Decreased bone mineral density and periodontal management

The definition of osteoporosis has evolved beyond low bone mineral density to include impaired bone morphology and matrix properties. As such, the subsequent bone density insufficiencies extend beyond the skeletal risks of fracture and have implications for oral health management patients. As our population ages there is a worldwide increase in the risk of decreased bone mineral density and its subsequent morbidity. This makes age an independent risk factor for fracture and decreased bone mineral density. Multiple examinations and diagnostic tests are currently used in combination to develop an algorithm to assess osteoporotic risk. Oral health care professionals should follow these principles and caution should be used in applying a single independent assessment to determine a patient's osteoporotic or bone metabolism risk. Therapeutic approaches for osteoporosis are often divided into nonpharmacological interventions and pharmacological therapies. The periodontist and other oral health care professionals should have a full understanding of the therapeutic options, benefits and implementation of preventive therapies. Bone turnover is a coupled event of bone formation and bone resorption and it is the imbalance of this homeostasis that results in osteoporosis. Based on this uncoupling of bone resorption and formation, osteoporosis or decreased bone mineral density and osteopenia, may be a risk factor for alveolar bone loss in periodontitis. The role of prevention and maintenance with a history of periodontitis and oesteopenia extends beyond biofilm control and should include management of bone mineral density. The chronic periodontal infection in a patient with osteopenia may place the patient at greatly increased risk for alveolar bone loss, gingival recession and root caries. A key component in the management is the oral health professional's knowledge of the interrelationship between skeletal health and periodontal health.     

Epidemiology and risk factors of periodontal diseases

Periodontal diseases are chronic inflammatory disorders encompassing destructive and nondestructive diseases of the periodontal supporting tissues of teeth. Gingivitis is a nondestructive disease ubiquitous in populations of children and adults globally. Aggressive periodontitis is characterized by severe and rapid loss of periodontal attachment often commencing at or after the circumpubertal age and is more prevalent among Latin Americans and subjects of African descent, and least common among Caucasians.Chronic periodontitis is a common disease and may occur in most age groups, but is most prevalent among adults and seniors world-wide. Approximately 48% of United States adults have chronic periodontitis, and similar or higher rates have been reported in other populations. Moderate and advanced periodontitis is more prevalent among the older age groups, and rates of 70% or more have been reported in certain populations. Chronic and aggressive periodontitis are multifactorial diseases caused primarily by dental plaque microorganisms, and with important modifying effects from other local and systemic factors. The study of the significance of demographic, environmental, and biologic variables is important for risk assessment and the control of periodontal diseases.     

Global oral health inequalities: task group--periodontal disease

Periodontal diseases constitute one of the major global oral health burdens, and periodontitis remains a major cause of tooth loss in adults worldwide. The World Health Organization recently reported that severe periodontitis exists in 5-20% of adult populations, and most children and adolescents exhibit signs of gingivitis. Likely reasons to account for these prevalent diseases include genetic, epigenetic, and environmental risk factors, as well as individual and socio-economic determinants. Currently, there are fundamental gaps in knowledge of such fundamental issues as the mechanisms of initiation and progression of periodontal diseases, which are undefined; inability to identify high-risk forms of gingivitis that progress to periodontitis; lack of evidence on how to prevent the diseases effectively; inability to detect disease activity and predict treatment efficacy; and limited information on the effects of integration of periodontal health as a part of the health care program designed to promote general health and prevent chronic diseases. In the present report, 12 basic, translational, and applied research areas have been proposed to address the issue of global periodontal health inequality. We believe that the oral health burden caused by periodontal diseases could be relieved significantly in the near future through an effective global collaboration.     

