CONTROVERSI

ES IN
PERIODONTIC
S
 INTRODUCTION

When a thing caeses to be a matter of controversy, it caeses to be a matter

of interest.
In reviewing past and present concepts and treatment modalities that are
available, it becomes evident that there are no completely accepted
principles and techniques.
On this note, I would like to present my topic for seminar:
CONTROVERSIES IN PERIODONTICS.
 VIRAL— BACTERIAL INTERACTIONS IN PERIODONTITIS

Recent   studies have demonstrated various human viruses, especially cytomegalo

. viruses   and Epstein Barr Viruses type 1, seem to play a part in pathogenesis of
human periodontitis.

Parra and Slotes reported that HCMV was present in 60 % of patients and EBV- IN
30%. Slots examined frequency of HCMV, EBV-2 and herpes simplex Viruses in
subgingival samples.

They reported 89% of samples yielded atleast one of three test viruses from deep
periodontal pockets and 56% yielded from shallow periodontal pockets
Dual virus infection seems to be particularly pathogenic and they may
accentuate bacterial virulence factor.

HCMV resides in monocytes, macrophages, and T cells and EBV in B

 
cells,
  which has the potential to impair major defense mechanism of the
periodontium.

Tiny et al. reported that high rate of active HCMV infection in early
localized aggressive periodontitis.

They suggested that puberty is an important for HCMV and EBV primary
infection or reinfection.

Puberty related perturbation of immune system

 CMV has been shown to lead decreased Polymorphonuclear Leukocyte
chemotaxis, phagocytosis, oxidative burst and intracellular killing capacity and it
may increase
 
the human susceptibility to bacterial infection.
 
HCMV infection of monocytes \ macrophage can induce prostaglandin E
2 production that may result in increased bone resorption and suppressed T
  lymphocyte function.
Mac Donald et al. emphasize the possible detrimental role of HCMV and EBV-1 in
periodontal repair.

 
Bacterial infection and other condition that promote diapedesis of
inflammatory cells in a tissue would increase possibility of initiating an HMCV
infection of the tissue.  
 
 
 Contreras et al. in 1999 conducted a study to examine relation ship between
subgingival herpes virus and periodontal disease and periodontopathogenic
  bacteria
 

The study confirmed positive relationship between subgingival EBV-1, HCMV and
  mixed herpes viral infections and clinical severity of periodontitis.

Viral infection promote subgingival pathogenic bacterial infection than vice versa.

Neutrophil dysfunction may serve to potentiate over growth and virulence of P

  gingivalis and other microbes.

 
 
 
 WIDTH OF THE KERATINIZED GINGIVA

 
 
Attached gingiva is firm, resilient and tightly bound to underlying
periosteum of alveolar bone.
 
Distance between mucogingival junction and projection on external surface
of the bottom of the gingival sulcus

 
Keratinized gingiva includes marginal gingiva also.
 
 
No standard width of keratinized gingiva has been established.

trauma of the prosthetic treatment.

 
It may be necessary to increase zone of healthy tissue if it is subjected to

 
 For many years the presence of adequate zone of gingiva was considered
critical for maintenance of marginal tissue health and for prevention of
continues loss of connective tissue attachment.

Narrow zone of gingiva --

1) was in sufficient to protect periodontium from injury caused by frictional forces

encountered during mastication and to dissipate the pull on the gingival
margin created by muscles of adjacent alveolar mucosa.

2) it will favor sub gingival plaque formation

3) it will also favor attachment loss and soft tissue recession

 Goldman and Cohen outlined a tissue barrier concept

Dense collagenous band of connective tissue

. retards or obstructs the spread of
inflammation better than does the loose fiber arrangement of the alveolar
mucosa.

Limits recession as result of inflammation

This view is indirectly supported by findings of Kennedy et al.after recall

evaluations of u patients from their 6 years longitudinal study of free
autogenous gingival grafts

ADEQUATE WIDTH OF GINGIVA

Some authors suggested that less than 1 mm.

