An Ecoregion-Based Approach to Protecting Half the Terrestrial Realm.

We assess progress toward the protection of 50% of the terrestrial biosphere to address the species-extinction crisis and conserve a global ecological heritage for future generations. Using a map of Earth's 846 terrestrial ecoregions, we show that 98 ecoregions (12%) exceed Half Protected; 313 ecoregions (37%) fall short of Half Protected but have sufficient unaltered habitat remaining to reach the target; and 207 ecoregions (24%) are in peril, where an average of only 4% of natural habitat remains. We propose a Global Deal for Nature-a companion to the Paris Climate Deal-to promote increased habitat protection and restoration, national- and ecoregion-scale conservation strategies, and the empowerment of indigenous peoples to protect their sovereign lands. The goal of such an accord would be to protect half the terrestrial realm by 2050 to halt the extinction crisis while sustaining human livelihoods.

Periodontal health of children with type 1 diabetes mellitus in Kuwait: a case-control study.

OBJECTIVE: The aim of this study was to evaluate periodontal health in children diagnosed with type 1 diabetes mellitus. SUBJECTS AND METHODS: Periodontal health was clinically examined and compared in 95 children diagnosed with type 1 diabetes and 61 healthy control subjects (4-14 years old). Plaque index, gingival index, clinical attachment loss and bleeding on probing were assessed on the 6 Ramfjord index teeth. Diabetes history was recorded based on information provided by the physician from the medical record of each diabetic child. Diabetes history included date of diagnosis, diabetes duration, age at diagnosis, latest reading for glycosylated hemoglobin and any existing diabetes complications. Data were analyzed using the Statistical Package for Social Science software, version 18. 'Periodontitis' was defined as at least one site with clinical attachment loss >2 mm on at least 2 teeth. RESULTS: Sixty-two of the diabetic children (65%) had poor compliance with dental care, and 42 of them (44%) had never visited the dentist before. The children with type 1 diabetes mellitus had a significantly higher plaque index and gingival index and more bleeding on probing than control subjects (p < 0.001). In the diabetic group, periodontitis was significantly associated with longer duration of diabetes (odds ratio 2.230, confidence interval 1.308-3.801; p = 0.003) and older age at diagnosis of diabetes (odds ratio 1.838, confidence interval 1.091-3.096; p = 0.022). CONCLUSIONS: Periodontal disease in young patients with type 1 diabetes was more evident than in those without diabetes. These data showed that diabetes duration may play a significant role in the progression of periodontal disease in diabetic children.

Diabetes mellitus and periodontal health: dentists' knowledge.

OBJECTIVES: There is a strong body of evidence to support the relationship between periodontal diseases and diabetes mellitus. Unless dental practitioners are aware of this link, they cannot apply the information to their daily practice. The aim of the study was, therefore, to evaluate the knowledge of dental practitioners concerning the effect of diabetes on periodontal health. SUBJECTS AND METHODS: This was a cross-sectional survey of randomly selected dental practitioners in Kuwait. Participants were asked about specific periodontal complications which they believed that patients diagnosed with diabetes were more susceptible to. RESULTS: A total of 220 dental practitioners (133 general dental practitioners and 87 dental specialists) participated in the study. Less than 60% of all study participants reported that tooth loss due to periodontal reasons and periodontal abscess were frequent among diabetic patients. Dental specialists, especially periodontists, were significantly more aware of periodontal complications associated with diabetes. Factors significantly associated with having knowledge about the effect of diabetes on periodontal health in logistic regression analysis were dentists who were older and those who were specialists. CONCLUSIONS: The results of this study indicate that knowledge about the effects of diabetes on periodontal health among this sample of dental practitioners is generally low, and dentists may underestimate the outcomes of periodontal diseases in diabetic patients.

Assessment of pain associated with the surgical placement of dental implants.