口腔黏膜病患者牙周健康状况调查分析

目的通过流行病学调查方法了解口腔黏膜病患者牙周健康状况,为口腔黏膜病患者牙周病的预防与治疗提供依据。方法对中国医科大学附属盛京医院口腔科门诊的黏膜病患者766人进行牙周专科检查,填写调查问卷,检查结果采用SPSS 13.0软件进行统计学分析。结果口腔黏膜病患者牙周健康者只有10.70%。不同性别、年龄、学历、口腔护理情况显著影响口腔卫生及口腔健康情况;口腔黏膜病中,患者就诊率最高的是口腔溃疡(34.20%),其次为扁平苔癣(32.64%);口腔溃疡及扁平苔藓的牙周炎患病率均较高,分别是95.42%和92.80%。结论口腔黏膜病的发病与发展与牙周健康水平有着密切的相关性,应从多角度分析口腔黏膜病患者牙周健康不良原因,及牙周健康不良是否会影响口腔黏膜病变,并采取积极预防及治疗措施。     

Microbiology and management of periodontal infections

The term periodontal disease refers to all diseases that involve the supportive structures of the periodontium. Peridontal diseases commonly begin as a gingivitis and progress to periodontitis. Necrotizing ulcerative gingivitis (NUG) is the most fulminate form of gingivitis. The two main forms of periodontitis are chronic periodontitis (also known as adult periodontitis) and aggressive periodontitis (also known as early onset periodontitis, destructive periodontitis, and juvenile periodontitis). Gingivitis treatment involves removing dental plaques and maintaining good oral hygiene. Periodontitis therapy should include root debriding, draining the infected root, and surgically resecting inflamed periodontal tissues. Systemic antimicrobials often are indicated in NUG, chronic periodontitis, and aggressive periodontitis. When possible, antimicrobial selection should be based upon culture and susceptibility testing of the subgingival flora.     

Changing periodontal concepts: treatment considerations

Many clinical trials conducted during the last decade have clarified controversial issues and resulted in changed periodontal paradigms. These modified concepts have therapeutic implications. Some salient altered periodontal concepts include the following: The mere presence of pathogens will not initiate periodontal diseases. Most subgingival bacteria reside in biofilms. Periodontal diseases are infections. Periodontal pathogens can be transferred between family members. The host response can be protective and destructive. Gingivitis does not usually proceed to periodontitis. Risk factors in conjunction with bacteria and the host response can affect the severity of disease, patterns of destruction, and the response to therapy. Many medical conditions (eg, diabetes, smoking, and HIV infection) may predispose patients to periodontitis. Associations between periodontitis and a number of systemic ailments (eg, diabetes, adverse pregnancy outcomes, and cardiovascular disease) have been detected and are being investigated to determine if there is a cause-and-effect relationship. Diagnostic and therapeutic implications of these altered paradigms are addressed throughout the article.     

Periodontal disease in children and adolescents of Latin America

Periodontal diseases are a group of infectious diseases that mainly include gingivitis and periodontitis. Gingivitis is the most prevalent form of periodontal disease in subjects of all ages, including children and adolescents. Less frequent types of periodontal disease include aggressive periodontitis, acute necrotizing ulcerative gingivitis and various diseases of herpesviral and fungal origin. This review aimed to retrieve relevant information from Latin America on the prevalence of periodontal diseases among children and adolescents of the region. Gingivitis was detected in 35% of young Latin American subjects and showed the highest frequencies in Colombia (77%) and Bolivia (73%) and the lowest frequency in Mexico (23%). The frequency of gingivitis in subjects from other Latin American countries was between 31% and 56%. Periodontitis may affect <10% of the young population in Latin America, but the data are based on only a few studies. A more precise assessment of the distribution and severity of periodontal disease in children and adolescents of Latin America may help policy makers and dentists to institute more effective public health measures to prevent and treat the disease at an early age to avoid major damage to the permanent dentition.     

Pemphigus vulgaris: effects on periodontal health

Increasing evidence indicates that systemic conditions are risk factors of periodontitis. Pemphigus is a group of bullous diseases affecting the oral cavity. The aim of this study was to assess the periodontal status of pemphigus vulgaris (PV) patients. The periodontal status of 50 PV patients and 50 healthy subjects was assessed by a single examiner. PV patients were assessed based on the Clinical Severity Score (CSS). Periodontal clinical parameters such as plaque score, full mouth gingival bleeding score, probing depth (PD), clinical attachment level (CAL) and radiological bone loss were recorded. Effects of age, gender, daily tooth brushing habit, oral lesions and treatment duration on the periodontal status of PV patients were also determined. A statistically significant difference was found between the PV group and the healthy group with respect to the plaque score, PD and CAL (P < 0.05). Logistic regression analysis confirmed that age, gender, and treatment did not significantly influence clinical severity of the disease (P > 0.05). Increased PD and CAL were found with an increase in the CSS. The poor periodontal status in PV patients suggests that PV may be involved in the initiation or progression of periodontitis.     

