Screening for periodontal disease

Abstract The prime objective of screening is to detect disease at an earlier stage than would normally occur with people presenting with the disease, on the assumption that earlier treatment would alter the natural history of the disease in a significant proportion. However, before a screening survey is done a number of conditions should be fulfilled. The disease should be an important health problem; there should be effective and acceptable treatments available for those with the disease; the natural history of the disease should be adequately understood and there should be an agreed policy on whom to treat. Periodontal disease does not fulfil many of the requirements for a disease suitable for population screening. There is no reliable evidence that earlier detection alters the natural history of the disease or the survival and function of the teeth. Neither is there sufficient information on the importance of clinical signs of periodontal disease. We do not know whether screening tests are able to detect periodontal diesease which is likely to have an important impact on periodontal health. For example, is bleeding an important sign of destructive periodontal disease? Does gingivitis evidenced as redness progress to alveolar bone destruction? The lack of answers to these questions casts serious doubts on the accuracy of estimates of periodontal treatment needs which include all persons with a positive gingivitis score as needing treatment. A number of other gaps in our knowledge relating to periodontal disease are outlined. Because of these, it was concluded that screening for periodontal disease is not justified at present. Instead, research should be directed at answering questions about the natural history of periodontal diseases, the effectiveness of prevention and treatment, the significance of clinical signs of periodontal disease and the validity, sensitivity and specificity of the signs.     

How beneficial is bacterial prophylaxis to periodontal health?

The term “probiotics” has become common among general practitioners. There has been an explosion in the interest regarding this topic, which is reflected in the number of scientific publications. The World Health Organization defined probiotics as: “Living microorganisms which when administered in adequate amount confirms a health benefit on the host”. Probiotics have been studied extensively in the gastrointestinal tract for their health‐promoting effects and have shown promising results. However, in recent times, probiotics have also been used in periodontal health and have shown promising results in controlling gastrointestinal tract infections. Probiotics have potential, but as with many other clinical situations, multicenter or randomized, controlled studies on humans are still required before they can be recommended as prophylaxis for caries or periodontal disease. In the present study, we review the effects of probiotics on maintaining periodontal health. Relevant studies were identified from 1970 to February 2010 using Old Medline, Cochrane Library, and Google Scholar.     

Validity and limitations of self-reported periodontal health

OBJECTIVES: To study the agreement between self-reported dental conditions and clinical findings in an adult population (20-84 years of age), and thus evaluate questionnaires as a tool in epidemiological studies of oral health, in general, and periodontal health, in particular. MATERIAL AND METHODS: A questionnaire was sent to 900 randomly selected subjects in the age groups 20-29, 50-59 and 75-84 years. Of these, 723 subjects (81.0%) answered the questionnaire and 20% of them underwent a clinical examination. RESULTS: As regards the remaining teeth, there was a mean difference of 1.4 teeth between the number indicated in the questionnaire and that found on the clinical examination. This difference was most marked in the older subjects. Eight of the nine subjects with removable dentures reported in their answers that they had removable dentures. Periodontal variables--we found significantly more subjects with pathological gingival pockets among those who stated that they had pockets than among those who answered that they did not (P = 0.01; chi-square independent test). Gingival bleeding was common in those who answered 'Yes' than in those who answered 'No' to the question concerning bleeding gums. This difference was significant (P = 0.05; chi-square independent test) in the three age groups. However, there was no correlation between the questionnaires and the clinical examination concerning tooth mobility. CONCLUSION: Questionnaires concerning oral status are valid concerning the number of remaining teeth and use of removable dentures. They are less reliable about specific periodontal variables, but can still become a valuable tool for epidemiological studies of periodontal health.     

