Predicting Periodontitis at State and Local Levels in the United States.

The objective of the study was to estimate the prevalence of periodontitis at state and local levels across the United States by using a novel, small area estimation (SAE) method. Extended multilevel regression and poststratification analyses were used to estimate the prevalence of periodontitis among adults aged 30 to 79 y at state, county, congressional district, and census tract levels by using periodontal data from the National Health and Nutrition Examination Survey (NHANES) 2009-2012, population counts from the 2010 US census, and smoking status estimates from the Behavioral Risk Factor Surveillance System in 2012. The SAE method used age, race, gender, smoking, and poverty variables to estimate the prevalence of periodontitis as defined by the Centers for Disease Control and Prevention/American Academy of Periodontology case definitions at the census block levels and aggregated to larger administrative and geographic areas of interest. Model-based SAEs were validated against national estimates directly from NHANES 2009-2012. Estimated prevalence of periodontitis ranged from 37.7% in Utah to 52.8% in New Mexico among the states (mean, 45.1%; median, 44.9%) and from 33.7% to 68% among counties (mean, 46.6%; median, 45.9%). Severe periodontitis ranged from 7.27% in New Hampshire to 10.26% in Louisiana among the states (mean, 8.9%; median, 8.8%) and from 5.2% to 17.9% among counties (mean, 9.2%; median, 8.8%). Overall, the predicted prevalence of periodontitis was highest for southeastern and southwestern states and for geographic areas in the Southeast along the Mississippi Delta, as well as along the US and Mexico border. Aggregated model-based SAEs were consistent with national prevalence estimates from NHANES 2009-2012. This study is the first-ever estimation of periodontitis prevalence at state and local levels in the United States, and this modeling approach complements public health surveillance efforts to identify areas with a high burden of periodontitis.

Self-reported measures for surveillance of periodontitis.

The purpose of this study was to evaluate the performance of self-reported measures in predicting periodontitis in a representative US adult population, based on 2009-2010 National Health and Nutrition Examination Survey (NHANES) data. Self-reported gum health and treatment history, loose teeth, bone loss around teeth, tooth not looking right, and use of dental floss and mouthwash were obtained during in-home interviews and validated against full-mouth clinically assessed periodontitis in 3,743 US adults 30 years and older. All self-reported measures (> 95% item response rates) were associated with periodontitis, and bivariate correlations between responses to these questions were weak, indicating low redundancy. In multivariable logistic regression modeling, the combined effects of demographic measures and responses to 5 self-reported questions in predicting periodontitis of mild or greater severity were 85% sensitive and 58% specific and produced an 'area under the receiver operator characteristic curve' (AUROCC) of 0.81. Four questions were 95% sensitive and 30% specific, with an AUROCC of 0.82 in predicting prevalence of clinical attachment loss ≥ 3 mm at one or more sites. In conclusion, self-reported measures performed well in predicting periodontitis in US adults. Where preferred clinically based surveillance is unattainable, locally adapted variations of these self-reported measures may be a promising alternative for surveillance of periodontitis.

Prevalence of periodontitis in adults in the United States: 2009 and 2010.

This study estimated the prevalence, severity, and extent of periodontitis in the adult U.S. population, with data from the 2009 and 2010 National Health and Nutrition Examination Survey (NHANES) cycle. Estimates were derived from a sample of 3,742 adults aged 30 years and older, of the civilian non-institutionalized population, having 1 or more natural teeth. Attachment loss (AL) and probing depth (PD) were measured at 6 sites per tooth on all teeth (except the third molars). Over 47% of the sample, representing 64.7 million adults, had periodontitis, distributed as 8.7%, 30.0%, and 8.5% with mild, moderate, and severe periodontitis, respectively. For adults aged 65 years and older, 64% had either moderate or severe periodontitis. Eighty-six and 40.9% had 1 or more teeth with AL ≥ 3 mm and PD ≥ 4 mm, respectively. With respect to extent of disease, 56% and 18% of the adult population had 5% or more periodontal sites with ≥ 3 mm AL and ≥ 4 mm PD, respectively. Periodontitis was highest in men, Mexican Americans, adults with less than a high school education, adults below 100% Federal Poverty Levels (FPL), and current smokers. This survey has provided direct evidence for a high burden of periodontitis in the adult U.S. population.

