Maximal strength training improves walking performance in peripheral arterial disease patients.

Peripheral arterial disease (PAD) patients have reduced muscle strength and impaired walking ability. The aim of this study was to examine the effects of maximal strength training (MST) on walking economy and walking performance in PAD patients. Ten patients with mild to moderate-severe claudication, classified as Fontaine stage II PAD and with functional limitations from intermittent claudication were recruited and went through an 8-week control period followed by an 8-week, three times a week, MST period. The patients performed four sets of five repetitions dynamic leg press with emphasis on maximal mobilization of force in the concentric action and with a progressive adjusted intensity corresponding to 85-90% of one repetition maximum (1 RM). After the MST period, leg press 1 RM significantly increased by 35.0 ± 10.8 kg (31.3%). Dynamic rate of force development, measured on a force plate installed on the leg press, increased by 1424 ± 1217 N/s (102.7%). The strength improvements led to a significant increase in walking economy of 9.7% when walking horizontally, and to a significant increase in walking performance of 13.6% measured on an incremental treadmill test to exhaustion. No changes were apparent after the control period. No changes in body mass or peak oxygen uptake were observed. MST increases strength in Fontaine stage II PAD patients and leads to improved walking economy. These results suggest that application of MST could accompany aerobic endurance training as a part of the treatment of PAD patients with mild to moderate-severe claudication.

The natural history of periodontal disease in man. Risk factors for progression of attachment loss in individuals receiving no oral health care.

BACKGROUND: Few investigations have reported on risk factors for periodontal attachment loss over time in subjects with no home or professional dental care. The purpose of this report was to identify potential risk factors for progression of periodontal attachment loss among male Sri Lankan tea laborers who participated in a 20-year investigation of the natural history of periodontal disease. METHODS: Data for this report were obtained from the 154 subjects who participated in the 1970 baseline and the final 1990 examinations and included data from their interim examinations performed in 1971, 1973, 1977, 1982, and 1985. Oral health assessments included: 1) attachment levels in millimeters on mesial and mesio-buccal surfaces of all but third molar teeth; 2) plaque index (PI); 3) gingival index (GI); 4) calculus index (CI); 5) caries index (DMFS); and 6) presence or absence of teeth. Other variables included age, history of smoking, and/or use of betel nut. Statistical analyses used multivariate repeated measures analysis of variance (ANOVA). RESULTS: The final adjusted model indicated that attachment loss increased significantly with age (X2 = 74.0; df = 1), GI (X2 = 45.5; df = 1), CI (X2 = 52.7; df = 1) and follow-up time (X2 = 219.8; df = 6, P<0.0001 for all variables). CONCLUSIONS: Age, GI, CI, and time were significantly associated with mean attachment loss over 20 years. Neither PI, history of smoking, or history of betel nut use were significantly associated with attachment loss over time.

The influence of margins of restorations of the periodontal tissues over 26 years.

AIM: The purpose of this investigation was to examine the long-term relationship between dental restorations and periodontal health. MATERIAL AND METHODS: The data derived from a 26-year longitudinal study of a group of Scandinavian middle-class males characterized by good to moderate oral hygiene and regular dental check-ups. At each of 7 examinations between 1969 and 1995, the mesial and buccal surfaces were scored for dental, restorative and periodontal parameters. The mesial sites of premolars and molars of 160 participants were observed during 26 years (1969-1995). A control group with 615 sound surfaces or filling margins located more than 1 mm from the gingival margin in all 7 surveys was compared with a test cohort with 98 surfaces which were sound or had filling margins located more than 1 mm from the gingival margin at baseline (1969) and had a subgingival filling margin 2 years after (1971). RESULTS AND CONCLUSIONS: The study confirmed the long held concept that restorations placed below the gingival margin are detrimental to gingival and periodontal health. In addition, this study suggests that the increased loss of attachment found in teeth with subgingival restorations started slowly and could be detected clinically 1 to 3 years after the fabrication and placement of the restorations. A subsequent "burn-out" effect was suggested.

Oral hygiene in the prevention of caries and periodontal disease.

While some periodontal disease may be as old as mankind itself, caries as a public health problem appeared with the development of flour and sugar mills, and the universal access to fermentable carbohydrates. As a consequence, during the last 500 years caries and periodontal disease have been the most common diseases afflicting the human mouth. Together, these two diseases have been responsible for untold pain and suffering, and for excessive destruction and loss of people's teeth. With improving social circumstances in most industrialised nations, increased availability and affordability of modern oral health care, and the promotion of conservative treatment concepts, the 20th century saw significant progress in eliminating pain and tooth loss. Moreover, during the last 50 years advances in the oral health sciences and in technology, have not only increased our understanding of the nature of these diseases and their causes, but also introduced and tested new approaches to their prevention.

