Association of antimicrobial and clinical efficacy: periodontitis therapy with minocycline microspheres.

OBJECTIVE: The objective of this study was to investigate the association between the antimicrobial and clinical efficacy of minocycline hydrochloride microspheres when used adjunctively with scaling and root planing. METHODS: 127 subjects with moderate-to-advanced chronic periodontitis were randomly assigned to receive either minocycline microspheres plus scaling and root planing (n = 62) or scaling and root planing alone (n = 65). Deoxyribose nucleic acid analysis and clinical data were obtained at baseline and 30 days after treatment. End points included changes in the mean sum of red complex bacteria, pocket depth, number of deep pockets, bleeding on probing, and clinical attachment level from baseline to day 30. Regression analysis determined the association between microbiological and clinical efficacy. RESULTS: Minocycline microspheres plus scaling and root planing reduced pocket depth, the number of deep pockets and bleeding on probing, and increased clinical attachment level significantly more than scaling and root planing alone (p < 0.05). Comparing minocycline microspheres plus scaling and root planing with scaling and root planing alone, the number needed to treat for a 2 mm pocket depth reduction difference was 6.5. Pocket depth reduction correlated significantly with a decrease in the numbers and proportions of red complex bacteria. Minocycline microspheres significantly improved all clinical parameters compared to scaling and root planing alone. CONCLUSIONS: The addition of minocycline microspheres to scaling and root planing led to a greater reduction in the proportions and numbers of red complex bacteria. The reduction in pocket depth was significantly correlated with the reduction of the proportions and numbers of red complex bacteria. Additionally, there were statistically greater improvements in all clinical parameters examined.

Periodontal disease status in gullah african americans with type 2 diabetes living in South Carolina.

BACKGROUND: African Americans have a disproportionate burden of diabetes. Gullah African Americans are the most genetically homogeneous population of African descent in the United States, with an estimated European admixture of only 3.5%. This study assessed the previously unknown prevalence of periodontal disease among a sample of Gullah African Americans with diabetes and investigated the association between diabetes control and the presence of periodontal disease. METHODS: Two hundred thirty-five Gullah African Americans with type 2 diabetes were included. Diabetes control was assessed by percentage of glycosylated hemoglobin (HbA1c) and divided into three categories: well controlled, <7%; moderately controlled, 7% to 8.5%; and poorly controlled, >8.5%. Participants were categorized as healthy (no clinical attachment loss [AL] or bleeding on probing) or as having early periodontitis (clinical AL > or =1 mm in at least two teeth), moderate periodontitis (three sites with clinical AL > or =4 mm and at least two sites with probing depth [PD] > or =3 mm), or severe periodontitis (clinical AL > or =6 mm in at least two teeth and PD > or =5 mm in at least one site). Observed prevalences of periodontitis were compared to rates reported for the National Health and Nutrition Examination Survey (NHANES) studies. RESULTS: All subjects had evidence of periodontal disease: 70.6% had moderate periodontitis and 28.5% had severe disease. Diabetes control was not associated with periodontal disease. The periodontal disease proportions were significantly higher than the reported national prevalence of 10.6% among African Americans without diabetes. CONCLUSION: Our sample of Gullah African Americans with type 2 diabetes exhibited a higher prevalence of periodontal disease compared to African Americans, with and without diabetes, as reported in NHANES III and NHANES 1999-2000.

The Periodontitis and Vascular Events (PAVE) pilot study: recruitment, retention, and community care controls.

BACKGROUND: Population-based clinical and laboratory studies have reported findings providing support for a possible relationship between periodontal disease and cardiovascular disease. The Periodontitis and Vascular Events (PAVE) pilot study was conducted to investigate the feasibility of a randomized secondary prevention trial to test whether treatment of periodontal disease reduces the risk for cardiovascular disease. METHODS: Five clinical centers recruited participants who had documented coronary heart disease and met study criteria for periodontal disease. Eligible participants were randomized to receive periodontal therapy provided by the study or community dental care. Follow-up telephone calls and clinic visits were planned to alternate at 3-month intervals after randomization, with all participants followed until at least the 6-month clinic visit. Participants were followed for adverse events and periodontal and cardiovascular outcomes. RESULTS: A total of 303 participants were randomized. Recruitment that involved active participation of a cardiologist with responsibility for the patients worked best among the strategies used. Of those who had not withdrawn, 93% completed the 6-month contact. During follow-up, 11% of the 152 subjects in the community dental care group reported receiving periodontal therapy outside of the study. CONCLUSIONS: If appropriate recruitment strategies are used, this pilot study demonstrated that it is feasible to conduct a secondary prevention trial of periodontal therapy in patients who have had coronary heart disease. If a community dental care group is used, sample size estimation needs to take into account that a non-trivial proportion of participants in this group may receive periodontal therapy outside of the study.