Translating periodontal data to knowledge in a learning health system

BackgroundA learning health system (LHS) is a health system in which patients and clinicians work together to choose care on the basis of best evidence and to drive discovery as a natural outgrowth of every clinical encounter to ensure the right care at the right time. An LHS for dentistry is now feasible, as an increased number of oral health care encounters are captured in electronic health records (EHRs).MethodsThe authors used EHRs data to track periodontal health outcomes at 3 large dental institutions. The 2 outcomes of interest were a new periodontitis case (for patients who had not received a diagnosis of periodontitis previously) and tooth loss due to progression of periodontal disease.ResultsThe authors assessed a total of 494,272 examinations (new periodontitis outcome: n = 168,442; new tooth loss outcome: n = 325,830), representing a total of 194,984 patients. Dynamic dashboards displaying performance on both measures over time allow users to compare demographic and risk factors for patients. The incidence of new periodontitis and tooth loss was 4.3% and 1.2%, respectively.ConclusionsPeriodontal disease, diagnosis, prevention, and treatment are particularly well suited for an LHS model. The results showed the feasibility of automated extraction and interpretation of critical data elements from the EHRs. The 2 outcome measures are being implemented as part of a dental LHS. The authors are using this knowledge to target the main drivers of poorer periodontal outcomes in a specific patient population, and they continue to use clinical health data for the purpose of learning and improvement.Practical ImplicationsDental institutions of any size can conduct contemporaneous self-evaluation and immediately implement targeted strategies to improve oral health outcomes.     

Wound healing following surgical and regenerative periodontal therapy

Clinical studies have evaluated the effect of conventional periodontal surgical therapy. In general, although some clinical gain in tissue support may be attained, these therapies do not support regeneration of the periodontal attachment. Even though the biological possibility of periodontal regeneration has been demonstrated, the clinical application of this intrinsic potential appears difficult to harness; thus also conceptually most intriguing candidate protocols face clinical challenges. In this review, we explore the bioclinical principles, condiciones sine quibus non, that unleash the innate potential of the periodontium to achieve clinically meaningful periodontal regeneration (i.e. space‐provision, wound stability and conditions for primary intention healing). Moreover, limiting factors and detrimental practices that may compromise clinical and biological outcomes are reviewed, as is tissue management in clinical settings.     

Effect of Intensive Oral Hygiene Regimen During Pregnancy on Periodontal Health,Cytokine Levels,and Pregnancy Outcomes: A Pilot Study

Background: Data are limited on the potential effect of intensive oral hygiene regimens and periodontal therapy during pregnancy on periodontal health, gingival crevicular fluid (GCF) and serum cytokines, and pregnancy outcomes. Methods: A clinical trial was conducted on 120 community‐dwelling, 16‐ to 35‐year‐old pregnant women at 16 to 24 weeks of gestation. Each participant presented with clinical evidence of generalized, moderate‐to‐severe gingivitis. Oral hygiene products were provided, together with instructions for an intensive daily regimen of hygiene practices. Non‐surgical therapy was provided at baseline. Oral examinations were completed at baseline and again at 4 and 8 weeks. In addition, samples of blood and GCF were collected at baseline and week 8. Mean changes in clinical variables and GCF and serum cytokine levels (interleukin [IL]‐1β, IL‐6, tumor necrosis factor [TNF]‐α) between baseline and week 8 were calculated using paired t test. Pregnancy outcomes were recorded at parturition. Results: Results indicated a statistically significant reduction in all clinical variables (P <0.0001) and decreased levels of TNF‐α (P = 0.0076) and IL‐1β (P = 0.0098) in GCF during the study period. The rate of preterm births (<37 weeks of gestation) was 6.7% (P = 0.113) and low birth weight (<2,500 g) was 10.2% (P = 1.00). Conclusions: Among the population studied, intensive instructions and non‐surgical periodontal therapy provided during 8 weeks at early pregnancy resulted in decreased gingival inflammation and a generalized improvement in periodontal health. Large‐scale, randomized, controlled studies are needed to substantiate these findings.     

Gingival crevicular fluid and saliva

Understanding the structure and function of the mouth, its tissues and secretions is of great interest to physiologists, cell biologists, immunologists and microbiologists but is also of fundamental interest to the dental professional interested in comprehending the aberrant processes associated with oral disease and in the application of effective clinical interventions. The field of periodontology, which has a truly multidisciplinary perspective cutting across leading edge molecular and cellular biology, clinical dentistry, epidemiology and behavioural science, exemplifies this. A paradigm shift in recent years has led to the consideration of the oral cavity (and, thus, oral disease) not in isolation but as a component integrated with systemic physiology, important in maintaining systemic health and reflective of systemic disease; this has served to promote periodontology, in particular, into the forefront of medicine in general. This volume of Periodontology 2000 considers the role of gingival crevicular fluid and saliva in physiological function, maintenance of oral tissue integrity, defense against pathogens and oral disease as well as the many, emerging applications of analysis of these fluids in support of periodontal disease diagnosis, prognosis and epidemiology. However, whilst the emphasis is on periodontal disease, the wider contexts of oral and systemic health are also key considerations.     

