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In This IssuePeriodontitis and

Renal Disease 1

In Practice 4

Hygiene Page 6

Clinical Practice 7

Health Care Trends 10

THE FORSYTH

INSTITUTE

Professional

Continuing

Education Program 11

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Colgate Oral Care Report

normal renal function (n = 4,928),reported a significant associationbetween the presence of antibodiesagainst certain PD pathogens anddiminished kidney function.2 Inparticular, high titers of antibodiesagainst P. gingivalis, T. denticola, S.noxia, A. actinomycetemcomitans, andV. parvulawere associated with anincreased risk of reduced renalfunction.2 In addition, patients whohad a higher total bacterial load, ahigher plaque score, or higherlevels of interproximal attachmentloss had lower glomerular filtrationrates and, therefore, worse renal

function.2

Periodontitis was found to beparticularly severe in a study ofpatients with end-stage renaldisease,3 all of whom were onmaintenance hemodialysis. Clinicalloss of attachment, papillarybleeding index, and plaque indexscores were reported to be moresevere than those found in thenormal control population. In fact,their status was comparable tocontrols without renal disease that

had full blown periodontal disease(PD controls). Patients with lesssevere renal disease, those oncontinuous ambulatory peritonealdialysis, and those with pre-dialysischronic kidney disease all hadintermediate levels of PD; moresevere than the general controls,but less severe than the PD controls(Figure 1, next page).3

Providing Continuing Education as a Service to Dentistry Worldwide

Editor-in-Chief

Dominick P. DePaola, DDS, PhD; U.S.A.President and CEOThe Forsyth Institute

Associate Editors

John J. Clarkson, BDS, PhD; Ireland

Saskia Estupin-Day, DDS, MPHPan American Health Organization; Wash., D.C.

Joan I. Gluch, RDH, PhD; U.S.A.

Kevin Roach, BSc, DDS, FACD; Canada

Zhen-Kang Zhang, DDS, Hon. FDS,RCS (Edin.); China

International Advisory Board

Per Axelsson, DDS, Odont.Dr.; Sweden

Irwin Mandel, DDS; U.S.A.

Roy Page, DDS, PhD; U.S.A.

Gregory Seymour, BDS, MDSc, PhD,MRCPath; Australia

Volume 17, Number 4, 2007

ORALCAREREPORTORALCAREREPORTTHE

A Summary Journal of Advances in Dentistry and Oral Health Care

Periodontal disease (PD) hasbeen widely reported to be associatedwith an increase in the systemic

inflammatory response, and hasemerged as a possible risk factor foratherosclerosis and cardiovasculardisease over the last decade. Thistopic has most recently beenaddressed in the Periodontal Page(Oral and Systemic HealthConsensus Statement) in Volume16, Number 3, of the Oral CareReport. New research now suggeststhat periodontitis may alsocontribute to the systemicinflammatory burden in renal

disease.1

Periodontitis andRenal Disease

Chronic renal failure is theresult of the progressive andirreversible loss of functioningnephrons in the kidney, whichproduces a decline in theglomerular filtration rate. Fiverecent studies2-6 have investigatedthe relationship between

periodontitis and renal disease;three with findings suggesting anassociation,2-4 and two that donot.5,6

Studies Suggesting anAssociation BetweenPeriodontitis and RenalDisease

A study that comparedpatients with reduced renalfunction (n = 103) with those with

Periodontitis andRenal Disease

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Diabetic patients are atincreased risk of developingperiodontitis; poor glycemiccontrol hastens the progression ofPD, which in turn seems to furtherimpair glycemic control.4 Inaddition, diabetic nephropathy is acommon complication of diabetes.A study of diabetic patients andrenal insufficiency (n = 529)

reported that periodontitis ispredictive of the development of

overt nephropathy and end-stagerenal disease.4 This study followeda population of type II diabeticAmerican Indians for up to 22years. Overt nephropathy wasdetermined by measuringmacroalbuminuria, the excretionof albumin protein in the urine.They found that the incidence ofboth end-stage renal failure andmacroalbuminuria increased withthe severity of periodontitisrecorded at the start of the study.After adjustments were made fordifferences in age, sex, diabetesduration, body mass index, andsmoking habits of the patients, theincidence of macroalbuminureawas between 2 and 2.6 times higheramong individuals with moderateto severe periodontitis, oredentulous individuals, thanamong those patients who had noor mild periodontitis (Figure 2).4

page 2

Figure 2. Incidence of Overt Nephropathy in Diabetic Patientswith Periodontal Disease