The Periodontitis and Vascular Events (PAVE) pilot study: adverse events.

BACKGROUND: During the last 15 years, a substantial number of population-based, clinical, laboratory, and animal studies have been published that reported findings on the relationship between periodontal disease and cardiovascular disease. The Periodontitis and Vascular Events (PAVE) pilot study was conducted to investigate the feasibility of a randomized secondary prevention trial to test whether treatment of periodontal disease reduces the risk for cardiovascular disease. This article describes the occurrence of adverse events during the pilot study. METHODS: The PAVE pilot study was a multicenter, randomized trial comparing periodontal therapy to community dental care. Baseline and follow-up clinic visits included a periodontal examination; blood, subgingival plaque, and crevicular fluid specimen collection; and medical and dental histories. Telephone follow-up contacts were scheduled to occur 3 months after randomization and every 6 months thereafter to assess adverse events or endpoints. RESULTS: Cardiovascular adverse events occurred with similar frequency (23 versus 24 [P = 0.85] in the community control and the treatment groups, respectively). There were 15 serious adverse events (SAEs) with a non-significantly higher percentage occurring in the community care group (6.6% versus 3.3%; P = 0.19). A time-to-event analysis of patterns of SAEs indicated that subjects in the periodontal therapy group tended to be less likely to experience an SAE over the entire 25 months of the study. CONCLUSION: For those individuals who remained in the study, it appears that provision of periodontal scaling and root planing treatment to individuals with heart disease resulted in a similar pattern of adverse events as seen in the community care group, which also received some treatment.

Mechanical therapy with adjunctive minocycline microspheres reduces red-complex bacteria in smokers.

BACKGROUND: Smoking increases the risk for periodontal disease and reduces the healing response. We examined the antimicrobial and clinical effects of scaling and root planing (SRP) with and without minocycline HCl 1 mg microspheres (MM) relative to smoking status in subjects with periodontitis. METHODS: A total of 127 subjects (46 never smokers, 44 former smokers, and 37 current smokers) with moderate to advanced periodontitis were randomized to receive MM + SRP (N = 62) or SRP alone (N = 65). Subgingival plaque samples collected at baseline and day 30 were examined for the presence of 40 periodontal bacteria by DNA probe analysis. RESULTS: MM + SRP reduced red-complex bacteria (RCB) numbers and proportions to a greater extent than SRP alone, irrespective of smoking status. RCB numbers were not reduced by SRP in current smokers. The difference in the reduction in numbers of RCB by SRP relative to MM + SRP in current smokers was statistically significant (P <0.05). Numbers and proportions of orange complex bacteria (OCB) were reduced in all groups treated with MM + SRP. Proportions of OCB increased in current smokers treated with SRP alone. In current smokers, MM + SRP significantly reduced probing depth (PD), increased clinical attachment level (CAL), and reduced bleeding on probing (BOP) to a greater extent than SRP alone (P <0.05). CONCLUSIONS: SRP alone was ineffective at reducing numbers or proportions of RCB or OCB in current smokers, whereas MM + SRP significantly reduced both. MM + SRP also improved PD, BOP, and CAL to a greater extent than SRP alone independent of smoking status.

Minocycline HCl microspheres reduce red-complex bacteria in periodontal disease therapy.

