Braz J Oral Sci. October-December 2006 - Vol.5 - Number 19 Association between dental prosthesis and periodontal disease in a rural Brazilian community Suzely Adas Saliba Moimaz * Nemre Adas Saliba * Orlando Saliba* Lívia Guimarães Zina* Márcio Rogério Curtis Bolonhez* *Preventive and Social Dentistry PostGraduation Program, Department of Pediatric and Social Dentistry, Araçatuba School of Dentistry, São Paulo State University - UNESP, Brazil Received for publication: August 13, 2006 Accepted: October 17, 2006 Abstract The aim of this study was to describe the periodontal conditions and to analyze the association between the wearing of fixed/removable partial dentures and periodontal disease in a representative adult rural population in southeast Brazil. Cross-sectional study of a representative sample comprising 200 individual aged 34-44 years. Data were collected by clinical examinations in accordance with the World Health Organization Basic Methods Criteria, which included the Community Periodontal Index and dental prosthesis exam. A descriptive analysis and the chi-square statistic were performed. In total, 40.5% of the individuals wore partial denture and 59.5% were non-users of denture. The prevalence of periodontal disease was 100%. The subjects scored either calculus (44.5%) or shallow pockets (47%), and only a small proportion was recorded as having deep pockets (8.5%). All denture wearer displayed periodontal problem in the sextant where the denture were recorded. The statistical analysis indicated that wearing partial dentures was found to be associated with considerable periodontal disease (X 2 = 10.75; p=0.0014). The periodontal condition of the study population can be considered unsatisfactory. The wearing of partial dental prosthesis was associated with periodontal disease, and a significant percentage of cases might have been prevented if plaque control interventions had been implemented. Key Words: periodontal diseases, dental prosthesis, oral health, periodontal index, epidemiology Correspondence to: Suzely Adas Saliba Moimaz Department of Pediatric and Social Dentistry, Araçatuba School of Dentistry, São Paulo State University Rua José Bonifácio, 1193 Vila Mendonça, 16015-050 Araçatuba, SP, Brasil. Phone: +55-18-3636-3250 Fax: +55-18-3636-4890 E-mail: [email protected] 1226 and transmission of excessive forces to the periodontal structures from occlusal surfaces of the framework of dentures. 205 partial denture wearers were examined. The differences in gingival inflammation between the plate and dental bar designs suggest that covering more gingival tissue promotes development of gingivitis. Continuing surveillance of levels and patterns of risk factors of periodontal disease is of fundamental importance to planning and evaluating community preventive activities and oral health promotion. shape and site of furcation. using the census data . This state is located in the southeast part of Brazil. probing depth. Other researches also confirm the importance of controlling biofilm in order to maintain individual oral health9-12. level and amount of dental restoration. diabetes mellitus. with it being most severe where the appliance closely contacted the gingival margin16. The sample size was obtained allowing 10% of sampling error 27. gingival inflammation and formation of periodontal pocket after dental prosthesis are fitted in16-21.1315 . These alterations are attributed to poor oral hygiene. Korea. At present. Severe periodontitis which may result in tooth loss is found in 5-15% of most populations5-6.5%1. at 65-74 years-old this rate go up to 66.Braz J Oral Sci. which verifies the state of periodontal health in view of gingival bleeding. The sample calculus was derived based on the prevalence of periodontal disease in the region. Dental prosthesis may influence the periodontal conditions. trauma. In Brazil. 5(19):1226-1231 Association between dental prosthesis and periodontal disease in a rural Brazilian community Introduction Dental caries and periodontal diseases have been historically considered the most important global oral health burdens. A global database was established and over a number of years an increasing number of oral epidemiological studies have been conducted applying World Health Organization (WHO) methodology and criteria7.3% of people aged 35-44 years wear at least one dental prosthesis. with significant differences (p<0. local and systemic factors may modify the pathogeny of periodontal disease. Many partial dentures framework designs contribute to increased or altered oral bacterial flora and formation of dental plaque20. but also on teeth in the opposing arch. like dental morphology. increased plaque and calculus accumulation. q is the probability of individuals of the sample not having this characteristic. The specific area where the data were collected has approximately 600 inhabitants (Information provided by Araçatuba Health Municipal Department and the Brazilian Institute of Geography and Statistics . In a three-year study with patients wearing fixed partial dentures with advanced periodontal disease. The significant role of local. The CPI has been widely used to measure the level of periodontal diseases and treatment needs in populations. Material and Methods Study methodology The target population of the present study was adults living in the rural area of Araçatuba in the Brazilian state of São Paulo. sociobehavioural and environmental factors in oral disease and health is demonstrated in a large number of epidemiological surveys 2-6. The following formula was used for the sample calculus27: N = p q / E2 p is the probability of individuals of the sample having this characteristic. The patients were chosen at random. the removable partial denture were associated with increased plaque accumulation. 