Ante-dependence modeling in a longitudinal study of periodontal disease: the effect of age, gender, and smoking status

Natural history of periodontal disease: The original Sri Lanka and Oslo studies

Susceptibility to periodontal disease depends on individual factors within the host response to the bacterial challenge. The study of these factors requires longitudinal studies of an undisturbed development of the disease process. On the basis of the original longitudinal studies on the natural histology of periodontal disease staged in Sri Lanka and Oslo/Norway, several analyses of periodontal parameters and tooth status have been performed. The main findings were that in the first 20 years of complete absence of oral hygiene practices or preventive services attachment was lost at various rates. Three groups of subjects could be identified: rapidly progressing (RP) (8%), moderately progressing (MP) (81%), and subjects with no disease progression (NP) (11%). In the second two decades, the RP subjects have lost most of their teeth and no NP patients were identified anymore. The progression rate in these two decades was much slower, and the tooth mortality decreased. It could be predicted that subjects who had lost more than 2 mm at age 30 would not maintain a functional dentition at age 60. The corresponding control population in Oslo was used to study the influence of gingival inflammation on the initiation and progression of periodontal disease. The pattern and rates of attachment loss were identified in a population that was exposed to optimal and regular preventive services from age 3 onward. In the observation period of 26 years, it could be demonstrated that gingival inflammation varied little throughout adult life and always bleeding sites occurred consistently in 10% to 20%. The role of ongoing gingivitis in the pathogenesis of attachment loss was identified and also reflected stability whenever it was absent. Tooth mortality was only found in subjects with ongoing gingivitis. After 50 years of tooth age, 63% of the teeth were still maintained, while 99.8% were maintained after 50 years when gingival inflammation had been absent. Consequently, continuous gingivitis represented a risk factor for tooth loss.

In vitro evaluation of the effect of the electronic cigarette aerosol, Cannabis smoke, and conventional cigarette smoke on the properties of gingival fibroblasts/gingival mesenchymal stem cells

OBJECTIVE

The current study aimed to evaluate the effect of electronic cigarette (EC) aerosol, Cannabis, and conventional cigarettes smoke on gingival fibroblast/gingival mesenchymal stem cells' (GF/G-MSCs) of never smokers.

MATERIAL AND METHODS

Human GF/G-MSCs (n = 32) were isolated and characterized using light microscopy, flow cytometry, and multilineage differentiation ability. Following the application of aerosol/smoke extracts, GF/G-MSCs were evaluated for cellular proliferation; colony-forming units (CFU-F) ability; cellular viability (using the MTT assay); mitochondrial depolarization using JC-1 dye; and genes' expression of ATM, p21, Oct4, and Nanog.

RESULTS

Colony-forming units and viability (OD 450 nm) were significantly reduced upon exposure to Cannabis (mean ± SD; 5.5 ± 1.5; p < .00001, 0.47 ± 0.21; p < .05) and cigarettes smoke (2.3 ± 1.2 p < .00001, 0.59 ± 0.13, p < .05), while EC aerosol showed no significant reduction (10.8 ± 2.5; p = .05, 1.27 ± 0.47; p > .05) compared to the control group (14.3 ± 3, 1.33 ± 0.12). Significantly upregulated expression of ATM, Oct4, and Nanog (gene copies/GADPH) was noticed with Cannabis (1.5 ± 0.42, 0.82 ± 0.44, and 1.54 ± 0.52, respectively) and cigarettes smoke (1.52 ± 0.75, 0.7 ± 0.14, and 1.48 ± 0.79, respectively; p < .05), whereas EC aerosol caused no statistically significant upregulation of these genes compared to the control group (0.63 ± 0.1, 0.31 ± 0.12, and 0.64 ± 0.46, respectively; p > .05). The p21 gene was not significantly downregulated in EC aerosol (1.22 ± 0.46), Cannabis (0.71 ± 0.24), and cigarettes smokes (0.83 ± 0.54) compared to the control group (p = .053, analysis of variance).

CONCLUSION

Cannabis and cigarettes smoke induce DNA damage and cellular dedifferentiation and negatively affect the cellular proliferation and viability of GF/G-MSCs of never smokers, whereas EC aerosol showed a significantly lower impact on these properties.

Data visualization of the relationship between smoking and periodontal site-specific effects across the lifespan in the US adult population

BACKGROUND

Data visualization techniques were used to ascertain (1) site-specific effects of cigarette smoking on the periodontium compared to never-smokers; (2) patterns of site-specific effects by age among current and never-smokers using contour maps.

METHODS

Data from 10,713 dentate participants aged ≥30 years in NHANES 2009-2014 were used. Pocket depth (PD) and clinical attachment level (CAL) for six sites/tooth were ascertained by smoking status and plotted using contour maps to identify new patterns.

