Dr. Mark Ryder

“Tobacco use has been associated with a variety of diseases including periodontal diseases. In this article, Dr. Ryder addresses ways in which the dental team can play a significant role in improving the patient’s overall health,” Dr. Peter O. Cabrera, Team Lead

Tobacco use in general and smoking in particular are the most important preventable risks for periodontal diseases. There has been a decline in the use of some tobacco products such as cigarettes in the United States and in other industrialized countries, thanks in part to public health education and smoking restriction laws.  However patients who use tobacco products still pose challenges to the dental practitioner. In addition, while some may believe cigar and pipe smoking are a safer alternative, there is a similar pattern of increased periodontal destruction-as well as comparable risks for other serious illness and conditions. Furthermore, smokeless tobacco users often will present with localized periodontal destruction at the site of tobacco placement. Tobacco users also do not respond as well to periodontal therapies including nonsurgical debridement, open flap debridement, regeneration procedures, periodontal plastic surgery, and implant therapy.

Several decades ago many clinicians believed the main effects of smoking on periodontal health and the poor response to therapy were mostly because of the misconception that smokers have more bacterial plaque. However smokers with good to excellent plaque control still lose more bone and respond poorly to periodontal therapy, even though smokers show less clinical gingival inflammation. These effects of tobacco on periodontal tissue appear mostly because of a suppression of the body’s ability to fight infection, and perhaps more importantly because of tobacco’s effects on stimulating tissue-destructive inflammation.

The dental practitioner should be encouraged by the beneficial effects of quitting on periodontal health and the response to therapies. For example, former smokers respond as well as patients who have never smoked to a variety of periodontal therapies. The dental practitioner is uniquely positioned to help prevent the patient from taking up using tobacco products, and in helping your patients who use tobacco to quit. These efforts require patience and reinforcement.

Regrettably, there is an abundance of inducements in the media worldwide to get patients to smoke or use other tobacco products. Strategies by tobacco makers to induce young patients to start using tobacco products are particularly troublesome as it is much more difficult to get a patient to stop using tobacco products when the habit is acquired at an early age. This is mostly because of the effects of habituation with the nicotine found in all tobacco products, which “wires the brain” for tobacco dependence.

Many smoking patients will see their dentist/hygienist more often than their physician. This gives the dental practitioner more opportunities and strategies to try to get their tobacco patients to quit. Perhaps the best known strategy for tobacco cessation now taught in almost all dental educational programs is a step by step approach known as the “5A” approach, coupled with some form of nicotine replacement therapy and/or other systemic medications such as a mild antidepressant or a nicotine receptor agonist. In addition, there are several other sources such as telephone quitlines and websites that the dentist/hygienist can use in their tobacco cessation efforts.  

These efforts by the dental practitioner require relatively little additional time in the practice and can result in better long-term (6-12 months) smoking cessation rates in a portion of patients. In addition, multiple attempts, coupled with demonstrations to the patient of the adverse effects of tobacco use, can increase these quit rates. Of particular importance to the dental practitioner is the evidence that quit rates are much higher once a patient experiences a tobacco related disease or condition (such as a heart attack), or is shown clear visible evidence of the damage from tobacco use. The dentist/hygienist can appeal to a patient’s sense of appearance by showing clear visible evidence such as gingival recession, tooth staining, radiographic bone loss, and other soft tissue changes in the mouth.

For those patients who continue to use tobacco products, the damage to the periodontium and other oral tissues should be minimized. Increased frequency of periodontal recalls and the use of local and/or systemic medications that can dampen the effects of tobacco on stimulating the products of destructive inflammation should be considered. The increased production and/or secretion of these inflammatory products can be partially suppressed by a variety of local or systemic anti-inflammatory agents. Currently antibiotics of the tetracycline family such as minocycline and doxycycline are the most widely used of these medications.

