Prevalence of periodontitis: misclassification, under-recognition or over-diagnosis using partial and full-mouth periodontal examination protocols

The Relationship Between Alkaline Phosphatase and Periodontitis: The Mediating Role of Cranial Bone Mineral Density

BACKGROUND

Periodontitis is a common chronic disease characterized by the destruction of periodontal tissues and the resorption of alveolar bone, which severely impacts the quality of life of patients. Alkaline phosphatase (ALP), as a crucial marker of bone metabolism, is involved in the bone formation process. However, the mechanisms linking ALP to periodontitis remain unclear. Bone mineral density (BMD) of the skull is an important indicator reflecting bone mineral content and bone strength, yet its mediating role in the relationship between ALP and periodontitis has not been thoroughly investigated.

OBJECTIVE

This study aimed to explore the association between serum ALP and the risk of periodontitis and to evaluate the potential mediating role of cranial BMD in this relationship, with the goal of providing new insights into the etiology of periodontitis and informing treatment strategies.

METHODS

Data from periodontitis patients from the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2014 were utilized with ALP as the independent variable, periodontitis as the dependent variable, and cranial BMD as the mediating variable. A logistic regression model was used to analyse the relationship between ALP and periodontitis, and subgroup analyses were conducted to explore the association between ALP and periodontitis in different subgroups. Restricted cubic splines (RCS) were used to explore the nonlinear relationship between the two. Additionally, mediation analysis was employed to study the potential mediating role of cranial BMD on the association between ALP and periodontitis.

RESULTS

After adjusting for confounding variables, ALP showed a significant positive association with periodontitis (OR: 1.006, 95% CI: 1.002-1.011, P < .05). Subgroup analyses showed that this association was particularly pronounced in males, drinkers, and individuals lacking physical activities. RCS analysis revealed a nonlinear relationship between ALP and periodontitis (P-non-linear = 0.0006), with a threshold level of 68 U/L. The mediation analysis revealed that cranial BMD played a mediating role of 2.71% in the relationship between ALP and periodontitis (P = .006). Furthermore, ALP was significantly negatively correlated with cranial BMD (β = -0.0016, 95% CI: -0.0024 to -0.0007, P < .001).

CONCLUSION

Elevated serum ALP levels were positively associated with an increased risk of periodontitis, and cranial BMD partially mediated this association. Monitoring ALP levels may contribute to the early diagnosis and intervention of periodontitis, while targeting bone metabolism regulation could offer a novel direction for the treatment of periodontitis.

Application of the 2018 Periodontal Status Classification to Epidemiological Survey Data (ACES) Framework to Estimate the Periodontitis Prevalence in the United States

AIMS

To compare periodontitis prevalence estimates based on the Application of the 2018 periodontal status Classification to Epidemiological Survey data (ACES) and the Centers for Disease Control and Prevention/American Academy of Periodontology (CDC/AAP) classification.

MATERIALS AND METHODS

National Health and Nutrition Examination Survey data for the years 2009/2010, 2011/2012 and 2013/2014 were survey-weighted and post-stratified to estimate the prevalence of periodontitis. Estimates based on ACES and CDC/AAP were cross-classified and stratified by age group. Prevalence estimates using different partial recording protocols were examined.

RESULTS

Using the ACES framework, the prevalence of adults with periodontitis was 93.1% (95% CI: 91.9-94.2) (Stage I: 17.9%; Stage II: 46.2%; Stage III: 16.7%; Stage IV: 12.4%). Complexity factors did not alter Stage II prevalence. The CDC/AAP classification yielded a periodontitis prevalence of 38.9% (95% CI: 36.4-41.4) (Mild: 3.5%; Moderate: 28.1%; Severe: 7.3%). Partial recording protocols resulted in increased prevalence in the lower stages of periodontitis.

CONCLUSIONS

The European Federation of Periodontology/American Academy of Periodontology Classification (using the ACES framework) overestimates periodontitis cases compared with the CDC/AAP classification. Including complexity factors in the ACES framework provides limited benefits in staging periodontitis. Partial-mouth recording protocols overestimate health and early disease stages while underestimating more severe disease.