BACKGROUND: Despite increasing popularity and established predictability, limited information is available on the pain experience associated with the surgical placement of dental implants. The aim of this study was to assess patient-reported pain during and after implant insertion and to evaluate factors associated with this pain. METHODS: This was a prospective, two-center study of adult patients scheduled for the surgical placement of one or more implants. Surgery was performed by an experienced periodontist or periodontal graduate students. Mean pain scores were evaluated with the use of a 0 to 10 scale during surgery and 24 hours and 1, 6, and 12 weeks after surgery and compared between the two centers. The association of pain scores at each time-point with patient-, operator-, and surgery-related factors was examined through univariate and multiple logistic regression analyses. RESULTS: Five hundred ten implants were placed in 234 patients during the study. Mean pain scores were highest at 24 hours after surgery (2.01 +/- 0.11) and decreased gradually thereafter. Pain intensity was mild for the majority of patients at all time-points, and only a few patients had moderate or severe pain. Regression analysis revealed that factors significantly associated with pain after 24 hours included operator experience (odds ratio [OR] = 24.86), pain during surgery (OR = 2.81), and female gender (OR = 2.51). After 1 week, pain levels were associated significantly with having pain after 24 hours (OR = 38.69) and having a surgical template used during surgery (OR = 1.11). CONCLUSIONS: Pain experienced by patients following the surgical placement of dental implants was generally mild and gradually decreased with time. Operator experience, female gender, surgical difficulty, and pain at earlier time-points were associated significantly with patient reports of pain.

Barriers to seeking preventive dental care by Kuwaiti adults.

OBJECTIVE: The aim of this study was to assess the prevalence of preventive dental visits and to identify self-reported barriers for this practice among Kuwaiti adults. MATERIALS AND METHODS: A self-administered, anonymous, structured questionnaire was distributed to a random sample of Kuwaiti nationals 18 years of age or older recruited from all six health districts of Kuwait. A total of 2,400 questionnaires were distributed. Multiple logistic regression analysis was performed to identify factors independently associated with not having a preventive dental visit for more than 1 year. RESULTS: Of the 2,400 questionnaires, 1,925 (80.2%) were completed. Of these, 620 (32.2%) had a dental visit within the previous 6 months, 504 (26.2%) between 6 and 12 months and 801 (41.6%) more than 12 months ago. The most common reasons for the last dental visits were pain or a dental emergency, need for restorative treatment, and an examination/prophylaxis. The strongest factors for not having preventive visits were not using a mouthrinse daily, flossing less than once a day, dental fear, belief that there is no need for visits unless pain was present, brushing the teeth less than twice a day, and believing that appointments are too far ahead. Also older respondents (>30 years), female gender, and those having only high school education or less were less likely to visit a dentist for preventive reasons. CONCLUSION: More than half of the studied population reported not having had a preventive visit for more than 1 year. Unfavorable self-care habits, dental fear and belief that visiting a dentist is necessary only for pain relief were the strongest factors for the nonattendance behavior.

Dental patient awareness of smoking effects on oral health: Comparison of smokers and non-smokers.

OBJECTIVES: The negative effects of cigarette smoking on oral health are well established, yet few studies assessed patient awareness of such effects. The aim of this study was to examine differences in dental patient knowledge and awareness of the effects of smoking on oral health between smokers and non-smokers. METHODS: Adult patients from 12 dental centers in Kuwait were asked to complete a 14-point self-administered structured questionnaire on the effects of smoking on oral health in this cross-sectional survey. Significant associations between oral health knowledge, smoking status, and sociodemographic variables were examined with univariate analysis and logistic regression. RESULTS: A total of 1012 subjects participated (response rate = 84.3%). The prevalence of smoking was 29.3%. Fewer smokers than non-smokers thought that oral health and smoking are related (92.2% vs. 95.8%; P = 0.020), and that smoking affected oral cancer (52.4% vs. 66.8%; P < 0.001), periodontal health (72% vs. 78%; P = 0.040), or tooth staining (86.1% vs. 90.9%; P = 0.018). Logistic regression analysis showed smokers to be significantly less aware of the oral health effects of smoking than non-smoking patients (OR=1.51; 95% CI: 1.05-2.16; P = 0.025). CONCLUSION: Smoking dental patients are significantly less aware of the oral health effects of smoking than non-smokers. Comparative studies in other populations may be warranted to ascertain the validity of these results.

