Representativeness of the "Ramfjord teeth" for epidemiologic studies of gingivitis and periodontitis

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.

Clinical parameters and inflammatory biomarkers among patients with multibracket appliances: a prospective clinical trial

BACKGROUND

Aim of the presented study was to investigate changes in clinical parameters and active matrix metalloproteinase-8 (aMMP-8) levels in gingival crevicular fluid of patients before and during treatment with multibrackets appliances.

METHODS

Fifty-five adolescents scheduled for the treatment were included. Clinical parameters and subgingival samples were obtained at six time points: 1 week before appliance insertion (T0), 3 (T1), 6 (T2) weeks, 3 (T3), 6 (T4) months, and 1 year (T5) after that. Gingival index and plaque index were assessed to evaluated changes on the clinical status. Subgingival samples were collected to analyze changes in aMMP-8.

RESULTS

Scores for gingival and plaque index increased after bracket insertion. The gingival index increased from T2 (p < 0.05) until T5 (p < 0.0001). Plaque index also increased, reaching its maximum peak at T3 (p < 0.05). Moreover, an increase of aMMP-8 levels (p < 0.05) was noted. There was no significant between upper and lower jaws.

CONCLUSIONS

Treatment with multibracket appliances in adolescents favors dental plaque accumulation and may transitionally increase gingival and plaque index and aMMP-8 levels leading to gingival inflammation, even 1 year after therapy began.

TRIAL REGISTRATION

This study was approved by the Ethics Committee of the dental medical association Rheiland-Pfalz, Germany (process no. 837.340.12 (8441-F)), and followed the guidelines of Good Clinical Practices.

Age estimation from alveolar bone loss, re-evaluation of Ruquet's method

There are many dental age estimation methods, but all the methods do not correspond, especially for aging methods for adults and mature individuals, to the reality of the forensic field, which favors simple, effective, and easy-to-use methods. Ruquet (2015) developed a method based on alveolar bone loss that predicts age for individuals between 25 and 60 years old and is even more accurate for those 25-40 years old. This study re-evaluated Ruquet's alveolar bone loss method using three-dimensional imaging of individuals whose age and sex were known, without taking into account their medical conditions. Digital measurements, from the cemento-enamel junction (CEJ) to the alveolar bone crest (ABC), were performed on the mesial and distal surfaces of teeth on 243 patients, independent of the tridimensional imaging test. With these measurements, two alveolar bone loss averages (ABL) were calculated, one with all the teeth present on the arches and another with only Ramfjörd's teeth. Bone loss showed a significant correlation with age (p < 0.001). The age estimation with all teeth and with only Ramfjörd's teeth showed a statistically significant difference, and age estimation was more accurate when all teeth were used. The assessment of alveolar resorption appears to be an interesting tool for age estimation in adult individuals. However, the method still lacks precision, and the mean absolute errors (MAEs) obtained by age group were all greater than 5 years, except for the age group 35-39 years old, for the age estimation with all teeth. Further studies should explore this existing correlation between alveolar bone loss and age and refine this method to make it more accurate.

Multiple Imputation for Partial Recording Periodontal Examination Protocols

AIM

Partial-mouth recording protocols often result in underestimation of population prevalence and extent of periodontitis. We posit that multiple imputation of measures such as clinical attachment loss for nonselected tooth sites in partial-mouth samples can reduce bias in periodontitis estimates.

METHODS

Multiple imputation for correlated site-level dichotomous outcomes in a generalized estimating equations framework is used to impute site-level binary indicators for clinical attachment loss exceeding a fixed threshold in partial-mouth samples. Periodontitis case definitions are applied to the imputed "complete" dentitions, enabling estimation of prevalence and other summaries of periodontitis for partial-mouth samples as if for full-mouth examinations. A multiple imputation-bootstrap procedure is described and applied for point and variance estimation of these periodontitis measures. The procedure is evaluated with pseudo-partial-mouth samples based on random site selection protocols of 28 to 84 periodontal sites repeatedly generated from full-mouth periodontal examinations of 3,621 participants in the 2013 to 2014 National Health and Nutrition Examination Survey (NHANES) survey.

RESULTS

Multiple imputation applied to partial-mouth samples overestimated periodontitis mean extent, defined as the number of sites with clinical attachment loss 3 mm or greater, by 9.5% in random site selection protocols with 84 sites and overestimated prevalence by 5% to 10% in all the evaluated protocols.

CONCLUSIONS

In the 2013 to 2014 NHANES data, multiple imputation of site-level periodontal indicators provides less biased estimates of periodontitis prevalence and extent than has been reported from estimates based on the direct application of full-mouth case definitions to partial-mouth samples. Multiple imputation provides a promising solution to the longstanding, vexing problem of estimation bias in partial-mouth recording, with potential application to a wide array of case definitions, periodontitis measures, and partial recording protocols.

KNOWLEDGE TRANSFER STATEMENT

Partial-mouth sampling, while a resource-efficient strategy for obtaining oral disease estimates, often results in underestimation of periodontitis metrics. Multiple imputation for nonselected periodontal sites produces pseudo-full-mouth data sets that may be analyzed and combined to produce estimates with small bias.

Effectiveness of AI-driven remote monitoring technology in improving oral hygiene during orthodontic treatment

OBJECTIVE

This study aimed to evaluate the effectiveness of Dental Monitoring™ (DM™) Artificial Intelligence Driven Remote Monitoring Technology (AIDRM) technology in improving the patient's oral hygiene during orthodontic treatment through AI-based personalized active notifications.

METHODS

A prospective clinical study was conducted on two groups of orthodontic patients. DM Group: (n = 24) monitored by DM weekly scans and received personalized notifications on the DM smartphone application regarding their oral hygiene status. Control Group (n = 25) not monitored by DM. Both groups were clinically assessed using Plaque Index (OPI) and the Modified Gingival Index (MGI). DM Group was followed for 13 months and the Control Group was followed for 5 months. Student-independent t test and paired t tests were used to investigate the mean differences between study groups and between time points for each group respectively.

RESULTS

At all time points, the mean differences indicated that the DM group had lower OPI and MGI values than the control group. The mean value for OPI and MGI were statistically significantly lower in the DM group (OPI = 1.96, MGI = 1.56) than in the control group (OPI = 2.41, MGI = 2.17) after 5 months. A rapid increase in mean OPI and MGI values was found between T0 and T1 for both study groups. A plateau effect for OPI scores appeared to occur from T1 to T5 for both study groups, but the plateau effect seemed to be more pronounced for the DM group than the study group. The MGI values for both study groups also increased dramatically from baseline to T5, however, a plateau effect was not observed.

CONCLUSIONS

The oral hygiene of orthodontic patients rapidly worsens over the first 3 months and plateaus after about 5 months of treatment. AIDRM by weekly DM scans and personalized active notifications may improve oral hygiene over time in orthodontic patients.

Oral hygiene and infective endocarditis: a case control study

OBJECTIVE

To determine if oral hygiene is associated with infective endocarditis (IE) among those at moderate risk for IE.

STUDY DESIGN

This is a case control study of oral hygiene among hospitalized patients with IE (cases) and outpatients with heart valve disease but without IE (controls). The primary outcome was the mean dental calculus index. Secondary outcomes included other measures of oral hygiene and periodontal disease (e.g., dental plaque, gingivitis) and categorization of blood culture bacterial species in case participants.

RESULTS

The 62 case participants had 53% greater mean dental calculus index than the 119 control participants (0.84, 0.55, respectively; difference = 0.29, 95% CI: 0.11, 0.48; P = .002) and 26% greater mean dental plaque index (0.88, 0.70, respectively; difference = 0.18, 95% CI: 0.01.0.36; P = .043). Overall, cases reported fewer dentist and dental hygiene visits (P = .013) and fewer dental visits in the 12 weeks before enrollment than controls (P = .007). Common oral bacteria were identified from blood cultures in 27 of 62 cases (44%).

CONCLUSIONS

These data provide evidence to support and strengthen current American Heart Association guidance that those at risk for IE can reduce potential sources of IE-related bacteremia by maintaining optimal oral health through regular professional dental care and oral hygiene procedures.

