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In This IssuePeriodontitis and
Renal Disease 1
In Practice 4
Hygiene Page 6
Clinical Practice 7
Health Care Trends 10
THE FORSYTH
INSTITUTE
Professional
Continuing
Education Program 11
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Colgate Oral Care Report
normal renal function (n = 4,928),reported a significant associationbetween the presence of antibodiesagainst certain PD pathogens anddiminished kidney function.2 Inparticular, high titers of antibodiesagainst P. gingivalis, T. denticola, S.noxia, A. actinomycetemcomitans, andV. parvulawere associated with anincreased risk of reduced renalfunction.2 In addition, patients whohad a higher total bacterial load, ahigher plaque score, or higherlevels of interproximal attachmentloss had lower glomerular filtrationrates and, therefore, worse renal
function.2
Periodontitis was found to beparticularly severe in a study ofpatients with end-stage renaldisease,3 all of whom were onmaintenance hemodialysis. Clinicalloss of attachment, papillarybleeding index, and plaque indexscores were reported to be moresevere than those found in thenormal control population. In fact,their status was comparable tocontrols without renal disease that
had full blown periodontal disease(PD controls). Patients with lesssevere renal disease, those oncontinuous ambulatory peritonealdialysis, and those with pre-dialysischronic kidney disease all hadintermediate levels of PD; moresevere than the general controls,but less severe than the PD controls(Figure 1, next page).3
Providing Continuing Education as a Service to Dentistry Worldwide
Editor-in-Chief
Dominick P. DePaola, DDS, PhD; U.S.A.President and CEOThe Forsyth Institute
Associate Editors
John J. Clarkson, BDS, PhD; Ireland
Saskia Estupin-Day, DDS, MPHPan American Health Organization; Wash., D.C.
Joan I. Gluch, RDH, PhD; U.S.A.
Kevin Roach, BSc, DDS, FACD; Canada
Zhen-Kang Zhang, DDS, Hon. FDS,RCS (Edin.); China
International Advisory Board
Per Axelsson, DDS, Odont.Dr.; Sweden
Irwin Mandel, DDS; U.S.A.
Roy Page, DDS, PhD; U.S.A.
Gregory Seymour, BDS, MDSc, PhD,MRCPath; Australia
Volume 17, Number 4, 2007
ORALCAREREPORTORALCAREREPORTTHE
A Summary Journal of Advances in Dentistry and Oral Health Care
Periodontal disease (PD) hasbeen widely reported to be associatedwith an increase in the systemic
inflammatory response, and hasemerged as a possible risk factor foratherosclerosis and cardiovasculardisease over the last decade. Thistopic has most recently beenaddressed in the Periodontal Page(Oral and Systemic HealthConsensus Statement) in Volume16, Number 3, of the Oral CareReport. New research now suggeststhat periodontitis may alsocontribute to the systemicinflammatory burden in renal
disease.1
Periodontitis andRenal Disease
Chronic renal failure is theresult of the progressive andirreversible loss of functioningnephrons in the kidney, whichproduces a decline in theglomerular filtration rate. Fiverecent studies2-6 have investigatedthe relationship between
periodontitis and renal disease;three with findings suggesting anassociation,2-4 and two that donot.5,6
Studies Suggesting anAssociation BetweenPeriodontitis and RenalDisease
A study that comparedpatients with reduced renalfunction (n = 103) with those with
Periodontitis andRenal Disease
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Diabetic patients are atincreased risk of developingperiodontitis; poor glycemiccontrol hastens the progression ofPD, which in turn seems to furtherimpair glycemic control.4 Inaddition, diabetic nephropathy is acommon complication of diabetes.A study of diabetic patients andrenal insufficiency (n = 529)
reported that periodontitis ispredictive of the development of
overt nephropathy and end-stagerenal disease.4 This study followeda population of type II diabeticAmerican Indians for up to 22years. Overt nephropathy wasdetermined by measuringmacroalbuminuria, the excretionof albumin protein in the urine.They found that the incidence ofboth end-stage renal failure andmacroalbuminuria increased withthe severity of periodontitisrecorded at the start of the study.After adjustments were made fordifferences in age, sex, diabetesduration, body mass index, andsmoking habits of the patients, theincidence of macroalbuminureawas between 2 and 2.6 times higheramong individuals with moderateto severe periodontitis, oredentulous individuals, thanamong those patients who had noor mild periodontitis (Figure 2).4