Factors associated with self-reported halitosis in Kuwaiti patients.

OBJECTIVES: Oral malodor is a common complaint of dental patients, yet limited data is available on the actual prevalence of this condition. The aim of this study was to assess the prevalence and factors associated with self-reported halitosis in Kuwaiti patients. METHODS: This was a cross-sectional study of Kuwaiti adults using a 19-point self-administered structured questionnaire on self-perception of halitosis. Significant associations between self-reported oral malodor and sociodemographic, medical history, and oral hygiene variables were examined with multiple logistic regression analysis. RESULTS: A total of 1551 subjects participated (response rate=86.2%). The prevalence of self-reported halitosis was 23.3%. Use of the toothbrush less than once daily was the factor most strongly associated with self-perceived halitosis (OR=2.68; 95% CI=1.83-3.92; p<0.001). Other factors significantly associated with self-perceived halitosis included current or past smoking (OR=2.51), female gender (OR=1.54), being 30 years of age or older (OR=1.35), having high school education or less (OR=1.41), history of chronic sinusitis (OR=1.58) or gastrointestinal disorders (OR=1.73), never using miswak (OR=1.56), and never using dental floss (OR=1.33). CONCLUSION: Inadequate oral hygiene practices were the factors most strongly associated with self-reported oral malodor in this sample of Kuwaiti patients. Other factors with significant associations included history of gastrointestinal tract disorders, chronic sinusitis, older age, female gender, and lower education levels.

Association of periodontal disease severity with diabetes duration and diabetic complications in patients with type 1 diabetes mellitus.

OBJECTIVES: The association between periodontal disease severity and diabetes complications and duration in patients with type 1 diabetes mellitus (DM) was investigated in this comparative cross-sectional study. MATERIALS AND METHODS: Twenty-nine patients with type 1 DM of < or = 5 years duration were compared with 43 patients with > 5 years duration of DM. Complete medical history and examination and assessments of retinopathy, neuropathy, and nephropathy were performed, followed by assessments of the plaque index (PI), pocket depth (PD), clinical attachment level (CAL), and the number of missing teeth by one examiner masked to the diabetic status of the patients. RESULTS: The number of missing teeth (4 versus 0) and CAL (2.88 vs 2.56 mm) were significantly higher in patients with longer DM duration (p < 0.05). For patients with > or = 5 years DM duration, periodontal disease severity was also greater in patients with one or more DM complications, as assessed by the number of missing teeth (17 vs 0; p < 0.001) and CAL (4.74 vs 2.81 mm; p < 0.01). Stepwise multiple regression analysis associated the presence of > or = 1 DM complications and smoking history with severe attachment loss (CAL > or = 7 mm; p < 0.001). CONCLUSION: Periodontal disease severity is associated with both DM duration and the presence of DM complications in this sample of type 1 DM patients.

Risk indicators for tooth loss due to periodontal disease.

BACKGROUND: Several risk indicators for periodontal disease severity have been identified. The association of these factors with tooth loss for periodontal reasons was investigated in this cross-sectional comparative study. METHODS: All extractions performed in 21 general dental practice clinics (25% of such clinics in Kuwait) over a 30-day period were recorded. Documented information included patient age and gender, medical history findings, dental maintenance history, toothbrushing frequency, types and numbers of extracted teeth, and the reason for the extraction. Reasons were divided into periodontal disease versus other reasons in univariate and binary logistic regression analyses. RESULTS: A total of 1,775 patients had 3,694 teeth extracted. More teeth per patient were lost due to periodontal disease than for other reasons (2.8 +/- 0.2 versus 1.8 +/- 0.1; P <0.001). Factors significantly associated with tooth loss due to periodontal reasons in logistic regression analysis were age >35 years (odds ratio [OR] 3.45; 95% confidence interval [CI] 2.79 to 4.26), male gender (OR 1.42; 95% CI 1.17 to 1.73), never having periodontal maintenance (OR 1.48; 95% CI 1.23 to 1.78), never using a toothbrush (OR 1.81; 95% CI 1.49 to 2.20), current or past smoking (OR 1.56; 95% CI 1.28 to 1.91), anterior tooth type (OR 3.23; 95% CI 2.57 to 4.05), and the presence of either of the following medical conditions: diabetes mellitus (OR 2.64; 95% CI 2.19 to 3.18), hypertension (OR 1.73; 95% CI 1.41 to 2.13), or rheumatoid arthritis (OR 4.19; 95% CI 2.17 to 8.11). CONCLUSION: Tooth loss due to periodontal disease is associated with the risk indicators of age, male gender, smoking, lack of professional maintenance, inadequate oral hygiene, diabetes mellitus, hypertension, rheumatoid arthritis, and anterior tooth type.

