Braz J Oral Sci. October-December 2006 - Vol.

5 - Number 19

Association between dental prosthesis

and periodontal disease in a rural
Brazilian community
Suzely Adas Saliba Moimaz *
Nemre Adas Saliba *
Orlando Saliba*
Lvia Guimares Zina*
Mrcio Rogrio Curtis Bolonhez*
*Preventive and Social Dentistry PostGraduation Program, Department of Pediatric
and Social Dentistry, Araatuba School of
Dentistry, So Paulo State University - UNESP,
Brazil

Received for publication: August 13, 2006

Accepted: October 17, 2006

Abstract
The aim of this study was to describe the periodontal conditions and
to analyze the association between the wearing of fixed/removable
partial dentures and periodontal disease in a representative adult rural
population in southeast Brazil. Cross-sectional study of a
representative sample comprising 200 individual aged 34-44 years.
Data were collected by clinical examinations in accordance with the
World Health Organization Basic Methods Criteria, which included
the Community Periodontal Index and dental prosthesis exam. A
descriptive analysis and the chi-square statistic were performed. In
total, 40.5% of the individuals wore partial denture and 59.5% were
non-users of denture. The prevalence of periodontal disease was 100%.
The subjects scored either calculus (44.5%) or shallow pockets (47%),
and only a small proportion was recorded as having deep pockets
(8.5%). All denture wearer displayed periodontal problem in the sextant
where the denture were recorded. The statistical analysis indicated
that wearing partial dentures was found to be associated with
considerable periodontal disease (X 2 = 10.75; p=0.0014). The
periodontal condition of the study population can be considered
unsatisfactory. The wearing of partial dental prosthesis was associated
with periodontal disease, and a significant percentage of cases might
have been prevented if plaque control interventions had been
implemented.
Key Words:
periodontal diseases, dental prosthesis, oral health, periodontal index,
epidemiology

Correspondence to:
Suzely Adas Saliba Moimaz
Department of Pediatric and Social Dentistry,
Araatuba School of Dentistry,
So Paulo State University
Rua Jos Bonifcio, 1193 Vila Mendona,
16015-050 Araatuba, SP, Brasil.
Phone: +55-18-3636-3250
Fax: +55-18-3636-4890
E-mail: sasaliba@foa.unesp.br

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Braz J Oral Sci. 5(19):1226-1231

Association between dental prosthesis and periodontal disease in a rural Brazilian community

Introduction
Dental caries and periodontal diseases have been historically
considered the most important global oral health burdens.
At present, the distribution and severity of oral diseases
vary in different parts of the world and within the same
country or region. In Brazil, 48.3% of people aged 35-44 years
wear at least one dental prosthesis; at 65-74 years-old this
rate go up to 66.5%1. The significant role of local, sociobehavioural and environmental factors in oral disease and
health is demonstrated in a large number of epidemiological
surveys 2-6.
A global database was established and over a number of
years an increasing number of oral epidemiological studies
have been conducted applying World Health Organization
(WHO) methodology and criteria7. To assess the periodontal
status of populations, the WHO recommended the
Community Periodontal Index (CPI) application, which
verifies the state of periodontal health in view of gingival
bleeding, periodontal calculus and pocket. The CPI has been
widely used to measure the level of periodontal diseases
and treatment needs in populations, and it allows for
international comparisons7.
Severe periodontitis which may result in tooth loss is found
in 5-15% of most populations5-6.
A classic study on experimental gingivitis in humans proved
that bacterial plaque or biofilm represents the main etiologic
factor of periodontal diseases8. Other researches also confirm
the importance of controlling biofilm in order to maintain
individual oral health9-12.
Acting jointly with biofilm, local and systemic factors may
modify the pathogeny of periodontal disease, like dental
morphology, shape and site of furcation, level and amount
of dental restoration, trauma, diabetes mellitus, genetic
factors and viruses12.
Dental prosthesis may influence the periodontal conditions,
the risk of caries and the amount of stress on natural teeth10,1315
. Various investigations have shown that there is an
increase in the mobility of the supporting teeth, gingival
inflammation and formation of periodontal pocket after dental
prosthesis are fitted in16-21. According to some authors22-24,
the removable partial denture were associated with increased
plaque accumulation, not only on tooth surfaces in direct
contact with the denture, but also on teeth in the opposing
arch, and in some cases, even on buccal surfaces of teeth.
These alterations are attributed to poor oral hygiene,
increased plaque and calculus accumulation, and
transmission of excessive forces to the periodontal structures
from occlusal surfaces of the framework of dentures. Many
partial dentures framework designs contribute to increased
or altered oral bacterial flora and formation of dental plaque20.
In a large case-control study conducted by the University
of Zagreb, Croatia, in 2002, 205 partial denture wearers were
examined; abutment teeth had higher scores related to