BACKGROUND: The objective of this trial was to measure the antimicrobial effects of a minocycline HCl microsphere (MM) local drug-delivery system when used as an adjunct to scaling and root planing (SRP). DNA probe analysis for 40 bacteria was used to evaluate the oral bacteria of 127 subjects with moderate to advanced chronic periodontitis. METHODS: Subjects were randomly assigned to either SRP alone (N = 65) or MM + SRP (N = 62). The primary endpoints of this study were changes in numbers and proportions of the red-complex bacteria (RCB) and the sum of Porphyromonas gingivalis, Tannerella forsythia (formally T. forsythensis), and Treponema denticola relative to 40 oral bacteria at each test site from baseline to day 30. Numbers of RCB from the five test sites were averaged to provide a value for each subject. RESULTS: MM + SRP reduced the proportion of RCB by 6.49% and the numbers by 9.4 x 10(5). The reduction in RCB proportions and numbers by SRP alone (5.03% and 5.1 x 10(5), respectively) was significantly less. In addition, MM + SRP reduced probing depth by 1.38 mm (compared to 1.01 mm by SRP alone), bleeding on probing was reduced by 25.2% (compared to 13.8% by SRP alone), and a clinical attachment level gain of 1.16 mm (compared to 0.80 mm by SRP alone) was achieved. CONCLUSION: These observations support the hypothesis that RCBs are responsible for periodontal disease and that local antimicrobial therapy using MM + SRP effectively reduces numbers of RCBs and their proportions to a greater extent than SRP alone.

Study design for calibration of clinical examiners measuring periodontal parameters.

BACKGROUND: We present an approach to examiner calibration study design where the number of calibration subjects is based on a specified margin of error (half-width of the 95% confidence interval [CI]) of the percentage of agreement (exact and within 1 mm) for both intra- and interexaminer reliability assessments. METHODS: An experienced standard examiner (S) trained three dental hygienists (A, B, and C) in correct procedures for obtaining a variety of periodontal measures. Duplicate measurements of probing depth (PD [mm]) and the free gingival margin to the cemento-enamel junction (CEJ-GM [mm]) were obtained in a pilot study to design a formal examiner calibration study, where sample sizes were adjusted for the effects of within-subject clustering of binary indices of agreement. RESULTS: Within-subject clustering of agreement indices resulted in an approximate four-fold increase in the variance of the estimates of percentage of agreement with the standard. PD and CEJ-GM percentage of exact agreement measurements (95% CI) for each examiner-standard pair, respectively, were as follows: AS=55% (48%, 61%) and 70% (62%, 78%); BS=52% (45%, 59%) and 73% (63%, 82%); and CS=55% (50%, 61%) and 72% (65%, 79%). The corresponding 95% CIs unadjusted for the effects of clustering underestimated the margin of error associated with the estimates of exact agreement by as much as 57% for PD and 68% for CEJ-GM. CONCLUSION: Failure to account for dependence among site-level agreement indices results in a false sense of precision in the resulting reliability estimates and can lead to faulty inference.

Supragingival plaque may modify the effects of subgingival bacteria on attachment loss.

BACKGROUND: Bacterial interactions in response to local and systemic factors may explain important features of the pathogenesis of periodontal disease. This study evaluates the role of supragingival plaque level on the relationship between subgingival microorganisms and the risk of attachment loss. METHODS: The study population consisted of 386 white women aged 45 years and older who had at least seven teeth. Subgingival plaque samples were taken from the mesio-buccal surface of six maxillary and six mandibular teeth using paper point technique. The samples were pooled, and immunofluorescence microscopy was performed to identify the following target microorganisms: Actinobacillus actinomycetemcomitans (Aa), Tannerella forsythensis (Tf), Campylobacter rectus (Cr), Prevotella intermedia (Pi), Capnocytophaga species (Cs), Porphyromonas gingivalis (Pg), Eubacterium saburreum (Es), and Fusobacterium nucleatum (Fn). The presence or absence of supragingival plaque and clinical attachment loss (CAL) were assessed at the same 12 sites where subgingival plaque samples were taken. The association of each microorganism with CAL was tested using multiple logistic regressions controlling for age, smoking status, and diabetes. Odds ratios (OR) and their 95% confidence intervals (CI) were calculated. RESULTS: At low supragingival plaque levels, only the presence of Pg was significantly associated with CAL (OR: 6.41, 95% CI: 1.30 to 31.70); all remaining microorganisms were also associated with increased but non-significant risk of CAL. At high supragingival plaque levels, the presence of Tf (OR: 2.40, 95% CI: 1.42 to 4.04) and Pg (OR: 3.71, 95% CI: 1.63 to 8.42) was significantly associated with increased risk of attachment loss. By contrast, the presence of Cs (OR: 0.55, 95% CI: 0.30 to 1.01) and Es (OR: 0.35, 95% CI: 0.15 to 0.82) was associated with decreased risk of attachment loss. Fn, Pi, and Cr were not significantly associated with CAL at either low or high supragingival plaque levels. CONCLUSIONS: This study suggests that the association of certain subgingival microorganisms with CAL changes in relation to supragingival plaque levels in older adult women. It also suggests that the overall effect of dental plaque is a function of the balance between pathogenic and other microorganisms that colonize this environment. Therefore, all microorganisms in the biofilm, including those with no apparent association with overt disease and those with negative associations, may play roles in the pathogenesis of periodontal diseases.

