Clinical Attachment Loss Measurements Research Articles

Multi-nutrients and periodontal disease - a new adjunct to improving treatment outcomes? A randomised placebo-control clinical trial.

This study by Laky et al. is a single-centre, double-blinded randomised placebo-controlled clinical trial, examining the effects of micronutrient supplementation in combination with non-surgical hygiene phase therapy (nsHPT)for Stage III and IV periodontal disease. The study was carried out at the Medical University of Vienna (Austria), School of Dentistry. The patients enrolled in the study were randomised to receive a commercially available multi-nutrient supplement (containing: vitamin C, vitamin E, zinc, selenium, alpha-lipoic-acid, cranberry extract, grapeseed extract, and coenzyme Q10) or a cellulose placebo to take for 2 months, alongside a course of non-surgical hygiene phase therapy. At baseline, the patients had a periodontal index screening (PSI) performed. Patients scoring >3 and meeting the inclusion criteria were enrolled in the trial. Oral hygiene instruction and patient education was performed, followed by 1 or more sessions of nsHPT depending on the clinical assessment of each patient, and a full periodontal probing depth (PPD) chart was recorded. The patients were then randomised to receive either the multi-nutrient supplement or the placebo to take twice daily for 8 weeks. Following this 8-week period the PPD as well as bleeding on probing (BOP), gingival recession (GR) and clinical attachment loss (CAL) were measured. The randomisation was carried out by a study-independent member of staff at the centre using a computer programme. A total of 149 patients were assessed for eligibility for this trial. Out of these patients, 83 were deemed to be unsuitable for the trial as they failed to meet the inclusion criteria, and 24 declined to participate. A total of 42 patients were then randomised to each arm of the study. The inclusion criteria included patients with Stage III and IV periodontal disease. Patients were deemed eligible if they met the following criteria: presence of 18 or more scorable teeth (excluding 3rd molars); >4 teeth with PPD of >6 mm; CAL > 5 mm, and no previous periodontal treatment in the past. Percentage bone loss at the most severe site, smoking status, and presence of diabetes and diabetic control were all taken into consideration. Patients were deemed ineligible for the trial if they were pregnant or under 18 years old. Exclusion criteria also included: recent periodontal abscess; a past or current co-morbidity which may confound the results of the study or endanger patients partaking in the study (i.e. malignancy, rheumatoid arthritis, and other severe systemic conditions); and obesity. PPD was used as the primary variable in this study. Other measured outcomes such as GR, CAL, BOP and other measurements taken, such as papillary bleeding index (PBI) and papillary inflamed surface area (PISA), were considered as secondary outcome variables. A variety of tests were used in order to assess the collected data. The Kolmogorov‒Smirnov test and Levene test were used for the equality of variances, and ICC and 95% CI were used when comparing periodontal chartings for PPD (in mm). Chi-square or Fisher tests were used for categorical data between intervention and placebo. The baseline and reevaluation data was compared using the McNemar test. All data was analysed using statistical software. Significant data is indicated by a p value < 0.05. The number of patients included for analysis was reduced to n = 20 for the intervention group and n = 19 for the placebo group. Patients were lost due to a variety of reasons including need for antibiotics and lost to follow-up. The authors concluded that in each arm of the trial, periodontal and hygiene parameters improved overall. The results show that the intervention group had a significantly higher reduction in PPD; however, following data analysis, these findings were found to be statistically insignificant. The authors conclude that the addition of a multi-nutrient supplement, alongside nsHPT for patients undergoing treatment for Stage III and IV periodontal disease, showed a reduction in PPD and BOP when compared with a placebo and nsHPT.