Systemic Inflammation, Endothelial Function, and Risk of Periodontitis in Overweight/Obese Adults

The network interaction between systemic inflammatory mediators, endothelial cell adhesion function, and adiponectin as mediators of the association between metabolic diseases and periodontitis has not been evaluated. The objective of this study is to assess whether the interaction of baseline serum levels of TNF-α, hs-CRP, ICAM-1, VCAM-1, and adiponectin leads to periodontitis. Five hundred and ninety-seven overweight/obese (overweight: BMI 25 to <30 kg/m2; obese: >30 kg/m2) adults, aged 40-65 years, with complete 3-year follow-up data were included. Generalized structural equation models with negative binomial regression were used to estimate the regression coefficient (β) for the outcome number of teeth with probing pocket depth (PPD) ≥ 4 mm and bleeding on probing (BOP) at 3-year follow-up for a 1 standard deviation unit increase (Δ = +1SD) in each biomarker. After adjusting for multiple covariates, baseline ICAM-1 and VCAM-1 had significant direct effects on increased log-transformed number of teeth with PPD ≥ 4 mm and BOP (β: 0.16; 95% CI: 0.02-0.30; β: 0.15; 95% CI: 0.02-0.30, respectively). Baseline hs-CRP showed a significant indirect effect via ICAM-1 on the log-transformed number of teeth with PPD ≥ 4 mm and BOP (β: 4.84; 95% CI: 0.27-9.42). Thus, elevated serum ICAM-1 and VCAM-1 have a significant direct effect and increased hs-CRP has a significant indirect effect on the predicted level of periodontitis at the 3-year follow-up among overweight/obese Hispanic adults.

uSing rolE-substitutioN In care homes to improve ORal health (SENIOR): a study protocol

Background

Dental service provision in the care home sector is poor, with little emphasis on prevention. Emerging evidence suggests that the use of Dental Care Professionals (dental therapists and dental nurses) as an alternative to dentists has the potential to improve preventive advice, the provision of care and access to services within care homes. However, robust empirical evidence from definitive trials on how to successfully implement and sustain these interventions within care homes is currently lacking. The aim of the study is to determine whether Dental Care Professionals could reduce plaque levels of dentate older adults (65 + years) residing in care homes.

Methods

This protocol describes a two-arm cluster-randomised controlled trial that will be undertaken in care homes across Wales, Northern Ireland and England. In the intervention arm, the dental therapists will visit the care homes every 6 months to assess and then treat eligible residents, where necessary. All treatment will be conducted within their Scope of Practice. Dental nurses will visit the care homes every month for the first 3 months and then three-monthly afterwards to promulgate advice to improve the day-to-day prevention offered to residents by carers. The control arm will be ‘treatment as usual’.

Eligible care homes (n = 40) will be randomised based on a 1:1 ratio (20 intervention and 20 control), with an average of seven residents recruited in each home resulting in an estimated sample of 280. Assessments will be undertaken at baseline, 6 months and 12 months and will include a dental examination and quality of life questionnaires. Care home staff will collect weekly information on the residents’ oral health (e.g. episodes of pain and unscheduled care). The primary outcome will be a binary classification of the mean reduction in Silness-Löe Plaque Index at 6 months. A parallel process evaluation will be undertaken to explore the intervention’s acceptability and how it could be embedded in standard practice (described in a separate paper), whilst a cost-effectiveness analysis will examine the potential long-term costs and benefits of the intervention.

Discussion

This trial will provide evidence on how to successfully implement and sustain a Dental Care Professional-led intervention within care homes to promote access and prevention.

Trial registration

ISRCTN16332897. Registered on 3 December 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06487-3.

Association between obstructive sleep apnea and periodontitis in Chinese male adults: A cross-sectional study

STATEMENT OF PROBLEM

An association between obstructive sleep apnea and periodontitis has been suggested, but supporting data are lacking.

PURPOSE

The purpose of this cross-sectional study was to investigate any association between obstructive sleep apnea and periodontitis in Chinese male adults.

MATERIAL AND METHODS

Ninety-three male adults (aged between 24 and 35 years) were recruited and examined between June and September 2019. Obstructive sleep apnea was diagnosed by using portable, overnight polysomnography, and all participants were classified into study and control groups based on the apnea-hypopnea index. Periodontal examinations were conducted before polysomnography measuring probing depth, clinical attachment level, and bleeding on probing. An objective nasal airway resistance assessment was also performed before polysomnography to quantify mouth breathing during sleep.

RESULTS

Overall, 40 (43.0%) participants had periodontitis, and 19 (20.4%) had obstructive sleep apnea; in those diagnosed with periodontitis, 13 of 40 (32.5%) also had obstructive sleep apnea. Obstructive sleep apnea was positively associated with periodontitis (odds ratio =3.719, 95% CI=1.234 to 11.209, P=.020). The obstructive sleep apnea group showed significantly higher bleeding on probing (P=.034) and clinical attachment level (P=.046). Correlation analysis showed a weak but positive correlation between the severity of obstructive sleep apnea and that of periodontitis. The regression analysis identified the lowest oxygen saturation (odds ratio=0.894, 95% CI=0.842 to 0.949, P=.002) to be significantly associated with the prevalence of periodontitis.

CONCLUSIONS

A significant association was observed between obstructive sleep apnea and periodontitis. Low oxygen saturation might be a predictive index for periodontitis, suggesting that hypoxia caused by obstructive sleep apnea might be related to the symptoms of periodontitis.

Oral health and oral health behavior in young adults with caries disease

Objective

The aim of this study was to describe and analyze oral health, oral health behaviors, and oral health-related quality of life (OHRQoL) in relation to the level of caries disease among caries-active young adults.

Material and methods

This study presents data from a sample of young adults (n = 135) with active caries disease who were enrolled in a clinical, randomized controlled trial. The independent variables of sociodemographics, oral health (gingivitis, plaque), oral health behaviors (such as toothbrushing, dental attendance, sugar-containing sweets and drinks), dental anxiety, self-rated oral health, and OHRQoL were collected. Multinomial logistic regression was used to simultaneously evaluate the associations between the independent variables and caries severity.

Results

Multinominal logistic regression showed that poor OHRQoL and gingivitis were associated with caries severity in a gradient fashion in accordance with caries disease activity. Also, irregular dental care and frequent consumption of sugary soda were significantly associated with very high caries severity.

Conclusions

The risk factors related to caries severity among young adults were poor OHRQoL, gingivitis, consumption of sugary soda and irregular dental care attendance, indicating the need for a combination of different interventions specifically health behavior change. Furthermore, these findings may contribute to identifying high caries-risk individuals.

Prevalence of gingival recession and its correlation with gingival phenotype in mandibular incisors region of orthodontically treated female patients: A cross-sectional study

Background:

Gingival recession is associated with dentin hypersensitivity, unesthetic appearance, and carious or noncarious cervical lesions. Orthodontic treatment, gingival thickness (GT), and keratinized tissue width (KTW) play roles in gingival recession etiology. The study is aimed to compare the prevalence of gingival recession in the mandibular incisor region of orthodontically-treated females with untreated controls, and to identify if there is any correlation among the GT, KTW, and gingival recession.

Subjects and Methods:

A total of 150 Saudi females were enrolled in this study. They were categorized into the treatment group (n = 75) and control group (n = 75). Background characteristics and clinical periodontal parameters including the plaque index, gingival index, GT, KTW, gingival recession length (GRL), and gingival recession width (GRW) were recorded and compared between groups, and any associations were identified.

Results:

Among the orthodontically-treated females, 31 (41.33%) had at least one mandibular incisor with gingival recession, in contrast to 18 (24%) of the controls. Pearson's correlation analysis indicated a significant positive correlation between the GT and KTW and between the GRL and GRW (P < 0.001). In addition, a significant negative correlation was observed between the KTW and GRL and between the KTW and GRW (P < 0.001). However, no significant correlation was found between the GT and GRL or between the GT and GRW.

Conclusions:

Our findings indicated that orthodontic treatment is a predisposing factor for the development or progression of gingival recession, particularly in females with a narrow KTW.

