ORAL CARE REPORT

Diabetes Mellitus and Tooth Loss

While many oral manifestations of diabetes mellitus (DM) have been described,
there is a large body of evidence identifying
DM as a systemic risk factor for periodontitis.1 DM is the only recognized systemic disease risk factor for periodontitis, and is the
most widely recognized oral complication
of DM.2 Recently, a new report examining
tooth loss in US adults from 40 years of information in the NHANES database has analyzed the effect of DM on tooth loss.3 The data
indicate that adults with DM have lost twice
as many teeth as adults without DM. This
report suggests that tooth loss should also
be recognized as a second major oral manifestation of DM, and again emphasizes the
need for patients and non-dental healthcare
providers to stress the need for regular oral
care for patients with DM.

The Association between DM

and Periodontitis
The association between DM and periodontitis has been extensively researched.
Both are chronic diseases, and it is well accepted that DM is associated with an enhanced
inflammatory response, together with inhibition of periodontal repair, which increases the risk of periodontitis.1,2,4,5 Recent studies provide additional support for the increase
in periodontal disease severity related to the
degree of dysglycemia, and have found
increased tooth loss in patients with pre-diabetes and patients with DM.6-10 Conversely,
there is data supporting the adverse impact
of severe periodontitis on glycemic control
in people with DM;2 however, in a review of
clinical studies, evidence for the impact of
periodontitis on glycemic control and on the
development of DM is considered limited.11

Periodontal Status and Tooth

Loss in Metabolic Syndrome/
Pre-Diabetes
Periodontal status and number of missing teeth were assessed in a study with 1,097
subjects who had been newly diagnosed with

pre-diabetes or DM.6 Subjects also received a

chairside HbA1c test. It was determined that
pre-diabetic subjects experienced more severe
periodontal disease than persons without DM,
and less than patients with DM, with the conclusion that periodontitis and tooth loss are
early complications of diabetes mellitus.6
Findings from a Japanese study also support
increased tooth loss in patients with metabolic syndrome.7 A five-year retrospective study
with 2,107 participants with at least three of
four components of the syndrome (obesity,
fasting glucose, reduced high-density lipoprotein, and elevated triglycerides) experienced
a statistically significant increase in tooth loss
compared to patients who did not have metabolic syndrome (p < 0.05). Overall, tooth loss
was experienced by 10.8% of subjects.7

Pre-diabetic subjects experienced

more severe periodontal disease
than persons without DM, and
less severe periodontal disease
than patients with DM.
Tooth Loss in the
Diabetic Population
In two early investigations, significant
differences in tooth loss were observed for
patients with DM compared to persons without DM. Using US data from the 2004
Behavioral Risk Factor Surveillance System,
a 2007 report concluded that adults with DM
are at increased risk for tooth loss.8 Using
data from 2,508 participants in NHANES
20032004, a second study reported significant differences in the number of missing
teeth in DM versus non-diabetic subjects
(p < 0.01); 28% of participants with DM were
edentulous versus 14% of non-diabetic participants (p < 0.05).9
Summarizing decades of data on tooth loss
for people with DM compared to the general
population, a more robust understanding
Click here to continue to next page

In This Issue
Diabetes Mellitus and Tooth Loss

CLINICAL PRACTICE - Dental

Practice-Based Research Networks

TECHNOLOGY - Use of Lasers

for Periodontal Treatment

DENTISTRY AND HEALTH CARE Oral Manifestations of HIV

Infection in the Era of Highly
Active Anti-Retroviral Therapy

PREVENTIVE DENTISTRY Maintenance of Dental Implants

10

HEALTHCARE TRENDS - The Best

Jobs of 2016: Good News for the
Dental Profession?

11

Educational Objectives
After reading this issue of the Colgate
Oral Care Report and correctly answering the questions in the Continuing
Education Quiz, you will
1. better understand the relationship of
dysglycemia (diabetes and pre-diabetes) to tooth loss, which is another
important oral complication of
diabetes;
2. understand the benefits of participation
in a Dental Practice-Based Research
Network, including increased emphasis
on evidence-based dental care;
3. become familiar with the latest evidence on the clinical benefits and risks
associated with the use of lasers in periodontal therapy;
4. know why dental professionals can play
an important role in the early detection and diagnosis of HIV/AIDS and in
monitoring the outcomes of highly
active anti-retroviral therapy; and
5. better understand the necessity for
stressing to implant patients the importance of regular maintenance visits and
personal oral hygiene to minimize and
manage peri-implant disease.

Volume 26, Number 2, 2016

Providing Continuing Education as a Service to Dentistry Worldwide

ORAL CARE REPORT

2
of tooth loss data has emerged.3 In the interval
from 1971 to 2012, for patients with DM, tooth
loss decreased from an average of 11.2 teeth
to 6.6 teeth (p < 0.001), and for persons without DM, from an average of 9.4 teeth to 3.4
teeth (p < 0.001; see Figure 1). In 2012, the
percent of persons with a functional dentition
was 68.8% for those with DM and 86.6% for
those without DM (at least 21 teeth), versus
38.6% and 52.3%, respectively, in 1971
(p < 0.001; see Figure 2).3 Differences between
ethnic/racial groups were also observed. NonHispanic blacks with DM were found to be at
increased risk for tooth loss compared to
Mexican-Americans or non-Hispanic whites
with DM (p < 0.001), and had a lower percent
of patients with a functional dentition.3
n 1971
n 2012

11.2
9.4
6.6

3.4
with DM

without DM

Figure 1. Tooth loss rates in 1971 and 2012 in patients with

and without DM.

n 1971
n 2012
68.8%

86.6%
52.3%

38.6%

with DM

without DM

Figure 2. Percentage of patients with and without DM having

a functional dentition.

A French study on subjects with and without DM also found significant differences in
rates of tooth loss.10 The overall prevalence
of tooth loss was 1.88 times greater for sub-

Tooth loss is significantly greater

in people with DM than the
general population, and fewer
people with DM have a
functional dentition.
jects with DM compared with subjects without DM or other chronic diseases, with statistically significant differences in the 4044 and
5559-year-old age groups (p < 0.01).10

Potential Use of Tooth Loss and

Periodontal Status as DM
Identifiers
DM is an enormous public health and
economic burden. In the United States alone
there were an estimated 29.1 million people
with DM in 2012, an increase of more than 3
million from 2010.12 Of the 29.1 million,
approximately 8.1 million had not been diagnosed and were unaware of their DM status.13
In addition, by 2012 there were an estimated
86 million pre-diabetic Americans 20 years
of age.13
Several studies have recently investigated
the use of tooth loss or other oral conditions
as identifiers for pre-diabetes and DM.14-16 In
one study, 601 subjects, 30 years-of-age and
older, were recruited; for the 535 subjects
reporting at least one risk factor for DM, a fasting plasma glucose test was administered.14 This
enabled comparison of glycemic status with
the results of a periodontal examination and
hemoglobin A1c (HbA1c) test. The results
showed a correlation between periodontal status and diabetic status. Seventy-three percent
of previously undiagnosed pre-diabetic and
diabetic subjects were identified using 4 missing teeth and 26% of teeth with a deep periodontal pocket as identifying markers. If a chairside HbA1c test result of at least 5.7% was also
included, 92% of pre-diabetic and diabetic subjects were identified.14 In a second study with
an additional 591 participants, the same
researchers demonstrated that correct identification of pre-diabetic patients and patients
with DM occurred 72% of the time using 4

missing teeth and 26% of teeth with a deep

periodontal pocket as identifiers in the HbA1c
sample, and 75% of the time when the two
study groups were combined. Adding the chairside HbA1c test increased the rate of correct
identification to 87% and to 90%, respectively (see Figure 3). It was concluded that dental
professionals could thereby identify persons
with pre-diabetes and DM using periodontal
status, missing teeth, and a simple chairside
test, and then provide referrals for medical
evaluation and care.15

DM and Pre-Diabetes:
Identifiers in the Dental Office
Study 1 participants
4 missing teeth and 26% teeth with
a deep pocket
Accurate 73% of time
Above plus HbA1c test
Accurate 92% of time (n = 535)
Study participants
4 missing teeth and 26% teeth with
a deep pocket
Accurate 72% of time
Above plus HbA1c test
Accurate 87% of time (n = 591)
Figure 3. DM and pre-diabetes: identifiers in the dental office.

