Braz J Oral Sci. October-December 2006 - Vol. 5 - Number 19

Association between dental and periodontal disease in a rural Brazilian community Suzely Adas Saliba Moimaz * Nemre Adas Saliba * Abstract The aim of this study was to describe the periodontal conditions and Orlando Saliba* to analyze the association between the wearing of fixed/removable Lívia Guimarães Zina* partial and periodontal disease in a representative adult rural Márcio Rogério Curtis Bolonhez* population in southeast Brazil. Cross-sectional study of a *Preventive and Social Dentistry Post- representative sample comprising 200 individual aged 34-44 years. Graduation Program, Department of Pediatric and Social Dentistry, Araçatuba School of Data were collected by clinical examinations in accordance with the Dentistry, São Paulo State University - UNESP, World Health Organization Basic Methods Criteria, which included Brazil the Community Periodontal Index and dental prosthesis exam. A descriptive analysis and the chi-square statistic were performed. In total, 40.5% of the individuals wore partial denture and 59.5% were non-users of denture. The prevalence of periodontal disease was 100%. The subjects scored either calculus (44.5%) or shallow pockets (47%), and only a small proportion was recorded as having deep pockets Received for publication: August 13, 2006 (8.5%). All denture wearer displayed periodontal problem in the sextant Accepted: October 17, 2006 where the denture were recorded. The statistical analysis indicated that wearing partial dentures was found to be associated with considerable periodontal disease (X2 = 10.75; p=0.0014). The periodontal condition of the study population can be considered unsatisfactory. The wearing of partial dental prosthesis was associated with periodontal disease, and a significant percentage of cases might have been prevented if plaque control interventions had been implemented.

Key Words: periodontal diseases, dental prosthesis, oral health, periodontal index, epidemiology

Correspondence to: Suzely Adas Saliba Moimaz Department of Pediatric and Social Dentistry, Araçatuba School of Dentistry, São Paulo State University Rua José Bonifácio, 1193 Vila Mendonça, 16015-050 Araçatuba, SP, Brasil. Phone: +55-18-3636-3250 Fax: +55-18-3636-4890 E-mail: [email protected] 1226 Braz J Oral Sci. 5(19):1226-1231 Association between dental prosthesis and periodontal disease in a rural Brazilian community

Introduction periodontal disease than non-abutment teeth, with significant Dental caries and periodontal diseases have been historically differences (p<0.01) for plaque, calculus and gingival index, considered the most important global oral health burdens. probing depth, tooth mobility and gingival recession20. At present, the distribution and severity of oral diseases The gingival health is adversely affected by removable partial vary in different parts of the world and within the same dentures, with it being most severe where the appliance country or region. In Brazil, 48.3% of people aged 35-44 years closely contacted the gingival margin16. The differences in wear at least one dental prosthesis; at 65-74 years-old this gingival inflammation between the plate and dental bar rate go up to 66.5%1. The significant role of local, socio- designs suggest that covering more gingival tissue promotes behavioural and environmental factors in oral disease and development of gingivitis, which may subsequently health is demonstrated in a large number of epidemiological predispose the area to periodontal disease25. surveys2-6. In a three-year study with patients wearing fixed partial A global database was established and over a number of dentures with advanced periodontal disease, carried out by years an increasing number of oral epidemiological studies the researches of the Yonsei University, Korea, it was have been conducted applying World Health Organization observed good results regarding the periodontal health (WHO) methodology and criteria7. To assess the periodontal situation26. status of populations, the WHO recommended the Continuing surveillance of levels and patterns of risk factors Community Periodontal Index (CPI) application, which of periodontal disease is of fundamental importance to verifies the state of periodontal health in view of gingival planning and evaluating community preventive activities and bleeding, periodontal calculus and pocket. The CPI has been oral health promotion. Studies suggest that the use of partial widely used to measure the level of periodontal diseases dentures may constitute a risk factor for periodontium health. and treatment needs in populations, and it allows for The aim of this study was to describe the periodontal international comparisons7. conditions and to analyze the association between the Severe periodontitis which may result in tooth loss is found wearing of fixed/removable partial dentures and periodontal in 5-15% of most populations5-6. disease in a representative adult rural population in southeast A classic study on experimental gingivitis in humans proved Brazil. that bacterial plaque or biofilm represents the main etiologic factor of periodontal diseases8. Other researches also confirm Material and Methods the importance of controlling biofilm in order to maintain Study methodology individual oral health9-12. The target population of the present study was adults living Acting jointly with biofilm, local and systemic factors may in the rural area of Araçatuba in the Brazilian state of São modify the pathogeny of periodontal disease, like dental Paulo. This state is located in the southeast part of Brazil, morphology, shape and site of furcation, level and amount and is one of the most important states of the country. of , trauma, diabetes mellitus, genetic Two hundred patients aged 35-44 years were examined factors and viruses12. between August 2004 and January 2005. The sample was Dental prosthesis may influence the periodontal conditions, randomly selected and weighted to represent the 35-44 year the risk of caries and the amount of stress on natural teeth10,13- old adult population of rural area of Araçatuba. The specific 15. Various investigations have shown that there is an area where the data were collected has approximately 600 increase in the mobility of the supporting teeth, gingival inhabitants (Information provided by Araçatuba Health inflammation and formation of periodontal pocket after dental Municipal Department and the Brazilian Institute of prosthesis are fitted in16-21. According to some authors22-24, Geography and Statistics - IBGE). The study sample included the removable partial denture were associated with increased 80 (40%) males and 120 (60%) females. plaque accumulation, not only on tooth surfaces in direct The sample size was obtained allowing 10% of sampling contact with the denture, but also on teeth in the opposing error27. The sample calculus was derived based on the arch, and in some cases, even on buccal surfaces of teeth. prevalence of periodontal disease in the region. The These alterations are attributed to poor oral hygiene, prevalence of periodontal disease in São Paulo State was increased plaque and calculus accumulation, and considered 55%, in accordance with research carried out by transmission of excessive forces to the periodontal structures the University of São Paulo in 199828. from occlusal surfaces of the framework of dentures. Many The following formula was used for the sample calculus27: partial dentures framework designs contribute to increased N = p q / E2 or altered oral bacterial flora and formation of dental plaque20. p is the probability of individuals of the sample having this In a large case-control study conducted by the University characteristic; q is the probability of individuals of the of Zagreb, Croatia, in 2002, 205 partial denture wearers were sample not having this characteristic. examined; abutment teeth had higher scores related to The patients were chosen at random, using the census data