Evaluation of the Effectiveness of an Interdisciplinary Preventive Oral Hygiene Program for Children with Congenital Heart Disease

It is recognized that children with congenital heart disease (CHD) are predisposed to having poorer oral health. Therefore, the purpose of this study was to evaluate the effectiveness of an interdisciplinary preventive oral hygiene program (POHP) for children with CHD. The aim was the reduction of the incidence of dental caries, as well as improvement of oral hygiene. The total number of participants in this study was 107 children with CHD aged between two to six years. At baseline, these children were compared to a healthy control group (HCG) of 101 children of similar age from five preschools in Giessen, Germany. All examinations were carried out before the introduction of a standardized POHP. The Quigley/Hein Plaque- (QHI), Silness/Loe Gingival- (GI) and Gingival Hyperplasia Index (GHI) were determined. Starting with baseline, the described procedures were repeated in the CHD group during two follow-ups after three and six months. In the first examination, compared to controls, CHD children showed a significantly (p < 0.05) poorer oral hygiene (QHI: 2.6; GI: 0.3; GHI: 0.2). All oral hygiene parameters (QHI, GI, GHI) of the CHD group improved significantly over the whole period of the preventive program (p < 0.05). These results demonstrated an improvement in CHD children involved in a standardized POHP. The data with regard to the general health of these risk patients, including prevention of endocarditis, demonstrate the necessity of an interdisciplinary approach between pediatric cardiologists, pediatricians and dentists.

Effects of a Caregiver Training Program on Oral Hygiene of Alzheimer's Patients in Institutional Care

OBJECTIVES

To investigate the effects of a caregiver training program on the oral hygiene of caregivers and patients with Alzheimer's disease (AD) and to identify program components and parameters for accurate assessment of outcomes.

DESIGN

Single-blinded prospective cohort study.

SETTING AND PARTICIPANTS

Patients with AD and caregivers in nursing homes in the Greater Zhengzhou Area, China.

METHODS

Initially 168 AD patient/caregiver pairs were recruited and randomly assigned to control, limited training, and comprehensive training groups. The mini-mental state examination, global deterioration scale, and Katz activities of daily living scale were conducted for patients with AD. Information on participants' oral hygiene habits and general oral health was collected. The modified Quigley-Hein Plaque Index (PI) and Gingival Index (GI) were used to assess oral hygiene and gingival health. Intervention included (1) an educational video showing the role of dental plaque and the modified Bass technique; and (2) caregivers practicing toothbrushing on themselves and patients with AD under professional guidance. Changes in oral hygiene and correlations between patient PI/GI and caregiver PI/GI were analyzed.

RESULTS

After 6 weeks, complete data for 146 AD patient/caregiver pairs were collected. Before enrollment, most patients with AD had very poor oral hygiene. Compared with controls and limited training, only comprehensive training was able to achieve steady reduction in PI and GI scores in patients with AD, which still fell short of desirable levels (PI: 2.46 ± 0.52, GI: 1.24 ± 0.24, week 6). PI and GI scores in caregivers saw steady improvement only through comprehensive training (PI: 1.41 ± 0.38, GI: 0.88 ± 0.19, week 6). Number of training sessions had the greatest influence on both patient PI and GI scores.

CONCLUSIONS AND IMPLICATIONS

Comprehensive caregiver training on toothbrushing skills is effective in improving the oral hygiene of caregivers and patients with AD in nursing homes. Additional evidence is needed to establish the optimal program structure.

Impact of 0.1% octenidine mouthwash on plaque re-growth in healthy adults: a multi-center phase 3 randomized clinical trial

Objectives

To investigate plaque inhibition of 0.1% octenidine mouthwash (OCT) vs. placebo over 5 days in the absence of mechanical plaque control.

Materials and methods

For this randomized, placebo-controlled, double-blind, parallel group, multi-center phase 3 study, 201 healthy adults were recruited. After baseline recording of plaque index (PI) and gingival index (GI), collection of salivary samples, and dental prophylaxis, subjects were randomly assigned to OCT or placebo mouthwash in a 3:1 ratio. Rinsing was performed twice daily for 30 s. Colony forming units in saliva were determined before and after the first rinse. At day 5, PI, GI, and tooth discoloration index (DI) were assessed. Non-parametric van Elteren tests were applied with a significance level of p < 0.05.

Results

Treatment with OCT inhibited plaque formation more than treatment with placebo (PI: 0.36 vs. 1.29; p < 0.0001). OCT reduced GI (0.04 vs. placebo 0.00; p = 0.003) and salivary bacterial counts (2.73 vs. placebo 0.24 lgCFU/ml; p < 0.0001). Tooth discoloration was slightly higher under OCT (DI: 0.25 vs. placebo 0.00; p = 0.0011). Mild tongue staining and dysgeusia occurred.

Conclusions

OCT 0.1% mouthwash inhibits plaque formation over 5 days. It therefore can be recommended when regular oral hygiene is temporarily compromised.

Clinical relevance

When individual plaque control is compromised, rinsing with octenidine mouthwash is recommended to maintain healthy oral conditions while side effects are limited.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00784-021-03781-3.

Symptom-orientated oral hygiene for children after heart transplantation: Effectiveness of a standardized prophylactic program

Children with CHD, especially heart-transplanted patients, are predisposed to have caries lesions, gingivitis and other oral findings like gingival hyperplasia. The aim of the study was the implementation of a specific oral hygiene program in these patients and its effect on the improvement of oral health, especially gingival overgrowth. For this, we used a newly developed systematic GHI to evaluate and describe this gingival alteration. Thirty-three children, aged 6 to 15 years with cardiac transplants (9 girls, 24 boys), were examined and introduced into a specific oral hygiene program. Each child showed evidence of gingival hyperplasia. They were randomly divided into three groups with the following oral care measurements: Group ZZ tooth brushing, Group ZZS tooth brushing and mouth rinsing, Group ZZSS tooth brushing, mouth rinsing and the use of an additional single and sulcus toothbrush. A significant decline of all oral health parameters could be proven in all groups. Gingival hyperplasia (GHI) improved as well as plaque accumulation (QHI). The children who used in addition to toothbrushing rinsing solutions and/or additional miniature toothbrushes showed better parameters of the gingival hygiene indexes from the baseline examination until the end of the study. The results show that any infant with cardiac transplant has to be introduced into an individualized oral hygiene program underlining the need of comprehensive dental care in cooperation with pediatric cardiology.

Efficacy of antioxidant mouthwash in the reduction of halitosis: A randomized, double blind, controlled crossover clinical trial

Background/purpose

Halitosis is the unpleasant and offensive odour in exhaled air, which is linked to the presence of volatile sulphur compounds (VSC). Different mouthwashes have been used to treat halitosis. The objective of this study was to test the effect of an antioxidant (AO) mouthwash, and mouthwash containing [0.05% chlorhexidine, 0.05% cetylpyridinium chloride, and 0.14% zinc lactate (CHX-CPC-Zn)] on VSC.

Material and methods

Thirty-five subjects with halitosis participated in this clinical trial. At the baseline visit, a breath sample was taken and analyzed for the level of hydrogen sulphide (H₂S), methyl mercaptan (CH₃SH), and dimethyl sulphide (CH₃SCH₃) using portable gas chromatography (OralChroma™). Two mouthwashes were randomly provided to each subject in addition to saline solution (NaCl 0.9%) as control. Subjects were instructed to rinse with 20 ml of the mouthwash for 1 min twice daily for 2 weeks. At second visit, post-treatment breath sample was taken. Afterward, the patient was asked to refrain from using mouthwash for a washout period of 1 week. A similar procedure was repeated for each mouthwash interval.

Results

No significant differences in VSC level between all three groups were detected at baseline. A significant reduction in VSC level was obtained after using CHX-CPC-Zn mouthwash. On other hand, both AO mouthwash and saline had no significant impact on the level of VSC.

Conclusion

CHX-CPC-Zn mouthwash has a significant effect on VSC level reduction in subjects with confirmed halitosis. Besides, using AO mouthwash regularly for 2 weeks did not have any impact on improving the level of halitosis.