Accuracy of NHANES periodontal examination protocols.

This study evaluates the accuracy of periodontitis prevalence determined by the National Health and Nutrition Examination Survey (NHANES) partial-mouth periodontal examination protocols. True periodontitis prevalence was determined in a new convenience sample of 454 adults ≥ 35 years old, by a full-mouth "gold standard" periodontal examination. This actual prevalence was compared with prevalence resulting from analysis of the data according to the protocols of NHANES III and NHANES 2001-2004, respectively. Both NHANES protocols substantially underestimated the prevalence of periodontitis by 50% or more, depending on the periodontitis case definition used, and thus performed below threshold levels for moderate-to-high levels of validity for surveillance. Adding measurements from lingual or interproximal sites to the NHANES 2001-2004 protocol did not improve the accuracy sufficiently to reach acceptable sensitivity thresholds. These findings suggest that NHANES protocols produce high levels of misclassification of periodontitis cases and thus have low validity for surveillance and research.

Microbiota associated with experimental peri-implantitis and periodontitis in adult Macaca mulatta monkeys.

This study examines the microbiota associated with the progression of experimental peri-implantitis and periodontitis induced concurrently in partially edentulous adult monkeys. Root-form and plate-form implants with fixed prosthesis in place for at least 12 months and their corresponding opposite molar teeth were ligated for 6 months. The microbiota in plaque around these ligated dental implants and molars were studied at 0, 1, 2, 3, and 6 months post-ligation. Plaque samples were analyzed by dark-field microscopy and selective and non-selective culture. Putative periodontal pathogens were detected as a major component of the microbiota cultured from plaque samples obtained from experimental peri-implantitis sites. Overall, the types and relative proportions of putative periodontal pathogens in plaque associated with ligature-induced peri-implantitis and ligature-induced periodontitis were similar. Only levels of anaerobic Actinomyces and spirochetes were significantly different between both sites. Spirochete levels were significantly higher at peri-implantitis sites when compared with levels at periodontitis sites after 6 months, and spirochete levels increased significantly between 0 and 6 months post-ligation at implant sites. Levels of spirochetes correlated significantly with probing depth and bone loss at peri-implantitis sites. Overall, Actinomyces levels were higher at periodontitis sites. Porphyromonas species were not detected continuously as part of the peri-implantitis microbiota. In conclusion, this study finds that the microbiota associated with the progression of experimental peri-implantitis and periodontitis occurring concurrently in partially edentulous mouths are similar.

Microbiota associated with consecutively placed loaded root-form and plate-form implants in adult Macaca mulatta monkeys.

This study describes the microbiota associated with consecutively placed root-form and plate-form implants placed in similar mandibular arches of rhesus (Macaca mulatta) monkeys and loaded with similar prostheses. The teeth and implants were maintained by monthly scaling and root planing. Twenty-four round (root-form) and 24 flat (plate-form) implants were placed in the loci of #18 and #31 in 36 adult monkeys. The microbiota around implants and mandibular molar teeth were studied quarterly from the day prostheses were loaded (Day 0) for 12 months. The microbiota were characterized by culture and dark field microscopy. Overall, levels of putative peri-implant pathogens studied declined or remained statistically unchanged at implant or mandibular molar sites. Levels of spirochetes and Porphyromonas species declined at mandibular molar teeth but increased at dental implant sites. Levels of A. actinomycetemcomitans declined significantly at implants and mandibular tooth sites during the period. No statistically significant difference was detected between levels of microorganisms colonizing root-form and plate-form implants. This study finds no significant increase in levels of putative peri-implant pathogens at root-form and plate-form implants sites in the first 12 months after prosthetic loading when maintained by monthly scaling.

Hemin-induced modifications of the antigenicity and hemin-binding capacity of Porphyromonas gingivalis lipopolysaccharide.