Treatment of periodontal disease in a patient with Ehlers-Danlos syndrome. A case report and literature review.

BACKGROUND: Ehlers-Danlos syndrome (EDS) designates a heterogeneous group of connective tissue disorders characterized by skin elasticity, tissue fragility, and chronic joint pain. Dental findings have been reported with some types of EDS. This case report describes the periodontal findings in a patient with a previously undiagnosed EDS type VIII. METHODS: Diagnostic aids utilized included microbial testing, histological examination, gingival crevicular fluid (GCF) analysis for the levels of C-telopeptide pyridinoline cross-links (ICTP), and genetic counseling. Periodontal treatment consisted of mechanical debridement and adjunctive antibiotic therapy. RESULTS: Genetic counseling and clinical presentation confirmed the diagnosis of EDS type VIII. Periodontal treatment led to marked clinical improvements and GCF levels of the bone resorptive marker ICTP were significantly reduced. The patient and her siblings are currently pursuing appropriate medical care and genetic counseling. CONCLUSION: Periodontal involvement may lead to the diagnosis of an underlying systemic condition. Identification of suspected etiological factors of periodontal disease may prove critical for the general well-being of some patients.

Guided tissue regeneration-based root coverage utilizing collagen membranes: technique and case reports.

Gingival recession defects have traditionally been treated with various grafting procedures. Recently, guided tissue regeneration with collagen membranes has shown promising results. This article reviews the rationale, indications, contraindications, and clinical methods for the use of bioabsorbable collagen membrane barriers. Several properties make collagen membranes attractive candidates for use as barriers in guided tissue regeneration-based root coverage procedures. These include the inhibition of epithelial migration and promotion of new connective tissue attachment; the ability to aggregate platelets, thereby facilitating wound stabilization and maturation; the promotion of cellular migration and wound closure; the elimination of the need for reentry surgery; and the ability to augment tissue thickness. Cases are presented to illustrate the surgical principles and techniques.

Knowledge about the association between periodontal diseases and diabetes mellitus: contrasting dentists and physicians.

BACKGROUND: There is a strong body of evidence that supports the relationship between periodontal diseases and diabetes mellitus (DM). Many patients are unaware of the effects of diabetes on oral health. Whether health care providers are applying the information about the link between DM and periodontal diseases in their practices depends on the levels of their knowledge of such valuable information. Therefore, the aims of this study are to evaluate the knowledge of dental and medical practitioners concerning the effects of diabetes on periodontal health and to find out if the practitioners are aware of the bidirectional relationship between periodontal diseases and DM. METHODS: This was a cross-sectional survey of randomly selected general practitioners practicing in Kuwait. Participants were asked about specific periodontal complications that they believed patients diagnosed with diabetes were more susceptible to, and their awareness of the bidirectional relationship between diabetes and periodontal diseases was evaluated. RESULTS: A total of 510 general practitioners (232 physicians and 278 dentists) participated in the study. There were no significant differences between the two groups regarding mean ages, sex distributions, and years in practice. Only 50% of all study participants believed that patients with diabetes were more susceptible to tooth loss because of periodontal diseases than were individuals without diabetes. Dentists were significantly more aware of gingival bleeding, tooth mobility, and alveolar bone resorption than were physicians. Factors significantly associated with having knowledge about the effects of diabetes on periodontal health in logistic regression analyses were older age, female sex, and the dental profession. CONCLUSION: The knowledge about the association between periodontal diseases and DM should be increased among dental and medical practitioners to effectively prevent, manage, and control diabetes and periodontal diseases.