page 2
Figure 2. Incidence of Overt Nephropathy in Diabetic Patientswith Periodontal Disease
From Shultis, et al.,20074
Casesper1000personyears
Macroalbinuria
0
5
10
15
20
25
30
35
40
45
50
End-Stage Renal Disease
None/mild periodontitis
Moderate periodontitis
Severe periodontitis
Edentulous
Figure 1. Periodontal Disease Status of Patients
with Renal Disease
CAPD: Continuous ambulatory peritoneal dialysisCKD: Chronic Kidney DiseasePD: Periodontal disease
From Borawski, et al.,20073
GingivalorPlaqueIndexScoreor
ClinicalAttachmentLoss(mm)
Hemodialysis(n=35)
0
1
2
3
4
5
6
Clinical attachment loss
Plaque index
Gingival index
CAPD(n=33)
Pre-DialysisCKD (n=38)
PD Controls(n=26)
General Controls(n=30)
In patients with renaldisease, a positivecorrelation between markers
for a systemic immuneresponse and the severity of
periodontal disease has beenreported; therefore,
periodontitis may contributeto the systemic inflammatory
burden in renal disease.
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Studies Not Suggesting an
Association BetweenPeriodontitis and Renal
DiseaseTwo other studies of renal
disease patients found nocorrelation between periodontitisand renal insufficiency. A study of52 patients on maintenancehemodialysis failed to find astatistically significant difference inthe bacterial composition of sub-gingival plaque between patients
and age-matched controls.5 Inaddition, no statistically significantdifferences in bleeding index,number of teeth, or the percentageof sites with more than a 3 mm lossof attachment were found. Unlikethe studies mentioned above, theinvestigators could not find anassociation between end-stage renaldisease and more severe PD.5
The second study, alongitudinal study of nine renaltransplant patients, recorded
subjects oral health through threestages of renal diseasepre-dialysis,dialysis, and post-transplant. Thestudy recorded no differencesbetween the three stages of thedisease using two measures of oralhealththe CommunityPeriodontal Index of TreatmentNeeds (CPITN) and theDecayed/Missing/Filled Teethindex.6 There was no increase inPD as the renal disease progressed
in these patients. However, sinceonly nine patients were availablefor follow up from a total of 39 whostarted the study, the results cannotbe treated as comprehensive.Larger studies with greaterstatistical power are needed toresolve the differences in resultsbetween these studies.
Overall, the prevalence ofmoderate to severe periodontitismay be higher in renal diseasepatients than in the general
population, and there is acorrelation between the severity of
the PD and renal insufficiency. Forpatients with type II diabetes,severe periodontitis may bepredictive of diabetic kidneydisease.
Periodontitis and
Cardiovascular Disease in
Renal Transplant Patients
While an increased incidenceof cardiovascular disease and
accelerated atherosclerosis in renaldisease patients are generally linkedto an increase in conventional riskfactors, PD is thought to play a rolein increasing systemic inflammationleading to increased atherosclerosis.A study of renal transplant patients(n = 83)7 found a significantpositive correlation between thelevels of gingival inflammation andthe carotid intima-media thickness(CIMT). Patients with a highgingival index had a mean CIMT
measurement of 0.85 ( 0.42) cm,while those with moderate or nogingivitis had a mean CIMTmeasurement of 0.68 ( 0.4;p = 0.01) cm. Therefore, a moresevere level of gingivalinflammation correlated with moreatherosclerosis in the carotidartery, suggesting that severe PDincreases the risk of cardiovasculardisease in renal transplant patients.7
Treatment of Periodontitisand the Reduction ofSystemic Inflammation
Periodontal therapy, such aslocal root surface debridement andmicrobial plaque control, and theconcomitant use of non-steroidalanti-inflammatory drugs have beenreported to reduce the systemicmarkers of inflammation.1Whilethere are undoubtedly manysources of inflammation for
page 3
patients with renal disease, controlof PD with effective therapy may
lead to an improvement in the levelof systemic inflammation in thesepatients, perhaps leading toimproved renal disease andcardiovascular outcomes.1OC
References
1. Craig RG, Kotanko P, Kamer AR, Levin NW.Periodontal diseasesA modifiable source ofsystemic inflammation for the end-stage renaldisease patient on haemodialysis therapy?Nephrol Dial Transplant 2007;22(2):312-315.