Previous studies have shown that the physical, biochemical, and antigenic properties of the bacterial outer membrane are profoundly influenced by the growth environment. In the present study, the effects of growth in hemin-replete (H+) and hemin-depleted (H-) media on the lipopolysaccharide (LPS) of the oral pathogen Porphyromonas gingivalis were investigated. Our studies show that LPS from P. gingivalis cultured in H+ media (H+LPS) expressed additional low-molecular-mass antigens, as determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blot (immunoblot) analysis. Particularly evident was a 26-kDa antigen (26 LPSC) that was lost from the LPS upon transfer of P. gingivalis into H- media. The loss of the 26 LPSC was accompanied by a marked reduction in the hemin-binding capacity of the LPS. The 26 LPSC was refractory to Coomassie blue staining and proteinase K digestion. H+LPS from strain W50/BE1, a nonpigmented pleiotropic strain, lacked the 26 LPSC and did not bind hemin. Polyclonal antiserum raised to whole-cell antigens of P. gingivalis A7436, W83, and HG405 grown in H+ media, but not in H- media, recognized the 26 LPSC in the purified H+LPS from any of the three strains. The immunoreactivities of sera from humans with (n = 24) or without (n = 25) periodontitis to the 26 LPSC and other H+LPS determinants were analyzed by Western blot. Overall, 75% of adult periodontitis patient sera reacted with multiple bands in the H+LPS stepladder, particularly in the range of 14 to 27 kDa. In contrast, only 20% of control sera reacted faintly with H+LPS bands in the range 27 to 34 kDa. The 26 LPSC was recognized by over 40% of sera from adult patients with periodontitis and none of the healthy control sera. Taken together, these results suggest that the antigenicity and hemin-binding properties of P. gingivalis LPS can be modified by growth in H+ media.

Experimental model for Porphyromonas gingivalis infection in animals.

A virulence model suitable for studying the dynamics of Porphyromonas gingivalis infection, including the pathogenicity of P. gingivalis in experimentally induced infections of multiple organs was developed using mouse and hamster. Virulence of P. gingivalis strains was expressed contrastingly in subcutaneous (sc) infection in the Murine abscess model (MAM) and the Hamsters abscess model (HAM). Subcutaneous infection in the MAM was characterized by a gravity abscess, spreading from the primary site of inoculation downwards, frequently erupting as a secondary lesion. In contract, s.c. P. gingivalis infection in HAM was characterized as a palpable localized abscess at the primary site of inoculation. When the Semi-Solid Agar (SSA) was added to the mono-culture of P. gingivalis, reproducibility of infection in both models was enhanced. P. gingivalis culture supplemented with haemin, or combined with oral Actinomyces viscosus had its virulence overtly enhanced and often fatal in the MAM. Menadione, Eh reducing agents and mixture with the Streptococcus or A. neaslundii did not potentiate virulence in either mode. Transtracheal challenge of the lungs of hamster with P. gingivalis initiated an early pneumonitis and later sequelae of necrosis and abscess formation. Also, abscess was induced by direct inoculation of P. gingivalis in the muscles, liver and testes, but did not induce intra-abdominal abscesses. In conclusion, the HAM applied with the SSA procedure caused a localized P. gingivalis tissue infection with practical advantages for quantitative and qualitative studies of P. gingivalis infections. This study also demonstrates the pathogenic potential of P. gingivalis by reproducing similar infections in multiple anatomical sites.

Clinical and microbiological observations of early polytetrafluoroethylene membrane exposure in guided bone regeneration. Case reports in primates.

Premature membrane exposure at one week is described in 3 Macaca mulatta monkeys as part of a sequence of experiments on guided bone regeneration. Clinical sequelae include redness, edema, and tissue slough. Bacteroides fragilis, Streptococcus pneumoniae, Prevotella intermedia, and Staphylococcus intermedius were detected at all prematurely exposed sites. Pseudomonas maltophilia, Strept, pneumoniae, and P. intermedia were the predominant organisms detected and consisted of more than 10% of the total anaerobic count.

Succession of putative peri-implant pathogens after root-form and plate-form implant placement in partially dentate adult monkeys.