1227 Braz J Oral Sci. 5(19):1226-1231 Association between dental prosthesis and periodontal disease in a rural Brazilian community

and other relevant municipal information. Intra-rater reliability and agreement with gold standard Exclusion criteria were presence of diseases/conditions that were assessed during and at the end of session. The may interfere with the clinical examination and the results. level of concordance for measures relative to periodontal Hence, subjects were excluded if they were diagnosed with conditions and denture identification was good (mean [kappa] psychiatric problems, intoxicated with alcohol or dugs, index was 0.80). pregnant women and smokers. Later, a pilot study was carried out on adults aged 35-44 years who attended the Araçatuba School of Dentistry Clinic Clinical examinations to test the feasibility of the study and dental examination. Examinations were performed by one dentist, assisted by a There was no need to change the methodology previously recorder, and they were conducted in a health center located proposed. Ten percent of the sample (N=20) was re-examined in the rural area. Letters were sent to selected individuals to test for reliability during the fieldwork. and explained the aims of the study and solicited participation. A few days later, the researchers visited the Ethical considerations individual and provided more information about the study This study was aware of the Code of Ethics of the World and encouraged participation. Eligible subjects who consent Medical Association (Declaration of Helsinki) and it received to participation were invited to go to the local health center ethical approval from the Research Ethics Committee of the in a specific day. Araçatuba School of Dentistry (file: FOA 2178/2003). The Clinical examinations were carried out in natural light. Gauze exams were undertaken with the understanding and written squares, cotton buds, sterile sets of plane mouth mirrors consent of each subject. and Community Periodontal Index (CPI) probes were packed Confidentiality was assured to participants and all recording in sufficient quantities for each working day. Strict procedures forms were numbered, but not named. for infection control were followed. The clinical examination lasted an average of 10 minutes per adult. Data analysis The Community Periodontal Index (CPI) was recorded for For the descriptive statistical analysis of the periodontal each sextant. Ten index teeth (17, 16, 11, 26, and 27 in the parameters, mean values were calculated for each patient maxilla, and 47, 46, 31, 36, and 37 in the mandible) in six and for sextant, since all patients present alterations in their sextants (17-14, 13-23, 24-27, 37-34, 33-43, and 44-47) were periodontal condition. The presence or absence of disease probed and scores ascribed to each sextant on the following and the identification of partial denture in the same sextant basis: score 0 - no signs of disease; score 1 - gingival bleeding were compared, for which the chi-square test were used. after gentle probing; score 2 - presence of supra or Level of statistical significance was chosen at p<0.05. subgingival calculus or other plaque retentive factors; score 3 - 4 or 5 mm deep periodontal pockets; score 4 - 6 mm or Results deeper periodontal pockets7. Of the 200 subjects recruited into the survey, 81 (40.5%) Molars were examined in pairs and the highest score was wore dental prosthesis, fixed and/or removable, and 119 recorded for each sextant. A sextant was examined if at least (59.5%) were non-users of denture. 2 teeth are present. A 0.5 mm ball-ended probe with color Table 1 and Figure 1 show the prevalence of periodontal markers at 3.5 and 5.5 mm was used to measure the CPI. The condition measured by the Community Periodontal Index WHO recommends that the pressure applied in probe should (CPI) on the subjects who underwent the periodontal examination. not exceed 20 grams. For each tooth, 6 sites were examined: Among these subjects, 100% presented some periodontal mesial, midline and distal on both vestibular and lingual/ problem, recorded by the sum of scores 2, 3 and 4, palatal surfaces. Probing depth was defined as the distance from the free gingival margin to the bottom of the pocket/sulcus7. 70 The use of dental prosthesis was evaluated according to 60 criteria recommend by WHO7: score 0: don’t wear dental 50 prosthesis; score 1: fixed partial denture wearer; score 2: 40 removable partial denture wearer; score 3: combined dentures 30

