Cochrane Database Syst Rev 2006; CD001724 (Read article online)

Needleman I, Worthington H, Giedrys-Leeper E, Tucker R

BACKGROUND: Conventional treatment of destructive periodontal (gum) disease arrests the disease but does not usually regain the bone support or connective tissue lost in the disease process. Guided tissue regeneration (GTR) is a surgical procedure that specifically aims to regenerate the periodontal tissues when the disease is advanced and could overcome some of the limitations of conventional therapy. OBJECTIVES: To assess the efficacy of GTR in the treatment of periodontal infra-bony defects measured against conventional surgery (open flap debridement (OFD)) and factors affecting outcomes. SEARCH STRATEGY: We conducted an electronic search of the Cochrane Oral Health Group Trials Register, MEDLINE and EMBASE up to April 2004. Handsearching included Journal of Periodontology, Journal of Clinical Periodontology, Journal of Periodontal Research and bibliographies of all relevant papers and review articles up to April 2004. In addition, we contacted experts/groups/companies involved in surgical research to find other trials or unpublished material or to clarify ambiguous or missing data and posted requests for data on two periodontal electronic discussion groups. SELECTION CRITERIA: Randomised, controlled trials (RCTs) of at least 12 months duration comparing guided tissue regeneration (with or without graft materials) with open flap debridement for the treatment of periodontal infra-bony defects. Furcation involvements and studies specifically treating aggressive periodontitis were excluded. DATA COLLECTION AND ANALYSIS: Screening of possible studies and data extraction was conducted independently. The methodological quality of studies was assessed in duplicate using individual components and agreement determined by Kappa scores. Methodological quality was used in sensitivity analyses to test the robustness of the conclusions. The Cochrane Oral Health Group statistical guidelines were followed and the results expressed as mean differences (MD and 95% CI) for continuous outcomes and risk ratios (RR and 95% CI) for dichotomous outcomes calculated using random-effects models. Any heterogeneity was investigated. The primary outcome measure was change in clinical attachment. MAIN RESULTS: The search produced 626 titles, of these 596 were clearly not relevant to the review. The full text of 32 studies of possible relevance was obtained and 15 studies were excluded. Therefore 17 RCTs were included in this review, 16 studies testing GTR alone and two testing GTR+bone substitutes (one study had both test treatment arms).No tooth loss was reported in any study although these data are incomplete where patient follow up was not complete. For attachment level change, the mean difference between GTR and OFD was 1.22 mm (95% CI Random Effects: 0.80 to 1.64, chi squared for heterogeneity 69.1 (df = 15), P < 0.001, I(2) = 78%) and for GTR + bone substitutes was 1.25 mm (95% CI 0.89 to 1.61, chi squared for heterogeneity 0.01 (df = 1), P = 0.91). GTR showed a significant benefit when comparing the numbers of sites failing to gain 2 mm attachment with risk ratio 0.54 (95% CI Random Effects: 0.31 to 0.96, chi squared for heterogeneity 8.9 (df = 5), P = 0.11). The number needed to treat (NNT) for GTR to achieve one extra site gaining 2 mm or more attachment over open flap debridement was therefore 8 (95% CI 5 to 33), based on an incidence of 28% of sites in the control group failing to gain 2 mm or more of attachment. For baseline incidences in the range of the control groups of 3% and 55% the NNTs are 71 and 4.Probing depth reduction was greater for GTR than OFD: 1.21 mm (95% CI 0.53 to 1.88, chi squared for heterogeneity 62.9 (df = 10), P < 0.001, I(2) = 84%) or GTR + bone substitutes, weighted mean difference 1.24 mm (95% CI 0.89 to 1.59, chi squared for heterogeneity 0.03 (df = 1), P = 0.85).For gingival recession, a statistically significant difference between GTR and open flap debridement controls was evident (mean difference 0.26 mm (95% CI Random Effects: 0.08, 0.43, chi squared for heterogeneity 2.7 (df = 8), P = 0.95), with a greater change in recession from baseline for the control group.Regarding hard tissue probing at surgical re-entry, a statistically significant greater gain was found for GTR compared with open flap debridement. This amounted to a weighted mean difference of 1.39 mm (95% CI 1.08 to 1.71, chi squared for heterogeneity 0.85 (df = 2), P = 0.65). For GTR + bone substitutes the difference was greater, with mean difference 3.37 mm (95% CI 3.14 to 3.61).Adverse effects were generally minor although with an increased treatment time for GTR. Exposure of the barrier membrane was frequently reported with a lack of evidence of an effect on healing. AUTHORS' CONCLUSIONS: GTR has a greater effect on probing measures of periodontal treatment than open flap debridement, including improved attachment gain, reduced pocket depth, less increase in gingival recession and more gain in hard tissue probing at re-entry surgery. However there is marked variability between studies and the clinical relevance of these changes is unknown. As a result, it is difficult to draw general conclusions about the clinical benefit of GTR. Whilst there is evidence that GTR can demonstrate a significant improvement over conventional open flap surgery, the factors affecting outcomes are unclear from the literature and these might include study conduct issues such as bias. Therefore, patients and health professionals need to consider the predictability of the technique compared with other methods of treatment before making final decisions on use. Since trial reports were often incomplete, we recommend that future trials should follow the CONSORT statement both in their conduct and reporting.There is therefore little value in future research repeating simple, small efficacy studies. The priority should be to identify factors associated with improved outcomes as well as investigating outcomes relevant to patients. Types of research might include large observational studies to generate hypotheses for testing in clinical trials, qualitative studies on patient-centred outcomes and trials exploring innovative analytic methods such as multilevel modelling. Open flap surgery should remain the control comparison in these studies.