Innate immune signaling and Porphyromonas gingivalis-accelerated atherosclerosis

Periodontal diseases are a group of diseases that lead to erosion of the hard and soft tissues of the periodontium, which, in severe cases, can result in tooth loss. Anecdotal clinical observations have suggested that poor oral health may be associated with poor systemic health; however, only recently have appropriate epidemiological studies been initiated, with defined clinical endpoints of periodontal disease, to address the association of periodontal disease with increased risk for cardiovascular and cerebrovascular disease. Although conflicting reports exist, these epidemiological studies support this connection. Paralleling these epidemiological studies, emerging basic scientific studies also support that infection may represent a risk factor for atherosclerosis. With P. gingivalis as a model pathogen, in vitro studies support that this organism can activate host innate immune responses associated with atherosclerosis, and in vivo studies demonstrate that this organism can accelerate atheroma deposition in animal models. In this review, we focus primarily on the basic scientific studies performed to date which support that infection with bacteria, most notably P. gingivalis, accelerates atherosclerosis. Furthermore, we attempt to bring together these studies to provide an up-to-date framework of emerging theories into the mechanisms underlying periodontal disease and increased risk for atherosclerosis, as well as identify intervention strategies to reduce the incidence of periodontal disease in humans, in an attempt to decrease risk for systemic complications of periodontal disease such as atherosclerotic cardiovascular disease.     

Periodontal innate immune mechanisms relevant to atherosclerosis

Atherosclerosis is a common cardiovascular disease in the USA where it is a leading cause of illness and death. Atherosclerosis is the most common cause for heart attack and stroke. Most commonly, people develop atherosclerosis as a result of diabetes, genetic risk factors, high blood pressure, a high‐fat diet, obesity, high blood cholesterol levels, and smoking. However, a sizable number of patients suffering from atherosclerosis do not harbor the classical risk factors. Ongoing infections have been suggested to play a role in this process. Periodontal disease is perhaps the most common chronic infection in adults with a wide range of clinical variability and severity. Research in the past decade has shed substantial light on both the initiating infectious agents and host immunological responses in periodontal disease. Up to 46% of the general population harbors the microorganism(s) associated with periodontal disease, although many are able to limit the progression of periodontal disease or even clear the organism(s) if infected. In the last decade, several epidemiological studies have found an association between periodontal infection and atherosclerosis. This review focuses on exploring the molecular consequences of infection by pathogens that exacerbate atherosclerosis, with the focus on infections by the periodontal bacterium Porphyromonas gingivalis as a running example.     

Nutrigenomics: the role of nutrients in gene expression

Improved understanding of the mechanism behind periodontal tissue destruction, the potential protective role of nutrients and the advent of modern genomic measurement tools has led to an increased interest in the association between nutrition and periodontal disease. To date, evidence for a direct link between periodontal disease and nutrition has come mainly from large observational cross‐sectional studies or very small double‐blind randomized supplementation trials, with a large proportion finding no significant association between the nutrient being analyzed and markers of periodontal disease status. The advent of the ‘genomic era’ has introduced the concept of nutrigenomic studies, which aim to reveal the relationship between nutrition and the genome to provide a scientific basis for improved public health through dietary means. Used alongside relatively inexpensive high‐throughput technology, this will allow the effect of diet on the etiology of periodontal disease to be studied in greater detail. As it is extremely likely that interactions between genotype and diet are important in determining the risk of the most common complex diseases, it is highly probable that these interactions will be important in determining periodontal disease risk. Numerous nutritional genetic studies where the outcome measures have been markers of disease risk, most notably cardiovascular disease and cancer, provide proof of principle, highlight the importance of understanding these interactions and illustrate where the effect of dietary modification on periodontal disease progression may have been overlooked previously by observational studies.     

