Unveiling the role of stress in periodontal etiopathogenesis: an evidence‐based review

Periodontal disease is a multifactorial disease affecting the supporting tissues of the teeth, resulting in progressive attachment loss and bone loss. Periodontal disease is influenced by various systemic, environmental, and psychologic factors that have the potential to alter periodontal tissues and host immune response, resulting in more severe periodontal destruction. Several studies have documented the relationship between psychosocial stress and chronic forms of periodontal disease. Stress impairs periodontal health through changes in behavior and complex interactions among the nervous, endocrine, and immune systems. The influence of stress on periodontal disease is affected by the emotional coping skills of the individual. Psychologic stress and depression may also influence the outcome of periodontal therapy. Stressful life events and coping skills are factors to consider in the risk of periodontal disease destruction and the potential for successful periodontal therapy. Therefore psychosocial stress is considered as an important risk factor for periodontal disease, and emotional stress in periodontitis patients should be diagnosed and treatment should be administered for the proper management and successful outcome of periodontal disease.     

The global burden of periodontal disease: towards integration with chronic disease prevention and control

Chronic diseases are accelerating globally, advancing across all regions and pervading all socioeconomic classes. Unhealthy diet and poor nutrition, physical inactivity, tobacco use, excessive use of alcohol and psychosocial stress are the most important risk factors. Periodontal disease is a component of the global burden of chronic disease, and chronic disease and periodontal disease have the same essential risk factors. In addition, severe periodontal disease is related to poor oral hygiene and to poor general health (e.g. the presence of diabetes mellitus and other systemic diseases). The present report highlights the global burden of periodontal disease: the ultimate burden of periodontal disease (tooth loss), as well as signs of periodontal disease, are described from World Health Organization (WHO) epidemiological data. High prevalence rates of complete tooth loss are found in upper middle‐income countries, whereas the tooth‐loss rates, at the time of writing, are modest for low‐income countries. In high‐income countries somewhat lower rates for edentulism are found when compared with upper middle‐income countries. Around the world, social inequality in tooth loss is profound within countries. The Community Periodontal Index was introduced by the WHO in 1987 for countries to produce periodontal health profiles and to assist countries in the planning and evaluation of intervention programs. Globally, gingival bleeding is the most prevalent sign of disease, whereas the presence of deep periodontal pockets (≥6 mm) varies from 10% to 15% in adult populations. Intercountry and intracountry variations are found in the prevalence of periodontal disease, and these variations relate to socio‐environmental conditions, behavioral risk factors, general health status of people (e.g. diabetes and HIV status) and oral health systems. National public health initiatives for the control and prevention of periodontal disease should include oral health promotion and integrated disease‐prevention strategies based on common risk‐factor approaches. Capacity building of oral health systems must consider the establishment of a financially fair service in periodontal care. Health systems research is needed for the evaluation of population‐oriented oral health programs.     

Strengthening the prevention of periodontal disease: the WHO approach

BACKGROUND: The aim of this paper is to provide an overview of the burden of periodontal disease in adult populations worldwide, to emphasize the essential risk factors common to periodontal disease and chronic diseases, to outline important new strategies for effective prevention of periodontal disease, and to inform about the role of the World Health Organization (WHO) in developing a national capacity for the prevention of disease. METHODS: Information about periodontal health status as measured by the Community Periodontal Index system is stored in the WHO Global Oral Health Data Bank. Updated information concerning WHO standard age groups was used to describe the prevalence rates of signs of periodontal disease, i.e., gingival bleeding, periodontal pocketing, and loss of attachment. RESULTS: Gingival bleeding is highly prevalent among adult populations in all regions of the world; advanced disease with deep periodontal pockets (> or =6 mm) affects approximately 10% to 15% of adults worldwide. The available evidence shows that important risk factors for periodontal disease relate to poor oral hygiene, tobacco use, excessive alcohol consumption, stress, and diabetes mellitus. Integrated preventive strategies based on the common risk factors approach are recommended for public health practice. CONCLUSIONS: The vast majority of countries need to establish a surveillance system for measuring progress in the control of periodontal disease and promotion of oral health. WHO has designed approaches for the integration of oral disease prevention within the prevention of non-communicable chronic diseases, and global strategies are currently being implemented in all regions of the world.     