The effect of antipsychotic medication and the associated hyperprolactinemia as a risk factor for periodontal diseases in schizophrenic patients: a cohort retrospective study

BackgroundPeriodontal disease is a major health problem that results in tooth loss and thus affects oral health, which affects quality of life. In particular, schizophrenic patients are at higher risk for periodontal disease due to several factors, including the effect of antipsychotic medications received by those patients. Accordingly, the aim of the present cohort retrospective study is to explore the effect of antipsychotics on periodontal health and the possible effect of antipsychotic-induced hyperprolactinemia as a risk factor for periodontal disease progression in schizophrenic patients.Methods and outcomesThe study population consisted of three groups: Group A (n = 21): schizophrenic patients that have been taking “prolactin-inducing” antipsychotics for at least 1 year; Group B (n = 21): schizophrenic patients who have been taking “prolactin-sparing” antipsychotics for at least 1 year; and Group C (n = 22): newly diagnosed schizophrenic patients and/or patients who did not receive any psychiatric treatment for at least 1 year. The study groups underwent assessment of periodontal conditions in terms of pocket depth (PD), clinical attachment loss (CAL), gingival recession, tooth mobility, and bleeding on probing (BOP). Also, bone mineral density was evaluated using DEXA scans, and the serum prolactin level was measured by automated immunoassay.ResultsResults revealed a statistically significant difference in PD, CAL, and serum prolactin levels (P ≤ 0.001, P = 0.001, and P ≤ 0.001, respectively) among the 3 study groups. For both PD and CAL measurements, group A has shown significantly higher values than both groups B and C, whereas there was no statistically significant difference between the values of groups C and B. Concerning serum prolactin levels, group A had significantly higher values than groups B and C (P ≤ 0.001 and P ≤ 0.001 respectively). There was a statistically significant difference (P ≤ 0.001) between the 3 study groups in terms of bone mineral density. Moreover, there was a statistically significant direct relation between serum prolactin level and other parameters including clinical attachment loss, pocket depth measurements and bone mineral density.ConclusionAccording to our results, it could be concluded that all antipsychotics contribute to the progression of periodontal disease, with a higher risk for prolactin-inducing antipsychotics. However, further long term, large sampled, interventional and controlled studies are required to reach definitive guidelines to allow clinicians properly manage this group of patients.

Contribution of dental health in cardiovascular secondary prevention

Abstract Backgrounds Previous studies have suggested that periodontitis is associated with cardiovascular disease (CVD), partly through exaggerated systematic inflammation through pathogens breaking into the bloodstream and their metabolic products. However, the clinical evidence in the cardiovascular secondary prevention is limited. In addition, there is a paucity of data about the contribution of comprehensively assessed dental health, including dental caries or teeth loss, to CVD incidence. Consequently, current ESC guideline for CVD prevention just briefly refers the contribution of dental health [1]. Objective To investigate the associations between teeth loss, periodontitis, and dental caries and incident major adverse cardiovascular events (MACE) in patients with existing CVD. Methods Patients with known CVD who were admitted to the Department of Cardiology between May 2012 and August 2015 were prospectively, consecutively enrolled. Patients underwent comprehensive dental examinations, including counts of lost teeth, dental caries, and periodontal measurements of clinical attachment loss (CAL), periodontal probing pocket depth (PPD), and bleeding on probing (BOP) by trained periodontists during the hospital stay. We assessed the associations between these dental measures and MACE, defined as a composite of cardiac death, acute myocardial infarction, stroke, and hospital re-admission for worsened congestive heart failure, using multivariate COX proportional hazard models and restricted mean survival time (RMST) analyses. P-values were adjusted by Bonferroni methods. Results Among 888 patients included for the present analyses, the mean age was 63.9 (SD: 13.1) years and there were 242 (27.3%) women. During a median follow-up of 4.6 (IQR: 1.4, 6.7) years, incident MACE was confirmed in 142 patients. In multivariate COX proportional hazard models, one more tooth loss was associated with 3 (95% CI: 1, 5) % higher hazard of MACE (adjusted p=0.020). Kaplan-Meier curves showing survival from MACE according to the quartiles of teeth loss were described in Figure 1. Compared with patients with 0 to ≤4 lost teeth, periods free from MACE (95% CI) by 5-years of follow-up were on average shorter by 0.17 (−0.04, 0.37) years, 0.26 (0.04, 0.49) years, and 0.59 (0.34, 0.85) years in patients with 5 to ≤7, 8 to ≤13, and &amp;gt;13 lost teeth, respectively. The RMST differences with varied cutoff years were shown in Figure 2. There were no significant associations between the number of dental caries, CAL, PPD, and BOP and MACE incidence. Conclusion In hospitalized patients due to existing cardiovascular diseases, total number of lost teeth was associated with incident MACE. Given that teeth loss is an ultimate consequence of periodontitis or dental caries, the present findings imply that efforts to prevent losing teeth by maintaining dental health would be effective measures for cardiovascular secondary prevention. Funding Acknowledgement Type of funding sources: None.

