Free sugars and gingival inflammation: A systematic review and meta-analysis.

AIM: Consumption of free sugars has been associated with chronic non-communicable diseases. The aim of the study was to investigate the effect of free-sugar consumption on gingival inflammation using a systematic review and meta-analysis based on the PICO question 'What impact does the restriction of free sugars have on the inflammation of gingival tissue?' MATERIALS AND METHODS: Literature review and analyses were based on the Cochrane Handbook for Systematic Reviews of Interventions. Controlled clinical studies reporting on free-sugar interventions and gingival inflammation were included. Risk of bias was performed with ROBINS-I and ROB-2, and effect sizes were estimated with robust variance meta-regressions. RESULTS: Of the 1777 primarily identified studies, 1768 were excluded, and 9 studies with 209 participants with gingival inflammation measures were included. Six of these studies reported on the dental plaque scores of 113 participants. Restriction of free sugars, when compared with no such restriction, was associated with statistically significantly improved gingival health scores (standard mean difference [SMD] = -0.92; 95% confidence interval [CI]: -1.43 to -0.42, p < .004; I2 [heterogeneity] = 46.8) and a trend towards lower dental plaque scores (SMD = -0.61; 95% CI: -1.28 to 0.05, p < .07; I2 = 41.3). The observed improvement of gingival inflammation scores with restricted consumption of free sugar was robust against various statistical imputations. No meta-regression models were feasible because of the limited number of studies. The median publication year was 1982. Risk-of-bias analysis showed a moderate risk in all studies. CONCLUSION: Restriction of free sugar was shown to be associated with reduced gingival inflammation. The systematic review was registered at PROSPERO (CRD 42020157914).

Phenotypic characteristics of adolescents with concave and convex facial profiles - The National Health Examination Survey.

It has been suggested that facial traits are informative on the inherited susceptibility to tuberculosis and obesity, two current global health issues. Our aim was to compare the phenotypic characteristics of adolescents with dental markers for a concave (n=420), a convex (n=978), and a straight (n=3542) facial profile in a nationally representative sample of United States adolescents. The results show that adolescents with a concave facial profile, when compared to a straight facial profile, had an increased waist-to-height ratio (Δ, 1.1 [95% CI 0.5-1.7], p<0.003) and an increased acne prevalence (OR, 1.5 [95% CI 1.2-1.9], p<0.001). Adolescents with a convex facial profile, when compared to a straight facial profile, had an increased prevalence of tuberculosis (OR, 4.3 [95% CI 1.4-13.1], p<0.02), increased ectomorphy (Δ, 0.3 [95% CI 0.2-0.4], p<0.0001), increased left-handedness (OR, 1.4 [95% CI 1.1-1.7], p<0.007), increased color-blindness (OR, 1.7 [95% CI 1.3-2.3], p<0.004), and rhesus ee phenotype (OR, 1.3 [95% CI 1.1-1.5], p<0.008). Adolescents with a concave facial profile, when compared to a convex profile, had increased mesomorphy (Δ, 1.3 [95% CI 1.1-1.5], p<0.0001), increased endomorphy (Δ, 0.5 [95% CI 0.4-0.6], p<0.0001), lower ectomorphy (Δ, 0.5 [95% CI 0.4-0.6], p<0.0001), and lower vocabulary test scores (Δ, 2.3 [95% CI 0.8-3.8], p<0.008). It is concluded that population-based survey data confirm that distinct facial features are associated with distinct somatotypes and distinct disease susceptibilities.

Systemic antibiotics and tooth loss in periodontal disease.

Systemic antibiotics have been recommended for the treatment of destructive periodontal disease. Our goal was to relate antibiotic use for medical or dental reasons to subsequent tooth loss in a cohort of 12,631 persons with destructive periodontal disease. After adjustment for age, smoking, and other confounders, the dispensing of antibiotics for 1-13 days, 14-20 days, or 21 or more days was not associated with reduced tooth loss [Adjusted rate ratio (RR) = 1.0; 95% Confidence Interval (CI) = 0.8-1.1; RR = 1.2; 95% CI = 0.9-1.4, and RR =1.2, 95% CI =1.0-1.3, respectively]. Numerous subgroup analyses were consistent with these overall null findings, with two exceptions: Longer courses of tetracyclines were associated with reduced tooth loss among persons receiving periodontal care, and penicillin was associated with reduced tooth loss among persons with more severe disease. Long-term, larger randomized trials are needed to provide evidence that antibiotics reduce tooth loss when used in the management of destructive periodontal disease.

Oral health-related quality of life of periodontal patients.