Apicocoronal height ought to exceed 3 mm
Third category of authors stated that adequate zone of gingiva is any dimension of
gingiva which ---
1) is compatible with gingival health or 2) prevents retraction of gingival
margin during movements of the alveolar mucosa.
 Lang and Loe conducted a study to evaluate the significance of the gingival zone.

The results showed that despite of the fact that tooth surfaces were free from
plaque, all sites with less than 2 mm exhibited persisting clinical signs of
inflammation..

In contrast teeth possessing least attached tissue s (cuspid and bicuspids) are least
involved periodontally as compared to molars.

Incidence of disease is greater on palatal and lingual surfaces of molars where

amount of keratinized tissue is greatest

Wenstrom and Lindhe have shown that a free gingival unit supported by a loosely
attached alveolar mucosa is not more susceptible to inflammation than a free gingival
unit that is supported by a wide zone of attached gingiva.

.
• Miyasato et al. (1997) ceased oral hygiene for a period of 25 days and
found no difference in development of clinical signs of gingival
inflammation between areas with minimal and those with appreciable
width of gingiva.

• Dorfman et al. examined 96 patients with bilateral side facial tooth

surfaces exhibiting minimal keratinzed tissues, which has been treated
with free gingival graft on one side and un treated control on other side.

• Width of keratinized gingiva on grafted site was increased to 4mm

following the treatment.

• The attachment level at grafted sites and control remained unchanged

through out the years.

• Thus narrow zone of gingiva has the same resistance to continues

attachment loss as wider zone of gingiva.
 TRAUMA FROM OCCLUSION
.
What is occlusal trauma?

The international workshop for classification of periodontal disease and conditions in

1999.
Occlusal Trauma - It is injury resulting in tissue changes within attachment
apparatus as a result of occlusal forces.
 

Primary Occlusal Trauma – Injury resulting in tissue changes from excessive occlusal
forces applied to a tooth or teeth with normal support.  

Secondary trauma from occlusion – Injury resulting in tissue changes from normal or
excessive occlusal forces applied to a tooth or teeth with reduced support.
 Role of occlusion in pathogenesis of periodontal disease

Occlusal trauma is associated with periodontal disease over 100 years.

In 1901 Karolyi ,in 1917 and 1926 Stillman indicated that excessive occlusal
force was the primary cause of periodontal disease.

These early reports created a background for controversy that continues to this day.
 
  Is there association between excessive occlusal forces and progression of
periodontal disease?
     At what point does an occlusal force become excessive.

When should treatment initiated and how should this treatment initiated and how
should this treatment accomplished?
 Several early authors felt that occlusal forces were the initiating factor in
periodontal disease and led to ongoing progression of periodontal lesion.

In an attempt to demonstrate this relationship several animal studies on

sheep and monkeys were conducted

Later some investigators state that traumatic occlusion causes changes

in attachment apparatus without involving gingival unit.

They postulated that change in attachment apparatus is mainly due to reduced

blood supply to periodontal ligament
Orban and Weinmann in 1933 using human autopsy material evaluated .

They concluded that there was no relation ship between excessive occlusal force
and periodontal destruction.

Instead they suggested that gingival inflammation extending in to supporting bone

was the cause of periodontal destruction
During the same time Glickman and co workers published studies.

These studies demonstrated a phenomenon described as an altered pathway of

destruction when an excessive occlusal force was present.

Change in orientation of gingival and periodontal fibers

Co destruction.
Vertical osseous defects

Based on this observation, use of occlusal adjustment was advocated as part of the
treatment of existing periodontal disease,

Occlusal adjustment to prevent periodontitis was not advocated

 Waertaug evaluated large number of human autopsy specimens to determine
relationship of morphology of osseous defect and excessive occlusal forces.

No relation between excessive occlusal force and vertical bone loss.

Polson and Lindhe conducted studies to evaluate effect of plaque and excessive
occlusal forces in animal models.