The Effect of Hypothyroidism on Bone Loss at Dental Implants

Hypothyroidism (HT) is an endocrine disorder characterized by abnormally reduced thyroid gland activity and is most commonly of autoimmune etiology. HT is associated with alterations in bone metabolism, and HT patients typically experience decreased bone resorption. The objective of this study was to use dental implants as standardized reference markers to compare the extent of alveolar bone loss in implant patients with and without HT. We examined medical and dental history records and radiographic data from 635 patients receiving 1480 implants during 2000–2017. The rate of bone loss was calculated from differences in radiographic bone levels over time, corrected for radiographic distortion. Peri-implant bone loss from patients with HT was significantly lower than for those without HT (t1252= −3.42; 95% confidence interval= 0.47–1.73; P &lt; .001; M = 0.53 and 1.63 mm/yr, respectively). A similar relationship persisted after excluding smokers and diabetics and after additionally excluding those on systemic steroids, hormone replacement therapy, hormone medications, or autoimmune diseases other than HT. Our data suggest that patients with HT have a decreased rate of bone loss around dental implants and may not be at increased risk for dental implant failure. The decreased bone metabolic rate among patients with HT might contribute to those findings.

Oral hygiene interventions for people with intellectual disabilities

BACKGROUND

Periodontal (gum) disease and dental caries (tooth decay) are the most common causes of tooth loss; dental plaque plays a major role in the development of these diseases. Effective oral hygiene involves removing dental plaque, for example, by regular toothbrushing. People with intellectual disabilities (ID) can have poor oral hygiene and oral health outcomes.

OBJECTIVES

To assess the effects (benefits and harms) of oral hygiene interventions, specifically the mechanical removal of plaque, for people with intellectual disabilities (ID).

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases to 4 February 2019: Cochrane Oral Health's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Register of Studies), MEDLINE Ovid, Embase Ovid and PsycINFO Ovid. ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. The Embase search was restricted by date due to the Cochrane Centralised Search Project, which makes available clinical trials indexed in Embase through CENTRAL. We handsearched specialist conference abstracts from the International Association of Disability and Oral Health (2006 to 2016).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and some types of non-randomised studies (NRS) (non-RCTs, controlled before-after studies, interrupted time series studies and repeated measures studies) that evaluated oral hygiene interventions targeted at people with ID or their carers, or both. We used the definition of ID in the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10). We defined oral hygiene as the mechanical removal of plaque. We excluded studies that evaluated chemical removal of plaque, or mechanical and chemical removal of plaque combined.

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened search records, identified relevant studies, extracted data, assessed risk of bias and judged the certainty of the evidence according to GRADE criteria. We contacted study authors for additional information if required. We reported RCTs and NRSs separately.

MAIN RESULTS

We included 19 RCTs and 15 NRSs involving 1795 adults and children with ID and 354 carers. Interventions evaluated were: special manual toothbrushes, electric toothbrushes, oral hygiene training, scheduled dental visits plus supervised toothbrushing, discussion of clinical photographs showing plaque, varied frequency of toothbrushing, plaque-disclosing agents and individualised care plans. We categorised results as short (six weeks or less), medium (between six weeks and 12 months) and long term (more than 12 months).Most studies were small; all were at overall high or unclear risk of bias. None of the studies reported quality of life or dental caries. We present below the evidence available from RCTs (or NRS if the comparison had no RCTs) for gingival health (inflammation and plaque) and adverse effects, as well as knowledge and behaviour outcomes for the training studies.Very low-certainty evidence suggested a special manual toothbrush (the Superbrush) reduced gingival inflammation (GI), and possibly plaque, more than a conventional toothbrush in the medium term (GI: mean difference (MD) -12.40, 95% CI -24.31 to -0.49; plaque: MD -0.44, 95% CI -0.93 to 0.05; 1 RCT, 18 participants); brushing was carried out by the carers. In the short term, neither toothbrush showed superiority (GI: MD -0.10, 95% CI -0.77 to 0.57; plaque: MD 0.20, 95% CI -0.45 to 0.85; 1 RCT, 25 participants; low- to very low-certainty evidence).Moderate- and low-certainty evidence found no difference between electric and manual toothbrushes for reducing GI or plaque, respectively, in the medium term (GI: MD 0.02, 95% CI -0.06 to 0.09; plaque: standardised mean difference 0.29, 95% CI -0.07 to 0.65; 2 RCTs, 120 participants). Short-term findings were inconsistent (4 RCTs; low- to very low-certainty evidence).Low-certainty evidence suggested training carers in oral hygiene care had no detectable effect on levels of GI or plaque in the medium term (GI: MD -0.09, 95% CI -0.63 to 0.45; plaque: MD -0.07, 95% CI -0.26 to 0.13; 2 RCTs, 99 participants). Low-certainty evidence suggested oral hygiene knowledge of carers was better in the medium term after training (MD 0.69, 95% CI 0.31 to 1.06; 2 RCTs, 189 participants); this was not found in the short term, and results for changes in behaviour, attitude and self-efficacy were mixed.One RCT (10 participants) found that training people with ID in oral hygiene care reduced plaque but not GI in the short term (GI: MD -0.28, 95% CI -0.90 to 0.34; plaque: MD -0.47, 95% CI -0.92 to -0.02; very low-certainty evidence).One RCT (304 participants) found that scheduled dental recall visits (at 1-, 3- or 6-month intervals) plus supervised daily toothbrushing were more likely than usual care to reduce GI (pocketing but not bleeding) and plaque in the long term (low-certainty evidence).One RCT (29 participants) found that motivating people with ID about oral hygiene by discussing photographs of their teeth with plaque highlighted by a plaque-disclosing agent, did not reduce plaque in the medium term (very low-certainty evidence).One RCT (80 participants) found daily toothbrushing by dental students was more effective for reducing plaque in people with ID than once- or twice-weekly toothbrushing in the short term (low-certainty evidence).A benefit to gingival health was found by one NRS that evaluated toothpaste with a plaque-disclosing agent and one that evaluated individualised oral care plans (very low-certainty evidence).Most studies did not report adverse effects; of those that did, only one study considered them as a formal outcome. Some studies reported participant difficulties using the electric or special manual toothbrushes.

AUTHORS' CONCLUSIONS

Although some oral hygiene interventions for people with ID show benefits, the clinical importance of these benefits is unclear. The evidence is mainly low or very low certainty. Moderate-certainty evidence was available for only one finding: electric and manual toothbrushes were similarly effective for reducing gingival inflammation in people with ID in the medium term. Larger, higher-quality RCTs are recommended to endorse or refute the findings of this review. In the meantime, oral hygiene care and advice should be based on professional expertise and the needs and preferences of the individual with ID and their carers.

Differential Misclassification of Disease under Partial-Mouth Sampling

Aim:

The effect of misclassification of a cluster-level dichotomous outcome (disease) due to partial-cluster sampling on its association with a dichotomous exposure is investigated.

Methods:

Disease (e.g., chronic periodontitis) is deemed to exist in a cluster (e.g., full mouth) when a condition of interest (e.g., pocket depth or clinical attachment loss exceeding an established threshold) is present in number and pattern across observations (e.g., tooth sites) in the cluster according to a specific criterion. When a subset of observations within each cluster is selected (i.e., partial-mouth sampling), specificity of disease is 100% (in the absence of site-level measurement error), whereas sensitivity is imperfect and generally unknown. Using conditional probability arguments, we investigate disease misclassification under partial-cluster sampling and its impact on the estimated disease-exposure association when the exposure is cluster level and measured without error.

Results:

When the probability of disease varies by exposure status, outcome misclassification at the cluster level is differential under partial-cluster sampling and depends on 1) the partial recording protocol, including the number of observations sampled and the particular sites selected in a cluster; 2) the joint probability structure of the condition within clusters; and 3) the criterion for disease. A numeric example demonstrates that disease-exposure odds ratios under partial-cluster random sampling can be biased in either direction (toward or away from the null) relative to gold-standard odds ratios under full-cluster sampling.

Conclusions:

In general, misclassification of disease is differential under partial-cluster sampling. In particular, sensitivity and negative predictive values depend on exposure status, which leads to biased inference.

Knowledge Transfer Statement:

Partial-mouth sampling causes disease misclassification probabilities, including sensitivity, to vary by exposure groups when disease prevalence differs between groups. As a result, disease-exposure associations may be under- or overestimated by standard analysis procedures for periodontal data relative to full-mouth estimates. Procedures that address bias are needed for partial-recording protocols.