2. Kshirsagar AV, Offenbacher S, Moss KL,
Barros SP, Beck JD.Antibodies to periodontalorganisms are associated with decreased kidneyfunction. The Dental Atherosclerosis Risk InCommunities study. Blood Purif 2007;25(1):125-132.
3. Borawski J, Wilczynska-Borawska M,Stokowska W, Mysliwiec M. The periodontalstatus of pre-dialysis chronic kidney disease andmaintenance dialysis patients. Nephrol DialTransplant 2007;22(2):457-464.
4. Shultis WA, Weil EJ, Looker HC, Curtis JM,Shlossman M, Genco RJ, et al. Effect ofperiodontitis on overt nephropathy and end-stage renal disease in type 2 diabetes. DiabetesCare 2007;30(2):306-311.
5. Castillo A, Mesa F, Liebana J, Garcia-Martinez O, Ruiz S, Garcia-Valdecasas J, et al.Periodontal and oral microbiological status ofan adult population undergoing haemodialysis:A cross-sectional study. Oral Dis2007;13(2):198-205.
6. Vesterinen M, Ruokonen H, Leivo T,Honkanen AM, Honkanen E, Kari K, et al. Oralhealth and dental treatment of patients withrenal disease. Quintessence Int 2007;38(3):211-219.
7. Genctoy G, Ozbek M, Avcu N, Kahraman S,Kirkpantur A, Yilmaz R, et al. Gingival healthstatus in renal transplant recipients: Relationshipbetween systemic inflammation and athero sclerosis.Int J Clin Pract 2007;61(4):577-582.
For the latest on the
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relationship, read
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Dental Flossing and
Interproximal CariesThe effectiveness of dental
flossing in caries prevention islargely supported by thelongstanding belief that flossingdisrupts and removes interproximaldental plaque, which is known tobe cariogenic.1 In fact, no clinicaltrials have been conducted inadults that investigate the effects offlossing on caries, nor that haveinvestigated the effects of flossing
in the presence of topicalfluorides.1 So what is the actualevidence for dental flossing andinterproximal caries prevention?
Basing their systematic reviewon six randomized clinical trials,Hujoel, et al.1 assessed the effect offlossing on interproximal cariesrisk. The overall characteristics ofthe six studies, which analyzed 808participants, ranging in age from 4to 13 years, over a period of 1.7 to3 years, are presented in the figure
at right. The outcomes, blindedexcept for one study,2were assessed
through either DFS, dfs or Defindices, based on clinical findingsalone, or both clinical andradiographic diagnostic criteria.1
The systematic review revealedthat infrequent or self-performedflossing showed no evidence ofbenefit on caries prevention.2-5
However, caries risk onpredominantly primary teeth wasreduced by 40% when professional
different clinical trials alsosuggest that the use of topicalfluorides may attenuate the
effectiveness of flossing.1
Animportant limitation of thestudies assessed is the absenceof rigorous control of thesubjects exposure to fluorides.1
Indeed, from one study toanother, fluoride exposurewas documented withinconsistent variables such asthe fluoride content ofdrinking water,3,4,6,7 the useof fluoridated or non-fluoridated toothpaste,4,5,7
flossing was provided on schooldays to first-grade childrenassumed to have poor oral hygiene
and low exposure to fluorides.6,7
LimitationsSome limitations to the
interpretation of these studiesshould be mentioned:
Compliance and caries riskin the population have beendemonstrated to be modifiersof the effectiveness of flossing.These were not controlledfor in these trials.1
The contrasting results of the
page 4
INPRACTICE
A systematic review of sixrandomized clinical trials inchildren revealed thatinfrequent or self-performed
flossing showed no benefit oncaries prevention.