Despite the decline in the prevalence of the use of tobacco products in many industrialized countries, tobacco will probably remain a major risk for periodontal diseases in the near future. Dentists and hygienists are in a unique position to help the tobacco patient quit. Therefore what the practitioner can do in helping the tobacco patient to quit can be beneficial for the patient’s oral health, overall health, and, when considering the hazards of second-hand smoke, for the general population.

Dr. Mark Ryder is a Professor and Chair of Periodontology and Director of the Postgraduate program in Periodontology at the University of California, San Francisco, where he has taught for 31 years. He received his dental and specialty training from the Harvard School of Dental Medicine. He has written more than 150 articles, abstracts and book chapters and lectures extensively on diagnosing and treating periodontal diseases..

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 The Set-Up “Tobacco use has been associated with a variety of diseases including periodontal diseases. In this article, Dr. Ryder addresses ways in which the dental team can play a significant role in improving the patient’s overall health,” Dr. Peter O. Cabrera, Team Lead

Do you know what tobacco use is doing to your patient

It is now well known in the health professions and in the general media that diabetes is one of the major public health concerns in the United States. While the general prevalence of Type I (insulin dependent) diabetes has remained essentially stable over the past several decades, the incidence and prevalence of Type II (non insulin dependent) diabetes has steadily risen, with 20-25 million Americans now affected.  This is  argely because of changes in dietary habits, with an accompanying rise in obesity, which is a major risk factor for Type II diabetes. 

While Type II diabetes has been characterized by a later onset in life, more recently, there has been an alarming increase in Type II diabetes in children, and that partially can be attributed to an increase in childhood obesity.  Currently, while the prevalence of Type I diabetes is approximately 5% of all diabetes cases, the prevalence of Type II diabetes is about 95%.  This dramatic increase in diabetic patients has had a major impact on dental practice, particularly when it comes to diagnosing and treating periodontal diseases.   

The traditional view of diabetes and periodontal disease was as a “one-way” relationship in which poor glycemic control (blood sugar levels) in the diabetic patient went hand-in-hand with an increased severity of periodontal disease and with poorer responses to treatment.  Over the past decade there has been a decrease in the prevalence of more severe forms of periodontal diseases in the United States, in part because of decreased smoking rates and better public awareness. However, the increase in the numbers of Type II diabetics, and in particular the large proportion of Type II diabetics who are not aware of their condition and have poor glycemic control, gives one pause to consider the possibility of an increase in the incidence of periodontal diseases and their accompanying management issues in the near future.  Furthermore, over the past decade new insights have developed for the influence of periodontal diseases on the diabetic patient.  Specifically, as one of the most common inflammatory diseases and microbial infections, periodontal diseases may have a significant influence on a diabetic patient’s glycemic control (glucose levels).  Thus we have come to realize that the relationship between periodontal diseases and diabetes is a “two-way” relationship. 

This article briefly summarizes the impact of this two-way relationship, as well as future directions in understanding periodontal disease and diabetes.

The influence of diabetes on periodontal diseases

Regardless of whether the dentist is dealing with a diabetic patient with Type I or Type II diabetes, the levels of glucose and control of those levels of glucose is of critical importance for the influence of diabetes on periodontitis.  It is now well known that patients with either Type I or Type II diabetes have a 2.5-3.5 fold greater risk in developing periodontal diseases. This places diabetes as one of the major risk factors for the development of periodontal diseases. In addition the diabetic periodontal patient with poor glycemic control (a fasting glucose more than 125 milligrams per decaliter of blood, a non fasting glucose level more than 200 milligrams per decaliter of blood, and/or a glycosylated hemoglobin level of more than 8% of the total hemoglobin) will respond less favorably to the full range of periodontally related therapies, including subgingival debridement, soft and hard tissue periodontal surgery, and implants. 

