Accuracy of NHANES periodontal examination protocols

Prevalence of self-reported severe periodontitis: Data from the population-based CONSTANCES cohort

AIM

To assess the prevalence of severe periodontitis based on the population-based CONSTANCES cohort using a validated self-reported questionnaire.

MATERIALS AND METHODS

Individuals were selected from the adult population in France using a random sampling scheme. Analyses were restricted to those invited in 2013-2014 who completed the periodontal health questionnaire at the 2017 follow-up. The risk of severe periodontitis was assessed using the periodontal screening score (PESS) and weighting coefficients were applied to provide representative results in the general French population.

RESULTS

The study included 19,859 participants (9204 men, mean age: 52.8 ± 12.6 years). Based on a PESS ≥ 5, 7106 participants were at risk of severe periodontitis, corresponding to a weighted prevalence of 31.6% (95% confidence interval: 30.6%-32.7%). This prevalence was higher among participants aged 55 and over, those with lower socio-economic status as well as current smokers, e-cigarette users and heavy drinkers. Among individuals at risk of severe periodontitis, only 18.8% (17.3%-20.4%) thought they had gum disease, although 50.5% (48.6%-52.5%) reported that their last dental visit was less than 6 months.

CONCLUSIONS

The present survey indicates that (1) self-reported severe periodontitis is highly prevalent with marked disparities between groups in the general French adult population, and (2) periodontitis could frequently be under-diagnosed given the low awareness.

Risk indicators for gingival recession in the esthetic zone: A cross-sectional clinical, tomographic, and ultrasonographic study

BACKGROUND

To evaluate the risk indicators associated with midfacial gingival recessions (GR) in the natural dentition esthetic regions.

METHODS

Cone-beam computed tomography (CBCT) results of thirty-seven subjects presenting with 268 eligible teeth were included in the cross-sectional study. Clinical measurements included presence/absence of midfacial GR; the depth of the midfacial, mesial, and distal gingival recession; the recession type (RT); keratinized tissue width (KT); and attached gingiva width (AG). Questionnaires were utilized to capture patient-reported esthetics and dental hypersensitivity for each study tooth. Buccal bone dehiscence (cBBD) and buccal bone thickness (cBBT) were measured on the CBCT scans. High-frequency ultrasonography was performed to assess gingival thickness (GT) and buccal bone dehiscence (uBBD). Intraoral optical scanning was obtained to quantify the buccolingual position of each study site (3D profile analysis). Multilevel logistic regression analyses with generalized estimation equations were performed to assess the factors associated with the conditions of interest.

RESULTS

The presence of midfacial GR was significantly associated with the history of periodontal treatment for pocket reduction (OR 7.99, p = 0.006), KT (OR 0.62, p < 0.001), cBBD (OR 2.30, p = 0.015), GT 1.5 mm from the gingival margin (OR 0.18, p = 0.04) and 3D profile 1 mm from the gingival margin (OR 1.04, p = 0.001). The depth of midfacial GR was significantly correlated to previous history of periodontal treatment (OR 0.96, p = 0.001), KT (OR -0.18, p < 0.001), presence of bone fenestration (OR 0.24, p = 0.044), and cBBD (OR 0.43, p < 0.001). The depth of midfacial GR was also the only factor associated with patient-reported esthetics (OR -3.38, p = 0.022), while KT (OR 0.77, p = 0.018) and AG (OR 0.82, p = 0.047) were significantly correlated with patient-reported dental hypersensitivity.

CONCLUSIONS

Several risk indicators of midfacial and interproximal GR in the esthetic region were identified. The use of imaging technologies allowed for detection of parameters associated with the conditions of interest, and, therefore, their incorporation in future clinical studies is advocated. Ultrasonography could be preferred over CBCT for a noninvasive assessment of periodontal phenotype.

The impact of dentition status and barriers to dental care services on perceived oral health of medicare beneficiaries

OBJECTIVE

To examine the association among barriers to dental care services, dentition groups, and self-reported oral health status for Medicare beneficiaries.

METHODS

We used data from the 2017 to 2018 National Health and Nutrition Examination Survey (NHANES), which included participants aged ≥65 years who were enrolled in Medicare and had completed the oral health exam. We created a dentition group variable using the detailed dental examination data to account for the presence of natural, replaced, removable, or missing teeth. Through bivariate and logistic analyses, we explored the relationship between barriers to receiving dental care services, dentition groups, and reported oral and general health statuses, along with other control variables.

RESULTS

For the total Medicare population as well as in the four subgroup analyses, we showed that those with barriers to dental care services were more likely to report fair or poor oral health status. Those who were edentulous, had complete dentures, or had less than a full mouth of teeth had greater barriers and worse oral and general health than did those with all-natural teeth. Among those who reported fair or poor general health, those with less than a full mouth of teeth showed similar levels of barriers to dental care services and worse perceived oral health than did those without any teeth.

CONCLUSIONS

Helping the 65 years and older population retain their teeth in good condition will improve their overall health. Investment in oral hygiene and health for the current and future Medicare populations could improve their overall health.

Oral manifestations in women using hormonal contraceptive methods: a systematic review

OBJECTIVES

To investigate the oral manifestations in women of reproductive age using hormonal contraceptive methods.

MATERIALS AND METHODS

This review is based on the PRISMA statement. A literature search incorporated observational studies from the last 21 years. An investigative question was formulated using the PICO model, studies were selected, and a quality analysis was performed using the modified STROBE guidelines. A bibliometric analysis was performed, and the data were examined.

RESULTS

Thirteen articles were included, with the majority evaluating periodontal status. Others analyzed factors such as the presence of alveolar osteitis, oral candidiasis, and salivary microbiome dysbiosis. Ten articles were deemed to have a low risk of bias.

CONCLUSIONS

Hormonal contraceptives may increase the risk of alveolar osteitis following tooth extraction and increase the presence of the Candida species in the oral cavity. They also affect the periodontium, such as the frequent development of gingivitis, but do not lead to changes in the salivary microbiome.

CLINICAL RELEVANCE

The increasing number of women using hormonal contraceptives and the knowledge that these contraceptives can produce oral cavity alterations underscore the need to evaluate the oral manifestations found in these women.

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.

Association between androgenetic alopecia and periodontitis

AIM

Androgenic alopecia (AGA) is men's most common form of hair loss. It is affected by changes in the expression and activity of 5αR and the metabolism of testosterone and DHT. There is an association between AGA and systemic inflammatory diseases. We hypothesized that there is an association between AGA and periodontal disease, as inflamed gingiva and periodontal fibroblasts have been shown to express more 5αR. Thus, this study aimed to evaluate the relationship between periodontal disease and AGA and the potential effect of aging on this association.

MATERIALS AND METHODS

Out of a cohort of 1088 individuals, 385 white males aged 25-65 with similar socioeconomic levels and without systemic disease were included. Periodontitis was defined using NHANES data. AGA was evaluated using the Norwood-Hamilton scale. The relationship between AGA, periodontal disease severity, and age was assessed.

RESULTS

There was a correlation between age and baldness (r = .421, p < .001). There was a significant correlation between AGA and periodontal disease in younger patients aged 25-34 and 35-44. (p < .042 and p < .036, respectively). There was no significant correlation between AGA and periodontal disease in the 45-54 and 55-65 age groups (p > .05).

CONCLUSION

There may be a relationship between periodontal disease and AGA in the 25-44 age range, suggesting that this association starts at an early age in adulthood.

Oral health and 10-year cardiovascular risk in US adults: mediating role of inflammatory diet and vitamin D

OBJECTIVE

To investigate whether E-DII or vitamin D mediates the relationship between oral health and cardiovascular disease (CVD) risk.

METHODS

This study involved 6616 participants aged over 30 years old from the National Health and Nutrition Examination Survey (NHANES) in 2009-2014. Dietary inflammation and 10-year CVD risk were evaluated via the Energy-adjusted Dietary Inflammatory Index (E-DII) and the Framingham Risk Score (FRS), respectively. We used correlation analysis and mediation analysis to investigate the role of dietary inflammation and vitamin D in the relationship between oral health and CVD risk.

RESULTS

Oral health indicators and CVD risk were positively correlated with E-DII (r > 0, P < 0.001) and negatively correlated with vitamin D levels (r < 0, P < 0.001). The estimated mediating role of E-DII and vitamin D in the overall association between oral health and 10-year risk of CVD ranged from 4.9 to 7.5% and 6.6 to 11.6%, respectively. Furthermore, the mediation proportion of E-DII and vitamin D levels in the total association between oral health indicators and FRS were increased in participants without periodontitis.

CONCLUSION

Both E-DII and serum vitamin D were mediated the association between oral problems and 10-year CVD risk, especially in participants without periodontitis. Among them, E-DII played a positive mediating role, and serum vitamin D levels was a negative mediator.

CLINICAL RELEVANCE

Anti-inflammatory diet and prevention of vitamin D deficiency might reduce the impact of oral problems on cardiovascular disease risk to some extent. The study highlights the important role of oral health and dietary inflammation and vitamin D in primary prevention of cardiovascular disease.