Self-reported oral hygiene habits and oral health problems of Kuwaiti adults.

OBJECTIVE: The aims of this study were to examine self-reported oral hygiene habits and oral health problems of a sample of adult Kuwaitis. MATERIALS AND METHODS: A self-administered, anonymous, structured questionnaire was distributed to 2,400 adult Kuwaiti nationals from all 6 governates of Kuwait assessing socio-demographic variables, oral hygiene habits, and oral health problems. RESULTS: Of the 2,400 questionnaires, 1,925 (80.25%) responded. Of these, 62% reported brushing their teeth at least twice daily, while daily use of dental floss was uncommon (11.8%). Adequate toothbrushing habits were significantly associated with female gender, educational level, non-smoking status, and history of recent preventive dental visits (p = 0.001). The majority of subjects reported multiple oral health problems (64.7% with 2 or more and 41.8% with 3 or more). Factors associated with multiple oral health complaints included younger age, smoking, not having a recent preventive dental visit, and brushing the teeth less than twice daily. CONCLUSIONS: Less than two-thirds of the sampled adult Kuwaitis followed the recommended toothbrushing frequency of twice daily or more, and the majority of subjects have not had a preventive dental visit in the previous 6 months. Furthermore, most subjects reported multiple oral health problems that are mostly preventable through adequate oral hygiene habits and regular preventive dental visits.

Reasons for tooth extraction in Kuwait.

OBJECTIVES: To investigate reasons for tooth extraction and its association with age and gender in Kuwait. SUBJECTS AND METHODS: A record of all tooth extractions performed in 21 general dental practice centers during a 1-month period was logged on specially designed study forms. The patient's age and gender, number of teeth extracted, and the reason(s) for the extraction were recorded. RESULTS: A total of 2,783 teeth were extracted in 1,604 patients (1.73 +/- 0.07 teeth per patient). Caries and periodontal disease were responsible for 43.7 and 37.4% of extractions, respectively. Caries was the principal cause for extraction in patients < or =40 years old (60.7%), while periodontal disease was the main cause of extractions in patients > or =40 years of age (63.0%). Extractions for caries and orthodontic reasons were more common in females, while extractions for periodontal disease were more prevalent in males. Molars and maxillary premolars were more commonly extracted due to caries, while mandibular premolars, and maxillary and mandibular anterior teeth (canines and incisors) were more commonly extracted due to periodontal disease. CONCLUSIONS: The data show that caries is the principal cause for extractions in younger patients, while periodontal disease accounts for the majority of tooth extractions in patients older than 40 years. Furthermore, this study indicates that more teeth per patient are lost to periodontal disease than for any other reason.

Implant recommendation as a replacement option after tooth loss for periodontal reasons.

PURPOSE: The aim of this study was to examine the frequency of implant recommendation by general dental practitioners to patients who had extractions as a result of periodontal disease and factors that influenced their decisions. MATERIALS AND METHODS: Dentists in each of 20 general dental practice centers in Kuwait were asked to document replacement options given to patients after all tooth extractions performed for periodontal reasons within a 30-day period. The association of demographic and medical/dental history variables with the decision to recommend an implant was statistically tested. RESULTS: A total of 711 patients with a mean age +/- of 47.34 +/- 0.45 years (range 18-96) had 2202 teeth extracted for periodontal reasons during the study period. Only 21 implants for 12 patients were offered as a replacement option (1.7%). Factors significantly associated with a less likelihood of implant recommendation included older age, male gender, diabetes mellitus, inadequate compliance with regular periodontal maintenance visits, inadequate oral hygiene practices, and anterior tooth types (P < 0.05; chi test). CONCLUSION: Dental implants were rarely recommended to patients losing their teeth for periodontal reasons by general dentists in Kuwait.

Factors associated with implant recommendation for single-tooth replacement.

