OBJECTIVE--To investigate a reported association between dental disease and risk of coronary heart disease. SETTING--National sample of American adults who participated in a health examination survey in the early 1970s. DESIGN--Prospective cohort study in which participants underwent a standard dental examination at baseline and were followed up to 1987. Proportional hazards analysis was used to estimate relative risks adjusted for several covariates. MAIN OUTCOME MEASURES--Incidence of mortality or admission to hospital because of coronary heart disease; total mortality. RESULTS--Among all 9760 subjects included in the analysis those with periodontitis had a 25% increased risk of coronary heart disease relative to those with minimal periodontal disease. Poor oral hygiene, determined by the extent of dental debris and calculus, was also associated with an increased incidence of coronary heart disease. In men younger than 50 years at baseline periodontal disease was a stronger risk factor for coronary heart disease; men with periodontitis had a relative risk of 1.72. Both periodontal disease and poor oral hygiene showed stronger associations with total mortality than with coronary heart disease. CONCLUSION--Dental disease is associated with an increased risk of coronary heart disease, particularly in young men. Whether this is a causal association is unclear. Dental health may be a more general indicator of personal hygiene and possibly health care practices.

https://www.bmj.com/content/bmj/306/6879/688.full.pdf

Dental disease and risk of coronary heart disease and mortality.

1. The interpretation of epidemiological data of periodontal disease is difficult, due to inconsistencies in the methodology used. It is not possible, therefore, to accurately assess if the prevalence of the periodontal diseases shows a world-wide decline. As long as the disease is assessed through accumulated clinical attachment loss, retention of the natural dentition in older ages entails increased prevalence in these cohorts. Contemporary epidemiological studies should ideally employ full-mouth examination of the periodontal tissues. Partial recording estimates are generally biased, especially when the prevalence of the disease is low. 2. Early-onset periodontitis is infrequent in all populations. Adult periodontitis is rather prevalent; however, advanced disease affects limited subfractions of the population (probably less than 10 to 15%). Although prevalence figures vary with race and geographic region, in most cases, the progression pattern of the disease seems compatible with the retention of a functional dentition throughout life. 3. Of a plethora of behavioral and environmental risk markers identified by multi-variate analysis, smoking and presence of certain subgingival microorganisms have been proven to be true risk factors. The same holds true for diabetes mellitus, a systemic condition that confers a risk for periodontal disease which is independent of the effect of other significant factors. 4. In certain cases, periodontal infections appear to have a systemic impact on the host. Most recent data indicate that periodontal disease may confer risk for coronary heart disease and pre-term low birth weight.

Periodontal Diseases: Epidemiology

In 1993, the 1st European Workshop on Periodontology explicitly recognized that there was insufficient knowledge to differentiate truly different forms of periodontal disease from differences in the presentation/severity of the same disease. In spite of recent progress in our understanding of periodontal diseases, the issue is far from having been resolved. Classification of periodontal diseases, therefore, remains based upon the definition of specific clinical syndromes. Early-onset periodontitis (EOP) is one such syndrome and comprises a group of pathological conditions leading to loss of periodontal tissues early in life. The notion that classifies periodontitis syndromes as "early-onset" or "adult" is primarily epidemiological in nature and is based on the observation that periodontitis is rather infrequent in children and young adults. Nevertheless, considerable epidemiological evidence indicates that periodontitis does affect children and young adults to a level of severity that may lead to premature exfoliation of primary and/or permanent teeth. Clinical presentation of periodontitis early in the life of an individual is thought to indicate that the etiologic agents have been able to cause considerable tissue damage over a relatively short period of time. It also implies either infection with highly virulent bacteria and/or a highly susceptible subject. The purpose of this review is to discuss the criteria generally utilized to classify EOP, provide the rationale to designate EOP as a distinct disease entity, and to review the evidence justifying a subclassification into particular subgroups of EOP.

Early-onset periodontitis.