Periodontal health in the shortened dental arch.

Design Multi-centre randomised controlled clinical trial with two prosthetic intervention arms conducted in 14 dental schools and universities in Germany from October 2000.Case selection Adults aged ≥35 years with bilateral missing molars, both canines and at least one premolar present on each side in one jaw were eligible for inclusion. Participants were randomly allocated to restoration of posterior teeth using a removable partial denture (RPD), or a fixed prosthesis (that is, a bridge) adhering to the concepts of the shortened dental arch (SDA) principles (no replacement posterior to the second molar). Randomisation was completed centrally using randomly permuted blocks stratified by age. Data were collected at baseline (following pre-prosthetic treatment) and patients were followed up at six months, annually for five years, eight years and ten years.Data analysis In total, 215 participants were randomised and allocated to either RPD group (n = 109) or SDA group (n = 106). Intention to treat (ITT) and modified per-protocol analysis were performed on both the RPD group (n = 79) and SDA group (n = 71). Per-protocol analysis was also undertaken on both the RPD group (n = 25) and SDA group (n = 22). The level of significance was set to a two-sided p value of 0.05. The confidence interval was set at 95%.Results When considering the differences in ten-year vertical clinical attachment loss measurements, ITT analysis showed the differences between the RPD and SDA groups were statistically significant (p ≤0.05) in both the study jaw (0.79 mm) and in all teeth (0.69 mm) in favour of the SDA group. Furthermore, the SDA group also performed more favourably in both bleeding on probing and plaque index parameters, with statistically significant changes demonstrated using positive regression coefficients.Conclusions There is evidence of reduced impact on the periodontium from an SDA approach compared to an RPD approach, although the difference is unlikely to be clinically significant.

Periodontal Health of Pre-Dialysis Chronic Kidney Disease Patients in a Northeast Peninsular Malaysia Tertiary Hospital.

IntroductionChronic kidney disease (CKD) is associated with periodontal disease due to its hyperinflammatory state. Limited studies have explored the prevalence of periodontal disease among CKD patients in Malaysia.ObjectiveTo assess the periodontal status of pre-dialysis CKD patients in Hospital Universiti Sains Malaysia.MethodsA total of 46 pre-dialysis CKD patients who attended the nephrology clinic at Hospital Universiti Sains Malaysia were enrolled in this study. Periodontal examination was performed using the periodontal probing depth (PPD), clinical attachment loss (CAL) and plaque index.ResultsThe majority of the CKD patients were Malay (95.7%) and 80.4% were males. The mean age of the patients was 58.5 years. Using PPD measurement, 37 (74.0%) of the patients had mild periodontitis, 9 (20.0%) had moderate periodontitis and 3 (6.0%) had no periodontitis. Based on CAL measurement, 12 (26%) patients had mild periodontitis, 29 (63.0%) had moderate periodontitis and 5 (11%) had severe periodontitis. The mean (standard deviation [SD]) value of mild and moderate-to-severe periodontitis by PPD measurement were 4.26 (0.26) and 5.24 (0.36), respectively. The mean of mild and moderate-to-severe periodontitis by CAL measurement were 2.66 (0.62) and 4.98 (0.73), respectively. There was no correlation between the periodontal parameters and estimated glomerular filtration rate (PPD: r = −0.160, P = 0.914; CAL: r = −0.135, P = 0.372; plaque index: r = 0.005, P = 0.974).ConclusionThis study revealed a greater prevalence and severity of chronic periodontitis among CKD patients. Thus, the periodontal health of CKD patients’ needs to be screened and monitored.