Resolution of inflammation in oral diseases

The resolution of inflammation is an essential endogenous process that protects host tissues from an exaggerated chronic inflammatory response. Multiple interactions between host cells and resident oral microbiome regulate the protective functions that lead to inflammation in the oral cavity. Failure of appropriate regulation of inflammation can lead to chronic inflammatory diseases that result from an imbalance between pro-inflammatory and pro-resolution mediators. Thus, failure of the host to resolve inflammation can be considered an essential pathological mechanism for progression from the late stages of acute inflammation to a chronic inflammatory response. Specialized pro-resolving mediators (SPMs), which are essential polyunsaturated fatty acid (PUFA)-derived autacoid mediators, aid in regulating the endogenous inflammation resolving process by stimulating immune cell-mediated clearance of apoptotic polymorphonuclear neutrophils, cellular debris, and microbes, restricting further neutrophil tissue infiltration, and counter-regulating pro-inflammatory cytokine production. The SPM superfamily contains four specialized lipid mediator families: lipoxins, resolvins, protectins, and maresins that can activate resolution pathways. Understanding the crosstalk between resolution signals in the tissue response to injury has therapeutic application potential for preventing, maintaining, and regenerating chronically damaged tissues. Here, we discuss the fundamental concepts of resolution as an active biochemical process, novel concepts demonstrating the role of resolution mediators in tissue regeneration in periodontal and pulpal diseases, and future directions for therapeutic applications with particular emphasis on periodontal therapy.

Probiotic adjuvant treatment in combination with scaling and root planing in chronic periodontitis: a systematic review and meta-analysis

This systematic review and meta-analysis assessed the impact of probiotic supplementation on treating chronic periodontal (CP) disease based on clinical and microbiological findings. Four databases were searched: Medline, Embase, Cochrane Library, and the Web of Science databases. The references to relevant studies were also manually searched. Analyses were conducted using the Review Manager 5.2 software, while the quality of randomised controlled trials was assessed with the Cochrane Risk of Bias tool. In total, 19 studies were included in the meta-analysis. Pooled results revealed that the adjuvant use of probiotics in the treatment of patients with periodontal disease was largely associated with good clinical efficacy. Resulting in statistically significant improvements in plaque index (P<0.05), periodontal probing depth (P<0.05), clinical attachment level (P<0.05), gingival index (P<0.05), bleeding on probing (P<0.05), deep probing depth (P<0.05), and levels of subgingival microbes (P<0.05) following probiotic supplementation. In summary, the results of this meta-analysis suggest that the administration of probiotics together with scaling and root planing can somewhat improve CP patient clinical outcomes and reduce levels of periodontal pathogens. However, more comprehensive experiments are needed to standardise probiotics and maximise their adjuvant therapy.

Association between the quality of plant-based diets and periodontitis in the U.S. general population

AIM

To investigate the relationship between plant-based diet indices (PDIs) and periodontitis and serum IgG antibodies against periodontopathogens in the U.S.

POPULATION

MATERIALS AND METHODS

We analysed cross-sectional data on 5651 participants ≥40 years of age from the Third National Health and Nutrition Examination Survey. Food frequency questionnaire data were used to calculate the overall PDI, healthy plant-based diet index (hPDI), and unhealthy plant-based diet index (uPDI). Periodontitis was defined using a half-reduced Centers for Disease Control and Prevention and American Academy of Periodontology case definition. Serum antibodies against 19 periodontopathogens were used to classify the population into two subgroups using hierarchical clustering. Survey-weighted multivariable logistic regressions were applied to assess the associations of PDI/hPDI/uPDI z-scores with periodontitis and hierarchical clusters after adjusting for potential confounders.

RESULTS

A total of 2841 (50.3%) participants were defined as having moderate/severe periodontitis. The overall PDI z-score was not significantly associated with the clinical and bacterial markers of periodontitis. By considering the healthiness of plant foods, we observed an inverse association between hPDI z-score and periodontitis (odds ratio [OR] = 0.925, 95% confidence interval [CI]: 0.860-0.995). In contrast, higher uPDI z-score (adherence to unhealthful plant foods) might increase the risk of periodontitis (OR = 1.100; 95% CI: 1.043-1.161). Regarding antibodies against periodontopathogens, the participants in cluster 2 had higher periodontal antibodies than those in cluster 1. The hPDI z-score was positively associated with cluster 2 (OR = 1.192; 95% CI: 1.112-1.278). In contrast, an inverse association between uPDI z-score and cluster 2 was found (OR = 0.834; 95% CI: 0.775-0.896).

CONCLUSIONS

Plant-based diets were associated with periodontitis, depending on their quality. A healthy plant-based diet was inversely related to an increased risk of periodontitis but positively related to elevated antibody levels against periodontopathogens. For an unhealthy plant-based diet, the opposite trends were observed.

The Role of Dyslipidemia in Periodontitis

Studies have suggested an important role of dyslipidemia, a condition with alterations in blood lipid levels, in promoting an additional effect on periodontal breakdown. Thus, this study aimed to explore the theoretical pathways associated with dyslipidemia and periodontitis. We used data from 11,917 US adults with complete periodontal examinations participating in the Third National Health and Nutrition Examination Survey (NHANES III). Our hypothesis was tested using structural equation modelling (SEM). Dyslipidemia was defined according to the National Cholesterol Education Program (NCEP-ATP III) and periodontitis as a latent variable reflecting the shared variance of the number of surfaces with periodontal pocket depth [PPD] = 4 mm, PPD = 5 mm, PPD ≥ 6 mm, clinical attachment level [CAL] = 4 mm, CAL = 5mm, CAL ≥ 6 mm, and furcation involvement. The model also considered distal determinants (age, sex, and socioeconomic status) and proximal determinants (HbA1c, smoking and alcohol consumption, and obesity). The model showed sufficient global fit (Root Mean Squared Error of Approximation = 0.04, 90%CI = 0.04−0.05, Tucker−Lewis Index = 0.93, Comparative Fit Index = 0.95). Age, sex, socioeconomic status, obesity, and smoking were directly associated with periodontitis (p < 0.01). Dyslipidemia revealed a significant direct effect on periodontitis (standardized coefficient [SC] = 0.086, SE 0.027; p < 0.01), also mediated via an indirect pathway through HbA1c (SC = 0.021; SE 0.010; p = 0.02) and obesity (SC = 0.036; SE 0.012; p < 0.01) and resulted in a total effect on periodontitis. Dyslipidemia was associated with periodontitis through a direct pathway and indirectly through HbA1c and obesity in the US population. These results support the need for a multi-professional approach to tackling oral and noncommunicable diseases (NCDs), directed at their common risk factors.

Association between Periodontitis and Diabetes Mellitus in the General Population

Purpose-

This study aimed to examine the association between periodontitis and diabetes mellitus.

Methods

Participants with natural teeth in one jaw from the Third United States National Health and Nutrition Examination Survey (1988-1994) were included in this analysis. Participants with moderate (> 4mm attachment loss in ≥ 2 mesial sites or 5mm pocket depth in ≥ 2 mesial sites) or severe (> 6mm attachment loss in ≥ 2 mesial sites and > 5mm pocket depth in ≥ 1 mesial site) periodontitis were classified as having periodontal disease. The rest of the participants were considered without periodontal disease. Diabetes mellitus was defined as fasting glucose ≥ 126mg/dL, hemoglobin A1c ≥ 6.5% or the use of antihyperglycemic medications. Multivariable logistic regression was used to examine the association between periodontitis and diabetes mellitus in all study population and subgroups stratified by demographics and comorbidities.

Results

This analysis included 13,000 participants [mean age 43.8 ± 19.1 years, 47.5% male, 30% whites]. About 12.7% (n = 1,656) of the study population had periodontitis, and 9.2% (n = 1,200) had diabetes. In a multivariable-adjusted model, presence (vs. absence) of periodontitis was associated with 66% increased odds of diabetes (OR (95% CI):1.66 (1.43-1.94); p < 0.001). Compared to those without periodontitis, the odds of diabetes among those with severe periodontitis was much higher (OR (95% CI): 2.31(1.72-3.11); p < 0.001) than in those with moderate periodontitis (OR (95% CI): 1.54(1.30-1.82); p < 0.001).

Conclusions

Periodontitis is associated with prevalent diabetes in a dose-response fashion, suggesting a bidirectional relationship between those two diseases. Patients with periodontal disease should be counseled regarding their elevated risk of diabetes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01010-6.

Validity of partial protocols to evaluate the prevalence of developmental defects of enamel in permanent dentition: a birth cohort study in Southern Brazil

OBJECTIVES

To evaluate the validity of partial protocols (PP) to assess the prevalence of developmental defects of enamel (DDE) in permanent teeth and identify the strength of the association between DDE and some risk factors, using PP compared to the full-mouth (FM) exam.

MATERIALS AND METHODS

This study was conducted in a population-based birth cohort of children born in 2004 in Pelotas, Southern Brazil. Socioeconomic, demographic, pre-, per-, and post-birth variables were collected. A subsample of 994 children was clinically examined for DDE in 2017, using the modified DDE index, using the "full- mouth" (FM) protocol. After FM had been performed, a dataset was created. Two different partial protocols (PP) were simulated from FM data: "only buccal surfaces (BS)" and "incisive and molars only (IM)." Sensitivity, absolute and relative bias, and inflation factors were calculated.

RESULTS

For any DDE, FM had prevalence of 40.8%. The prevalence of DDE was 38.8% and 36.0%, for BS and IM protocols, respectively. When tested for any DDE, PP "BS" and "IM" showed high sensitivity. The underestimation of the true prevalence did not exceed 6.9% for PP "BS" and 16.1% for PP "IM." All protocols showed similar magnitude of association with the selected risk factors.

CONCLUSION

Both PP "BS" and "IM" can be used to estimate the prevalence of DDE in epidemiological studies.

CLINICAL RELEVANCE

Oral health surveys now have the option of using PP to collect DDE prevalence and investigate their association with risk factors, being less time-consuming, expensive, and labor intensive.