BACKGROUND AND OBJECTIVE: The purpose of this study was to assess the oral health-related quality of life of patients presenting to a periodontal specialist by means of six questions, and to assess the perceived oral health by means of one question. Self-assessments of oral health were associated with clinical characteristics. MATERIAL AND METHODS: Logistic regression models were used to associate self-assessments with clinical characteristics in a cross-sectional study. RESULTS: On the six-item questionnaire, close to 20% (295/1480) of the patients reported that teeth, gums or dentures had an impact fairly often or very often on one or more items (eating, relaxing, avoiding going out, feeling self-conscious, pain or discomfort). On the single question requesting a self-assessment of oral health, 42% (628/1468) rated their oral health as fair or poor. Both common oral health-related quality of life problems and worse perceived oral health were associated with having more than eight teeth with>5 mm periodontal pockets (odds ratio=1.45, 95% confidence interval=1.01-2.08; and odds ratio=2.83, 95% confidence interval=2.08-3.84, respectively), compared with patients who had fewer than three teeth with>5 mm periodontal pockets. CONCLUSION: Oral health-related problems in patients presenting to a periodontal specialist office negatively affect their quality of life. If some of the findings of this study can be confirmed in other studies, it could change the perception of chronic periodontitis as a silent disease.

Chlorhexidine and preservation of sound tooth structure in older adults. A placebo-controlled trial.

The Trial to Enhance Elderly Teeth Health (TEETH) was designed to test the impact of regular rinsing with a 0.12% chlorhexidine (CHX) solution on tooth loss, and the causes of tooth loss (caries, periodontal disease and trauma) were also investigated. This paper reports on the effectiveness of a 0.12% CHX solution for controlling caries using a tooth surface (coronal and root) survival analysis. A total of 1,101 low income elders in Seattle (United States) and Vancouver (Canada), aged 60-75 years, were recruited for a double-blind clinical trial and assigned to either a CHX (n = 550) or a placebo (n = 551) mouth rinse. Subjects alternated between daily rinsing for 1 month, followed by weekly rinsing for 5 months. All sound coronal and root surfaces at baseline were followed annually for up to 5 years. At each follow-up examination, those tooth surfaces with caries, restored, or extracted were scored as 'carious'. The hazard ratio associated with CHX for a sound surface to become filled, decayed, or extracted was 0.87 for coronal surfaces (95% confidence interval: 0.71-1.14, p = 0.20) and 0.91 for root surfaces (95% confidence interval: 0.73-1.14, p = 0.41). These findings suggest that regular rinsing with CHX does not have a substantial effect on the preservation of sound tooth structure in older adults.

Secular trends in socio-economic disparities in edentulism: USA, 1972-2001.

For health care planning and policy, it is important to determine whether socio-economic disparities in edentulism, an ultimate marker of oral health, have improved over time. The aim of this study was to investigate the socio-economic disparities in edentulism between 1972 and 2001. Representative samples of the United States population, 25-74 years old, were obtained from NHANES I (1972), III (1991), and 1999-2002. Differences in the edentulism prevalence between high and low socio-economic positions (SEP) were compared. Differences in edentulism prevalence remained stable over approximately three decades (p = 0.480), being 10.6 percentage points in 1972, 12.1 percentage points in 1991, and 11.3 percentage points in 2001. Exploratory subgroup analyses suggested that disparities decreased for those individuals reporting a dental visit in the prior year and those reporting never having smoked. In conclusion, the absolute prevalence difference in edentulism between low and high socio-economic positions has remained unchanged over the last three decades.

Spurious associations in oral epidemiological research: the case of dental flossing and obesity.

BACKGROUND: Individuals with increased oral health awareness may also have increased general health awareness, and vice versa. Such associations between oral and general health awareness has the potential to induce spurious associations in oral epidemiological research. OBJECTIVE: To assess the extent to which oral self-care patterns and general health awareness are confounded, we investigated the association between flossing and obesity, two lifestyle factors that are unlikely to be causally related. METHODS: A cross-sectional study of 1497 individuals presenting for an initial periodontal exam by the specialist. Self-reported flossing behaviors and body mass index (BMI) categories were related using logistic regression models. RESULTS: After adjustment for confounding variables, lack of daily flossing was associated in a dose-dependent way with morbid obesity (odds ratio (OR), 20.3; 95% confidence interval (CI), 2.7-154.0), obesity (OR, 2.1; 95% CI, 1.5-2.9), and being overweight (OR, 1.7; 95% CI, 1.3-2.2). When restricting to never smokers, a significant relationship between obesity and lack of flossing remained. CONCLUSION: The strong associations between two causally unrelated oral and general lifestyle characteristics indicate that simplistic epidemiologic methodology is unlikely to provide insights into causal mechanisms of oral diseases or oral-systemic relationships.