Insulin resistance predicts the risk of gingival/periodontal inflammation

OBJECTIVES

Evaluate whether insulin resistance (IR) predicts the risk of oral inflammation, assessed as the number of sites with bleeding on probing (BOP) and number of teeth with probing pocket depths (PPD) ≥ 4 mm and BOP.

METHODS

Data on 870 overweight/obese diabetes free adults, aged 40-65 years from the San Juan Overweight Adults Longitudinal Study over a three-year period, was analyzed. Baseline IR, assessed using the Homeostasis Model Assessment of IR (HOMA-IR) index, was divided into tertiles. BOP was assessed at buccal and lingual sites, and PPD at six sites per tooth. Negative binomial regression was used to estimate the risk ratios (RRs) for oral inflammation adjusted for baseline age, gender, smoking status, alcohol intake, education, physical activity, waist circumference, mean plaque index, and baseline number of sites with BOP, or number of teeth with PPD≥4 mm and BOP. The potential impact of tertiles of serum TNF-α and adiponectin on the IR-oral inflammation association was also assessed in a subsample of 597 participants.

RESULTS

Participants in the highest HOMA-IR tertile at baseline had significantly higher numbers of sites with BOP [RR = 1.19, 95% confidence interval (CI): 1.03-1.36] and number of teeth with PPD ≥ 4 mm and BOP (RR = 1.39, 95% CI: 1.09-1.78) at follow-up, compared with individuals in the lower two HOMA-IR tertiles. Neither TNF-α nor adiponectin confounded the associations.

CONCLUSION

IR significantly predicts gingival/periodontal inflammation in this population.

A new way to estimate disease prevalence from random partial-mouth samples

AIM

Standard partial-mouth estimators of chronic periodontitis (CP) that define an individual's disease status solely in terms of selected sites underestimate prevalence. This study proposes an improved prevalence estimator based on randomly sampled sites and evaluates its accuracy in a well-characterized population cohort.

METHODS

Importantly, this method does not require determination of disease status at the individual level. Instead, it uses a statistical distributional approach to derive a prevalence formula from randomly selected periodontal sites. The approach applies the conditional linear family of distributions for correlated binary data (i.e. the presence or absence of disease at sites within a mouth) with two simple working assumptions: (i) the probability of having disease is the same across all sites; and (ii) the correlation of disease status is the same for all pairs of sites within the mouth.

RESULTS

Using oral examination data from 6793 participants in the Arteriolosclerosis Risk in Communities study, the new formula yields CP prevalence estimates that are much closer than standard partial mouth estimates to full mouth estimates.

CONCLUSIONS

Resampling of the cohort shows that the proposed estimators give good precision and accuracy for as few as six tooth sites sampled per individual.

Associations of Toll-Like Receptor and β-Defensin Polymorphisms with Measures of Periodontal Disease (PD) in HIV+ North American Adults: An Exploratory Study

Polymorphisms in toll-like receptor (TLR) and β-defensin (DEFB) genes have been recognized as potential genetic factors that can influence susceptibility to and severity of periodontal diseases (PD). However, data regarding associations between these polymorphisms and PD are still scarce in North American populations, and are not available in HIV+ North American populations. In this exploratory study, we analyzed samples from HIV+ adults (n = 115), who received primary HIV care at 3 local outpatient HIV clinics and were monitored for PD status. We genotyped a total of 41 single nucleotide polymorphisms (SNPs) in 8 TLR genes and copy number variation (CNV) in DEFB4/103A. We performed regression analyses for levels of 3 periodontopathogens in subgingival dental plaques (Porphyromonas gingivalis [Pg], Treponema denticola [Td], and Tannerella forsythia [Tf]) and 3 clinical measures of PD (periodontal probing depth [PPD], gingival recession [REC], and bleeding on probing [BOP]). In all subjects combined, 2 SNPs in TLR1 were significantly associated with Td, and one SNP in TLR2 was significantly associated with BOP. One of the 2 SNPs in TLR1 was significantly associated with Td in Caucasians. In addition, another SNP in TLR1 and a SNP in TLR6 were also significantly associated with Td and Pg, respectively, in Caucasians. All 3 periodontopathogen levels were significantly associated with PPD and BOP, but none was associated with REC. Instrumental variable analysis showed that 8 SNPs in 6 TLR genes were significantly associated with the 3 periodontopathogen levels. However, associations between the 3 periodontopathogen levels and PPD or BOP were not driven by associations with these identified SNPs. No association was found between DEFB4/103A CNV and any periodontopathogen level or clinical measure in all samples, Caucasians, or African Americans. Our exploratory study suggests a role of TLR polymorphisms, particularly TLR1 and TLR6 polymorphisms, in PD in HIV+ North Americans.

Regular consumption of Lactobacillus reuteri-containing lozenges reduces pregnancy gingivitis: an RCT

Aim

This randomized controlled trial assessed the impact of Lactobacillus reuteri on pregnancy gingivitis in healthy women.

Materials and Methods

Forty‐five healthy women (24 test/21 placebo) with pregnancy gingivitis in the third trimester of pregnancy were enrolled. At baseline Gingival Index (GI) and Plaque Index (PlI) were assessed at the Ramfjord teeth and venous blood taken for TNF‐α analysis. Subsequently participants were randomly provided with lozenges to be consumed 2 × daily until birth (approx. 7 weeks) containing ≥10⁸CFU L. reuteri ATCC PTA 5289 and ≥10⁸CFU L. reuteri DSM 17938 (test) or being devoid of L. reuteri (placebo). Within 2 days after birth recording of GI, PlI and blood sampling were repeated.

Results

At baseline, mean GI and mean PlI did not differ significantly between both groups. In the test group mean TNF‐α serum level was significantly (p < 0.02) lower than in the placebo group. At reevaluation, mean GI and mean PlI of the test group were both significantly (p < 0.0001) lower than in the placebo group. Mean TNF‐α serum level did no longer differ significantly between the groups.

Conclusions

The consumption of L. reuteri lozenges may be a useful adjunct in the control of pregnancy gingivitis.

Relationship between periodontal disease and asthma among overweight/obese adults

AIM

To assess the relationship between oral health and asthma.

METHODS

Data from 1315 overweight or obese individuals, aged 40-65 years were used. Asthma was self-reported, whereas periodontitis, bleeding on probing (BOP) and plaque index were determined by clinical examinations.

RESULTS

Using logistic regression adjusting for gender, smoking status, age, body mass index, family history of asthma and income level, revealed that the odds ratio (OR) of asthma for a participant with severe periodontitis was 0.44 (95% confidence interval: 0.27, 0.70) that of a participant with none/mild periodontitis. On the other hand, proportion of BOP sites and plaque index were not statistically significant. For a participant with severe periodontitis, the OR of taking asthma medication was 0.20 (95% confidence interval: 0.09, 0.43) that of a participant with none/mild periodontitis. Moreover, proportion of BOP sites was statistically associated with use of asthma medication, whereas plaque index still remained non-significant.

CONCLUSION

Participants with severe periodontitis were less likely to have asthma. Stronger evidence of an inverse association was found when using asthma medication as outcome.

Lipid-lowering agents use and systemic and oral inflammation in overweight or obese adult Puerto Ricans: the San Juan Overweight Adults Longitudinal Study (SOALS)

The effects of lipid-lowering agents (LLA) on reducing systemic and oral inflammation have not been evaluated.

OBJECTIVE

To assess the association of LLA use with high-sensitivity C-reactive protein (hs-CRP) and oral inflammation.

DESIGN

Cross-sectional analysis using baseline data from 1300 overweight/obese participants aged 40-65 years, recruited for the ongoing San Juan Overweight Adults Longitudinal Study. Serum hs-CRP was measured by ELISA, gingival/periodontal inflammation was evaluated as bleeding upon probing (BOP), and LLA was self-reported. Separate logistic models were performed for systemic and oral inflammation.

RESULTS

In all, 24% participants reported history of dyslipidaemia, of which, 50.3% self-reported LLA use. Sixty percent of the participants had elevated hs-CRP (>3 mg/dl) and 50% had high BOP (defined as at or above the median: 21%). After adjusting for age, gender, smoking, HDL-C, physical activity, diabetes, blood pressure medications, and percent body fat composition, LLA users had significantly lower odds of elevated hs-CRP compared to LLA non-users (OR = 0.58; 95% CI: 0.39-0.85). After adjusting for age, gender, smoking status, educational level, mean plaque index and percent body fat, LLA users had significantly lower odds of high BOP compared to LLA non-users (OR = 0.62; 95% CI: 0.42-0.91).