A Finnish review reported data from a

prospective, 13-year population-based survey
(19972010) with 8,446 subjects16 having 9
missing teeth (base = 32 teeth since wisdom
were counted) and edentulism were found
to be significantly associated with DM
(p < 0.04 and p < 0.012, respectively). It was
concluded that missing teeth could be included as a risk indicator for DM.16

Implications and Dental Visits

Patients with DM experience more severe
periodontal disease and greater tooth loss than
persons without DM, with intermediate levels of periodontal disease and tooth loss
observed for pre-diabetic patients. While there
is inconclusive data to support the position
that improvements in periodontal health have
Click here to continue to next page

ORAL CARE REPORT

Tooth loss and periodontal status
have been found to correlate with
DM status, and can be used as
DM identifiers.
any impact on DM status,10,17 more frequent
dental visits and periodontal care are indicated to improve periodontal health and to
maintain a functional dentition in patients
with DM. More frequent visits for care (biannual versus annual) have been shown to
reduce tooth loss in high risk patients, which
would include patients with DM.18,19 Taken
together, these data suggest a real opportunity for dental professionals to identify and
refer patients for medical care.
However, adults with DM actually access
dental care less frequently than persons without DM.10,20 Significantly lower utilization of
dental services was observed in a French study
of patients with DM who were 45 years of
age, and fewer patients with DM 50 years
of age received a scaling and prophylaxis.10 A
US analysis of 105,718 dentate adults
(n = 4,605 with DM) found that 65.8% of
adults with DM had a dental visit in the prior
year, compared with 73.1% for persons without DM (p = 0.0000). African-Americans and
Hispanics had fewer visits than non-Hispanic
Caucasians.20 This creates a further dilemma,
since ethnic groups with fewer dental visits
also have a higher prevalence of DM.13

Conclusions
Increased awareness and education is
required at the public health level to contain
the rapidly increasing number of patients with
DM and pre-diabetes. All healthcare personnel should encourage a healthy lifestyle, screening when indicated, and appropriate medical care. Efforts should also include increasing awareness of the oral complications associated with DM and promoting dental visits
for oral health care. Findings that periodontal status and tooth loss may help identify persons with dysglycemia are encouraging and
could result in earlier diagnosis and referral
for medical assessment and care.

3
In conclusion, increased collaboration
across healthcare disciplines is required to
C
identify and treat patients with DM. O

References
Lalla E, Papapanou PN. Diabetes mellitus
and periodontitis: A tale of two common
interrelated diseases. Nat Rev Endocrinol
2011;7(12):738-48.
2. Chapple IL, Genco R, Working Group 2 of
the Joint EFP/AAP Workshop. Diabetes and
periodontal diseases. Consensus report of
the Joint EFP/AAP Workshop on periodontitis and systemic diseases. J Periodontol
2013;84(4):S106-12.
3. Luo H, Pan W, Sloan F, Feinglos M, Wu B.
Forty-year trends in tooth loss among
American adults with and without diabetes
mellitus: An age-period-cohort analysis. Prev
Chronic Dis 2015;12:E211.
4. Preshaw PM, Alba AL, Herrera D, Jepsen
S, Konstantinidis A, Makrilakis K, Taylor R.
Periodontitis and diabetes: a two-way relationship. Diabetologia 2012;55:21-31.
5. Taylor JJ, Preshaw PM, Lalla E. A review of
the evidence for pathogenic mechanisms
that may link periodontitis and diabetes. J
Periodontol 2013;84(4 Suppl):113-34.
6. Lamster IB, Cheng B, Burkett S, Lalla E.
Periodontal findings in individuals with
newly identified pre-diabetes or diabetes
mellitus. J Clin Periodontol 2014;41(11):
1055-60.
7. Furuta M, Liu A, Shinagawa T, Takeuchi
K, Takeshita T, Shimazaki Y, Yamashita Y.
Tooth loss and metabolic syndrome in middle-aged Japanese adults. J Clin Periodontol
2016 Feb 4. doi: 10.1111/jcpe.12523. [Epub
ahead of print]
8. Kapp JM, Boren SA, Yun S, LeMaster J.
Diabetes and tooth loss in a national sample of dentate adults reporting annual dental visits. Prev Chronic Dis 2007;4(3):A59.
9. Patel MH, Kumar JV, Moss ME. Diabetes
and tooth loss: an analysis of data from the
National Health and Nutrition Examination
Survey, 2003-2004. J Am Dent Assoc
2013;144(5):478-85.
10. Mayard-Pons ML, Rilliard F, Libersa JC,
Musset AM, Farge P. Database analysis of a

11.

1.

12.

13.

14.

15.

16.

17.

18.

19.

20.

French type 2 diabetic population shows a

specific age pattern of tooth extractions and
correlates health care utilization. J Diabetes
Complications 2015;29(8):993-7.
Borgnakke WS, Ylstalo PV, Taylor GW,
Genco RJ. Effect of periodontal disease on
diabetes: systematic review of epidemiologic observational evidence. J Periodontol
2013;84(4 Suppl):135-52.
American Diabetes Society. Statistics about
diabetes. Available at: http://www.diabetes.org/diabetes-basics/statistics/?loc=dbslabnav.
Centers for Disease Control and Prevention.
National diabetes statistics report, 2014.
Atlanta (GA): US Department of Health
and Human Services. Available at:
http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf.
Lalla E, Kunzel C, Burkett S, Cheng B,
Lamster IB. Identification of unrecognized
diabetes and pre-diabetes in a dental setting. J Dent Res 2011;90(7):855-60.
Lalla E, Cheng B, Kunzel C, Burkett S,
Lamster IB. Dental findings and identification of undiagnosed hyperglycemia. J Dent
Res 2013;92(10):888-92.
Liljestrand JM, Havulinna AS, Paju S,
Mannisto S, Salomaa V, Pussinen PJ. Missing
teeth predict incident cardiovascular events,
diabetes, and death. J Dent Res
2015;94(8):1055-62.
Engebretson S, Kocher T. Evidence that periodontal treatment improves diabetes outcomes: a systematic review and meta-analysis. J Periodontol 2013;84(4):S153-63.
Giannobile WV, Braun TM, Caplis AK,
Doucette-Stamm L, Duff GW, Kornman KS.
Patient stratification for preventive care
in dentistry. J Dent Res 2013;92(8):694701.
Dannewitz B, Zeidler A, Husing J, Saure D,
Pfefferle T, Eickholz P, Pretzl B. Loss of
molars in periodontally treated patients.
Results ten years and more after active periodontal therapy. J Clin Periodontol
2016;43(1):53-62.
Tomar SL, Lester A. Dental and other health
care visits among US adults with diabetes.
Diabetes Care 2000;23(10):1505-10.

ORAL CARE REPORT

CLINICAL PRACTICE
Dental Practice-Based Research Networks
Clinical studies evaluating or comparing treatments have often been conducted
in controlled university settings, and are sometimes criticized as not representing the conditions encountered in clinical practice. As a
result, medical and dental practice-based
research networks have been developed that
combine data from a large number of private
practices, each following a defined protocol,
and allow for the variances that occur in the
provision of care in the community. Dental
practice-based research networks (DPBRNs)
have generated data on clinical questions and
reports are now being published. In particular, information regarding different approaches to the management of dental caries and
endodontic lesions is being generated.1-7 This
information provides insight into current practices and challenges, and suggests future clinical approaches.

Findings from DPBRNs:

Dental Caries Management
Evidence-based dental caries management involves caries risk assessment (CRA),
accurate diagnosis of caries lesions as early as
possible, and a staged approach whereby early
lesions are managed preventively and more
advanced lesions are restored. Each aspect
has been investigated in DPBRNs.