RESULTS

In the overall sample, 19% (n = 2015) were current smokers and 56% (n = 6013) were never-smokers. Contour maps of the overall sample showed teeth/sites most affected with mean PD > 2.1 mm were molars (2,3,15,18,19,30,31) in mesio-lingual (ML) and disto-lingual (DL) sites. Most affected sites for current smokers were interproximal sites of most posterior teeth. Among never-smokers, fewer teeth/sites were affected with PD > 2.1 mm, whereas among smokers, number of affected teeth/sites increased with age. Overall, teeth/sites most affected with mean CAL≥2.1 mm were noted in 2,3(ML), 3(DL), 14(DF, DL), 15(MF, ML), 18(ML), 19(DL, ML), and 30-31(ML, DL) with upper anterior teeth least affected. Among current smokers, several teeth/sites were affected (CAL≥2.1 mm): 2,3(all six sites), 4(ML, DL), 9(ML), 11-21(DL), 13-18(DF, ML, MIL, DL), 19-20(DF, ML, MIL), 14-18(MIF), 21(MIF, ML, DL), 22(MF), 23-27(MIL), 24-26(MIL, MF, DF in 26), 27(MF), 28(MF, ML, DL), 29-31(all 6 sites except MIF 30,31). As age increased, more teeth/sites were affected among smokers and by the 5th decade nearly all teeth/sites had CAL≥2.0 mm.

CONCLUSIONS

Contour mapping identifies patterns and dramatically visualizes the substantial periodontal site-specific differences. Current smokers had more affected teeth and/or periodontal sites with a different contour pattern than never-smokers.

Factors affecting decision making at reassessment of periodontitis. Part 2: interpretation of clinical findings - systemic factors

This paper is the second in a four-part series outlining treatment planning at periodontal reassessment. The first article focussed on the information that should be gathered at the reassessment appointment. Treatment can involve a range of non-surgical and surgical approaches. A variety of general, practical and local site factors can affect the choice of one option over another in choosing the most predictable treatment option. Residual periodontal probing depths can be associated with both systemic and local factors. This article (part 2) outlines systemic factors that need to be assessed when faced with residual periodontal probing depths.

Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions

A new periodontitis classification scheme has been adopted, in which forms of the disease previously recognized as "chronic" or "aggressive" are now grouped under a single category ("periodontitis") and are further characterized based on a multi-dimensional staging and grading system. Staging is largely dependent upon the severity of disease at presentation as well as on the complexity of disease management, while grading provides supplemental information about biological features of the disease including a history-based analysis of the rate of periodontitis progression; assessment of the risk for further progression; analysis of possible poor outcomes of treatment; and assessment of the risk that the disease or its treatment may negatively affect the general health of the patient. Necrotizing periodontal diseases, whose characteristic clinical phenotype includes typical features (papilla necrosis, bleeding, and pain) and are associated with host immune response impairments, remain a distinct periodontitis category. Endodontic-periodontal lesions, defined by a pathological communication between the pulpal and periodontal tissues at a given tooth, occur in either an acute or a chronic form, and are classified according to signs and symptoms that have direct impact on their prognosis and treatment. Periodontal abscesses are defined as acute lesions characterized by localized accumulation of pus within the gingival wall of the periodontal pocket/sulcus, rapid tissue destruction and are associated with risk for systemic dissemination.

Contemporary approaches for identifying individual risk for periodontitis

Key breakthroughs in our understanding of the etiology and principles of predictable treatment of patients with chronic periodontitis first emerged in the late 1960s and carried on into the mid-1980s. Unfortunately, some generalizations of the evidence led many to believe that periodontitis was a predictable result of exposure to bacterial plaque accumulations over time. For a brief period, the initial plaque concept was translated by some to implicate specific bacterial infections, with both concepts (plaque exposure and specific infection) being false assumptions that led to clinical outcomes which were frustrating to both the clinician and the patient. The primary misconceptions were that every individual was equally susceptible to periodontitis, that disease severity was a simple function of magnitude of bacterial exposure over time, and that all patients would respond predictably if treated based on the key principles of bacterial reduction and regular maintenance care. We now know that although bacteria are an essential initiating factor, the clinical severity of periodontitis is a complex multifactorial host response to the microbial challenge. The complexity comes from the permutations of different factors that may interact to alter a single individual's host response to challenge, inflammation resolution and repair, and overall outcome to therapy. Fortunately, although there are many permutations that may influence host response and repair, the pathophysiology of chronic periodontitis is generally limited to mild periodontitis with isolated moderate disease in most individuals. However, approximately 20%-25% of individuals will develop generalized severe periodontitis and probably require more intensive bacterial reduction and different approaches to host modulation of the inflammatory outcomes. This latter group may also have serious systemic implications of their periodontitis. The time appears to be appropriate to use what we know and currently understand to change our approach to clinical care. Our goal would be to increase our likelihood of identifying those patients who have a more biologically disruptive response combined with a more impactful microbial dysbiosis. Current evidence, albeit limited, indicates that for those individuals we should prevent and treat more intensively. This paper discusses what we know and how we might use that information to start individualizing risk and treat some of our patients in a more targeted manner. In my opinion, we are further along than many realize, but we have a great lack of prospective clinical evidence that must be accumulated while we continue to unravel the contributions of specific mechanisms.

Natural history of periodontitis: Disease progression and tooth loss over 40 years

OBJECTIVES

To assess long-term attachment and periodontitis-related tooth loss (PTL) in untreated periodontal disease over 40 years.

MATERIAL AND METHODS

Data originated from the natural history of periodontitis study in Sri Lankan tea labourers first examined in 1970. In 2010, 75 subjects (15.6%) of the original cohort were re-examined.