From Shultis, et al.,20074

Casesper1000personyears

Macroalbinuria

0

5

10

15

20

25

30

35

40

45

50

End-Stage Renal Disease

None/mild periodontitis

Moderate periodontitis

Severe periodontitis

Edentulous

Figure 1. Periodontal Disease Status of Patients

with Renal Disease

CAPD: Continuous ambulatory peritoneal dialysisCKD: Chronic Kidney DiseasePD: Periodontal disease

From Borawski, et al.,20073

GingivalorPlaqueIndexScoreor

ClinicalAttachmentLoss(mm)

Hemodialysis(n=35)

0

1

2

3

4

5

6

Clinical attachment loss

Plaque index

Gingival index

CAPD(n=33)

Pre-DialysisCKD (n=38)

PD Controls(n=26)

General Controls(n=30)

In patients with renaldisease, a positivecorrelation between markers

for a systemic immuneresponse and the severity of

periodontal disease has beenreported; therefore,

periodontitis may contributeto the systemic inflammatory

burden in renal disease.

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Studies Not Suggesting an

Association BetweenPeriodontitis and Renal

DiseaseTwo other studies of renal

disease patients found nocorrelation between periodontitisand renal insufficiency. A study of52 patients on maintenancehemodialysis failed to find astatistically significant difference inthe bacterial composition of sub-gingival plaque between patients

and age-matched controls.5 Inaddition, no statistically significantdifferences in bleeding index,number of teeth, or the percentageof sites with more than a 3 mm lossof attachment were found. Unlikethe studies mentioned above, theinvestigators could not find anassociation between end-stage renaldisease and more severe PD.5

The second study, alongitudinal study of nine renaltransplant patients, recorded

subjects oral health through threestages of renal diseasepre-dialysis,dialysis, and post-transplant. Thestudy recorded no differencesbetween the three stages of thedisease using two measures of oralhealththe CommunityPeriodontal Index of TreatmentNeeds (CPITN) and theDecayed/Missing/Filled Teethindex.6 There was no increase inPD as the renal disease progressed

in these patients. However, sinceonly nine patients were availablefor follow up from a total of 39 whostarted the study, the results cannotbe treated as comprehensive.Larger studies with greaterstatistical power are needed toresolve the differences in resultsbetween these studies.

Overall, the prevalence ofmoderate to severe periodontitismay be higher in renal diseasepatients than in the general

population, and there is acorrelation between the severity of

the PD and renal insufficiency. Forpatients with type II diabetes,severe periodontitis may bepredictive of diabetic kidneydisease.

Periodontitis and

Cardiovascular Disease in

Renal Transplant Patients

While an increased incidenceof cardiovascular disease and

accelerated atherosclerosis in renaldisease patients are generally linkedto an increase in conventional riskfactors, PD is thought to play a rolein increasing systemic inflammationleading to increased atherosclerosis.A study of renal transplant patients(n = 83)7 found a significantpositive correlation between thelevels of gingival inflammation andthe carotid intima-media thickness(CIMT). Patients with a highgingival index had a mean CIMT

measurement of 0.85 ( 0.42) cm,while those with moderate or nogingivitis had a mean CIMTmeasurement of 0.68 ( 0.4;p = 0.01) cm. Therefore, a moresevere level of gingivalinflammation correlated with moreatherosclerosis in the carotidartery, suggesting that severe PDincreases the risk of cardiovasculardisease in renal transplant patients.7

Treatment of Periodontitisand the Reduction ofSystemic Inflammation

Periodontal therapy, such aslocal root surface debridement andmicrobial plaque control, and theconcomitant use of non-steroidalanti-inflammatory drugs have beenreported to reduce the systemicmarkers of inflammation.1Whilethere are undoubtedly manysources of inflammation for

page 3

patients with renal disease, controlof PD with effective therapy may

lead to an improvement in the levelof systemic inflammation in thesepatients, perhaps leading toimproved renal disease andcardiovascular outcomes.1OC

References

1. Craig RG, Kotanko P, Kamer AR, Levin NW.Periodontal diseasesA modifiable source ofsystemic inflammation for the end-stage renaldisease patient on haemodialysis therapy?Nephrol Dial Transplant 2007;22(2):312-315.

2. Kshirsagar AV, Offenbacher S, Moss KL,

Barros SP, Beck JD.Antibodies to periodontalorganisms are associated with decreased kidneyfunction. The Dental Atherosclerosis Risk InCommunities study. Blood Purif 2007;25(1):125-132.

3. Borawski J, Wilczynska-Borawska M,Stokowska W, Mysliwiec M. The periodontalstatus of pre-dialysis chronic kidney disease andmaintenance dialysis patients. Nephrol DialTransplant 2007;22(2):457-464.