Br Dent J 2002 Dec 7; 193(11): 657-9; discussion 643 (Read article online)

Chestnutt IG

BACKGROUND: The internet provides a potentially invaluable source of health education material for members of the public. OBJECTIVES: This study aimed to investigate the nature and quality of periodontal-related patient information on the world-wide web. METHODS: The search term ' "gum disease" AND "patient information" ' was entered into three common internet search engines. The top 50 sites identified by each search engine were downloaded and assessed for authorship, content, accord with accepted dental practice, currency, and references to peer reviewed data. RESULTS: The search term returned in excess of 3,615 hits across the three search engines. Of the top 150 identified, 68 were deemed relevant to patients seeking information on periodontal disease. Of these, 17 were duplicated either within or between search engines, therefore the following analysis is based on the remaining 51 sites. The majority of sites (25) were authored by individual dental practitioners, with sites originating in the USA predominating (80%). Information on the aetiology, signs and symptoms, and treatment options for periodontal disease was provided by 38, 38, and 29 sites respectively. This information was deemed in accordance with conventional periodontal practice in 27, 33, and 23 cases respectively. Only seven sites indicated the currency of the information and five provided peer-reviewed references for further reading. The rank order identified by the search engines meant that sites providing comprehensive and authoritative information, were not readily differentiable from sites whose primary objective was promoting attendance at specific dental practices. CONCLUSIONS: Judicious and active support from professionals is required to aid patients' interpretation of the information identified and to direct them to the most instructive sites.

Eur J Dent Educ 2005 Nov; 9(4): 164-70 (Read article online)