Diagnostic accuracy of severe periodontitis for Ramfjord teeth based on different classifications

OBJECTIVE

To evaluate the accuracy of Ramfjord teeth (RT) protocol for the diagnosis of severe periodontitis based on different classifications and explore the misclassification bias such as teeth loss.

METHODS

Patients (n = 435) receiving full-mouth periodontal examination (FMPE) were included. Patients were classified as severe (stage III/IV) periodontitis and no/mild/moderate (no/stage I/II) periodontitis according to the case definition proposed by the Centers for Disease Control and Prevention (CDC) and the American Academy of Periodontology (AAP)-(CDC/AAP), a new classification introduced by AAP and the European Federation of Periodontology (EFP)-(AAP/EFP), and consensus of Chinese experts (CCE). Sensitivity, specificity, positive predictive value, negative predictive value, Youden's index, and area under the receiver operating characteristic curve (AUROC) compared with FMPE were evaluated.

RESULTS

The specificity of RT was 86.8%, 92.2%, and 77.1% when compared with FMPE protocol based on CDC/AAP, AAP/EFP, and CCE classifications, while the AUROC value was 0.934, 0.961, and 0.886 specifically. The loss of the first molar leads to the greatest reduction in the detection rate of severe periodontitis.

CONCLUSIONS

RT showed the highest specificity based on the new AAP/EFP classification. The loss of the first molar leads to the greatest reduction in the detection rate of severe periodontitis.

Association between oral health and cognitive function among Chinese older adults: the Taizhou imaging study

BACKGROUND

We aimed to investigate the association between oral health and cognitive function in a sample of older adults from a Chinese rural community.

METHODS

The cross-sectional cognitive function of 677 individuals were assessed by Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA). A comprehensive profile of the oral health status was evaluated by questionnaire and clinical examination.

RESULTS

Multiple covariates-adjusted regression models demonstrated decayed teeth (DT) and decayed/missing/filled teeth (DMFT) were negatively associated with MoCA score (all p < 0.05). Calculus index (CI) and clinical attachment loss (CAL) were significantly associated with the lower MoCA, short-term memory and executive function score, respectively (all p < 0.05). Additionally, participants with missing teeth unrestored tend to get lower MMSE and MoCA scores (p < 0.05). The results also showed that increased DT and CI were modestly associated with higher odds of cognitive impairment (p < 0.05).

CONCLUSIONS

There is an association between oral health and global cognition. Poor periodontal status was strongly associated with worse global cognition performance, especially in the short-term memory and executive domain for the aging population.

Periodontitis prevalence and severity in inflammatory bowel disease: A case-control study

BACKGROUND

Recent evidence is supporting the notion of a microbiological and immunological continuum on the gum-gut axis in health and disease. Therefore, the purpose of this study was to assess the prevalence and risk indicators of periodontitis in patients with Crohn's disease (CD) or ulcerative colitis (UC) compared to age- and sex-matched controls without inflammatory bowel disease (IBD).

METHODS

A total of 180 IBD (117 CD, 60 UC, 3 IBD-unclassified) and 180 healthy controls were compared for their periodontitis diagnosis (Centers for Disease Control and Prevention/American Academy of Periodontology [CDC/AAP] case definition) and full-mouth periodontal parameters. In addition, explorative logistic regression models were performed.

RESULTS

Significantly more patients with IBD had moderate/severe periodontitis (85.6% vs. 65.6%, p < 0.001) and severe periodontitis (36.7% vs. 25.6%, p < 0.001) than controls. Differences were higher in the 35-50 and 51-65 age groups, without significant changes between CD and UC. IBD subjects presented chances ∼3.5 higher of having moderate/severe periodontitis (p < 0.001). Significant variables associated with periodontitis in the whole sample were older age, presence of IBD, and higher full-mouth plaque scores, whereas in the IBD group they were male sex, IBD-associated surgery, and IBD duration and localization (pancolitis). Positive risk indicators for IBD were periodontitis severity and higher bleeding scores, while smoking was negatively associated with UC.

CONCLUSIONS

Relevant associations between IBD and periodontitis were found, being modified by CD and UC clinical characteristics. Preventive and therapeutic strategies involving the gum-gut axis should be enforced in IBD patients.