4. Shultis WA, Weil EJ, Looker HC, Curtis JM,Shlossman M, Genco RJ, et al. Effect ofperiodontitis on overt nephropathy and end-stage renal disease in type 2 diabetes. DiabetesCare 2007;30(2):306-311.

5. Castillo A, Mesa F, Liebana J, Garcia-Martinez O, Ruiz S, Garcia-Valdecasas J, et al.Periodontal and oral microbiological status ofan adult population undergoing haemodialysis:A cross-sectional study. Oral Dis2007;13(2):198-205.

6. Vesterinen M, Ruokonen H, Leivo T,Honkanen AM, Honkanen E, Kari K, et al. Oralhealth and dental treatment of patients withrenal disease. Quintessence Int 2007;38(3):211-219.

7. Genctoy G, Ozbek M, Avcu N, Kahraman S,Kirkpantur A, Yilmaz R, et al. Gingival healthstatus in renal transplant recipients: Relationshipbetween systemic inflammation and athero sclerosis.Int J Clin Pract 2007;61(4):577-582.

For the latest on the

oral-systemic disease

relationship, read

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whitepapers.

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Dental Flossing and

Interproximal CariesThe effectiveness of dental

flossing in caries prevention islargely supported by thelongstanding belief that flossingdisrupts and removes interproximaldental plaque, which is known tobe cariogenic.1 In fact, no clinicaltrials have been conducted inadults that investigate the effects offlossing on caries, nor that haveinvestigated the effects of flossing

in the presence of topicalfluorides.1 So what is the actualevidence for dental flossing andinterproximal caries prevention?

Basing their systematic reviewon six randomized clinical trials,Hujoel, et al.1 assessed the effect offlossing on interproximal cariesrisk. The overall characteristics ofthe six studies, which analyzed 808participants, ranging in age from 4to 13 years, over a period of 1.7 to3 years, are presented in the figure

at right. The outcomes, blindedexcept for one study,2were assessed

through either DFS, dfs or Defindices, based on clinical findingsalone, or both clinical andradiographic diagnostic criteria.1

The systematic review revealedthat infrequent or self-performedflossing showed no evidence ofbenefit on caries prevention.2-5

However, caries risk onpredominantly primary teeth wasreduced by 40% when professional

different clinical trials alsosuggest that the use of topicalfluorides may attenuate the

effectiveness of flossing.1

Animportant limitation of thestudies assessed is the absenceof rigorous control of thesubjects exposure to fluorides.1

Indeed, from one study toanother, fluoride exposurewas documented withinconsistent variables such asthe fluoride content ofdrinking water,3,4,6,7 the useof fluoridated or non-fluoridated toothpaste,4,5,7

flossing was provided on schooldays to first-grade childrenassumed to have poor oral hygiene

and low exposure to fluorides.6,7

LimitationsSome limitations to the

interpretation of these studiesshould be mentioned:

Compliance and caries riskin the population have beendemonstrated to be modifiersof the effectiveness of flossing.These were not controlledfor in these trials.1

The contrasting results of the

page 4

INPRACTICE

A systematic review of sixrandomized clinical trials inchildren revealed thatinfrequent or self-performed

flossing showed no benefit oncaries prevention.

Study

FlossingInterventionandCompliance

Control

Design

Wright, et al.(1979)6 (1980)7

Professionalat school

Supervised

No contralateralprofessionalflossing

Split-mouth

Granath, et al. (1979)5

Self-performed Unsupervised

No contralateralflossing

Split-mouth

Gisselsson, et al.(1988)3 (1994)4

Professionalevery 3rd month

Supervised

No professionalflossing

Parallel

(1983)2

Self-performed Unsupervised

No flossinginstructions

Parallel

Controlled Trials on Flossing and Interproximal Caries

*Difference between mean of interproximal surfaces examined per child and mean number of carious interproximalsurfaces at baseline multiplied by the number of children in the control group

Adapted from Hujoel, et al. 20061

CariesRisk

Flossing Group

Control Group

(374)

(Surfaces)

0.00

0.05

0.10

0.15

0.20

0.25

0.30

(624) (4199/3836) (414/289.5*) (1245/1229) (927/1810)

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professional flossing with chlorhexidine gel onapproximal caries in 12- to 15-year-oldschoolchildren. Caries Res 1988;22(3):187-192.

4. Gisselsson H, Birkhed D, Bjorn AL. Effect ofa 3-year professional flossing program withchlorhexidine gel on approximal caries and costof treatment in preschool children. Caries Res1994;28(5):394-399.

