Bleeding on Probing As It Relates to Smoking Status in Patients Enrolled in Supportive Periodontal Therapy for at Least 5&#X
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J Clin Periodontol 2015; 42: 150–159 doi: 10.1111/jcpe.12344 Christoph A. Ramseier1, Bleeding on Probing as it relates Damiano Mirra1, Christian Schutz€ 1, Anton Sculean1, Niklaus P. Lang1, Clemens Walter2 and to smoking status in patients Giovanni E. Salvi1 1Department of Periodontology, School of Dental Medicine, University of Bern, Bern, enrolled in supportive Switzerland; and 2Department of Periodontology Endodontology and Cariology, School of Dental Medicine, University of periodontal therapy for at least Basel, Basel, Switzerland 5 years Ramseier CA, Mirra D, Schutz€ C, Sculean A, Lang NP, Walter C, Salvi GE. Bleeding on Probing as it relates to smoking status in patients enrolled in supportive periodontal therapy for at least 5 years. J Clin Periodontol 2015; 42: 150–159. doi: 10.1111/jcpe.12344. Abstract Aim: To relate the mean percentage of bleeding on probing (BOP) to smoking status in patients enrolled in supportive periodontal therapy (SPT). Materials and Methods: Retrospective data on BOP from 80741 SPT visits were related to smoking status among categories of both periodontal disease severity and progression (instability) in patients undergoing dental hygiene treatment at the Medi School of Dental Hygiene (MSDH), Bern, Switzerland 1985–2011. Results: A total of 445 patients were identified with 27.2% (n = 121) being smok- ers, 27.6% (n = 123) former smokers and 45.2% (n = 201) non-smokers. Mean BOP statistically significantly increased with disease severity (p = 0.0001) and periodontal instability (p = 0.0115) irrespective of the smoking status. Periodon- tally stable smokers (n = 30) categorized with advanced periodontal disease dem- onstrated a mean BOP of 16.2% compared to unstable smokers (n = 15) with a mean BOP of 22.4% (p = 0.0291). Assessments of BOP in relation to the percent- age of sites with periodontal probing depths (PPD) ≥4 mm at patient-level yielded a statistically significantly decreased proportion of BOP in smokers compared to non-smokers and former smokers (p = 0.0137). Conclusions: Irrespective of the smoking status, increased mean BOP in SPT Key words: bleeding on probing; cigarette patients relates to disease severity and periodontal instability while smokers dem- smoking; supportive periodontal therapy onstrate lower mean BOP concomitantly with an increased prevalence of residual PPDs. Accepted for publication 25 November 2014 Conflict of interest and source of Bleeding on probing (BOP) has been 1971, Lang et al. 1986, 1990). In funding statement used in clinical practice as a brief, patients with a mean percent- diagnostic tool for many years to age of BOP ≤20% have been The authors declare that there are no evaluate both gingival inflammation acknowledged as periodontally sta- conflicts of interest in this study. and periodontal stability in patients ble while a mean BOP of ≥30% This study was supported by the Swiss attending supportive periodontal represented a greater risk for peri- National Program to Stop Smoking, € Switzerland. therapy (SPT) (Muhlemann & Son odontal disease progression and 150 © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Bleeding on probing and smoking status 151 subsequent tooth loss (Joss et al. aim of this study was to evaluate the determined at the end of active peri- 1994, Matuliene et al. 2008). mean patient-level BOP as it relates odontal therapy and at each SPT Periodontal diseases are highly to the smoking status in a sample of visit based on the patient’s periodon- prevalent among smokers (Tomar & patients enrolled in SPT provided by tal parameters such as the percent- Asma 2000, Gatke et al. 2012). The dental hygiene students at the Medi age of BOP and the severity of impact of smoking on periodontal School of Dental Hygiene (MSDH), periodontal disease. Subsequent SPT diseases and their suspected patho- Bern, Switzerland. intervals were determined according genesis has continuously been to the BOP at each visit. With summarized within comprehensive patients demonstrating a BOP of less Materials and Methods literature reviews (Rivera-Hidalgo than 20%, the previously determined 2003, Palmer et al. 2005, Warn- SPT interval was increased by akulasuriya et al. 2010, Chambrone Study sample 1–2 months while not exceeding a et al. 2014). Due to the impaired This study was designed in continua- maximum of 12 months. In contrast, outcomes following active periodon- tion of the previously reported retro- with patients demonstrating a BOP tal treatment and lower attendance spective longitudinal cohort study of more than 20%, the previously compliance with SPT, the mainte- based on demographic and clinical determined SPT interval was nance of periodontal stability in cig- data collected from patient records decreased by 1–2 months down to a arette smokers remains to be a at the Medi School of Dental minimum of 3 months, respectively. difficult task (Matuliene et