The use of dental implants for single-tooth replacement has been established as a predictable treatment option; yet, limited data are available as to how frequently this option is recommended to patients. The aim of the present study was to examine the frequency of implant recommendation by general dental practitioners after single-tooth extraction and factors influencing their decision to recommend an implant. All single-tooth extractions performed in 26 general dental practice clinics in Kuwait over a 30-day period were examined. Dentists in these centers used the study form to record demographic data, the type of tooth extracted, reason for extraction, and replacement options presented to the patients. Univariate and logistic regression analyses were used to examine associations between background factors and decisions to recommend implant therapy. A total of 1367 patients (mean age, 37.9 +/- 11.8 years) had an extraction of one tooth during the study period. Forty-three patients were offered implants as a replacement option (3.3% of the total sample; 8.6% of patients who were offered tooth replacement options). Factors associated significantly with the recommendation of an implant by Kuwaiti dentists to their patients included younger age, regular dental maintenance visits, and adequate oral hygiene practices (P < 0.05; binary logistic regression). Dental implant recommendation for single-tooth replacement in the present sample of dentists was low. Factors associated significantly with dentist recommendation of an implant for single-tooth replacement included age, history of dental maintenance, and oral hygiene practices.

Effects of specific nutrients on periodontal disease onset, progression and treatment.

OBJECTIVES: The aim of this paper is to review the available literature pertaining to the effects of specific nutritional elements (e.g. vitamin B-complex, vitamin C and dietary calcium) on general wound healing, periodontal disease status and response to periodontal therapy. METHODS: Critical appraisal of various studies that have evaluated the effects of calcium, ascorbic acid and vitamin B-complex in wound healing and periodontal treatment. RESULTS: Periodontal disease onset, progression and response to therapeutic interventions have been shown to be influenced by several systemic, local and environmental modifying factors. Nutritional supplementation has been suggested as a possible influencing factor on periodontal status and wound healing. Several studies have reported various degrees of association between nutritional elements/supplements and periodontal status, and others have reported possible positive influences of nutritional supplementation on periodontal therapeutic outcomes. Future research needs to more fully explore the presence and strength of association between nutrition and periodontal health. CONCLUSIONS: Data collected from the literature suggests that nutrient supplementation causes minimal or no side effects. However, the efficacy of prophylactic nutrient supplementation for the prevention of the onset and progression of periodontal disease, or for the enhancement of periodontal wound healing, remains to be determined.

Creation of interimplant papillae through a split-finger technique.

PURPOSE: The purpose of this pilot study is to propose a technique, the split-finger approach, to preserve/promote papillae formation. MATERIALS AND METHODS: Twenty-one patients with 39 implants consecutively placed in the maxillary anterior region were evaluated at 6 months to 1 year after prosthodontic restoration. The implants evaluated included 16 single-tooth implants, 1 2-unit implant prosthesis, 2 4-unit tooth implants, 1 6-unit prostheses, and 1 7-unit restoration. The papillae were recorded as 0 = no papillae; 1 = < or =50% of the gingival embrasure height; 2 = >50% but <100% of embrasure height; 3 = 100% closure of the proximal space; and 4 = overgrowth of the interproximal tissue. RESULTS: Data from this pilot study showed no class 0, class 1, or class 4 interproximal papillae after the final restoration. The 16 single-tooth restorations and 32 papillae had an average mesial papilla score of 3 and an average of 2.82 for the distal interproximal space. The average papilla score of the other implant papillae sites were 2.7 at 6 months to 1 year. A lower papilla score was noted in interimplant papillae. CONCLUSIONS: The proposed split-finger technique could serve as a clinically useful alternate procedure to promote/augment papillae formation around dental implants.

Dental implant design and its relationship to long-term implant success.

The purpose of this review is to evaluate the effects of the biomechanical aspects of dental implant design on the quality and strength of osseointegration, the bone-implant interface, and their relationships to the long-term success of dental implants. The engineering design of implants is based on many interrelated factors, including the geometry of the implant, mechanical properties, and the initial and long-term stability of the implant-tissue interface. There is no one "optimal" design criterion. However, implants can be engineered to maximize strength, interfacial stability, and load transfer by using different materials, surfaces, and thread designs. Limited information is currently available in addressing how implant thread design influences the overall implant success. Therefore, this article reviews and discusses design elements of various dental implant systems currently in use as they affect the quality of osseointegration and their relationship to overall long-term success patterns.