5. Granath LE, Martinsson T, Matsson L,Nilsson G, Schroder U, Soderholm B.Intraindividual effect of daily supervised flossingon caries in schoolchildren. Community DentOral Epidemiol 1979;7(3):147-150.

6. Wright GZ, Banting DW, Feasby WH. TheDorchester dental flossing study: Final report.Clin Prev Dent 1979;1(3):23-26.

7. Wright GZ, Feasby WH, Banting DW.Theeffectiveness of interdental flossing with and

without a fluoride dentifrice. Pediatr Dent1980;2:105-109.

the use of 0.2% NaF solutionfor rinsing,2,3,5 or the

application of topicalfluoride.2

The evaluation of thepossible harmful effects ofself-performed flossing wasnot examined.1

Nevertheless, the evidenceprovided is consistent with theconcept that dental flossing, whenproperly performed, candramatically reduce the risk ofinterproximal caries in young

children with poor oral hygieneand low fluoride exposure.1 Forthese reasons, Hujoel, et al.1 suggest

that dental professionals determinethe feasibility, on an individual

patient basis, of frequent,professional-quality flossing, and toassess its effect on the future needfor caries interventions.OC

References

1. Hujoel PP, Cunha-Cruz J, Banting DW,Loesche WJ. Dental flossing and interproximalcaries: A systematic review. J Dent Res2006;85(4):298-305.

2. Gisselsson H, Bjorn AL, Birkhed D.Immediate and prolonged effect of individualpreventive measures in caries and gingivitis

susceptible children. Swed Dent J 1983;7(1):13-21.

3. Gisselsson H, Birkhed D, Bjorn AL. Effect of

Professional Education

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Oral Bacterial

Species Associatedwith Halitosis

Halitosisalso referred to asmalodoror bad breathis a commonproblem, affecting approximately30% of the general population.1 Itis often caused by bacteria in theoral cavity that produce variousmalodorous substances, such asvolatile sulfur compounds.1,2 Thedorsal tongue surface has been

identified as an important site ofthis bacterial activity.2 It istherefore useful to examinespecific bacterial species present inthis area of the mouth, and explorewhich of these species may beassociated with halitosis.

Previous studies haveidentified certain types of bacteria,such as Streptococcus salivarius, thatpredominate in normal subjects.1

On the other hand, Gram-negativeanaerobic bacteria have been

associated with the production ofmalodorous compounds.1 Untilrecently, bacteria could only beidentified by traditional culturemethods which did not succeed inidentifying the majority of bacterialspecies present in the mouth;3

many bacterial species are resistantto cultivation in the laboratory.4

While not specific to halitosis,incomplete identification ofpathogens translates into anincomplete understanding of a

disease.4 Fortunately, newerlaboratory techniques, such aspolymerase chain reaction (PCR),have allowed identification ofadditional bacterial strains,doubling the number of distinctspecies estimated to infect thehuman oral cavity from 400 to 800.1

Clinical StudiesTwo recent clinical studies

have used these techniques to

compare bacterial species presentin adults with and without

halitosis.1,3 Several species werementioned as being mostassociated with halitosis in bothstudies, such as Solobacterium moorei,Eubacterium,Dialister, andFirmicutes.Six other bacterial species werementioned in only one of these twostudies (see table).

Both studies concurred thatbacteria belonging to theuncultivated phylum known asTM7 were among the species mostassociated with halitosis. Theimportance of newly or not-yet-identified strains associated withhalitosis was also highlighted.3

Specifically, among thepredominant microbes found onlyin subjects with halitosis, therewere 13 distinct non-cultivablespecies which were present in 38%of subjects with halitosis.3

Recent research with modernculture-independent techniques isproducing a more detailed portrait

of bacterial species present in thehuman oral cavity. Overall, thesestudies indicate that there is indeed

a difference in the composition ofbacterial species between subjects

with halitosis and control subjects.The relationship of these species,with factors such as the productionof volatile sulfur compounds,warrants further examination toconfirm their contribution tohalitosis, and could lead to thedevelopment of specificantimicrobial therapy for thiscommon problem.3OC

References

1. Kazor CE, Mitchell PM, Lee AM, Stokes LN,Loesche WJ, Dewhirst FE, et al. Diversity ofbacterial populations on the tongue dorsa ofpatients with halitosis and healthy patients.J Clin Microbiol 2003;41(2):558-563.

2. Miyazaki H, Sakao S, Katoh Y, Takehara T.Correlation between volatile sulphur compoundsand certain oral health measurements in thegeneral population. J Periodontol1995;66(8):679-684.