Oral diagnosis and treatment planning: part 3. Periodontal disease and assessment of risk

Periodontal diseases are diagnosed on the basis of clinical signs, with radiographs assisting in treatment planning decisions and in the delivery of periodontal care. In the first instance, use of a screening system, to screen out patients with minimal or no disease, and to screen in those with disease requiring full diagnosis and treatment planning for periodontitis, is a very helpful approach. The full diagnostic approach relies on periodontal probing and the response to probing. Periodontal probing depth measurements and periodontal attachment level registrations are recordings of clinical findings, which depend upon the state of health of the periodontal tissues to a large extent.     

Report on experiences with a one-year action at the Gondar College of Medical Sciences in Ethiopia. 3. Influence of diabetes mellitus on the teeth supporting apparatus

Systemic diseases--like diabetes mellitus--are able to injure the local and common resistance of an organism. Therefore we must expect a more intensive and severer progress of gingivitis and periodontitis in diabetic patients in comparison with a non-diabetic control-group. On the Gondar College of Medical Sciences in Northwest-Ethiopia are investigated 77 Insulin-obliged diabetics and 312 persons for control by means of the plaque-Index, the Oral-Hygiene-Index simplified. The DMF/T-Index and the Gingivitis-respectively Periodontal-Disease-Index for evaluation of the oral health situation. The comparison shows that the diabetic group has a moderate higher Plaque-pictures of gingivitis or periodontitis. This confirms our opinion that the diabetes mellitus is a risk-factor for the development of periodontal diseases. Therefore patients with diabetes mellitus should perform a very intensive care for mouth-hygiene.     

Impact of Smoking Cessation on Periodontal Tissues

There is cumulative evidence supporting the negative effects of smoking on periodontal tissues. Smoking cessation can be successfully accomplished through specific programs, including behaviour modification and medications, and has been suggested as a suitable way to reduce the risk of several diseases, including periodontitis. The aim of this review is to provide a concise overview of the current knowledge about the impact of smoking cessation on periodontal tissues and therapy, with data from studies published in the last 15 years. Literature was searched using Medline database from 2005 up to and including September 2020 using medical subject heading (MeSH) terms and other search terms, restricted to the English language. Studies were evaluated and summarised in a narrative review format. Results demonstrated that there is convincing evidence to support the benefits of tobacco cessation in reducing the risk of periodontitis and tooth loss. In addition, the harmful effects of smoking on periodontal tissues seem to be assuaged as the number of years since quitting increases. The existing current evidence, even limited, also shows that smoking cessation may result in additional benefits to the outcome of nonsurgical periodontal treatment. Periodontal care providers should not only check their patient's smoking habit for estimating risk of disease progression and predictability of periodontal therapy, but they should also help smokers improve their oral and systemic health by providing efficient and personalised tobacco‐cessation counselling and treatment.     