Diagnostic performance of the AAP/EFP classification and the CDC/AAP case definition among pregnant women and a practical screening tool for maternal periodontal diseases

Background and Objective

There is a limited number of studies on the performance assessment of the 2017 AAP/EFP classification and the CDC/AAP case definition among pregnant females. This study evaluated the agreement between these two systems and explored a practical tool for screening maternal periodontal diseases by general dentists.

Materials and Methods

Totally, 204 systemically healthy females at different phases of pregnancy underwent a full‐mouth periodontal examination. Demographic characteristics, lifestyles, and systemic conditions were recorded. Referring to the CDC/AAP definition, the diagnostic performance of the AAP/EFP classification was evaluated by the area under the ROC curve (AUC) and statistical tests (e.g., Youden's index and kappa coefficient). Additionally, a modified scoring system of the FDI Periodontal Diseases Chairside Guide (FDI‐CG) was formulated with the addition of pregnancy for testing accordingly.

Results

Overall, there were 22.1% of the participants in early phase of pregnancy (7–13 weeks) and 77.9% in late phase (34–36 weeks). The majority of them were below 35 years and non‐smokers without gestational diabetes. Notably, 30.9% of subjects presented with Moderate/Severe periodontitis (CDC/AAP), and 35.8% with Stages II‐IV periodontitis (AAP/EFP). Referring to the CDC/AAP definition, the AUC, Youden's index, and κ of the AAP/EFP classification were 0.979, 0.890, and 92.9%, respectively. The modified FDI‐CG system improved the AUC (0.815), Youden's index (63.0%), and κ (0.544) with reference to the original one.

Conclusions

This study shows that the AAP/EFP classification is in high agreement with the CDC/AAP definition among the pregnant women. The phases of pregnancy‐integrated FDI scoring system may serve as a convenient screening tool for maternal periodontal diseases in general dental practice.

Periodontitis Is Associated With Heart Failure: A Population-Based Study (NHANES III)

Objectives: The aim of this study was to investigate the relationship between periodontitis and heart failure using the Third National Health and Nutrition Examination Survey (NHANES III). Methods: Participants who had received a periodontal examination were included and investigated for the occurrence of heart failure. The included participants were divided into no/mild periodontitis and moderate/severe periodontitis groups according to their periodontal status. Weighted prevalence of heart failure was calculated, and weighted logistic regressions models were used to explore the association between periodontitis and heart failure. Possible influencing factors were then explored through subgroup analysis. Results: Compared with that of the no/mild periodontitis group, the incidence of heart failure in participants with moderate/severe periodontitis was 5.72 times higher (95% CI: 3.76-8.72, p < 0.001). After adjusting for gender, age, race, body mass index, poverty income ratio, education, marital status, smoking status, drinking status, hypertension, diabetes, stroke, and asthma, the results showed that the incidence of heart failure in the moderate/severe group was 3.03 times higher (95% CI: 1.29-7.13, p = 0.012). Subgroup analysis showed that criteria, namely, male, 40-60 years old, non-Hispanic white, body mass index >30, poverty income ratio ≥1, not more than 12 years of education, currently drinking, stroke but no diabetes, or asthma supported moderate/severe periodontitis as a risk factor for heart failure (p < 0.05). Conclusion: According to data from this nationally representative sample from the United States, periodontitis is associated with an increased risk of heart failure.

Exploring periodontitis misclassification mechanisms under partial-mouth protocols

AIM

To investigate the sources of periodontitis misclassification under partial-mouth protocols (PMPs) and to explore possible approaches to enhancing protocol validity.

MATERIALS AND METHODS

Using data from 10,680 adults with 244,999 teeth from the National Health and Nutrition Examination Survey, we compared tooth-, site-, and quadrant-specific periodontal parameters and case identification under full-mouth protocols and PMPs. Separately, we utilized population measures of tooth-specific periodontal severity to generate PMPs with tooth selection based on the population ranking of clinical severity and assessed the sensitivity of case identification.

RESULTS

Symmetry of clinical severity was generally confirmed, with the exception of lingual inter-proximal sites, which yielded greater sensitivity in identifying periodontitis compared to buccal sites due to more severe pocketing and attachment loss on average. Misclassification of severe periodontitis occurred more frequently under commonly implemented PMPs compared to ranking-based selection of teeth, which yielded sensitivity estimates of 70.1%-79.4% with the selection of 8 teeth and reached 90% with the selection of only 14 teeth.

CONCLUSIONS

Clinical symmetry and sources of periodontitis misclassification were confirmed. The proposed selection of teeth based on population rankings of clinical severity yielded optimal sensitivity estimates for the detection of severe periodontitis and may present a favourable alternative to current options.

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.

High serum iron markers are associated with periodontitis in post-menopausal women: A population-based study (NHANES III)

AIM

To investigate the association between increased serum markers of iron (ferritin and transferrin saturation) and the severity and extent of periodontitis in post-menopausal (PM) women.

MATERIALS AND METHODS

Data from 982 PM women participating in NHANES III were analysed. Exposures were high ferritin (≥300 μg/ml) and transferrin saturation (≥45%). The primary outcome was moderate/severe periodontitis defined according to Centers for Disease Control and Prevention and the American Academy of Periodontology. The extent of periodontitis was also assessed as outcome: proportion of sites affected by clinical attachment loss ≥4 mm and probing depth ≥4 mm. Crude and adjusted prevalence ratio (PR) and mean ratio (MR) were estimated using Poisson regression.

RESULTS

The prevalence of moderate/severe periodontitis was 27.56%. High ferritin was associated with moderate/severe periodontitis in the crude (PR 1.55, p = .018) and in the final adjusted model (PR 1.53, p = .008). High ferritin and transferrin saturation levels were associated with a higher proportion of sites with clinical attachment loss ≥4 mm (p < .05).

CONCLUSIONS

The increasing serum iron markers seem to contribute to periodontitis severity and extent in PM women.

Systematic review of studies examining contribution of oral health variables to risk prediction models for undiagnosed Type 2 diabetes and prediabetes

Objective

To conduct systematic review applying “preferred reporting items for systematic reviews and meta‐analyses statement” and “prediction model risk of assessment bias tool” to studies examining the performance of predictive models incorporating oral health‐related variables as candidate predictors for projecting undiagnosed diabetes mellitus (Type 2)/prediabetes risk.

Materials and Methods

Literature searches undertaken in PubMed, Web of Science, and Gray literature identified eligible studies published between January 1, 1980 and July 31, 2018. Systematically reviewed studies met inclusion criteria if studies applied multivariable regression modeling or informatics approaches to risk prediction for undiagnosed diabetes/prediabetes, and included dental/oral health‐related variables modeled either independently, or in combination with other risk variables.

Results

Eligibility for systematic review was determined for seven of the 71 studies screened. Nineteen dental/oral health‐related variables were examined across studies. “Periodontal pocket depth” and/or “missing teeth” were oral health variables consistently retained as predictive variables in models across all systematically reviewed studies. Strong performance metrics were reported for derived models by all systematically reviewed studies. The predictive power of independently modeled oral health variables was marginally amplified when modeled with point‐of‐care biological glycemic measures in dental settings. Meta‐analysis was precluded due to high inter‐study variability in study design and population diversity.

Conclusions

Predictive modeling consistently supported “periodontal measures” and “missing teeth” as candidate variables for predicting undiagnosed diabetes/prediabetes. Validation of predictive risk modeling for undiagnosed diabetes/prediabetes across diverse populations will test the feasibility of translating such models into clinical practice settings as noninvasive screening tools for identifying at‐risk individuals following demonstration of model validity within the defined population.

Oral Health, Diabetes, and Inflammation: Effects of Oral Hygiene Behaviour

Introduction

The aim of this research was to assess the association between inflammation and oral health and diabetes, as well as the mediating role of oral hygiene practice in this association.

Methods

Data were from the 2009–2010 National Health and Nutrition Examination Survey. The analytical sample consisted of 2,191 respondents aged 50 and older. Poor oral health was clinically defined by significant tooth loss (STL) and periodontal disease (PD). Diabetes mellitus (DM) was determined by glycemic levels. The outcome variable was serum C-reactive protein (CRP) level, dichotomised as ≥1 mg/dL (elevated CRP) vs <1 mg/dL (not elevated CRP). Two path models, one using STL and DM as the independent variable, the other using PD and DM as the independent variable, were estimated to assess the direct effects of having poor oral health and DM on elevated CRP and the mediating effects of dental flossing.

Results

In path model 1, individuals having both STL and DM (adjusted odds ratio [AOR], 1.92; 95% confidence interval [CI], 1.30–2.82) or having STL alone (AOR, 2.30; 95% CI, 1.68–3.15) were more likely to have elevated CRP than those with neither STL nor DM; dental flossing (AOR, 0.92, 95% CI, 0.88–0.96) was associated with lower risk of elevated CRP. In path model 2, no significant association was found between having both PD and DM and elevated CRP; dental flossing (AOR, 0.91; 95% CI:, 0.86–0.94) was associated with lower risk of elevated CRP.

Conclusions

Findings from this study highlight the importance of improving oral health and oral hygiene practice to mitigate inflammation. Further research is needed to assess the longer-term effects of reducing inflammation.

Access to dental care and blood pressure profiles in adults with high socioeconomic status

Background

Reduced access to dental care may increase cardiovascular risk; however, socioeconomic factors are believed to confound the associations. We hypothesized that the relation persists despite economic wellness and high education, with reduced access to dental care affecting cardiovascular risk at least in part through its effect on blood pressure (BP), possibly mediated by systemic inflammation.