Diagnosing Primary Caries Lesions

Factors associated with the use and selection of diagnostic techniques to assess one-surface primary caries lesions prior to restoration
placement on a virgin surface were measured
in a study involving 228 DPBRN dentists and
more than 5,500 surfaces.1 The frequency of
use of diagnostic techniques was surfacedependent (p < 0.0001); as would be expected based on current recommendations and
standards of care, a visual-tactile examination
together with radiographs were most frequently
used for posterior proximal lesions.1 Fewer
insured than uninsured patients and fewer
older patients received radiographs. It was
hypothesized that insurance benefits limited
the number of radiographs taken, as did older
patients staying with the same dentist for a long
time. Significant differences in the frequency
of radiographs were also observed for differ-

ent DPBRN regions, proposed to be associated with differences in training and local norms.
Adjunctive diagnostics were rarely used.1

16%

Managing Questionable Occlusal

Caries (QOC) Lesions
In QOC lesions, surface changes indicative of caries are present (e.g., roughness or
staining), while radiographic evidence is
absent. QOC lesions (n = 1,341) were assessed
at baseline by 82 DPBRN dentists, and at 20
months the same surfaces were reexamined
(by 53 of 82 dentists).2 At baseline, 116 lesions
were treated invasively, 192 received sealants,
and for the remainder, fluorides and/or oral
hygiene instruction were provided and the
lesions monitored. At 20 months, 90% of the
monitored lesions continued to be monitored;
61 were sealed and the remaining 4% restored.
Of the surfaces initially sealed, two required
invasive treatment. It was concluded that a
monitoring approach would be appropriate
for QOC lesions.2

Management of Enamel Caries

An observational study with 229 dentists
was conducted to determine treatment provided for occlusal and proximal caries lesions
in virgin surfaces in 4,397 patients.3 Seven hundred and eighteen of 4,064 occlusal surfaces
(16%) and 246 of 4,149 proximal surfaces
(6%) that were restored had only enamel
caries (see Figure 1). Placement of occlusal
restorations limited to the enamel varied by
practice type, and varied by region from 4%
to 24% (p < 0.05). Treatment variations
observed for proximal surfaces were similar.
Other significant factors for treatment provided included the ethnicity of the dentist and
patient. Very few occlusal enamel restorations
were placed by dentists in the Scandinavian
region; noninvasive treatment of enamel caries
lesions is widely practiced in Scandinavia,8 in
line with evidence-based recommendations
for patients at low and moderate risk for caries.
In US DPBRN regions, fewer occlusal enamel restorations were placed by dentists performing CRA.3 Nonetheless, no statistically
significant differences were observed in a separate study of patient-specific caries preventive protocols based on use of CRA.9

6%
Occlusal with
enamel caries

Proximal with
enamel caries

Figure 1. Percentage of restored surfaces with only enamel

caries lesions.

Managing Failed Restorations

When restorations fail, options include
repair or replacement of the restorations, or
more extensive treatment. Among 194 DPBRN
dentists, treatment decisions for failed restorations (n = 8,770 in 6,643 patients) varied with
the reason for failure, restorative material, location and type of tooth, restoration size (number of surfaces), and whether the treating dentist had placed the original restoration.4 Overall,
repair was more likely if the treating dentist,
rather than another dentist, had placed the
failed restoration (p < 0.001). Repair of molar
restorations was also more likely when the treating dentist, rather than another dentist, had
placed that restoration (p < 0.001). Amalgam
restorations and fractured restorations were
more likely to be replaced than non-amalgam
restorations and non-fractured restorations if
the treating dentist had placed the original
restoration (p < 0.001 and p = 0.001, respectively); replacement of amalgam restorations
was also more likely if a different dentist had
placed the failed restoration (p < 0.001).4

The management of enamel caries

lesions and failed restorations
varies significantly among
DPBRN dentists.
Findings in Endodontics
In other DPBRN research, isolation techniques5,6 and severe post-treatment pain7 have
been studied. While use of a rubber dam is
considered the standard of care during root
canal therapy (RCT),10 in one study with 1,490

ORAL CARE REPORT

DPBRN clinicians, only 47% reported always
using a rubber dam; 12% always used cotton
rolls, 5% sometimes used no isolation, and the
remainder used a variety of isolation methods
(see Figure 2).5 Factors influencing rubber dam
use included time since graduation, frequency of performing RCT, clinic setting, and
whether additional training had been received.5
Attitudes and beliefs regarding the effectiveness, convenience, time required, and easeof-use of rubber dams vary significantly.6 Based
on responses from DPBRN dentists, the dentists could be grouped into 4 categories; the
group collectively regarding rubber dams as
ineffective and difficult to use had the lowest
consistent usage (7%), versus 82% of the group
regarding rubber dams as most effective.6
47%
36%

Outcomes of Involvement
in a DPBRN
Treatment differences based on the
degree of involvement of clinicians within a
DPBRN have been observed. The management
of dental caries was investigated in one study
spanning 2005 through 2011 and involving
17 clinic sites; increasing involvement lead to
significantly decreased restoration rates.11 Over
the six-year period, restoration rates for dental caries lesions dropped from 79.5% to 47.6%
overall (p < 0.01). Between 2005 and 2008,
the reduction in restoration rates by dentists
who were highly involved in the DPBRN was
approximately double the reductions of less
involved dentists (see Figure 3). It was also
found that attendance at meetings was associated with reductions in the number of restorations placed by individual dentists, and that
over time an additional effect was noted, whereby less engaged dentists within the DPBRN
also changed treatment behaviors.11
n 2005
n 2008

88%
82%

12%
73%

5%

63%
n
n
n
n

Rubber dam always

Cotton rolls always
No isolation sometimes
Variety of methods

Figure 2. Isolation techniques used by DPBRN dentists.

Attitudes and beliefs regarding the

effectiveness, convenience, time
required, and ease-of-use of rubber
dams vary significantly.
Potential predictors of severe pain following RCT were researched in a study involving 62 clinicians.7 Pain assessments were made
1 week pre-treatment for patients, and 1 week
post-treatment for patients completing the
study (n = 652). Pre-operative predictors of
severe pain were determined to include: pain
intensity (p = 0.0003); number of days when
pain interfered with normal activities
(p = 0.0005); a diagnosis of symptomatic apical periodontitis (p = 0.045); and, pain worsened by stress (p = 0.013).7 The identification
of predictors of severe pain using real-life
DPBRN data means that patients could be
more accurately informed on the likelihood
of post-operative pain and that pain could be
better managed.7

High Involvement

Low Involvement

Figure 3. Restoration rates by DPBRN dentists between 2005

and 2008.

Conclusions
Although DPBRN studies involve nonrandom selection of clinicians, they have more
commonalities with general practice than university settings. Research studies within
DPBRNs, as discussed in this article, provide
insights on treatment differences in a reallife setting. Participating in a DPBRN offers
opportunities for involvement in research
which in itself increases the practice of evidence-based care, and over time less engaged
practitioners in the same DPBRN setting also
make care decisions based on evidence. This
research can then be used to determine strategies to promote the use of evidence-based care
by dental professionals, leading to improved
clinical outcomes. O
C

References
1.

Rindal BJ, Gordan VV, Litaker MS, Bader JD,

Fellows JL, Qvist V, Wallace-Dawson MC,
Anderson ML, Gilbert GH. Methods dentists
use to diagnose primary caries lesions prior
to restorative treatment: Findings from The

Dental PBRN. Tex Dent J 2015;132(2):102-9.

