NL Journal of Dentistry and Oral Sciences
(ISSN: 3049-1053)

Introduction

Periodontal diseases are common, complicated interplays between periodontopathogenic bacteria and the host’s immune response inflicted by risk factors such as smoking, diabetes mellitus, hypertension, stress and heredity. Periodontal disease amelioration results in attachment and alveolar bone loss and consequential tooth mobility [1]. Periodontal diagnosis employing full-mouth clinical examination is well thought-out the “gold standard” to settle subject periodontal status [2]. However, clinical examination demands the evaluation of many parameters and the registering of a lot of information which take a lot of time and effort both for patients and examiners, that may lead to assessment inaccuracy and substantial abandon [3,4].

Radiographic assessment is crucial for demonstrating interproximal periodontal bone levels to figure out the treatment plan, prognosis of periodontally-affected teeth and providing baseline information for the assessment of treatment outcomes [5]. Additionally, it emerges as essential to periodontitis classification grounded on stages described by severity, and grades reflecting disease advancement [6]. Moreover, radiographic examination displays an accessible and satisfactory method that exhibited a strong correlation with the clinical findings and clinical attachment loss [7,8].

Panoramic radiographs offer a general elaboration of the severity and extent of periodontal disease and the allocation of bony defects, particularly in the measurement of periodontal bone loss [9] that was successfully confirmed as a trustworthy tool for extensive surveillance studies [10]. By virtue of the diminished radiation dose, panoramic radiographs are usually the only radiographs used in epidemiological surveys and regarded as a regular diagnostic aid providing a precious screening chance. Furthermore, the certainty of panoramic radiograph-grounded periodontal bone loss being a screening implement for periodontitis diagnosis under the 2018 case definition was reported as a reliable tool in periodontitis cases screening and surveillance [11].

Our dental teaching hospital provides dental services to many patients with various age, ethnicity, nationalities, and socioeconomic status. Therefore, it provides an opportunity to know about the extent and the severity of periodontal disease in our city population, which help establish a community-based program to increase the awareness of periodontal disease prevention and detect periodontitis early in the mild forms to prevent progression to more severe forms. Moreover, although previous studies on the prevalence of periodontal bone loss in our country have been undertaken [12-14], periodontal bone loss prevalence and correlation with associated risk factors has not been studied in our city. Hence, the aim of this study was to evaluate the prevalence and correlation of periodontal bone status with associated risk factors among the university dental teaching hospital patients.

Materials and Methods

Study design

Participants included in this retrospective study were patients who sought dental treatment from January to December 2019 with a total number of 2983 patients using their routinely done panoramic radiographs before their examination. Blind, standardized, recorded data on gender, age, oral hygiene status using the Silness and Loe plaque index [15], smoking status and systemic condition were obtained from patients’ records without including any identifying information. Inclusion criteria were panoramic radiographs from dentulous patients above 18 years of age. Exclusion criteria were set to rule out poor-quality images and records with insufficient data.

Panoramic radiographs were taken using Gendex Orthoralix 9200 DDE Digital Cephalometric and Panoramic X-Ray (Gendex Dental System, USA). Panoramic radiographs’ quality was assessed following the criteria submitted by Sabarudin and Tiau [16]. Each image was scored with a 4-point numerical grading scale addressing anatomical coverage, density and contrast as well as anatomical structures.

Anatomical coverage scales were 1. Inappropriate coverage 2. Suspected coverage 3. Visibility of coverage relevant to clinical needs 4. Optimal coverage.

Density and contrast scales comparing enamel to dentin were 1. Poor density and inadequate contrast 2. Unsatisfactory density with adequate contrast 3. Satisfactory density and contrast 4. Excellent density and contrast.

Anatomical structures scales were 1. Significant structures are not visible 2. Only broad details seen 3. Small details are visualized 4. Fine details are visualized. Panoramic radiograph was rated as better image quality when it had all the scores with 3 or 4 numerical grading whereas all scores’ grading of 1 or 2 indicated poor image quality [17].

Radiographic examination was performed with a high-resolution computer monitor in a dark room by a single examiner. Periodontal bone status was assessed by calculating the proportion of the linear measurement total bone height (distance from the tooth’s apex to alveolar bone crest) to the total root length (distance from the tooth’s apex to CEJ) in all teeth. Adopting the standardized formality by Rydén et al. [10], healthy periodontium was considered when the proportion was ≥ 80%, while mild-to-moderate Periodontitis was described when the proportion was 79 - 66%, whereas severe periodontitis was defined when the proportion was < 66%. The assessments for the same radiographs were registered twice and the first assessment was sightless for the purpose of intraexaminer reliability.