Use of an antiseptic rinse (NanArgol) for the oral hygiene maintenance of subjects with fixed appliances: A randomized clinical trial

BACKGROUND

The risk of periodontal diseases development increased in patients with malocclusion undergoing orthodontic treatment. Thus, the aim of this study was to examine the efficacy of the use of adjunctive rinses with nano-Argentum to standard oral hygiene regimen in subjects wearing fixed orthodontic appliances.

MATERIALS AND METHODS

Eighty patients were observed for 1 year. They were divided in two groups: in test group patients were instructed to rinse with non-ionic colloidal silver solution according to protocol for 6 months as an adjunct to standard; in control group the patients followed the standard oral hygiene regimen. Index of efficiency of oral hygiene (PHPm), community periodontal index (CPI) and papillary-marginal-alveolar index (PMA) were evaluated before treatment and after 1 and 6 months. For statistics analysis, Mann-Whitney, Kruskal-Wallis tests and Pearson criterion were used.

RESULTS

Baseline hygiene levels in two groups had no differences. Oral hygiene indices were significantly lower in the test group in comparison with control after 1 month (PHPm = 0.38 ± 0.18 and 1.19 ± 0.45, respectively, p < 0.01; PMA = 11.78 ± 8.5 and 47.25 ± 20.9, respectively, p < 0.05; CPI = 0.65 ± 0.53 and 1.53 ± 0.77, respectively, p < 0.01) and 6 months (PHPm = 0.5 ± 0.2 and 1.2 ± 0.4, respectively, p < 0.01; PMA = 11.62 ± 19.6 and 66.33 ± 27.9, respectively, p < 0.01; CPI = 0.63 ± 0.73 and 1.68 ± 0.78, respectively, p < 0.01).

CONCLUSIONS

The use of the test solution as an adjunct to standard oral hygiene provided a significant beneficial effect in terms of oral hygiene in patients undergoing orthodontic treatment.

Self-reported questionnaire on periodontal condition validated for use in Brazil

There is a current expectation of instruments for periodontal condition surveillance worldwide. The present study aimed to validate the Oral Health Questions Set B (OHQB) for the Brazilian Portuguese and evaluate its temporal stability. This is a sequential mixed-method investigation. After the forward-backward translation process to the Brazilian Portuguese, the OHQB Brazil (OHQB-Br) was applied to 156 participants (39.5 ± 14.14 years; 51.9% males). In sequence, through a full-mouth six-sites/teeth examination and in accordance with the original instrument, the periodontal diagnosis was obtained (March 2020). In January 2021, the OHB-BR was reapplied (n = 71). Ordinal alpha and McDonald's omega tested the internal consistency of the OHQB-Br. Temporal stability was investigated [Spearman correlation, intraclass correlation coefficient (ICC), and the Bland-Altman]. The concurrent validity was also verified, considering the periodontal clinical diagnosis (Kruskal Wallis). The ordinal alpha (0.69) and McDonald's omega (0.73) coefficients showed an adequate internal consistency of the OHQB-Br. The OHQB-Br temporal stability was high, as demonstrated by the Spearman coefficient (0.80) and ICC (0.79) and by the Bland-Altman plot. A concurrent validity showed a direct relationship between the OHQB-Br and the clinical condition of no periodontitis, mild, moderate, and severe periodontitis (p < 0.05). Because the OHQB-Br shows internal validity, temporal stability, and adequately identifies periodontal health and moderate/severe periodontitis, the instrument might represent an important tool, at the public level or other settings, for periodontal surveillance in Brazil.

Accuracy of Estimating Periodontitis and Its Risk Association Using Partial-Mouth Recordings for Surveillance Studies: A Systematic Review and Meta-Analysis

Objectives

Our aim is to conduct an up-to-date systematic review and meta-analysis pertaining to the accuracy of using the partial-mouth recording protocol (PRP) in surveillance studies to estimate the periodontitis prevalence, extent, severity, and its risk associations.

Methods

Medline and Embase databases were searched for studies which assessed the periodontitis prevalence, severity, extent, or its risk associations using PRPs versus full-mouth recording protocols (FRPs); searches were conducted up until May 26, 2021. The risk of bias and the applicability of the studies were assessed using the QUADAS-2 tool. Both qualitative data synthesis and quantitative data synthesis were performed, and comparisons were done for the accuracy and precision of PRPs for different periodontitis outcomes. The study's protocol was registered through the International Platform of Registered Systematic Review and Meta-analysis Protocols (registration number: INPLASY202160032).