Study
FlossingInterventionandCompliance
Control
Design
Wright, et al.(1979)6 (1980)7
Professionalat school
Supervised
No contralateralprofessionalflossing
Split-mouth
Granath, et al. (1979)5
Self-performed Unsupervised
No contralateralflossing
Split-mouth
Gisselsson, et al.(1988)3 (1994)4
Professionalevery 3rd month
Supervised
No professionalflossing
Parallel
(1983)2
Self-performed Unsupervised
No flossinginstructions
Parallel
Controlled Trials on Flossing and Interproximal Caries
*Difference between mean of interproximal surfaces examined per child and mean number of carious interproximalsurfaces at baseline multiplied by the number of children in the control group
Adapted from Hujoel, et al. 20061
CariesRisk
Flossing Group
Control Group
(374)
(Surfaces)
0.00
0.05
0.10
0.15
0.20
0.25
0.30
(624) (4199/3836) (414/289.5*) (1245/1229) (927/1810)
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professional flossing with chlorhexidine gel onapproximal caries in 12- to 15-year-oldschoolchildren. Caries Res 1988;22(3):187-192.
4. Gisselsson H, Birkhed D, Bjorn AL. Effect ofa 3-year professional flossing program withchlorhexidine gel on approximal caries and costof treatment in preschool children. Caries Res1994;28(5):394-399.
5. Granath LE, Martinsson T, Matsson L,Nilsson G, Schroder U, Soderholm B.Intraindividual effect of daily supervised flossingon caries in schoolchildren. Community DentOral Epidemiol 1979;7(3):147-150.
6. Wright GZ, Banting DW, Feasby WH. TheDorchester dental flossing study: Final report.Clin Prev Dent 1979;1(3):23-26.
7. Wright GZ, Feasby WH, Banting DW.Theeffectiveness of interdental flossing with and
without a fluoride dentifrice. Pediatr Dent1980;2:105-109.
the use of 0.2% NaF solutionfor rinsing,2,3,5 or the
application of topicalfluoride.2
The evaluation of thepossible harmful effects ofself-performed flossing wasnot examined.1
Nevertheless, the evidenceprovided is consistent with theconcept that dental flossing, whenproperly performed, candramatically reduce the risk ofinterproximal caries in young
children with poor oral hygieneand low fluoride exposure.1 Forthese reasons, Hujoel, et al.1 suggest
that dental professionals determinethe feasibility, on an individual
patient basis, of frequent,professional-quality flossing, and toassess its effect on the future needfor caries interventions.OC
References
1. Hujoel PP, Cunha-Cruz J, Banting DW,Loesche WJ. Dental flossing and interproximalcaries: A systematic review. J Dent Res2006;85(4):298-305.
2. Gisselsson H, Bjorn AL, Birkhed D.Immediate and prolonged effect of individualpreventive measures in caries and gingivitis
susceptible children. Swed Dent J 1983;7(1):13-21.
3. Gisselsson H, Birkhed D, Bjorn AL. Effect of
Professional Education
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Oral Bacterial
Species Associatedwith Halitosis
Halitosisalso referred to asmalodoror bad breathis a commonproblem, affecting approximately30% of the general population.1 Itis often caused by bacteria in theoral cavity that produce variousmalodorous substances, such asvolatile sulfur compounds.1,2 Thedorsal tongue surface has been
identified as an important site ofthis bacterial activity.2 It istherefore useful to examinespecific bacterial species present inthis area of the mouth, and explorewhich of these species may beassociated with halitosis.
Previous studies haveidentified certain types of bacteria,such as Streptococcus salivarius, thatpredominate in normal subjects.1
On the other hand, Gram-negativeanaerobic bacteria have been
associated with the production ofmalodorous compounds.1 Untilrecently, bacteria could only beidentified by traditional culturemethods which did not succeed inidentifying the majority of bacterialspecies present in the mouth;3
many bacterial species are resistantto cultivation in the laboratory.4
While not specific to halitosis,incomplete identification ofpathogens translates into anincomplete understanding of a
disease.4 Fortunately, newerlaboratory techniques, such aspolymerase chain reaction (PCR),have allowed identification ofadditional bacterial strains,doubling the number of distinctspecies estimated to infect thehuman oral cavity from 400 to 800.1
Clinical StudiesTwo recent clinical studies
have used these techniques to
compare bacterial species presentin adults with and without
halitosis.1,3 Several species werementioned as being mostassociated with halitosis in bothstudies, such as Solobacterium moorei,Eubacterium,Dialister, andFirmicutes.Six other bacterial species werementioned in only one of these twostudies (see table).