CORRELATION OF SERUM OSTEOCALCIN LEVEL AND PERIODONTAL ATTACHMENT LOSS WITH OSTEOPOROSIS RISK STATUS IN POSTMENOPAUSAL WOMEN

Objective: To assess the relationship between serum osteocalcin and periodontal clinical attachment loss (CAL) in postmenopausal women in relation to their osteoporosis risk status.Methods: A cross-sectional study was carried out on 71 postmenopausal women in Kenari District, Central Jakarta, Indonesia. The periodontal examination for all the subjects included a CAL measurement. The serum osteocalcin level was analyzed using ELISA.Results: The correlation between the serum osteocalcin level in patients with CAL and the risk of osteoporosis was analyzed with the Spearman test. The normal group had 29 subjects (40.84%), the osteopenic group had 23 subjects (32.39%), and the osteoporotic group had 19 subjects (26.76%). There was a significant correlation between CAL and the osteoporosis high-risk status (p&lt;0.05) and no significant correlation between the serum osteocalcin level and the osteoporosis status (p&gt;0.05).Conclusion: No correlation was found between CAL and the serum osteocalcin level (p&gt;0.05).

Relationship Between Body Mass Index (Bmi) And Periodontal Status of Adult patients Visiting Department of Periodontics, Melaka Manipal Medical College-A Cross Sectional Study

Malaysia has been experiencing modernization for the last few decades. With modernization and urbanization, also comes a change in lifestyle, which is pointed more to a sedentary lifestyle and unhealthy dietary habits. This results in a staggering rate of obesity. The aim of this study was to find out the correlation between BMI and periodontal status in Malaccan patients visiting Faculty of Dentistry, Melaka-Manipal Medical College, Malaysia. Body Mass Index (BMI) was calculated using weight in kilograms and height chart and periodontal status was examined using clinical attachment loss measurements and Community Periodontal Index (CPI). From the study, it shows that there is no significant relationship between body mass index and periodontitis. However, a higher body mass index could be a potential risk factor for periodontitis in age group 35–54 years old.

Modelling changes in clinical attachment loss to classify periodontal disease progression

AimThe goal of this study was to identify progressing periodontal sites by applying linear mixed models (LMM) to longitudinal measurements of clinical attachment loss (CAL).MethodsNinety‐three periodontally healthy and 236 periodontitis subjects had their CAL measured bi‐monthly for 12 months. The proportions of sites demonstrating increases in CAL from baseline above specified thresholds were calculated for each visit. The proportions of sites reversing from the progressing state were also computed. LMM were fitted for each tooth site and the predicted CAL levels used to categorize sites regarding progression or regression. The threshold for progression was established based on the model‐estimated error in predictions.ResultsOver 12 months, 21.2%, 2.8% and 0.3% of sites progressed, according to thresholds of 1, 2 and 3 mm of CAL increase. However, on average, 42.0%, 64.4% and 77.7% of progressing sites for the different thresholds reversed in subsequent visits. Conversely, 97.1%, 76.9% and 23.1% of sites classified as progressing using LMM had observed CAL increases above 1, 2 and 3 mm after 12 months, whereas mean rates of reversal were 10.6%, 30.2% and 53.0% respectively.Conclusion LMM accounted for several sources of error in longitudinal CAL measurement, providing an improved method for classifying progressing sites.