Standards for reporting chronic periodontitis prevalence and severity in epidemiologic studies

Periodontal diseases are common and their prevalence varies in different populations. However, prevalence estimates are influenced by the methodology used, including measurement techniques, case definitions, and periodontal examination protocols, as well as differences in oral health status. As a consequence, comparisons between populations are severely hampered and inferences regarding the global variation in prevalence can hardly be drawn. To overcome these limitations, the authors suggest standardized principles for the reporting of the prevalence and severity of periodontal diseases in future epidemiological studies. These principles include the comprehensive reporting of the study design, the recording protocol, and specific subject‐related and oral data. Further, a range of periodontal data should be reported in the total population and within specific age groups. Periodontal data include the prevalence and extent of clinical attachment loss (CAL) and probing depth (PD) on site and tooth level according to specific thresholds, mean CAL/PD, the CDC/AAP case definition, and bleeding on probing. Consistent implementation of these standards in future studies will ensure improved reporting quality, permit meaningful comparisons of the prevalence of periodontal diseases across populations, and provide better insights into the determinants of such variation.     

牙周炎症与心血管系统健康的临床研究

目的研究牙周炎症与心血管系统健康状况间的关系。方法选择遵义医学院附属医院体检中心常规体检者233人,检查其6颗Ramfjord指数牙牙周探诊深度和探诊出血情况,并采用12导联心电图仪检查记录受检者心电图,根据心电图表现分为心电图异常与正常二组进行牙周指数及全身情况的比较分析。结果心电图异常组牙周炎症程度显著高于正常组（P〈0.01或P〈0.05）,牙周探诊深度和探诊出血与心电图异常显著相关;牙周炎症是心电图异常的危险因素（OR=1.96,P〈0.05）。结论牙周炎症与心电图异常相关,可能是心血管疾病的危险因素之一。     

Indices for measuring periodontitis: a literature review

Indices are important tools to measure, quantify and treat periodontitis both in epidemiological and clinical situations and are based on the prevailing understanding of the pathogenesis of periodontal disease. However, there is dearth of literature on collective information of periodontal indices formulated to date. This article collectively describes the evolution and the present concept of formulation of periodontal indices based on the multi-factorial nature of periodontal disease and also provides some direction for future periodontal indices. Periodontal indices have evolved from the simple Russell's index to the current usage of measurement of clinical attachment level in the recording of indices. The use of dichotomous measurements and the Genetic Susceptibility Index are the new additions to the periodontal indices. Nevertheless, an ideal would be an index that will keep pace with the ever changing concept of the pathogenesis of periodontal disease.     

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。     

Epidemiology of periodontal status in dentate adults in France, 2002-2003

BACKGROUND AND OBJECTIVE: Few recent nationwide studies of the periodontal landscape in European countries have been developed from the point of view of attachment loss and pocket depth. Decision makers are not always in a position to estimate the burden of periodontal disease. The purpose of this study was to investigate the prevalence and the oral distribution of periodontal status among dentate adults in the general population of France. MATERIAL AND METHODS: In 2002-2003, a National Periodontal and Systemic Examination Survey was organized to a stratified quota sample of 2144 adults, aged 35-64 years, nationwide. Participants with six or more teeth were selected from the Health Examination Centers of the National Health Insurance. Measurement of periodontal health was assessed by clinical attachment level and probing depth. RESULTS: A total of 95.40% and 82.23% of adults were found to have clinical attachment loss and periodontal pockets, respectively. Population prevalence estimates indicated that loss of attachment > or = 5 mm is 46.68% and probing depth (> 5 mm) is 10.21%. However, clinical attachment loss of > or = 5 mm occurred in only 0.88 sites in an individual. Periodontal depth pocket generalized forms were as follows: 78% slight, 18% moderate and 4% severe. Multiple logistic regression analyses showed significant differences of attachment loss values between types of tooth (molar, incisors, canines, or premolars). CONCLUSION: Based on the International Classification of Periodontal Diseases, approximately 50% of adults in France may suffer from a severe attachment loss problem. Periodontal pockets are an uncommon condition in France. Significant differences in the prevalence of loss of attachment and probing depth with respect to location of attack have implications in the purchase and development of screening and treatment services.     