Both studies concurred thatbacteria belonging to theuncultivated phylum known asTM7 were among the species mostassociated with halitosis. Theimportance of newly or not-yet-identified strains associated withhalitosis was also highlighted.3
Specifically, among thepredominant microbes found onlyin subjects with halitosis, therewere 13 distinct non-cultivablespecies which were present in 38%of subjects with halitosis.3
Recent research with modernculture-independent techniques isproducing a more detailed portrait
of bacterial species present in thehuman oral cavity. Overall, thesestudies indicate that there is indeed
a difference in the composition ofbacterial species between subjects
with halitosis and control subjects.The relationship of these species,with factors such as the productionof volatile sulfur compounds,warrants further examination toconfirm their contribution tohalitosis, and could lead to thedevelopment of specificantimicrobial therapy for thiscommon problem.3OC
References
1. Kazor CE, Mitchell PM, Lee AM, Stokes LN,Loesche WJ, Dewhirst FE, et al. Diversity ofbacterial populations on the tongue dorsa ofpatients with halitosis and healthy patients.J Clin Microbiol 2003;41(2):558-563.
2. Miyazaki H, Sakao S, Katoh Y, Takehara T.Correlation between volatile sulphur compoundsand certain oral health measurements in thegeneral population. J Periodontol1995;66(8):679-684.
3. Haraszthy VI, Zambon JJ, Sreenivasan PK,Zambon MM, Gerber D, Rego R, et al.Identification of oral bacterial species associatedwith halitosis. JADA 2007;138(8):1113-1120.
4. Relman DA. New technologies, human-microbe interactions, and the search forpreviously unrecognized pathogens. J Infect Dis2002;186 Suppl 2:S254-S258.
page 6
HYGIENE PAGE
BacterialSpeciesCommon toBoth Studies
BacterialSpeciesIdentified inOne of theStudies
Haraszthy, et al.,20073
Solobacterium moorei
Eubacteriumspecies
Dialister species
Uncultivated phylum TM7(included in unidentifiedoral bacteria)
Firmicutes species
Granulicatella elegens
Porphyromonasspecies
Staphylococcus warneri
Prevotella intermedia
Kazor, et al.,20031
Solobacterium moorei
Eubacterium sulci
Dialister clone BS095
TM7 clone DR034
clone BW009 Streptococcus(of Firmicutes phyla)
Fusobacterium periodonticum
Atopobium parvulum
Predominant Bacterial Species Found Only in SubjectsWith Halitosis in Two Recent Clinical Studies1,3
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risk factors include: age; Caucasianrace; cancer diagnosis; and
osteopenia/osteoporosis diagnosisconcurrent with cancer diagnosis.3
Treatment and PreventionStrategies
BRONJ staging and treatmentstrategies are outlined in the tablebelow. If possible, optimize dentalhealth and allow osseous healingprior to initiating bisphosphonatetherapy.3
In asymptomatic patients who
are receiving IV bisphosphonatetherapy, maintaining good oralhygiene is important as apreventive measure. Avoidprocedures that involve directosseous injury. Non-restorableteeth can be treated by crownremoval and endodonticprocedures.3
In asymptomatic patients whoare receiving oral bisphosphonates,elective dentoalveolar surgery is
not contraindicated; however,patients should be informed of the
risk of compromised bone healing.Although more research is needed,it appears that risk for BRONJ inthis group may be associated withbisphosphonate treatment of threeor more years.3
Management StrategiesNo delays in planned surgeries
are required for individuals whohave taken oral bisphosphonatesfor less than three years. In the
event that dental implants areplaced, informed consent shouldbe provided relating to possiblefuture implant failure anddevelopment of BRONJ should thepatient continue to take oralbisphosphonates. Monitoring ofthese patients is recommended.3
For patients who have takenoral bisphosphonates for less thanthree years and have takencorticosteroids concomitantly, or
Bisphosphonate-
Related Osteonecrosisof the Jaws (BRONJ)
Bisphosphonate therapyused primarily in the treatment ofosteoporosis and cancer-relatedconditionscarries a risk ofbisphosphonate-relatedosteonecrosis of the jaws (BRONJ).In 2003-2004, the first cases of non-healing, exposed, necrotic bone inthe jaws of patients treated with i.v.
bisphosphonates were reported.
