David R. Moles

A systematic review of definitions of periodontitis and methods that have been used to identify this disease

OBJECTIVE To perform a systematic review and critical analysis of the definitions of periodontitis and the methods which have been used to identify and measure this disease. MATERIAL AND METHODS Relevant publications were identified after searching MEDLINE, EMBASE, SCISEARCH and LILACS electronic databases. Screening of titles and abstracts and data extraction was conducted independently by two reviewers. To be included in the review, studies were required to define periodontitis and to indicate how it was measured. Studies that related purely to gingivitis, and/or intervention studies, and/or studies where prevalence or severity of periodontitis was not a principal outcome were excluded. RESULTS From a total of 34,72 titles and abstracts, 104 potentially relevant full text papers were identified. Of these, 15 met the criteria for inclusion in the final stage of the review. The survey revealed heterogeneity between the studies in the measurement tools used, particularly the types of probes and the sites and areas of the mouth that were assessed. There was also heterogeneity in the use of clinical attachment loss (CAL) and pocket probing depth (PPD) as criteria for periodontitis. In the 15 studies, the threshold for a diagnosis of periodontitis when CAL was the criterion ranged from 2 to > or =6 mm and when PPD was used, from 3 to > or =6 mm. CONCLUSIONS This review has confirmed previous work which has suggested that epidemiological studies of periodontal diseases are complicated by the diversity of methodologies and definitions used. The studies that were reviewed utilized a minimum diagnostic threshold defining periodontitis, at a given site in terms of CAL of 2 mm and PPD of 3 mm.

Association between overweight/obesity and periodontitis in adults. A systematic review

Overweight and obesity have been suggested to be associated with periodontitis as published in studies and narrative summaries. This project presents results of a systematic review investigating the association between overweight or obesity (as defined by the World Health Organization) and periodontitis.

Oral and Dental Aspects of Chronic Renal Failure

The present article reviews, in detail, the current knowledge of the oral and dental aspects of chronic renal failure (CRF). Worldwide, increasing numbers of persons have CRF; thus, oral health care staffs are increasingly likely to provide care for patients with such disease. Chronic renal failure can give rise to a wide spectrum of oral manifestations, affecting the hard or soft tissues of the mouth. The majority of affected individuals have disease that does not complicate oral health care; nevertheless, the dental management of such individuals does require that the clinician understand the multiple systems that can be affected. The clinician should also consider the adverse side-effects of drug therapy and appropriate prescribing, in view of compromised renal clearance.

Systematic review of implant outcomes in treated periodontitis subjects

OBJECTIVES To determine implant outcomes in partially dentate patients who have been treated for periodontitis compared with periodontally healthy patients. MATERIAL AND METHODS All longitudinal studies (until March 2006) of endosseous dental implants of at least 6 months of loading were searched. Studies presented with one or more of the outcome measures (implant survival, success, bone-level change, peri-implantitis) were included. Screening, data abstraction and quality assessment were conducted independently and in duplicate. RESULTS From 4448 citations, 546 full-text papers were screened and nine studies were included. Overall, the non-periodontitis patients demonstrated better outcomes than treated periodontitis patients. However, the strength of evidence showed that the studies included were at a medium to high risk of bias, with lack of appropriate reporting and analysis of outcomes plus lack of accounting for confounders, especially smoking. Furthermore, the studies showed variability in the definitions of treated and non-periodontitis, outcome criteria and quality of supportive periodontal therapy. Meta-analysis could not be performed due to heterogeneity of the chief study characteristics. CONCLUSIONS There is some evidence that patients treated for periodontitis may experience more implant loss and complications around implants than non-periodontitis patients. Evidence is stronger for implant survival than implant success; methodological issues limit the potential to draw robust conclusions.

Quality of RCTs in Periodontology— A Systematic Review

Randomization, concealment of treatment allocation, blinding, and patient follow-up are key quality components of randomized controlled trials (RCTs). The objective of this study was to assess the quality of RCTs in periodontology using these evidence-based components. Following a detailed search, screening and quality assessments of RCTs were conducted in duplicate and independently. The results showed that although 91% of trials were described as randomised, adequate methods for randomization and allocation concealment were found in 17% and 7% of studies, respectively. Blinding was adequate for the caregiver in 17% and for the examiner in 55% of studies. A clear accounting of all participants was present in 56% of reports. This rigorous systematic review revealed that the quality of RCTs in periodontology, judged by their publications, frequently does not meet recommended standards. If this quality is reflected in actual study conduct, fundamental errors could have a significant impact on the outcomes of these trials.

