclusion.

RESULTS

Of 331 potentially relevant publications, five studies fulfilled the inclusion criteria. Because of heterogeneity of the studies, a meta-analysis could not be performed. One study reported that the progression of clinical attachment loss (AL) ≥3 mm during a 6-year period was approximately three times higher among smokers than quitters (P <0.001). Two studies (10 and 20 years of follow-up) observed a decrease in radiographic bone loss of ≈30% among quitters when compared with smokers. Among individuals receiving non-surgical periodontal treatment, quitters were more likely to have periodontal probing depth reductions (P <0.05) than non-quitters/oscillators. No differences in AL were observed.

CONCLUSION

Based on the limited available evidence, smoking cessation seems to have a positive influence on periodontitis occurrence and periodontal healing.

Specific infections as the etiology of destructive periodontal disease: a systematic review

Destructive periodontal disease has been primarily defined and investigated as an infectious disease. The aim of this study was to systematically search for cohort studies where microbiological diagnoses were performed before the onset of destructive periodontal disease and where statistically significant associations were identified. A search was executed in PubMed. The results showed that three studies published after 2005 supported the infection hypothesis for one putative periodontal pathogen: Aggregatibacter actinomycetemcomitans. These three studies were conducted in predominantly non-Caucasian pediatric populations living in geographic areas with an elevated child-mortality rate. These studies did not obtain physical or laboratory markers of health, making it possible that A. actinomycetemcomitans was not a cause but a marker for poor environmental or systemic health. No cohort studies were identified supporting the infection hypothesis in adults, Caucasians or in a population residing in areas with child-mortality rates reflective of healthy population goals. While the possibility cannot be excluded that A. actinomycetemcomitans has an etiological role in certain specific pediatric populations, there are no cohort studies supporting an infectious etiology of destructive periodontal disease in adults.

Effects of smoking and genotype on the PSR index of periodontal disease in adults aged 18-49

Studies have found both genetic and environmental influences on chronic periodontitis. The purpose of this study was to examine the relationships among previously identified genetic variants, smoking status, and two periodontal disease-related phenotypes (PSR1 and PSR2) in 625 Caucasian adults (aged 18–49 years). The PSR Index was used to classify participants as affected or unaffected under the PSR1 and PSR2 phenotype definitions. Using logistic regression, we found that the form of the relationship varied by single nucleotide polymorphism (SNP): For rs10457525 and rs12630931, the effects of smoking and genotype on risk were additive; whereas for rs10457526 and rs733048, smoking was not independently associated with affected status once genotype was taken into consideration. In contrast, smoking moderated the relationships of rs3870371 and rs733048 with affected status such that former and never smokers with select genotypes were at increased genetic risk. Thus, for several groups, knowledge of genotype may refine the risk prediction over that which can be determined by knowledge of smoking status alone. Future studies should replicate these findings. These findings provide the foundation for the exploration of novel pathways by which periodontitis may occur.

Dentistry and population approaches for preventing dental diseases

Dental professionals are expected to engage in oral disease prevention, but their tools limit the approach to chair side activities based on the common notion that the major dental diseases, dental caries, gingivitis and periodontitis, are behavioural diseases shaped by individual lifestyles. However, lifestyles also have causes and individual behaviours reflect cultural norms, expectations and opportunities that are socio-economically determined and structurally maintained. Importantly, the effects of the societal and socio-economic determinants reach way above their influences as individual attributes, and effective approaches to the prevention and control of oral diseases are aligned with this causal chain. Unfortunately, the ethos and philosophy of dentistry is focused to a downstream, patient-centred, curative and rehabilitative approach to oral diseases. Whilst such services are needed to care for those who have already suffered the consequences of oral diseases, they do not influence population oral health. A more balanced distribution of efforts and resources along the whole range of intervention points from the downstream curative to the upstream structural healthy policy approaches is required if appropriate, evidence-based, effective, cost-effective, sustainable, equitable, universal, comprehensive and ethical delivery of health care, including oral health care, is the goal. The implementation of healthy policies and sound approaches to population oral health will require substantial commitment and political will on the part of the public and their elected officials.