1227

periodontal disease than non-abutment teeth, with significant

differences (p<0.01) for plaque, calculus and gingival index,
probing depth, tooth mobility and gingival recession20.
The gingival health is adversely affected by removable partial
dentures, with it being most severe where the appliance
closely contacted the gingival margin16. The differences in
gingival inflammation between the plate and dental bar
designs suggest that covering more gingival tissue promotes
development of gingivitis, which may subsequently
predispose the area to periodontal disease25.
In a three-year study with patients wearing fixed partial
dentures with advanced periodontal disease, carried out by
the researches of the Yonsei University, Korea, it was
observed good results regarding the periodontal health
situation 26.
Continuing surveillance of levels and patterns of risk factors
of periodontal disease is of fundamental importance to
planning and evaluating community preventive activities and
oral health promotion. Studies suggest that the use of partial
dentures may constitute a risk factor for periodontium health.
The aim of this study was to describe the periodontal
conditions and to analyze the association between the
wearing of fixed/removable partial dentures and periodontal
disease in a representative adult rural population in southeast
Brazil.
Material and Methods
Study methodology
The target population of the present study was adults living
in the rural area of Araatuba in the Brazilian state of So
Paulo. This state is located in the southeast part of Brazil,
and is one of the most important states of the country.
Two hundred patients aged 35-44 years were examined
between August 2004 and January 2005. The sample was
randomly selected and weighted to represent the 35-44 year
old adult population of rural area of Araatuba. The specific
area where the data were collected has approximately 600
inhabitants (Information provided by Araatuba Health
Municipal Department and the Brazilian Institute of
Geography and Statistics - IBGE). The study sample included
80 (40%) males and 120 (60%) females.
The sample size was obtained allowing 10% of sampling
error 27. The sample calculus was derived based on the
prevalence of periodontal disease in the region. The
prevalence of periodontal disease in So Paulo State was
considered 55%, in accordance with research carried out by
the University of So Paulo in 199828.
The following formula was used for the sample calculus27:
N = p q / E2
p is the probability of individuals of the sample having this
characteristic; q is the probability of individuals of the
sample not having this characteristic.
The patients were chosen at random, using the census data

Association between dental prosthesis and periodontal disease in a rural Brazilian community

and other relevant municipal information.

