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Indian Journal of Community Medicine

A Study of Epidemiological Factors Influencing Periodontal Diseases in selected Areas of District Ludhiana, Punjab

Author(s): M. Sood

Vol. 30, No. 2 (2005-04 - 2005-06)

Introduction:

The periodontium consists of investing and supporting tissues of teeth i.e. gingivae (gums), periodontal ligaments, cementum and alveolar bone. It is widely affected by dental plaque - a diverse microbial community found on tooth surface, embedded in a matrix of polymers of bacterial and salivary origin1. Later other supporting structures become involved so that small pus filled pockets form around teeth. There is loss of attachment and bone loss leading to tooth motility.

Epidemiological studies conducted in various countries report that 5-20% of any population will have severe forms of periodontitis and moderate disease affects a majority of adults3. Studies conducted in India show that every second person above the age of 35 years has gum pockets and 35% of total teeth extracted after the age of 35 years are due to periodontal disease4. The disease process is enhanced under the effect of smoking/tobacco5,6,7 and predisposes to coronary heart disease8 due to an increased risk of thromboembolic phenomena.

Materials and Methods:

The present cross-sectional study on epidemiological correlates of periodontal disease was carried out in field practice areas of Dept. of Social and Preventive Medicine, Dayanand Medical College, Ludhiana Statistical estimates of sample size were made according to established formulae9.

Systematic random sampling chose 500 urban and 500 rural subjects Periodontal status of each of study subjects was assessed as per recommendations of the World Health Organization10,11. Instruments used were sets of plane mouth mirror and periodontal probe with graduated shank, which were disinfected in 2% glutaraldehyde after each use. Data were analyzed on computer using spss software. Chi square test of significance was applied.

Results:

In the present study 94 subjects admitted to being current smokers while 30 were former smokers. Prevalence of bleeding gums was 85.1% and 86.7% in current and former smokers are compared to 66.5% in never smokers. This difference is statistically significant. (Table I)

Out of 34 subjects with previously diagnosed coronary artery disease, only 17.6% showed healthy periodontium as compared to overall 29.3% prevalence in general population, 82.3% subjects with coronary artery disease (CAD) showed bleeding gums, 100.0% showed calculus, 82.3% shallow and deep periodontal pockets and 79.4% showed loss of tooth attachment. These findings depict a significant association of coronary artery disease with periodontal disease when compared with prevalence of above-mentioned conditions in general population (97.0%, 29.1%, 12.5% and 13.3% respectively. (Table II)

Table I - Comparison of Periodontal Status of Subjects as per Smoking Habits

Type of smoker Number Examined Community Periodontal Index (CPI)
Healthy Bleeding Calculus Pocket (4-5mm) Pocket (≥6mm) Loss of Attachment
N % N % N % N % N % N %
Never 876 275 31.4 583 65.5 846 96.6 198 22.6 65 7.4 70 7.9
Current 94 15 15.96 80 85.1 94 100.0 74 78.7 51 54.3 54 57.4
Former 30 3 10.0 26 86.7 30 100.0 19 63.3 9 30.0 9 30.0
Total 1000 293* 29.3 689* 68.9 970* 97.0 291* 29.1 125* 12.5* 133 13.3
*p < 0.01

Table II -Periodontal Status of Subjects with Respect to Smokeless Tobacco Use

Form of Tobacco Number Examined Community Periodontal Index (CPI)
Healthy Bleeding Calculus Pocket (4-5mm) Pocket (≥6mm) Loss of Attachment
N % N % N % N % N % N %
Khaini 120 0 0.0 118 98.3 120 100.0 108 90.0 65 54.2 50 41.7
Quid 16 2 12.5 13 81.2 16 100.0 13 81.2 10 62.5 09 56.2
Zarda 155 19 12.3 118 76.1 155 100.0 121 78.1 74 47.7 73 47.1
None 701 210 29.9 470 67.0 673 96.0 168 24.0 56 8.0 56 8.0
Misri 08 2* 25.0 6 75.0* 8 100.0* 6 75.0 4 50.0 4 50.0 *

p<0.01

Table III -Comparison of Periodontal Status of Subjects with Respect to Presence of Coronary Artery Disease

Subjects Number Examined Community Periodontal Index (CPI)
Healthy Bleeding Calculus Pocket (4-5mm) Pocket (≥6mm) Loss of Attachment
N % N % N % N % N % N %
With Coronary artery disease 34 .06 17.6 28 82.3 34 100.0 28 82.3 28 82.3 27 79.2
Total subjects 1000 293 29.3* 689 68.9* 97 97.0* 291 29.1* 125 12.5* 133 13.3