Tobacco smoking affects bacterial acquisition and colonization in oral biofilms

Recent evidence suggests that smoking affects the composition of the disease-associated subgingival biofilm, yet little is known about its effects during the formation of this biofilm. The present investigation was undertaken to examine the contributions of smoking to the composition and proinflammatory characteristics of the biofilm during de novo plaque formation. Marginal and subgingival plaque and gingival crevicular fluid samples were collected from 15 current smokers and from 15 individuals who had never smoked (nonsmokers) following 1, 2, 4, and 7 days of undisturbed plaque formation. 16S rRNA gene cloning and sequencing were used for bacterial identification, and multiplex bead-based flow cytometry was used to quantify the levels of 27 immune mediators. Smokers demonstrated a highly diverse, relatively unstable initial colonization of both marginal and subgingival biofilms, with lower niche saturation than that seen in nonsmokers. Periodontal pathogens belonging to the genera Fusobacterium, Cardiobacterium, Synergistes, and Selenomonas, as well as respiratory pathogens belonging to the genera Haemophilus and Pseudomonas, colonized the early biofilms of smokers and continued to persist over the observation period, suggesting that smoking favors early acquisition and colonization of pathogens in oral biofilms. Smokers also demonstrated an early proinflammatory response to this colonization, which persisted over 7 days. Further, a positive correlation between proinflammatory cytokine levels and commensal bacteria was observed in smokers but not in nonsmokers. Taken together, the data suggest that smoking influences both the composition of the nascent biofilm and the host response to this colonization.

Is self interdental cleaning associated with dental plaque levels, dental calculus, gingivitis and periodontal disease?

BACKGROUND AND OBJECTIVE

To ascertain whether interdental cleaning behaviours of Australian adults were associated with lower levels of plaque, gingivitis and periodontal disease.

MATERIAL AND METHODS

Data were obtained from the National Survey of Adult Oral Health 2004-06. Outcome variables were three indicators of oral hygiene outcomes (the presence or not of dental plaque, dental calculus and gingivitis) and two of periodontal disease (the presence or not of at least one tooth with a periodontal pocket or clinical attachment loss of ≥ 4 mm). The independent variable was classified into the following three groups: regularly clean interproximally 'at least daily' (daily+); 'less than daily' (< daily); and 'do not regularly clean interproximally' (reference group). Poisson regression with robust variance estimation was used to calculate prevalence ratios (PRs) and 95% confidence intervals (95% CIs) relative to the reference group, adjusted for covariates.

RESULTS

Regular self interdental cleaning was associated with less dental plaque (< daily, PR = 0.89, 95% CI = 0.84, 0.95; and daily+, PR = 0.89, 95% CI = 0.82, 0.96), less dental calculus (< daily, PR = 0.88, 95% CI = 0.80, 0.97; and daily+, PR = 0.79, 95% CI = 0.70, 0.89) and lower levels of moderate/severe gingivitis (daily+, PR = 0.85, 95% CI = 0.77, 0.94). Periodontal pocketing was less likely for the < daily group (PR = 0.61, 95% CI = 0.46, 0.82), but was not associated with daily+ cleaning (PR = 0.99, 95% CI = 0.663, 1.49). There was not a significant association between interdental cleaning and clinical attachment loss (< daily, PR = 0.90, 95% CI = 0.77, 1.05; and daily+, PR = 1.17, 95% CI = 0.95, 1.44).

CONCLUSION

Regular interdental cleaning was associated with better oral hygiene outcomes, such as dental plaque and gingivitis, although there was no significant association between regular interdental cleaning and clinical attachment loss.

The biology, prevention, diagnosis and treatment of periodontal diseases: scientific advances in the United States

BACKGROUND

Major scientific advances in periodontology in the past 150 years have fundamentally changed how clinicians detect and treat periodontal diseases. These advances include the demonstration that gingivitis and periodontitis are biofilm-induced infections caused by components of the indigenous oral microbiota, and that host inflammatory-immunologic responses to these microbial challenges are responsible for most of the observed tissue damage.

TYPES OF STUDIES REVIEWED

In this brief overview, the authors focus on the discovery of the relationships between dental plaque and the host periodontal tissues. They highlight some of the pioneers in the United States who shaped new approaches to prevention and treatment of periodontal disease.

RESULTS

Biofilms that cause gingivitis and periodontitis are complex polymicrobial communities that are resistant to antimicrobial agents and host defense mechanisms. An increased understanding of natural inflammation-resolving mechanisms suggests that control of inflammation is at least as important as is antimicrobial therapy in the treatment of periodontal infections. Data from randomized controlled clinical trials have shown that most conventional forms of periodontal therapy are effective as long as patients comply with posttreatment maintenance programs.

CONCLUSIONS

Many mechanisms involved in the repair and regeneration of periodontal tissues have been identified. Results of laboratory studies of factors that enhance prevention and treatment of periodontal disease have made the transition to clinical practice. Advances in the fields of molecular biology, human genetics and stem cell biology have set the stage for significant discoveries that will pave the way for the development of procedures needed for the predictable regeneration of periodontal tissues. As a result, new generations of people in the United States can expect to retain a healthy and functional dentition for a lifetime.