These studies agreed removal of plaque and control of inflammation would stop
.
progression of periodontal disease whether or not excessive occlusal forces are
present.

Meitner reported when squirrel monkeys was subjected to repeated mechanical

injury in combination with marginal periodontitis, the connective tissue loss was
not greater than that of specimen in which periodontitis alone was induced.

Thus these appeared to be no co destructive effect on connective tissue

attachment.
PROBLEM IN RELATING FINDING FROM ANIMAL
RESEARCH TO THE HUMAN DENTITION

An ideal model on which to study occlusion is not yet to be found.

If a high crown on tooth of a dog or monkey, the tooth will intrude and recognize a
new position while human tooth gets progressively mobile.
 Parafunctional habit is a major factor in human occlusal trauma, monkeys and dogs
not known to have such persistent habits
  
Periodontal disease naturally occurs in humans.

In the animals models the lesion of periodontal is induced artificially.

With treatment these artificially treated lesion repair more predictably than naturally
occurring lesions

•                
 PERIODONTAL – ENDODONTIC CONTROVERSY
 

• Two questions have been raised and continue to be matters of dispute.

• 1) Is periodontal disease a cause of pulpal necrosis?

• 2) Can a pulpless tooth be cause of periodontal disease?

 
The effect of periodontal disease and
procedures on the dental pulp
 Periodontal diseases

• Recent publications have suggested that periodontal disease is a direct

cause of Pulpal atrophy and necrosis.

• The pathways for communication and therefore for the extension of

disease from a periodontal pocket to pulp are through patent dentinal
tubules, lateral canals, and apical foramina.

• Many histological and clinical studies suggest, however, that such

relationships rarely, if ever, result in pulp necrosis.
• Kirkham examined 100 periodontally involved teeth and found only 2% had
lateral canals located in a periodontal pocket.

• Tagger & Smukler removed roots from molar teeth so extensively involved
with periodontal disease that root amputation was required, and found that
none of the resected roots showed inflammatory changes.

• Haskell et al also removed roots from maxillary molars with periodontal

involvement and found no inflammatory cells or very few inflammatory cells
present in the pulps of the periodontally involved resected roots.
• Czarnecki & Schilder performed a histological study of intact, caries free
teeth and compared the pulp of teeth, which had periodontal disease.

The pulp of the periodontally involved teeth were all histologically similar to
caries free teeth .

Teeth with extensive decay or extensive restortations showed evidence of

pulpal pathosis.

• Ross & Thompson evaluated the progress of 100 patients with maxillary molar
furcation involvement over a period of 5—24 years.

Of the 387 maxillary molars, 79% had at least 50% or less bone support
around one root prior to periodontal treatment.

Only 4% required root canal treatment subsequent to periodontal therapy. None

were ascribed to the effects of advanced periodontal disease in pulp.
 
 Jaoui et al. studied patients with advanced periodontal disease for 5—14
years after completion of active periodontal treatment .

Of the 571 teeth that did not have root canal treatment at time of completion
of periodontal treatment, only one tooth required root canal treatment over
the 5 to 14 year recall period.
 

Pulpal insult through patent dentinal tubules or the occasional exposed lateral
canal have relatively insignificant effect on the ability of the dental pulp
tissue to survive.
 Periodontal procedures

• The clinical research studies by Ross Thompson, Bergenholtz , Nyman

and Jaoui et al evaluated patients who presented with advanced
periodontal disease, received periodontal treatment.

• They received follow up maintenance for periods ranging from 4 to 24

years. There were 1,623 teeth in the combined studies

• Four percent required root canal treatment subsequent to periodontal

treatment, and follow up periodontal care.

• Cause of pulp necrosis was mainly due to pulpal exposure.

• Extension of periodontal disease to involve the root apices is also cited

as a reason for root canal treatment
 
• In summary dental pulp is capable of surviving significant insults and
that the effect of periodontal disease as well as periodontal treatment is
on the dental pulp is negligible.