The underlying reasons for this adverse effect of diabetes on periodontal tissues include an impaired ability to combat bacterial infection, an impaired wound healing, an impaired ability to regenerate tissue, an increase in destructive inflammatory substances in the response to infection, and perhaps most importantly,  the multiple damaging effects of the combination of glucose to a variety of proteins, termed advanced glycation end products (AGEs). These AGEs can cause local tissue damage by stimulating release of destructive inflammatory products, damaging the terminal circulation to the periodontal tissues, and stimulating alveolar bone resorption.  As similar mechanisms of damage occurs in other parts of the body, some now consider periodontitis the sixth cardinal sign of diabetes, which also includes vision loss, kidney failure, damage to the nervous system, cardiovascular diseases and general impaired wound healing.  

To prevent this chain of destructive periodontal events, it is important for the dental clinician to ensure the patient has acceptable glycemic control, particularly when performing the full range of periodontal procedures.

The influence of periodontal diseases on diabetes

In the diabetic patient, the presence of any chronic or acute infection and/or inflammatory disease can exacerbate the diabetic condition. Bacterial products and inflammatory products from diseased periodontal tissues can enter the bloodstream and induce greater insulin resistance in a variety of tissues in the body. With this impaired ability to respond to insulin to store glucose, periodontal diseases can further elevate levels of glucose and glycosylated hemoglobin. Additional support for the role of periodontal diseases in glycemic control comes from recent studies on the beneficial effects of a variety of periodontal treatments that reduce clinical periodontal inflammation, including debridement of bacterial deposits with or without antibiotics.  These studies have shown that such conventional periodontal treatments can lower levels of glycosylated hemoglobin by an average of approximately 0.8%.  While this number may not seem significant when compared with reductions in glycosylated hemoglobin with insulin injections for Type I diabetes, this improvement is comparable to reductions seen with many of the oral medications used in the treatment of Type II diabetes.

While the appreciation of diabetes and periodontal diseases as a “two-way” relationship has been an important new development, with impact on all dental practices, there is probably more to this story. In particular, the mutual influence of obesity on both periodontal diseases and diabetes, making this a “three-way” relationship, has received considerable recent attention. All three conditions are linked by inflammation and infection.  With the increase of the prevalence of obesity in the United States, Type II diabetes, and combinations of these conditions into metabolic syndromes, the dental practitioner will continue to play a pivotal role in both the oral health of these patients, as well as the overall health of the patient.

It is now well known in the health professions and in the general media that diabetes is one of the major public health concerns in the United States.

Diabetes and the periodontal patient

“Nutrition plays a key role in periodontal health and healing. Many issues in this field remain unsolved. In this article, Dr. Ryder explores some aspects of nutrition and periodontics.,”

	Periodontal diseases are among the most common inflammatory diseases with a primary bacterial etiology. As such a common inflammatory disorder, it is understandable that dental clinicians often face questions from patients, as well as colleagues, about how nutritional approaches can help prevent and treat periodontal diseases.

	It seems like every month we see new studies on the potential benefits food supplements, vitamins, minerals, and certain foods have on periodontal health. From a broader nutritional perspective, there have been interesting and important new insights into the association between obesity and inflammatory disease in general and periodontal diseases in particular. Nutrition and periodontal diseases is an extensive, complex field, making it easy for clinicians to lose their bearings as to what may or may not work. Several unsubstantiated claims have been made based on anecdotal evidence, rather than well-designed studies. This is understandable as nutritional studies are, by their nature, difficult to perform because nutritional deficiencies can have serious effects on a person’s level of inflammation, resistance to infection and overall health. Studies on less severe dietary deficiencies or dietary supplements and their effect on periodontal disease, which involve not only the study of gingival inflammation but also the loss of periodontal support, require long observation periods and a large numbers of patients

	Patients and fellow dentists often want to know how effective vitamin supplements are in preventing and treating periodontal diseases. Almost every vitamin has been suggested as a possible supplement for treating periodontitis. We know severe deficiencies in certain vitamins, such as B complex vitamins like Riboflavin (B2) and Folic Acid, can increase clinical signs of periodontal inflammation and breakdown. Vitamin E’s anti-inflammatory effects may make it an effective topical application for reducing gingival inflammation. Researchers are exploring this through animal testing. 