Statin use and tooth loss in chronic periodontitis patients.

BACKGROUND: Statins have anti-inflammatory and bone stimulating properties that may positively affect chronic periodontitis. Our objective in this study was to evaluate whether statin use by chronic periodontitis patients had a beneficial impact on tooth loss. METHODS: In a retrospective cohort study (N patients = 1,021; mean follow-up = 7.1 years), dental records were merged with pharmacy data. Any statin use during 3 years, statin use during each of 3 consecutive years (regular use), and any statin use during the first 3 years after the initial periodontal exam were evaluated as predictors of tooth loss using negative binomial regression models with adjustment for potential confounding factors. RESULTS: Any statin use during 3 years was not associated with tooth loss rate in the year subsequent to the 3-year period (rate ratio [RR] = 1.00; 95% confidence interval [CI] = 0.56 to 1.81). Regular statin use during 3 years was associated with a non-significant 37% reduced tooth loss rate in the year subsequent to the 3-year period (RR = 0.63; 95% CI = 0.32 to 1.25). Any statin use during the first 3 years after the initial periodontal exam was associated with a 48% decreased tooth loss rate in year 4 and subsequent years (RR = 0.52; 95% CI = 0.29 to 0.95). CONCLUSIONS: Our findings were mixed for an association of statin use with reduced tooth loss in chronic periodontitis patients. Lack of control for some potential confounders, particularly smoking, and evaluation of different patterns of statin usage hamper the interpretation of the results. Exploration of these findings in additional epidemiological studies may be worthwhile.

Dental flossing and interproximal caries: a systematic review.

Our aim was to assess, systematically, the effect of flossing on interproximal caries risk. Six trials involving 808 subjects, ages 4 to 13 years, were identified. There were significant study-to-study differences and a moderate to large potential for bias. Professional flossing performed on school days for 1.7 years on predominantly primary teeth in children was associated with a 40% caries risk reduction (relative risk, 0.60; 95% confidence interval, 0.48-0.76; p-value, < 0.001). Both three-monthly professional flossing for 3 years (relative risk, 0.93; 95% confidence interval, 0.73-1.19; p-value, 0.32) and self-performed flossing in young adolescents for 2 years (relative risk, 1.01; 95% confidence interval, 0.85-1.20; p-value, 0.93) did not reduce caries risk. No flossing trials in adults or under unsupervised conditions could be identified. Professional flossing in children with low fluoride exposures is highly effective in reducing interproximal caries risk. These findings should be extrapolated to more typical floss-users with care, since self-flossing has failed to show an effect.

Mercury exposure from dental filling placement during pregnancy and low birth weight risk.

Several European countries have guidelines suggesting that women should not receive mercury-containing dental amalgam fillings during pregnancy. One concern raised by several studies is that mercury exposure during pregnancy may lead to decreased birth weight. A population-based, case-control study was designed to investigate whether placement of mercury-containing fillings in 1993-2000 during pregnancy increased the low-birth-weight risk. Cases and controls were sampled from enrollees of a dental insurance plan with live singleton births in Washington State; 1,117 women with low-birth-weight infants (< 2,500 g) were compared with a random sample of 4,468 women with infants weighing 2,500 g or more. The results indicated that 13% of a dentally insured population had one or more restorative procedures during pregnancy that, regardless of chemical composition, did not increase the low-birth-weight risk (odds ratio = 0.96, 95% confidence interval: 0.88, 1.05). The 4.9% of the women (n = 249) who had at least one mercury-containing amalgam filling during pregnancy were not at an increased risk for a low-birth-weight infant (odds ratio = 0.75, 95% confidence interval: 0.45, 1.26) and neither were women who had 4-11 amalgam fillings placed (odds ratio = 1.00, 95% confidence interval: 0.27, 3.68). This study found no evidence that mercury-containing dental fillings placed during pregnancy increased low-birth-weight risk.

Efficiency issues among statistical methods for demonstrating efficacy of caries prevention.

Although repeated tooth-surface-specific information is commonly collected during a longitudinal caries clinical trial, traditional methods often make limited use of the repeated measures. Newer methods of analysis, such as methods based on time-to-event and methods for longitudinal or clustered data, have the potential to increase the efficiency of the statistical analysis. We compare a range of analytical methods from the traditional analysis based only on the number of caries onsets to newer methods that incorporate time at risk and surface-specific information, such as Poisson regression methods for clustered data, with respect to the efficiency of treatment comparisons. Under most circumstances, the greatest gain in efficiency associated with time-to-event methods will be due to the ability of subjects to contribute caries onsets to the analysis until they are lost from the study. Incorporating the number of surfaces at risk, the surface time at risk, and surface-specific characteristics will typically produce only a modest gain in efficiency.