• The weight of evidence in literature shows that clinical significance of

the relationship between periodontal disease and dental pulp has been
exaggerated in historical and much of the current periodontal –
endodontic literature
 Effect of endodontically involved teeth on periodontal
health and healing

. Only in recent years the potential effect of a tooth with a necrotic pulp or
a tooth that had root canal treatment was considered as a risk factor in
the initiation of periodontal disease.
• Pulpless tooth with a periapical lesion promotes the initiation of
periodontal pocket formation and interfere with healing of periodontal
lesion after periodontal treatment.
  Jansson et al. state that teeth teeth with periapical lesion had lost more
proximal bone .
0.19 mm\ year vs 0.06mm\ year for teeth with no periapical lesion or
where there is evidence of reduction in lesion size.
• Sanders et el. reported in 1983 that after the use of freeze – dried bone
allografts 65% of teeth that did not have root canal treatment showed
complete or greater than 50% bone fill in periodontal osseous defects.

• While only 33% of teeth which had root canal treatment prior to
periodontal surgical procedure had complete or greater 50% bone fill.
 ROLE OF LYMPHOCYTES IN PERIODONTITIS

• Inflammatory cells, predominantly lymphoid cells and macrophages

thought to be engaged in controlling bacterial challenge.

• Participation of these cells in a major way in process of tissue

destruction had not yet been conceived.

• In 1970 antibodies to cell surface markers became available which

allowed sub categorization of T lymphocytes in to two major subsetsCD 4
and CD8.

• .CD4 molecules serves as a co receptor for major histocompatibility class

two molecules on antigen presenting cells.

• CD8 molecule is a co receptor for MHC class one molecules of the target
cells.
 Phenotypic Analysis

• Phenotypic analysis shows that there are no numerical abnormalities of

T helper cells or major cells.

• There may be altered ratios of CD4 to CD8 in periodontal lesions of

aggressive periodontitis patients
 Functional studies

• T and B-lymphocytes are present in lesions of early onset periodontitis

patients.
• Two accepted activities of the lymphocytes are.

1) They may provide protection against host from infectious agents.

2) they contribute to host tissue damage.

B cells and their linear descendents secrete immunoglobulins (IgG) that

may inactivate bacterial toxins, prevent bacterial adherence and
promote bacterial phagocytosis by polymorphonuclear leukocytes.
 Juvenile periodontitis patients frequently have elevated levels of serum
IgG antibodies against AA antigens.

• But still there has been controversy that whether these antibodies were
protective or not.

• IgG2 antibodies are the predominant sub class presented.

• IgG2 antibodies are not been thought to be effective direct opsonins, or

activators of direct classical pathway.

• IgG2 antibodies can kill AA only when neutrophil has the proper allotypic
form of fc receptor.

• Abnormal lymphocyte function in early onset periodontitis as manifested

by lower than normal levels of non stimulated DNA synthesis in cultured
peripheral blood mononuclear cells.

• This reaction has been called autologous mixed lymphocyte function

(AMLR )
• In some of the studies of periodontal disease patient AMLR returned to
normal after periodontal treatment.

• It is not known how diminished AMLR relates to early onset

periodontitis.It has been suggested that reduced AMLR relate to
improper regulation of B cell responses.

• In 1974 Langer et al. reported that peripheral blood lymphocyte from

juvenile periodontitis patients exhibited reduced blastogenic response
to dental plaque and gram –ve bacteria.

• Several other studies following this early reports found that

lymphocytes from periodontitis patients exhibited more exacerbated
than normal blastogenic response to mitogens and bacterial antigens.

• This phenomenon remains with no strong scientific evidence although it

may be related to reduce AMLR via reduced population of suppressor
inducer T cells.
 ROOT - CONDITIONING
• Exposed root surface as result of periodontitis has undergone
substantial alteration and may no longer serve as an appropriate
substrate for cell attachment.

• Loss of collagen fiber insertion, contamination of root surface by

bacteria and alteration in mineral density.

• Root surface also lack chemotactic stimuli for migration of cell capable
of producing periodontal regeneration.