48. periodontal calculus and pocket. The aim of this study was to describe the periodontal conditions and to analyze the association between the wearing of fixed/removable partial dentures and periodontal disease in a representative adult rural population in southeast Brazil. in accordance with research carried out by the University of São Paulo in 199828. which may subsequently predispose the area to periodontal disease25. The sample was randomly selected and weighted to represent the 35-44 year old adult population of rural area of Araçatuba. Studies suggest that the use of partial dentures may constitute a risk factor for periodontium health. and in some cases. even on buccal surfaces of teeth. in 2002. Two hundred patients aged 35-44 years were examined between August 2004 and January 2005. A classic study on experimental gingivitis in humans proved that bacterial plaque or biofilm represents the main etiologic factor of periodontal diseases8. calculus and gingival index. the WHO recommended the Community Periodontal Index (CPI) application. tooth mobility and gingival recession20. genetic factors and viruses12.IBGE). In a large case-control study conducted by the University of Zagreb. the risk of caries and the amount of stress on natural teeth10. and is one of the most important states of the country.01) for plaque. The prevalence of periodontal disease in São Paulo State was considered 55%. The gingival health is adversely affected by removable partial dentures. not only on tooth surfaces in direct contact with the denture. it was observed good results regarding the periodontal health situation 26. the distribution and severity of oral diseases vary in different parts of the world and within the same country or region. According to some authors22-24. The study sample included 80 (40%) males and 120 (60%) females. Acting jointly with biofilm. To assess the periodontal status of populations. Various investigations have shown that there is an increase in the mobility of the supporting teeth. Croatia. and it allows for international comparisons7. carried out by the researches of the Yonsei University. abutment teeth had higher scores related to 1227 periodontal disease than non-abutment teeth. no signs of disease. Intra-rater reliability and agreement with gold standard dentist were assessed during and at the end of session. score 2 . score 1: fixed partial denture wearer. 16. Gauze squares. Probing depth was defined as the distance from the free gingival margin to the bottom of the pocket/sulcus7. but not named. pregnant women and smokers. 70 60 Sextants (%) Braz J Oral Sci. Clinical examinations Examinations were performed by one dentist.6 mm or deeper periodontal pockets7.gingival bleeding after gentle probing. score 4 . score 1 . subjects were excluded if they were diagnosed with psychiatric problems. 13-23. intoxicated with alcohol or dugs. for which the chi-square test were used. 1 . The exams were undertaken with the understanding and written consent of each subject. Among these subjects. Araçatuba.Percentage distribution of sextants by the highest Community Periodontal Index (CPI) score.4 or 5 mm deep periodontal pockets.80).5 mm was used to measure the CPI. Strict procedures for infection control were followed.presence of supra or subgingival calculus or other plaque retentive factors. 31. The WHO recommends that the pressure applied in probe should not exceed 20 grams. For each tooth. 0 0 1 2 3 4 X CPI Fig. sterile sets of plane mouth mirrors and Community Periodontal Index (CPI) probes were packed in sufficient quantities for each working day. Level of statistical significance was chosen at p<0. since all patients present alterations in their periodontal condition. 6 sites were examined: mesial. Ten index teeth (17. The session focused on the interpretation of indexes measuring pathologies sought during examinations and identification of dental prosthesis. Later. the researchers visited the individual and provided more information about the study and encouraged participation. Eligible subjects who consent to participation were invited to go to the local health center in a specific day. score 3: combined dentures (fixed/removable) wearer. score 3 . 81 (40. 100% presented some periodontal problem. 46.5%) wore dental prosthesis. midline and distal on both vestibular and lingual/ palatal surfaces. Brazil. score 2: removable partial denture wearer. 33-43. The level of concordance for measures relative to periodontal conditions and denture identification was good (mean [kappa] index was 0. Clinical examinations were carried out in natural light. The Community Periodontal Index (CPI) was recorded for each sextant. Confidentiality was assured to participants and all recording forms were numbered. and 47. A 0. 1228 . A few days later. a pilot study was carried out on adults aged 35-44 years who attended the Araçatuba School of Dentistry Clinic to test the feasibility of the study and dental examination. 37-34. Table 1 and Figure 1 show the prevalence of periodontal condition measured by the Community Periodontal Index (CPI) on the subjects who underwent the periodontal examination.5 and 5. Letters were sent to selected individuals and explained the aims of the study and solicited participation. 