Methods

We first assessed the sociodemographic and clinical characteristics related to last dental visit timing (≤ or >6 months; self‐reported) using national representative cross‐sectional data. Then, the association of last dental visit timing with clinic BP was selectively investigated in highly educated, high income participants, further matched for residual demographic and clinical confounders using propensity score matching (PSM). The mediating effect of systemic inflammation was formally tested. Machine learning was implemented to investigate the added value of dental visits in predicting high BP over the variables included in the Framingham Hypertension Risk Score among individuals without an established diagnosis of hypertension.

Results

Of 27,725 participants included in the population analysis, 46% attended a dental visit ≤6 months. In the PSM cohort (n = 2350), last dental visit attendance >6 months was consistently associated with 2 mmHg higher systolic BP (P = 0.001) and with 23 to 35% higher odds of high/uncontrolled BP compared with attendance ≤6 months. Inflammation mildly mediated the association. Access to dental care improved the prediction of high BP by 2%.

Conclusions

Dental care use impacts on BP profiles independent of socioeconomic confounders, possibly through systemic inflammation. Regular dental visits may contribute to preventive medicine.

Sleep duration and severe periodontitis in middle-aged Japanese workers

AIM

To evaluate the association between sleep duration and severe periodontitis in Japanese workers.

MATERIALS AND METHODS

This cross-sectional study included 1130 workers (mean age 43.0 years) who underwent full-mouth periodontal examinations and health check-ups and completed a self-administered questionnaire that included questions on sleep duration. Logistic regression and a restricted cubic spline model were used to analyse the data.

RESULTS

Severe periodontitis was identified in 6.3% of the study population. Those with <5, 5-5.9, 6-6.9, 7-7.9, and ≥8 hr of sleep were 6.7%, 17.4%, 40.3%, 26.3%, and 8.9%, respectively. After adjusting for potential confounders, study participants who slept <5 hr were more likely to have severe periodontitis (adjusted odds ratio = 2.64; 95% confidence interval = 1.06-6.60) than those who slept 7-7.9 hr. The spline model, with a reference value of 399 min (the median sleep duration), showed a non-linear association between sleep duration and severe periodontitis, where an increased prevalence of severe periodontitis was observed only among those with a shorter sleep duration. The prevalence of severe periodontitis did not increase with longer sleep duration.

CONCLUSIONS

Short sleep duration was associated with severe periodontitis in this cohort of Japanese adults.

Combined association of cognitive impairment and poor oral health on mortality risk in older adults: Results from the NHANES with 15 years of follow-up

Background

Cognitive impairment and poor oral health are frequently seen among older adults. Both conditions have been identified as risk factors for mortality. However, the combined associations of cognitive impairment and poor oral health with mortality have not been well studied and are therefore the aim of this cohort study.

Methods

We analyzed data from the National Health and Nutrition Examination Survey (1999–2002) linked with mortality data obtained from the 2015 public‐use linked mortality file. Cognitive impairment was defined as a digit symbol substitution test score lower than the lowest quartile. Oral health status was assessed based on presence of untreated caries, moderate to severe periodontitis, and edentulism. The combined effects of caries/periodontitis or edentulism and cognitive impairment on all‐cause and cardiometabolic mortality were examined using the Cox proportional hazard models after adjusting for potential confounders including demographic characteristics, lifestyle, biomarkers, and comorbidities.

Results

In total, 1973 participants were enrolled in the prospective study. At a median follow‐up of 13.4 years, 978 participants had died (264 deaths because of cardiometabolic disease). Cognitive impairment, periodontitis, and edentulism were each found to be significant predictors of all‐cause mortality. Caries, however, was not significantly related to mortality. When analyzing these predictors in combination, a diagnosis of cognitive impairment and periodontitis was associated with an 83.1% increase in all‐cause mortality risk and an 87.7% increase in cardiometabolic mortality risk compared with healthy controls. Similarly, the risk for all‐cause mortality was highest in cases where impaired cognition and edentulism co‐occurred (adjusted hazard ratio = 1.701, 1.338–2.161).

Conclusion

Concomitant presence of cognitive impairment and periodontitis or edentulism can be associated with a higher risk of mortality among older U.S. adults.

Diagnostic accuracy of severe periodontitis case definitions: Comparison of the CDC/AAP, EFP/AAP, and CPI criteria

BACKGROUND

This cross-sectional study aimed to evaluate the diagnostic accuracy of severe periodontitis by three different case definitions.

METHODS

Patients aged >35 years (n = 243, mean age = 47.8 ± 9.3 years) were evaluated by periodontal examinations and classified in patients with severe periodontitis according to the case definition proposed by the Centers for Disease Control and Prevention (CDC) in collaboration with the American Academy of Periodontology (AAP)-CDC/AAP, the new periodontal disease classification proposed jointly by the AAP and the European Federation of Periodontology (EFP/AAP), and the Community Periodontal Index (CPI). The primary outcome was to compare the diagnostic accuracy of severe periodontitis between the three case definitions. Sensitivity (SS), specificity (SP), and area under the receiver operating characteristic (ROC) curve were used to analyze the accuracy.

RESULTS

The proportion of subjects presenting the most severe definitions of each classification was: severe periodontitis (CDC/AAP) = 47.3%, type III and IV periodontitis (EFP/AAP) = 43.2% and CPI code 4 = 44.4%. When comparing the CDC/AAP case definitions with the EFP/AAP classification, SS, SP, and ROC of 81.7%, 91.4%, and 0.866 (CI, 95%: 0.816 to 0.916), respectively, were obtained. Similarly, when comparing CDC/AAP to CPI code 4, SS, SP, and ROC of 81.7%, 89.1%, and 0.854 (CI, 95%: 0.802 to 0.906), respectively, were obtained. When type III and IV periodontitis (EFP/AAP) was compared with CPI code 4, the values were 92.4%, 92%, and 0.922 (CI, 95%: 0.883 to 0.961), respectively.

CONCLUSIONS

The EFP/AAP classification and the CPI demonstrated high diagnostic accuracy with the CDC/AAP case definition to diagnose severe periodontitis.

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.

The Effect of Periodontitis on Dementia and Cognitive Impairment: A Meta-Analysis

The association between periodontal disease and dementia/cognitive impairment continues to receive increasing attention. However, whether periodontal disease is a risk factor for dementia/cognitive impairment is still uncertain. This meta-analysis was conducted to comprehensively analyze the effect of periodontitis on dementia and cognitive impairment, and to assess the periodontal status of dementia patients at the same time. A literature search was undertaken on 19 October 2020 using PubMed, Web of Science, and Embase with different search terms. Two evaluators screened studies according to inclusion and exclusion criteria, and a third evaluator was involved if there were disagreements; this process was the same as that used for data extraction. Included studies were assessed with the Newcastle-Ottawa Scale (NOS), and results were analyzed using software Review Manager 5.2. Twenty observational studies were included. In the comparison between periodontitis and cognitive impairment, the odds ratio (OR) was 1.77 (95% confidence interval (CI), 1.31–2.38), which indicated that there was a strong relationship between periodontitis and cognitive impairment. There was no statistical significance in the effect of periodontitis on dementia (OR = 1.59; 95%CI, 0.92–2.76). The subgroup analysis revealed that moderate or severe periodontitis was significantly associated with dementia (OR = 2.13; 95%CI, 1.25–3.64). The mean difference (MD) of the community periodontal index (CPI) and clinical attachment level (CAL) was 0.25 (95%CI, 0.09–0.40) and 1.22 (95%CI, 0.61–1.83), respectively. In this meta-analysis, there was an association between periodontitis and cognitive impairment, and moderate or severe periodontitis was a risk factor for dementia. Additionally, the deterioration of periodontal status was observed among dementia patients.

Association between Dietary Inflammatory Index and Periodontitis: A Cross-Sectional and Mediation Analysis

Inflammation-modulating elements are recognized periodontitis (PD) risk factors, nevertheless, the association between dietary inflammatory index (DII) and PD has never been appraised. We aimed to assess the association between DII and PD and the mediation effect of DII in the association of PD with systemic inflammation. Using the National Health and Nutrition Examination Survey 2009–2010, 2011–2012 and 2013–2014, participants who received periodontal exam and provided dietary recall data were included. The inflammatory potential of diet was calculated via DII. PD was defined according to the 2012 case definition. White blood cells (WBC), segmented neutrophils and C-reactive protein (CRP) were used as proxies for systemic inflammation. The periodontal measures were regressed across DII values using adjusted multivariate linear regression and adjusted mediation analysis. Overall, 10,178 participants were included. DII was significantly correlated with mean periodontal probing depth (PPD), mean clinical attachment loss (CAL), thresholds of PPD and CAL, WBC, segmented neutrophils and DII (p < 0.01). A linear regression logistic adjusted for multiple confounding variables confirmed the association between DII and mean PPD (B = 0.02, Standard Error [SE]: 0.02, p < 0.001) and CAL (B = −0.02, SE: 0.01, p < 0.001). The association of mean PPD and mean CAL with both WBC and segmented neutrophils were mediated by DII (from 2.1 to 3.5%, p < 0.001). In the 2009–2010 subset, the association of mean CAL with serum CRP was mediated by DII (52.0%, p < 0.01). Inflammatory diet and PD may be associated. Also, the inflammatory diet significantly mediated the association of leukocyte counts and systemic inflammation with PD.