RESULTS

PTL over 40 years varied between 0 and 28 teeth (mean 13.1). Four subjects presented with no PTL, while 12 were edentulous. Logistic regression revealed attachment loss as a statistically significant covariate for PTL (p < .004). Markov chain analysis showed that smoking and calculus were associated with disease initiation and that calculus, plaque, and gingivitis were associated with loss of attachment and progression to advanced disease. Mean attachment loss <1.81 mm at the age of 30 yielded highest sensitivity and specificity (0.71) to allocate subjects into a cohort with a dentition of at least 20 teeth at 60 years of age.

CONCLUSIONS

These results highlight the importance of treating early periodontitis along with smoking cessation, in those under 30 years of age. They further show that calculus removal, plaque control, and the control of gingivitis are essential in preventing disease progression, further loss of attachment and ultimately tooth loss.

The Association between Periodontal Status, Serum Lipid Levels, Lipoprotein Associated Phosholipase A2 (Lp-PLA2) in Chronic Periodontitis Subjects and Healthy Controls

INTRODUCTION

Lipoprotein associated phospholipase A2 (Lp-PLA2) has been explored as a potential biomarker for Cardiovascular Disease (CVD). The human Lp-PLA2 is a serine-dependent, Ca2+- independent enzyme. It gives way to oxidised free fatty acids and lysophosphatidyl choline by hydrolysing oxidised phospholipids, that leads to smooth muscle cell apoptosis, inflammatory cell chemotaxis and endothelial cell dysfunction in CVD. Owing to its role in inflammation, it may influence the development and progression of periodontitis as well.

AIM

To compare the demographic variables, Gingival Index(GI), Bleeding On Probing (BOP), Probing Pocket Depth (PPD), and Clinical Attachment Level (CAL) with serum lipid profile and Lp-PLA2 level in Chronic Periodontitis (CP) subjects.

MATERIALS AND METHODS

A total of 75 subjects were selected and divided into three groups; based on the inclusion and exclusion criteria: Group I - 25 subjects with severe generalized CP with CAL ≥ 5 mm in more than 30% of sites. Group II -25 subjects with moderate generalized CD with clinical CAL 3 mm-4 mm in more than 30% of sites. Group III- 25 systemically and periodontally healthy volunteers who served as control. Clinical parameters such as Plaque Index (PI), BOP, Probing Depth (PD) and CAL, lipid profile such as Total Cholesterol (TC), Triglyceride (TG), High density Lipoprotein (HDL), Low Density Lipoprotein (LDL), Very Low Density Lipoprotein (VLDL) as well as Lp-PLA2 were assessed. One-way ANOVA and Tukey's Post-hoc test were used for data analysis.

RESULTS

Age was higher in Group I and II when compared to Group III. Group II showed a significant correlation between PI and LDL. In Group III, lower PI was significantly correlated with high HDL and low LDL and BOP was positively correlated with TG and HDL. A significant association of Lp-PLA2 was found to be higher with increase in the TG and VLDL level in Group I and Group II when compared to Group III.

CONCLUSION

The study concluded that Lp-PLA2, TG and VLDL already being a predictor biomarker for atherosclerotic disease can be an inflammatory marker for periodontitis.

Relationship of Bone Metabolism Biomarkers and Periodontal Disease: The Osteoporotic Fractures in Men (MrOS) Study

CONTEXT

Periodontitis is an inflammatory disease of tooth-supporting tissue leading to bone destruction and tooth loss. Periodontitis affects almost 50% of adults greater than 30 years of age.

OBJECTIVE

This study evaluated the association between biomarkers linked to bone formation and resorption with the occurrence and progression of periodontal disease in older men (≥ 65 y).

DESIGN

The Osteoporotic Fractures in Men (MrOS) study is a prospective, observational study among men 65 years of age and older.

SETTING

This ancillary study, Oral and Skeletal Bone Loss in Older Men, was conducted at two of the six MrOS study sites (Birmingham, AL and Portland, OR).

PATIENTS

Patients underwent medical and dental evaluation. Diagnoses of periodontitis were based on clinical attachment loss, pocket depth, calculus, plaque, and bleeding on a random half-mouth. Bone metabolism biomarkers included serum levels of calcium, phosphate (Pi), alkaline phosphatase, albumin, carboxy-terminal collagen crosslinks (CTX), N-terminal propeptides of type I procollagen, isoform 5b of tartrate-resistant acid phosphatase, and urine alpha- carboxy-terminal collagen crosslinks (alpha-CTX) and beta-CTX and serum levels of calciotropic hormones vitamin D (25(OH)D) and PTH.

MAIN OUTCOME MEASURES

The aim of this study is to correlate bone metabolism biomarkers with prevalence and progression of periodontal disease in older men.

RESULTS

Patients with more severe periodontitis had significantly higher levels of PTH (P trend = .0004), whereas 25(OH)D was lower (P trend = .001). In a subset of men reevaluated at a second dental visit, improvement of periodontitis was associated with lower alpha-CTX, beta-CTX, and CTX levels at baseline after adjusting for age, site, and body mass index.

CONCLUSION

This study suggests that a distinct set of biomarkers of bone metabolism are associated with more severe periodontal disease (PTH, 25(OH)D) and periodontal progression (alpha-CTX, beta-CTX, and CTX) over time.

Laser supported reduction of specific microorganisms in the periodontal pocket with the aid of an Er,Cr:YSGG laser: a pilot study

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a radial firing tip of an Er,Cr:YSGG laser as an adjunct to a nonsurgical periodontal treatment.