Is periodontitis associated with oral neoplasms?

BACKGROUND: Infections have been suggested in the etiology of oral cancer. This study was carried out to evaluate the effect of periodontal disease on oral soft tissue lesions. METHODS: A total of 13,798 subjects aged 20 years and older with at least six natural teeth and who participated in the Third National Health and Nutrition Examination Survey (NHANES III) constituted the study population. Severity of periodontal disease was represented by clinical attachment loss (CAL) and was dichotomized as < or =1.5 mm versus >1.5 mm according to its distributions in the NHANES III population. Three separate dependent variables were employed: 1) tumor (non-specific); 2) precancerous lesions; and 3) any oral soft tissue lesion. The independent effect of CAL on those three dependent variables was assessed by weighted multiple logistic regression analyses adjusting for the effects of number of filled teeth, number of decayed teeth, presence of prosthesis, age, gender, race/ethnicity, education, tobacco, alcohol, occupational hazard, and interaction term "tobacco*occupational hazard." Odds ratios (OR) and their 95% confidence intervals (CI) were calculated. RESULTS: CAL was not related to the presence of any soft tissue lesion (OR = 1.09, 95% CI: 0.91 to 1.31), but was specifically related to the presence of tumor (OR = 4.57, 95% CI: 2.25 to 9.30) and precancerous lesions (OR = 1.55, 95% CI: 1.06 to 2.27). CONCLUSION: This study suggests associations between periodontal disease and the risk for precancerous lesions and tumors generating a hypothesis about a possible relationship between periodontal disease and oral neoplasms. Prospective or well-designed case-control studies with histologically confirmed incident oral cancer cases are necessary to confirm this relationship.

A proposed model linking inflammation to obesity, diabetes, and periodontal infections.

BACKGROUND: Obesity is an important risk factor for diabetes, cardiovascular disease, and periodontal disease. Adipocytes appear to secrete proinflammatory cytokines which may be the molecules linking the pathogenesis of these diseases. We evaluated the relationship between obesity, periodontal disease, and diabetes mellitus insulin resistance as well as the plasma levels of tumor necrosis factor alpha (TNFalpha) and its soluble receptors (sTNFalpha) to assess the relationship of inflammation to obesity, diabetes, and periodontal infections. METHODS: The relationship between periodontal disease, obesity, and insulin resistance was examined in the Third National Health and Nutrition Examination Survey (NHANES III). In a population of 12,367 non-diabetic subjects, the variable body mass index (BMI) was used as an assessment of obesity and periodontal disease was assessed by mean clinical attachment loss. The plasma levels of TNFalpha and sTNFalpha were assessed in subsets of 1,221 adults from Erie County, New York, who represented the highest and lowest quartile of BMI. These subjects had extensive periodontal and medical evaluations. RESULTS: In the NHANES III portion of the study, BMI was positively related to severity of periodontal attachment loss (P <0.001). Weighted multiple logistic regressions showed that this relationship is likely mediated by insulin resistance, since overweight individuals (with BMI >or=27 kg/m2) with high levels of insulin resistance (IR) exhibited an odds ratio of 1.48 (95% confidence interval 1.13 - 1.93) for severe periodontal disease as compared to overweight subjects with low IR. In the Erie County adult population, the highest levels of TNFalpha and sTNFalpha receptors were found in those individuals in the highest quartile of BMI. A positive correlation of TNFalpha levels with periodontal disease was found only in those in the lowest quartile of BMI. CONCLUSIONS: Obesity is a significant predictor of periodontal disease and insulin resistance appears to mediate this relationship. Furthermore, obesity is associated with high plasma levels of TNFalpha and its soluble receptors, which in turn may lead to a hyperinflammatory state increasing the risk for periodontal disease and also accounting in part for insulin resistance. Further studies of the molecular basis of insulin resistance and its relationship to diabetes, periodontal disease, and obesity are necessary to fully test the hypothesis that adipocyte production of proinflammatory cytokines is a pathogenic factor linking obesity to diabetes and periodontal infections.