Makhija SK, Gilbert GH, Funkhouser E, Bader
JD, Gordan VV, Rindal BJ, et al. Twenty-month
follow-up of occlusal carious lesions deemed
questionable at baseline: Findings from The
National Dental Practice-Based Research
Network. J Am Dent Assoc 2014;145(11):1112-8.
3. Fellows JL, Gordan VV, Gilbert GH, Rindal
DB, Qvist V, Litaker MS, et al. Dentist and practice characteristics associated with restorative treatment of enamel caries in permanent
teeth: multiple-regression modeling of observational clinical data from The National
Dental PBRN. Am J Dent 2014;27(2):91-9.
4. Gordan VV, Riley J, 3rd, Geraldeli S, Williams
OD, Spoto JC, 3rd, Gilbert GH, National
Dental PCG. The decision to repair or replace
a defective restoration is affected by who
placed the original restoration: findings from
the National Dental PBRN. Tex Dent J
2015;132(7):448-58.
5. Lawson NC, Gilbert GH, Funkhouser E,
Eleazer PD, Benjamin PL, Worley DC,
National Dental PCG. General dentists use
of isolation techniques during root canal treatment: from the National Dental Practice-based
Research Network. J Endod 2015;41(8):121925.
6. Gilbert GH, Riley JL, Eleazer PD, et al.
Discordance between presumed standard of
care and actual clinical practice: the example of rubber dam use during root canal treatment in the National Dental Practice-Based
Research Network. BMJ Open 2015;5:e009779.
doi:10.1136/bmjopen-2015-009779.
7. Law AS, Nixdorf DR, Aguirre AM, Reams GJ,
Tortomasi AJ, Manne BD, Harris DR, National
Dental PCG. Predicting severe pain after root
canal therapy in the National Dental PBRN.
J Dent Res 2015;94(3 Suppl):37-43.
8. Voinea-Griffin A, Rindal DB, Fellows JL,
Barasch A, Gilbert GH, Safford MM. DPBRN
Collaborative Group. Pay-for-performance
in dentistry: what we know. J Health Qual
2010;32:51-8.
9. Riley JL, 3rd, Gordan VV, Ajmo CT, Bockman
H, Jackson MB, Gilbert GH. Dentists use of
caries risk assessment and individualized caries
prevention for their adult patients: Findings
from The Dental Practice-Based Research
Network. Tex Dent J 2015;132(1):18-29.
10. American Association of Endodontists. AAE
Position Statement: Dental Dams. Available
at: http://www.aae.org/uploadedfiles/clinical_resources/guidelines_and_position_statements/dentaldamstatement.pdf.
11. Rindal DB, Flottemesch TJ, Durand EU,
Godlevsky OV, Schmidt AM, Gilbert GH,
National Dental PCG. Practice change toward
better adherence to evidence-based treatment
of early dental decay in the National Dental
PBRN. Implement Sci 2014;9:177.
2.

ORAL CARE REPORT

TECHNOLOGY
Use of Lasers for Periodontal Treatment
Laser is an acronym for light amplification by stimulated emission of radiation,
and is a technology that utilizes light emitted
coherently, resulting in an intensely focused
beam that can be used to accomplish a range
of tasks. The application of lasers in surgery
has generated a great deal of interest in many
healthcare disciplines. In dentistry, the use
of lasers for periodontal therapy has been of
particular interest, however results regarding efficacy are mixed. There is some evidence
that lasers can be an effective adjunct when
used as part of nonsurgical periodontal therapy, while the data regarding use of lasers during periodontal surgery does not support the
use of these devices. This area of research suffers from a paucity of well-controlled clinical
trials.

Lasers for Periodontal

Procedures
The use of lasers has been proposed for
sulcular debridement, laser-assisted new attachment procedures (LANAP), reduction of
biofilm, wound healing, periodontal debridement, gingivectomy, crown lengthening, and
wound healing.1 Lasers used include CO2,
Nd:YAG, ERL, and diode lasers; wavelengths
used range from 532 nm to 10,600 nm.2-4

Nonsurgical Periodontal Therapy

The American Academy of Periodontology
issued a position paper in 2011, stating that
there was minimal evidence supporting the
use of lasers as an adjunct or monotherapy for
subgingival debridement, and inconsistent
results for bacterial reductions.5 Since then, a
number of additional studies and several systematic reviews examining their use for periodontal debridement have been published.
One systematic review examined studies published between 1990 and 2012 on diode
and Nd:YAG lasers.6 Randomized controlled/controlled/retrospective studies of
at least six months duration and conducted
in otherwise healthy adults were included;
these studies evaluated periodontal pocket
probing depth (PPD) reductions, bleeding
on probing (BOP), and gain in clinical attachment levels. Six of 77 studies met the inclusion criteria, and a prior review on Nd:YAG
lasers was also examined.6,7 Six studies demonstrated reduced PPD and BOP. It was concluded that adjunctive use of diode and
Nd:YAG lasers may result in additional clinical benefit compared to traditional periodontal

debridement alone. It was, however, further

concluded that evidence was limited and that
long-term, randomized clinical trials are necessary.6 In a separate review of nine studies
published up to September 2013, it was concluded that improvements in PPD and clinical attachment levels (CAL) with adjunctive
use of a diode laser were similar to those of
traditional periodontal debridement alone,
and that while bleeding scores were significantly reduced, the reduction was minimal
and of questionable clinical relevance.8
Randomized controlled trials on diode
lasers (n = 14), Nd:YAG lasers (n = 3) and
erbium lasers (n = 3) were included in an evidence-based review comparing traditional periodontal debridement alone and with adjunctive therapies.9 Using diode lasers for photodynamic therapy (PDT; n = 10) was found to
offer a potential benefit.9 During PDT, the
sulcus is irrigated with methylene blue dye,
after which the laser light interacts with the
dye and causes bacterial cell death.4 The reviewers were unable to determine whether the
moderate benefit outweighed potential harm.
No evidence was found for any benefit with
adjunctive use of Nd:YAG or erbium lasers,
or for diode lasers used for non-PDT (n = 4;
see table).9
LANAP and soft tissue curettage procedures remove sulcular epithelium and have
been promoted as a method to enhance clinical attachment. Nonetheless, no clinically

There is evidence that the use of

diode lasers for PDT in
conjunction with traditional nonsurgical periodontal therapy may
be of benefit, while there is
insufficient evidence for non-PDT
use of diode lasers, or for Nd:YAG
or erbium lasers.
ty.12-15 An immediate decrease in sensitivity, with
relief maintained at 30 days, has been observed
following one treatment with a diode laser.13
The ability of lasers to relieve dentinal hypersensitivity is a desirable attribute, given that
the smear layer on exposed root surface dentin
is removed during periodontal debridement.

Surgical Periodontal Therapy

Surgical periodontal procedures include
gingivectomy, flap surgery, and regenerative
procedures using guided tissue regeneration
(GTR) and enamel matrix derivatives (EMD).
A review of randomized controlled trials (n =
9) published in English up to December 2014
was conducted to assess the efficacy of surgical
periodontal procedures with and without adjunctive use of lasers.16 No statistically significant differences in PPD reductions were observed for
flap surgery or GTR/EMD, with and without
use of a laser (p = 0.33 and p = 0.98, respective-

Evidence for Benefit of Adjunctive Use of Lasers with Traditional Periodontal Debridement9
Type

#
Studies

Total
Participants

Diode for PDT

10

306

Diode (non-PDT)
Erbium
Nd:YAG

4
3
3

98
82
82

Evidence
of Benefit
Some benefit, unclear if benefit
outweighs potential harm
Insufficient
Insufficient
Insufficient

Adapted from: ADA Center for Evidence-Based Dentistry. Systematic review and meta-analysis on the nonsurgical
treatment of chronic periodontitis by scaling and root planing with or without adjuncts. July 2015.

significant improvements in CAL are observed

following these procedures compared with
traditional nonsurgical periodontal therapy.10,11

Reducing Dentinal Hypersensitivity

Several studies have found lasers to be
effective in sealing dentinal tubules, including carbon dioxide and diode lasers, thereby
providing relief from dentinal hypersensitivi-

ly); similar results were also found for CAL gains

following flap surgery or GTR/EMD (p = 0.44
and p = 0.78, respectively).16
When used to perform a gingivectomy,
soft-tissue lasers provide good visualization
of the clinical site. Since lasers also promote
tissue coagulation and hemostasis, their use
may also reduce transient bacteremia during
surgical procedures.17