Exclusion criteria were presence of diseases/conditions that
may interfere with the clinical examination and the results.
Hence, subjects were excluded if they were diagnosed with
psychiatric problems, intoxicated with alcohol or dugs,
pregnant women and smokers.
Clinical examinations
Examinations were performed by one dentist, assisted by a
recorder, and they were conducted in a health center located
in the rural area. Letters were sent to selected individuals
and explained the aims of the study and solicited
participation. A few days later, the researchers visited the
individual and provided more information about the study
and encouraged participation. Eligible subjects who consent
to participation were invited to go to the local health center
in a specific day.
Clinical examinations were carried out in natural light. Gauze
squares, cotton buds, sterile sets of plane mouth mirrors
and Community Periodontal Index (CPI) probes were packed
in sufficient quantities for each working day. Strict procedures
for infection control were followed. The clinical examination
lasted an average of 10 minutes per adult.
The Community Periodontal Index (CPI) was recorded for
each sextant. Ten index teeth (17, 16, 11, 26, and 27 in the
maxilla, and 47, 46, 31, 36, and 37 in the mandible) in six
sextants (17-14, 13-23, 24-27, 37-34, 33-43, and 44-47) were
probed and scores ascribed to each sextant on the following
basis: score 0 - no signs of disease; score 1 - gingival bleeding
after gentle probing; score 2 - presence of supra or
subgingival calculus or other plaque retentive factors; score
3 - 4 or 5 mm deep periodontal pockets; score 4 - 6 mm or
deeper periodontal pockets7.
Molars were examined in pairs and the highest score was
recorded for each sextant. A sextant was examined if at least
2 teeth are present. A 0.5 mm ball-ended probe with color
markers at 3.5 and 5.5 mm was used to measure the CPI. The
WHO recommends that the pressure applied in probe should
not exceed 20 grams. For each tooth, 6 sites were examined:
mesial, midline and distal on both vestibular and lingual/
palatal surfaces. Probing depth was defined as the distance
from the free gingival margin to the bottom of the pocket/sulcus7.
The use of dental prosthesis was evaluated according to
criteria recommend by WHO7: score 0: dont wear dental
prosthesis; score 1: fixed partial denture wearer; score 2:
removable partial denture wearer; score 3: combined dentures
(fixed/removable) wearer.

Intra-rater reliability and agreement with gold standard

dentist were assessed during and at the end of session. The
level of concordance for measures relative to periodontal
conditions and denture identification was good (mean [kappa]
index was 0.80).
Later, a pilot study was carried out on adults aged 35-44
years who attended the Araatuba School of Dentistry Clinic
to test the feasibility of the study and dental examination.
There was no need to change the methodology previously
proposed. Ten percent of the sample (N=20) was re-examined
to test for reliability during the fieldwork.
Ethical considerations
This study was aware of the Code of Ethics of the World
Medical Association (Declaration of Helsinki) and it received
ethical approval from the Research Ethics Committee of the
Araatuba School of Dentistry (file: FOA 2178/2003). The
exams were undertaken with the understanding and written
consent of each subject.
Confidentiality was assured to participants and all recording
forms were numbered, but not named.
Data analysis
For the descriptive statistical analysis of the periodontal
parameters, mean values were calculated for each patient
and for sextant, since all patients present alterations in their
periodontal condition. The presence or absence of disease
and the identification of partial denture in the same sextant
were compared, for which the chi-square test were used.
Level of statistical significance was chosen at p<0.05.
Results
Of the 200 subjects recruited into the survey, 81 (40.5%)
wore dental prosthesis, fixed and/or removable, and 119
(59.5%) were non-users of denture.
Table 1 and Figure 1 show the prevalence of periodontal
condition measured by the Community Periodontal Index
(CPI) on the subjects who underwent the periodontal examination.
Among these subjects, 100% presented some periodontal
problem, recorded by the sum of scores 2, 3 and 4,
70
60

Sextants (%)

Braz J Oral Sci. 5(19):1226-1231

50
40
30
20
10

Pilot study and calibration

Dental examiners participated in a 5-day training and
calibration session. The session focused on the
interpretation of indexes measuring pathologies sought
during examinations and identification of dental prosthesis.

0
0

CPI

Fig. 1 - Percentage distribution of sextants by the highest Community

Periodontal Index (CPI) score. Araatuba, Brazil, 2006.