Periodontal disease and the incidence of tooth loss in postmenopausal women.

BACKGROUND: The role of periodontal disease as a predictor of incident tooth loss in postmenopausal women has not been determined. The aim of this cohort study was to determine the extent of the association between baseline periodontal status and incident tooth loss in a population of postmenopausal women. METHODS: The study population included 106 dentate white postmenopausal women who participated in a cross-sectional study between 1989 and 1991 who were willing and eligible to have a repeat examination after 10 to 13 years. At baseline, full-mouth assessment of periodontal status was performed clinically and radiographically. Assessment of tooth loss during follow- up was assessed clinically by a periodontist. Odds ratio (OR) and its 95% confidence interval (CI) for each periodontal variable was obtained from separate multiple logistic regression analyses adjusting for the effect of age, household income, smoking, hormone therapy, snack consumption, and number of decayed teeth. RESULTS: Sixty-one (57.5%) subjects lost at least one tooth during follow-up. Mean tooth loss per person was 1.81 +/- 2.77. After adjusting for confounders, each millimeter of alveolar bone loss at baseline increased the risk of tooth loss 3-fold (OR = 3.26; 95% CI: 1.60 to 6.64). The risk of tooth loss also increased 2.5 times for each millimeter of clinical attachment loss (OR = 2.50; 95% CI: 1.24 to 5.07). Probing depth (OR = 2.53; 95% CI: 0.98 to 6.53), gingival bleeding (OR = 1.99; 95% CI: 0.21 to 18.94), calculus (OR = 2.05; 95% CI: 0.91 to 4.61), and plaque (OR = 0.70; 95% CI: 0.13 to 3.34) were not significantly associated with incident tooth loss. CONCLUSION: Periodontal disease, especially measured by alveolar bone loss, is a strong and independent predictor for incident tooth loss in postmenopausal women.

Reproducibility of probing depth measurement using a constant-force electronic probe: analysis of inter- and intraexaminer variability.

BACKGROUND: Probing depth (PD) is a commonly used method to determine periodontal disease severity in both treating and evaluating disease progression. Agreement among examiners collecting data in scientific investigations is necessary to establish reliable criteria for determining levels of periodontal attachment loss. The objective of our study was to evaluate inter- and intraexaminer variability of PD measurements among study examiners using a constant force periodontal probe, and to compare the variability of tooth-mean and quadrant-mean. METHODS: Three examiners, who had been previously trained and calibrated, performed measurements on 20 volunteers. Intra- and interexaminer variability of sites was determined by means of standard error of measurement (SE). Data analysis included determination of error for both quadrant mean and tooth mean. RESULTS: PD measurements for the quadrant-mean were used to calculate the intraexaminer variability, resulting in a mean (SD) value for an SE of 0.40 mm (+/- 0.02). Interexaminer variability for quadrant mean was 0.16 mm (+/- 0.02). For tooth-mean SE, the intraexaminer variability values were equal to 0.38 mm (+/- 0.07), and interexaminer variability equal to 0.24 mm (+/- 0.05). CONCLUSIONS: All three examiners participating in our study were able to obtain reliable measurements for PD, using the constant force electronic probe. Reproducibility did not vary appreciably when using the whole quadrant mean compared to the tooth mean. These trained examiners were able to provide reproducible measures under 0.5 mm.

Periodontal disease and recurrent cardiovascular events in survivors of myocardial infarction (MI): the Western New York Acute MI Study.

BACKGROUND: Periodontal disease and cardiovascular disease (CVD) have been the focus of much research, but little is known about their roles in the recurrent event risk in patients with CVD. This study investigates whether periodontal disease is related to recurrent CVD events and mortality in survivors of incident myocardial infarction (MI). METHODS: Participants (668 males and 216 females; mean age: 54 + or - 8.5 years) were recruited (1997 through 2004) from two western New York county hospitals and completed an interviewer-administered questionnaire regarding lifestyle habits, clinical measurements, and a comprehensive dental examination. The periodontal disease status was measured by the mean clinical attachment loss (AL). Follow-up surveys assessed hospitalizations or medical procedures; cardiovascular events were validated by medical records. A National Death Index (NDI) Plus search was conducted. The outcome was recurrent fatal and non-fatal cardiovascular events (International Classification of Diseases codes 390 to 450). RESULTS: After an average follow-up of 2.9 years, 154 events were reported. Among never-smokers, the adjusted hazard ratio (95% confidence interval) for the mean clinical AL (millimeters) was 1.43 (1.09 to 1.89). No associations were found in ever-smokers (clinical AL by smoking interaction: P <0.05). CONCLUSION: These findings indicate that periodontal disease may be an important factor in determining recurrent cardiovascular events in MI patients and not merely a marker for the effects of cigarette smoking.