Bias induced by self-reported smoking on periodontitis-systemic disease associations.

Non-causal associations between periodontitis and systemic diseases may be spuriously induced by smoking because of its strong relationship to both. The goal of this study was to evaluate whether adjustment for self-reported smoking removes tobacco-related confounding and eliminated such spurious confounding. Using NHANES III data, we evaluated associations between attachment loss and serum cotinine after adjustment by self-reported number of cigarettes smoked. Cotinine, a metabolite of nicotine, should not be related to attachment loss, if self-reported smoking captures the effect of tobacco on attachment levels. Adjustment for self-reported cigarette smoking did not completely remove the correlation between attachment loss and serum-cotinine level (r = 0.075, n= 1507, p = 0.003). Simulation studies indicated similar results for time-to-event data. These findings demonstrate the difficulty in distinguishing the effects of periodontitis from those of smoking with respect to a smoking-related outcome. Future studies should report results of analyses on separate subcohorts of never-smokers and smokers.

A hidden periodontitis epidemic during the 20th century?

OBJECTIVES: Increasing evidence suggests a strong causal link between smoking and periodontitis. The goal of this study was to impute how the secular changes in smoking prevalence during the 20th century impacted the advanced periodontitis incidence in the US. METHODS: Epidemiological analyses based on US prevalence data of advanced periodontitis and smoking, and predictions of future smoking prevalence. RESULTS: Assuming other risk factors for periodontitis remained constant, we estimated that the incidence of advanced periodontitis decreased by 31% between 1955 and 2000. The changes in smoking habits, and consequently the changes in periodontitis incidence, depended strongly on education and gender. Between 1966 and 1998, we estimated a 43% decreased periodontitis incidence among college-educated individuals versus only an 8% decrease among individuals with less than a high school education. Between 1955 and 1999, we estimated a 41% decrease among males versus a 14% decrease among females. By the year 2020, the incidence of advanced periodontitis may decrease 43% from its level in 1955. CONCLUSIONS: A periodontitis epidemic fueled by smoking remained hidden for most of the 20th century. Because this epidemic was hidden, it distorted our understanding of the treatment and etiology of periodontitis. The socioeconomic polarization of this epidemic will dictate alterations in patterns of periodontal care.

Does chronic periodontitis cause coronary heart disease? A review of the literature.

BACKGROUND: Chronic periodontitis, or CP, has been associated with coronary heart disease, or CHD. This article reviews the available prospective CP-CHD evidence. LITERATURE REVIEWED: In nine cohort studies, CP was associated with a 15 percent greater risk of developing CHD. Conclusions from individual studies depended on study characteristics. Summary risk estimates for studies controlling for smoking intensity (five of nine studies) or health awareness (two of nine studies) or studies with more than 600 CHD events (three of nine studies) suggest that CP is either not at all or weakly associated with CHD. Summary risk estimates for the studies that did not control for these factors or that examined an insufficient number of CHD events reported a weak increase in CHD risk associated with CP (20 percent greater). These data suggest that the CP-CHD associations observed in smaller studies are due to insufficient control for lifestyle differences. In addition, one cohort study reported that edentulous people had a CHD risk similar to that of people with CP. Therefore, the plausibility of dental infection elimination affecting CHD risk appears limited. SUMMARY: Current evidence supporting a causal CP-CHD link is weak. Rigorous methodological and analytical control of lifestyle factors such as smoking will be required to elucidate whether the CP-CHD disease association is either small or nonexistent. CLINICAL IMPLICATIONS: Cigarette smoking destroys both oral and systemic health. Because of this strong common causal factor, oral and systemic health are linked. Dentistry should continue to play an important role in implementing smoking prevention and cessation programs.

Pre-existing cardiovascular disease and periodontitis: a follow-up study.

Periodontal infections in individuals with pre-existing heart disease are believed to increase the risk for future coronary heart disease (CHD) events. The goal of this study was to search for an association between periodontitis and CHD events among individuals with pre-existing heart disease, reported in the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. Dentate adults (n = 636) with a history of pre-existing cardiovascular disease were followed for CHD events. The presence of periodontitis and gingivitis did not increase CHD risk among these at-risk individuals (hazard ratio [HR], 0.97, and 95% confidence interval [CI], 0.72-1.31; and HR, 1.09, and 95% CI, 0.79-1.50, respectively). When limited to individuals with a self-reported prior heart attack, periodontitis was associated with a 34% decreased CHD risk (HR, 0.66; 95% CI, 0.42-1.05). It is concluded that periodontitis or gingivitis does not elevate CHD risk among individuals with a prior heart attack or self-reported pre-existing cardiovascular disease.