CONCLUSIONS

Lipid-lowering agents may reduce both systemic and oral inflammatory responses.

Design aspects of a case-control clinical investigation of the effect of HIV on oral and gastrointestinal soluble innate factors and microbes

INTRODUCTION

The impaired host defense system in HIV infection impacts the oral and gastrointestinal microbiota and associated opportunistic infections. Antiretroviral treatment is predicted to partially restore host defenses and decrease the oral manifestation of HIV/AIDS. Well-designed longitudinal studies are needed to better understand the interactions of soluble host defense proteins with bacteria and virus in HIV/AIDS. "Crosstalk" was designed as a longitudinal study of host responses along the gastrointestinal (GI) tract and interactions between defense molecules and bacteria in HIV infection and subsequent therapy.

PURPOSE

The clinical core formed the infrastructure for the study of the interactions between the proteome, microbiome and innate immune system. The core recruited and retained study subjects, scheduled visits, obtained demographic and medical data, assessed oral health status, collected samples, and guided analysis of the hypotheses. This manuscript presents a well-designed clinical core that may serve as a model for studies that combine clinical and laboratory data.

METHODS

Crosstalk was a case-control longitudinal clinical study an initial planned enrollment of 170 subjects. HIV+ antiretroviral naïve subjects were followed for 9 visits over 96 weeks and HIV uninfected subjects for 3 visits over 24 weeks. Clinical prevalence of oral mucosal lesions, dental caries and periodontal disease were assessed.

RESULTS

During the study, 116 subjects (47 HIV+, 69 HIV-) were enrolled. Cohorts of HIV+ and HIV- were demographically similar except for a larger proportion of women in the HIV- group. The most prevalent oral mucosal lesions were oral candidiasis and hairy leukoplakia in the HIV+ group.

DISCUSSION

The clinical core was essential to enable the links between clinical and laboratory data. The study aims to determine specific differences between oral and GI tissues that account for unique patterns of opportunistic infections and to delineate the differences in their susceptibility to infection by HIV and their responses post-HAART.

Assessing periodontitis in populations: a systematic review of the validity of partial-mouth examination protocols

OBJECTIVE

To estimate bias associated with partial-mouth periodontal examination (PMPE) protocols regarding estimates of prevalence, severity and extent of clinical attachment loss (CAL), pocket depth (PD) and gingival recession (REC).

MATERIAL AND METHODS

A search was made for articles published in English, from 1946 to 2012, which compared PMPE versus full-mouth periodontal examination protocols for CAL or PD ≥ 4 mm or REC ≥3 mm thresholds. PMPE protocols were evaluated for sensitivity of estimates of periodontitis prevalence, relative biases for severity and extent estimates.

RESULTS

A review of the literature identified 12 studies which reported 32 PMPE protocols. Three PMPE protocols which had sensitivities ≥85% and relative biases ≤0.05 in absolute values for severity and extent estimates were as follows: (1) half-mouth six-sites, (2) diagonal quadrants six-sites and (3) full-mouth mesiobuccal-midbuccal-distobuccal (MB-B-DB). Two other PMPE protocols (full-mouth and half-mouth mesiobuccal-midbuccal-distolingual) performed well for prevalence and severity of periodontitis; however, their performance in estimates of extent was unknown.

CONCLUSIONS

Among the 32 PMPE protocols listed, the half-mouth six-sites and full-mouth MB-B-DB protocols had the highest sensitivities for prevalence estimates and lowest relative biases for severity and extent estimates.

Reliability of partial-mouth recording systems to determine periodontal status: a pilot study in an adult Portuguese population

BACKGROUND

The efficacy of various partial-mouth recording (PMR) systems is analyzed in the evaluation of periodontal status, using index teeth and different combinations of quadrants.

METHODS

The study group was formed of 108 adults aged 25 to 65 years old. A full-mouth examination (FME) was performed in all participants to determine the periodontal probing depth (PD) and clinical attachment level (CAL) at six sites per tooth. The results of PMR using the Ramfjord teeth, the Community Periodontal Index of Treatment Needs teeth, and the four quadrants individually and combined in pairs were compared to the results obtained with FME.

RESULTS

Concordance with FME in terms of the prevalence of patients with PD ≥4 mm, CAL ≥2 mm, and CAL ≥4 mm was lowest with examination of single quadrants and highest with combinations that included one superior and one inferior quadrant.

CONCLUSIONS

PMR systems, particularly with combinations of a superior plus an inferior quadrant, could be useful to evaluate periodontal status based on PD and CAL. This tool could be useful for epidemiologic surveys on periodontal status.

Effect of Nadir CD4+ T cell count on clinical measures of periodontal disease in HIV+ adults before and during immune reconstitution on HAART

BACKGROUND

The contribution of HIV-infection to periodontal disease (PD) is poorly understood. We proposed that immunological markers would be associated with improved clinical measures of PD.

METHODS

We performed a longitudinal cohort study of HIV-infected adults who had started highly active antiretroviral therapy (HAART) <2 years. PD was characterized clinically as the percent of teeth with ≥ 1 site with periodontal probing depth (PPD) ≥ 5.0mm, recession (REC) >0mm, clinical attachment level (CAL) ≥ 4.0mm, and bleeding on probing (BOP) at ≥ 4 sites/tooth and microbiologically as specific periodontopathogen concentration. Linear mixed-effects models were used to assess the associations between immune function and PD.

RESULTS

Forty (40) subjects with median 2.7 months on HAART and median nadir CD4+ T-cell count of 212 cells/μl completed a median 3 visits. Over 24 months, CD4+ T-cell count increased by a mean 173 cells/µl (p<0.001) and HIV RNA decreased by 0.5 log10 copies/ml (p<0.001); concurrently, PPD, CAL and BOP decreased by a mean 11.7%, 12.1%, and 14.7% respectively (all p<0.001). Lower nadir CD4+ T-cell count was associated with worse baseline REC (-6.72%; p=0.04) and CAL (9.06%; p<0.001). Further, lower nadir CD4+ T-cell count was associated with a greater relative longitudinal improvement in PPD in subjects with higher baseline levels of Porphyromonas gingivalis (p=0.027), and BOP in subjects with higher baseline levels of Porphyromonas gingivalis or Treponema denticola (p=0.001 and p=0.006 respectively). Longitudinal changes from baseline in CD4+ T-cell count and level of HIV RNA were not independently associated with longitudinal changes in any clinical markers of PD.

CONCLUSION

Degree of immunosuppression was associated with baseline gingival recession. After HAART initiation, measures of active PD improved most in those with lower nadir CD4+ T-cell counts and higher baseline levels of specific periodontopathogens. Nadir CD4+ T-cell count differentially influences periodontal disease both before and after HAART in HIV-infected adults.

BANA-Positive Plaque Samples Are Associated with Oral Hygiene Practices and Not CD4+ T Cell Counts in HIV-Positive Patients

Background. The “red complex” microorganisms, namely, Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythia are considered as potential pathogens causing HIV-associated periodontal diseases. Moreover, it has been recognized that an association exists between CD4+ T cell counts and periodontal disease progression. Objective. To establish whether CD4+ T cell counts or oral hygiene plays a greater role in producing BANA-positive results in HIV-associated periodontal disease. Materials and Methods. One hundred and twenty HIV-positive patients participated in the study, and their CD4+ T cell counts were obtained from their medical records. The six Ramfjord teeth were used for evaluating periodontal clinical indices and subgingival plaque sampling. BANA test was used for the detection and prevalence of the “red complex” bacteria in plaque samples. Results. A majority of 69.17% HIV-positive patients were BANA-positive. No significant associations were found between BANA and CD4+ T cell counts. A highly significant association was found between BANA with probing depth and clinical attachment level (P ≤ 0.0001) and between BANA and the use of interdental aids (P = 0.0168). Conclusion. HIV-associated periodontal diseases are strongly related to oral hygiene practices rather than the effect of CD4+ T cell counts, and the use of interdental aids was marked as a significant predictor of BANA-negative plaque samples.