Association between periodontitis and acute myocardial infarction: a case–control study of a nondiabetic population

Periodontitis and acute myocardial infarction (AMI) are two diseases that share common risk factors. The role of periodontitis as an independent risk factor for cardiovascular disease has been under debate. The aim of this study was to investigate whether an association exists between periodontitis and AMI in a nondiabetic population, using multiple periodontal case definitions. Periodontal examination was performed in 204 patients with AMI. The control group comprised 102 healthy subjects, without significant coronary disease, confirmed angiographically. Periodontitis was assessed using measurements of clinical attachment loss (CAL), probing depth and number of missing teeth. From these measurements, five different case definitions of periodontitis were generated. Using the continuous forms of periodontal measurements, the odds ratio (95% confidence interval) of the association with incident AMI was 1.74 (1.26-2.50), 1.83 (1.10-3.17) and 1.08 (1.06-1.13) for mean CAL, probing depth and number of missing teeth, respectively. A consistent positive association was observed regardless of the case definition of periodontitis. In this nondiabetic population, the association between periodontitis and AMI was consistent across different measurements and/or definitions of periodontitis. The strength of the association increased concomitantly with the robustness of the criteria used to define periodontitis.

Radiological analysis of the relationship between occlusal tooth wear and mandibular alveolar bone density and height

The aim of this study was to examine the relationship between occlusal tooth wear and mandibular alveolar bone density (ABD) and alveolar bone height (ABH) using computer-assisted densitometric image analysis (CADIA) program. The study was comprised of 134 mandibular first molar teeth in 90 patients with various degrees of occlusal tooth wear. The degree of tooth wear was classified according to the tooth wear index (TWI). Periodontal examinations were performed on all patients and included plaque index, gingival index, probing depth, and clinical attachment loss measurements. ABD and ABH were measured from intraoral digital periapical radiographs and analyzed using CADIA. No increases in ABD were observed between TWI 0 and TWI 1 or between TWI 0 and TWI 2 (P > 0.05). However, increases in ABD were observed between TWI 0 and TWI 3 (P < 0.01), TWI 1 and TWI 3 (P < 0.01), TWI 1 and TWI 2 (P < 0.05) and TWI 2 and TWI 3 (P < 0.05). In addition, ABH was found to increase with increase in wear, with the exception of the interval between TWI 0 and TWI 1. Occlusal tooth wear does not result in any radiologically identifiable changes in the alveolar bone during the initial stages of wear; however, significant increases in both ABD and ABH may be observed as tooth wear progresses.

Avaliação da perda de inserção dentária em pacientes com doença renal crônica em hemodiálise

Chronic kidney failure (CKF) is a clinical syndrome due to the slow, progressive and irreversible loss of the glomerular filtration rate. CKF may be associated with several oral manifestations, such as xerostomia, uremic stomatitis and periodontitis, diagnosed as clinical attachment loss (CAL). 92 patients, from the Prontorim Hemodialysis Clinic of Fortaleza, Ceará, Brazil, were investigated. Only 34 patients (37%) were eligible for periodontal investigation, which consisted of CAL measurement (values grater than 2 mm diagnosing periodontitis). CAL measurements ranged from 1.31 to 5.27 mm (2.30 ± 0.96 mm). 18 (52.9%) patients had smaller than 2 mm CAL, while 16 (47.1%) had periodontitis. Tooth loss and considerable CAL were observed in this study. Nevertheless, factors such as social status should be considered in further investigations.

Investigation of matrix metalloproteinase‐1 −1607 1G/2G polymorphism in a Turkish population with periodontitis

Matrix metalloproteinase-1 (MMP-1) is a proteolytic enzyme that degrades extracellular matrix and plays a fundamental role during destruction of periodontal tissues. The aim of this study was to examine the association between MMP-1 -1607 1G/2G polymorphism and chronic periodontitis susceptibility in a Turkish population. A total of 180 subjects were enrolled in this study. All the subjects received a periodontal examination including full-mouth clinical attachment loss measurements, probing depths, plaque index scores, gingival index scores and radiographic bone loss ratios. Three groups formed according to periodontal conditions were healthy, moderate periodontitis and severe periodontitis groups. MMP-1 -1607 1G/2G gene promoter polymorphism was genotyped using a polymerase chain reaction-restriction fragment length polymorphism method. Analysis of the polymorphism showed no differences in distribution of the MMP-1 -1607 1G/2G polymorphism among healthy, moderate periodontitis and severe periodontitis groups (p>0.05). When the groups were further stratified by smoking status, we found no significant differences in genotype distributions, allele frequencies and carriage rates among any groups either (p>0.05). On the basis of the results, no significant association is found for the MMP-1 -1607 1G/2G polymorphism with susceptibility to periodontitis. Moreover, smoking status did not seem to affect this result.