	A variety of vitamin supplements may have some yet-to-be-demonstrated beneficial effects. Perhaps the most attention, as well as the best evidence, for vitamin and mineral supplementation comes from our classic understanding of Vitamin C’s role, and the new evidence for the role Vitamin D and calcium plays in periodontal health.

	We know the dietary Vitamin C (or ascorbic acid) deficiency, known as scurvy, can lead to severe periodontal inflammation, loss of periodontal support and tooth loss. Dietary Vitamin C supplementation can help reduce this severe condition. While overt scurvy is relatively rare, reported cases condition still appear in the literature as case reports. We most often see it in special patient groups such as the malnourished and autistic children.

	Less severe deficiencies in Vitamin C can lead to increased gingival inflammation and periodontal breakdown. This, too, often can be corrected with Vitamin C supplementation.

	During the past decade, Vitamin D and calcium’s role in periodontal inflammation and host defenses has emerged. Both adequate Vitamin D levels and calcium intake are important for healthy bones, including bone support around the teeth. Severe calcium loss in bones, such as in post-menopausal women who develop osteoporosis, can make patients more susceptible to periodontal bone loss.

	However, Vitamin D’s role in maintaining healthy bones is just part of the story. Recent evidence shows Vitamin D has several other important beneficial effects, both for overall health and possibly for periodontal health. These studies show Vitamin D can boost the body’s resistance to infection and reduce destructive clinical inflammation. Studies on large populations have shown that gingival inflammation is associated with lower levels of serum Vitamin D. These exciting new observations have led to several studies designed to examine the possible benefits Vitamin D supplementation has on improving periodontal health, particularly in populations without sufficient levels of this vitamin, either through lack of sun exposure or diet.

	The major initial cause of periodontal diseases is the complex organization of bacterial plaque that accumulates on the tooth surface as a maturing biofilm with an increase in the proportion of potentially more toxic bacteria. Fellow dentists often ask about the possibility of using probiotics as a nutritional supplement. The idea behind such an approach would be to disrupt the harmful biofilm’s development by substituting a less harmful species of bacteria into the plaque biofilm. In the last several years, some published studies have shown using a probiotic drink with a benign form of lactobacillus can help reduce some of gingival inflammation’s clinical and laboratory signs. While these initial observations show promise, we need to await further studies to know whether this probiotic approach has the potential for major, long-term therapeutic effect on periodontal treatment.

	As periodontal diseases have both a microbial cause and a major inflammatory component, it is understandable that other nutritional approaches with anti-inflammatory effects may show promise in periodontal treatment.

	Omega-3 fatty acids, which are found in oily fish and other foods, and their anti-inflammatory effects have generated considerable interest in the last several years. In particular, these Omega 3 fatty acids resolve pathways of inflammation toward an anti-inflammatory and reparative profile. Animal studies have shown the benefits Omega-3 fatty acids have on periodontal inflammation. Whether these benefits carry over to human periodontal disease awaits future human studies.

	It is clear nutrition’s role in periodontal disease is a promising area of investigation, with some potentially novel new approaches emerging in the near future. For now, it is important for all our patients to maintain a balanced diet with adequate intake of essential vitamins and minerals at the minimum recommended daily requirements.

	As to whether specific dietary supplements can be used in excess of these daily requirements as a way to prevent or treat periodontal diseases is still open to speculation and still requires large-scale, well-designed studies to confirm. We certainly should educate our patients about the potential for harm if any of these supplements are taken in severe excess, such as sharing case reports on the harmful effects excess Vitamin A supplementation can have. In addition, several studies suggest that excessive intake of ginger, ginseng, garlic or gingko biloba may increase bleeding tendencies. This may lead to an increased tendency for the gingival to bleed on probing, and may prolong bleeding times during surgical procedures. However, if our patients wish to explore taking nutritional supplements specifically to prevent or treat periodontal diseases, we certainly shouldn’t discourage this approach. We do need to make sure our patients understand that while this approach may have benefits, “the jury is still out” on most of these dietary approaches, ”but they should “stay tuned” for future developments.