METHODS

Twelve patients with chronic or aggressive periodontitis were treated by conventional periodontal treatment using ultrasonic devices and hand instruments and, additionally, in two quadrants with an Er,Cr:YSGG laser. A new radial firing tip (RFPT 14-5, Biolase) was used with 1.5 W, 30 Hz, 11% air, 20% water, and pulse duration 140 μs. Microbiological smears were taken before treatment, one day after lasing, and three and six months after lasing. Pocket depths of all periodontal sites were measured before and six months after treatment.

RESULTS

The total bacterial load of Prevotella intermedia, Tannerella forsythia, Treponema denticola, Fusobacterium nucleatum, Porphyromonas gingivalis, and Aggregatibacter actinomycetemcomitans inside the pocket was reduced significantly throughout the whole examination time. Greater pocket depth reductions were observed in all groups. There was a slight higher reduction of pocket depth in the lased group after six months.

CONCLUSIONS

These results support the thesis that Er,Cr:YSGG laser supported periodontal treatment leads to a significant reduction of periopathogenes and thereby helps the maintenance of periodontal health.

Comparing clinical attachment level and pocket depth for predicting periodontal disease progression in healthy sites of patients with chronic periodontitis using multi-state Markov models

Aim

To understand degeneration of healthy sites and identify factors associated with disease progression in patients with chronic periodontitis.

Material and Methods

Data on healthy sites from 163 American and Swedish subjects were analysed using two-three-state (health, gingivitis, chronic periodontitis) Markov models based on bleeding on probing (BOP), and either clinical attachment level (CAL) + BOP or pocket depth (PD) + BOP.

Results

In 2 years, 10% (CAL + BOP) and 3% (PD + BOP) of healthy sites developed chronic periodontitis. On average, healthy sites remained healthy for 32 months before transiting in both models. Most transitions (87–97%) from health were to the gingivitis state. The expected duration of the gingivitis lesion was 4–5 months and sites recovered with a high probability (96–98%). Disease severity as measured by number of sites with CAL/PD > 4 mm at baseline and smoking, were associated with fast progression from health to chronic periodontitis within 6 months as were gingival redness in the PD + BOP model only. With age, the rate of disease progression to gingivitis decreased.

Conclusion

Transition probabilities for gingivitis and chronic periodontitis were higher with CAL + BOP than with PD + BOP. Smoking and disease severity were significant predictors for fast progression.

Salivary immunoglobulin classes in Nigerian smokers with periodontitis

AIM: To determine the levels of salivary immunoglobulin classes in Nigerian smokers and non-smokers with periodontitis.

METHODS: Sixty-nine individuals were recruited into this study after obtaining informed consent. They were subdivided into three groups that consisted of 20 (aged 46 ± 11 years) cigarette smokers with periodontitis (S+P); 24 (40 ± 12 years) smokers without periodontitis (S-P); and 25 (53 ± 11 years) non-smokers with periodontitis (NS+P). An oral and maxillofacial surgeon used radiographs for periodontal probing for the diagnosis of periodontitis. The smokers included subjects who smoked at least six cigarettes per day and all the periodontitis patients were newly diagnosed. About 5 mL of unstimulated saliva was expectorated by each subject into plain sample bottles. Salivary immunoglobulin levels were estimated using enzyme linked immunosorbent assay. Student’s t test was used to determine significant differences between the means. Values of P < 0.05 were regarded as significant.

RESULTS: No significant differences were observed in the mean salivary levels of the immunoglobulin classes (IgG, IgA, IgM and IgE) when S+P was compared with S-P. Mean salivary levels of IgA (520.0 ± 155.1 ng/mL vs 670.0 ± 110 ng/mL, P = 0.000) and IgM (644.5 ± 160.0 ng/mL vs 791.4 ± 43.7 ng/mL, P = 0.000) were significantly lower in the S+P compared with NS+P group. Salivary IgA (570.4 ± 145.6 ng/mL vs 670.0 ± 110 ng/mL, P = 0.008) and IgM (703.1 ± 169.3 ng/mL vs 791.4 ± 43.7 ng/mL, P = 0.012) levels were significantly lower in the S-P compared with NS+P group. Only one (5%) periodontal patient had detectable levels of salivary IgE (0.20 IU/mL). Similarly, only one smoker (4.17%) had detectable levels of salivary IgE (0.04 IU/mL) and two non-smokers (9.52%) had detectable levels of IgE (0.24 IU/mL).

CONCLUSION: Our study suggests that reduced salivary IgA and IgM levels in smokers with periodontitis could enhance increased susceptibility to periodontitis.

Clinical outcomes of single-visit oral prophylaxis: a practice-based randomised controlled trial

BACKGROUND

Practice-based general dental practitioners routinely provide "scale and polish" or "oral prophylaxis" to patients attending their practices. Despite its routine provision, there is no evidence to support the clinical effectiveness of single-visit scale and polish, nor the frequency at which it should be provided. A recent systematic review recommended that future trials investigating scale and polish should involve dental practice patients.