A Proposed Model Linking Inflammation to Obesity, Diabetes, and Periodontal Infections.

BACKGROUND: Obesity is an important risk factor for diabetes, cardiovascular disease, and periodontal disease. Adipocytes appear to secrete proinflammatory cytokines which may be the molecules linking the pathogenesis of these diseases. We evaluated the relationship between obesity, periodontal disease, and diabetes mellitus insulin resistance as well as the plasma levels of tumor necrosis factor alpha (TNFα) and its soluble receptors (sTNFα) to assess the relationship of inflammation to obesity, diabetes, and periodontal infections. METHODS: The relationship between periodontal disease, obesity, and insulin resistance was examined in the Third National Health and Nutrition Examination Survey (NHANES III). In a population of 12,367 non-diabetic subjects, the variable body mass index (BMI) was used as an assessment of obesity and periodontal disease was assessed by mean clinical attachment loss. The plasma levels of TNFα and sTNFα were assessed in subsets of 1,221 adults from Erie County, New York, who represented the highest and lowest quartile of BMI. These subjects had extensive periodontal and medical evaluations. RESULTS: In the NHANES III portion of the study, BMI was positively related to severity of periodontal attachment loss (P <0.001). Weighted multiple logistic regressions showed that this relationship is likely mediated by insulin resistance, since overweight individuals (with BMI ≥27 kg/m2 ) with high levels of insulin resistance (IR) exhibited an odds ratio of 1.48 (95% confidence interval 1.13 - 1.93) for severe periodontal disease as compared to overweight subjects with low IR. In the Erie County adult population, the highest levels of TNFα and sTNFα receptors were found in those individuals in the highest quartile of BMI. A positive correlation of TNFα levels with periodontal disease was found only in those in the lowest quartile of BMI. CONCLUSIONS: Obesity is a significant predictor of periodontal disease and insulin resistance appears to mediate this relationship. Furthermore, obesity is associated with high plasma levels of TNFα and its soluble receptors, which in turn may lead to a hyperinflammatory state increasing the risk for periodontal disease and also accounting in part for insulin resistance. Further studies of the molecular basis of insulin resistance and its relationship to diabetes, periodontal disease, and obesity are necessary to fully test the hypothesis that adipocyte production of proinflammatory cytokines is a pathogenic factor linking obesity to diabetes and periodontal infections.

Alcohol consumption and periodontal disease. The Third National Health and Nutrition Examination Survey.

OBJECTIVE: This study was carried out to evaluate the effect of alcohol consumption on the severity of periodontal disease. MATERIAL AND METHODS: This cross-sectional study employed 13,198 subjects of the Third National Health and Nutrition Examination Survey (NHANES III) aged 20 and older who have at least six natural teeth. Alcohol intake was represented both as a continuous variable and dichotomized using 5, 10, 15, and 20 drinks/week as cut-points. Periodontal disease was represented by clinical attachment loss (CAL) and was assessed both as a continuous variable and dichotomized as <1.5 mm and >/=1.5 mm. Independent effect of alcohol on CAL was assessed by weighted multiple linear and logistic regression analyses adjusting simultaneously for the effects of age, gender, race, education, income, smoking, diet, diabetes, gingival bleeding, number of remaining teeth. RESULTS: There was a significant linear relationship between number of drinks per week and log CAL (p=0.0001). Odds ratios for the risk of attachment loss using 5, 10, 15, and 20 drinks/week as cut-points were 1.22 [1.02-1.47], 1.39 [1.13-1.71], 1.54 [1.22-1.93], and 1.67 [1.25-2.23], respectively. CONCLUSION: Alcohol consumption may be associated with increased severity of CAL in a dose-dependent fashion. Prospective studies and studies of mechanism are needed to confirm the role of alcohol as a risk factor for periodontal disease.