The Role of Inflammatory Diet and Vitamin D on the Link between Periodontitis and Cognitive Function: A Mediation Analysis in Older Adults

Patients suffering from periodontitis are at a higher risk of developing cognitive dysfunction. However, the mediation effect of an inflammatory diet and serum vitamin D levels in this link is unclear. In total, 2062 participants aged 60 years or older with complete periodontal diagnosis and cognitive tests from the National Health and Nutrition Examination Survey (NHANES) 2011-2012 and 2013-2014 were enrolled. The Consortium to Establish a Registry for Alzheimer's disease (CERAD) word learning subtest (WLT) and CERAD delayed recall test (DRT), the animal fluency test (AFT) and the digit symbol substitution test (DSST) was used. Dietary inflammatory index (DII) was computed via nutrition datasets. Mediation analysis tested the effects of DII and vitamin D levels in the association of mean probing depth (PD) and attachment loss (AL) in all four cognitive tests. Periodontitis patients obtained worse cognitive test scores than periodontally healthy individuals. DII was negatively associated with CERAD-WLT, CERAD-DRT, AFT and DSST, and was estimated to mediate between 9.2% and 36.4% of the total association between periodontitis with cognitive dysfunction (p < 0.05). Vitamin D showed a weak association between CERAD-DRT, AFT and DSST and was estimated to between 8.1% and 73.2% of the association between periodontitis and cognitive dysfunction (p < 0.05). The association between periodontitis and impaired cognitive function seems to be mediated both by a proinflammatory dietary load and vitamin D deficiency. Future studies should further explore these mediators in the periodontitis-cognitive decline link.

Biological Aging and Periodontal Disease: Analysis of NHANES (2001-2002)

INTRODUCTION

Periodontitis is a chronic inflammatory disease caused by multiple potential contributing factors such as bacterial biofilm infection of the tissues surrounding the teeth and environmental determinants and a dysregulated host response for modifying and resolving the inflammation. Because periodontal disease is a major public health concern with substantial increases in the prevalence and severity in aging populations, previous studies of periodontitis tended to approach the disease as an age-associated outcome across the life span. However, few investigations have considered that, as a chronic noncommunicable disease, periodontitis may not simply be a disease that increases with age but may contribute to more rapid biologic aging.

OBJECTIVES

Increasing population data supports the potential disconnect between chronological aging and biologic aging, which would contribute to the heterogeneity of aging phenotypes within chronologic ages across populations. Thus, our aim was to test whether periodontal disease affects biological aging across the life span.

METHODS

The prevalence of periodontitis in the adult US population is a portion of the assessment of the National Health and Nutrition Examination Survey (NHANES), which has been ongoing since 1971 through 2-y cycles sampling populations across the country. We used NHANES 2001-2002 to test the hypothesis that the presence/severity of periodontal disease as an exposure variable would negatively affect telomere length, a measure of biological aging, and that this relationship is modified by factors that also affect the progression of periodontitis, such as sex, race/ethnicity, and smoking.

RESULTS

The data demonstrated a significant impact of periodontitis on decreasing telomere lengths across the life span. These differences were modulated by age, sex, race/ethnicity, and smoking within the population.

CONCLUSION

The findings lay the groundwork for future studies documenting broader effects on biological aging parameters as well as potential intervention strategies for periodontitis in driving unhealthy aging processes.

KNOWLEDGE TRANSFER STATEMENT

Periodontitis is a chronic inflammatory disease and dysregulated host response. Shortening of telomeres is a reflection of biologic aging. Decreased telomere lengths with periodontitis are seemingly related to chronic infection and persistent local and systemic inflammation. These findings suggest that periodontitis is not simply a disease of aging but may also transmit chronic systemic signals that could affect more rapid biological aging. Clinicians can use this outcome to recognize the role of periodontitis in driving unhealthy aging processes in patients.

Clustering by periodontitis-associated factors: A novel application to NHANES data

BACKGROUND

Unsupervised clustering is a method used to identify heterogeneity among groups and homogeneity within a group of patients. Without a prespecified outcome entry, the resulting model deciphers patterns that may not be disclosed using traditional methods. This is the first time such clustering analysis is applied in identifying unique subgroups at high risk for periodontitis in National Health and Nutrition Examination Surveys (NHANES 2009 to 2014 data sets using >500 variables.

METHODS

Questionnaire, examination, and laboratory data (33 tables) for >1,000 variables were merged from 14,072 respondents who underwent clinical periodontal examination. Participants with ≥6 teeth and available data for all selected categories were included (N = 1,222). Data wrangling produced 519 variables. k-means/modes clustering (k = 2:14) was deployed. The optimal k-value was determined through the elbow method, formula = ∑ (x_i ² ) - ((∑ x_i )2 /n). The 5-cluster model showing the highest variability (63.08%) was selected. The 2012 Centers for Disease Control and Prevention/American Academy of Periodontology (AAP) and 2018 European Federation of Periodontology/AAP periodontitis case definitions were applied.

RESULTS

Cluster 1 (n = 249) showed the highest prevalence of severe periodontitis (43%); 39% self-reported "fair" general health; 55% had household income <$35,000/year; and 48% were current smokers. Cluster 2 (n = 154) had one participant with periodontitis. Cluster 3 (n = 242) represented the greatest prevalence of moderate periodontitis (53%). In Cluster 4 (n = 35) only one participant had no periodontitis. Cluster 5 (n = 542) was the systemically healthiest with 77% having no/mild periodontitis.

CONCLUSION

Clustering of NHANES demographic, systemic health, and socioeconomic data effectively identifies characteristics that are statistically significantly related to periodontitis status and hence detects subpopulations at high risk for periodontitis without costly clinical examinations.

A 5-year longitudinal association between dietary fermented soya bean (natto) intake and tooth loss through bone mineral density in postmenopausal women: The Yokogoshi cohort study

OBJECTIVE

In this 5-year cohort study, we aimed to determine whether the intake of natto, a fermented soya bean food product, has an indirect effect on tooth loss incidence through BMD changes among postmenopausal women.

BACKGROUND

Evidence indicates (1) that natto has a beneficial effect on bone health and (2) that a decrease in bone mineral density (BMD) is associated with tooth loss.

METHODS

The study recruited 435 postmenopausal women (average age = 64.2 years). Natto intake (exposure) was assessed at baseline using a food frequency questionnaire. Lumbar spine BMD and number of teeth were measured at baseline and 5-year follow-up. BMD change (mediator) and the number of teeth lost (outcome) over time were calculated. The mediation model consisted of these 3 variables. Mediation analysis was performed to test the indirect effect of the natto intake measured through BMD change on tooth loss.

RESULTS

During the study, the mean number of teeth lost was 1.2 (standard deviation = 1.8), and the mean BMD decline was 2.5% (standard deviation = 7.1). After adjusting for potential confounders, increasing habitual natto intake was significantly indirectly associated with a lower incidence of tooth loss mediated by BMD change (incidence rate ratio of tooth loss among women with "≥1 pack/day" natto intake was 0.90 [95% confidence interval = 0.82-0.99] compared to those with natto consumption of "rarely").

CONCLUSIONS

Dietary natto intake is significantly indirectly associated with a lower incidence of tooth loss among postmenopausal women, and systemic bone density could be a mediator of this association.

The role of dental insurance in mitigating mortality among working-age U.S. adults with periodontitis

AIM

To assess the relationship of dental insurance with all-cause mortality and mortality due to cardiovascular diseases (CVD), diabetes mellitus (DM), and cerebrovascular diseases (CBD) among those with periodontitis.

MATERIALS AND METHODS

NHANES III and its associated mortality data set were used in this study. The outcome variables were "all-cause mortality" and "combined mortality" due to CVD, DM, and CBD. The independent variable was dental insurance stratified over periodontitis status. Unweighted frequencies with weighted column percentages were used for descriptive statistics, and chi-square test was applied for significance. Cox proportional hazard models were used for stratified multivariable analyses. All analyses were performed in SAS v9.4 accounting for survey data complexities. Significance level was kept at 5%.

RESULTS

The mortality was 14.58% for all-cause mortality and 4.06% for combined mortality among those with periodontitis in this study. Dental insurance significantly reduced the hazard of all-cause mortality among those with periodontitis (HR: 0.75; 95% CI: 0.61 - 0.93), adjusted for covariates. However, no association of dental insurance with combined mortality was observed among periodontitis group.

CONCLUSIONS

Dental insurance reduces hazard of all-cause mortality among those with periodontitis. Dental insurance ensures access to dentists and improves oral and dental health. Longitudinal study is needed to establish causality.

Association of periodontitis with leukocyte telomere length in US adults: A cross-sectional analysis of NHANES 1999 to 2002

BACKGROUND

This study examines the association of periodontitis with telomere length (TL) and effect modification by population characteristics.

METHODS

We analyzed data from 3,478 participants from the 1999 to 2002 National Health and Nutrition Examination Survey. Probing depth, attachment loss, and bleed on probing (BOP, available for 1,973 participants only) were examined on the distal, mesial, or mid-facial site of each tooth in two randomly selected quadrants. We defined periodontitis severity according to the Centers for Disease Control/American Academy of Periodontology guideline. TL from leukocytes was measured with qPCR. We used linear and logistic regression to examine the adjusted association of different severity of periodontitis and BOP with continuous TL (bp) and dichotomized short TL (<median), respectively. To assess effect modification, we stratified the analyses by a priori selected population characteristics including sex, age, body weight status, smoking, and cardiometabolic comorbidity.

RESULTS

Moderate BOP (<10% bleeding sites) was significantly associated with a shorter continuous TL (β = -89.0, SE = 37.8). Moderate to severe periodontitis was significantly associated with 47% (95% confidence interval [IL], 1.04 to 2.09) higher odds of shorter TL, compared with those with mild or no periodontitis. The association was stronger in those who were female (adjusted OR, 1.76; 95% CI, 1.10 to 2.83), overweight or obese (adjusted OR, 1.64; 95% CI, 1.12 to 2.41), or had cardiometabolic comorbidities (adjusted OR, 2.13; 95% CI, 1.38 to 3.29).