METHODS

A practice-based parallel randomised controlled trial with 24-month follow-up was conducted. Healthy adults (Basic Periodontal Examination [BPE] codes <3) were randomly assigned to 3 groups (6-month, 12-month, or 24-month interval between scale and polish). The primary outcome was gingival bleeding with the hypothesis that 6-monthly scale and polish would result in lower prevalence than 12-month or 24-month frequency. Follow-up measurements were recorded by examiners blinded to the allocation. 125, 122 and 122 participants were randomised to the 6-month, 12-month and 24-month groups respectively. Complete data set analyses were conducted for 307 participants: 107, 100, and 100 in the 6-month, 12-month and 24-month groups respectively. Chi-square test and ANOVA were used to compare treatment groups at follow-up. Logistic regression and ANCOVA were used to estimate the relationship between outcome and treatment group, adjusted for baseline values. Multiple imputation analyses were also carried out for participants with incomplete data sets.

RESULTS

Prevalence of gingival bleeding at follow-up was 78.5% (6-month), 78% (12-month) and 82% (24-month) (p = 0.746). There were no statistically significant differences between groups with respect to follow-up prevalence of plaque and calculus. Statistically significant differences detected in the amount (millimetres) of calculus were too small to be clinically significant. Seventeen (4.6%) participants were withdrawn from the trial to receive additional treatment.

CONCLUSIONS

This trial could not identify any differences in outcomes for single-visit scale and polish provided at 6, 12 and 24 month frequencies for healthy patients (with no significant periodontal disease). However, this is the first trial of scale and polish which has been conducted in a general practice setting and the results are not conclusive. Larger trials with more comprehensive measurement and long-term follow up need to be undertaken to provide a firm evidence base for this intervention. This trial informs the design of future practice-based trials on this subject.

The effects of age and gender on gingival tissue and peripheral blood T-lymphocyte subsets: a study in mice

The aim of this study is to investigate the effects of age and gender on relative number of CD4+ and CD8+ T lymphocyte and CD4+/CD8+ ratios in gingival tissue and peripheral blood of periodontally healthy BALB/c mice with flow cytometric analysis. The study was carried out on periodontally healthy 60 BALB/c mice. They were separated into five groups according to the life expectancy: Group I (newborn, 1-10 days old), Group II (age at weaning, 21-28 days old), Group III (age of sexual maturity, puberty, 7-8 weeks old), Group IV (adult, 8 months old), and Group V (the aged, 14 and over). Males and females were equally represented in each group. CD4+ and CD8+ T lymphocytes and CD4+/CD8+ ratio values in gingival tissue and peripheral blood were determined using flow cytometry in the biopsy samples. The relative number of CD8+ T lymphocyte in gingival tissue was higher in puberty (p < 0.05) and the aged (p < 0.05), with more significantly difference in males (p < 0.05). The CD4+/CD8+ ratios in gingival tissue were lower in puberty group and the-aged groups compared to the other groups (p < 0.05). The peripheral blood CD4+/CD8+ ratio increased in puberty and the aged groups. These differences were more significant in females than in males (p < 0.05). There were considerable negative correlations between CD4+/CD8+ T lymphocyte ratio in gingival tissue and CD4+/CD8+ T lymphocyte ratio in peripheral blood in puberty (r = 0.647, p < 0.01) and the aged ( r = 0.599, p < 0.05). In conclusion, our data suggest that CD4+/CD8+ T lymphocyte ratios in peripheral blood increase periodontally healthy mice in puberty and the old groups, while CD4+/CD8+ T lymphocyte ratios in gingival tissue decrease in the same groups. The relative number of CD8+ T lymphocytes increases in gingival tissue in puberty and the old groups when it decreases in peripheral blood. Results from this study indicated that periodontally healthy BALB/c mice may represent important information to determine the character of an immune response in the course of a lifetime.

Destructive periodontitis lesions are determined by the nature of the lymphocytic response

It is now 35 years since Brandtzaeg and Kraus (1965) published their seminal work entitled "Autoimmunity and periodontal disease". Initially, this work led to the concept that destructive periodontitis was a localized hypersensitivity reaction involving immune complex formation within the tissues. In 1970, Ivanyi and Lehner highlighted a possible role for cell-mediated immunity, which stimulated a flurry of activity centered on the role of lymphokines such as osteoclast-activating factor (OAF), macrophage-activating factor (MAF), macrophage migration inhibition factor (MIF), and myriad others. In the late 1970s and early 1980s, attention focused on the role of polymorphonuclear neutrophils, and it was thought that periodontal destruction occurred as a series of acute exacerbations. As well, at this stage doubt was being cast on the concept that there was a neutrophil chemotactic defect in periodontitis patients. Once it was realized that neutrophils were primarily protective and that severe periodontal destruction occurred in the absence of these cells, attention swung back to the role of lymphocytes and in particular the regulatory role of T-cells. By this time in the early 1990s, while the roles of interleukin (IL)-1, prostaglandin (PG) E(2), and metalloproteinases as the destructive mediators in periodontal disease were largely understood, the control and regulation of these cytokines remained controversial. With the widespread acceptance of the Th1/Th2 paradigm, the regulatory role of T-cells became the main focus of attention. Two apparently conflicting theories have emerged. One is based on direct observations of human lesions, while the other is based on animal model experiments and the inability to demonstrate IL-4 mRNA in gingival extracts. As part of the "Controversy" series, this review is intended to stimulate debate and hence may appear in some places provocative. In this context, this review will present the case that destructive periodontitis is due to the nature of the lymphocytic infiltrate and is not due to periodic acute exacerbations, nor is it due to the so-called virulence factors of putative periodontal pathogens.