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Braz J Oral Sci. 5(19):1226-1231

Association between dental prosthesis and periodontal disease in a rural Brazilian community

Table 1 - Percentage distribution of subjects and mean number of sextants by the highest Community Periodontal Index (CPI)
score. Araatuba, Brazil, 2006.
CPI Score

% patients
Mean number of sextants

Total

44.5

47

8.5

100.0

0.4

0.1

3.9

1.1

0.1

0.4

6.00

independently of wearing of dentures. The subjects scored

either calculus (score 2) or shallow pockets (score 3), and
only a small proportion was recorded as having deep pockets
(score 4). All denture wearer displayed periodontal problem,
as calculus and periodontal pocket, in the sextant where the
dentures were recorded.
A mean number of 4 sextants presented bleeding and calculus
as worse condition, and the sum of these conditions (score
1 and 2) represented 67.13% of total of sextants, whereas
only 1 sextant were found to have a pocket of 4 mm or more,
score 3 and 4 represented by 19.71% of sextants. The mean
number of sextants with healthy periodontal tissues was 0.4,
which represents 6.25% of the total. Excluded sextant (score
x), due to there remaining less than 2 teeth, were less prevalent
(6.83%).
The relationship between subjects categorized as exhibiting
considerable periodontal disease (score 3 and 4 as worse
condition) and those categorized as partial denture wearer is
demonstrated in table 2.
For the 35- to 44-year-olds rural population, being a partial
denture wearer was significantly associated with an
increased likelihood of being categorized as exhibiting
considerable periodontal disease (X2 = 10.75; p=0.0014).
Discussion
This paper set out to address the hypothesis that there was
an association between the wearing of fixed/removable partial
dentures and periodontal condition in a Brazilian adult rural
population. The results of this analysis suggest that partial

dentures may play an important role in the development of

periodontal disease.
In this study, all subjects presented signs of periodontal
disease. The percentage of patients with periodontal pockets
was relatively high (55.5%), but when only deep pockets
were considered, the percentage found was much lower
(8.5%). A mean number of 5.2 sextant presented bleeding or
more severe problems; however, only 1.2 sextants had 4 mm
or deeper periodontal pockets. This means that the
periodontal alterations were more generalized, affecting more
sextants, and having a few severely involved teeth. Thus,
gingivitis was the principal clinical manifestation of
periodontal disease in the subjects examined.
In 2003, a National epidemiological survey showed a
percentage of 46.2%, 21.9% and 7.9%, respectively, of
individuals with no periodontal problem within the age range
of 15 to 19, 35 to 44 and 65 to 74 years1. On comparing the
1986 and 2003 national surveys, the decrease in the rates of
periodontal disease prevalence in the Brazilian population is
most likely due to conditions such as the consolidation of
the National Public Health System and the greater care given
to oral health.
A study verified the periodontal conditions and treatment
needs according to the Community Periodontal Index of
Treatment Needs (CPITN) in a worker population in Brazil29.
The results showed a mean number of 0.1 healthy sextants,
and calculus and shallow pocket were the most prevalent
periodontal condition, similar to our findings.
Among the factors that account for poor periodontal

Table 2 - Number and percentage distribution of sextants by the presence of periodontal disease and use of partial dentures.
Araatuba, Brazil, 2006.
Periodontal disease
Prosthesis

Present

Absent

Total

Present

172 (15%)

(0%)

174 (16%)

Absent

871 (78%)

73 (7%)

944 (84%)

Total

1 043 (93%)

75 (7%)

1 118 (100%)

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Braz J Oral Sci. 5(19):1226-1231

Association between dental prosthesis and periodontal disease in a rural Brazilian community