(fixed/removable) wearer. Sextants (%) 20

10

Pilot study and calibration 0 Dental examiners participated in a 5-day training and 01234X calibration session. The session focused on the CPI interpretation of indexes measuring pathologies sought Fig. 1 - Percentage distribution of sextants by the highest Community during examinations and identification of dental prosthesis. Periodontal Index (CPI) score. Araçatuba, Brazil, 2006.

1228 Braz J Oral Sci. 5(19):1226-1231 Association between dental prosthesis and periodontal disease in a rural Brazilian community

Table 1 - Percentage distribution of subjects and mean number of sextants by the highest Community Periodontal Index (CPI) score. Araçatuba, Brazil, 2006.

CPI Score

0 1 2 3 4 X 9 Total

% patients 0 0 44.5 47 8.5 0 - 100.0

Mean number of sextants 0.4 0.1 3.9 1.1 0.1 0.4 - 6.00

independently of wearing of dentures. The subjects scored dentures may play an important role in the development of either calculus (score 2) or shallow pockets (score 3), and periodontal disease. only a small proportion was recorded as having deep pockets In this study, all subjects presented signs of periodontal (score 4). All denture wearer displayed periodontal problem, disease. The percentage of patients with periodontal pockets as calculus and periodontal pocket, in the sextant where the was relatively high (55.5%), but when only deep pockets dentures were recorded. were considered, the percentage found was much lower A mean number of 4 sextants presented bleeding and calculus (8.5%). A mean number of 5.2 sextant presented bleeding or as worse condition, and the sum of these conditions (score more severe problems; however, only 1.2 sextants had 4 mm 1 and 2) represented 67.13% of total of sextants, whereas or deeper periodontal pockets. This means that the only 1 sextant were found to have a pocket of 4 mm or more, periodontal alterations were more generalized, affecting more score 3 and 4 represented by 19.71% of sextants. The mean sextants, and having a few severely involved teeth. Thus, number of sextants with healthy periodontal tissues was 0.4, gingivitis was the principal clinical manifestation of which represents 6.25% of the total. Excluded sextant (score periodontal disease in the subjects examined. x), due to there remaining less than 2 teeth, were less prevalent In 2003, a National epidemiological survey showed a (6.83%). percentage of 46.2%, 21.9% and 7.9%, respectively, of The relationship between subjects categorized as exhibiting individuals with no periodontal problem within the age range considerable periodontal disease (score 3 and 4 as worse of 15 to 19, 35 to 44 and 65 to 74 years1. On comparing the condition) and those categorized as partial denture wearer is 1986 and 2003 national surveys, the decrease in the rates of demonstrated in table 2. periodontal disease prevalence in the Brazilian population is For the 35- to 44-year-olds rural population, being a partial most likely due to conditions such as the consolidation of denture wearer was significantly associated with an the National Public Health System and the greater care given increased likelihood of being categorized as exhibiting to oral health. considerable periodontal disease (X2 = 10.75; p=0.0014). A study verified the periodontal conditions and treatment needs according to the Community Periodontal Index of Discussion Treatment Needs (CPITN) in a worker population in Brazil29. This paper set out to address the hypothesis that there was The results showed a mean number of 0.1 healthy sextants, an association between the wearing of fixed/removable partial and calculus and shallow pocket were the most prevalent dentures and periodontal condition in a Brazilian adult rural periodontal condition, similar to our findings. population. The results of this analysis suggest that partial Among the factors that account for poor periodontal

Table 2 - Number and percentage distribution of sextants by the presence of periodontal disease and use of partial dentures. Araçatuba, Brazil, 2006.