P value *P <0.01

Discussion:

The fact that tobacco smokers have a higher prevalence of periodontal disease has been documented in various studies. In a study on peripheral blood monocytes from healthy nonsmoking donors it was found that nicotine leads to increase in secretion of prostaglandin E2 via up-regulation of lipopolysaccharide mediated pathways. More over smokers also tend to have a poorer oral hygiene status than nonsmokers2. Smoking also reduces antibodies in saliva and leads to xerostomia which can cause many oral health problems (www.Periodontitis.net). The influence of smoking on adult Periodontitis and serum IgG2 levels has been established12. A strong association between smoking and attachment loss was found in a study in subjects with minimal or no periodontal disease13. The vasoconstrictive effect of nicotine causes a reduction in gingival blood flow, which translates into a weakening of defenses of gingiva14. Smoking also depresses level of circulating antibodies, chemotactic and phagocytic activities of oral polymorphonucleocytes.

A higher prevalence of periodontal disease in smokeless tobacco users has been reported elsewhere also15. Poor oral hygiene status of these subjects has been shown to play a major role in this in addition to the effect tobacco per se has on periodontal tissues that is irritation of tissues and lowering of their resistance.

The association between cardiovascular disease and periodontal disease has been extensively studied. It is a well known fact that periodontal infection leads to a systemic exposure to bacteria during dental manipulations and that the infection periodontium may be a source of potentially deleterious mediators3,14. Two important limitations encountered during the course of study were (a) subjectivity of response of subjects with regard to personal habits could not be ruled out. (b) Relatively small sample size in age group above 60 had to be accepted in view of exclusion criteria of edentulous persons. However, a need for increasing the awareness of people regarding oral health is clearly evident from the findings of this study.

References:

  1. Marsh PD, Bradshaw DJ. Dental Plaque as a Biofilm. J Ind. Microbiol 1995 Sep; 15 (3): 169-175.
  2. Spolsky VW, Epidemiology of gingival and periodontal diseases. Clinical Periodontology, WB Saunders Company, New York, 1996; 61-81.
  3. Research Science and Therapy Committee of the American Academy of Periodontogy. Position Paper-Epidemiology of Periodontal Diseases. J Periodontol 1996; 67:935-945.
  4. Kulkarni AT, Sachdeva NI, The Problems of Oral Health in India. Swasth Hind 1995, May June: 62-64.
  5. Riveria-Hidalgo F. Smoking and Periodontal Disease-A review of literature. J Periodontol 1986; 57 (10): 617-624.
  6. Goultshin J, Cohen HDS, Donchin M, Association of Smoking with Periodontal treatment Needs. J Peridontol 1990; 61: 364-367.
  7. Zambon JJ, Grossi SG, Machtei EE, Ho AW, Dunford R, Genco RJ. Cigarette smoking increases risk of subgingival infection with periodontal pathogens. J Periodontol 1996;67 (suppl) : 1050-1054.
  8. Beck J, Garcia R, Heiss G, Vokonas SP, Offenbacher S. Periodotal Disease and Cardiovascular Disease. J Periodontol 1996: 67 (10): 1123-1137.
  9. Sampling Methods, In Mahajan BK ed. Methods in Biostatistics for Medical Students and Research Workers. Jaypee Brothers Medical Publishers Delhi, 1997; 92-94.
  10. Epidemiology, Etiology and Prevention of Periodontal Diseases. Report of a WHO Scientific group. Technical report series 621. World Health Organization Geneva, 1978.
  11. Oral health surveys -Basic Methods. World Health Organization Geneva, 1997
  12. The Influence of Smoking And Race On Adult Periodontitis And Serum IgG2 Levels. J Periodontol 1998, 68:171-177.
  13. The Effect of Smoking on Individuals with Minimal Periodontal Destruction J. Periodontol 1998;69 : 165-170.
  14. Genco RJ Current view of Risk Factors for Periodontal Diseases. J Clinical Periodontol 1990 : 17;533-541.
  15. Warnakulsurya K. Smoking and Chewing habits in sri Lanka-Implications for oral Cancers and Pre-cancers. In Gupta PC, Hammer JE 3, Murti PR eds Control of Tobacco Related Cancers and Other Diseases. Oxford University Press, Bombay 1992, 113-120.

Deptt. of Community Medicine, DMC, Ludhiana

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