Response to Periodontal Therapy in Diabetics and Smokers.

Diabetics and smokers are two patient groups at high risk for periodontal disease who also exhibit impaired wound healing and, therefore, constitute two different groups in whom the relationship between host-parasite interaction, outcome of periodontal therapy, and systemic factors is best represented. The results of two independent clinical trials involving treatment of periodontal disease in diabetics and smokers are presented. A new treatment regimen-for the management of periodontal disease associated with diabetes mellitus is proposed. This treatment approach incorporates both antimicrobial agents and pharmacological modulation of the host response. Elimination of periodontal infection and reduction of periodontal inflammation in diabetic patients resulted in a significant short-term reduction in the concentration of glycosylated hemoglobin (HbA1c ). Control of chronic infections and modulation of the host response offer a new therapeutic approach in the management of patients with both diabetes and periodontal disease. The effect of smoking on periodontal healing is also discussed. The clinical and microbiological response of smokers to non-surgical periodontal therapy is compared to non-smokers. In addition, possible mechanisms whereby diabetes mellitus and cigarette smoking increase the severity of periodontal disease are discussed. J Periodontol 1996;67:1094-1102.

The Role of Osteopenia in Oral Bone Loss and Periodontal Disease.

Osteoporosis and periodontitis are diseases which affect a large number of women and men, with incidence increasing with advancing age. Osteopenia is a reduction in bone mass due to an imbalance between bone resorption and formation, favoring resorption, resulting in demineralization and leading to osteoporosis. Osteoporosis is a disease characterized by low bone mass and fragility and a consequent increase in fracture risk. Periodontitis is characterized by inflammation of the supporting tissues of the teeth, resulting in resorption of the alveolar bone as well as loss of the soft tissue attachment to the tooth and is a major cause of tooth loss and edentulousness in adults. The relationship of osteopenia to oral bone loss and periodontal disease has been addressed in a limited number of studies. A review of current knowledge regarding this relationship is presented. Interpretation of the literature is complicated by the variety of methods used to assess osteopenia, oral bone mass, and periodontitis, as well as varying definitions of outcomes of interest. Results of a previously unpublished study are presented which suggest that severity of osteopenia is related to loss of alveolar crestal height and tooth loss in post-menopausal women. The literature on the relationship among these disorders is limited and points to the need for additional studies which thoroughly evaluate the influence of potential confounding factors to further define the relationship between low bone mineral density and periodontal disease in larger populations. Clearer understanding of this relationship may aid health care providers in their efforts to detect and prevent osteoporosis and periodontal disease. Increased dialogue among medical and dental professionals will be increasingly important in achieving and maintaining patients' optimal health. J Periodontol 1996;67:1076-1084.

Reproducibility of Probing Depth Measurements Using a Constant-Force Electronic Probe: Analysis of Inter- and Intraexaminer Variability.

BACKGROUND: Probing depth (PD) is a commonly used method to determine periodontal disease severity in both treating and evaluating disease progression. Agreement among examiners collecting data in scientific investigations is necessary to establish reliable criteria for determining levels of periodontal attachment loss. The objective of our study was to evaluate inter- and intraexaminer variability of PD measurements among study examiners using a constant force periodontal probe, and to compare the variability of tooth-mean and quadrant-mean. METHODS: Three examiners, who had been previously trained and calibrated, performed measurements on 20 volunteers. Intraand interexaminer variability of sites was determined by means of standard error of measurement (SE). Data analysis included determination of error for both quadrant mean and tooth mean. RESULTS: PD measurements for the quadrant-mean were used to calculate the intraexaminer variability, resulting in a mean (SD) value for an SE of 0.40 mm (± 0.02). Interexaminer variability for quadrant mean was 0.16 mm (± 0.02). For tooth-mean SE, the intraexaminer variability values were equal to 0.38 mm (± 0.07), and interexaminer variability equal to 0.24 mm (± 0.05). CONCLUSIONS: All three examiners participating in our study were able to obtain reliable measurements for PD, using the constant force electronic probe. Reproducibility did not vary appreciably when using the whole quadrant mean compared to the tooth mean. These trained examiners were able to provide reproducible measures under 0.5 mm. J Periodontol 2003;74:1736-1740.