Public health workforce information: a state-level study.

A two-stage sample survey was used to estimate the size of Texas' professional public health workforce and to describe its composition in terms of employment settings, job characteristics, and individual characteristics. The estimated 17,700 public health professionals employed in 1995 represented approximately three percent of the state's total health workforce. About 55 percent of all these professionals worked in agencies that provide population-based public health services. An estimated seven percent had formal public health education. These findings raise issues concerning the numerical adequacy of the state's supply of public health professionals, the adequacy of their educational preparation, and the human resources capacity of the state's official public health agencies.

The informativeness of attachment loss on tooth mortality.

BACKGROUND: In periodontal clinical trials, clinical attachment level measurements are commonly used as surrogates for tooth loss. Conclusions regarding treatment efficacy in these trials are valid if: 1) the surrogate is informative on tooth loss, and 2) the surrogate captures the effect of treatment on tooth loss. The goal of this study was to evaluate the first criterion: Are serial clinical attachment loss measurements informative on overall tooth mortality? METHODS: Young Norwegian men (aged 17 to 35) were first examined in 1969 (n=565) and followed for 26 years with examinations in 1971 (n=381), 1973 (n=292), 1975 (n=245), 1981 (n=228), 1988 (n=202), and 1995 (n=223). Several aspects of the serial attachment loss measurements were related to tooth mortality risk using statistical models that take into account the time-dependent changes of the clinical attachment loss measurements. RESULTS: The results provided evidence that moderate attachment losses were informative on tooth mortality. Both the lifetime cumulative attachment loss, as well as attachment loss since young adulthood, of > or = 2 mm or > or = 3 mm was informative on tooth mortality. Tooth mortality risk increased as the attachment loss increased; loss > or = 3 mm at the buccal or mesial site increased tooth mortality risk, by 91% (relative risk, 1.91; 95% confidence interval, 1.01-3.60) and 270% (RR, 3.70; 95% CI, 1.83-7.49), respectively. CONCLUSIONS: We concluded that clinical attachment loss was moderately informative on overall tooth mortality in this Norwegian population. Since this finding has now been demonstrated in 3 different populations, the focus of further research should be on evaluating whether the second criterion for a valid surrogate is satisfied: Does clinical attachment loss capture the effect of periodontal treatments on tooth loss?

Forty-five-year tooth survival probabilities among men in Oslo, Norway.

Changes in tooth survival probabilities over a person's lifetime have remained largely unexplored. The goal of this study was to evaluate changes in the 45-year tooth survival probabilities in a cohort of 565 Norwegian males who were examined in 1969 as young adults, and followed up into mid-life (examination years and sample sizes (n): 1971 (n = 381), 1973 (n = 292), 1975 (n = 245), 1981 (n = 228), 1988 (n = 202), and 1995 (n = 223). The results indicated that the tooth survival probabilities varied considerably both (i) among teeth within individuals, and (ii) over time. The 45-year survival probabilities for the 28 teeth fell into the following ranges: larger than 95% for incisors and cuspids; between 84% and 92% for premolars; and between 59% and 96% for molars. Over the first 4 post-eruptive decades, the tooth mortality risks (excluding orthodontic extractions) were: 1st decade, 2.0% (from 1.7 to 2.4%); 2nd decade, 0.2% (from 0.1 to 0.4%); 3rd decade, 0.6% (from 0.4 to 0.8%); and 4th decade, 1.1% (from 0.8 to 1.5%). The tooth mortality risks in the 2nd, 3rd, and 4th decades were probably somewhat underestimated (due to dropout bias), suggesting that the true underlying tooth mortality hazard function may have been V-shaped. The conclusions were that the tooth mortality hazard during the first 4 post-eruptive decades was bathtub-shaped and that it varied considerably among teeth within individuals.

Gingival inflammation and subgingival calculus as determinants of disease progression in early-onset periodontitis.