ORAL CARE REPORT

Potential Benefits and
Risks of Lasers
Potential benefits of lasers include biofilm
reduction in periodontal pockets, hemostasis,
precision treatment, selective removal of calculus, reduced post-operative swelling and pain,
and faster healing. Biofilm reduction has been
observed with the adjunctive use of lasers,
although the results are variable; one study found
significant differences in the total bacterial level,
and the levels of Porphyromonas gingivalis and
Treponema denticola, six months following therapy.1,5,18-20 Mixed results with respect to CAL
improvements have also been observed.1,5,18-20
Less discomfort has been found with the use
of Er:YAG lasers as a monotherapy for SRP than
with ultrasonic scaling,20 and effective soft tissue coagulation is achieved using a diode laser.16
Low-level light laser therapy (LLLT) uses a wavelength of 600 nm to 950 nm; adjunctively, LLLT
and diode lasers have been shown in one study
to reduce inflammation, stimulate healing, and
increase patient comfort.4 Adjunctive LLLT
reduced sulcular bleeding, clinical attachment
loss, and PPD in another study.21

LLLT has been shown in one

study to reduce inflammation,
stimulate healing, and increase
patient comfort. However, laserinduced damage to alveolar bone
and root surfaces can occur as a
result of heat generated by lasers.
There are, however, potential risks associated with the use of lasers. Adjacent tissues may
be damaged due to the heat generated by lowwavelength lasers during their application on,
or next to, periodontal tissues. It is important
to consider the power level, wavelength, other
settings, and the tissue being lased. Laser-induced
damage to alveolar bone and root surfaces can
occur as a result of overheating.4,16 Higher wavelength lasers (e.g., ERL laser) generate significantly less heat.4
Occupational health hazards are a further
consideration. Protective eyewear must be worn
by clinical personnel and the patient while a
laser is being used, and gazing at laser light must
be avoided to prevent irreversible eye damage.
In addition, there are concerns over the presence of pathogens in laser plumes; therefore,
precautions should be taken, including use of
a high-filtration surgical face mask.22

Lasers promote tissue coagulation

and hemostasis and therefore may
also reduce transient bacteremia.

Conclusions
Based on the available data, laser therapy may offer some benefits when used adjunctively with nonsurgical periodontal therapy;
specifically, a benefit has been attributed to
the use of diode and Nd:YAG lasers. No statistically significant differences in clinical outcomes have been observed with use of a laser
as a monotherapy or as an adjunct for surgical periodontal therapy. Nonetheless, laser
use can reduce inflammation and post-operative discomfort, and the ability of lasers to
provide relief from dentinal hypersensitivity
is advantageous. The challenging nature of
comparisons of existing studies is a recurring
theme, as many studies involve only a few subjects and demonstrate a great deal of variation in study design and subjects, the types
of lasers used, and the parameters under which
they are used.16
In conclusion, there is still a need for welldesigned, long-term, randomized controlled
clinical trials with large numbers of subjects
to obtain conclusive evidence on the clinical
benefits and risks associated with the use of
lasers in periodontal therapy. O
C

References
1.

2.

3.

4.

5.

6.

7.

8.

American Dental Association Council on

Scientific Affairs. Statement on Lasers in
Dentistry. Available at: http://www.ada.org/
en/about-the-ada/ada-positions-policies-andstatements/statement-on-lasers-in-dentistry.
Schwarz F, Aoki A, Becker J, Sculean A. Laser
application in non-surgical periodontal therapy: a systematic review. J Clin Periodontol
2008;35(Suppl 8):29-44.
Sgolastra F, Petrucci A, Gatto R, Monaco A.
Efficacy of Er:YAG laser in the treatment of
chronic periodontitis: systematic review and
meta-analysis. Lasers Med Sci 2012;27:661-73.
Low SB, Mott A. Laser technology to manage periodontal disease: a valid concept? J
Evid Based Dent Pract 2014;14(Suppl 15):4-9.
American Academy of Periodontology.
Statement on the efficacy of lasers in the nonsurgical treatment of inflammatory periodontal disease. J Periodontol 2011;82:513-4.
Roncati M, Gariffo A. Systematic review of
the adjunctive use of diode and Nd:YAG lasers
for nonsurgical periodontal instrumentation.
Photomed Laser Surg 2014;32(4):186-97.
Slot DE, Kranendonk A, Paraskevas S, Van der
Weijden F. The effect of a pulsed Nd:YAG laser
in non-surgical periodontal therapy: a systematic review. J Periodontol 2009;80:1041-56.
Slot DE, Jorritsma KH, Cobb CM, Van der
Weijden FA. The effect of the thermal diode
laser (wavelength 808-980 nm) in non-surgical periodontal therapy: a systematic review
and meta-analysis. J Clin Periodontol
2014;41(7):681-92.

9.

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21.

22.

ADA Center for Evidence-Based Dentistry.

Systematic review and meta-analysis on the
nonsurgical treatment of chronic periodontitis by scaling and root planing with or without adjuncts. July 2015.
American Academy of Periodontology.
Statement on gingival curettage. J Periodontol
2002;73(10):1229.
Dederich DN. Commentary. Evid Based Dent
2015:16:16. doi:10.1038/sj.ebd.6401078.
Sgolastra F, Petrucci A, Gatto R, Monaco A.
Effectiveness of laser in dentinal hypersensitivity treatment: a systematic review. J Endod
2011;37:297-303.
George VT, Mathew TA, George N, John S,
Prakash SM, Vaseem MS. Efficacy of diode
laser in the management of dentin hypersensitivity following periodontal surgery. J
Int Oral Health 2016;8(1):103-8.
Etemadi A, Sadeghi M, Dadjou MH. The effects
of low level 660 nm laser irradiation on pain
and teeth hypersensitivity after periodontal
surgery. J Lasers Med Sci 2011;2(3):103-8.
Doshi S, Jain S, Hegde R. Effect of low-level
laser therapy in reducing dentinal hypersensitivity and pain following periodontal flap surgery. Photomed Laser Surg 2014;32(12):700-6.
Behdin S, Monje A, Lin GH, Edwards B,
Othman A, Wang HL. Effectiveness of laser
application for periodontal surgical therapy:
systematic review and meta-analysis. J
Periodontol 2015;86(12):1352-63.
Maddi A, Alluri LS, Ciancio SG. Management of
gingival overgrowth in a cardiac transplant patient
using laser-assisted gingivectomy/gingivoplasty. J
Int Acad Periodontol 2015;17(3):77-81.
Gokhale SR, Padhye AM, Byakod G, Jain SA,
Padbidri V, Shivaswamy S. A comparative evaluation of the efficacy of diode laser as an adjunct
to mechanical debridement versus conventional
mechanical debridement in periodontal flap
surgery: a clinical and microbiological study.
Photomed Laser Surg 2012;30:598-603.
Kamma JJ, Vasdekis VG, Romanos G. The
effect of diode laser (980 nm) treatment on
aggressive periodontitis: evaluation of microbial and clinical parameters. Photomed Laser
Surg 2009;27(1):11-9.
Tomasi C, Schander K, Dahln G, Wennstrm
JL. Short-term clinical and microbiologic
effects of pocket debridement with an Er:YAG
laser during periodontal maintenance. J
Periodontol 2006;77(1):111-8.
Aykol G, Baser U, Maden I, Kazak Z, Onan
U, Tanrikulu-Kucuk S, Ademoglu E, Issever
H, Yalcin F. The effect of low-level laser therapy as an adjunct to non-surgical periodontal treatment. J Periodontol 2011;82(3):481-8.
Centers for Disease Control and Prevention.
Guidelines for infection control in dental
health-care settings 2003. MMWR 2003;
52(RR-17):1-66.