Examiner alignment and assessment in clinical periodontal research

Periodontal research typically relies on clinical examiners to assess variables such as gingival inflammation, plaque scores or probing depths as a means of determining treatment outcomes or for performing group comparisons. The quality of the gathered information is dependent, to a large extent, on the skills of the examiner(s) and on the validity of the assessment methods that are used. Attempts have been made to increase the objectivity of periodontal assessments, for example by introducing scoring systems for gingival inflammation, but within these systems there is often considerable scope for variation when interpreting the scoring criteria, leading to subjectivity when assigning scores to individual periodontal sites. This has led to an awareness of the importance of examiner alignment and assessment to improve the data quality by standardizing techniques and improving examiner reliability. Examiner alignment and assessment is used in preference to the term 'examiner calibration' because calibration implies comparison with an accurate or 'gold' standard, which is not available in periodontal research. In this review, we consider the historical perspective that led to the development of clinical scoring systems for periodontal research using gingival inflammation as an example. A clinical protocol for undertaking examiner alignment and assessment is presented, and we review the common sources of error and bias that can lead to difficulties in aligning examiners, and consider how they can be eliminated. It is particularly important that subjects who are recruited to the examiner alignment and assessment study present with a comparable level of disease to the subjects who will ultimately be recruited to the planned clinical trial. Another challenge in examiner alignment and assessment is applying appropriate statistical tests to assess the outcome of the alignment exercise. In the periodontal literature, the statistic kappa is frequently used to confirm an adequate degree of examiner agreement, but kappa is bound to significant restrictions when applied for this purpose. Through the use of case studies, we present different approaches to data analysis from calibration studies, focusing on continuous variables (such as probing depths and attachment levels) or ordinal data (such as gingival or plaque indices), to enable a correct, although frequently conservative, interpretation of data generated during examiner alignment and assessment studies.

Recording and surveillance systems for periodontal diseases

This paper describes tools used to measure periodontal diseases and the integration of these tools into surveillance systems. Tools to measure periodontal diseases at the surveillance level have focussed on current manifestations of disease (e.g. gingival inflammation) or disease sequelae (e.g. periodontal pocket depth or loss of attachment). All tools reviewed in this paper were developed based on the state of the science of the pathophysiology of periodontal disease at the time of their design and the need to provide valid and reliable measurements of the presence and severity of periodontal diseases. Therefore, some of these tools are no longer valid. Others, such as loss of periodontal attachment, are the current de-facto tools but demand many resources to undertake periodical assessment of the periodontal health of populations. Less complex tools such as the Community Periodontal Index, have been used extensively to report periodontal status. Laboratory tests for detecting putative microorganisms or inflammatory agents present in periodontal diseases have been used at the clinical level, and at least one has been tested at the population level. Other approaches, such as self-report measures, are currently under validation. In this paper, we do not review indices designed to measure plaque or residual accumulation around the tooth, indices focussed only on gingival inflammation or radiographic approaches with limited applicability in surveillance systems. Finally, we review current case-definitions proposed for surveillance of periodontal disease severity.

T-RFLP-based differences in oral microbial communities as risk factor for development of oral diseases under stress

The human oral microbiome is comprised of approximately 800 different bacterial species many of which are as yet uncultivated. Their dynamics and variability in relation to health and disease are still poorly understood. Here we tested the hypothesis that the emergence of stress-induced periodontal diseases is predictable based on the composition of the initial microbiota. As a model, we analysed 58 individuals performing a challenging expedition (exposure to various stress-factors due to changes in diet, hygiene, temperature, physical and mental stress) in remote regions of the Himalayans (Annapurna Himal). Plaque samples were taken at start (Bhulbule) and destination (3000 meter difference in altitude) seven days later (Manang). Twenty-eight individuals remained symptom-free (Group I) while 30 participants developed periodontal problems, mostly gingivitis (Group II). The microbiota was monitored via T-RFLP-analysis of amplified 16S rRNA genes directly from the plaque samples. Based on the Additive-Main-Effects-Multiplicative-Interactions-model (AMMI) using the T-Rex software variation from T-RF main effects was at least 95%, indicating that most variation was due to inherent differences in microbial communities among individuals. However, an interaction signal up to 3% was consistently observed between groups I and II but not between the two time points of sampling regardless of selected analytical parameters. The data, supported by heterogeneity, diversity and similarity indices indicated marked differences between groups I and II already prior the onset of clinical symptoms. These differences may provide the basis for using ecological parameters of oral microbial communities as early diagnostic marker for the onset of oral disorders and infections.

Characterizing traditionally defined periodontal disease in HIV+ adults

BACKGROUND

Results have varied from previous studies examining the level and extent of periodontal disease (PD) in HIV-1 infected (HIV+) adults. These studies used different methodologies to measure and define PD and examined cohorts with divergent characteristics. Inconsistent methodological approaches may have resulted in the underestimation of traditionally-defined PD in HIV+ individuals.

OBJECTIVES

To characterize the level, extent and predictors (i.e. immunologic, microbiologic, metabolic and behavioral) of PD in an HIV+ cohort during the era of highly active antiretroviral therapy (HAART).

STUDY DESIGN

Cross-sectional study.

SETTING

HIV+ adults receiving outpatient care at three major medical clinics in Cleveland, OH. Subjects were seen from May, 2005 to January, 2008.

MEASUREMENTS

Full-mouth periodontal examinations included periodontal probing depth (PPD), recession (REC) and clinical attachment level (CAL). Subgingival plaque was assessed for DNA levels of Porphyromonas gingivalis (Pg), Tannerella forsythia, and Treponema denticola by real-time DNA PCR assays developed for each pathogen. Rather than using categories, we evaluated PD as three continuous variables based on the percent of teeth with >or=1 site per tooth with PPD >or= 5mm, REC > 0 mm and CAL >or= 4mm.

RESULTS

Participants included 112 HIV+ adults. Each subject had an average 38% (+/-24%) of their teeth with at least one site of PD >or= 5 mm, 55% (+/-31%) of their teeth with at least one site of REC > 0 mm, and 50% (+/-32%) of their teeth with at least one site of CAL >or= 4 mm. CD4+ T-cell count <200 cells/mm(3) was significantly associated with higher levels of REC and CAL, but not PPD. Greater levels of Pg DNA were associated with PPD, REC and CAL.By regression analysis, CD4+ T-cell count <200 cells /mm3 had approximately twice thedeleterious effect on CAL as did smoking (standardized beta coefficient 0.306 versus 0.164) [corrected]. Annual dental visit compliance remained an independent predictor for lower levels of PD.

CONCLUSIONS

The level and extent of PD were high in this cohort even though most patients were being treated with HAART. The definition of periodontal disease used and cohort characteristics examined can influence the level of periodontal disease reported in studies of persons with HIV. Traditional periodontal pathogens are associated with PD in this cohort. Those with CD4+ T-cell counts <200 cells/mm(3) are at greater risk for PD. Therefore, earlier HAART initiation may decrease exposure to immunosuppression and reduce PD morbidity. Continuity of dental care remains important for HIV+ patients even when they are being treated with HAART.

Effect of partial recording protocols on severity estimates of periodontal disease

OBJECTIVES

The study aim was to assess bias magnitudes of periodontal disease severity estimates for specific partial recording protocols (PRPs) in epidemiological studies.

MATERIAL AND METHODS

Estimates of mean clinical attachment loss (MCAL) and mean probing pocket depth (MPPD) were derived for 20 different PRPs using full-mouth periodontal data from 1437 dentate Brazilian subjects 14-103 years old having at least four teeth. Biases, relative biases and intra-class correlations for all PRPs were evaluated. Graphical methods were used to assess how well the PRP-based estimates agreed with full-mouth scores across levels of disease.

RESULTS

Slightly higher levels of disease were evidenced on lingual than on buccal sites. Seven multi-site PRPs and the Ramfjörd PRP produced small biases in MPPD (-0.17 to 0.04 mm) and MCAL with relative biases under 8% and 4% in absolute value for MPPD and MCAL, respectively. Biases for full- and random half-mouth-based PRPs were similar. The three-site random half-mouth MB-B-DL and the Ramfjörd PRPs produced the smallest biases, with relative biases <3% in absolute value for MPPD and MCAL.