This report describes the succession of putative peri-implant pathogens in partially dentate monkeys after dental implantation and prosthetic reconstruction. Tooth and implant (6 root-end form, 4 blade-vent implants) sites in eight monkeys were monitored microbiologically and clinically during the pre-implant stage, abutment connection stage, bridge placement stage, and three and six months after the bridge placement stage. Tooth and implant sites were cleaned monthly post-extraction. Microbiological studies included dark field microscopy, selective and non-selective culture, and primary phenotypic characterization of culture isolates. After implant surgery, the median proportion of several putative peri-implant pathogens studied were significantly elevated. Following fixture placement, P. intermedia replaced P. melaninogenica as the predominant Black Pigmented Anaerobic Bacilli (BPAB) in the mouth. After abutment connection stage, levels of P. intermedia, A. actinomycetemcomitans, F. nucleatun, Haemophilus sp. and spirochetes were significantly elevated at implant and tooth sites. Three months after bridge installations, P. intermedia and A. actinomycetemcomitans remained significantly elevated at implant sites. At six months after bridge installation, levels of P. intermedia, F. nucleatum and A. actinomycetemcomitans declined significantly relative to levels at three months. Porphyromonas sp. and spirochetes were not significantly elevated although their levels correlated with gingival redness. P. intermedia, Porphyromonas sp. and spirochetes levels correlated significantly with probing depth. Correlation was detected between P. gingivalis and spirochetes; and between A. actinomycetemcomitans and F. nucleatum. Our studies show a transitional increase in levels of several organisms resembling putative pathogens of human peri-implant infection, associated with implant placements in partially edentulous mouths and supports early prophylactic interventions to control their levels.

Sub-gingival microflora in Macaca mulatta species of rhesus monkey.

The Macaca mulatta species of rhesus monkey is one of several non-human primate (nhp) models for periodontal disease. This report presents the bacteriology of the gingival sulci in M. mulatta monkeys. Three sub-gingival sites (maxillary right central incisor, the disto-buccal of the mandibular left second molar and mesio-buccal of the mandibular right second molar) of 9 monkeys were evaluated clinically before scaling and 7 days after scaling. Plaque samples were obtained from sub-gingival sites before clinical examination and studied bacteriologically by dark field microscopy, selective and non-selective culture, and by primary phenotypic characterizations of culture isolates. Several gingival sites presented with mild gingival inflammation. Anaerobic and facultatively anaerobic bacteria were the predominant flora colonizing the gingival sulci. The major microbial groups were Haemophilus species (100% of sites; percentage of total anaerobic count (TAC): 21-51), Peptostreptococcus micros (89%, 7.5-29.5), Actinomyces sp. (85%, 7-27), Fusobacterium nucleatum (90%, 5-8), Actinobacillus actinomycetemcomitans (73%, 1.3-12), black-pigmented anaerobic rods (BPAR) (80%, 0.6-6.5) and oral streptococci (80%, 0.2-1.0). Microbial groups detected less often were Wolinella sp. (66%, 0-2.6), Capnocytophaga sp. (30%), Eikenella corrodens (4.7%, 0), Campylobacter sp. (28%, 0-0.1) and spirochetes (4.7%, 0-0.07). Seven days after gingival sites were scaled, the plaque score and indices for gingival inflammation declined significantly. The gingival flora after scaling were characterized by lower proportions of the Actinomyces sp., P. micros and BPAR; and increased proportions of the oral streptococci, relative to pre-scaling levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Rapid presumptive identification of human black pigmented Bacteroides species.

A simple and reliable technique is described for the rapid presumptive identification of black pigmented Bacteroides species of human origin. This method involved a microtitration technique that detected the hydrolysis of specific chromogenic enzyme substrates and haemagglutination of sheep erythrocytes. Pure cultures of black pigmented Bacteroides strains, representing the eight human species, were successfully differentiated and identified within 4 h by the identification scheme developed with this method. This is a highly reproducible method and the scheme should be useful in laboratories lacking the sophisticated equipment often needed for the identification of black pigmented Bacteroides.

Coaggregation of black-pigmented Bacteroides species with other oral bacteria.

Coaggregation of Bacteroides gingivalis and other black-pigmented bacteroides with several oral bacteria was studied with "reagent" strains specially prepared by methods that have been described previously. B. gingivalis coaggregated with Veillonella, Capnocytophaga and Actinomyces spp., but not with any Streptococcus spp. Coaggregation of B. gingivalis with other bacteria was inhibited and reversed by lactose. Of the asaccharolytic black-pigmented bacteroides, only B. gingivalis demonstrated any coaggregation with other bacteria, whereas within the saccharolytic species, B. loescheii showed a marked ability to coaggregate with several species of oral bacteria. This property of coaggregation by B. gingivalis may be an important factor in the pathogenesis of periodontal infections.