Immunomodulatory effects of stem cells

Adult‐derived mesenchymal stem cells have received considerable attention over the past two decades for their potential use in tissue engineering, principally because of their potential to differentiate into multiple stromal‐cell lineages. Recently, the immunomodulatory properties of mesenchymal stem cells have attracted interest as a unique property of these cells that may be harnessed for novel therapeutic approaches in immune‐mediated diseases. Mesenchymal stem cells have been shown to inhibit the proliferation of activated T‐cells both in vitro and in vivo but to stimulate T‐regulatory cell proliferation. Mesenchymal stem cells are also known to be weakly immunogenic and to exert immunosuppressive effects on B‐cells, natural killer cells, dendritic cells and neutrophils through various mechanisms. Furthermore, intravenous administration of allogeneic mesenchymal stem cells has shown a marked suppression of host immune reactions in preclinical animal models of large‐organ transplant rejection and in various autoimmune‐ and inflammatory‐based diseases. Some clinical trials utilizing human mesenchymal stem cells have also produced promising outcomes in patients with graft‐vs.‐host disease and autoimmune diseases. Mesenchymal stem cells identified from various dental tissues, including periodontal ligament stem cells, also possess multipotent and immunomodulatory properties. Hence, dental mesenchymal stem cells may represent an alternate cell source, not only for tissue regeneration but also as therapies for autoimmune‐ and inflammatory‐mediated diseases. These findings have elicited interest in dental tissue mesenchymal stem cells as alternative cell sources for modulating alloreactivity during tissue regeneration following transplantation into human leukocyte antigen‐mismatched donors. To examine this potential in periodontal regeneration, future work will need to assess the capacity of allogeneic periodontal ligament stem cells to regenerate periodontal ligament in animal models of periodontal disease. The present review describes the immunosuppressive effects of mesenchymal stem cells on various types of immune cells, the potential mechanisms through which they exert their mode of action and the preclinical animal studies and human clinical trials that have utilized mesenchymal stem cells, including those populations originating from dental structures.     

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

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

Heart and periodontal diseases: does evidence exist of association?

Cardiovascular diseases represent one of the main causes of death in developed societies. These diseases are not only important because of the mortality they generate, but also due to the high number of affected persons under treatment that the health systems of different countries have to support. Hence, the early detection of risk factors triggering these diseases has been seen as the most effective mechanism to prevent them. Over the last few years periodontal pathology has been more or less related to the suffering of cardiovascular diseases. This fact could be of great clinical and epidemiological relevance owing to the actual considerable prevalence of periodontal diseases. In the present review, the clinical and physiopathological factors which scientifically support this association are analyzed,reaching the conclusion that further studies are needed to have the proof that said association represents a determinate risk factor for the suffering of cardiovascular diseases.     

Periodontal conditions among the old elderly: five-year longitudinal study

In the past three decades, there has been a significant rise in the number of old elderly (85+ years old) in Finland, and more of these individuals are retaining their natural teeth. Numerous cross-sectional studies have reported on the periodontal health of the elderly (aged 75+), but very few long-term follow-ups have been reported. This study forms a part of the population-based Helsinki Aging Study (HAS) and compares the periodontal health status and the treatment needs at baseline with those of the same population five years later. The baseline study, in 1990–91, examined the dentate elderly born in 1904, 1909, and 1914, living in Helsinki, Finland (n = 196). The follow-up study was completed in 1995–96 (n = 73). Periodontal status was recorded by means of the Community Periodontal Index of Treatment Needs (CPITN) in 175 dentate subjects (55 males and 120 females) who met the criteria at baseline, and in 57 dentate elderly (17 males and 40 females), aged 81, 86, and 91 years, who remained at follow-up. Among the 57 dentate elderly who participated in both baseline and follow-up examinations, the mean number of teeth decreased from 15.9 to 15.1, and the mean number of remaining sextants from 4.2 to 3.7. There were minor changes in the periodontal health status during this five-year period, with an increase in code 2 (from 43% to 58%) and a decrease in code 3 (from 38% to 25%). Nevertheless, the overall treatment needs remained unchanged. It can be concluded that the periodontal health of the elderly had remained stable for 5 years, and almost no change was observed in their treatment needs. Therefore, periodontal disease in the elderly who are relatively healthy is not caused by the aging process.     