Polychronopoulou A, Kawamura M

AIM: This study explored cross-cultural differences of self-reported oral health behaviours between Greek and Japanese dental students. PARTICIPANTS: The sample population included 877 dental students, 539 students registered at the University of Athens Dental School, and 338 registered at the Hiroshima University Dental School. MATERIAL AND METHODS: Oral health behaviour was assessed using the Greek and Japanese versions of a 20-item questionnaire entitled Hiroshima University-Dental Behavioural Inventory (HU-DBI). RESULTS: The mean questionnaire score of the Japanese students (7.40) was significantly greater than that of the Greek peers (6.86, P = 0.001), indicating better oral self-care behaviour amongst the Japanese students; however, the overall difference was mainly attributed to their additional sixth study year. Greek and Japanese students provided significantly different answers to 14 of 20 HU-DBI items. Greeks significantly more often were required by their dentist to evaluate their brushing technique (OR = 14.4, P < 0.01), checked their teeth in the mirror after brushing (OR = 8.1, P < 0.01), worried about bad breath (OR = 6.7, P < 0.01), and believed that gum disease is preventable by tooth brushing alone (OR = 2.1, P < 0.05), whereas their Japanese peers significantly more often felt comfortable to clean their teeth without the use of a toothpaste (OR = 0.3, P < 0.01), believed that they take much time to brush their teeth (OR = 0.3, P < 0.01), used a child-sized toothbrush (OR = 0.2, P < 0.01), and put off going to the dentist until having toothache (OR = 0.4, P < 0.01). CONCLUSIONS: Considerable differences in dental health attitudes/behaviour exist amongst students in the two countries reflecting the different culture and the health education system of the students; moreover, it is possible to distinguish Greek dental students from Japanese peers with a probability of more than 89% by using the HU-DBI instrument.

J Am Diet Assoc 2003 May; 103(5): 615-25 (Read article online)

Touger-Decker R, Mobley CC,

It is the position of the American Dietetic Association (ADA) that nutrition is an integral component of oral health. The ADA supports the integration of oral health with nutrition services, education, and research. Collaboration between dietetics and dental professionals is recommended for oral health promotion and disease prevention and intervention. Scientific and epidemiological data suggest a lifelong synergy between nutrition and the integrity of the oral cavity in health and disease. Oral health is an integral part of systemic and nutritional health. Two primary oral infectious diseases are directly influenced by diet and nutrition. Dental caries or tooth decay is modulated by numerous factors, including diet composition and frequency. Periodontal or gum disease is associated with malnutrition. Chronic diseases such as diabetes and cardiovascular disease that are modulated by diet and nutrition intervention have oral sequelae. As we advance in our discoveries of the links between oral and nutrition health, practitioners of both disciplines must learn to provide screening, baseline education, and referral to each other as part of comprehensive client/patient care. The future of dietetics practice requires dietetics professionals to provide medical nutrition therapy (MNT) that incorporates a person's total health needs, including oral health. Inclusion of both didactic and clinical practice concepts that illustrate the role of nutrition in oral health is essential in both dental and dietetic education programs. Collaborative endeavors between dietetics and dentistry in research, education, and delineation of health provider practice roles are needed to ensure comprehensive health care to persons with oral infectious disease and/or oral manifestations of systemic diseases.

J R Soc Health 2006 Jan; 126(1): 28-32 (Read article online)

Matear D, Barbaro J

AIM: The provision of dental services to elderly populations is a complicated area. When clients are cognitively impaired, a new set of variables are introduced as care can be influenced by designated family members, caregivers or administrators, who are responsible for the oral health care of the client and may influence the types of treatment the client will receive. Differences in attitudes and perceptions, with respect to oral health, may lead to better or worse access to care. The goals of this study are: (a) to gain a better understanding of the perceptions which may govern access and barriers to care within the institutionalised elderly population; and (b) to improve information on where and how to target educational and service resources, in order to reduce barriers to care. METHOD: A convenience (non-randomised) sample of 100 residents with caregivers was selected from nursing homes without organised access to oral healthcare services. A structured interview was conducted with 40 family members. Questions explored the importance and priorities of dental services for elderly people in institutions. RESULTS: Services which family members deemed of highest importance were dentures (both to replace teeth and adjustments on existing dentures), pain relief, emergency dentistry, fillings, cleanings, check-ups, tooth removal and treatment for advanced gum disease. Services that family members felt were less important were complex restorations, cleaning instruction to caregivers and seniors, and services by a specialist. Services considered to be of least importance were root canal treatment and implants. The top service priorities identified by the sample of family members included: cleanings to prevent mouth disease; check-ups including X-rays; fillings; dentures to replace teeth; and dental treatment to relieve pain. CONCLUSION: This study found that family members and caregivers would like a basic dental service including check-ups and preventive care, with restorative, denture and surgical intervention when required.