Longitudinal Study of the Association Between Smoking as a Periodontitis Risk and Salivary Biomarkers Related to Periodontitis

BACKGROUND

Insufficient data exist regarding the long-term influence of lifestyle factors including smoking on periodontal health. The objective of this study was to examine the prospective association between smoking and periodontal disease progression and the effects of smoking on salivary biomarkers related to periodontitis.

METHODS

Probing depth (PD) was measured at health checkups of workers in 1999 and 2003; additionally, lifestyle information was obtained through a questionnaire. In 2003, 219 of 256 (86%) workers examined at baseline completed PD measurements; saliva samples were also collected. Change in PD was used for assessment of periodontitis progression when three or more sites displayed an increase of >or=2 mm over 4 years. Salivary biomarker levels were determined by real-time polymerase chain reaction and enzyme assay. Statistical methods included bivariate and multivariate regression analyses.

RESULTS

In the multiple logistic model, in which lifestyle-related factors served as independent variables, significant variables were current smoking and hours of sleep; respective odds ratios were 2.3 and 2.1. Additionally, 38.5% of periodontal disease progression was attributable to current smoking. Moreover, pack-years of smoking showed a dose-response relationship with disease progression. Levels of salivary markers including prostaglandin E(2), lactoferrin, albumin, aspartate aminotransferase, lactate dehydrogenase, and alkaline phosphatase were significantly lower in current smokers than in non-current smokers. However, no meaningful differences in the proportions of six periodontal pathogens were observed between current and non-current smokers.

CONCLUSIONS

Smoking exerted the greatest influence on periodontitis risk among lifestyle factors. Smoking may suppress the host-defense system, which may promote periodontal disease progression.

Tannerella forsythensis prtHGenotype and Association With Periodontal Status

BACKGROUND

The prtH gene of Tannerella forsythensis encodes for a cysteine protease possessing virulent properties. Subgingival colonization by T. forsythensis with this genotype has been suggested to be a discriminator between periodontal health and disease. This study examined the prevalence of T. forsythensis prtH genotype in subgingival plaque and its association with periodontal disease progression and current disease status.

METHODS

Subjects harboring T. forsythensis in their subgingival plaque were identified using real-time polymerase chain reaction (PCR). The presence or absence of the prtH genotype was assessed by conventional PCR. Probing depths and relative attachment levels were also assessed.

RESULTS

The prtH genotype was detected in 13 of 56 (23.2%) subjects harboring T. forsythensis in their subgingival plaque. Periodontal disease progression was defined as two or more sites with > or = 2 mm attachment loss in the previous 2-year period; current disease was defined as four or more sites with probing depths > or = 4 mm. The odds of periodontal disease (progression and/or current disease) were 1.55 times greater in subjects harboring prtH genotype T. forsythensis than in subjects in whom prtH was not detected. The prtH genotype was associated with higher numbers of T. forsythensis. In subjects with high levels of T. forsythensis, prtH genotype was associated with an increased extent of periodontal disease 2 years subsequently.

CONCLUSIONS

These results show that T. forsythensis prtH genotype is associated with high levels of T. forsythensis. However, further work is needed to determine whether it also is a useful marker of periodontal disease progression in T. forsythensis-infected subjects.

Tobacco smoking and periodontal health in a Saudi Arabian population

BACKGROUND

The objective of this study was to examine the association between tobacco smoking, in particular water pipe smoking, and periodontal health.

METHODS

A total of 262 citizens of Jeddah, Saudi Arabia in the age range from 17 to 60 years volunteered to participate in the study. The clinical examinations were carried out at King Faisal Specialty Hospital and Research Center in Jeddah and included assessments of oral hygiene, gingival inflammation, and probing depth. Smoking behavior was registered through a questionnaire and confirmed by an interview. Participants were stratified into water pipe smokers (31%), cigarette smokers (19%), mixed smokers (20%), and non-smokers (30%).

RESULTS

The mean probing depth per person was 3.1 mm for water pipe smokers, 3.0 mm for cigarette smokers, 2.8 mm for mixed smokers, and 2.3 mm for non-smokers. The association between smoking and probing depth was statistically significant controlling for age (P <0.001). The association between lifetime smoking exposure and mean probing depth was statistically significant in water pipe as well as cigarette smokers controlling for age (P <0.001). Using multivariate analysis, besides smoking, the gingival and plaque indexes were associated with increased probing depth. The prevalence of periodontal disease defined as a minimum of 10 sites with a probing depth > or =5 mm was 19.5% in the total population, 30% in water pipe smokers, 24% in cigarette smokers, and 8% in non-smokers. The prevalence was significantly greater in water pipe and cigarette smokers compared to non-smokers (P <0.001). The relative risk for periodontal disease increased by 5.1- and 3.8-fold in water pipe and cigarette smokers, respectively, compared to non-smokers (P <0.001 and P <0.05, respectively).

CONCLUSIONS

An association was observed between water pipe smoking and periodontal disease manifestations in terms of probing depth measurements. The impact of water pipe smoking was of largely the same magnitude as that of cigarette smoking.

Analytical epidemiology of periodontitis

AIMS

To review the literature related to the analytical epidemiology of periodontitis generated over the past decade. This review does not deal with descriptive epidemiologic studies of the prevalence, extent and severity of periodontitis with respect to global geography, but focuses exclusively on analytical epidemiology issues, including the challenges posed by the use of different case definitions across studies, current theories and models of disease progression, and risk factors associated with the onset and progression of periodontitis.