Dr. Mark Ryder is a Professor and Chair of Periodontology and Director of the Postgraduate program in Periodontology at the University of California, San Francisco, where he has taught for 31 years. He received his dental and specialty training from the Harvard School of Dental Medicine. He has written more than 150 articles, abstracts and book chapters and lectures extensively on diagnosing and treating periodontal diseases.

 The Set-Up  “Nutrition plays a key role in periodontal health and healing. Many issues in this field remain unsolved. In this article, Dr. Ryder explores some aspects of nutrition and periodontics.,” Dr. Peter O. Cabrera, Team Lead

Nutrition's role in perio

	“The field of Periodontology is dynamic, and the role of the different practitioners is rapidly evolving. It is important for dentists and hygienists to stay on top of the latest research and trends. In this excellent review, Dr. Ryder examines the topic of prevalence of periodontitis from a public health and practical clinical perspective. His observations and recommendations provide a solid foundation for looking at this important topic.”-Dr. Peter Cabrera, Team Lead

	One of the most rewarding aspects of being a dental practitioner is that we are all in the midst of an ever-changing profession. Over the past century we have seen our profession move from extraction and tooth replacement, to more sophisticated and esthetically oriented restoration approaches, to caries prevention with fluoridation, sealants, and better patient education and awareness. Now we are at a time where the most advanced tools in regeneration biology, genetics, material sciences and bioengineering are being applied to dentistry.

	In the past century, we’ve seen similar changes in the field of periodontology. In particular for the periodontal specialist, the nature of clinical practice has undergone dramatic changes. The most significant change has been a shift in periodontal specialty practices from the treatment of moderate to severe periodontal diseases and conditions, to practices that devote more of their efforts toward implant placement and preparation of implant sites in more complex cases, and to a full range of soft and hard tissue periodontal plastic surgery procedures.

	With this change in the emphasis of periodontal practice toward these implant and esthetic procedures, an important question for the general practitioner and hygienist is: Does this mean the prevalence of periodontal diseases that we all learned about in school is on the decline?

	For those of us who practice in dental school settings or in areas with indigent populations, that answer would be “not really,” as we continue to see and treat patients with more advanced periodontal diseases. Indeed studies have shown the prevalence of periodontal diseases are related to lower socioeconomic status. However, there is an important trend in dentistry that has the general practitioner and hygienist beginning to take on the diagnosis, treatment and maintenance of their patients with periodontal diseases, particularly for those patients with mild to moderate forms of these diseases.

	Yet a central question remains: “Is the prevalence of periodontal disease on the decline, particularly in the United States and other developed countries?” In this brief review, we will present our current understanding of current trends in the prevalence of periodontal diseases.

	In looking at the possible trends in periodontal disease prevalence over the past 50-60 years there are several broad developments to consider. These include better public awareness of the role of bacterial plaque in the development of gingival inflammation, and the importance of plaque control in removing this plaque. The current variety and number of advertisements, public educational programs, anti-plaque agents, mechanical toothbrushes and other new designs of oral cleaning devices have certainly led to a decrease in the incidence and prevalence of periodontal diseases.

	Equally important in this possible decline in the prevalence of periodontal diseases is the drop in the rates of smoking over the past decades. Indeed numerous studies point to smoking as the major preventable risk factor for the development and severity of periodontal diseases. The decline in periodontal diseases has progressed hand-in-hand with the decline in smoking rates. Some leading researchers, such as Philippe Hujoel at the University of Washington, have characterized the link between smoking and periodontal disease and the subsequent decline in periodontal disease with declines in smoking as the “hidden epidemic of periodontal disease” in the 20th century.

	On the other hand, the trend toward an aging population in the United States and in other developed countries may seem to counteract these beneficial influences such as education, advertising and declines in tobacco use. In fact, aging may be the most important “non-preventable” risk factor in the extent of periodontal attachment loss. However, it appears that even though our older patients may have more bone loss, clinical attachment loss and/or recession, the bottom line is with good plaque control and frequent and appropriate maintenance recalls, the rates of tooth loss in the elderly are not significantly affected.