Periodontal attachment loss in an untreated isolated population of Brazil

BACKGROUND

The aim of this study was to assess the prevalence, extent, and severity of clinical attachment loss (CAL) and to investigate the association of demographic, socioeconomic, and behavioral risk indicators with CAL in an untreated isolated population in Brazil.

METHODS

All subjects aged > or =12 years were identified by a census. Participants were submitted to a full-mouth clinical examination of six sites per tooth and were interviewed using a structured, written questionnaire.

RESULTS

Among the 214 subjects who were interviewed and examined clinically, CAL > or =5 mm in at least one site was observed in 8% of the 12- to 19-year-olds and in all dentate subjects > or =50 years of age; the age-dependent prevalence of CAL > or =7 mm in at least one site ranged from 5% among 12- to 19-year-olds to 83% among subjects > or =50 years old. Multivariate analysis identified plaque (odds ratio [OR] = 2.8), supragingival calculus (OR = 2.9 to 10.6), age > or =30 years (OR = 11.4), and smoking (OR = 2.4) as risk indicators for CAL > or =5 mm and smoking (OR = 8.2) as a risk indicator for CAL > or =7 mm.

CONCLUSIONS

CAL is highly prevalent in this isolated population. The high occurrence of CAL in young age groups and the confirmation of traditional risk indicators for CAL in this study suggest that other factors, such as host susceptibility, may be needed to explain the high levels of CAL found. Age and behavioral factors were risk indicators associated significantly with the CAL found in this population and may be useful indicators of high-risk subjects for periodontal diseases.

Cannabis smoking and periodontal disease among young adults

CONTEXT

Tobacco smoking is a recognized behavioral risk factor for periodontal disease (through its systemic effects), and cannabis smoking may contribute in a similar way.

OBJECTIVE

To determine whether cannabis smoking is a risk factor for periodontal disease.

DESIGN AND SETTING

Prospective cohort study of the general population, with cannabis use determined at ages 18, 21, 26, and 32 years and dental examinations conducted at ages 26 and 32 years. The most recent data collection (at age 32 years) was completed in June 2005.

PARTICIPANTS

A complete birth cohort born in 1972 and 1973 in Dunedin, New Zealand, and assessed periodically (with a 96% follow-up rate of the 1015 participants who survived to age 32 years). Complete data for this analysis were available from 903 participants (comprising 89.0% of the surviving birth cohort).

MAIN OUTCOME MEASURE

Periodontal disease status at age 32 years (and changes from ages 26 to 32 years) determined from periodontal combined attachment loss (CAL) measured at 3 sites per tooth.

RESULTS

Three cannabis exposure groups were determined: no exposure (293 individuals, or 32.3%), some exposure (428; 47.4%), and high exposure (182; 20.2%). At age 32 years, 265 participants (29.3%) had 1 or more sites with 4 mm or greater CAL, and 111 participants (12.3%) had 1 or more sites with 5 mm or greater CAL. Incident attachment loss between the ages of 26 and 32 years in the none, some, and high cannabis exposure groups was 6.5%, 11.2%, and 23.6%, respectively. After controlling for tobacco smoking (measured in pack-years), sex, irregular use of dental services, and dental plaque, the relative risk estimates for the highest cannabis exposure group were as follows: 1.6 (95% confidence interval [CI], 1.2-2.2) for having 1 or more sites with 4 mm or greater CAL; 3.1 (95% CI, 1.5-6.4) for having 1 or more sites with 5 mm or greater CAL; and 2.2 (95% CI, 1.2-3.9) for having incident attachment loss (in comparison with those who had never smoked cannabis). Tobacco smoking was strongly associated with periodontal disease experience, but there was no interaction between cannabis use and tobacco smoking in predicting the condition's occurrence.

CONCLUSION

Cannabis smoking may be a risk factor for periodontal disease that is independent of the use of tobacco.

Caries management: technical solutions to biological problems or evidence-based care?

Caries-related clinical decision-making remains a centrepiece of clinical dentistry. However, the oral disease patterns are rapidly changing towards the better among major sections of the populations, most notably in the high-income countries. The caries decline is well documented among children and younger adults, and is gradually seen to trickle into middle and old age as well. Although it is tempting for the dental profession to take the credit for this development, the evidence points in a different direction. The major contribution of dentistry seems primarily related to changes in the treatment philosophies towards a less interventionist approach. This review aims to spur a further change in the diagnostic and treatment criteria used in the management of dental caries for the benefit of the oral health status of our patients. We must come to terms with the fact that our traditional core skills, our manual dexterity and technical competence, have less to offer to oral health than we have been accustomed to think. The dental schools and the professional dental organizations must carry the responsibility for promoting the necessary changes in the caries related clinical decision-making strategies to allow practicing dentists to provide appropriate oral health care to our populations.