al. 2010, Hygiene (MSDH), Bern, Switzerland Meyer-Baumer€ et al. 2012, Ramseier over the years 1985–2011 (Ramseier Clinical records et al. 2014). et al. 2014). All patients treated at Periodontal tissues are well vas- the MSDH aged 20 years or older, Demographic data and medical his- cularised (Egelberg 1966). Upon bac- returning at least 5 years for SPT, tory information as recorded at the terial challenge of the dental biofilm, with known tobacco use status, and initial examination were gathered the clinical signs of tissue inflamma- complete information from clinical from the patient records such as the tion such as the changes in gingival records were considered for the general health status, the use of colour, the gingival swelling or the analysis. However, patients reporting medications, and tobacco use increase of gingival crevicular fluid to be diagnosed with Diabetes (Type recorded as smoker (i.e. current smo- flow are mainly caused by alterations I and II) or taking medication ker), former smoker (i.e. self- of the periodontal vascular system potentially affecting gingival bleed- reported ex-smoker), or non-smoker (Nair et al. 2003, Scott & ing were excluded from the study. (i.e. never smoker). Further informa- Singer 2004, Apatzidou et al. 2005, Due to the retrospective nature of tion was collected such as the dura- Mokeem et al. 2014). In cigarette this study no ethical approval from tion of active periodontal therapy, smokers, however, current evidence the Swiss Ethics Committee of the the initial interval for SPT as deter- suggests that as a consequence of Canton of Bern, Switzerland was mined following active periodontal tobacco use periodontal inflamma- mandatory. Further permission to treatment, and the duration of SPT tory responses to the bacterial chal- conduct this study was granted by provided at the MSDH. Retrospec- lenges are generally modified the Medi School of Dental Hygiene tive clinical data gathered from the (Meekin et al. 2000, Rezavandi et al. (MSDH), City of Bern, Switzerland. patient records at each SPT visit 2002, Mavropoulos et al. 2003, Shi- included the percentage of BOP, the mazaki et al. 2006, Farina et al. number of teeth and the number of 2013). The impact of smoking Patient care at the MSDH sites with periodontal probing depths includes various alterations on vas- As previously reported, upon their (PPD) of 4, 5 and ≥6 mm at six sites cular tissue metabolism, immune entry at the MSDH, all patients were per tooth respectively. According to response, vasoconstriction, angiogen- fully examined according to the stan- the standard of care at the MSDH, esis or oxygenation profiles even dard of care and diagnosed for oral sites with PPD 0–3 mm were not though a distinct smoking associated diseases (Ramseier et al. 2014). Peri- recorded. pathohistological correlate seems to odontally healthy patients were pro- be lacking (Preber & Bergstrom€ vided with adequate prophylaxis 1985, Bergstrom€ & Bostrom€ 2001, while periodontally diseased patients Severity of periodontal disease Nair et al. 2003, Scott & Singer were treated with non-surgical peri- For the purpose of this study and in 2004, Apatzidou et al. 2005, Souza odontal therapy by the dental hygiene order to relate patient-level mean et al. 2012, Liu et al. 2014). students. Each periodontal patient BOP to smoking status among sever- With potential significance to the was re-evaluated and treated with ity of periodontal disease, all clinical monitoring of smokers dur- periodontal surgery when indicated. patients were categorized according ing SPT, consequently, patient-level Following prophylaxis or active to their baseline PPD either with I) BOP may be lower leading to chal- periodontal therapy, all patients were “no or mild periodontal disease”, II) lenges regarding diagnosis and enrolled into the MSDH’s suppor- “moderate periodontal disease” and assessment of periodontal disease tive periodontal therapy (SPT) pro- III) “advanced periodontal disease”. progression and possibly to false gram according to the MSDH’s Patients within category I) presented negative interpretation (Preber & standards. with PPD of ≤4 mm (no site exceed- Bergstrom€ 1986, Dietrich et al. 2004, Throughout the study period, ing PPD of 4 mm) while patients Liu et al. 2014). Therefore, the main the appropriate SPT intervals were within category III) presented with © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 152 Ramseier et al. PPD of ≥4 mm and at least 10 sites levels (non-smokers, former smokers distributed and were representative of PPD ≥6 mm. Consequently, and smokers) was tested using of the Swiss population in this period patients not fitting into the catego- approximate F-tests. (BAG 2013a,b). The mean age of the ries I) or III) were selected into cate- In order to analyse dependences entire patient sample was 42.6 gory II) demonstrating PPD of of categorical and categorized (Æ11.5) years with a range of 20 to ≥4 mm and a maximum of 9 sites numerical variables with the binary- 81 years while 55.1% (n = 245) were with PPD of ≥6 mm.