This study was undertaken to test the hypothesis that gingival inflammation and dental calculus are important determinants of the development and progression of early-onset periodontitis. The study sample included 156 individuals who were 13-20 years old at baseline and who were examined 2x during 6 years to assess the attachment loss, gingival state and the presence of dental calculus. 33 (21%), 62 (40%), and 61 (39%) individuals were classified as having localized, generalized, or incidental EOP, respectively. The results showed an increase in the % of teeth with overt gingivitis and subgingival calculus, and also an increase in the % of teeth showing attachment loss during the 6-year period in all classification groups. Of teeth with 0-2 mm attachment loss at the beginning of the study and which developed > or = 3 mm attachment loss during the following 6 years, there were 2x as many teeth with overt gingival inflammation, and 4x more teeth with subgingival calculus at baseline than teeth without. Gingivitis and subgingival calculus when present at both examinations resulted in a stronger association with the development of new lesions than presence of these variables at baseline. Teeth with gingivitis at baseline had a significantly higher mean attachment loss during 6 years than teeth without gingivitis (p<0.0001), and teeth with subgingival calculus at baseline had a significantly higher mean attachment loss than teeth without subgingival calculus (p<0.0001). The presence of gingivitis and subgingival calculus at baseline and 6 years later was associated with the occurrence of even higher disease progression during this period. The association between gingival inflammation and subgingival calculus and the development and progression of attachment loss during the study period in the generalized and the localized EOP groups was significantly higher than the association in the incidental EOP group. In an appreciable % of the sites in all 3 groups, however, the presence of the 2 factors was not associated with attachment loss during 6 years. The results suggest a significant association between gingival inflammation and subgingival calculus and the development and progression of early-onset periodontitis.

Periodontal diseases in the United States population.

Recent epidemiologic surveys and studies have provided important information on the prevalence, extent, and severity of periodontal diseases in the United States. Over 50% of adults had gingivitis on an average of 3 to 4 teeth. Subgingival calculus was present in 67% of the population. Adult periodontitis, measured by the presence of periodontal pockets > or = 4 mm, was found in about 30% of the population on an average of 3 to 4 teeth. Severe pockets > or = 6 mm were found in less than 5% of the population. Attachment loss > or = 3 mm was found in 40% of the population. Gingival recession accounted for a significant amount of attachment loss. The prevalence of early-onset periodontitis ranged from less than 1% in 14- to 17-year-olds to 3.6% in young adults aged 18 to 34. Extensive and severe periodontitis was much more prevalent in minorities, people with less than a high school education, and those who had seen a dentist infrequently and had subgingival calculus. Smoking and diabetes have been identified as risk factors, especially diabetics with poor metabolic control, a long duration of the disease, and extensive subgingival calculus. Under managed care, there has been an expansion of soft tissue management programs in the offices of general dentists and referral guidelines which limit referral of patients with moderate periodontitis. Quality-assurance mechanisms will be essential for the diagnosis and treatment of persons with periodontitis.

Putative periodontal pathogens in subgingival plaque of young adults with and without early-onset periodontitis.

This study assessed the associations between putative periodontal pathogens and early-onset periodontitis (EOP) in a population of 248 subjects, 13 to 19 years of age at baseline, derived from a representative sample of U.S. young adults. The subjects were selected based on the presence or absence of attachment loss at baseline. The attachment level was assessed clinically at baseline and at a 6-year follow-up examination, and the presence of 7 bacterial species was assessed at follow-up using DNA probes. The individuals were classified into generalized, localized, incidental EOP, and no-periodontitis groups based on the extent and severity of attachment loss; and classified as having rapid, moderate, slow, and no progression based on the rate of periodontal progression during the 6 preceding years. In the EOP groups there were significantly higher percentages of individuals with detectable levels of Porphyromonas gingivalis, Prevotella intermedia, Fusobacterium nucleatum, Campylobacter rectus, and Treponema denticola. In addition, the EOP group had significantly higher levels of these 5 microorganisms compared to the no-periodontitis group. There were also higher percentages of individuals with these species and higher levels of bacteria in the group showing disease progression than the group without progression. In a descending order of importance, P. gingivalis, T. denticola, and P. intermedia were the microorganisms significantly associated with the generalized and/or rapidly progressing disease. F. nucleatum and C. rectus were also associated with EOP, but to a lesser degree. In the present population Actinobacillus actinomycetemcomitans was not significantly associated with EOP, though it was recovered more often from subjects with localized EOP. Eikenella corrodens was present equally in subjects with and without disease. The results show that several bacterial species are associated with EOP, and that P. gingivalis and T. denticola are of particular importance and may play a significant role in the more severe and progressive forms of EOP.

Clinical features of early-onset periodontitis.

The authors estimate the prevalence of early-onset periodontitis, or EOP, in U.S. adolescents and describe the clinical features that occur at an early stage in those who have EOP. In 1986 and 1987, about 10.0 percent of African-American, 5.0 percent of Hispanic and 1.3 percent of white U.S. adolescents had EOP. Clinical features that may be useful in the early detection of EOP include overt gingival inflammation, dental calculus and a high rate of caries, restorations and tooth loss.