Clinical and other risk indicators for early periodontitis in adults

BACKGROUND: Periodontal diseases affect over half the adults in the U.S., disproportionately affecting minority populations. Periodontitis can be treated in early stages, but it is not clear what features indicate, or could be risk factors for, early stages of periodontal attachment loss. This study aimed to evaluate associations between clinical and other risk indicators of early periodontitis. METHODS: A cross-sectional evaluation of 225 healthy and early periodontitis adults aged 20 to 40 years was performed. Clinical measurements, demographic information, and smoking histories were recorded. Analyses evaluated demographic and clinical associations with health and early periodontitis disease categories and periodontal attachment loss. Patterns of attachment loss at interproximal and buccal/lingual sites were evaluated. RESULTS: Subject age, plaque, and measures of gingivitis exhibited associations with attachment loss and probing depth. More periodontal attachment loss was detected in African-American and Hispanic subjects compared to Asian and Caucasian subjects. Smoking history was associated with attachment loss. At interproximal sites, lower molars most frequently had attachment loss, whereas at buccal/lingual sites, higher proportions of lower bicuspid teeth demonstrated attachment loss compared with other sites. CONCLUSIONS: In this study of subjects with minimal attachment loss, gingival inflammation was associated with early periodontitis. Lower molar interproximal sites were frequently associated with interproximal attachment loss, whereas lower bicuspid teeth were at risk for gingival recession on buccal surfaces.     

Periodontal status of HIV-seropositive and AIDS patients.

Few reported studies have evaluated the periodontal status of individuals infected by human immunodeficiency virus (HIV). The majority of these reports have evaluated the periodontal status of individuals presenting to dental care facilities due to oral problems. These reports suggest that severe gingival inflammation and attachment loss are often associated with HIV seropositive patients. The purpose of this study was to evaluate the periodontal status of HIV seropositive patients without biasing the data towards those presenting to dentists with oral problems. Sixty-three consenting male patients presenting to the infectious disease clinic at the Medical College of Virginia Hospitals were examined to determine the status of their periodontal health. Gingival index, plaque index, pocket depths, and attachment loss were determined using standard indices. Participants were first grouped according to the modified CDC Classification System for HIV infection and then categorized according to HIV risk factors for purposes of statistical analysis. No significant differences could be found in the gingival or periodontal status of subjects who were HIV seropositive versus those with AIDS. Periodontal status was also not significantly different for individuals based upon risk group. Periodontal health of the participants was similar to the general population (HIV status unknown). This would indicate that, although HIV gingivitis and HIV periodontitis have been documented in a number of HIV-infected patients, the frequency of affected individuals is less than previous reports would suggest.     

Potential correlation between periodontitis and coronary heart disease--an overview

The role of periodontal disease remains a headline-generating topic. Periodontal disease, caused chiefly by bacteria, is characterized by inflammation, bacteremia, a strong immune response, and loss of connective tissue attachment and bone. It is speculated that a continuous long-term exposure to oral bacteremia and bacterial toxins induces immune responses that could contribute to coronary atherosclerosis and, in conjunction with other risk factors, lead to coronary heart disease and myocardial infarction. Periodontal disease might initiate pathological changes in blood vessel walls and act as a precursor of atherosclerosis in susceptible hosts. Many causal factors can play a role in heart diseases. Periodontal disease caused by pathogen bacteria as a low-grade inflammation could represent one of several possible causal factors of heart disease.     

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目的调查分析特殊教育学校学生的牙周健康状况。方法2010年1-3月从江西省吉安市特殊教育学校中选择3所学校，根据年级分层抽取不同班级，再从各班级中随机抽样7-18岁学生共157名；同时从该市普通中小学中采用同种抽样方法抽取112名学生为对照。采用视诊和探诊相结合方法检查全口牙周，检查的内容包括牙周健康状况、牙结石、牙龈出血、牙周袋和牙周附着丧失，并对两组学生的牙周检查情况进行对比。结果特殊教育学校学生牙结石检出率、牙龈出血栓出率、牙周袋检出率和附着丧失检出率均高于普通学校（P〈0．05）。结论特殊教育学校学生口腔卫生状况较差，应得到更多的关心和重视。     

Can we successfully maintain risk patients?