	To be able to say periodontal diseases are on the decline, it is necessary for us to look at large scale surveys taken over several decades. If we look at early studies on the prevalence of periodontal disease there are reports that found up to 87% (in a 1955 survey) of the examined population had chronic destructive periodontal disease.

	One of the best examples of these reported declines would be the National Health and Nutrition Examination Survey III, which included periodontal measurements. This survey was done for thousands of subjects from 1988-94, 1999-2000, and 2000-2004, and will be revived for the next survey beginning in 2012.

	On the surface the trends in the prevalence of periodontal disease over these time periods was quite dramatic, with rates declining from 35% to 7.3% to 4.2%. However it should be noted the methods for assessing periodontal disease were different in each survey. In particular all of these larger scale surveys used partial probing to measure pocket depths, and/or clinical attachment level approaches that look at selected teeth, selected quadrants, and/or selected surfaces of teeth.

	However, several studies have shown that these partial examination techniques may underestimate the true prevalence of periodontal diseases by as much as 70% when compared with full probing/full-mouth examinations. While full-mouth examinations are generally impractical when conducting such a survey on a very large population, there is a need to adopt a standard definition for periodontal diseases.

	One such possible clinical definition developed by the American Academy of Periodontology and the Centers for Disease Control and Prevention would use a simple but consistent system for classifying moderate or severe periodontitis in large population studies (Page and Eke 2007) as follows: Severe Periodontitis-2 or more interproximal sites with clinical attachment loss greater or equal to 6 mm (not on the same tooth) and one or more sites with pocket depths greater or equal to 5 mm; Moderate Periodontitis-2 or more interproximal sites with clinical attachment loss greater or equal to 4 mm (not on the same tooth) or 2 or more interproximal sites with pocket depths greater or equal to 5 mm (not on the same tooth); No or Mild Periodontitis-neither “moderate” nor “severe” periodontitis. Hopefully, future studies will use a standard definition and survey approach to define periodontal diseases.

What this all means to the general practitioner and hygienist

	Despite all these limitations in measuring periodontal disease trends over time, one can conclude the prevalence of the more severe forms of periodontal disease appear to be on the decline in the United States. Studies have shown that general practitioners still refer patients with severe forms of periodontal disease to a specialist, and treat patients with mild or mild to moderate forms in their own offices.

	It is important for general dentists to diagnose, treat and monitor the patients they manage in their practices. This includes a full-mouth probing at the initial visit, reevaluation after initial treatment that would address all possible local and systemic factors (e.g. debridement, plaque control instruction, smoking cessation, etc.), maintaining and monitoring their patients on appropriate recall intervals and referring to a specialist where warranted.

	Many general practices adhere to these important principles of diagnosis, treatment, maintenance, reassessment and possible referral. However, studies have shown a considerable proportion of practices do not perform initial full-mouth periodontal exams, and rely instead on radiographs and/or do not keep their periodontal patients on a regular recall maintenance program. Thus, for the current and future general dentist and hygienist, there is an urgent need to improve both the periodontal educational programs in dental and dental hygiene schools, and in strengthening continuing education programs on the diagnosis and treatment of periodontal diseases.

Dr. Mark Ryder is a Professor and Chair of Periodontology and Director of the Postgraduate program in Periodontology at the University of California, San Francisco where he has been a faculty member for 31 years. He received his dental and specialty training from the Harvard School of Dental Medicine. He is the author of more than 150 articles, abstracts and book chapters and has lectured extensively in continuing education courses on the diagnosis and treatment of periodontal diseases both in the United States and abroad. He has received awards both from the University of California and from national organizations for his entertaining and informative lectures, and for his contributions to dental education.

 The Set-Up  “The field of Periodontology is dynamic, and the role of the different practitioners is rapidly evolving. It is important for dentists and hygienists to stay on top of the latest research and trends. In this excellent review, Dr. Ryder examines the topic of prevalence of periodontitis from a public health and practical clinical perspective.