ORAL CARE REPORT

DENTISTRY AND HEALTH CARE

Oral Manifestations of HIV Infection in the Era of
Highly Active Anti-Retroviral Therapy
When

infection with the human

immunodeficiency virus (HIV) was first identified, oral manifestations were among the earliest clinical signs of infection. Oral hairy leukoplakia (OHL), oral candidiasis (OC), Kaposis
sarcoma (KS), and oral ulcerations were all
observed to be frequent presentations in HIVpositive patients, while this is not the case in
the general population.1 The prevalence of
oral lesions increased with time since seroconversion, and as the CD4 T-cell count
declined. In addition, OHL and OC were
found to be disease indicators and to predict
more rapid progression to acquired immunodeficiency syndrome (AIDS). Other oral manifestations in HIV-positive patients include oral
warts, linear gingival erythema, necrotizing
ulcerative periodontitis, and xerostomia.2,3

HAART alters the prevalence and

pattern of HIV-related oral manifestations and has also changed
HIV/AIDS into a chronic disease.
In pediatric HIV disease, OC is the most
common oral manifestation, with a prevalence
of 6% to 45% across several studies, including erythematous and pseudomembranous
lesions and angular cheilitis.4 Oral manifestations of pediatric HIV infection differ from
oral manifestations in adults, with a relatively
low prevalence of OHL in HIV-infected children; reports of KS in children have been rare.4
Unilateral or bilateral parotid gland enlargement occurs more frequently in children, with
up to an 18.4% prevalence across studies; it
is typically painless.4-6

Highly Active Anti-Retroviral

Therapy
In the absence of effective treatments,
HIV infection is associated with high morbidity and mortality in adults and children. The
initial introduction of antiretroviral drugs
helped to reduce morbidity and mortality.
Highly active anti-retroviral therapy (HAART),
also known as combination antiretroviral therapy since it involves treatment with multiple
anti-retroviral agents, was subsequently introduced. HAART reduces the viral load and

increases the CD4 count,7 helps to improve

immune function, delays progression to AIDS,
and reduces morbidity and mortality. HAART
thereby changes HIV/AIDS into a chronic
disorder that is managed over decades, and
has also altered the prevalence and pattern
of HIV-related oral manifestations.8

Oral Manifestations Reduced

by HAART
The overall prevalence, frequency, and
severity of HIV/AIDS-associated oral lesions
has declined since the introduction of
HAART.7,9-11 In patients receiving HAART,
prevalences of 32% and 37.5% were reported in two studies, compared with 56% and
47.6%, respectively, for patients not receiving HAART. 9,12 The prevalence of oral lesions
was reduced by 30% and 24% in two other
studies.13,14 OC, OHL, and KS are all less prevalent in patients receiving HAART. In patients
in another study (n = 103), an OC prevalence
of 66% was found prior to HAART, reduced
to 9.7% after at least four weeks of HAART,
and completely absent after seven months.7
HAART is the only current recommendation
for the prevention of KS and OHL.15 Longerduration HAART (> 5 months) has been
found to significantly reduce the prevalence
of OC (p < 0.001), linear gingival erythema
(p = 0.01), and recurrent aphthous ulcers
(p = 0.03) compared to short-duration HAART
(< 4 months).10 OC is the most common oral
manifestation observed during HAART, as
demonstrated in one six-year retrospective
study with 744 patients.15

OC, OHL, and KS are less

prevalent in patients receiving
HAART than in patients not
receiving HAART.
Oral Manifestations Increased
by HAART
Hyperpigmentation of the oral mucosa
was reported in one study to be present in 14%
of adult patients receiving HAART compared
with 10% not receiving HAART,9 and in another, in 38% and 20% of patients, respectively,

with a mean duration of 4.9 months of

HAART.11 Furthermore, there was no statistically significant difference in the number of
patients with oral hyperpigmentation in the
HAART and non-HAART groups when the
CD4 count was 200, while at CD4 counts
> 200, 43.8% of HAART patients experienced
oral hyperpigmentation compared to 14.8%
who did not receive HAART (p = 0.02).11 This
demonstrates a relationship between HAART
efficacy in improving CD4 counts and the
increased occurrence of oral hyperpigmentation11 (see Figure 1). However, another
report found no statistically significant differences in the prevalence of oral hyperpigmentation in HAART and non-HAART children or adults.10 In a pediatric study (n = 221),
no children with CD4 counts 500 had oral
hyperpigmentation prior to anti-retroviral
therapy (ART), while four children (of 127)
experienced lesions following ART.16 For the
48 children with CD4 counts 200, four children and 15 children exhibited oral hyperpigmentation prior to and during ART, respectively.16 Another study, however, found minimal differences in oral hyperpigmentation
between HAART and non-HAART groups.10

Figure 1. Hyperpigmentation in a patient receiving HAART.

The prevalence and incidence of human

papilloma virus-induced oral warts has
increased significantly since the introduction
of HAART, believed to possibly be the result
of immune reconstitution17 (Figure 2). In
one retrospective nine-year study (n = 1,280),
anti-retroviral therapy increased the prevalence of oral warts by 300% and HAART by
600% (p = 0.01).18 In addition, increased salivary gland disease is observed in children and
adults treated with HAART.1,4

ORAL CARE REPORT

9
9.

10.

11.

Figure 2. Oral warts in a patient receiving HAART.

The prevalence and incidence of

human papilloma virus-induced
oral warts has increased significantly since the introduction of
HAART.
Implications for Patient Care
Early detection of the oral manifestations
of HIV/AIDS continues to be important for
patient care whether or not patients are receiving HAART. Given the reduced prevalence
of some oral lesions with HAART, some oral
manifestations may not be as readily evident
as indicators of disease progression. On the
other hand, reductions in lesions at the individual patient level may serve as a proxy for
laboratory testing of HAART efficacy,17,19 and
a recurrence of lesions may be a signal that
therapy is failing. An exaggerated response
may also indicate immune reconstitution and
requires management.8 The presence or
increased presence of oral warts or oral hyperpigmentation may also serve as proxies indicating HAART efficacy.

Acknowledgment: With thanks to HIVdent for the use

of Figures 1 and 2 in this article.

References
1.

2.

3.

4.

5.

6.

Conclusions
The oral manifestations of HIV/AIDS differ in HAART and non-HAART patients. It is
important for dental professionals to recognize these differences and the associated oral
manifestations. By detecting these oral manifestations, dental professionals can play an
important role in the early detection and diagnosis of HIV/AIDS, and in monitoring the outcomes of HAART. This in turn leads to earlier intervention, reduced morbidity and mortality, and reduced risk of transmission. O
C

12.

7.

8.

Greenspan JS. Sentinels and signposts: the epidemiology and significance of the oral manifestations of HIV disease. Oral Dis 1997;3(1
Suppl):13-7.
Lamster IB, Grbic JT, Bucklan RS, Mitchell-Lewis
D, Reynolds HS, Zambon JJ. Epidemiology and
diagnosis of HIV-associated periodontal diseases.
Oral Dis 1997;3(1 Suppl):141-8.
Reznik DA. Oral manifestations of HIV disease.
Perspective December 2005/January 2006;
13(5):143-8.
Dos Santos Pinheiro R, Frana TT, Ribeiro CMB,
Leo JC, De Souza IPR, Castro GF. Oral manifestations in human immunodeficiency virus
infected children in highly active antiretroviral
therapy era. J Oral Path & Med 2009;38:613-22.
Pongsiriwet S, Iamaroon A, Kanjanavanit S,
Pattanaporn K, Krisanaprakornkit S. Oral lesions
and dental caries status in perinatally HIV-infected children in Northern Thailand. Int J Paediatr
Dent 2003;13(3):180-5.
Meless D, Ba B, Faye M, Diby JS, Nzor S, Datt
S, Diecket L, NDiaye C, Aka EA, Kouakou K,
Ba A, Ekouvi DK, Dabis F, Shiboski C, Arriv
E. Oral lesions among HIV-infected children
on antiretroviral treatment in West Africa. Trop
Med Int Health 2014;19:246-55.
Schmidt-Westhausen AM, Priepke F, Bergmann
FJ, Reichart PA. Decline in the rate of oral opportunistic infections following introduction of highly active antiretroviral therapy. J Oral Pathol Med
2000;29(7):336-41.
Patton LL, Ramirez-Amador V, Anaya-Saavedra
G, Nittayananta W, Carrozzo M, Ranganathan
K. Urban legends series: oral manifestations of
HIV infection. Oral Dis 2013;19(6):533-50.

13.

14.

15.

16.

17.

18.

19.