The most fundamental premise in the current view of periodontal disease is that not all individuals are at equal risk for disease and disease progression. Studies reveal that about 5-20% of the population is at risk for severe disease progression. The purpose of this paper is to define at-risk patients, review risk factors and indicators of disease progression, and outline an evidence-based strategy that includes both self-care and professional care for maintaining periodontal health. Risk factors/risk indicators considered include history of previous disease, increased pocket depth and loss of clinical attachment, frequency of dental care, specific bacterial pathogens, and systemic/environmental host factors such as smoking, diabetes mellitus, genetics, and stress. Because host factors may have more influence on disease progression than periodontal pathogens, personal and professional maintenance care must include the role of the host in periodontal disease progression. By examining the evidence surrounding these complex issues, dentists and dental hygienists are able to determine the extent to which evidence supports available approaches to maintain periodontal health and control disease progression.     

Periodontitis epidemiology: is periodontitis under‐recognized,over‐diagnosed,or both?

Currently, two principal forms of destructive periodontal disease are recognized – chronic periodontitis and aggressive periodontitis – but their distinction in epidemiologic studies has been rather problematic because of substantial overlap of their primary features. This review critically appraises some key features relevant to the epidemiology of human periodontitis that underlie its core ‘identity’ as a bacterial biofilm‐induced, inflammatory disease and discusses its impact within the larger context of aging populations. The currently adopted epidemiologic methodologies/definitions that result in the almost ubiquitous prevalence of periodontitis indeed overestimate the occurrence of the disease that may actually put individuals at a true biologic, functional or psychosocial disadvantage. Use of these definitions has inevitably promoted the inference that periodontitis constitutes an insurmountable oral health problem. In contrast, reliance solely on physical measurements of probing depth and/or attachment loss under‐recognizes the true impact that periodontitis may have on the well‐being of individuals. It is currently unclear whether inclusion of the psychosocial and systemic dimensions of the disease in case definitions would result in higher or lower prevalence estimates. The review concludes that periodontitis should no longer be defined solely by gingival/periodontal inflammation in the presence of increased probing depths and attachment loss but should incorporate additional dimensions capturing impaired function, esthetics, and impact on general health and quality of life. A multidimensional approach to the assessment of periodontitis would facilitate an improved understanding of its epidemiology and consequences.     

Further evidence for periodontal disease as a risk indicator for adverse pregnancy outcomes

Background: Although there is increasing evidence to suggest an association between periodontal disease and adverse pregnancy outcomes, the issue remains controversial. Study objective: This study tested the hypothesis that periodontal disease is a risk indicator for preterm delivery of low-birthweight infants. Materials and methods: The study sample comprised 443 pregnant women with a mean (± standard deviation) age of 24.13 (±5.30) years. At first visit, maternal oral health status was assessed by the measurement of probing pocket depth and clinical attachment loss, and periodontal status was graded as absent, mild, moderate or severe. An association was sought between pregnancy outcomes and maternal periodontal status. Results: While controlling for other factors, significant associations were found between pregnancy outcomes and maternal periodontal index scores. Conclusion: This study provides further evidence that periodontal disease is a risk indicator for adverse pregnancy outcomes.Key words: Periodontal disease, low birthweight, preterm birth     

Risk indicators for periodontal disease in a remote Canadian community--a dental practice-based study