METHODS

Relevant publications in the English language were identified after Medline and PubMed database searches.

FINDINGS AND CONCLUSIONS

There is a conspicuous lack of uniformity in the definition of periodontitis used in epidemiologic studies, and findings from different research groups are not readily interpretable. There is a lack of studies that specifically address the distinction between factors responsible for the onset of periodontitis versus those affecting its progression. Colonization by specific bacteria at high levels, smoking, and poorly controlled diabetes have been established as risk factors for periodontitis, while a number of putative factors, including specific gene polymorphisms, have been identified in association studies. There is a clear need for longitudinal prospective studies that address hypotheses emerging from the cross-sectional data and include established risk factors as covariates along with new exposures of interest. Intervention studies, fulfilling the "targeting" step of the risk assessment process, are particularly warranted. Obvious candidates in this context are studies of the efficacy of elimination of specific bacterial species and of smoking cessation interventions as an alternative to the traditional broad anti-plaque approach in the prevention and control of periodontitis. Ideally, such studies should have a randomized-controlled trial design.

Augmented transforming growth factor-beta1 in gingival crevicular fluid of smokers with chronic periodontitis

BACKGROUND

Patients who smoke are at increased risk for chronic periodontitis (CP). Also, CP patients who smoke exhibit significantly less reduction of probing depths and gains in clinical attachment compared to non-smokers following periodontal therapy. Several studies suggest that the effects of smoking on the host response may be paramount in regulating the basal systemic inflammatory status and therapeutic outcomes in this cohort. Growth factors, specifically transforming growth factor beta1 (TGF-beta1), are critical in regulating the wound healing response by controlling cell division, differentiation, and motility. The hypothesis to be tested was that gingival crevicular fluid (GCF) TGF-beta1 production was altered in smokers compared to non-smokers with CP.

METHODS

GCF was collected from smokers and non-smokers with CP, both at baseline and 1 to 2 weeks after initial therapy. GCF volume was determined using an electronic device and TGF-beta1 concentration was measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Smokers exhibited a higher mean concentration of GCF TGF-beta1 at baseline compared to non-smokers (P = 0.03). After initial therapy, smokers exhibited significantly less reduction in mean GCF volume compared to non-smokers (P = 0.04).

CONCLUSIONS

Augmented constitutive production of GCF TGF-beta1 in smokers may explain the clinical appearance of fibrotic gingival tissue exhibited by this patient cohort. A diminished reduction in GCF volume in smokers following root instrumentation suggests a chronic inflammatory status in conjunction with an ineffective host response. These findings support the concept that smokers with CP display an altered local inflammatory response after initial therapy, perhaps symptomatic of colonization by residual periodontal pathogens.

Influence of age, sex, plaque and smoking on periodontal conditions in a population from Bauru, Brazil

Epidemiology is the study of health and disease in populations, and of how these conditions are influenced by heredity, biology, physical environment, social environment, and personal behavior. There are many epidemiological studies in Brazilian population but few about the influence of some risk factors in periodontal conditions. This cross-sectional study was performed to assess the influence of age, sex, plaque and smoking on periodontal disease in a population from Bauru (Brazil). Data concerning periodontal status were collected from 380 patients in the University of São Paulo (USP). Measurements of periodontal pocket depths (PPD), clinical attachment levels (CAL), plaque index (PI) of four sites in all teeth were registered. The influence of age, sex and smoking habits on the periodontal parameters were statistically evaluated using descriptive statistical and ANOVA. The correlation between plaque and periodontal parameters was analyzed by Pearson's correlation coefficient. The results showed an increase in the mean of periodontal destruction (PPD and CAL) and a higher number of sites with severe losses with increasing age. Correlation among percentage of sites with plaque and periodontal parameters (PPD and CAL) were positive but weakly related. The male group showed significantly higher means of CAL than the female. Smokers had significantly higher PPD and CAL means than non-smokers. Aging, smoking habit, male sex, and percentage of sites with plaque were associated with a great increase of periodontal destruction, being important factors in the diagnosis of the periodontal disease in this Brazilian population.

Acquisition and loss of Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans and Prevotella intermedia over a 5-year period: effect of a triclosan/copolymer dentifrice

OBJECTIVES

The present study describes the natural history of Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans and Prevotella intermedia over a 5-year period and the effect of a triclosan/copolymer dentifrice on these organisms in a normal adult population.

MATERIAL AND METHODS

Subgingival plaque samples were collected from 504 adult volunteers. Probing pocket depths (PPD) and relative attachment levels were measured using an automated probe. Participants were matched for disease status (CPI), plaque index, age and gender, and allocated to receive either a triclosan/copolymer or placebo dentifrice. Re-examination and subgingival plaque sampling was repeated after 1, 2, 3, 4 and 5 years. P. gingivalis, A. actinomycetemcomitans and P. intermedia were detected and quantitated using an enzyme linked immunosorbent assay. Logistic regression and generalised linear modelling were used to analyse the data.

RESULTS

This 5-year longitudinal study showed considerable volatility in acquisition and loss (below the level of detection) of all three organisms in this population. Relatively few subjects had these organisms on multiple occasions. While P. gingivalis was related to loss of attachment and to PPD >/=3.5 mm, there was no relationship between A. actinomycetemcomitans or P. intermedia and disease progression over the 5 years of the study. Smokers with P. gingivalis had more PPD >/=3.5 mm than smokers without this organism. There was no significant effect of the triclosan dentifrice on P. gingivalis or A. actinomycetemcomitans. Subjects using triclosan were more likely to have P. intermedia than those not using the dentifrice; however this did not translate into these subjects having higher levels of P. intermedia and its presence was uniform showing no signs of increasing over the course of the study.