Statistical Analysis

Data were gathered, tabulated and then analyzed using SPSS version 20. They were displayed as frequencies, and comparisons were made using the chi-squared test (X2) while correlations were evaluated using Pearson correlation coefficients (r). P-values less than 0.05 were considered significant.

Results

A total of 2983 patient records were examined, out of which 373 records were excluded due to absent or insufficient recorded data or low-quality panoramic radiographs. Out of the total 2610 records, Oral hygiene status was poor in 795 (30.5%) patients, fair in 982 (37.6%) patients and good in 833 (31.9%) patients, whereas 1178 (45.1%) were current smokers and 1432 (54.9%) were non-smokers. Regarding associated systemic diseases, 995 (38.1%) patients had no associated systemic diseases, while 1046 (40.1%) had diabetes mellitus and 569 (21.8%) had hypertension.

Periodontal bone loss was found in 1521 (58.3%) panoramic radiographs while 1089 (41.7%) radiographs showed healthy periodontium without periodontal bone loss.

Periodontal bone status and oral hygiene status

Table (I) shows the frequency of periodontal bone status in relation to oral hygiene status. The frequency of patients with healthy periodontium was found mostly in those with good oral hygiene and dramatically declined with fair and poor oral hygiene (p = 0.000). The frequency of patients with mild-to-moderate periodontitis and those with severe periodontitis was rising progressively with oral hygiene worsening and mostly with poor oral hygiene (p = 0.000). The Pearson correlation value (r = -0.689) indicated a significant negative correlation between oral hygiene status and periodontitis development and severity.

Table 1. Frequency of periodontal bone status in relation to oral hygiene status

*Significant at p value < 0.05

X² chi square test

Periodontal bone status and smoking

Table (II) shows the frequency of periodontal bone status in relation to smoking. The frequency of patients with healthy periodontium was statistically greater in non-smokers than smokers (p = 0.000). In contrast, the frequency of patients with mild-to-moderate periodontitis and those with severe periodontitis was statistically greater in smokers than non-smokers (p = 0.000). The Pearson correlation value (r= 0.794) indicated a significant positive correlation between smoking and the severity of periodontitis.

Table 2. Frequency of periodontal bone status in relation to smoking

*Significant at p value < 0.05
X² chi square test

Periodontal bone status and associated systemic disease

Table (III) shows the frequency of periodontal bone status in relation to associated systemic disease. The frequency of patients with healthy periodontium was statistically greater in those without associated systemic disease than those with associated systemic disease (p = 0.000). Conversely, the frequency of patients with mild- to-moderate periodontitis and those with severe periodontitis was significantly greater in those with associated systemic disease than those without associated systemic disease (p = 0.000). Moreover, the frequency of diabetic patients with mild-to-moderate and severe periodontitis (15.7% and 13.2% respectively) was statistically greater than hypertensive patients (8.3% and 6.7% respectively). The Pearson correlation value (r= 0.479) showed a significant positive correlation between the association of systemic diseases and the severity of periodontitis.

Table 3. Table 3. Frequency of periodontal bone status in relation to associated systemic disease

*Significant at p value < 0.05
X² chi square test

Discussion

The present study was conducted to evaluate the prevalence and correlation of periodontal bone status to associated risk factors among patients attended to Umm Al-qura university dental teaching hospital during the year 2019 using panoramic radiographs. Panoramic radiographs were used in this study as they are taken routinely before examination to all patients attending the hospital for any kind of dental services, whereas full- mouth periapical and bite wing radiographs are taken adjunctively only to a small number of patients who will be treated in the comprehensive care clinic for full-mouth rehabilitation. The author tried to take as large sample size as possible to be a true representative of the Makkah population. Besides, it had been reported that panoramic and intraoral radiographic periodontal bone loss measurements had been evidenced to be clinically coinciding [18]. Moreover, only high-quality panoramic images having all the scores with 3 or 4 numerical grading based on the criteria submitted by Sabarudin and Tiau [16] were used in this study.

Genetics, stress, smoking, systemic diseases and poor oral hygiene are risk factors that had been well demonstrated in the literature to be implicated in periodontal disease initiation and progression [19]. The current study revealed that 56.7% of the study population presented with different forms of periodontitis had fair to poor oral hygiene and a significant negative correlation was found between oral hygiene status and the evolution of periodontitis, which advocates improving oral hygiene status to minimize the risk of acquiring periodontal disease. Earlier studies reported coincident results that fair to poor oral hygiene increases the risk of periodontitis by two- to five-fold [20,21]. This could be due to pathogenic bacterial dental biofilm implication in tissue destruction as well as their ability to provoke an inflammatory immune host response that leads to the release of inflammatory mediators involved in alveolar bone resorption and periodontal tissue damage.