J Ethnopharmacol 2004 Oct; 94(2-3): 261-6 (Read article online)

Hebbar SS, Harsha VH, Shripathi V, Hegde GR

The present ethnomedicine survey covers the Dharwad district of Karnataka in southern India. It was revealed that 35 plants belonging to 26 families are being used to treat different types of oral ailments like toothache, plaque and caries, pyorrhea and aphthae. Sixteen of these plants were new claims for the treatment of oral ailments not previously reported in the ethnomedicinal literature of India. Basella alba, Blepharis repens, Capparis sepiaria, Oxalis corniculata and Ricinus communis are used for the treatment of aphthae; Azima tetracantha, Caesalpinia coriaria, Cleome gynandra, Gossypium herbacium, Leucas aspera, Merremia chryseides, Pergularia daemia, Prosopis juliflora and Solanum nigrum are used to treat tooth ache and Cassia hirsuta and Cassia tora are used in the treatment of plaque and caries.

Pac Health Dialog 2003 Mar; 10(1): 68-75 (Read article online)

Cutress TW

Periodontal (or gum) disease is historically endemic in all indigenous communities in the South Pacific Region. While the disease becomes evident in mature adults the pathology becomes overt by adolescence or earlier. The initial gum inflammation progresses increasingly with age and may lead to pathological destruction of the tooth supporting tissues, tooth loosening and potential tooth loss. For most adults the disease presents as an adult-onset generalized chronic marginal-gingivitis-periodontitis-calculus complex. Microbiological components of dental plaque on tooth surfaces and dental calculus initiate the pathology. While the general clinical features are similar between adults and between communities, epidemiological studies have identified variations in disease progression. Also severity of the disease may be influenced by systemic health factors such as diabetes, known to be common in the Region. A common outcome, loss of teeth, usually becomes evident from the fourth decade onwards. Once established the plaque- gingivitis- calculus- periodontitis complex becomes increasingly difficult to reverse. Early adoption and maintenance of routine oral care actions through family, social, community and educational actions will improve long-term oral health, tooth loss, potentially adverse systemic health and in general better lifestyles.

J Med Virol 2005 Oct; 77(2): 216-20 (Read article online)

Lins L, Almeida H, Vitvisk L, Carmo T, Paraná R, Reis MG

Hepatitis C is a worldwide public health problem and its transmission is clearly associated with the parenteral route, however, the virus has also been isolated from other body fluids. Hepatitis C virus (HCV) RNA has been detected in saliva, yet the relationship between HCV and oral pathology is not clearly understood. Therefore, an investigation on HCV-RNA in saliva and its correlation with oral pathology was undertaken. Saliva and blood samples were collected from 50 anti-HCV positive patients and from 25 patients with non-HCV chronic liver disease. HCV-RNA was detected in all of the saliva samples from the HCV positive group. None of the saliva or serum samples from the non-HCV group were positive for HCV-RNA. The patients were examined for dental and oral health (dentate, partially dentate, edentulous, evidence of gum disease, or mucosal lesions); however, no correlation was found between HCV-RNA in saliva, oral health, and viral load. These results suggest that HCV-RNA presence in saliva is independent of the viral load and the oral pathology of HCV positive individuals.