916例2型糖尿病患者牙周健康调查及影响因素分析

目的： 调查上海市第六人民医院内分泌科就诊的2型糖尿病患者的牙周健康状况,探讨相关影响因素,为针对性地开展区域内2型糖尿病患者的牙周病防治工作提供流行病学依据。方法： 对2018年11月—2018年12月间至上海市第六人民医院内分泌科就诊的2型糖尿病患者进行牙周检查以及问卷调查。牙周检查参考WHO推荐的《口腔健康调查基本方法》中的检查标准,对指数牙的相关牙周指标进行检查和计分,包括探诊深度、探诊出血、临床附着丧失、牙石指数、菌斑指数等。通过问卷调查获取社会人口学信息、糖尿病史、牙周健康相关行为等信息。采用SPSS 22.0软件包进行数据统计和分析。结果： 参与完成调查的916名2型糖尿病受试者中,共有670例牙周炎患者,牙周炎总体患病率为73.14%,牙周炎患者人均缺牙数4.85（颗）。糖尿病患者较高的年龄、较长的病程及糖尿病并发症是牙周炎的危险因素。随着患者年龄增加、病程延长以及糖尿病相关并发症的出现,糖尿病患者牙周炎的患病率显著上升（P<0.05）。结论： 2型糖尿病患者的牙周健康情况不容乐观,牙周炎的早期预防和治疗极为关键,需要关注高龄、长期病程的糖尿病患者的牙周健康状况,并对该人群开展针对的口腔预防保健。     

Periodontal treatment and prophylaxis in the frail elderly

Throughout the world the numbers of elderly are rapidly increasing. Survival to age 80 years and beyond is now commonplace in many industrialized nations. Of particular concern to the health professions is the previously unimagined growth in the population aged 80 years and over who are at increased risk of morbidity and disability. The rates of edentulism and tooth loss are rapidly declining with a consequent increase in the risk of developing periodontitis. Periodontal treatment and prophylaxis for the frail and the functionally dependent elderly involve a complete analysis of the physical and emotional status of the patient. The effects of chronic conditions, illnesses and medications on the ability of the older patient to accept treatment must be understood if periodontal care is to have a reasonable chance of success. In medically compromised patients and in patients who are unable to maintain oral hygiene, non-surgical periodontal therapy may be the best approach to treatment, although there are alternative routes to treatment as well as prevention. Periodontal diseases can be treated successfully in the aged and periodontal health can be sustained.     

The effect of periodontal disease on medical and dental costs in a middle-aged Japanese population: a longitudinal worksite study

BACKGROUND: Although periodontal disease is one of the most common chronic diseases, it is not clear whether periodontal disease is associated with increased health care costs. The authors examined the effect of periodontal disease on medical and dental costs and use for 3.5 years prospectively. METHODS: The data were derived from health and dental examinations and health insurance claims of 4,285 Japanese civil officers aged 40 to 59 years. The subjects were divided into three categories: no pathological pocket, moderate periodontitis, and severe periodontitis. Age, gender, smoking, body mass index, and hypertension were adjusted in a multivariate analysis after excluding subjects with any history of liver disease, heart disease, or diabetes mellitus. RESULTS: The cumulative cost for subjects with severe periodontitis was approximately 21% higher than for subjects with no pathological pocket, and the hospital admission rates of subjects with severe periodontitis were highest (male: odds ratio [OR]=.34; 95% confidence interval [CI]: 1.00 to 1.80; female: OR=1.29; 95% CI: 0.75 to 2.20). In males, the annual hospital costs of subjects with severe periodontitis were 75% higher than for subjects with no pathological pocket. There was no clear trend identified for outpatient care. The annual dental visit rates and costs for subjects with severe periodontitis were highest in both genders. Periodontal disease might increase the medical care costs for diabetes mellitus, digestive disease, and liver disease. CONCLUSION: Periodontal disease may have played an important role in the cumulative health care cost increases in middle-aged adults over a period of only a few years.     

Oral inflammatory load: Neutrophils as oral health biomarkers

Periodontal diseases present a significant challenge to our healthcare system in terms of morbidity from the disease itself as well as their putative and deleterious effects on systemic health. The current method of diagnosing periodontal disease utilizes clinical criteria solely. These are imprecise and are somewhat invasive. There is thus significant benefit to creating a non-invasive test as a method of screening for and monitoring of periodontal diseases, and, in particular, chronic periodontitis. Oral polymorphonuclear neutrophil (oPMN) counts have been found to correlate with extent of oral inflammation and the presence and severity of periodontal diseases. Potentially then, quantification of oPMNs might be used to identify and measure the severity of oral inflammation (oral inflammatory load; OIL) in subjects with healthy and inflamed periodontal tissues, demonstrating a positive correlation between higher oPMN counts and the extent/severity of OIL. These findings support the development and utilization of a non-invasive chair-side test enabling rapid, accurate, and objective screening of OIL based on measurement of oPMN numbers (similar to white blood cell levels in blood as used in medicine for assessment of infection). The use of such a test before, during, and after treatment of gingivitis and periodontitis could lead to improvements in timing of intervention (ie, when inflammation is active) thereby reducing long-term morbidity.     