• Apical migration of junctional epithelium along root surface over

connective tissue following surgical therapy also appear to inhibit
regeneration
• Scaling and root planning is effective in removing bacterial deposits as well
as removing endotoxins from exposed root surface.

• How ever it results in formation of smear layer is thought to serve as a

physical barrier between periodontal tissues and root surface and may
inhibit formation of new connective tissue attachment to root surface.

• Root conditioning of these periodontally involved root surface will eliminate

cytotoxic materials, will dematerializes the planed root surface,will also
expose and enlarge opening of dentinal tubules and will dematerializes the
inter tubular dentin.

• Exposed collagen matrix of dentin is chemotactic for PMN, macrophage

and fibroblasts.

• It can also support the attachment and migration of fibroblast.

• Root surface demineralization will also enhance healing

 HISTOLOGICAL AND CLINICAL SUTDIES

• College of dentistry --Columbus asses the efficacy of root surface

biomodification through tetracycline citric acid or EDTA in patients with
chronic periodontitis.

• They included all the studies evaluating histological and clinical effects
of citric acid, tetracycline and EDTA.

• They excluded studies evaluating effects of extra cellular matrix protein,

enamel matrix protein or growth factors applied to root surface.
 Main results

• Thirty-four studies incorporating total patient population of 575 were

analyzed, 26 for citric acid, 5 for tetracycline and 3 EDTA treatment.

• Four of eight human histological studies represents regeneration with

use of citric acid and only 1 of 18 clinical studies reported attachment
gain.

• Of 5 studies using tetracycline, 1 histological study and 1 clinical study

reported attachment gain.

• No regeneration was reported in the 3 studies evaluating use of EDTA.

 Reviewer’s conclusion

• Evidence to data suggests that use of citric acid, tetracycline and EDTA
to modify root surface provides no benefit of clinical significance to
regeneration in patients with chronic periodontitis
 Root conditioning delays wound healing?

• Selvig et al. examined wound healing in experimental fenestration

defects following conditioning of defects walls with either saline or citric
acid.

• Following elevation of mucoperiosteal flaps, fenestral defects where

covered with polytetrafluroethylene membrane.

• Post surgically after 14 days healing appears to be delayed in citric

acid treated site as compared to the control.
RESTORATION OR IMPLANT PLACEMENT: A
growing treatment planning quandary

Regardless of the implant system, the placement and functional success of

endosseous implants is greater than 90%.

Is a tooth with questionable prognosis restored or intervened with dental

implant?

Should a tooth with large post and core restoration and failing endodontic
procedure is re treated conventionally or should it be extracted?

Is it better to replace such a tooth with an implant?

If the implants fail to integrate or if restoration is an esthetic failure, would it

have been better to retain the tooth?

Answering such questions is a challenge for clinicians. Clinical and economic

factors should be considered in making such decisions.
 Clinical factors
The heavily restored tooth

• These teeth may have been restored multiple times, have minimal
external coronal dentin for an adequate restorative ferrule.

• The post space can be so large that internal dentinal walls of the
preparations are too thin.

• If greater force is to be exerted on a tooth, increase in the resistance

form should be made.

• Crown lengthening can increase resistance but at the expense of

removing bone of adjacent teeth.

• Orthodontic extrusion can also be considered but extrusion adds both

additional financial cost and increased time to treatment.
 Immediate implant placement along with single stage surgical placement
limits number of procedures.

Before the acceptance of sinus augmentation procedures, the choice might

have been to retain teeth with root resective and endodontic re
treatment procedures.

Previously it was thought that implants in posterior maxillae or mandible

was less ideal.
.