Clinical classification of periodontitis in adolescents and young adults.

THE AIM OF THIS STUDY was to determine the degree to which clinical classifications based on cross-sectional assessments endure in the course of development of early-onset periodontitis (EOP), and to introduce new criteria which might improve the clinical classification of these diseases. Subjects with EOP and a matched group without EOP were identified within a national probability sample examined during the 1986/87 survey of US schoolchildren. Of these, 265 subjects (mean age 16 years) were re-examined during the 1992/93 school year. The clinical attachment level of teeth was assessed, and the individuals were classified into localized juvenile periodontitis (LJP), generalized juvenile periodontitis (GJP), incidental attachment loss (IAL), and no-periodontitis groups using three classification methods previously described. A fourth method that considered the extent and severity of attachment loss and the number of missing teeth was introduced to classify the individuals at baseline and at follow-up as having localized, generalized, or incidental EOP, and no-periodontitis groups. Furthermore, the individuals were classified using criteria based on the rate and pattern of change in attachment loss during 6 years. The results showed low correlations between the baseline classifications and the classifications at the 6-year follow-up examination, irrespective of the method used. In addition, the cross-sectional classifications were not predictive of the rate of progression of periodontal disease in these subjects. In the generalized disease group, two-thirds of the individuals exhibited moderate/rapid disease progression, while one-third had slow or no progression. In the localized disease group, one-half of the individuals had moderate/rapid disease progression and one-half had slow or no progression. In the incidental disease group one-fourth of the individuals had moderate/rapid disease progression and three-fourths had slow or no progression. We propose that the term early-onset periodontitis be used as a generic term to describe periodontal disease before its normal onset. In addition, we suggest that incidental, localized, and generalized EOP are heterogenous groups comprising rapidly and slowly progressing forms within each classification. The findings suggest that a classification system in which subsets of the disease that are defined according to a combination of cross-sectional criteria and the disease progression may be useful in studies of EOP. Furthermore, the findings suggest that clinical classifications of EOP be used as generic descriptors until a full understanding of the pathogenesis of this disease is accomplished.

Gingival state and dental calculus in early-onset periodontitis.

This study was undertaken to 1) compare the prevalence of gingival inflammation and dental calculus in adolescents with early-onset periodontitis and their matched controls and 2) assess and compare the relationship between the presence of dental calculus and the extent of gingival bleeding and attachment loss in these subjects. The study group consisted of 1,285 13 to 20 year-old individuals, 651 males and 634 females, selected from a national survey of the oral health of U.S. adolescents in 1986/1987. It included 709 (55.2%) Blacks, 224 (17.4%) Hispanics, and 352 (27.4%) Whites. Eighty-nine subjects had localized or generalized juvenile periodontitis (JP), 218 had incidental attachment loss (IAL), and 978 were without clinical attachment loss (controls). The controls were matched to cases on gender, race, age, and geographic location. The subjects were examined clinically to assess the percentage of sites with gingival bleeding and supragingival calculus only and subgingival calculus with or without supragingival calculus. The IAL and JP groups had significantly more gingival bleeding and subgingival calculus than the controls. Also, the JP group had significantly higher prevalence of both conditions than the IAL group. The percentage of sites with supragingival calculus was not different between the groups, but varied by ethnicity. Hispanics with JP had the highest percentage of sites with gingival bleeding and subgingival calculus, and the lowest percentage of sites with only supragingival calculus. The results demonstrate that gingival inflammation and subgingival calculus are associated with early periodontal breakdown, and contradict earlier reports of early-onset periodontitis not being associated with these factors.

Dental caries and tooth loss in adolescents with early-onset periodontitis.

The aim of this study was to assess the caries experience and tooth loss over 6 years in subjects with early-onset periodontitis as compared to their matched controls, and to describe the characteristics of teeth lost during this period. A multi-stage probability sample representing 8th to 12th grade U.S. schoolchildren were screened during the 1986/1987 school year to identify subjects with early-onset periodontitis (cases). The examination included measuring the clinical attachment level, presence of caries and dental restorations, and tooth loss. A random sample of controls without early-onset periodontitis were selected for a follow-up examination and were matched to cases on gender, race, age, and geographic location. A total of 266 subjects, with a mean age of 16 years at baseline, were examined during the 1992/1993 school year and were classified into localized (LJP) and generalized juvenile periodontitis (GJP), incidental attachment loss (IAL), and control groups. Whites had more caries experience than Blacks and Hispanics, but there were no significant differences in tooth loss between the ethnic groups. The LJP and the IAL groups, respectively, had higher and lower overall caries experience than the control group. The LJP group had a significantly higher number of missing teeth at follow-up, and exhibited more extensive tooth mortality during 6 years than the control group. The GJP group also showed more tooth loss than the control group, but the difference was not statistically significant. In the LJP, GJP, IAL, and control groups, respectively, 43%, 32%, 26%, and 18% of the subjects lost teeth over 6 years due to disease. The findings showed differences in caries activity between the early-onset periodontitis groups and a variation by race. The findings suggest that loss of periodontal support was the principal cause for tooth loss in the LJP and GJP groups, and that dental caries was the principal cause for tooth extraction in the IAL and the control groups.