Diagnostic & therapeutic strategies for the management of the diabetic patient

The bridge between oral and systemic health exists and becomes more concrete as data continue to emerge in support of this relationship. The medical management of diabetes is affected by the presence of chronic infections, such as periodontitis. This article reviews the pathogenesis of periodontal disease as it relates to diabetes. The author discusses patient susceptibility in terms of risk and recommends risk assessment to determine optimal treatment strategies. Patients with poorly controlled diabetes are at greater risk for developing periodontitis. The opportunity for systemic exposure to periodontal pathogens and proinflammatory mediators associated with periodontitis is discussed relative to their specific effects on patients with diabetes. The importance of good metabolic control in terms of risk for developing long-term complications of diabetes is presented and the impact of periodontitis on achieving adequate metabolic control is described. Special considerations for the management of patients with diabetes in the dental office are reviewed, including the signs and symptoms of diabetes, risk assessment for diabetes, and the challenges of "tight control" with insulin and oral agents with regards to hypoglycemia. It is recommended by the author that a thorough medical history of the patient be obtained, that the patient's medications are known, that the dentist consults with the patient's physician to assess the patient's glycemic control, and that the patient's blood glucose levels and dietary intake be monitored before treatment. Finally, the author reviews the long-term complications of diabetes, particularly the oral complications that can affect overall health. The author concludes with the belief that the treatment of periodontal diseases should not be considered optional or elective but, instead, should be a necessary and integral part of a patient's overall healthcare program.     

正畸治疗策略中牙周支持组织改建的风险考量

随着成年正畸患者比例的增加,牙周状况对正畸治疗效果的影响以及正畸治疗与牙周支持组织改建的关系逐渐成为焦点。越来越多的正畸医师意识到,正畸治疗前牙周炎症应得到有效控制。牙周炎可增加正畸治疗的难度,导致额外的牙槽骨吸收;因此,降低牙周炎患者在正畸治疗过程中牙周组织健康状况恶化的风险成为临床医师关注的重点。除牙周炎外,正畸治疗也有可能导致牙龈退缩。另外,正畸治疗中应考虑特定类型的牙槽骨缺损情况:如骨开窗、骨开裂与正畸牙移动的关系。本文主要从牙周炎与正畸、牙龈退缩与正畸以及骨开窗和(或)骨开裂与正畸三方面阐述正畸治疗中牙周支持组织的风险考量。     

Interaction between periodontal disease and systemic secondary amyloidosis: from inflammation to amyloidosis

Background: It has become increasingly clear in recent years that periodontal disease can cause a dramatic increase in the levels of markers of systemic inflammation, and that periodontal treatment can result in reduction in the levels of these markers. We have previously shown that the prevalence of moderate to severe periodontitis was significantly higher in patients with familial Mediterranean fever (FMF) with amyloidosis than in patients with FMF without amyloidosis. Thus, the aim of this study is to investigate if chronic periodontitis is associated with secondary amyloidosis in the Black Sea region of Turkey. Methods: A total of 112 patients with biopsy‐proven secondary amyloidosis (59 patients with FMF, 40 patients who were either chronically infected or had malignant disease, 13 patients with periodontitis) and 22 healthy subjects, were included in this study. Periodontal health and disease were evaluated using gingival index (GI), papillary bleeding index (PBI), plaque index (PI), and periodontal disease index (PDI). The concentrations of serum acute phase reactants (APRs) were measured at baseline and at 4 to 6 weeks after completion of the non‐surgical periodontal therapy. Results: The prevalence of moderate to severe periodontitis was 47.5% in patients with FMF, 72.5% in patients who were either chronically infected or had malignant disease, and 84.6% in patients with periodontitis. Serum levels of APRs in patients with amyloidosis were reduced significantly after non‐surgical periodontal therapy (P <0.01). Conclusions: Periodontitis can increase the levels of APRs and potentiate the development of amyloidosis either by themselves or association with traditional factors, such as FMF and other chronic inflammatory diseases. Thus, preventing or treating periodontitis might prevent or at least alleviate the progression of amyloidosis. Periodontal evaluation should be performed as part of a medical assessment and considered as an etiologic factor for secondary amyloidosis.     