CONCLUSIONS

Bias for MPPD or MCAL estimates varies by site type, number of sites per tooth and number of quadrants included in the PRP.

Use of Preexisting Radiographs for Assessing Periodontal Disease in Epidemiologic Studies

OBJECTIVES

This study evaluates the feasibility of obtaining preexisting dental radiographs by mail, the validity of assessing alveolar bone loss from posterior radiographs compared to full mouth, and the validity of alveolar bone loss assessed from radiographs taken at different times.

METHODS

This investigation uses data obtained for a study evaluating associations between oral conditions, blood biomarkers, and coronary heart disease within two large cohorts: the Nurses' Health Study and the Health Professionals Follow-up Study. If consenting participants had dental radiographs, we requested these radiographs from their dentists. Some dentists returned multiple sets of radiographs, which enabled us to conduct this study. A calibrated periodontist read all radiographs with good intraexaminer reliability (r=0.91). We compared posterior radiographs to full mouth (n=121 sets), as well as radiographs taken at different times (mean difference of 5 years) (n=102 pairs).

RESULTS

Of the 812 participants, 81 percent consented and 66 percent provided radiographs. Posterior radiographs underestimated periodontitis (> or =1 site with > or =5 mm alveolar bone loss) prevalence by 6 percent (53.7% vs 57.0%) compared to full mouth, with sensitivity of 0.94 (95% confidence interval [CI]=0.86, 0.98) and specificity of 1. Spearman correlation coefficients comparing mean alveolar bone loss were 0.70 for anterior versus posterior teeth (mean difference=0.48), 0.92 for posterior teeth versus full mouth (mean difference=0.25), and 0.78 for pairs of radiographs taken at different times (mean difference=0.01). The kappa statistic was 0.70 comparing radiographs taken within 5 years and 0.29 when the period extended beyond 5 years.

CONCLUSION

Preexisting radiographs are feasible for use in epidemiologic studies and provide valid assessments of periodontal disease.

Partial recording protocols for periodontal disease assessment in epidemiological surveys

The objective of the present study was to compare the reliability of four partial-mouth protocols for assessing shallow, moderate, and deep sites for periodontal pocket depth and clinical attachment levels. Periodontal pocket depth and clinical attachment level measurements were recorded for 156 subjects (age > 30). The four models of partial-mouth protocols compared were: Model I: all sites per tooth in the random half-mouth protocol randomly selecting one maxillary and mandibular quadrant, Model II: buccal sites in a full-mouth protocol, Model III: buccal sites in the random half-mouth protocol randomly selecting one maxillary and mandibular quadrant, Model IV: all sites per tooth using Community Periodontal Index teeth. In comparison with full mouth examination, Model I did not show significant differences for periodontal pocket depth and clinical attachment level parameters. Models II and III were different for some periodontal pocket depth means, and Model IV significantly overestimated all clinical parameters related to periodontal disease. Model I appears to be adequate to substitute for the full-mouth examination to assess the prevalence and severity of chronic periodontal disease in adults.

Validity of the "Community Periodontal Index of Treatment Needs" (CPITN) for population periodontitis screening

The aim of the present study was to validate two versions of CPITN for periodontitis diagnosis. A sample of 400 individuals underwent full mouth periodontal examination including Clinical Attachment Loss, Periodontal Pocket Depth, and Sub-gingival Calculus. Full and partial CPITN versions were derived from this exam (gold standard). Contingency tables were constructed and operational characteristics obtained, as well as ROC curves. The results show 58% sensitivity for full CPITN and 80.6% specificity. Positive and negative predictive values were 87% and 46.3%, respectively. According to the test, estimated periodontitis prevalence was 46%, while the figure obtained with the gold standard was 69%. The partial version of the CPITN showed 50% sensitivity and 87.1% specificity. Positive and negative predictive values were 89.6% and 43.9%, respectively. Estimated periodontitis prevalence, through partial CPITN, was 30.5%. Adjusted global agreement (kappa) for partial and full CPITN was 0.32 and 0.29, respectively. Both CPITN versions disagreed significantly with gold standard results (chi-square p < 0.001). As a conclusion, both total and partial CPITN failed to reflect the real periodontal status of the sample.

The relationship between selected measures of periodontal status and demographic and behavioural risk factors

OBJECTIVE

To assess differences between selected periodontal measures by demographic and behavioural factors in a nationally representative sample of the United States.

METHODS

Data for 11,347 person's ages 20-79 years from the third National Health and Nutrition Examination Survey (NHANES III) were used. Indices and measures constructed from NHANES III data used for this study were: derived community periodontal index (dCPI), attachment loss extent index (ALEI), attachment loss (AL) scores, and a Periodontal Status Measure (PSM) developed for this study.

RESULTS

The influence of demographic and behavioural factors varied across the four indices examined in multivariate cumulative logistic models. Moreover, there was significant effect modification by cigarette smoking with age in the ALEI and AL models. The odds ratio (OR) of increasing periodontal disease status among 20-39 year olds as measured by AL or ALEI for current smokers compared with non-smokers were OR=6.2 (95% confidence interval (CI)=4.1, 8.7) and OR=5.6 (95% CI=3.7, 8.7), respectively. In a similar comparison, the OR for dCPI was 2.6 (95% CI=1.7, 3.8). Furthermore, Mexican American ethnicity was generally not significant in any models using dCPI, PSM, AL, or ALEI and prior dental visit was more likely to be significant only in the dCPI and PSM models.

DISCUSSION

Among the well-known demographic and behavioural influences on periodontal health status, some, such as race/ethnicity and prior dental visit status have different relationships with differing periodontal measures employed to assess periodontal status. Moreover, potential interactions among cofactors also are dependent upon the measure selected. Periodontal research findings may be influenced significantly by periodontal measure selection and its affect on measurement validity. This may have particular relevance to issues concerning disease surveillance and assessing reduction of disparities in oral health. Consequently, a renewed approach to developing appropriate measures for periodontal epidemiology is needed.

Validity and reliability of partial examination to assess severe periodontitis

OBJECTIVES

To compare the extent and severity index (ESI) with a gold standard represented by actual readings of loss of attachment on six sites around all teeth present (excluding third molars).

METHODS

Five standardized dentists (kappa=0.6) examined 712 subjects > or =20 years of age at a dental school (1993-1995). Sensitivity, specificity, positive and negative predictive values, and true and apparent prevalence were established.

RESULTS

True severe periodontitis prevalence was 95.8%. ESI underestimated the severity (0.1 mm), extent (4%), and prevalence (16%) of periodontitis. The severity, as established by ESI, coincided 23.4% with the gold standard. ESI failed to identify 16.7% of subjects with severe periodontal disease, but specificity and positive predictive value were very high.

CONCLUSIONS

The underestimation of severe periodontitis through ESI may lead to inadequate recommendations for further treatment. Accurately identifying subjects with severe periodontitis requires a full-mouth examination. Because the ESI relies on measurements taken on only 28 periodontal sites to estimate the periodontitis status of the entire mouth, the validity and reliability of ESI may be modified by the prevalence of severe periodontal disease and the distribution of disease according to age and operational definitions.

The usefulness of using Ramfjord teeth in predicting periodontal status of a Tanzanian adult population

OBJECTIVES

The only partial mouth index that has been validated against full-mouth examinations in the East African population is the CPITN (Community Periodontal Index of Treatment Needs). Since the Ramfjord index can potentially shorten the examination time by almost half, we evaluated Ramfjord teeth in predicting full-mouth periodontal status of an adult population in Tanzania.

MATERIAL AND METHODS

Pocket depth was measured for 192 consecutive patients aged from 15 to 77 years (36 years old on average); 86 (45%) females referred to the Department of Restorative Dentistry, Muhimbili National Hospital, Tanzania between January 1997 and December 1999, and the mean pocket depth for full-mouth and Ramfjord teeth was calculated.

RESULTS

The correlation between the mean pocket depth calculated from the full-mouth and Ramfjord teeth was 0.96. The beta coefficient for the mean pocket depth measured by Ramfjord teeth to predict the full-mouth mean was 0.94, and was not affected by adjustment for age, missing teeth or sex.

CONCLUSION

This overall high agreement between Ramjford teeth and full-mouth periodontal pocket situation confirms the epidemiological validity of Ramfjord's dental sample in our setting.