The results of the present study showed a significant difference between smokers and non-smokers in all patients with different periodontal bone status and a significant positive correlation between smoking and the development and severity of periodontal bone loss. These results are in line with several epidemiological and clinical studies that confirmed an adverse impact of smoking on periodontal health [22,23]. Smoking adversely alters the host’s response via impairing neutrophils functions, decreasing fibroblast proliferation and collagen production, vasoconstrictive effects, as well as increasing collagenase and osteoclastic activity [24]. Furthermore, clinical attachment loss and bone resorption was reported to be two to five times greater in smokers than non- smokers [25].

In the current study, the frequency of patients with mild-to-moderate periodontitis and those with severe periodontitis was significantly greater in those with associated systemic disease than those without associated systemic disease. Diabetes mellitus and hypertension were the only systemic diseases involved in the present study, as they are the disorders most commonly reported to have a relationship with periodontal disease in the literature. The significant positive correlation between the association of systemic diseases and periodontal bone loss in this study was consistent with previous studies suggesting that these systemic diseases exaggerate periodontal destruction [26,27].

Chronic inflammation may be the main mechanism linking diabetes and periodontitis. Many studies suggest that diabetes produces a state of chronic inflammation. The level of circulating tumor necrosis factor (TNF) in diabetic patients was found to be higher than that in non-diabetic patients, and the inflammatory level in different tissues was also higher and mainly manifested as increased vascular permeability and inflammatory cell infiltration [28]. Moreover, it has been shown that chronic hyperglycemia might activate various mechanisms that result in oxidative stress, augmented inflammation and apoptosis [29].

Conversely, periodontal disease could exert an adverse impact on glycemic control in diabetic patients. Periodontitis could cause increased systemic amounts of TNF-α, interleukin-6 and C-reactive protein along with the resultant enhanced systemic inflammation, which might contribute to insulin resistance. Moreover, periodontitis was reported to increase oxidative stress, which leads to cytokine imbalance and immune dysfunction. As a result, HbA1c levels were elevated in the blood and glucose transporter-4 receptor transcription was reduced, resulting in impaired insulin secretion, which might lead to chronic hyperglycemia [30]. Additionally, periodontal therapy was found to significantly reduce glycated hemoglobin levels in diabetic patients through the significant reduction of systemic inflammation levels, which might restore insulin sensitivity, thereby improving glycemic control [31].

Most of the systematic reviews and meta analyses studies reported a positive association between hypertension and periodontitis. Whether the relationship between periodontitis and hypertension is causal or casual is uncertain. Periodontitis and hypertension share common denominators, such as smoking, older age, overweight/ obesity and stress. However, a common genetic background involving genes entailed in the immune function was demonstrated [32]. The same allele was found to be correlated with both enhanced level of blood pressure and periodontitis documenting a causal genetic relationship between hypertension and periodontitis which implicated the immune system. A high-salt diet, environmental provocative for hypertension, taken for one week was found to diminish neutrophils antibacterial responses through increasing glucocorticoid production which results in immunosuppression [33].

Similarly, various studies have documented that hypertensive patients exhibit a more severe periodontal status [34]. Clinical and experimental evidence suggests that this bond might exist because hypertension causes microcirculatory ischemia, altered bacterial composition of the biofilm, enhanced inflammation and increased oxidative stress. On the other hand, periodontitis might lead to increased chronic systemic inflammation with increased inflammatory biomarkers and endothelial dysfunction, which might increase the risk of developing hypertension. Likewise, periodontitis was found to be associated with a higher likelihood of uncontrolled hypertension despite the administration of antihypertensive medications [35]. Additionally, periodontal therapy was reported to present a parallel improvement in blood pressure profile after treatment [32], proving that inflammation could be a plausible link between hypertension and periodontitis.

The present study has some limitations in that it is a single-center study, and its results cannot be generalized since hospital patients yield greater estimates of the disease than field studies. Panoramic radiography does not reveal the extent of involvement on the facial and lingual surfaces and lacks accurate imaging of osseous defects three-dimensionally. Moreover, other factors that might have influenced systemic conditions and hence periodontal disease severity was not described, such as glycemic control, the duration since diabetes had been diagnosed, abdominal obesity, stress and salt intake.

Conclusion

A significant positive correlation exists between periodontal bone loss and smoking, fair-to-poor oral hygiene as well as diabetes mellitus and hypertension. Radiographic assessment of periodontal bone loss is a rapid and accessible tool in periodontitis screening studies.

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