Periodontal disease and general health

There is considerable interest in the possible relationship between periodontal disease and pregnancy complications, cardiovascular disease, diabetes and respiratory diseases. This interest has been stimulated by data obtained from epidemiological studies and a better understanding of the pathogenesis of periodontal disease. Whilst much of the data support an association between oral and general health, further studies are needed to accept or reject a causal relationship.     

Periodontal disease and the ageing patient

The UK's population is getting older and the number of older individuals retaining their teeth is increasing. Greater demands are therefore being placed on general dental practitioners for periodontal therapy. Many factors, including the ageing process itself, impact directly or indirectly on periodontal health. This article discusses these factors, their interrelationship and their relevance to clinical management of periodontal disease in older patients. CLINICAL RELEVANCE: This article aims to give the practitioner an insight into the issues involved in managing older patients with periodontal diseases.     

An overview of periodontal regenerative procedures for the general dental practitioner

The complete regeneration of the periodontal tissues following periodontal disease remains an unmet challenge, and has presented clinicians with a remarkably difficult clinical challenge to solve given the extensive research in this area and our current understanding of the biology of the periodontal tissues. In particular as clinicians we look for treatments that will improve the predictability of the procedure, improve the magnitude of the effect of treatment, and perhaps most importantly in the long term would extend the indications for treatment beyond the need for single enclosed bony defects to allow for suprabony regeneration, preferably with beneficial effects on the gingival soft tissues. A rapid development in both innovative methods and products for the correction of periodontal deficiencies have been reported during the last three decades. For example, guided tissue regeneration with or without the use of bone supplements has been a well-proven treatment modality for the reconstruction of bony defects prior to the tissue engineering era. Active biomaterials have been subsequently introduced to the periodontal community with supporting dental literature suggesting that certain factors should be taken into consideration when undertaking periodontal regenerative procedures. These factors as well as a number of other translational research issues will need to be addressed, and ultimately it is vital that we do not extrapolate results from pre-clinical and animal studies without conducting extensive randomized clinical trials to substantiate outcomes from these procedures. Whatever the outcomes, the pursuit of regeneration of the periodontal tissues remains a goal worth pursuing for our patients. The aim of the review, therefore is to update clinicians on the recent advances in both materials and techniques in periodontal regenerative procedures and to highlight the importance of both patient factors and the technical aspects of regenerative procedures.     

Is There a Positive Effect of Smoking Cessation on Periodontal Health? A Systematic Review

Background: Although the detrimental effects of tobacco on the periodontal tissues have been reported extensively, little is known about the potential beneficial effect of smoking cessation on periodontal health. The aim of this systematic review is to evaluate the effect of smoking cessation on periodontitis progression and response to periodontal therapy. Methods: Two independent reviewers completed the review process through title (n = 118), abstract (n = 24), and whole‐paper selection (n = 5). Sources include Medline and EMBASE databases (up to December 2012) and a reference list of selected studies. Prospective studies comparing progression rates of periodontitis between smokers and quitters and clinical trials evaluating the effect of smoking‐cessation programs, alone or in combination with periodontal treatment, were included. At least 1 year of follow‐up was required for inclusion. Results: Of 331 potentially relevant publications, five studies fulfilled the inclusion criteria. Because of heterogeneity of the studies, a meta‐analysis could not be performed. One study reported that the progression of clinical attachment loss (AL) ≥3 mm during a 6‐year period was approximately three times higher among smokers than quitters (P <0.001). Two studies (10 and 20 years of follow‐up) observed a decrease in radiographic bone loss of ≈30% among quitters when compared with smokers. Among individuals receiving non‐surgical periodontal treatment, quitters were more likely to have periodontal probing depth reductions (P <0.05) than non‐quitters/oscillators. No differences in AL were observed. Conclusion: Based on the limited available evidence, smoking cessation seems to have a positive influence on periodontitis occurrence and periodontal healing.