Quality of life = health, wealth…and teeth!

To answer these and other questions, Allen and McMillan* designed a study to test the hypothesis that adults with teeth had a better oral health-related quality of life than did adults without teeth. Furthermore, they theorized that adults seeking implants had the poorest health-related quality of life.

Method. Four groups (103 subjects) were studied: 1) Patients with a poor history of wearing complete dentures who sought dental implants, 2) Patients seeking implants, but receiving a complete denture instead, 3) Patients seeking to replace their existing complete dentures, and 4) Patients with teeth who received routine dental care (who served as the controls).

All subjects completed an Oral Health Impact Profile (OHIP) and a questionnaire (SF36) pre- and post-treatment. The OHIP is a comprehensive measure of 49 statements related to oral health that evaluates functional limitations, pain, psychological discomfort, physical disability, and handicaps. The SF36 is a generic health status measure that consists of 35 statements divided into 8 subscales: physical functioning, social functioning, role limitation-physical, role limitation-emotional, mental health, vitality, pain, and general health perception. Finally, there is a last question that asks subjects to globally assess his or her present general health status to that of 1 year previously.

At the end of the study, all subjects (except the control group with teeth) were evaluated relative to their satisfaction with their prostheses pre- and post-treatment.

Results/Discussion. Ninety-eight patients completed the study. All denture wearers (Groups 1, 2, and 3) expressed similar dissatisfaction with their dentures when they first sought treatment. Their complaints included looseness, pain beneath the dentures, and difficulty eating with unstable dentures. Most complained about mandibular dentures but not about their maxillary dentures.

While initial denture satisfaction (or lack of it) was similar in all subjects, the baseline OHIP indicated differing psychological consequences when it came to total tooth loss. As expected, subjects with teeth had the lowest OHIP scores. Patients seeking implants (Groups 1 and 2) had higher OHIP scores than subjects (Group 3) who sought a denture replacement without knowing about or being offered an implant alternative.

What does this mean? While complaints by denture wearers may be similar relative to their dental problems, their psychological makeup and needs are quite different. Both affect their outcome. Once subjects in Group 1 received their dental implants, their satisfaction levels were raised irrespective of whether their implant prosthesis was a fixed bridge or a removable prosthesis on top of the implants. Likewise, subjects in Group 3 were satisfied with their outcome because they perceived an improvement from the new prostheses they had desired. Subjects in Group 2, however, were not as satisfied, even if they received a better fitting prosthesis, because they sought - and were denied - implants.

The post-operative data of the SF36 health status measure differed from the OHIP results. All groups had similar responses. The authors concluded that the SF36 captures aspects of general health but not oral health outcomes.

Conclusions. Patients who received the treatment of their choice were most satisfied with the outcomes and reported significant improvement in their oral health-related quality of life. While patients receiving dental implants were satisfied with their results, their post-treatment OHIP scores remained higher than the pre-operative OHIP scores of those in Group 3, the patients who sought and received new dentures. The issue, stated the authors, may not be the relative post-treatment scores, but rather that the scores changed as a result of treatment. Regardless of treatment, patients with their own teeth reported the best quality of life-outcomes.

Comments. This research highlights important elements critical to successful patient care. For starters, clinicians should be aware that patients who choose to replace dentures with implants have a poor oral health-related quality of life and that some of these issues remain post-treatment. These issues may continue post-treatment, but to a lesser extent. The polar opposite is the patient who is successfully functioning with complete dentures. Their oral-related quality of life is fundamentally better than their counterparts who seek implants. It may be wise to leave them that way even though we know that implants make prostheses more stable.

*Allen PF and McMillan AS: A longitudinal study of the quality of life outcomes in older adults requesting implant prostheses and complete removable dentures. Clin Oral Impl Res 14:173-179, 2003.

Prenatal care includes healthy gums

In a study of 1,115 pregnant women conducted by researchers at the University of North Carolina-Chapel Hill*, women with severe periodontal disease developed preeclampsia more than twice as often as those with good gingival health. Preeclampsia is a hypertensive disorder that can lead to organ damage and, in a worse-case scenario, death.

Each subject in this study received a periodontal examination at the time they enrolled in the study and within 48 hours of delivering their baby. Severe periodontal disease was classified as having 15 or more sites with pockets greater than (or equal to) 4mm. Only 763 women completed the study, of which 100 had severe periodontal disease. Of these, 6% who had severe periodontal disease at their baseline examination developed preeclampsia. In addition, 4% more (for a total of 10%) had severe periodontal disease at their post-partum examination but not at baseline, who also developed preeclampsia.

How did women with healthy gums fare? Two percent of this group had their periodontal condition worsen during pregnancy and developed preeclampsia. In addition, 3% of the healthy group developed preeclampsia though their gums remained healthy at the time they gave birth. For comparison, preeclampsia affects 5-10% of all pregnancies, but these percentages do not indicate periodontal health.

From this other published papers, we should consider the effects of untreated periodontal disease during pregnancy…but do we know why? One hypothesis is that bacteria from women with active periodontal disease enter the bloodstream and affect the placental unit. This incites an inflammatory response in the placenta or may cause oxidative stress early in the pregnancy. These result in placental damage and preeclampsia. Given the well-documented fact that periodontal disease in pregnant women is associated with low birth weight and may put the newborn at risk, women of child-bearing age should be encouraged to practice good oral hygiene measures and make certain their periodontal conditions are treated before/and during pregnancy.