1,2
In subsequent years further caseswere identified, and in 2006, theAmerican Association of Oral andMaxillofacial Surgeons published aposition paper on this topic.3 Thefollowing is a summary of theirreport.
BRONJ DiagnosisBRONJ may be diagnosed if
patients demonstrate: current orprevious treatment with a
bisphosphonate; exposed bone inthe maxillofacial region persistingmore than eight weeks; and nohistory of radiation therapy to thejaws.3
Risk FactorsDrug-related risk factors for
the development of BRONJinclude the potency of thebisphosphonates and duration oftherapy. Intravenouslyadministered bisphosphonatesconfer a much greater risk thanoral agents. In general, greaterpotency and longer duration areassociated with greater risk. Localrisk factors include: dentoalveolarsurgery (e.g., extractions, implants,periapical surgery, periodontaltherapy with osseous injury); localanatomical characteristics (e.g.,lingual tori, mylohyoid ridge,palatal tori); and concomitant oraldisease. Demographic and systemic
CLINICAL PRACTICE
BRONJ Staging
At-risk Category:No apparent exposed/necrotic bone inpatients who have been treated with eitheroral or IV bisphosphonates
Stage 1:Exposed/necrotic bone in patients whoare asymptomatic and have no evidenceof infection
Stage 2:Exposed/necrotic bone associated withinfection (pain and erythema in region ofexposed bone with or without purulentdrainage)
Stage 3:Exposed/necrotic bone in patients withpain, infection, and at least one of thefollowing: pathologic fracture, extra-oralfistula, or osteolysis extending to theinferior border
Treatment Strategies
No treatment required
Patient education about BRONJrecommended
Antibacterial mouth rinse
Quarterly clinical follow-up
Patient education
Assessment of indications for continuedbisphosphonate therapy
Symptomatic treatment with broad-spectrumoral antibiotics
Antibacterial mouth rinse and pain control
Superficial debridement to relieve soft tissueirritation
Antibacterial mouth rinse
Antibiotic therapy and pain control
Surgical debridement/resection to addresslonger term infection and pain
BRONJ Staging and Treatment Strategies
Adapted from the American Association of Oral and M axillofacial Surgeons Position Paper, 20063
page 7
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References
1. Marx RE. Pamidronate (Aredia) andzoledronate (Zometa) induced avascular
necrosis of the jaws: A growing epidemic. J Oral
Maxillofac Surg 2003;61(9):1115-1117.
2. Ruggiero SL, Mehrotra B, Rosenberg TJ,
Engroff SL. Osteonecrosis of the jaws associated
with the use of bisphosphonates: A review of 63
cases. J Oral Maxillofac Surg 2004;62(5):527-
534.
3. American Association of Oral and Maxillofacial
Surgeons. Position paper on bisphosphonate-
related osteonecrosis of the jaws. 2006.
http://www.aaoms.org/docs/position_papers/
osteonecrosis.pdf (Accessed 2 Oct 2007).
patients with BRONJ, response tothe surgical treatment algorithms
used for osteomyelitis orosteoradionecrosis is lesspredictable. Surgical debridementis variably effective; it is difficult toobtain a surgical margin with viablebleeding bone because of thebisphosphonate exposure. Electivedentoalveolar surgery should beavoided in these patients.Extraction of symptomatic teethwithin exposed, necrotic boneshould be considered because it isunlikely that this will exacerbatethe necrotic process.3OC
The Colgate Oral Care Reportwelcomes its new
continuing education partner
The Forsyth InstituteFounded in 1910, The Forsyth Institute is the worlds
leading independent organization dedicated to scientificresearch, clinical, and educational programs in oral and
related biomedical science. Forsyth is honored to now serve
as the continuing education sponsor of the Oral Care Report.