CONCLUSIONS

Periodontitis was associated with TL, a biomarker of cellular aging. The association was stronger in females, overweight or obese, or those with cardiometabolic diseases. Treatment on periodontitis could potentially protect individuals from aging-related diseases.

Effectiveness of a family-centered behavioral and educational counselling approach to improve periodontal health of pregnant women: a randomized controlled trial

BACKGROUND

Poor oral hygiene and high hormone levels during pregnancy can lead to a deterioration in periodontal health. This study assessed the effectiveness of a family-centered behavioral and educational counselling program on improving the periodontal health of women during pregnancy and postpartum.

METHODS

A randomized controlled trial was conducted among pregnant women (10th-22nd gestational week) and their husbands. Participating families were randomized into test and control groups. Intervention in the test group included explanation of oral health education (OHE) pamphlets, oral hygiene instruction, individualized feedback, and proposed solutions to overcome barriers in self-care. Reinforcements were implemented in the 3rd trimester of pregnancy and six months postpartum. In the control group, only OHE pamphlets were distributed. The assessed outcomes were bleeding on probing (BOP), periodontal pocket (Poc), loss of clinical attachment (LoA), and Visible Plaque Index (VPI). The data collection was carried out at baseline (T₀), in the 32nd gestational week (T₁), and 12 months postpartum (T₂).

RESULTS

Altogether 589 pregnant women were recruited, and 369 attended all three visits (test:188; control:181). In the test group, the mean VPI score at T₀ was 0.19, which decreased to 0.14 at T₁ and 0.15 at T₂. In the control group, the mean VPI decreased from 0.19 at T₀ to 0.16 at T₁, but increased to 0.22 at T₂. A main effect of time and intervention and an interaction between time and intervention were detected (all p < 0.05), indicating that the intervention effect differed between T₁ and T₂. The test group showed a significantly greater decrease over time than the control group did. Similarly, the mean BOP% decreased more significantly over time in the test group (T₀:57%, T₁:46%, T₂:35%) than in the control group (T₀:58%, T₁:52%, T₂:46%). For Poc and LoA, there were improvements in both study groups at 12 months postpartum, compared with during pregnancy (p < 0.001).

CONCLUSIONS

Providing family-centered, behavioral, and educational counselling to pregnant women at an early stage of pregnancy and with reinforcements can improve their oral hygiene and reduce gingival inflammation. The effect can be sustained over an extended period and is greater than that of distributing oral health leaflets alone.

TRIAL REGISTRATION

Clinicaltrials.gov , #NCT02937194. Registered 18 October 2016. Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02937194?cond=Family-centered+oral+health+promotion+for+new+parents+and+their+infants&draw=2&rank=1.

Active gingival inflammation is linked to hypertension

BACKGROUND

Cardiovascular diseases (CVD) including hypertension, are characterized by underlying systemic inflammation. Periodontitis, which can impact the systemic inflammatory burden has recently been linked to high blood pressure (BP). However, the relationship of gingival bleeding, as an easily accessible marker of periodontal disorder, with hypertension, remains unclear.

METHODS

Survey-based propensity score matching (PSM) incorporating major confounders shared between hypertension and periodontal diseases was applied to cross-sectional NHANES III data from 5396 adults at least 30 years old who underwent BP measurement and periodontal examination, identifying two matched groups with and without gingival bleeding. The association of bleeding gums with SBP (mmHg) and high/uncontrolled BP was then assessed with generalized additive models incorporating inflammatory markers. Stratification by periodontal status (healthy; gingivitis; stable periodontitis; unstable periodontitis) was performed. Variables importance was estimated using machine learning.

RESULTS

Gingival bleeding (gingivitis; unstable periodontitis) was independently associated with +2.6 mmHg (P < 0.001) SBP compared with no bleeding (healthy periodontium; stable periodontitis), and with greater odds (OR = 1.42; 95% CI = 1.19-1.68; P < 0.001) of high/uncontrolled BP. Participants with unstable periodontitis had higher SBP than those with stable periodontitis (+2.1 mmHg; P < 0.001) or gingivitis (+5.3 mmHg; P < 0.001). Unstable periodontitis and gingivitis were consistently associated with increased risk of high/uncontrolled BP (OR = 1.65, 95% CI = 2.14-1.82; OR = 1.49, 95% CI = 1.22-1.82, respectively). Inflammatory markers allowed a maximum of 12% gain in the models' predictive power.

CONCLUSION

Gingival bleeding contributes to shaping the relationship between periodontal diseases and BP, but the burden represented by periodontitis is also crucial. Periodontal evaluation might be of importance in difficult to control hypertension.

Wisdom teeth, periodontal disease, and C-reactive protein in US adults

OBJECTIVES

The study aim was to evaluate the associations among the presence of wisdom teeth (third molars, M3), periodontal disease, and serum C-reactive protein (CRP) in the US adult population, thus to generate population-based evidence to inform heart disease prevention and dental care.

STUDY DESIGN

We performed secondary data analysis of the 2009-2010 National Health and Nutrition Examination Survey (NHANES), and included 3752 people aged 30 years and older who participated in the periodontal examination.

METHODS

Descriptive analyses were performed to determine the prevalence of M3 presence, periodontal disease, and elevated CRP. Multivariate logistic regression modeling was used to determine the association between M3 presence, periodontal disease, and elevated CRP.

RESULTS

The prevalence of M3 presence, periodontal disease (probing periodontal pockets depth (PPD)≥ 4 mm), and elevated serum C-reactive protein level (≥5 mg/L) was 39%, 41%, and 19% respectively. M3 presence was highest among men, younger adults, Blacks and Hispanics compared to Non-Hispanic Whites, those who did not attend college, and people with low incomes (P < 0.001). M3 presence, adjusted for sociodemographic and health characteristics, was independently associated with periodontal disease (adjusted [Adj.] odds ratio [OR] 1.61, 95% confidence interval [CI] 1.31, 1.97), and periodontal disease was independently associated with elevated serum CRP (Adj. OR 1.35, 95% CI 1.06, 1.73), but we did not find M3 presence associated with elevated serum CRP (Adj. OR 1.02, 95% CI 0.79, 1.31).

CONCLUSIONS

We observed expected associations between M3 presence and periodontal disease, and periodontal disease and elevated CRP. However, M3 presence alone is not associated with elevated CRP. Further research into cardiovascular health hazards related to the retention of wisdom teeth is needed, including examining possible relationships with other inflammatory factors.

A Preliminary Study on the Ability of the Trypsin-Like Peptidase Activity Assay Kit to Detect Periodontitis

This study aimed to explore whether the Trypsin-Like Peptidase Activity Assay Kit (TLP-AA-Kit), which measures the activity of N-benzoyl-dl-arginine peptidase (trypsin-like peptidase), can be used as a reliable tool for periodontitis detection in population-based surveillance. In total, 105 individuals underwent a full-mouth periodontal examination and provided tongue swabs as specimens for further analyses. The results of the TLP-AA-Kit were scored between 1 and 5; higher scores indicated higher trypsin concentrations. Receiver operating characteristic analyses were used to evaluate the predictive validity of the TLP-AA-Kit, where the periodontitis case definition provided by the Centers for Disease Control/American Academy of Periodontology served as the reference. Severe and moderate periodontitis were identified in 4.8% and 16.2% of the study population, respectively. The TLP-AA-Kit showed high diagnostic accuracy for severe periodontitis, with an area under the curve of 0.93 (95% confidence interval = 0.88-0.99). However, the diagnostic accuracy of the TLP-AA-Kit for moderate/severe periodontitis was not reliable. While further studies are necessary to validate our results, the results provided herein highlight the potential of the TLP-AA-Kit as a useful tool for the detection of periodontitis, particularly in severe cases, for population-based surveillance.

Periodontal and peri-implant diseases in centenarians

AIMS

To report the prevalence of periodontal and peri-implant diseases in centenarians in South-Western Germany, examine associations with sociodemographic factors and explore age-related trends.

MATERIAL AND METHODS

Eligible persons born before 1920 were identified from population registries in South-Western Germany. A total of 55 centenarians were visited at home or in nursing care facilities. Of them, 35 were dentate, 33 of which underwent periodontal examination. Implants in 2 edentulous patients were also registered.

RESULTS

The mean number of teeth was 9.5 ± 7.1; centenarians in need of nursing care had considerably less teeth than others (8.5 versus. 17.0 teeth, p = .03). Mean probing depth was 2.7 ± 0.8mm; mean clinical attachment loss was 4.2 ± 1.7 mm. Severe tooth mobility (degree 2 or 3) and furcation involvement were present in approximately 3% of eligible teeth. According to CDC/AAP classification, 25.8% of centenarians had no or mild periodontitis, 54.8% of centenarians had moderate periodontitis, and only 19.4% were severely affected. Of 27 implants examined in 5 centenarians, 59.3% were classified as healthy, 29.6% had peri-implant mucositis, and 11.1% had peri-implantitis.

CONCLUSIONS

This study reveals the predominance of moderately severe disease in centenarians. While there were high levels of moderate periodontitis and peri-implant mucositis, signs of severe periodontitis, severe furcation involvement, tooth mobility or peri-implantitis were less frequent.