Opportunistic screening for oral cancer and precancer in general dental practice: results of a demonstration study

Objectives To demonstrate the feasibility of opportunistic oral cancer and precancer screening in general dental practice and to determine the prevalence of relevant lesions and risk habits in a population of general dental practice attenders.Design A prospective demonstration study, recruiting patients opportunistically.Setting General dental practices.Methods Eighteen general dental practitioners took part in this study. Each attended training sessions to be advised of the study protocol and the criteria of a positive and negative screen. Patients over the age of 35 years were prospectively and opportunistically recruited. Each patient was asked to complete a health questionnaire concerning age, gender, ethnicity, smoking and drinking habits. The dentist then examined the soft tissues and recorded the presence or absence of lesions independently on a second form. The forms were collated and data were analysed to determine prevalence of lesions and associations with risk habits.Results Data on 2,265 patients were available for analysis. Oral lesions were detected in 319 patients (14.1%). Ninety-four patients (4.2%) had lesions considered to be either malignant or potentially malignant. There was a significant association between positive lesions and male gender (IRR 1.86, 95% CI 1.22-2.82), heavy smoking (males: IRR 3.68, 95% CI 2.10-6.43: female; IRR 3.58, 95% CI 1.35–9.50) and heavy alcohol use in males (IRR 2.98, 95% CI 1.06–3.47).Conclusions The results suggest that patients attending general dental practices are representative of the general population both in terms of lesion prevalence and high risk habits such as smoking and drinking. This supports the view that opportunistic screening in a general dental practice setting may be a realistic alternative to population screening. Further research is needed to determine the cost effectiveness of this approach and to investigate the value of targeting high risk groups within this population. General dental practice is ideal for the evaluation of such systems prior to extending these studies to other healthcare settings.

Amoxicillin and metronidazole as an adjunctive treatment in generalized aggressive periodontitis at initial therapy or re‐treatment: a randomized controlled clinical trial

BACKGROUND Previously, we showed that systemic metronidazole and amoxicillin significantly improved the outcomes of non-surgical debridement in generalized aggressive periodontitis patients. This study aimed to observe whether re-treatment with adjunctive antimicrobials would give the placebo group benefits comparable with the test group. METHODS Thirty-eight of 41 subjects, from the initial 6-month trial, completed the second phase, re-treatment of sites with remaining pockets 5 mm. Subjects on placebo in phase one, received adjunctive antibiotics for 7 days. Clinical parameters were collected at 2 months posttreatment (8 months from baseline). RESULTS Patients who received antibiotics at initial therapy, showed statistically significant improvement in pocket depth reduction and in the % of sites improving above clinically relevant thresholds, compared with patients who received antibiotics at re-treatment. In deep pockets (7 mm), the mean difference was 0.9 mm (p=0.003) and in moderate pockets (4-6 mm) it was 0.4 mm (p=0.036). For pockets converting from 5 to 4 mm, this was 83% compared with 67% (p=0.041) and pockets converting from 4 to 3 mm was 63% compared with 49% (p=0.297). CONCLUSIONS At 8 months, patients who had antibiotics at initial therapy showed statistically significant benefits compared with those who had antibiotics at re-treatment.