OBJECTIVES: The purpose of this cross-sectional study was to identify risk markers and risk indicators for periodontal attachment loss in a remote Canadian community. Of special interest was the association between smoking and periodontal disease experience. METHODS: Data were collected from a convenience sample of 187 adult patients attending a dental office in a rural community located in Northern Ontario. Information was obtained via a questionnaire and a periodontal examination. The questionnaire included the use of dental services, self-care behaviors, general health status, smoking, and personal characteristics. Periodontal health was assessed using the mean periodontal attachment loss (MPAL), measured at two sites on all remaining teeth and the proportions of sites examined with loss of 2 mm or more and 5 mm or more. Plaque scores and measures of the number of missing teeth also were obtained. The relationships between mean periodontal attachment loss, the proportion of sites with 5 mm or more of loss and independent variables such as age, sex, current smoking status, mean tooth plaque scores, flossing frequency, and regularity of preventive dental visits were examined in bivariate and multivariate analyses. RESULTS: The data revealed a mean periodontal attachment loss of 3.9 mm (SD=1.5). The mean proportion of sites examined with loss of 2 mm or more was 0.89 and the mean proportion with loss of 5 mm or more was 0.35. In linear regression analysis, plaque scores, the number of missing teeth, age, current smoking status, regularity of dental visits, and flossing frequency had statistically significant independent effects and explained 60.0 percent of the variance in mean periodontal attachment loss. Just over 30 percent of subjects had severe periodontal disease, defined as 50 percent or more of sites examined with loss of 5 mm or more. In logistic regression analysis, missing teeth, dental visiting, smoking status, age, and flossing frequency had significant independent effects. The strongest association observed was with smoking, which had an odds ratio of 6.3. The logistic regression model correctly predicted 64.3 percent of cases with severe disease. CONCLUSIONS: The data indicate that the periodontal health of these patients is poor. Risk indicators or markers of poor periodontal health in the population studied included missing teeth, plaque scores, age, current smoking status, regularity of dental visits, and flossing frequency. This supports previous findings that behavioral factors play an important role in periodontal disease.     

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.     

Association between extent of periodontal attachment loss and self-reported history of heart attack: an analysis of NHANES III data

Coronary heart disease is responsible for one of every five deaths in the United States. Recent epidemiological studies have shown an association between periodontal disease and coronary heart disease. The purpose of this cross-sectional study was to verify this association using data from the third National Health and Nutrition Examination Survey (NHANES III). Data for 5564 people 40 years of age and older who had complete periodontal assessments and information on heart attack were evaluated. The outcome was the self-reported history of heart attack (yes vs. no). The main independent variable was the percent of periodontal sites per person with attachment loss of 3 mm or greater (categorized as 0%, > 0-33%, > 33-67%, and > 67%). Periodontal attachment loss was measured at two sites per tooth in randomly assigned half-mouths, one upper and one lower quadrant. The covariables included sociodemographic variables and established risk factors for cardiovascular disease. Relative to the 0% category, the unadjusted odds of heart attack increased with each higher category of attachment loss-2.2 (95% confidence interval = 1.3-3.8), 5.5 (3.4-9.1), and 9.8 (4.5-21.0), respectively. Adjustment for age, sex, race, poverty, smoking, diabetes, high blood pressure, body mass index, and serum cholesterol decreased these odds to 1.4 (0.8-2.5), 2.3 (1.2-4.4), and 3.8 (1.5-9.7), respectively. This study supports findings from previous studies of an association between periodontal disease and coronary heart disease.     

Global periodontal disease epidemiology

Our understanding of the global epidemiology of periodontal disease has changed considerably over the past 50 years. This change has been influenced not only by our evolving knowledge of the natural history and distribution of the disease, but also by changing measurement methodologies. Although great strides have been made in describing the underlying contributions of microorganisms and plaque ecology, as well as the inflammatory and host responses, there is still much that is not known regarding risk susceptibility and prevention effectiveness. The focus of global periodontal epidemiology during the last half century has been on identifying populations who have periodontal disease and situations where disparities in disease prevalence exist between groups. Unlike dental public health activities directed toward dental caries, less effort has been made in periodontal epidemiology with regard to surveying or monitoring groups who may be at greater risk for moderate or severe disease and evaluating public health initiatives directed at mitigating risk or reducing such periodontal disease prevalence. Additionally, there is limited information regarding current national estimates of periodontal disease in most countries. Although numerous periodontal studies have been performed globally, very few are epidemiological studies using nationally representative samples. The aim of this critical review is to discuss the historical context of global periodontal disease epidemiology, highlight key activities and findings over the past decade in global periodontal epidemiology, and comment on how changes in the practice of epidemiology may affect global periodontology over the coming decade.