Int J Dent Hyg 2004 Aug; 2(3): 132-6 (Read article online)

El-Qaderi SS, Quteish Ta'ani D

The aim of this study was to assess periodontal knowledge and periodontal status in 20-60-year-old adult population in northern Jordan. A convenient sample consisting of 722 adults was included in this study. A questionnaire incorporating items related to socio-demographic and periodontal knowledge questions was completed before clinical examination, using the Community Periodontal Index of Treatment Needs (CPITN). The results showed that the proportions of subjects who reported bleeding gums, gums' irritation, rough tooth surface and gum disease decreased steadily with age, there is an evident linear trend with high statistical significant difference among various age groups (P < 0.001). Furthermore, the proportions of subjects who answered correctly the periodontal knowledge questions related to plaque definition and its role in disease aetiology and prevention, decreased with age, with a high significant difference for all knowledge questions (P < 0.001). The prevalence of subjects with healthy periodontium (score 0) decreased with age, being 41.1% among 20-29-year-old group and 11.1% in 50-60-year-old group. Similar trend was seen for bleeding on probing (score 1) whilst calculus deposit (score 2) was the major problem in all age groups over 29 years. The prevalence of periodontal pockets was relatively low, with a range of 4.5-18.6% for shallow pockets (score 3) and 2.9-11.1% for deep pockets in younger and older age groups, respectively. Younger age group had more healthy sextants than older age groups. In addition, sextants with bleeding on probing were highest in 20-29-year-old age group (1.8) compared with that in 50-60-year-old age group (0.60) whilst those with calculus deposits varied slightly among different age groups (1.50-1.65). Sextants affected by shallow or deep pockets increased steadily with age. Such a finding was also noted in excluded sextants, with an increase from 0.15 at 20-29 year-old group to 0.94 at the age of 50-60 years. It is concluded that health knowledge and status related to periodontal disease is still poor in northern Jordan. Therefore, dental health education provision is necessary to improve oral health knowledge and conditions among population in general and among older population in particular.

Int J Dent Hyg 2005 May; 3(2): 74-82 (Read article online)

Alwaeli HA, Al-Jundi SH

Certain conditions may have an affect on gingival status and may aggravate pre-existing disease, especially in persons with poor oral hygiene. Pregnancy is one of these conditions. In addition, there is evidence in the literature suggesting an association between periodontal diseases in pregnant women and giving birth to premature, low-birth infants. The purpose of this study was to evaluate the degree of periodontal health knowledge, and awareness, among pregnant women in Jordan. This was carried out by cross-sectional survey using self-administered, structured questionnaires distributed at six maternity care centres in Irbid City. Questionnaire items addressed personal and socio-demographic variables and periodontal health awareness and knowledge of pregnant women. Women (n = 300) were randomly chosen from attendants to these centres. Of the 300 questionnaires distributed, only 275 pregnant women ages 16-45 years with a mean of 29 year responded and were included in the study. Data were analysed by chi-squared test with the level of significance set at (P < 0.05). About one-third of the participants had secondary level of education; it appeared that a minority of the pregnant women had knowledge or ability to identify dental plaque (16.4%) and its harmful effects (22.5%), while most of them (88%) were aware that bleeding gums indicated the presence of periodontal disease. The differences in the responses to knowledge questions were only significant for question number one (What is plaque?) among different educational levels and groups. This study revealed that (71.6%) of the pregnant women knew the main cause of gum disease; however 56% of them do not believe that frequency of teeth brushing should be increased during pregnancy and only 5.1% believed there might be a relationship between gum diseases and premature labour. Knowledge and awareness for pregnant women about their teeth and gingival condition is generally poor. Pregnant women need accurate information about their teeth and oral health. Simple educational preventive programmes on oral self-care and disease prevention before and during pregnancy should be provided to improve oral health.