Patil N, Chaurasia VR, Babaji P, Ramesh D,

Jhamb K, Sharma AM. The effect of highly
active antiretroviral therapy on the prevalence
of manifestation in human immunodeficiency virus-infected patients in Karnataka, India.
Eur J Dent 2015;9(1):47-52.
Jose R, Chandra S, Puttabuddi JH, Vellappally
S, Al Khuraif AA, Halawany HS, Abraham NB,
Jacob V, Hashim M. Prevalence of oral and
systemic manifestations in pediatric HIV
cohorts with and without drug therapy. Curr
HIV Res 2013;11(6):498-505.
Umadevi KM, Ranganathan K, Pavithra S,
Hemalatha R, Saraswathi TR, Kumarasamy
N, Solomon S, Greenspan JS. Oral lesions
among persons with HIV disease with and
without highly active antiretroviral therapy
in southern India. Oral Pathol Med
2007;36(3):136-41.
Patton LL, McKaig R, Strauss R, Rogers D, Eron
JJ, Jr. Changing prevalence of oral manifestations of human immuno-deficiency virus in
the era of protease inhibitor therapy. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod
2000;89:299-304.
Ceballos-Salobrea A, Gaitn-Cepeda LA,
Ceballos-Garcia L, Lezama-Del Valle D. Oral
lesions in HIV/AIDS patients undergoing highly active antiretroviral treatment including protease inhibitors: a new face of oral AIDS? AIDS
Patient Care STDS 2000;14(12):627-35.
Tappuni AR, Fleming GJ. The effect of antiretroviral therapy on the prevalence of oral
manifestations in HIV-infected patients: a UK
study. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2001;92(6):623-8.
Patton LL. Current strategies for prevention
of oral manifestations of human immunodeficiency virus. Oral Surg Oral Med Oral Pathol
Oral Radiol 2016;121(1):29-38.
Subramaniam P, Kumar K. Oral mucosal
lesions and immune status in HIV-infected
Indian children. J Oral Pathol Med 2015;44:
296-9.
Askinyte D, Matulionyte R, Rimkevicius A. Oral
manifestations of HIV disease: A review.
Stomatologija 2015;17(1):21-8.
Greenspan D, Canchola AJ, MacPhail LA,
Cheikh B, Greenspan JS. Effect of highly active
antiretroviral therapy on frequency of oral
warts. Lancet 2001;357(9266):1411-2.
Ramrez-Amador V, Ponce-de-Len S, AnayaSaavedra G, Crabtree Ramrez B,Sierra-Madero
J. Oral lesions as clinical markers of highly active
antiretroviral therapy failure: a nested casecontrol study in Mexico City. Clin Infect Dis
2007;45:925-32.

ORAL CARE REPORT

10

PREVENTIVE DENTISTRY
Maintenance of Dental Implants
Dental implants have proven to be a
transformative treatment for the replacement
of missing teeth.1 Nevertheless, complications
do occur and it can be anticipated that these
will be encountered more frequently in clinical practice with the widespread adoption
of dental implant treatment.2 Potential complications following osseointegration include
peri-implant mucositis, peri-implantitis,
implant loss, and prosthetic problems. Periimplant mucositis and peri-implantitis, respectively, are similar to gingivitis and periodontitis.3 Peri-implant mucositis is a plaque-induced
inflammation of the peri-implant soft tissues
that presents with bleeding on probing and/or
suppuration, and increased probing depths;
peri-implantitis additionally involves progressive loss of peri-implant bone in excess of the
amount that would be expected with physiological bone remodelling.3

Prevalence and Risk Factors

The prevalence of peri-implant mucositis and peri-implantitis varies across studies, in
part due to variable definitions of both diseases
in different studies. The prevalence of periimplant mucositis and peri-implantitis ranges
across studies from 19% to 65% and 1% to
47%, respectively; the corresponding weighted mean prevalences are 43% and 22%.4
Risk factors include a history of periodontal disease, poor oral hygiene, an inability to clean
around implant restorations and prostheses,
smoking, and the presence of residual cement
(see Figure 1).3 In a 10-year study on the influence of a history of periodontal disease, significant differences in the number of patients experiencing peri-implant bone loss were observed.5
In that study, 10.7% of patients with no history
of periodontal disease had received treatment
for peri-implant disease in the intervening years,
compared with 27% and 47.2% of patients with
a history of moderate and severe periodontal
disease, respectively. Eighteen implants (of 101
re-examined) had been lost; of the remaining
83 implants, a probing depth 6 mm was found
in 1.7% of patients with no history of periodontal disease, compared with 15.9% and 27.2%,
respectively, in patients with a history of moderate and severe periodontal disease.5

Risk Factors for

Peri-Implant Disease
History of periodontal disease
Poor oral hygiene
Lack of/inadequate implant
maintenance
Inability to clean around restorations
Smoking
Presence of residual cement
Figure 1. Risk factors for peri-implant disease.

Poorly controlled diabetes mellitus and

occlusal overload may also be associated with
peri-implantitis.3 In addition, an absence
of/inadequate peri-implant maintenance therapy is a known risk factor for peri-implant disease.6 Implant maintenance is essential to help
prevent clinical complications, and both personal and professional care are necessary components of a successful maintenance program.

A history of periodontal disease

increases risk for peri-implant
mucositis and peri-implantitis.
Maintenance Visits and Therapy
A thorough extra- and intra-oral examination is required at periodic maintenance
visits, together with radiographs to assess crestal bone levels and compare them with the
crestal bone levels at baseline and follow-up
examinations. Maintenance therapy includes
removal of plaque and calculus using manu-

al implant scalers or implant-safe ultrasonic

scalers with plastic tips. A prophylaxis using
a rubber cup or brush, flossing, and/or air
polishing with glycine powder may also be
performed. Oral hygiene instruction should
be provided and, as indicated, tobacco cessation and other behavior modification advice
given.7,8 Home care consists of twice-daily
brushing, interdental cleaning, and potentially the use of adjunctive devices and antimicrobial agents. Home care should be customized for the individual patient. Removable
superstructures should be removed and
cleaned extra-orally with a soft brush and denture-cleaning agent.9
Successful prevention of peri-implant disease has been reported with maintenance
recalls ranging from three to four months and
up to 18 months.7 The frequency of maintenance therapy should be determined by clinical judgment, together with the needs of individual patients, e.g., a patient with excellent
oral hygiene versus a patient with poor oral
hygiene. Clinical practice guidelines were
recently issued by the American College of
Prosthodontists, recommending periodic
recalls at least every six months and more often
for at-risk patients.9 Maintenance visits can
help reverse peri-implant mucositis before
peri-implantitis can develop. Maintenance
therapy every six months, together with excellent oral hygiene results, has also been found
to result in good long-term clinical outcomes
following peri-implant surgery to treat periimplantitis, with one five-year study finding
no attachment loss in 87% of implants treated (n = 71).10

Clinical practice guidelines recommend periodic recalls at least

every 6 months and more often for
at-risk implant patients.
The Impact of Discontinued
Maintenance Therapy
Discontinuation of implant maintenance
is a frequently occurring problem. In a
Japanese study, 26.6% of implant patients
(n = 688) had discontinued maintenance over
a three-year period (i.e., did not return within six months of the prior maintenance visit);
discontinuation was greater in patients with
poorer plaque control.11 In a study following
80 patients who had previously experienced
peri-implant mucositis, 18% of patients who
received preventive maintenance and 43.9%
of patients who did not receive regular preventive maintenance experienced peri-implantitis within five years.12

Implant patients who receive

regular preventive maintenance
are less likely to experience
peri-implantitis.
A university-based retrospective chart
review, spanning a 17-year period, assessed
implant survival rates in 1,020 patients for one
randomly selected implant per patient. Four
years post-placement, the cumulative survival
rates with regular (at least annual), irregular,
and no maintenance visits to the university
clinic were 97.6%, 94.3%, and 87.4%, respectively (see Figure 2).7 In addition, the implant
failure rate was 90% lower for patients receiving regular maintenance versus no maintenance (p = 0.001).7 All implants were standard lengths and diameters.