condition are the lack of professional advice regarding oral

health maintenance and the low rate of follow-up19.
Besides, the prevalence of periodontal diseases in rural
populations seems to be higher than in urban populations.
A research performed in rural and urban areas of a Brazilian
city compared the oral health condition of these regions,
including the main oral diseases as dental decay and
periodontal disease, and the authors observed that rural
residents had worse index than urban residents30. Another
study carried out in a rural area of So Paulo State, Brazil,
found values as 99.5% of children aged 6 to 14 years
presenting signs of periodontal disease 31. Despite some
methodological differences among surveys performed with
rural populations, it is distinguished the worse periodontal
conditions of these populations. To understand these
differences, it is necessary to know the social determinants
of health involved in the health-disease process of
periodontal disease, like income, education, habitation
conditions, work, transport, sanitation and environment. In
developing countries as Brazil, the iniquities are present in
many sections and regions, and the social difficulties can be
higher to the population of rural areas, with small wages,
worse habitation condition, difficulties in the access of
children to school and of people to health services.
Various researches18-20 have shown that, on comparing the
periodontal condition of abutment teeth and natural teeth, a
statistically significant difference was found between both
periodontal conditions, the abutment teeth presenting a
greater depth of gingival crevice, an increase of calculus
and dental mobility. It is believed that the increase in plaque
accumulation is related to negligence of the patient and not
necessarily brought about by the prosthesis. That
periodontal alterations may be solely due to the patients
poor oral hygiene with no prosthesis involvement in this
result32.
Older patients maintain hygiene of natural teeth better than
denture hygiene, and their results underscore the need for
better instruction on maintaining denture hygiene20.
A study comparing patients with removable partial dentures,
patients with no prosthesis, or patients with fixed partial
dentures showed the greatest plaque and calculus
deposition, periodontal probing depth, and alveolar bone
loss on the abutment teeth in removable partial denture
wearers 33.
Some studies examined effects of forces transmitted to
abutment teeth, jiggling, and eventual orthodontic tooth
movement, and the results showed that such forces did not
induce periodontal disease or progressive destruction of the
periodontium if good hygiene was maintained 19,32.
The prevalence of denture wearers with periodontal disease
in the present survey was significant. The factors related to
the development of periodontal disease could be involved
both in sites with and without dentures, and probably one

of the most evident factors was poor oral hygiene as

observed by the authors during the clinical examinations.
Thus, evaluation of the wearing of partial dentures and
periodontal condition must be carried out based on several
evidences related to the importance of controlling bacterial
plaque in order to preserve the integrity of the periodontium.
However, the in situ effect of dental prosthesis must not be
overlooked in relation to its multiple functionality aspects,
such as definition of margins and prosthetic adaptation
which, if not correct, may effectively contribute to the
development of periodontal disease.
Agreement exists among several authors about the need for
oral home care and a regular recall system, which influences
the success of prostheses26,34-35. Clinical studies showed that
when providing a regular recall system with control, reinstruction and re-motivation, partial dentures might not
cause any damage of the periodontium. In a retrospective
study, the changes in the periodontal conditions of patients
wearing different designs of removable partial dentures over
long-term were evaluate, and found a higher deterioration in
the abutment teeth than in the non-abutment teeth 35 .
According to these authors, the substantial dental and
periodontal destruction in patients with partial dentures is
found more frequently in patients who had a poor oral hygiene
and seldom visited their dentist. Every patient should be
included in a preventive oral health service, with control of
bacterial plaque by the dentist and the patient.
To maximize cost-effectiveness, prevention and control of
periodontal diseases should be based on predicted risk of
developing these diseases. In populations with low level of
oral hygiene and limited oral health care resources, a whole
population strategy for general oral health promotion should
be applied36. Besides this, based on the risk profile, the basic
strategy should be individualized treatment to eliminate
infection by periopathogens and to control or/and reduce
modifying risk indicators, risk factors and prognostic risk
factors, as the wearing of dental prostheses.
For rural populations, the strategies must emphasize the
importance of adapting the services to the necessities and
difficulties of those populations. The access to health
services must be facilitated so all can be assisted, not only
in relation to curative treatment, but also, and mainly, to
preventive and educative activities.
Finally, the results highlight the need for further
epidemiologic studies to clarify the relationship between
dental prosthesis and periodontal disease, types of dentures
and period of development of disease.
In conclusions, the wearing of partial dental prosthesis was
associated with periodontal disease in this study population,
and a significant percentage of cases might have been
prevented if plaque control interventions had been
implemented. The results suggest a need for populationsbased plaque control programs in an attempt to reduce the

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Braz J Oral Sci. 5(19):1226-1231

Association between dental prosthesis and periodontal disease in a rural Brazilian community

incidence of development of periodontal disease in

population.
Acknowledgements
This work was supported by general institutional funds from
the Research Foundation of State of So Paulo, Brazil
(FAPESP).

20.

21.

22.

23.

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