Periodontal Status as Predictor of Prematurity and Low Birth Weight

The objective was to verify the relation between periodontal status and prematurity/low birth weight. a case control study of 211 women, 44 being mothers of children born with weight below 2.500g or gestational age of less than 37 weeks (case group) and 177 mothers of children born with weight of over 2.500g or more and gestational age of 37 weeks or more (control group). The women were invited to reply to a questionnaire during the interview. A single dentist performed a complete periodontal exam in the oral cavity of each participant, including: probing depth, recession, plaque index, bleeding on probing, and clinical attachment loss measurements. Descriptive analysis of the study variables was performed and the statistical significance was calculated at 5%, using the chi-squared test. There was no statistically significant difference in the clinical parameters between the groups. The findings showed no association between periodontal status and prematurity/low birth weight.

Position Paper: Diagnosis of Periodontal Diseases.

This position paper on the diagnosis of periodontal diseases was prepared by the Research, Science and Therapy Committee of the American Academy of Periodontology. It is intended for the information of the dental profession and other interested parties. The purpose of the paper is to provide the reader with a general overview of the important issues related to the diagnosis of periodontal diseases. It is not intended as a comprehensive review of the subject. J Periodontol 2003;74:1237-1247.

Low prevalence of a periodontitis-associated interleukin-1 composite genotype in individuals of Chinese heritage.

Polymorphisms in the interleukin-1 (IL-1) gene cluster have been associated with an increased risk of developing certain diseases. A specific composite genotype of IL-1A and IL-1B polymorphisms, consisting of allele 2 of both IL-1A +4845 and IL-1B +3954 (formerly +3953) has been associated with an increased risk of severe adult periodontitis. Approximately 30% of the European population carry this genotype. The prevalence of the above IL-1A and IL-1B composite genotype in populations of different ethnic origins is unknown. Therefore, the primary aim of this study was to determine the prevalence of the IL-1 composite genotype in individuals of Chinese heritage, since epidemiologic studies indicate that periodontitis is widespread among ethnic Chinese. An additional aim was to evaluate if there was an association between the composite genotype and the severity of periodontal disease. A convenience sample of 300 volunteers of Chinese heritage (ages 21 to 69 years) received a periodontal examination including full-mouth clinical attachment loss measurements, probing depths, plaque index scores, and bleeding on probing. Blood was collected from a fingerstick and placed on a blotting paper card. The blood samples were analyzed for IL-1A +4845 and IL-1B +3954 polymorphisms using polymerase chain reaction (PCR)-based methods. Only 7 of the 300 subjects (2.3%) carried the composite IL- 1 genotype consisting of allele 2 of both IL-1A +4845 and IL-1B +3954. Allele 2 of the IL-1A +4845 polymorphism was carried by 17.0% (51/300) of the subjects; of these, only 2 were homozygous. Allele 2 of the IL-1B +3954 polymorphism was much rarer with only 3.3% (10/300) of the study population carrying this marker. All of the people who carried the IL-1B polymorphism were heterozygous. Too few of the subjects were positive for the IL-1 composite genotype to establish any relationship with the susceptibility to periodontitis. It was concluded that the prevalences of both IL-1A and IL-1B polymorphisms are dramatically lower in Chinese than those reported for Europeans. Findings from this study bring into question the usefulness of the composite genotype of allele 2 of both IL-1A +4845 and IL-1B +3954 as a method for determining the susceptibility of Chinese patients to adult periodontitis.

The informativeness of attachment loss on tooth mortality.

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? 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. 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. 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?