维、汉患者牙周病知识和口腔保健行为的比较

目的：通过对口腔科维吾尔族和汉族患者的牙周病知识水平和口腔保健行为的调查，了解两民族对牙周病认知程度和保健行为的差异及二者之间的关系。方法：以问卷方式调查了161例维吾尔族患者和339例汉族患者牙周病相关知识，并记录其牙周状况。结果：维吾尔族患者对牙周病的病因和早期症状以及防治知识认知率低于汉族患者，差异有统计学意义，维吾尔族患者中能够使用正确的刷牙方法和经历过洁治术的人数少于汉族患者。了解牙周保健知识以及接受过牙周治疗是影响患者牙周保健行为的因素之一。结论：提示维吾尔族患者的牙周病知识水平和牙周保健行为能力低于汉族患者，必须加强健康教育，应该以改变其口腔保健行为作为重点，并充分发挥少数民族护士的作用。     

Periodontal manifestations of systemic disease

Periodontitis is a chronic bacterial infection of the supporting structures of the teeth. The host response to infection is an important factor in determining the extent and severity of periodontal disease. Systemic factors modify periodontitis principally through their effects on the normal immune and inflammatory mechanisms. Several conditions may give rise to an increased prevalence, incidence or severity of gingivitis and periodontitis. The effects of a significant number of systemic diseases upon periodontitis are unclear and often it is difficult to causally link such diseases to periodontitis. In many cases the literature is insufficient to make definite statements on links between certain systemic factors and periodontitis and for several conditions only case reports exist whereas in other areas an extensive literature is present. A reduction in number or function of polymorphonuclear leukocytes (PMNs) can result in an increased rate and severity of periodontal destruction. Medications such as phenytoin, nifedipine, and cyclosporin predispose to gingival overgrowth in response to plaque and changes in hormone levels may increase severity of plaque-induced gingival inflammation. Immuno-suppressive drug therapy and any disease resulting in suppression of the normal inflammatory and immune mechanisms (such as HIV infection) may predispose the individual to periodontal destruction. There is convincing evidence that smoking has a detrimental effect on periodontal health. The histiocytoses diseases may present as necrotizing ulcerative periodontitis and numerous genetic polymorphisms relevant to inflammatory and immune processes are being evaluated as modifying factors in periodontal disease. Periodontitis severity and prevalence are increased in diabetics and worse in poorly controlled diabetics. Periodontitis may exacerbate diabetes by decreasing glycaemic control. This indicates a degree of synergism between the two diseases. The relative risk of cardiovascular disease is doubled in subjects with periodontal disease. Periodontal and cardiovascular disease share many common risk and socio-economic factors, particularly smoking, which is a powerful risk factor for both diseases. The actual underlying aetiology of both diseases is complex as are the potential mechanisms whereby the diseases may be causally linked. It is thought that the chronic inflammatory and microbial burden in periodontal disease may predispose to cardiovascular disease in ways proposed for other infections such as with Chlamydia pneumoniae. To move from the current association status of both diseases to causality requires much additional evidence. Determining the role a systemic disease plays in the pathogenesis of periodontal disease is very difficult as several obstacles affect the design of the necessary studies. Control groups need to be carefully matched in respect of age, gender, oral hygiene and socio-economic status. Many studies, particularly before the aetiological importance of dental plaque was recognised, failed to include such controls. Longitudinal studies spanning several years are preferable in individuals both with and without systemic disease, due to the time period in which periodontitis will develop.