Saudi Med J 2003 Oct; 24(10): 1087-91 (Read article online)

Almas K, Al-Malik TM, Al-Shehri MA, Skaug N

OBJECTIVE: The aim of this study was to find out the knowledge and practices of oral hygiene methods among primary and secondary school teachers in Riyadh, Kingdom of Saudi Arabia (KSA). METHODS: The study was carried out using a self-administered questionnaire. Four hundred and seventy teachers, male 236 (50.2%) and female 234 (48.8%) responded with a response rate of 85.5%. The study was conducted during October to December 2001 at primary and secondary schools in Riyadh City, KSA. RESULTS: Almost 86% of male and 90% of female teachers felt that dental caries is due to the wrong method of tooth brushing, while sugar and sugary drinks were considered the main factor by 90% of male and 98% of female teachers. Seventy-five percent of male and 72% of female teachers considered irregular tooth brushing a cause of gums disease with 32% of male and 39% of female teachers not knowing details with regards to microbial relationship of gum disease. Tooth brushing preference was common among 45% male and 49% female teachers due to perceived effect of better cleaning, while almost an equal percentage of male and females (62%) used miswak due to Sunnah. Thirty-three point five percent of female teachers brushed 3 times a day as compared to 19% male teachers. On daily basis brushing 3 times, a day was common among >5000 SR monthly income group. Male teachers preferred horizontal tooth brushing (40%) while female teachers preferred circular tooth brushing (45%). Miswak was more commonly used by male teachers as compared to female teachers. Female school teachers had a higher income as compared to male schoolteachers. Thirty-two percent of females and 28% of male teachers were regular attendees to the dentist. Males were more satisfied by their oral health as compared to female teachers and 56% of male and 63% of female teachers visited the dentist only on having pain (toothache). CONCLUSION: It is concluded that there is much resemblance in knowledge and practice of oral hygiene habits among male and female schoolteachers and there is a need to enhance their knowledge regarding oral health and disease. Both need more awareness regarding oral health promotion to have a positive role in school oral health education for their students in collaboration with oral health care workers.

J Clin Epidemiol 2004 Aug; 57(8): 853-7 (Read article online)

Fisher MA, Gilbert GH, Shelton BJ

OBJECTIVE: To describe racial differences in receipt of dental services and dental insurance; and to determine the effectiveness of specific dental services in facilitating recovery in symptom-specific and race-specific subgroups. STUDY DESIGN AND SETTING: Using a restricted cohort analytic method, Florida Dental Care Study prospective cohort data were used to quantify associations between dental service use and the quality of life measure, "recovery" from oral disadvantage due to functional limitation. RESULTS: Non-Hispanic Whites (NHW) were more likely to have a dental visit [odds ratio (OR); 95% confidence interval: 3.5; 2.2-5.3], corrective treatment (OR=2.1; 1.3-3.3), caps (OR=28.8; 6.6-126.4), and dental insurance coverage for caps (OR=2.9; 1.4-5.9). After adjusting for other covariates: (1) among NHW with severe gum disease, those receiving extractions were more likely to recover (OR=7.8; 1.0-59.1), but those receiving caps were less likely to recover (OR=0.1; 0.01-0.6); (2) among Non-Hispanic Blacks (NHB) with a sensitive tooth, those receiving corrective treatment (OR=3.2; 1.2-8.8) or extractions (OR=3.8; 1.3-11.2) were more likely to recover; (3) among NHB with tooth disease, those receiving corrective treatment (OR=2.3; 1.0-5.0) and extractions (OR=2.8; 1.2-6.5) were more likely to recover. CONCLUSION: There were racial differences in dental insurance, in the receipt of dental services and in the effectiveness of dental services in improving oral health-related quality of life.

Spec Care Dentist 2004 Nov-Dec; 24(6): 301-7 (Read article online)

Slaughter A, Smith VJ, Taylor L

This study was conducted to understand perceptions that may influence oral self-care behaviors among elderly African American adults living in an urban community. Four focus groups at two senior centers were recruited, involving a total of 25 participants. Content analysis and ethnographic summaries were used to identify themes, common concepts and language. The results indicated that although the participants recognized the advantages of routine brushing, the importance of keeping teeth clean to prevent gum disease was not widely acknowledged. On the basis of these focus groups, the authors suggest that health promotion approaches for adults who are elderly should be linked to the audience's cultural norms and perceptions regarding the benefits of oral hygiene practices.