ORALCAREREPORT
page 8
for patients who have taken oralbisphosphonates for more than
three years, discontinuation ofbisphosphonate therapy (drugholiday) for at least three monthsprior to the oral surgeryifsystemic conditions permitisrecommended.3
Patients with Established
BRONJ
Treatment objectives are toeliminate pain, control infection,and minimize the progression oroccurrence of bone necrosis. In
THE
A Summary Journal of Advances in Dentistry and Oral Health Care
ORALCAREREPORT
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Many countries are facingfinancial strains as the pressure forspending is affecting governmentappropriations for health-relatedprograms. Previous policies inmany countries have favored eldersand children, but the demographictrends are starting to show greatergrowth in the aging populationcompared to children. Adding tothe strain, the number of childrenboth in the United States and
globally is increasing at a rate thatis outpacing the current level ofchildcare programs.
The recent attempt in the U.S.to extend greater dental coverageto children came in the form of theState Childrens Health InsurancePlan (SCHIP). And while it failedto override a presidential veto byonly a few votes, it failednonetheless. Regrettably, there wastoo much pressure favoring other
budgetary items to allow inclusionof oral health for children into thenations health care policy.
Unfortunately, this may not bean isolated case as we look into thefuture. Many countries areexperiencing an increase in thenumbers of low income children.European, African, Asian, andPacific Rim countries, for example,are all showing demographicgrowth in their lower-income childpopulations.
Are we witnessing the dawn ofan era of declining oral health for
large minority sections of ourglobal societies? Not if we dontwant to ... We can decide to not let
this happen. But to do so, theprimary public policy emphasis must beon prevention. The dentalprofession, schools, government,and educators must raise the valueof prevention in their day-to-dayactivities. If we wait for dentaldisease to occur, there are simplynot enough dentists in the U.S.,Europe, Asia, and elsewhere torepair the damage.
Dental health policy forchildren must stress prevention the
world over.
Prevention for children cancome in many forms, includingcommunity- and school-basedprograms, dental professionactivities, or engagement of themedical and allied healthproviders. Schools andgovernments will need tocooperate and participate. We willneed all the help we can get if weare going to give the children ofthe world a chance for lifelong oralhealth.OC
Editor-in-Chief Dominick P. DePaola,
DDS, PhD; U.S.A.President and CEOThe Forsyth Instiute
2007 Colgate-Palmolive Company.All rights reserved.Printed on Recycled PaperThe Oral Care Report(ISSN 1520-0167) is supported bythe Colgate-Palmolive Companyfor oral care professionals. TheProfessional Continuing EducationProgram is sponsored by The ForsythInstitute and underwritten by a grant
from the Colgate-Palmolive Company.The Forsyth Institute does not endorsethe products of any company. Medicalwriting by BioMedCom Consultants,inc., Montral, QC (Canada).
Published by Professional AudienceCommunications, Inc., Yardley, PA(U.S.A.).Address comments, queries andaddress changes to:
The Oral Care ReportColgate Continuing Education
Services CoordinatorThe Forsyth Instiute140 The FenwayBoston, MA 02115 USAe-mail:colgateoralcarereport@forsyth.org.
MEMBERPUBLICATION
AMERICANASSOCIATION OFDENTAL EDITORS
HEALTH CARE TRENDSHEALTH CARE TRENDSGUAM
The dental profession, schools,government, and educatorsmust raise the value of
prevention in their day-to-dayactivities.
If we wait for dental diseaseto occur, there are simply notenough dentists in the U.S.,Europe, Asia, and elsewhereto repair the damage.
Dental health policy forchildren must stress preventionthe world over if we are goingto give the children of theworld a chance to havelifelong good oral health.
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Access to Dental Care for Children
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PROFESSIONAL CONTINUING EDUCATION PROGRAMTHE FORSYTH INSTITUTE
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CONTINUING EDUCATIO
ANSWER SHEET AND
ENROLLMENT FORM
VOLUME 17 NO. 4
Name _____________________________
Title _____________________________[General Dentist, Specialty (type), RDH, o
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This quiz can be taken interactively online via www.colgateprofessional.com
1. In a study on renal disease and periodontitis,lower glomerular filtration rates were reported
to be associated witha) a high titer of antibodies against P. gingivalis, S.
noxia, A. actinomycetemcomitans, T. denticola, andV. parvula.
b) a higher level of interproximal attachment loss.c) a higher total bacterial load.d)All of the above
2. Which of the following is true?a)A study of diabetic patients showed no
correlation between periodontitis and renalfailure.
b)A study of diabetic patients with renalinsufficiency reported that periodontitis ispredictive of the development of overtnephropathy and end-stage renal disease.
c) Diabetic patients are not considered at risk ofdeveloping periodontitis.
d) Mild periodontitis was strongly associated withrenal disease in diabetic patients.