Decision for implant placement may change if patient is a heavy smoker or

if they are an uncontrolled diabetic, factors which could compromise
implants
 The Furcation involvement

• Reducing attachment levels for crown lengthening or for root resective

procedures may have a negative long-term impact.
• Periodontally involved molars are the most common teeth lost.
• Furcation and concavities associated with them make them difficult to
treat.
• Resecting roots can improve debridement acess but literature differs as
to success of root amputations or hemi–sections.
• Reasons for failures were current decay, endodontic failure,root
fractures and less commonly, recurrent periodontal dis
• Resection may require osseous removal to the adjacent teeth, as crown
lengthening does.
• If osteoplasty \ ostectomy is not performed then plaque – retentive
areas are created
 Hemi–section

• Hemi–section, the length of root trunk affects how much bone is

removed to create positive osseous architecture.

• To create a positive osseous architecture a large amount of bone must

be removed on remaining root and adjacent tooth..

• If the patient’s anatomy requires sinus augmentation, then clinician may

reconsider treating tooth with root resection.
 Difficult anterior esthetic cases

• The use of dental implants to replace anterior teeth is one of the last
areas to gain acceptance by dental profession.

• The greatest benefit is avoidance of unnecessary preparations of non-

restored teeth adjacent to an implant.

• Professional acceptance of implants in esthetic zone has increased

because they are    
    
• Better pre-surgical planning guidelines.    
   
• More option in diameter of implants fixtures.
      
• Great variety of abutments.    
   
• Better techniques for preparing edentulous ridge.

• Better prosthetic techniques to produce a high esthetic final restoration.

 ECONOMIC FACTORS

• Clinician as well as patients many times elects best economic option

than best treatment option.

• Some still argue that the long-term success rates of implants are not
high enough and that questionable teeth should be maintained until
they become hopeless.
 Hand versus Ultrasonic Instrumentation
• Partial removal of cementum became established as a therapeutic
procedure over one century ago.

• Mergenhen and Hampp were the first to demonstrate that plaque –

related gram-negative bacteria produce the complex lipo-polysachride
endotoxins described by Boe in 1941

• Aleo and De Renzius scientifically proved the significance of root

cementum bound endotoxin removal in periodontally diseased teeth.

• In 1974 they showed that cementum of these involved teeth contains

endotoxins and also found that this lipo-polysachride is toxic to cells in
vitro.
 Comparison
• Many investigators have compared hand and ultrasonic instrumentation.

• Nishimine and O’ Leary showed that root planning was more effective than
ultra sonic scaling in removing endotoxins from periodontally involved root
surfaces.

• Two investigations evaluated the smoothness of root surfaces at an

ulrtastructural level following hand and ultrasonic instrumentation.

• One study reported a much smoother root following ultrasonic scaling. The
second study reported opposite results.

• Luiggi and Gian conducted a study to compare efficacy of ultrasonic and

hand instrumentation.

• They found no significant differences between fibroblast growth on

periodontally involved root surfaces treated with hand instruments and with
ultra sonic scalers.
• Several studies reported on an increased efficiency of subgingival
instrumentation with both sonic and ultra sonic scalers, since manual
instrumentation takes longer to achieve the same clinical results
(Dargoo 1992,Copulos et al. 1993).

• Power driven instruments have been shown to be superior in treatment

of class 2 and class 3 furcations (Leon & Vogel 1987).

• Development of heat at scaler tip when water-cooling is not sufficient.

This increased temperature may cause injury to pulpal and periodontal
tissues.

• Another draw back is formation of pathogenic bacterial aerosols and

the reduced tactile sensation in comparison to hand instruments.
 NONSURGICAL AND
SURGICAL PERIODONTAL
THERAPY
 NONSURGICAL
PERIODONTAL THERAPY

• Conventional nonsurgical periodontal therapy consists of mechanical supra and

subgingival tooth debridement

• Reducing the bacterial load and altering the microbial composition towards a
flora more associated with health,which in turn result in lower levels of
inflammation and relative stability in periodontal attachment levels.

• In the past, endotoxin or lipopolysacchairde derived from cells of gram-negative

bacteria was though to be so firmly attached to the root surface.

• More recent studies on extracted teeth indicate that endotoxins are superficially
bound and can be removed by such means as brushing.