Porphyromonas gingivalis is one of the major causative organisms of periodontitis and has been shown to be susceptible to toluidine blue-mediated photosensitization in vitro. The aims of the present study were to determine whether this technique could be used to kill the organism in the oral cavities of rats and whether this would result in a reduction in the alveolar bone loss characteristic of periodontitis. The maxillary molars of rats were inoculated with P. gingivalis and exposed to up to 48 J of 630-nm laser light in the presence of toluidine blue. The number of surviving bacteria was then determined, and the periodontal structures were examined for evidence of any damage. When toluidine blue was used together with laser light there was a significant reduction in the number of viable P. gingivalis organisms. No viable bacteria could be detected when 1 mg of toluidine blue per ml was used in conjunction with all light doses used. On histological examination, no adverse effect of photosensitization on the adjacent tissues was observed. In a further group of animals, after time was allowed for the disease to develop in controls, the rats were killed and the level of maxillary molar alveolar bone was assessed. The bone loss in the animals treated with light and toluidine blue was found to be significantly less than that in the control groups. The results of this study show that toluidine blue-mediated lethal photosensitization of P. gingivalis is possible in vivo and that this results in decreased bone loss. These findings suggest that photodynamic therapy may be useful as an alternative approach for the antimicrobial treatment of periodontitis.

https://aac.asm.org/content/aac/47/3/932.full.pdf

In Vivo Killing of Porphyromonas gingivalis by Toluidine Blue-Mediated Photosensitization in an Animal Model

Dental calculus, both supra- and subgingival occurs in the majority of adults worldwide. Dental calculus is calcified dental plaque, composed primarily of calcium phosphate mineral salts deposited between and within remnants of formerly viable microorganisms. A viable dental plaque covers mineralized calculus deposits. Levels of calculus and location of formation are population specific and are affected by oral hygiene habits, access to professional care, diet, age, ethnic origin, time since last dental cleaning, systemic disease and the use of prescription medications. In populations that practice regular oral hygiene and with access to regular professional care, supragingival dental calculus formation is restricted to tooth surfaces adjacent to the salivary ducts. Levels of supragingival calculus in these populations is minor and the calculus has little if any impact on oral-health. Subgingival calculus formation in these populations occurs coincident with periodontal disease (although the calculus itself appears to have little impact on attachment loss), the latter being correlated with dental plaque. In populations that do not practice regular hygiene and that do not have access to professional care, supragingival calculus occurs throughout the dentition and the extent of calculus formation can be extreme. In these populations, supragingival calculus is associated with the promotion of gingival recession. Subgingival calculus, in "low hygiene" populations, is extensive and is directly correlated with enhanced periodontal attachment loss. Despite extensive research, a complete understanding of the etiologic significance of subgingival calculus to periodontal disease remains elusive, due to inability to clearly differentiate effects of calculus versus "plaque on calculus". As a result, we are not entirely sure whether subgingival calculus is the cause or result of periodontal inflammation. Research suggests that subgingival calculus, at a minimum, may expand the radius of plaque induced periodontal injury. Removal of subgingival plaque and calculus remains the cornerstone of periodontal therapy. Calculus formation is the result of petrification of dental plaque biofilm, with mineral ions provided by bathing saliva or crevicular fluids. Supragingival calculus formation can be controlled by chemical mineralization inhibitors, applied in toothpastes or mouthrinses. These agents act to delay plaque calcification, keeping deposits in an amorphous non-hardened state to facilitate removal with regular hygiene. Clinical efficacy for these agents is typically assessed as the reduction in tartar area coverage on the teeth between dental cleaning. Research shows that topically applied mineralization inhibitors can also influence adhesion and hardness of calculus deposits on the tooth surface, facilitating removal. Future research in calculus may include the development of improved supragingival tartar control formulations, the development of treatments for the prevention of subgingival calculus formation, the development of improved methods for root detoxification and debridement and the development and application of sensitive diagnostic methods to assess subgingival debridement efficacy.

Dental calculus: recent insights into occurrence, formation, prevention, removal and oral health effects of supragingival and subgingival deposits

Results of 61 CPITN surveys in 39 countries for the age group 15-19 yr, stored in the WHO Global Oral Data Bank as of 1 July 1987, are assembled in an overview showing percentages of persons according to the highest score for each person and the mean numbers of sextants affected per person. The most frequently observed condition was score 2 (calculus with or without bleeding), although some shallow pocketing of 4 or 5 mm was present in most populations surveyed. It should thus be emphasized that the major thrust of activities in periodontal care should be in health promotion and education, leading to improved oral hygiene.

M. H. Leclercq

Papers

Periodontal conditions in adults, 35–44 years of age: an overview of CPITN data in the WHO Global Oral Data Bank

Profiles of periodontal conditions in adolescents measured by CPITN.

Profiles of periodontal conditions in older age cohorts, measured by CPITN.