Tobacco use and incidence of tooth loss among US male health professionals

Data on the dose-dependent effects of smoking and smoking cessation on tooth loss are scarce. We hypothesized that smoking has both dose- and time-dependent effects on tooth loss incidence. We used longitudinal data on tobacco use and incident tooth loss in 43,112 male health professionals, between 1986 and 2002. In multivariate Cox models, current smokers of 5 to 14 and 45+ cigarettes daily had a two-fold (HR, 1.94; 95% CI, 1.72, 2.18) and three-fold (HR, 3.05; 95% CI, 2.38, 3.90) higher risk of tooth loss, respectively, compared with never-smokers. Risk decreased with increasing time since cessation, but remained elevated by 20% (95% CI, 16%, 25%) for men who had quit 10+ years before. Current pipe/cigar smokers had a 20% (95% CI, 1.11, 1.30) increased risk of tooth loss compared with never- and former smokers of pipes/cigars.

An overview of the epidemiology of periodontal diseases in Latin America

The aim of the present review was to identify the presence of periodontal diseases and the relative importance of known risk factors in Latin American countries. The retrieved data are sparse and inconsistent, lacking information for the majority of the countries. Gingivitis is ubiquitous in the region, affecting all ages independently of the socioeconomic background. The extension of bleeding may vary greatly, ranging from 40% to 70% of sites. The prevalence of aggressive periodontitis is higher in Latin America than in industrialized countries. Prevalence ranges from 0.3% to 4.5%, and the localized form is the less prevalent. The prevalence of chronic periodontitis is high, with a large variation (40-80%) probably due to differences in methodology and diagnostic criteria. Regional differences may be relevant. Known risk factors are present in the populations studied. Non-modifiable factors such as age, gender and genetics have been associated in Brazilian and Chilean populations. Tobacco smoking and diabetes are relevant risk factors. The importance of socioeconomic status, although present as a risk factor, has been largely underestimated. Oral hygiene is extremely deficient in the area although it is a cultural habit in most populations. It can be concluded that periodontal diseases are highly prevalent in Latin American populations. Its prevalence and extent are associated with known risk factors. Oral hygiene habits are deficient. Well designed epidemiological studies with external validity are needed.

Periodontal Status in Smokers and Never-Smokers: Clinical Findings and Real-Time Polymerase Chain Reaction Quantification of Putative Periodontal Pathogens

BACKGROUND

Smoking is a well-known risk factor for destructive periodontal disease, but its relationship with periodontal status and subgingival microbiota remains unclear. Inherent limitations of microbiological methods previously used may partly explain these mixed results, and real-time polymerase chain reaction (PCR) has been presented as a valid alternative. The aim of the present study was to investigate the clinical condition and microbiological profile of patients with chronic periodontitis as related to the habit of smoking.

METHODS

Fifty patients (33 to 59 years old), 25 smokers and 25 never-smokers, constituted the sample. The visible plaque index (VPI), gingival bleeding index (GBI), bleeding on probing (BOP), periodontal probing depth (PD), clinical attachment loss (CAL), and gingival crevicular fluid (GCF) volume were recorded. Real-time PCR quantified Porphyromonas gingivalis, Micromonas micros, Dialister pneumosintes, Actinobacillus actinomycetemcomitans and total bacteria in subgingival samples.

RESULTS

Smokers and never-smokers showed similar values for VPI, GBI, and BOP. Smokers had deeper PD in buccal/lingual sites and higher CAL independently of the tooth surface. The GCF volume was smaller in smokers, independent of the PD. Similar amounts of total bacteria and P. gingivalis were observed for both groups. Significantly higher numbers of D. pneumosintes and M. micros were present in smokers and associated with moderate and deep pockets. When heavy smokers were considered, higher counts of total bacteria, M. micros, and D. pneumosintes were observed.

CONCLUSIONS

Smoking seems to have a detrimental impact on the periodontal status and microbiological profile of patients with periodontitis. Compared to never-smokers, smokers had deeper pockets, greater periodontal destruction, and higher counts of some putative periodontal pathogens.