CONCLUSION

The present 5-year longitudinal study has shown the transient nature of colonisation with P. gingivalis, A. actinomycetemcomitans and P. intermedia in a normal adult population. The use of a triclosan-containing dentifrice did not lead to an overgrowth of these organisms. The clinical effect of the dentifrice would appear to be independent of its antimicrobial properties.

The effect of a triclosan-containing dentifrice on the progression of periodontal disease in an adult population

OBJECTIVES

The aim of the present study was to determine the effect of unsupervised, long-term use of a 0.3% triclosan/2% copolymer dentifrice on the progression of periodontal disease in a general adult population.

METHODS

Five hundred and four volunteers were enrolled in a double-blind, controlled clinical trial. Participants were matched for disease status, plaque index, age and gender. At the baseline examination, probing pocket depths and relative attachment levels were recorded and participants were assigned to either the test or control group. Re-examinations took place after 6, 12, 24, 36, 48 and 60 months. Subgingival plaque samples were collected at each examination and assayed for Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans and Prevotella intermedia. A generalised linear model was used to analyse the data, with a number of covariates thought to influence the responses included as the possible confounding effects.

RESULTS

The triclosan/copolymer dentifrice had a significant effect in subjects with interproximal probing depths > or =3.5 mm, where it significantly reduced the number of sites with probing depths > or =3.5 mm at the following examination, when compared with the control group (p<0.001). Furthermore, this effect increased with increasing numbers of affected sites. There was no effect of the triclosan/copolymer dentifrice in individuals without probing depths > or =3.5 mm at the previous examination. Other factors significantly affecting probing pocket depths (PPD) included increasing age, smoking and presence of P. gingivalis. PPD > or =3.5 mm were positively associated with loss of attachment some 2 years later.

CONCLUSION

This study showed that in a normal adult population, unsupervised use of a triclosan/copolymer dentifrice is effective in slowing the progression of periodontal disease.

Dental diseases and loss of teeth in a group of Finnish alcoholics: a radiological study

A total of 85 Finnish alcohol-dependent subjects and 53 controls were studied with panoramic radiography. The aim was to study the possible associations between prolonged alcohol consumption and dental health. The mean number of teeth, caries lesions, endodontic treatments, periapical lesions, marginal bone loss, and periodontal infrabony pockets was studied. The subjects met the diagnostic criteria of alcohol dependence as set out in DSM-IV and ICD-10. The control group comprised social drinking volunteers with an AUDIT score < or =8. For the final results the subjects were divided into groups on the basis of sex and age. The social backgrounds of the subjects were similar, except for employment and smoking. The results show significantly fewer teeth and more caries in the alcoholic group. There was a tendency for the alcoholics <45 years of age to have more endodontically treated teeth than the controls, but no difference in the number of periapical lesions in endodontically treated teeth was found. Horizontal bone loss and the presence of calculus were more frequent in alcoholic men than in alcoholic women. Significantly more horizontal bone loss was observed in the group of alcoholic nonsmokers than in nonalcoholic nonsmokers. In the nonsmoking groups alcoholics had significantly more periodontal destruction than the nonsmoking controls. We conclude that radiological dental health among individuals dependent on alcohol is weakened by more caries, more horizontal bone loss, and more numerous vertical infrabony pockets than social drinkers.

A longitudinal study of interleukin-1 gene polymorphisms and periodontal disease in a general adult population

BACKGROUND

Cross-sectional studies have demonstrated that a specific polymorphism (allele 2 of both IL-1A +4845 and IL-1B +3954) in the IL-1 gene cluster has been associated with an increased susceptibility to severe periodontal disease and to an increased bleeding tendency during periodontal maintenance. The aim of the present study was to investigate the relationship between IL-1 genotype and periodontitis in a prospective longitudinal study in an adult population of essentially European heritage.

METHODS

From an ongoing study of the Oral Care Research Programme of The University of Queensland, 295 subjects consented to genotyping for IL-1 allele 2 polymorphisms. Probing depths and relative attachment levels were recorded at baseline, 6, 12, 24, 36, 48 and 60 months using the Florida probe. Periodontitis progression at a given site was defined as attachment loss > or =2 mm at any observation period during the 5 years of the study and the extent of disease progression determined by the number of sites showing attachment loss. Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans and Prevotella intermedia were detected using ELISA.

RESULTS

38.9% of the subjects were positive for the composite IL-1 genotype. A relationship between the IL-1 positive genotype and increased mean probing pocket depth in non-smokers greater than 50 years of age was found. Further, IL-1 genotype positive smokers and genotype positive subjects with P. gingivalis in their plaque had an increase in the number of probing depths > or =3.5 mm. There was a consistent trend for IL-1 genotype positive subjects to experience attachment loss when compared with IL-1 genotype negative subjects.

CONCLUSION

The results of this study have shown an interaction of the IL-1 positive genotype with age, smoking and P. gingivalis which suggests that IL-1 genotype is a contributory but non-essential risk factor for periodontal disease progression in this population.