• Thus systematic root planing to remove cementum does not seem warranted.
• Furcation opening is often less than 1 mm, too small to be effectively
reached with relatively larger curettes.

• Most of the new ultrasonic tips are approximately 0.50mm in diameter,

which may favor ultrasonics as the instruments of choice for furcation
sites.

• One study on instrumentation of furcations with and without surgical

access indicates that no major differences were observed between use
of curettes or ultrasocics in the closed treatment groups and in wide
furcations.
 PERIODONTAL SURGERY

• The following have been proposed as the aims of periodontal surgery:

• Accessibility to previously in accessible root surfaces.

• Production of healthy dento-gingival junction that would enable the

patient to practice a high level of plaque removal.

• Reduction of probing depths to allow - a) effectively delivered

maintenance and home care and b) the monitoring and or diagnosis of
recurrent inflammation and progressive periodontal disease.
 COMPARISON OF SURGICAL AND NONSURGICAL
TREATMENT MODALITIES

• An early study employing a split-mouth design was that of knowles et

al.
. Three modalities were tested sub-gingival curettage, modified Widman
flap surgery and pocket elimination surgery

• After evaluation for eight years all techniques resulted in favorable

changes in the means of the clinical parameters measured

• The surgical techniques resulted in slightly more pocket reduction in

deep pockets.
• The modified Widman flap resulted in the greatest clinical attachment
gain.

• In studies comparing the effects of root planing and modified Widman

flap surgery over 6 years of observation,.

• The modified Widman flap resulted in more pocket reduction in initially

deep pockets, although mean attachment levels were similar.
 In summary, following points may be deduced
from available literature.

• Both non-surgical and surgical therapies have been shown to result

in similar mean improvements of clinical scores.

• Data for the possible adjunctive effect of surgical procedures on

patients/sites unresponsive to initial therapy are scarce.

• Data for the possible adjunctive effect of surgical procedures on

patients believed to be at high risk to ongoing attachment loss are
scarce.

• Other than studies on regenerative techniques data for the

comparable effects of different surgical modalities on furcation areas
are also scarce.

• Data for long-term outcome measures, such as tooth loss and quality
of life issues, are scarce.
PERIODONTITIS – SYSTEMIC
DISEASE ASSOCIATIONS IN
THE PRESENCE OF SMOKING
– CAUSAL OR
COINCIDENTAL?
• No Current issue in periodontal research is more visible or controversial
than the relationship between periodontitis and systemic diseases.

• Four lines of evidence suggests that the observed periodontitis-systemic

disease associations are in part a result of confounding by smoking

• First, no periodontitis-systemic disease associations have been identified

among neversmokers.

• Second, periodontitis and smoking mimic one another with respect to the
types of diseases with which they are associated (e.g. lung cancer and
Parkinson’s disease).

• Third, only studies with inadequate adjustment for smoking report

significant periodontitis-systemic disease associations.

• Lastly, elimination of dental infection, unlike smoking cessation, does not

reduce coronary heart disease risk.
 Smoking, the epidemoiologists’ perspective

• Individuals with periodontitis are more likely to be current or past

cigarette smokers.

• When individuals with and without periodontitis are compared it is to be

expected that individuals with periodonititis will have more smoking-
related diseases, such as coronary heart disease, lung cancer, low-
birth weight babies etc.,..

• Statistical adjustment of control for confounding is possible.

• Such statistical adjustment can be used to eliminate some but not all of
the bias caused by the smokers.
• The imperfect smoking questionnaires,the inability to ask questions or otherwise
obtain information on important characteristics of smoking, all make it virtually
impossible to have perfect statistical adjustment for smoking.

• Wherever past or current smokers are included in the analyses, biased

periodontitis – systematic disease associations will be reported.

• Therefore, primary analyses should be limited to healthy never-smokers both

because smoking is such a strong risk factor and because the magnitude of
smoking cannot be well measured.
 Effect of smoking on Periodontitis cannot be
distinguished from the effect of smoking on
systemic diseases
• Periodontitis-systemic disease associations have not been identified
among never-smokers.