Serum antibodies to periodontal pathogens and markers of systemic inflammation

AIM

We examined the relationship between serum antibodies against Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans, and plasma fibrinogen and serum C-reactive protein (CRP) in a nationally representative sample.

METHODS

Data on 2,973 participants aged 40 years and older from the third National Health and Nutrition Examination Survey, second phase (1991-1994) were used. Three logistic regression models adjusted for gender, race, educational attainment, diabetes, cigarette smoking, body mass index (BMI), and other inflammatory conditions were constructed, based on three different assumptions: (A) no access to dental/periodontal data; (B) knowledge of number of teeth present but not of clinical periodontal status; and (C) knowledge of both dental and clinical periodontal status.

RESULTS

High fibrinogen (>400 mg/dl) was unrelated to P. gingivalis and A. actinomycetemcomitans antibodies in all models. High CRP (>0.4 mg/dl) was related to high antibody levels to P. gingivalis in models A [odds ratios (OR) 1.63, 95% confidence intervals (CI) 1.15-2.32], B (OR 1.69, 95% CI 1.18-2.41), and C (OR 1.58, 95% CI 1.12-2.23). In model C, high CRP was related to >30% extent of attachment loss of >or=3 mm (OR 1.58, 95% CI 1.19-2.08). Antibodies to A. actinomycetemcomitans were not associated with high CRP levels in any model.

CONCLUSIONS

High serum titre to P. gingivalis and the presence of periodontal disease are independently related to high CRP levels.

Periodontal diseases

The periodontal diseases are highly prevalent and can affect up to 90% of the worldwide population. Gingivitis, the mildest form of periodontal disease, is caused by the bacterial biofilm (dental plaque) that accumulates on teeth adjacent to the gingiva (gums). However, gingivitis does not affect the underlying supporting structures of the teeth and is reversible. Periodontitis results in loss of connective tissue and bone support and is a major cause of tooth loss in adults. In addition to pathogenic microorganisms in the biofilm, genetic and environmental factors, especially tobacco use, contribute to the cause of these diseases. Genetic, dermatological, haematological, granulomatous, immunosuppressive, and neoplastic disorders can also have periodontal manifestations. Common forms of periodontal disease have been associated with adverse pregnancy outcomes, cardiovascular disease, stroke, pulmonary disease, and diabetes, but the causal relations have not been established. Prevention and treatment are aimed at controlling the bacterial biofilm and other risk factors, arresting progressive disease, and restoring lost tooth support.

Impact of periodontal preventive programmes on the data from epidemiologic studies

This report provides only circumstantial evidence for the impact of programmes on periodontal epidemiology. The prerequisites for programmes and campaigns are described, and epidemiologic data on periodontal disease are compared with known changes in factors that may be affected by such activities. Unfortunately, parameters for periodontal disease as a process are not available. Only variables indicating irreversible effects on the periodontal status can be obtained. A lack of appropriate studies creates additional problems. This review indicates that preventive programmes and campaigns to improve oral hygiene have affected periodontal epidemiologic data concerning gingivitis and mild/moderate periodontitis favourably. Severe periodontitis seems not to have been influenced by such activities. Smoking is strongly associated with the severity of periodontitis. Therefore, a positive effect may be anticipated following the smoking cessation campaigns currently introduced worldwide. However, because of the irreversible nature of our epidemiologic parameters, it will take decades before any effect may be evident. It is recommended that periodontal epidemiology should be revitalized by introducing a nominalistic categorization instead of the changing essentialistic approaches used so far in order to facilitate the interpretation of data.

A socio-economic perspective on periodontal diseases: a systematic review

OBJECTIVE

The aim of this systematic review was to ascertain whether socio-economic conditions increase the risk of periodontal diseases.

METHODS

A MEDLINE search was conducted for the period 1965-April 2004. Only original articles were included; 47 studies remained for the final assessment. The studies were analysed regarding the outcome of the association between socio-economic variables and periodontal disease, depending on the study design (cross-sectional survey or longitudinal case-control) and whether smoking was included or not.

RESULTS

Twenty-nine out of 36 studies with a cross-sectional design were in favour of the association between socio-economic factors and periodontal diseases. In the studies with a longitudinal or case-control design, there were five in favour of the association, and also six against. When smoking was included in the analysis of cross-sectional studies, a significant association between socio-economic variables and periodontal disease was found in 11 studies and no significance in another five studies. The corresponding figures for case-control studies showed four studies being significant, but also four studies showing no significance.

CONCLUSION

Based on relevant study designs and including smoking in the analysis, the socio-economic variables associated with periodontal diseases appear to be of less importance than smoking.