Early-onset periodontitis: progression of attachment loss during 6 years.

We studied the pattern of progression of early-onset periodontitis and the change in the extent and severity of the periodontal condition in adolescents who were followed for 6 years. In a national survey of the oral health of U.S. children, 14,013 adolescents were examined clinically in 1986/1987 to assess the periodontal attachment loss of teeth. Individuals with early-onset periodontitis within this population were identified and classified into localized juvenile periodontitis (LJP), generalized juvenile periodontitis (GJP), and incidental attachment loss (IAL) groups. Ninety-one subjects, 13 to 20 years old at baseline, were examined 6 years later. They included 51 males and 40 females; and 72 Blacks, 6 Hispanics, and 13 Whites. They were clinically re-examined and then reclassified according to their periodontal status at follow-up. The severity and extent of these diseases continued to increase during the study period. In teeth that were affected at baseline, the lesions had progressed to include deeper portions of the periodontium, and more of the teeth unaffected at baseline exhibited periodontal attachment loss at follow-up, thus changing the disease characteristics and the basis for the clinical classification. Of the individuals classified with LJP at baseline, 62% continued to have LJP 6 years later and 35% developed GJP. Of those classified with GJP initially, all but two (82%) continued to have GJP at follow-up. Among the IAL group, 28% of subjects developed LJP or GJP, and 30% were reclassified in the no attachment loss group. Molars and incisors were the teeth most often affected in all three groups. The mean change in attachment loss over 6 years in the LJP, GJP, and IAL groups was 0.45, 1.12, and 0.13 mm, respectively. The present findings demonstrate the limitations of the currently used morphological criteria in the classification of early-onset periodontitis. The findings also suggest that the difference between LJP and GJP is in the number and type of teeth involved, and that the two classifications progress similarly, with some cases of LJP developing into GJP.

The natural history of periodontal disease. The correlation of selected microbiological parameters with disease severity in Sri Lankan tea workers.

The purpose of this study was to assess the prevalence of A. actinomycetemcomitans, Porphyromonas gingivalis and Prevotella intermedia, and their association with periodontal disease states in a population sample from Sri Lanka. Based on clinical parameters, a total of 536 sites in 268 male Sri Lankan tea workers were categorized as healthy, or showing gingivitis only, moderate or advanced periodontitis. Bacterial samples were obtained from all sites and the three target bacteria identified by indirect immunofluorescence. P. intermedia, P. gingivalis and A. actinomycetemcomitans were found in 76%, 40% and 15% of the subjects, respectively. Of the 536 periodontal sites, 10.5% were categorized with "no disease", 14% "gingivitis only": 59% with moderate and 16% with advanced periodontitis. The prevalence of P. gingivalis and P. intermedia was significantly higher in sites with moderate and advanced periodontitis than in sites with no disease or gingivitis only. A. actinomycetemcomitans was not found in healthy sites, but occurred with equal frequency in sites with gingivitis, moderate and advanced periodontitis. The association between these three bacteria and periodontal diseases in Sri Lankan tea laborers was similar to that described for other non-industrialized and industrialized countries.

Changing paradigms in restorative dentistry.

Dramatic improvements in oral health have occurred during the last twenty years. Success is most noticeable in children and young adults, but also extends to the general population. The impact from declining disease rates, improved restorative materials and techniques, new diagnostics and treatments, a broad array of preventives, and better ways to deliver products and services to the public are demonstrated in the decline in the number of restorative procedures performed each year, including a 40% decline in the use of amalgam over the last eleven years. The new paradigm for restorative dentistry calls for an increasingly conservative approach to treatment. The question now is not primarily whether amalgam, composite, or any other material will fill a cavity. The real issue is to make the distinction between caries as a disease and caries as a lesion. Treating caries as a disease requires a new approach to patient management. A diagnosis of caries requires that a patient risk profile be established. We can no longer be limited in our efforts to merely restore the individual tooth surface. This paper discusses the need to cure disease and restore the total integrity of our patients' oral health.