Effects of periodontal disease on glycemic control, complications, and incidence of diabetes mellitus

Diabetes mellitus is a group of metabolic disorders with high mortality and morbidity associated with complications such as cardiovascular disease, kidney disease, and stroke. The prevalence of diabetes is 9.4% in US adults, and prevalence increases markedly with age, with 1 in 4 adults aged ≥65 years affected by diabetes. The estimated number of adults with type 2 diabetes globally almost tripled between 2002 and 2017, reflecting increases seen in the USA and elsewhere. This increase raises concerns about the increased morbidity and mortality associated with the complications of diabetes, including periodontal disease and tooth loss. There is a reciprocal adverse relationship between diabetes and periodontal disease, with diabetes as a major risk factor for periodontal disease, and in those patients with diabetes who also have periodontal disease then there are adverse effects on glycemic control and complications such as cardiovascular disease and end stage renal disease. In this review, those studies detailing the adverse effects of periodontal disease and diabetes will be discussed. Also, evidence is accumulating that periodontitis may play a role in increasing the incidence of new cases of type 2 diabetes, and possibly gestational diabetes. Of course, these studies need to be expanded to better understand the effects of periodontitis on diabetes glycemic control, complications, prediabetes, and the incidence of new cases. However, given the tremendous burden of diabetes on society, the dental profession should be proactive in preventing and treating periodontal disease, not only to preserve the dentition, but also to minimize the adverse effects of periodontitis on diabetes and its complications.

Association between periodontitis and pulmonary function based on the Third National Health and Nutrition Examination Survey (NHANES III)

OBJECTIVES

The purpose of this study was to investigate the association between impaired pulmonary function and periodontitis.

MATERIALS AND METHODS

From the Third National Health and Nutrition Examination Survey data, we examined the association between pulmonary function and severity of periodontitis using the univariate and multivariate regression models. Moreover, the association between obstructive or restrictive spirometry patterns and periodontitis status was also determined by multivariable logistic regression analysis.

RESULTS

A total of 10,645 participants were included in our study. The values of predicted FEV1%, predicted FVC%, and FEV1/FVC were found to gradually decline with increasing severity of periodontitis (p < .001). Obstructive and restrictive pulmonary functions were significantly associated with severity of periodontitis.

CONCLUSION

Individuals with a greater degree of periodontitis had poor pulmonary function. However, further long-term cohort studies are required for a comprehensive evaluation.

Relationship between preterm birth and post-partum periodontal maternal status: a hospital-based Romanian study

PURPOSE

This cross-sectional case-control study of post-partum women aimed to estimate whether maternal periodontitis was a predictive contributor to preterm birth and to identify other risk factors associated with preterm birth in our target population.

METHODS

The case group included women who delivered preterm (74 cases) and the control group included women who had a normal term delivery (120 controls). Medical records, a 16-item questionnaire, and a full-mouth periodontal examination were used to collect information about socio-demographic characteristics, general health problems, birth-related information, behavioral factors and periodontal status. Logistic regression analysis was used to estimate the strength of the relationship between predictors and the categorical outcome variable, preterm birth.

RESULTS

The bivariate analysis revealed the significant associations between preterm birth and socio-demographic factors (educational level, p = 0.003), antepartum smoking habit (p = 0.001) and birth weight lower than 2500 g (p < 0.001). The multivariate analysis highlighted that the presence of post-partum maternal periodontitis and its severity remained independent risk factors of preterm birth in the presence of antepartum smoking habit and route of delivery [adjusted OR 2.26, 95% CI (1.06; 4.82), respectively, OR 3.46, 95% CI (1.08; 11.15)].

CONCLUSION

Post-partum maternal periodontal disease and its severity might, in part, be considered as contributor to preterm deliveries before 37 weeks of gestation.

Recent epidemiologic trends in periodontitis in the USA

The most important development in the epidemiology of periodontitis in the USA during the last decade is the result of improvements in survey methodologies and statistical modeling of periodontitis in adults. Most of these advancements have occurred as the direct outcome of work by the joint initiative known as the Periodontal Disease Surveillance Project by the Centers for Disease Control and Prevention and the American Academy of Periodontology that was established in 2006. This report summarizes some of the key findings of this important initiative and its impact on our knowledge of the epidemiology of periodontitis in US adults. This initiative first suggested new periodontitis case definitions for surveillance in 2007 and revised them slightly in 2012. This classification is now regarded as the global standard for periodontitis surveillance and is used worldwide. First, application of such a standard in reporting finally enables results from different researchers in different countries to be meaningfully compared. Second, this initiative tackled the concern that prior national surveys, which used partial-mouth periodontal examination protocols, grossly underestimated the prevalence of periodontitis of potentially more than 50%. Consequently, because previous national surveys significantly underestimated the true prevalence of periodontitis, it is not possible to extrapolate any trend in periodontitis prevalence in the USA over time. Any difference calculated may not represent any actual change in periodontitis prevalence, but rather is a consequence of using different periodontal examination protocols. Finally, the initiative addressed the gap in the need for state and local data on periodontitis prevalence. Through the direct efforts of the Centers for Disease Control and Prevention and the American Academy of Periodontology initiative, full-mouth periodontal probing at six sites around all nonthird molar teeth was included in the 6 years of National Health and Nutrition Examination Surveys from 2009-2014, yielding complete data for 10 683 dentate community-dwelling US adults aged 30 to 79 years. Applying the 2012 periodontitis case definitions to the 2009-2014 National Health and Nutrition Examination Surveys data, the periodontitis prevalence turned out to be much greater than previously estimated, namely affecting 42.2% of the population with 7.8% of people experiencing severe periodontitis. It was also discovered that only the moderate type of periodontitis is driving the increase in periodontitis prevalence with age, not the mild or the severe types whose prevalence do not increase consistently with age, but remain ~ 10%-15% in all age groups of 40 years and older. The greatest risk for having periodontitis of any type was seen in older people, in males, in minority race/ethnic groups, in poorer and less educated groups, and especially in cigarette smokers. The Centers for Disease Control and Prevention and the American Academy of Periodontology initiative reported, for the first time, the periodontitis prevalence estimated at both local and state levels, in addition to the national level. Also, this initiative developed and validated in field studies a set of eight items for self-reported periodontitis for use in direct survey estimates of periodontitis prevalence in existing state-based surveys. These items were also included in the 2009-2014 National Health and Nutrition Examination Surveys for validation against clinically determined cases of periodontitis. Another novel result of this initiative is that, for the first time, the geographic distribution of practicing periodontists in relation to the geographic distribution of people with severe periodontitis is illustrated. In summary, the precise periodontitis prevalence and distribution among subgroups in the dentate US noninstitutionalized population aged 30-79 years is better understood because of application of valid periodontitis case definitions to full-mouth periodontal examination, in combination with reliable information on demographic and health-related measures. We now can monitor the trend of periodontitis prevalence over time as well as guide public health preventive and intervention initiatives for the betterment of the health of the adult US population.

Periodontitis as the risk factor of chronic kidney disease: Mediation analysis

AIM

To determine sequences and magnitude of causality among periodontitis, diabetes and chronic kidney disease (CKD) by mediation analysis.

METHODS

Ten-year-data were retrieved from the Electric Generation Authority of Thailand (EGAT) study. A cohort of 2,635 subjects was identified with no CKD at baseline. The interested outcome was CKD incidence defined as glomerular filtration rate <60 ml/min/1.73 m² . The percentage of proximal sites with clinical attachment loss ≥5 mm was used to represent periodontitis. Mediation analysis with 1,000-replication bootstrapping was applied to two causal diagrams, diagram A (Periodontitis → Diabetes → CKD) and diagram B (Diabetes → Periodontitis → CKD).

RESULTS

The cumulative incidence of CKD was 10.3 cases per 100 persons during 10-year period. In diagram A, each increasing percentage of proximal sites with severe periodontitis increased the adjusted odds ratio of CKD 1.010 (95% CI: 1.005, 1.015) and 1.007 (95% CI: 1.004, 1.013), by direct and indirect effect through diabetes, respectively. In diagram B, diabetes increased the odds of CKD twofold, with 6.5% of this effect mediated via periodontitis.

CONCLUSIONS

Periodontitis had significant direct effect, and indirect effect through diabetes, on the incidence of CKD. Awareness about systemic morbidities from periodontitis should be emphasized.

Validity of self-reported periodontal measures, demographic characteristics, and systemic medical conditions

BACKGROUND

The objective of the present study was to assess self-reported periodontal screening questions, demographic characteristics, systemic medical conditions, and tobacco use for predicting periodontal disease among individuals seeking dental therapy in a university dental clinic.

METHODS

In this retrospective study, a total of 4,890 randomly selected dental charts were evaluated from among patients who had attended the University of Minnesota School of Dentistry clinics for treatment. Radiographic bone loss measurements were used to assess the severity of periodontal disease. Demographic characteristics as well as medical history of the patients were also recorded. Five self-reported periodontal screening questions were included, with answers limited to Yes/No. Generalized logit models were used to assess the association between bone loss and the predictors.

RESULTS

The sample's mean age was 54.1 years and included 52.6% males and 14.9% smokers, with a mean of 3.5 missing teeth. Self-reported tooth mobility, history of "gum treatment," and the importance of retaining teeth as well as age, tobacco use, and cancer were statistically significant predictors (P < 0.05) of a radiographic diagnosis of moderate and severe periodontal disease. With respect to severe periodontal disease, significant associations (P < 0.05) were also found with "bleeding while brushing," gender, diabetes, anxiety, and arthritis.

CONCLUSIONS

Self-reported periodontal screening questions as well as demographic characteristics, smoking, and systemic medical conditions were significant predictors of periodontal disease, and they could be used as valid, economic, and practical measures.

