Dr. Mark J. Weingarden

Background: Despite previous studies addressing the link between preterm or low birth weight infants and maternal periodontitis, extreme preterm births have received far less attention.  This study is designed to address the possible association between maternal periodontal disease and preterm or extreme preterm birth. 

Methods: Immediately after childbirth, 1,207 women underwent an examination in which periodontal disease was assessed according to two alternative definitions: 1) four or more teeth with at least one site showing probing depth (PD) > or = 4mm and clinical attachment loss (AL) > or = 3mm, and 2) at least one site showing PD and clinical AL > or = 4mm.  For each of these definitions, two types of multivariate analysis were conducted: a linear regression analysis for the number of gestation weeks, and a more specific ordinal logistic regression analysis for the ordinal variable gestation time categorized as normal (term) (n=1,046 women) or mild-moderate (n=146 women) or extreme preterm (n=15 women). 

Results:  Periodontal disease was associated with fewer weeks of gestation by linear regression (definition 1: P = 0.012: definition 2: P<0.001 and with preterm (n=161: mild-moderate and extreme) or extreme preterm births (n=15) by ordinal logistic regression (definition 1: odds ratio [OR] = 1.83, 95% confidence interval [CI]: 1.28 to 2.62: definition 2: OR = 2.37, 95% CI: 1.62 to 3.46). 

Conclusion: Our findings suggest that periodontal disease is associated with a premature or extremely premature birth. 

J Periodontology 2010;81:350-358

Our periodontal maintenance report includes over 300 pieces of clinical information, developed specifically for the patient’s general dentist and hygienist, providing a complete and thorough update on that patient’s periodontal status.  In the past, most clincians, understandably, have focused primarily on the pocket depths. While these are certainly important numbers, they are not the most critical piece of information.  The most vital information given by this report is the “plaque control” and the “bleeding index”, the numbers that tell us the presence or absence of inflammation and the risk of recurrent disease activity.  

We now know that inflammation is the periodontal “red flag” which guides us in the detection, treatment and control of gum disease.  The AAP reports:

“Research has long suggested an association between gum disease and other health issues including heart disease, stroke and diabetes, but now scientists are beginning to shift their focus to understanding why these connections exist.  An emerging theory, and one gaining support from researchers worldwide, is that inflammation may link the mouth to the body.  Inflammation is the body’s instinctive reaction to fight off infection, guard against injury or shield against irritation.  Inflammation is often characterized by swelling, redness, heat and pain around the affected area.  While inflammation initially intends to heal the body over time, chronic inflammation can lead to dysfunction of the infected tissues, and therefore more severe health complications.

According to Dr. Susan Karabin, Past President of the American Academy of Periodontology and a practicing periodontist in New York City, periodontal disease is a textbook example of an inflammatory disorder: ‘for many years, dental professionals believed that gum disease was solely the result of a bacterial infection caused by a build-up of plaque between the teeth and under the gums.  While plaque accumulation is still a factor in the development and progression of gum disease, researchers now suspect that the more severe symptoms, namely swollen, bleeding gums; recession around the gum line, and loss of the bone that holds the teeth in place, may be caused by the chronic inflammatory response to the bacterial infection, rather than the bacteria itself’. 

American Academy of Periodontology-November 24, 2008

The success or failure of periodontal treatment is very much dependent upon control of the inflammation.  This requires a record keeping system designed to focus upon inflammation and its cause, not just the pockets.  This requires a time commitment from the clinician, devoted to helping the patient achieve plaque control effectiveness at home.  

Bottom line – be on the look out for inflammation.  If insurance limits the feasible amount of time you can devote to helping patients with their home care, make sure that the periodontist you work with is on top of inflammation!   

Questions or comments?  Feel free to contact us at 412-487-8288 or visit our website at www.pittsburghimplantsandperio.com

 An article in the Journal of Periodontology, May 2010 issue addresses the issue of “risk factors” in diagnosing and treating periodontal disease in 2010.   The authors, Kenneth S. Kornman and Donald Clem discuss how periodontal disease is treated differently today, than in the past.  

“…If one considers emerging evidence linking chronic inflammation to multiple systemic conditions, including cardiovascular events, Alzheimer’s disease, and diabetes, then pain and disfigurement of uncontrolled periodontitis have far-reaching systemic effects encompassing not only natural dentition, localized soft tissues and bone, but other diseases that may degrade the quality of living and may threaten life itself. 

Over recent decades, the inflammatory process itself, as measured by the blood mediators, such as high-sensitivity C-reactive protein, has been identified as a primary modifier of many chronic diseases, including periodontitis.  Clinicians recognize that systemic levels of inflammatory mediators in individual patients may result from genetic variations or from modifiable factors, such as diet, body fat, and unresolved chronic inflammation.  

In 1968 the focus of periodontal therapy, and much of medicine, was on the current level of disease, with the assumption that most patients exhibited a clinical expression of disease resulting from a single common etiology.  We argue that in 2010 treatment planning and patient monitoring must consider a complex web of factors beyond the current level of disease to include assessing risk factors predictive of future disease progression and of prognosis with treatment.  Explicit evaluation of risk factors allows the clinician to modify treatment and therefore risk…. For example, if a patient with severe periodontitis is a smoker, we cannot ignore this risk factor whether we choose to treat the patient with or without the use of implants or regenerative technologies.  

What has changed since 1968?  First, treatment decisions are now based on not only tooth-level evaluations of past destruction, but also patient-level assessments of risk factors for disease progression.  These may include concomitant systemic disease; conditions such as HIV, cancer chemotherapy, and organ transplant, which immunocompromise; pharmaceutical agents; menopausal issues; nutritional status; tobacco use; unresolved stress; and various genetic influences.   Second, achievement of good treatment outcomes has become potentially more critical.  Although not definitively proven, it seems very likely that proper periodontal care targeting elimination of inflammation will contribute to a decreased incidence of other chronic diseases.  Given current knowledge, it is reasonable to conclude that failure to maintain the periodontium in a state of low to no inflammation in certain patients will increase the likelihood of loss of teeth, implants and dental dysfunction, and potentially increase the risk for systemic diseases.  

One thing that has not changed in 40 years of managing these patients; dentistry for the long-term stability of patients who are in need of periodontal and restorative reconstruction requires a team approach to care in which restorative dentists and periodontists work together to achieve long-term health and well being for the patients they serve.”

Dr. Mark J. Weingarden

www.pittsburghimplantsandperio.com