Periodontal disease

Prosthesis Present Absent Total

Present 172 (15%) 2 (0%) 174 (16%)

Absent 871 (78%) 73 (7%) 944 (84%)

Total 1 043 (93%) 75 (7%) 1 118 (100%)

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condition are the lack of professional advice regarding oral of the most evident factors was poor oral hygiene as health maintenance and the low rate of follow-up19. observed by the authors during the clinical examinations. Besides, the prevalence of periodontal diseases in rural Thus, evaluation of the wearing of partial dentures and populations seems to be higher than in urban populations. periodontal condition must be carried out based on several A research performed in rural and urban areas of a Brazilian evidences related to the importance of controlling bacterial city compared the oral health condition of these regions, plaque in order to preserve the integrity of the periodontium. including the main oral diseases as dental decay and However, the in situ effect of dental prosthesis must not be periodontal disease, and the authors observed that rural overlooked in relation to its multiple functionality aspects, residents had worse index than urban residents30. Another such as definition of margins and prosthetic adaptation study carried out in a rural area of São Paulo State, Brazil, which, if not correct, may effectively contribute to the found values as 99.5% of children aged 6 to 14 years development of periodontal disease. presenting signs of periodontal disease31. Despite some Agreement exists among several authors about the need for methodological differences among surveys performed with oral home care and a regular recall system, which influences rural populations, it is distinguished the worse periodontal the success of prostheses26,34-35. Clinical studies showed that conditions of these populations. To understand these when providing a regular recall system with control, re- differences, it is necessary to know the social determinants instruction and re-motivation, partial dentures might not of health involved in the health-disease process of cause any damage of the periodontium. In a retrospective periodontal disease, like income, education, habitation study, the changes in the periodontal conditions of patients conditions, work, transport, sanitation and environment. In wearing different designs of removable partial dentures over developing countries as Brazil, the iniquities are present in long-term were evaluate, and found a higher deterioration in many sections and regions, and the social difficulties can be the abutment teeth than in the non-abutment teeth35. higher to the population of rural areas, with small wages, According to these authors, the substantial dental and worse habitation condition, difficulties in the access of periodontal destruction in patients with partial dentures is children to school and of people to health services. found more frequently in patients who had a poor oral hygiene Various researches18-20 have shown that, on comparing the and seldom visited their dentist. Every patient should be periodontal condition of abutment teeth and natural teeth, a included in a preventive oral health service, with control of statistically significant difference was found between both bacterial plaque by the dentist and the patient. periodontal conditions, the abutment teeth presenting a To maximize cost-effectiveness, prevention and control of greater depth of gingival crevice, an increase of calculus periodontal diseases should be based on predicted risk of and dental mobility. It is believed that the increase in plaque developing these diseases. In populations with low level of accumulation is related to negligence of the patient and not oral hygiene and limited oral health care resources, a “whole necessarily brought about by the prosthesis. That population” strategy for general oral health promotion should periodontal alterations may be solely due to the patient’s be applied36. Besides this, based on the risk profile, the basic poor oral hygiene with no prosthesis involvement in this strategy should be individualized treatment to eliminate result32. infection by periopathogens and to control or/and reduce Older patients maintain hygiene of natural teeth better than modifying risk indicators, risk factors and prognostic risk denture hygiene, and their results underscore the need for factors, as the wearing of dental prostheses. better instruction on maintaining denture hygiene20. For rural populations, the strategies must emphasize the A study comparing patients with removable partial dentures, importance of adapting the services to the necessities and patients with no prosthesis, or patients with fixed partial difficulties of those populations. The access to health dentures showed the greatest plaque and calculus services must be facilitated so all can be assisted, not only deposition, periodontal probing depth, and alveolar bone in relation to curative treatment, but also, and mainly, to loss on the abutment teeth in removable partial denture preventive and educative activities. wearers33. Finally, the results highlight the need for further Some studies examined effects of forces transmitted to epidemiologic studies to clarify the relationship between abutment teeth, jiggling, and eventual orthodontic tooth dental prosthesis and periodontal disease, types of dentures movement, and the results showed that such forces did not and period of development of disease. induce periodontal disease or progressive destruction of the In conclusions, the wearing of partial dental prosthesis was periodontium if good hygiene was maintained 19,32. associated with periodontal disease in this study population, The prevalence of denture wearers with periodontal disease and a significant percentage of cases might have been in the present survey was significant. The factors related to prevented if plaque control interventions had been the development of periodontal disease could be involved implemented. The results suggest a need for populations- both in sites with and without dentures, and probably one based plaque control programs in an attempt to reduce the 1230 Braz J Oral Sci. 5(19):1226-1231 Association between dental prosthesis and periodontal disease in a rural Brazilian community

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