*Boggess KA, Lieff S, Murtha AP, Moss K, Beck J, and Offenbacher S: Periodontal disease associated with risk of preeclampsia. Obstet Gynecol 101:227-231, 2003.

Dental Sci-Fi meets the Terminator

The title of this piece has many layers. Read the article and draw your own conclusions.

We agree, in principle, that dental research should develop preventive and therapeutic measures to alleviate pain and suffering caused by teeth. After all, dentistry has been committed to eradicating 2 of the 3 most common diseases known to mankind: dental caries and periodontal disease. (The common cold is the third most common disease…and we haven't learned how to control that, yet). Fluoride and improved oral hygiene measures have reduced dental decay by 70% across the nation. The incidence of periodontal disease has greatly declined from afflicting 80% of the adult population to approximately 25% of all adults (depending on which study you read) as a result of plaque-reducing treatments, better dental care, and public awareness.

If the challenge to reduce decay and gum disease wasn't enough, researchers have thrown down a new gauntlet: eliminate wisdom teeth. They don't mean extract every wisdom tooth in every person's mouth, they mean figure out a way to prevent them from ever forming. Why consider this? And is it a good idea? You be the judge.

Authors of a recent article in the Journal of the ADA* proposed the following:

1. Neanderthal and Cro-Magnon man (and woman) needed to chew on their third molars (wisdom teeth) due to their fibrous diet and the need for teeth as weapons
2. Enter evolution. Modern human jaws are shorter than those in our prehistoric ancestors due to the fact we are not as dependent on teeth for survival. We no longer need teeth to function weapons; we are no longer hunter/gatherers; we walk erect; we have softer diets that require little in the way of tooth power.
3. Third molars often remain impacted; third molars are of little use; third molars may cause pain and infections.

The authors challenge the profession to develop techniques to prevent the formation of third molars. In other words, eliminate them before they become a nuisance. This reminds us of the Terminator movies that send Arnold back in time to prevent a futuristic problem. Is their idea feasible? They think so, by developing a way to prevent the ectodermal lamina dura from interacting with the jaw mesenchyma. When these two tissues interact, they form a tooth. Since this doesn't start to occur until well after 5 years of age, there is ample opportunity to prevent the key tissues from interacting and, in turn, prevent the wisdom teeth from forming.

Is this a desirable goal? After all, couples can now determine the sex of their unborn child, and can often choose what day it is to be born. Witness the increase of Caesarean sections that are more a matter of convenience than a necessity. What about genetically engineered foods? Blight-free potatoes? Cloning? Do we tamper with evolution? Terminate aspects of human development we don't like? Alter the species in artificial ways? How about genetically altering kids so they won't need braces? Now there's an idea!

*Silvestri AR and Singh I: The unresolved problem of the third molar (Would people be better off without it?) JADA 134:450-455, 2003.

Prenatal care includes healthy gums

To New Yorkers, a smear means cream cheese spread on a bagel. To dentists asked to treat tooth sensitivity, a smear relates to the "dentinal smear." The smear layer is a thin protective coating that seals the dentinal tubules that are exposed once the gums recede and outer tooth surface (cementum) wears down from vigorous toothbrushing. Why is it important to retain this smear layer and the smear plugs that clog the dentinal tubules? The smear layer naturally protects teeth and reduces sensitivity to cold and other stimuli. Efforts should be made to keep Nature's protective sealant intact.

For those uncertain of what dentinal tubules are, they penetrate through the dentin and dentin is the hard material that protects the nerve canal. When the outer layers of enamel and cementum wear away, the dentin is exposed. Think of dentin being constructed like a fiber optic cable with countless tubules emanating from the center and insulated on the outside with a layer of cementum. Each tubule has tiny nerve endings that may cause pain when stimulated. Under normal circumstances, as the cementum wears away these tubules are sealed by a thin protective smear layer.

How easy is it to remove this smear layer? Easy. Very easy. Researchers* tested cola drinks, orange juice, white wine, vinegar, and mucolytic syrup and found that each sample (all are mild acids) removed and dissolved the smear layer plus the smear plugs that clogged the dentinal tubules. Once removed, the dentinal permeability was increased and the teeth became hypersensitive. So the next time you pause for the drink that refreshes, pour some Florida sunshine into a glass, have some chilled Pinot Grigio, sprinkle balsamic dressing, or brush your teeth too hard, think of receded gums, exposed roots…and a bagel with a smear.

*Prati C, Montebugnoli L, Suppa P, Valdrè G, and Mongiorgi R: Permeability and morphology of dentin after erosion induced by acidic drinks. J Perio 74:428-436, 2003.

Surgical Lectures | Hygiene Club | Dentists Only

Park Avenue Periodontal Associates
532 Park Avenue, New York, NY 10021
Telephone (212) 838-0940   Fax (212) 355-4784
E-Mail Contacts

Copyright © 2000-2005, Park Avenue Periodontal Associates. All rights reserved. Please read our legal disclaimer.