Cytotoxic activity of crude extracts of Bacteroides gingivalis.

The cytotoxic activities of culture supernates, crude cell extracts and cell-wall materials of Bacteroides gingivalis were investigated in vitro. Each component was cytotoxic to Vero cells and, to a lesser extent, Wi 38 cells. The cytotoxic agents had similar effects on the cell lines to butyric acid, propionic acid and a partially-purified trypsin-like protein extracted from a clinical isolate of B. gingivalis; the effects were eliminated by heat. Cytotoxic materials obtained from young cultures were more susceptible to heat than those from older cultures. The heart-labile substance inside and outside the bacterial cell in young cultures of B. gingivalis may contribute to its overall cytotoxic activity.

Quantity of soap as a variable in handwashing.

The purposes of this study were to assess the effect of two quantities (1 mL or 3 mL) of four different handwashing products on reductions in log colony-forming units (CFU) from the hands and to determine the amount of liquid soap used for handwashing by personnel in one hospital. First, 40 subjects were assigned by block randomization to one of four handwashing products (4% chlorhexidine gluconate in a detergent base, two alcohol hand rinses, and a liquid, nonantimicrobial soap) to be used in either 1 mL or 3 mL amounts per wash. Each subject washed his or her hands 15 times per day for five days. After one and five days of handwashing there were significant reductions over baseline in log CFU between handwashing products (P less than 0.001). Additionally, subjects using 3 mL of antiseptic soap had significantly greater reductions in log CFU than those using 1 mL (P less than 0.001). Among subjects using control liquid soap there was no such dose response. Second, a survey of 47 members of a hospital nursing staff from nine specialty areas and ten individuals in the general population was conducted to measure amounts of two liquid soaps used for handwashing. Amount of soap ranged from 0.4 to 9 mL per handwash. Personnel working in clinical areas where patients were at high risk for nosocomial infection used significantly more soap than did others (P less than 0.05). We conclude that quantity of soap used for handwashing is one variable influencing the microbial counts on hands, and that the quantity of soap used by health care personnel varies considerably.

In-vitro anti-microbial susceptibility of clinical isolates of pathogenic bacteria to ten antibiotics including phosphomycin.

The minimum inhibitory concentration (MIC) of ten antibiotics was determined for various bacterial pathogens isolated from clinical specimens in a Lagos hospital. The in-vitro activity of penicillin and tetracycline was not very impressive and a similarity was noticed in the resistance patterns of these two antibiotics, while the activity in vitro of the relatively more toxic aminoglycosides and chloramphenicol was high for Gram-negative rods. Ceftazidime demonstrated the highest activity in vitro against all pathogens studied. Cefoxitin, cefuroxime and phosphomycin demonstrated an impressive activity in vitro. Clindamycin was very active against strains of Staphylococcus aureus. beta-lactamase production amongst these strains was studied and the clinical significance of this and their MIC results are discussed.

Efficacy of alcohol-based hand rinses under frequent-use conditions.

Fifty volunteers randomly assigned to one of five hand washing agents (10 subjects per agent)--a nonantiseptic liquid soap (control), an antiseptic hand rinse containing 60% isopropyl alcohol (IPA) with emollients (Alc A), an antiseptic hand rinse containing 70% IPA and 0.5% chlorhexidine gluconate with emollients (Alc B), an antiseptic containing 4% chlorhexidine gluconate and 4% IPA (CHG), and 70% IPA--washed their hands 15 times per day for 5 days under supervision by using a standardized technique and measured amounts of test agent. Microbiologic samples of hand flora were obtained at base line and after hand washes 1 and 15 on test days 1 and 5. After the initial hand wash there were significant reductions over base line in aerobic and anaerobic log CFU among those using Alc A, CHG, and IPA. By the end of the first day of hand washing (15 washes), there were 2-log or greater reductions in aerobic counts among subjects using all antiseptics, but no significant reductions in controls. By the end of day 5, all agents produced significant reductions in aerobic (P = 0.0002) and anaerobic (P = 0.002) counts over control soap. Subject assessment of effects of hand washing on the skin and overall satisfaction varied significantly by product (P = 0.04 and 0.05, respectively). We conclude that alcohol-based hand rinses are highly efficacious, and such products are recommended as a health care personnel hand wash, particularly when sink and running water are inaccessible.