Assessment of motivation and psychological characteristics of adult orthodontic patients

INTRODUCTION In recent years, the demand for adult orthodontic treatment has grown rapidly; yet there is a paucity of information on this subgroup of patients. It is well known that understanding the psychological characteristics and motives of any patient is fundamental and that these factors might affect patient satisfaction and adherence with treatment. There is therefore a need for clinicians to improve their understanding of this subgroup to enhance the patients experience of treatment delivery and to increase the potential for a successful treatment outcome. The aim of this study was to develop a measure for the assessment of motivating factors and psychological characteristics of adults seeking orthodontic treatment. METHODS This study involved the qualitative development of a valid patient-centered questionnaire to assess motivating factors for adults seeking orthodontic treatment. This was achieved through semi-structured in-depth interviews; key themes were identified and used to construct a questionnaire assessing motivation for treatment. This was then combined with 3 previously validated questionnaires to measure self-esteem, anxiety or depression, and body image and facial body image. The questionnaire was distributed to 172 adult orthodontic patients at different stages of treatment in a large teaching hospital in the United Kingdom. In addition, the self-esteem, body image, and facial body image scores were compared with data on orthognathic patients from the same hospital and with data from members of the general public. RESULTS Desire to straighten the teeth and improve the smile were the key motivating factors for the adult group studied. Other motives included to improve the bite, improve facial appearance, and close (dental) spacing. With respect to the psychological characteristics of self-esteem, body image, and facial body image, the adult orthodontic group was comparable with the general public. However, differences were noted when comparing data from the adult orthodontic group with previously collected data on orthognathic patients. CONCLUSIONS The motives for adults to seek orthodontic treatment are numerous and varied, whereas psychological traits appear to be closer to those of the general public than to orthognathic patients.

Orofacial granulomatosis: Clinical features and long-term outcome of therapy

BACKGROUND Orofacial granulomatosis (OFG) is a chronic inflammatory disorder characterized by persistent or recurrent soft tissue enlargement, oral ulceration, and a variety of other orofacial features. There remain few detailed reports of the clinical features and long-term response to therapy of substantial groups of patients with OFG. OBJECTIVE The aim of this study was to determine retrospectively the clinical, hematologic, and histopathological features of a large case series of patients with OFG. In addition the long-term response to therapy was examined. METHODS Clinically relevant data of 49 patients with OFG who attended a single oral medicine unit in the United Kingdom were retrospectively examined. The analyzed parameters included diagnostic features, clinical manifestations, and outcomes and adverse side effects of therapy. RESULTS Labial swelling was the most common presenting clinical feature at diagnosis (75.5%), followed by intraoral mucosal features other than ulceration such as cobblestoning and gingival enlargement (73.5%). Mucosal ulceration was observed in 36.7% of patients whereas extraoral facial manifestations such as cutaneous erythema and swelling were present in 40.8% of patients. Of the 45 patients who required treatment, 24 (53.3%) were treated with topical corticosteroids/immunosuppressants only, whereas 21 (46.7%) received a combined therapy (topical plus systemic corticosteroids/immunosuppressants and/or intralesional corticosteroids). The long-term outcome analysis showed complete/partial resolution of tissue swelling and oral ulceration in 78.8% and 70% of patients, respectively. LIMITATIONS The main limitation of the current study was its retrospective design and methodology including differences in reporting clinical features and outcome. CONCLUSIONS OFG can show multiple facial and mucosal clinical features. Long-term treatment with topical and/or combined therapy is needed in the majority of patients. Response to therapy is highly variable even though in the long-term complete/partial disease resolution can be obtained in the majority of patients. Mucosal ulceration tends to be more recalcitrant than orofacial swelling. Adverse side effects of therapy are rare.

Is alcohol responsible for more intra-oral cancer?

The role of the major risk factors, tobacco smoking and alcohol consumption, on trends in intra-oral cancer mortality in England and Wales between 1911 and 1990 was investigated, using lung cancer and liver cirrhosis as surrogate markers for smoking and drinking. Standardised mortality data on lung cancer and liver cirrhosis from the Office of Population Censuses and Surveys, aggregated into 5-year time periods for ages 35-64 and 65+ years, were regressed on corresponding data for intra-oral cancer. The strongest associations were in males aged 35-64 with a high negative correlation between lung and intra-oral cancer (rho=-0.98, 95% CI -0.99 to -0.96, P<0. 01) and, conversely, a positive correlation between liver cirrhosis and intra-oral cancer (rho=0.71, 95% CI 0.34 to 0.89, P<0.01). The findings suggest that rising alcohol consumption since the 1950s is more closely related to increasing intra-oral cancer incidence and mortality than smoking, most notably among younger males since the early 1970s.