Results

A total of 14 studies were included. The studies had a considerable degree of heterogeneity, along with a moderate risk of bias and applicability concerns. Several factors influenced the accuracy or precision of using PRPs, including the age, distribution of periodontitis in the studied population, PRP selection, total PRP sites, the threshold for minimum sites with CAL, and the severity of periodontitis case definitions. Overall, the PRP with the highest accuracy and precision mainly included (1) a full-mouth protocol at the following partial sites: mesiobuccal-midbuccal-distolingual (MB-B-DL), mesiobuccal-distolingual (MB-DL), mesiobuccal-midbuccal-distobuccal (MB-B-DB), mesiobuccal-distobuccal (MB-DB), and 84 sites using the random site selection method (RSSM) and (2) random-half-mouth (RHM) protocols.

Conclusions

The PRPs with the highest overall accuracy and precision in estimating the periodontitis prevalence, extent, severity, and risk associations included the full-mouth assessment at the following partial sites: MB-B-DL, MB-DL, MB-B-DB, MB-DB, and 84 sites using RSSM and RHM protocols.

Accuracy and precision of using partial-mouth recordings to study the prevalence, extent and risk associations of untreated periodontitis

To study the accuracy and precision of estimating the prevalence, extent and associated risks of untreated periodontitis using partial-mouth recording protocols (PRPs) Methods: A purposive sample of 431 individuals who had never been treated for periodontal disease was recruited from screening clinics at the King Saud bin Abdul-Aziz University for Health Sciences. Data were collected using questionnaires and clinical examinations. The prevalence, extent and risk associations of periodontitis were evaluated. Three PRPs were compared to full-mouth recordings (FRPs) in terms of the sensitivity, specificity, predictive values, and absolute bias. Results: The prevalence of periodontitis was estimated with the highest accuracy and precision by examinations of the full mouth at the mesiobuccal and distolingual sites (FM)MB-DL, followed by random half-mouth (RHM) recordings. The extent of periodontitis was estimated with high precision using all the PRPs, and the absolute bias ranged from -0.6 to -2.3. The absolute bias indicated by OR for risk associations was small for the three PRPs and ranged from -0.8 to 0.8. Conclusion: (FM)MB-DL and RHM were the PRPs with moderate to high levels of accuracy and precision for estimating the prevalence and risk associations of periodontitis. The extent of periodontitis was estimated with high precision using all three PRPs. The results of this study showed that the magnitude and direction of bias were associated with the severity of periodontitis, the selected PRPs and the magnitude of the risk associations.

Validation of a self-report questionnaire for periodontitis in a Japanese population

We aimed to assess the validity of the self-report questionnaire for periodontitis in a Japanese population. A Japanese 9-item self-report questionnaire, developed by translating English-version questions that were used to detect periodontitis, was validated against full-mouth clinically-assessed periodontitis in 949 Japanese adults (average age = 43.2 years). Multivariable logistic regression modeling was used to calculate the area under the receiver operating characteristic curve (AUC), wherein the periodontitis case definition of the Centers for Disease Control and Prevention/American Academy of Periodontology was considered the gold standard. Severe, moderate, and mild periodontitis were identified in 6.2%, 30.0%, and 6.7% of the study population, respectively. Self-reported oral health questions combined with socio-demographic and health-related variables had an AUC > 0.70 (range, 0.71-0.87) for any periodontitis category. Four oral health questions ("have gum disease," "loose tooth," "lost bone," and "bleeding gums") were selected in the parsimonious model for severe periodontitis. The periodontitis screening score generated by the responses to these four questions had an AUC, sensitivity, and specificity of 0.82, 73.1%, and 74.3%, respectively, where the cut-off was set at 2 points. In conclusion, a locally adapted version of the self-report questionnaire had an acceptable diagnostic capacity for the detection of periodontitis in this study population.