No
maintenance
Irregular
maintenance

94.3%

Regular
maintenance

97.6%

Figure 2. Four-year cumulative survival rates.

titis, which is especially important since periimplantitis typically progresses more quickly
than periodontitis.3,13 Furthermore, at this time
there is no evidence-based standard of care
or effective nonsurgical intervention treatment for peri-implantitis;3 this further increases the importance of prevention, early diagnosis, and treatment of peri-implant mucositis before it can progress to peri-implantitis.
Given the increasing number of implants
placed each year, improved patient compliance with maintenance therapy is one of the
key components required to combat an
increasing number of complications.
Educating patients on the importance of regular maintenance visits based on individual
risk and encouraging patient personal oral
hygiene are critical to minimize and manage
peri-implant disease, and thereby improve
treatment outcomes for patients. O
C

References
1.

2.
3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Implications and Conclusions

Discontinuing a regular maintenance program is clearly associated with an increased
risk of complications. Regular maintenance
therapy is effective in reversing peri-implant
mucositis before it progresses to peri-implan-

87.4%

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mucositis and peri-implantitis: A current understanding of their diagnoses and clinical implications. J Periodontol 2013;84(4):436-43.
Derks J, Tomasi C. Peri-implant health and disease. A systematic review of current epidemiology. J Clin Periodontol 2015;42(16 Suppl):158-71.
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Ten-year results of a three arms prospective cohort
study on implants in periodontally compromised
patients. Part 2: clinical results. Clin Oral Implants
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Bagramian RA, Wang HL, Catena A. Impact of
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ORAL CARE REPORT

11

HEALTHCARE TRENDS
The Best Jobs of 2016: Good
News for the Dental Profession?
U

Editor-in-Chief
Ira B. Lamster, DDS, MMSc
Professor of Health Policy &
Management,
Mailman School of Public Health
Dean Emeritus,
Columbia University College of
Dental Medicine

International Editorial Board

P. Mark Bartold, BDS, BScDent
(Hons), PhD, DDSc, FRACDS
(Perio); Australia
John J. Clarkson, BDS, PhD; Ireland
Kevin Roach, BSc, DDS, FACD;
Canada
Prof. Cassiano K. Rsing; Brazil
Mariano Sanz, DDS, MD; Spain
Ann Spolarich, RDH, PhD; USA
Xing Wang, MD, PhD; China
Rebecca S. Wilder, RDH, MS; USA
David T.W. Wong, DMD, DMSc; USA
2016 Colgate-Palmolive Company.
All rights reserved.
The Oral Care Report
(ISSN 1520-0167) is supported by
the Colgate-Palmolive Company for
oral care professionals.
Editorial Quality Control by Teri S.
Siegel. Layout and graphic design by
Horizons Advertising and Graphic
Design, Morrisville, PA (USA).
Published by Professional Audience
Communications, Inc., Yardley, PA
(USA).
E-mail comments and queries to the
Editor, Oral Care Report...
ColgateOralCareReport@gmail.com

Earn 3 CE credits
for this issue
of the
Oral Care Report
online at
www.colgateprofessional.com.

.S. News and World Report is a weekly magazine covering news and current events. It is well known
for its rankings of colleges and universities, hospitals, and other aspects of our society. The magazines
rankings are well publicized, and are used as an unofficial gauge of what is best in the United States.
A recent report from U.S. News and World Report listed the best jobs for 2016.1 The report ranks jobs in
essential industries, including health care, technology, business, sales and marketing, and social services.
Overall, the editors believe the job market is robust, with a projected increase of 6.5% between 2014 and
2024. This will mean 10 million new jobs in the next decade. The rankings for jobs consider the number
of job opportunities, potential for growth, work-life balance, and compensation. The list includes the 100
top jobs, as well as by specific criteria, such as best salary. Of note, Orthodontist and Dentist were the
two top jobs on the list, and Oral and Maxillofacial Surgeon was third on the list of best-paying jobs,
after Anesthesiologist and Surgeon. Dental Hygienist was on the list at number thirty-two.
Since the U.S. News and World Report rankings are highly regarded and often cited, this ranking
reflects positively upon the dental profession. A report such as this, however, must stimulate a broader
discussion of both the current state of the dental profession and the professions future.
The dental profession offers many advantages to someone considering a career in health care.
Enhancing a persons ability to function and eat a balanced diet, alleviating pain when present, and
improving a patients smile, general appearance, and ability to socialize are all important, meaningful
outcomes. Dental providers often develop long-standing relationships with their patients, and become
more than just a provider delivering a service on a routine schedule. However, the external and internal
stressors faced by the profession must also be considered.
The American Dental Association, through its Health Policy Institute, has examined the Future of
Dentistry2 and identified a number of trends that define the profession at present, and will shape the
future. The five trends that define the present include
1. increased utilization of dental services by children, but reduced utilization by working age
adults;
2. cost barriers for some working-age adults needing oral healthcare services;
3. per capita spending on dental services in the United States has plateaued;
4. an increasing number of dentists entering the workforce; and
5. dentists earnings are declining, which is similar to what is seen for other professions, including attorneys and veterinarians.
The 5 forces reshaping dental practice include
1. a changing, larger healthcare environment with a greater emphasis on prevention and wellness, and a so-called pay for performance that places value on longer-term outcomes of
care;
2. an increase in the number of children seeking dental care (due in part to the expansion of
Medicaid coverage), as well as the percent of older adults who require care as edentulism is
reduced;
3. an increase in consumerism as health care is viewed by patients as a commodity and value
becomes important.
4. the need for dental care to consider how it can become involved in interprofessional practice, as the focus shifts to providers working together; and
5. a diminishing number of solo dental practices and a greater number of group practices.
Further, these challenges will be accompanied by opportunities:
1. Dental professionals should welcome the emphasis on value, where the focus is on improved
patient outcomes at a lower cost.
2. The greater demand for services by children and older adults should be addressed. Further,
there is expected to be an increase in the number of adult Medicaid enrollees as states expand
these programs.
3. Collaboration with other healthcare providers will improve patient flow between healthcare
disciplines.
These vectors are driven in part by external forces, but changes in how care is delivered are also
occurring, including a reduced reliance on dental amalgam,3 the development of new, smart dental
materials, and the continuing development of implantology. The use of auxiliaries to expand access to
care continues to be discussed and debated,4 and the ability to provide dental services to a greater number of people will be one critical measure of how successful the dental profession will be in the future.
Change characterizes health care. While health care in general remains an attractive career option,
the dental profession must try to shape, not be shaped, by these influences. As the healthcare landscape
changes, each of us, either individually or as part of a local, regional, or national effort, must participate
in defining the future of the profession. This will be accomplished by balancing exciting clinical advances5,6
with the need to deliver cost-efficient care to the largest number of patients, especially those with difficulty accessing services.7,8 O
C

References:
1.
2.
3.
4.
5.
6.

7.
8.

Snider S. Introducing the Best Jobs of 2016. U.S. News. http://money.usnews.com/money/careers/articles/2016-01-26/introducing-the-best-jobs-of-2016.

Future of Dentistry. American Dental Association. http://www.ada.org/en/education-careers/dental-studentresources/ada-success/future-of-dentistry.
Mackey TK, Contreras JT, Liang BA. The Minamata Convention on Mercury: attempting to address the global
controversy of dental amalgam use and mercury waste disposal. Sci Total Environ 2014;472:125-9.
Fiset L. DENTEX: The emergence of dental therapists in the United States. JAAPA 2016;29:1-5.
de Sousa FF, Ferraz C, Rodrigues LK, Nojosa Jde S, Yamauti M. Nanotechnology in dentistry: drug delivery systems for the control of biofilm-dependent oral diseases. Curr Drug Deliv 2014;11:719-28.
Hammerle CH, Cordaro L, van Assche N, Benic GI, Bornstein M, Gamper F, et al. Digital technologies to support planning, treatment, and fabrication processes and outcome assessments in implant dentistry. Summary
and consensus statements. The 4th EAO consensus conference 2015. Clin Oral Implants Res 2015;26(Suppl
11):97-101.
Dahm TS, Bruhn A, LeMaster M. Oral care in the long-term care of older patients: How can the dental hygienist meet the need? J Dent Hyg 2015;89:229-37.
Dyer TA, Robinson PG. The acceptability of care provided by dental auxiliaries: A systematic review. J Am Dent
Assoc 2016;147:244-54.