• Periodontitis and smoking are associated with similar health risks.

• Conflicting study results can be explained in terms of statistical

adjustment for tobacco smoking.

• Dental infection elimination through complete tooth removal, unlike

smoking cessation, does not reduce health risks.
 Periodontitis and chronic obstructive
pulmonary disease (COPD)
• Among past and current smokers, periodontitis significantly increased
the risk for COPD.

• When the analysis included past, current, and never smokers with
adjustment for reported smoking dose and duration, the HR for COPD
decreased by 7%.

• Finally, when the analysis was limited to never-smokers, periodontitis

was associated with a small and insignificant increased risk for COPD.
 Periodontitis and lung cancer

• Among past and current smokers, periodontitis significantly increased

the risk for lung cancer

• When the analysis included never, past, or current smokers, with

adjustment for smoking the HR for lung cancer associated with
periodontitis decreased by 49%.

• When the analysis was limited to never-smokers, the opposite

association was present.

• Periodontitis was associated with a decreased risk for lung cancer, not
an increased risk.
 Periodontitis and stroke

• Among past and current smokers, periodontitis marginally increased

the risk for stroke.

• When the analysis included never, past or current smokers with

adjustment for smoking, the HR for stroke associated with periodontitis
decreased by 8%.

• Finally, when the analysis was limited to never-smokers, periodontitis

increased the HR for stroke by 11%.

• These findings differ from previously reported results.

 Periodontitis and coronary heart disease (CHD)

• Among past and current smokers, periodontitis significantly increased the risk
for CHD by 26%.

• Among past, current and never-smokers the HR for CHD associated with
periodontitis was 1.13.

• Finally, when the analysis was limited to never-smokers, the HR for CHD
associated with periodontitis became insignificant).

• Imperfect adjustment for smoking history is inducing associations between

periodontitis and smoking related diseases.
• There is also hope that periodontal treatments can reverse an
increased CHD risk..

• Findings from the same cohort study indicated that complete

elimination of all dental infections by extraction does not decrease
CHD risk..

• Then why would an incomplete, imperfect and reversible decreasing of

the bacterial load by means of periodontal treatments decrease CHD
risk?

• Some have offered the explanation that the risk, once established, is
not reversible and therefore primary periodontitis prevention trials rather
than secondary prevention should be initiated.
 Conflicting study results can be explained in
terms of statistical adjustment for tobacco
smoking
• Study was categorized as having good adjustment for smoking when the
number of cigarettes smoked per day was taken into account in the
analyses.

• When a study did not take into account the number of cigarettes smoked
per day the study was categorized as poorly adjusted.

• There have been a total of nine cohort studies published on the

periodontitis-CHD associations.

• Periodontitis was not significantly associated with CHD among those

studies that provided a good adjustment for smoking dose.

• In contrast, periodontitis was significantly associated with CHD in the

four studies that either did not adjust for smoking or adjusted crudely.
 Dental infection elimination through complete
tooth removal does not reduce health risks

• There is certainly hope that secondary prevention of CHD events can

occur through periodontal treatment.

• Current epidemiological evidence does not support the hope that

periodontitis plays a role in secondary heart disease prevention.

• A cohort study in the US population suggests that periodontitis does not

increase the risk for secondary heart disease events.

• Individuals with periodontitis and pre-existing heart disease were found

to be at the same risk for developing a secondary heart disease event
as the individuals with pre-existing heart disease but without
periodontitis.
• There is also hope that periodontal treatments can reverse an
increased CHD risk..

• Findings from the same cohort study indicated that a definitive,

irreversible, and complete elimination of all dental infections by
extraction does not decrease CHD risk.

• Then how incomplete, imperfect and reversible decreasing of the

bacterial load by means of periodontal treatments decrease CHD risk?

• Some have offered the explanation that the risk, once established, is
not reversible and therefore primary periodontitis prevention trials rather
than secondary prevention should be initiated.
CONCLUSION
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