Bidirectional Association between Metabolic Control in Type-2 Diabetes Mellitus and Periodontitis Inflammatory Burden: A Cross-Sectional Study in an Italian Population

This study assessed the periodontal conditions of type 2 diabetes (T2DM) patients attending an Outpatient Center in North Italy and explored the associations between metabolic control and periodontitis. Periodontal health of 104 T2DM patients (61 men and 43 women, mean age of 65.3 ± 10.1 years) was assessed according to CDC/AAP periodontitis case definitions and Periodontal Inflamed Surface Area (PISA) Index. Data on sociodemographic factors, lifestyle behaviors, laboratory tests, and glycated hemoglobin (HbA1c) levels were collected by interview and medical records. Poor glycemic control (HbA1c ≥ 7%), family history of T2DM, and C-reactive protein levels were predictors of severe periodontitis. An increase in HbA1c of 1% was associated with a rise in PISA of 89.6 mm². On the other hand, predictors of poor glycemic control were severe periodontitis, waist circumference, unbalanced diet, and sedentary lifestyle. A rise in PISA of 10 mm² increased the odds of having HbA1c ≥ 7% by 2%. There is a strong bidirectional connection between periodontitis and poor glycemic control. The inflammatory burden posed by periodontitis represents the strongest predictor of poor glycemic control.

Adjunctive effect of locally delivered antimicrobials in periodontitis therapy: A systematic review and meta-analysis

AIM

To answer the following PICOS question: in adult patients with periodontitis, which is the efficacy of adjunctive locally delivered antimicrobials, in comparison with subgingival debridement alone or plus a placebo, in terms of probing pocket depth (PPD) reduction, in randomized clinical trials with at least 6 months of follow-up.

MATERIAL AND METHODS

A systematic search was conducted: 59 papers, reporting 50 different studies, were included. Data on clinical outcome variables changes were pooled and analysed using weighted mean differences (WMDs) and 95% confidence intervals (CI), and prediction intervals (PI), in case of significant heterogeneity.

RESULTS

Statistically significant differences were observed, in 6- to 9-month studies, for PPD (WMD = 0.365, 95% CI [0.262; 0.468], PI [-0.29; 1.01]) and clinical attachment level (CAL) (WMD = 0.263, 95% CI [0.123; 0.403], PI [-0.43; 0.96]). For long-term studies, significant differences were observed for PPD (WMD = 0.190, 95% CI [0.059; 0.321]), but not for CAL. For adverse events, no differences were observed. Results were affected by study design (split-mouth versus parallel studies) and assessment (full- or partial-mouth), as well as by the formulation tested.

CONCLUSIONS

The use adjunctive locally delivered antimicrobials in periodontitis therapy results in statistically significant benefits in clinical outcomes, without relevant side effects.

Correlation between the caries status of the first permanent molars and the overall DMFT Index: A cross-sectional study

To analyze whether a correlation exists between the caries status (Decayed, Missing and Filled Teeth, DMFT Index) of the first permanent molars (FPMs) and that of the full permanent dentition of Mexican adolescents, and to propose its use in large epidemiological studies of dental caries.We conducted a cross-sectional study of 1538 adolescents from 12 to 15 years old. Based on a clinical oral examination, we determined the DMFT Indices of their FPMs (FPM-DMFT) and of their full permanent dentition (comprehensive DMFT Index). We explored each FPM to determine whether it was with or without caries, filled, missing or sealed. For our statistical analysis, we used Fisher exact test and Spearman correlation in Stata software.After examining a total of 6157 FPMs, we found that 56.8% of our sample of adolescents had no caries in their 4 FPMs whereas 4.9% experienced caries in all 4. No significant differences emerged by sex (P > .05); however, by age, the older adolescents experienced greater FPM-DMFT (P < .05). Analysis yielded a correlation of r = 0.8693 between the FPM-DMFT and comprehensive DMFT scores (P < .0001) of participants. The underestimation of caries prevalence (DMFT > 0) was 5.4% (48.6% vs 43.2%), while the DMFT Index was underestimated at 0.34 (1.15 vs 0.81).The strong correlation between the FPM-DMFT and comprehensive DMFT Indices suggests that overall caries status can be inferred on the basis of FPM caries status. This evidence is useful when conducting large epidemiological studies such as national surveys.