3. Which of the following statements about studieson periodontitis and renal disease is false?a) Overall, studies show a correlation between the
severity of periodontal disease and renalinsufficiency.
b) Renal transplant patients with severeperiodontitis had more carotid atherosclerosisthan those with no or moderate periodontitis.
c) Renal failure causes periodontitis.d) Patients on hemodialysis had more severe
periodontitis than those with pre-dialysischronic kidney disease.
4. Effective periodontal therapy maya) reduce periodontal disease.b) improve systemic inflammation.c) lead to better renal disease and cardiovascular
outcomes.d)All of the above
5. Which one of the following is not a modifier ofthe effectiveness of flossing?a)Administration of topical fluoridesb) Protein consumptionc)Assessment of complianced) Caries risk in the population
6. Professional flossing, performed in school onfirst-grade children with poor oral hygiene andlow exposure to fluorides, was reported to reducecaries risk bya) 0%b) 20%c) 40%d) 60%
7. Controlled clinical trials to support the role offlossing in the prevention of interproximal cariesexist fora) unsupervised flossing by school-age children.b) professional flossing to school-age children.c) self-performed flossing by adults.d)All of the above
8. Which substances are produced by bacteria andassociated with halitosis?
a) Insoluble proteinsb) Ethanol mixturesc) Nucleic acidsd)Volatile sulfur compounds
9. Which modern laboratory technique has allowedthe identification of additional strains of bacteriainfecting the human oral cavity?a)Automated cell cultureb) Polymerase chain reactionc) Rapid breath testd)Antibody binding assays
10. How many distinct bacterial strains are currentlyestimated to infect the human oral cavity?a) 100b) 400c) 800
d) 120011. Which bacterial species was found ONLY in
subjects with halitosis in two recent clinicalstudies?a) Streptococcus salivariusb) Cryptobacteium curtumc) Solobacterium mooreid) Neisseria flavescens
12. BRONJ may be diagnosed if patients demonstratea) current or previous treatment with a
bisphosphonate.b) exposed bone in the maxillofacial region
persisting more than eight weeks.c) no history of radiation therapy to the jaws.d)All of the above
13. Compared with bisphosphonates of lower potencyand taken for shorter durations, those with greaterpotency and taken for longer duration areassociated witha) greater risk for BRONJ.b) equal risk for BRONJ.c) lower risk for BRONJ.d) greater risk for BRONJ when bisphosphonates are
orally administered.
14. Which of the following statements is false?a) Few patients receiving bisphosphonates develop
BRONJ spontaneously; it is most often acomplication that arises following dentoalveolarsurgery.
b) If systemic conditions permit, initiation ofbisphosphonate therapy should be delayed untildental health is optimized.
c) No delays in planned surgeries are required forindividuals who have taken oral bisphosphonatesfor less than three years.
d) None of the above.
15. Which of the following statements regardingpatients with established BRONJ is true?a) Response to the surgical treatment algorithms
commonly used for osteomyelitis orosteoradionecrosis is less predictable in patientswith BRONJ.
b) Elective dentoalveolar surgery should be avoidedin patients with established BRONJ.
c) Extraction of symptomatic teeth within exposed,necrotic bone is unlikely to exacerbate thenecrotic process.
d)All of the above
This continuing education (CE) program is offered by The Forsyth Institute. Each volume of the Oral Care Report(OCR) consists of 4 issues, each of which contains multiple-choice, two credit
hour (CE) examinations sponsored by The Forsyth Institute, an ADA Continuing Education Recognition Program(CERP) provider.
Participants who have passed an examination will receive a Verification of Participation letter awarding two (2) CEcredits from The Forsyth Institute continuing education program.
Quizzes may be submitted at any time for credit. Refund requests related to the automated payment process will be honored.
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A Summary Journal of Advances in Dentistry and Oral Health Care
P.O. Box 243, Yardley, PA 19067
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