Plaque-induced gingivitis: Case definition and diagnostic considerations

OBJECTIVE

Clinical gingival inflammation is a well-defined site-specific condition for which several measurement systems have been proposed and validated, and epidemiological studies consistently indicate its high prevalence globally. However, it is clear that defining and grading a gingival inflammatory condition at a site level (i.e. a "gingivitis site") is completely different from defining and grading a "gingivitis case" (GC) (i.e. a patient affected by gingivitis), and that a "gingivitis site" does not necessarily mean a "GC". The purpose of the present review is to summarize the evidence on clinical, biochemical, microbiologic, genetic markers as well as symptoms associated with plaque-induced gingivitis and to propose a set of criteria to define GC.

IMPORTANCE

A universally accepted case definition for gingivitis would provide the necessary information to enable oral health professionals to assess the effectiveness of their prevention strategies and treatment regimens; help set priorities for therapeutic actions/programs by health care providers; and undertake surveillance.

FINDINGS

Based on available methods to assess gingival inflammation, GC could be simply, objectively and accurately identified and graded using bleeding on probing score (BOP%) CONCLUSIONS: A patient with intact periodontium would be diagnosed as a GC according to a BOP score ≥ 10%, further classified as localized (BOP score ≥ 10% and ≤30%) or generalized (BOP score > 30%). The proposed classification may also apply to patients with a reduced periodontium, where a GC would characterize a patient with attachment loss and BOP score ≥ 10%, but without BOP in any site probing ≥4 mm in depth.

Association between periodontal inflammation and hypertension using periodontal inflamed surface area and bleeding on probing

AIM

Periodontitis is a relapsing-remitting disease. Compared with bleeding on probing (BoP), expression of disease activity, periodontal inflamed surface area (PISA), incorporates chronic disease parameters. We tested the association of PISA and BoP with blood pressure (BP) in NHANES III.

MATERIALS AND METHODS

A total of 8,614 subjects (≥30 years) with complete periodontal and BP examinations were enrolled. PISA was derived from periodontal probing depth and BoP. The association of PISA and BoP with high/uncontrolled BP was examined by multiple-adjusted models. Inflammatory markers were tested as possible mediators. A machine learning (ML) approach was used to define the relative importance of PISA and BoP and estimate the power of BP status prediction.

RESULTS

Compared to no inflammation, severe PISA and BoP were associated with 43% (p < .001) and 32% (p = .006) higher odds of high/uncontrolled BP (≥130/80 mmHg), and with higher systolic BP by ≈4 (p < .001) and 5 (p < .001) mmHg, respectively. Inflammatory markers appeared to mediate this association with various extents, without threshold effect. BoP predicted high/uncontrolled BP more efficiently than PISA using ML.

CONCLUSION

PISA and BoP describe the association of periodontal inflammation and hypertension with subtle differences. The contribution of local inflammation to the global inflammatory burden might explain the observed findings.

Prevalence of periodontitis and alveolar bone loss in a patient population at Harvard School of Dental Medicine

Background

Although several studies assessed the prevalence of alveolar bone loss, the association with several risk factors has not been fully investigated. The aim of this article is to measure the prevalence of periodontitis by calculating the mean alveolar bone loss/level of posterior teeth using bitewing radiographs among the patients enrolled in the clinics at Harvard School of Dental Medicine and address risk factors associated with the disease.

Methods

One thousand one hundred thirty-one patients were selected for radiographic analysis to calculate the mean alveolar bone loss/level by measuring the distance between the cementoenamel junction and the alveolar bone crest on the mesial and distal surfaces of posterior teeth. Linear regression with Multi-level mixed-effect model was used for statistical analysis adjusting for age, sex, race, median household income, and other variables.

Results

Mean alveolar bone level of the whole sample was 1.30 mm (±0.006). Overall periodontitis prevalence for the sample was 55.5% (±1.4%). Moderate periodontitis prevalence was 20.7% (±1.2%), while 2.8% (±0.5%) of the whole sample had severe periodontitis. Adjusted mean alveolar bone loss was higher in older age groups, males, Asian race group, ever smokers, and patients with low median household income.

Conclusion

The effect of high household income on the amount of bone loss can be powerful to the degree that high household income can influence outcomes even for individuals who had higher risks of developing the disease. Public health professionals and clinicians need to collaborate with policy makers to achieve and sustain high quality of healthcare for everyone.

Placental colonization with periodontal pathogens: the potential missing link

Observational studies demonstrate that women with severe periodontitis have a higher risk of adverse pregnancy outcomes like preterm birth and low birthweight. Standard treatment for periodontitis in the form of scaling and root planing during the second trimester failed to reduce the risk of preterm or low birthweight. It is premature to dismiss the association between periodontitis and adverse pregnancy outcomes because one explanation for the failure of scaling and root planing to reduce the risk of adverse pregnancy outcomes is that periodontal pathogens spread to the placental tissue prior to periodontal treatment. In the placenta, orally derived organisms could cause direct tissue damage or mediate a maternal immune response that impairs the growth of the developing fetus. Sequencing studies demonstrate the presence of organisms derived from the oral microbiome in the placenta, but DNA-based sequencing studies should not be the only technique to evaluate the placental microbiome because they may not detect important shifts in the metabolic capability of the microbiome. In humans, polymerase chain reaction and histology have detected periodontal pathogens in placental tissue in association with multiple adverse pregnancy outcomes. We conclude that both placental and oral microbiomes may play a role in periodontitis-associated adverse pregnancy outcomes. However, the measure to determine the association between periodontal pathogens in the placenta and adverse pregnancy outcomes should be the amount and prevalence, not the mere presence of such microorganisms. Placental colonization with periodontal pathogens thus potentially represents the missing link between periodontitis and adverse pregnancy outcomes.

Periodontitis in US Adults: National Health and Nutrition Examination Survey 2009-2014

BACKGROUND

This report presents weighted average estimates of the prevalence of periodontitis in the adult US population during the 6 years 2009-2014 and highlights key findings of a national periodontitis surveillance project.

METHODS

Estimates were derived for dentate adults 30 years or older from the civilian noninstitutionalized population whose periodontitis status was assessed by means of a full-mouth periodontal examination at 6 sites per tooth on all non-third molar teeth. Results are reported according to a standard format by applying the Centers for Disease Control and Prevention/American Academy of Periodontology periodontitis case definitions for surveillance, as well as various thresholds of clinical attachment loss and periodontal probing depth.

RESULTS

An estimated 42% of dentate US adults 30 years or older had periodontitis, with 7.8% having severe periodontitis. Overall, 3.3% of all periodontally probed sites (9.1% of all teeth) had periodontal probing depth of 4 millimeters or greater, and 19.0% of sites (37.1% of teeth) had clinical attachment loss of 3 mm or greater. Severe periodontitis was most prevalent among adults 65 years or older, Mexican Americans, non-Hispanic blacks, and smokers.

CONCLUSIONS

This nationally representative study shows that periodontitis is a highly prevalent oral disease among US adults.

PRACTICAL IMPLICATIONS

Dental practitioners should be aware of the high prevalence of periodontitis in US adults and may provide preventive care and counselling for periodontitis. General dentists who encounter patients with periodontitis may refer these patients to see a periodontist for specialty care.

Oral Diseases Associated with Nonalcoholic Fatty Liver Disease in the United States

The US prevalence of nonalcoholic fatty liver disease (NAFLD) is 30.6% and increasing. NAFLD shares some risk factors with periodontitis and dental caries. We explored the association between NAFLD and several oral conditions among US adults, using data from the cross-sectional, nationally representative National Health and Nutrition Examination Survey (NHANES), 1988 to 1994. NAFLD was assessed with ultrasonography (USON), the screening gold standard not available in the more recent NHANES, and the noninvasive Fibrosis Score (FS), Fatty Liver Index (FLI), and US Fatty Liver Index (US-FLI) as other screening alternatives. There were 5,421 eligible dentate adults aged 21 to 74 y with complete relevant data, with transferrin levels ≤50%, without hepatitis B or C, who were not heavy drinkers. Multivariable models were developed to examine the independent effects of moderate-severe periodontitis, untreated dental caries, caries experience, and tooth loss (<20 teeth) on NAFLD while controlling for clinical, biological, and sociodemographic factors. Weighted estimates for odds ratios (ORs) and 95% CIs were calculated with logistic regression. Between 17% and 24% of adults had NAFLD depending on the classification criteria. In adjusted models, as compared with those with better oral health, adults with <20 teeth were more likely to have NAFLD depending on the measure (USON: OR = 1.50, 95% CI = 1.11 to 2.02; FS: OR = 4.36, 95% CI = 3.47 to 5.49; FLI: OR = 1.99, 95% CI = 1.52 to 2.59; US-FLI: OR = 2.32, 95% CI = 1.79 to 3.01). People with moderate-severe periodontitis were more likely to have NAFLD (USON: OR = 1.54, 95% CI = 1.06 to 2.24; FS: OR = 3.10, 95% CI = 2.31 to 4.17; FLI: OR = 1.61, 95% CI = 1.13 to 2.28; US-FLI: OR = 2.21, 95% CI = 1.64 to 2.98). People with any untreated caries were more likely to have NAFLD (USON: OR = 1.51, 95% CI = 1.20 to 1.90; FLI: OR = 1.80, 95% CI = 1.33 to 2.44). NAFLD was associated with tooth loss, periodontitis, and, for some NAFLD measures, untreated dental caries but not overall caries experience after controlling for several key sociodemographic and behavioral factors. Results suggest that further evaluation is needed to better understand this health-oral health interrelationship and potential opportunities for medical-dental integration.