3 and 4. and they were conducted in a health center located in the rural area. 26. and 119 (59. Data analysis For the descriptive statistical analysis of the periodontal parameters. Hence. and 37 in the mandible) in six sextants (17-14. The presence or absence of disease and the identification of partial denture in the same sextant were compared. Results Of the 200 subjects recruited into the survey. and 27 in the maxilla. 5(19):1226-1231 50 40 30 20 10 Pilot study and calibration Dental examiners participated in a 5-day training and calibration session. The clinical examination lasted an average of 10 minutes per adult. There was no need to change the methodology previously proposed. 24-27. A sextant was examined if at least 2 teeth are present.5%) were non-users of denture. Exclusion criteria were presence of diseases/conditions that may interfere with the clinical examination and the results. The use of dental prosthesis was evaluated according to criteria recommend by WHO7: score 0: don’t wear dental prosthesis.Association between dental prosthesis and periodontal disease in a rural Brazilian community and other relevant municipal information. Ethical considerations This study was aware of the Code of Ethics of the World Medical Association (Declaration of Helsinki) and it received ethical approval from the Research Ethics Committee of the Araçatuba School of Dentistry (file: FOA 2178/2003). 11. and 44-47) were probed and scores ascribed to each sextant on the following basis: score 0 . assisted by a recorder.5 mm ball-ended probe with color markers at 3. fixed and/or removable. 2006. Ten percent of the sample (N=20) was re-examined to test for reliability during the fieldwork. recorded by the sum of scores 2.05. cotton buds. Molars were examined in pairs and the highest score was recorded for each sextant. 36. mean values were calculated for each patient and for sextant. 0014). CPI Score % patients Mean number of sextants 0 1 2 3 4 X 9 Total 0 0 44.71% of sextants.9%. 35 to 44 and 65 to 74 years1.1 3. the percentage found was much lower (8. The percentage of patients with periodontal pockets was relatively high (55. Among the factors that account for poor periodontal Table 2 . and calculus and shallow pocket were the most prevalent periodontal condition. In 2003.5 47 8.83%). The relationship between subjects categorized as exhibiting considerable periodontal disease (score 3 and 4 as worse condition) and those categorized as partial denture wearer is demonstrated in table 2. and only a small proportion was recorded as having deep pockets (score 4). The results showed a mean number of 0.4 - 6.2 sextant presented bleeding or more severe problems.4 0. p=0. Thus. 5(19):1226-1231 Association between dental prosthesis and periodontal disease in a rural Brazilian community Table 1 . A mean number of 4 sextants presented bleeding and calculus as worse condition. 2006. and the sum of these conditions (score 1 and 2) represented 67. score 3 and 4 represented by 19. but when only deep pockets were considered. being a partial denture wearer was significantly associated with an increased likelihood of being categorized as exhibiting considerable periodontal disease (X2 = 10.5%). gingivitis was the principal clinical manifestation of periodontal disease in the subjects examined. Periodontal disease Prosthesis Present Absent Total Present 172 (15%) 2 (0%) 174 (16%) Absent 871 (78%) 73 (7%) 944 (84%) Total 1 043 (93%) 75 (7%) 1 118 (100%) 1229 .13% of total of sextants. A mean number of 5.Number and percentage distribution of sextants by the presence of periodontal disease and use of partial dentures.2 sextants had 4 mm or deeper periodontal pockets. The subjects scored either calculus (score 2) or shallow pockets (score 3).0 0. A study verified the periodontal conditions and treatment needs according to the Community Periodontal Index of Treatment Needs (CPITN) in a worker population in Brazil29. in the sextant where the dentures were recorded.4. due to there remaining less than 2 teeth.1 0. For the 35. as calculus and periodontal pocket. which represents 6. only 1. and having a few severely involved teeth.25% of the total. 21. Brazil.5 0 - 100.1 0. all subjects presented signs of periodontal disease. affecting more sextants.2%.to 44-year-olds rural population. the decrease in the rates of periodontal disease prevalence in the Brazilian population is most likely due to conditions such as the consolidation of the National Public Health System and the greater care given to oral health.9 1. Araçatuba. of individuals with no periodontal problem within the age range of 15 to 19. In this study.9% and 7.Percentage distribution of subjects and mean number of sextants by the highest Community Periodontal Index (CPI) score. similar to our findings. This means that the periodontal alterations were more generalized. Araçatuba.1 healthy sextants. Brazil. however. The mean number of sextants with healthy periodontal tissues was 0. 