Fractal dimension on dental radiographs.

OBJECTIVES: (1) To compare fractal dimension (FD) from periapical radiographs with FD from panoramic radiographs; (2) to correlate FD with cortical thickness and morphology; and (3) to correlate FD with a reported history of osteoporotic fractures. METHODS: Information on fracture and smoking history was obtained by a telephone interview with 281 elderly (>60 years of age) patients who had periapical and panoramic radiographs exposed on the same date. FD was measured in several locations on both types of radiograph. Mandibular cortical thickness and morphology were obtained from the panoramic radiograph. RESULTS: FD measured in the mandible was lower than FD in the maxilla. Same-jaw measurements had a higher correlation than same-side measurements. FD measured on panoramic radiographs was lower than FD from periapical radiographs. There was a negative correlation between cortical thickness and FD. FD was higher in subjects with more mandibular cortical porosities and resorption. The mean panoramic FD from subjects with a history of osteoporotic fractures was significantly higher, after adjusting for smoking, gender, age, height and weight. CONCLUSIONS: FD measured on panoramic radiographs is lower than FD measured on periapical radiographs. FD is higher in both types of radiograph in subjects with a thinner, severely eroded mandibular cortex and a history of osteoporotic fractures. This study confirms other reports that FD increases when bone mass decreases. In addition, it suggests that panoramic radiographs can be used as a possible alternative for the measurement of FD to periapical radiographs.

Examining the link between coronary heart disease and the elimination of chronic dental infections.

BACKGROUND: While it has been suggested that periodontal disease may be associated with coronary heart disease, or CHD, there are no data to suggest that the elimination of chronic dental infections actually lowers the risk of developing chronic CHD. The goal of this study was to determine whether people with a definitive elimination of all potential dental infections--edentulous people, who are at the optimum endpoint of dental infection elimination from a CHD perspective--lower their CHD risk over time when compared with people who have a specific dental infection, periodontitis. METHODS: The authors examined data from a prospective cohort of 4,027 people who participated in the First National Health and Nutrition Examination Survey, or NHANES I, Epidemiologic Follow-up Study. The primary outcome measure was the first CHD event. RESULTS: During a mean follow-up of 17 years, there were 1,238 CHD events (538 fatal). The confirmed elimination of chronic dental infections did not lead to a decreased risk of experiencing a CHD event (relative risk, 1.02; 95 percent confidence interval, 0.86-1.21). The CHD risk among people with and without chronic dental infections remained constant over time with respect to each other (test for increasing or decreasing trend over time: not significant, chi2(1) = 0.48; P = .93). CONCLUSIONS: People who had a complete, definitive and long-term elimination of all potential dental infections through extraction of all teeth did not have lower CHD risk when compared with people with diagnosed periodontitis. CLINICAL IMPLICATIONS: Until evidence is found to the contrary, the authors suggest that prevention of CHD should not be used as the basis for recommending treatment to eliminate chronic dental infections.

The dentogingival epithelial surface area revisited.

Recent studies implicating periodontitis as a cause of systemic diseases have reported that the surface area of periodontal pockets exposed to bacterial biofilm ranges from 50 cm2 to 200 cm2. Since the root surface area of the typical human dentition (excluding 3rd molars) is 75 cm2, these estimates appear too large. The goal of this study was to relate linear periodontal probing measurements to the dentogingival surface area (DGES). The DGES comprises both the sulcular and junctional epithelium, present in health, as well as any intervening pocket epithelium present in periodontitis. Formulas to estimate the DGES from clinical measures were derived from a meta-analysis of root surface areas, published values of root length, and a study that related the percent remaining root surface area to the percent remaining root length. These formulas were applied to a survey of the adult US population, the Veterans Affairs (VA) Dental Longitudinal Study, and a population of individuals visiting a periodontist. Individuals without periodontitis had a typical DGES of 5 cm2. Among individuals with periodontitis, the mean DGES in the three samples ranged from 8 cm2 (ranging from 1 cm2 to 29 cm2) to 20 cm2 (ranging from 2 cm2 to 44 cm2). It was concluded that the mean DGES among individuals with periodontitis ranges from 8 cm2 to 20 cm2, considerably smaller than the range of 50 cm2 to 200 cm2 currently assumed.