2006. On comparing the 1986 and 2003 national surveys. were less prevalent (6.00 independently of wearing of dentures. respectively.5%). Discussion This paper set out to address the hypothesis that there was an association between the wearing of fixed/removable partial dentures and periodontal condition in a Brazilian adult rural population. The results of this analysis suggest that partial dentures may play an important role in the development of periodontal disease. All denture wearer displayed periodontal problem.Braz J Oral Sci. a National epidemiological survey showed a percentage of 46.75. Excluded sextant (score x). whereas only 1 sextant were found to have a pocket of 4 mm or more. risk factors and prognostic risk factors. Besides this. To maximize cost-effectiveness. transport. The access to health services must be facilitated so all can be assisted. Another study carried out in a rural area of São Paulo State.5% of children aged 6 to 14 years presenting signs of periodontal disease 31. the strategies must emphasize the importance of adapting the services to the necessities and difficulties of those populations. However. worse habitation condition.32. the in situ effect of dental prosthesis must not be overlooked in relation to its multiple functionality aspects. In conclusions. the changes in the periodontal conditions of patients wearing different designs of removable partial dentures over long-term were evaluate. such as definition of margins and prosthetic adaptation which. not only in relation to curative treatment. A study comparing patients with removable partial dentures. the wearing of partial dental prosthesis was associated with periodontal disease in this study population. a statistically significant difference was found between both periodontal conditions. Agreement exists among several authors about the need for oral home care and a regular recall system. reinstruction and re-motivation. A research performed in rural and urban areas of a Brazilian city compared the oral health condition of these regions. Brazil. Clinical studies showed that when providing a regular recall system with control. The results suggest a need for populationsbased plaque control programs in an attempt to reduce the 1230 . which influences the success of prostheses26. and the social difficulties can be higher to the population of rural areas. it is distinguished the worse periodontal conditions of these populations. In populations with low level of oral hygiene and limited oral health care resources. and a significant percentage of cases might have been prevented if plaque control interventions had been implemented. and the authors observed that rural residents had worse index than urban residents30. the abutment teeth presenting a greater depth of gingival crevice. work. patients with no prosthesis. The prevalence of denture wearers with periodontal disease in the present survey was significant. For rural populations. In developing countries as Brazil. Some studies examined effects of forces transmitted to abutment teeth. an increase of calculus and dental mobility. but also. prevention and control of periodontal diseases should be based on predicted risk of developing these diseases. difficulties in the access of children to school and of people to health services. and eventual orthodontic tooth movement. found values as 99. That periodontal alterations may be solely due to the patient’s poor oral hygiene with no prosthesis involvement in this result32. Older patients maintain hygiene of natural teeth better than denture hygiene. to preventive and educative activities. periodontal probing depth. on comparing the periodontal condition of abutment teeth and natural teeth. and alveolar bone loss on the abutment teeth in removable partial denture wearers 33. partial dentures might not cause any damage of the periodontium. and their results underscore the need for better instruction on maintaining denture hygiene20. or patients with fixed partial dentures showed the greatest plaque and calculus deposition. and mainly. a “whole population” strategy for general oral health promotion should be applied36. like income.Braz J Oral Sci. based on the risk profile. the iniquities are present in many sections and regions. with control of bacterial plaque by the dentist and the patient. The factors related to the development of periodontal disease could be involved both in sites with and without dentures. as the wearing of dental prostheses. habitation conditions. it is necessary to know the social determinants of health involved in the health-disease process of periodontal disease. and probably one of the most evident factors was poor oral hygiene as observed by the authors during the clinical examinations. the substantial dental and periodontal destruction in patients with partial dentures is found more frequently in patients who had a poor oral hygiene and seldom visited their dentist. including the main oral diseases as dental decay and periodontal disease. with small wages. the results highlight the need for further epidemiologic studies to clarify the relationship between dental prosthesis and periodontal disease. Despite some methodological differences among surveys performed with rural populations. may effectively contribute to the development of periodontal disease. According to these authors. evaluation of the wearing of partial dentures and periodontal condition must be carried out based on several evidences related to the importance of controlling bacterial plaque in order to preserve the integrity of the periodontium. Thus. sanitation and environment. Various researches18-20 have shown that. To understand these differences. 5(19):1226-1231 Association between dental prosthesis and periodontal disease in a rural Brazilian community condition are the lack of professional advice regarding oral health maintenance and the low rate of follow-up19. jiggling. if not correct.34-35. the basic strategy should be individualized treatment to eliminate infection by periopathogens and to control or/and reduce modifying risk indicators. 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Report "Association Between Dental Prosthesis and Periodontal Disease in a Rural Brazilian Community"