3. Haraszthy VI, Zambon JJ, Sreenivasan PK,Zambon MM, Gerber D, Rego R, et al.Identification of oral bacterial species associatedwith halitosis. JADA 2007;138(8):1113-1120.

4. Relman DA. New technologies, human-microbe interactions, and the search forpreviously unrecognized pathogens. J Infect Dis2002;186 Suppl 2:S254-S258.

page 6

HYGIENE PAGE

BacterialSpeciesCommon toBoth Studies

BacterialSpeciesIdentified inOne of theStudies

Haraszthy, et al.,20073

Solobacterium moorei

Eubacteriumspecies

Dialister species

Uncultivated phylum TM7(included in unidentifiedoral bacteria)

Firmicutes species

Granulicatella elegens

Porphyromonasspecies

Staphylococcus warneri

Prevotella intermedia

Kazor, et al.,20031

Solobacterium moorei

Eubacterium sulci

Dialister clone BS095

TM7 clone DR034

clone BW009 Streptococcus(of Firmicutes phyla)

Fusobacterium periodonticum

Atopobium parvulum

Predominant Bacterial Species Found Only in SubjectsWith Halitosis in Two Recent Clinical Studies1,3

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risk factors include: age; Caucasianrace; cancer diagnosis; and

osteopenia/osteoporosis diagnosisconcurrent with cancer diagnosis.3

Treatment and PreventionStrategies

BRONJ staging and treatmentstrategies are outlined in the tablebelow. If possible, optimize dentalhealth and allow osseous healingprior to initiating bisphosphonatetherapy.3

In asymptomatic patients who

are receiving IV bisphosphonatetherapy, maintaining good oralhygiene is important as apreventive measure. Avoidprocedures that involve directosseous injury. Non-restorableteeth can be treated by crownremoval and endodonticprocedures.3

In asymptomatic patients whoare receiving oral bisphosphonates,elective dentoalveolar surgery is

not contraindicated; however,patients should be informed of the

risk of compromised bone healing.Although more research is needed,it appears that risk for BRONJ inthis group may be associated withbisphosphonate treatment of threeor more years.3

Management StrategiesNo delays in planned surgeries

are required for individuals whohave taken oral bisphosphonatesfor less than three years. In the

event that dental implants areplaced, informed consent shouldbe provided relating to possiblefuture implant failure anddevelopment of BRONJ should thepatient continue to take oralbisphosphonates. Monitoring ofthese patients is recommended.3

For patients who have takenoral bisphosphonates for less thanthree years and have takencorticosteroids concomitantly, or

Bisphosphonate-

Related Osteonecrosisof the Jaws (BRONJ)

Bisphosphonate therapyused primarily in the treatment ofosteoporosis and cancer-relatedconditionscarries a risk ofbisphosphonate-relatedosteonecrosis of the jaws (BRONJ).In 2003-2004, the first cases of non-healing, exposed, necrotic bone inthe jaws of patients treated with i.v.

bisphosphonates were reported.

1,2

In subsequent years further caseswere identified, and in 2006, theAmerican Association of Oral andMaxillofacial Surgeons published aposition paper on this topic.3 Thefollowing is a summary of theirreport.

BRONJ DiagnosisBRONJ may be diagnosed if

patients demonstrate: current orprevious treatment with a

bisphosphonate; exposed bone inthe maxillofacial region persistingmore than eight weeks; and nohistory of radiation therapy to thejaws.3

Risk FactorsDrug-related risk factors for

the development of BRONJinclude the potency of thebisphosphonates and duration oftherapy. Intravenouslyadministered bisphosphonatesconfer a much greater risk thanoral agents. In general, greaterpotency and longer duration areassociated with greater risk. Localrisk factors include: dentoalveolarsurgery (e.g., extractions, implants,periapical surgery, periodontaltherapy with osseous injury); localanatomical characteristics (e.g.,lingual tori, mylohyoid ridge,palatal tori); and concomitant oraldisease. Demographic and systemic

CLINICAL PRACTICE

BRONJ Staging

At-risk Category:No apparent exposed/necrotic bone inpatients who have been treated with eitheroral or IV bisphosphonates

Stage 1:Exposed/necrotic bone in patients whoare asymptomatic and have no evidenceof infection

Stage 2:Exposed/necrotic bone associated withinfection (pain and erythema in region ofexposed bone with or without purulentdrainage)

Stage 3:Exposed/necrotic bone in patients withpain, infection, and at least one of thefollowing: pathologic fracture, extra-oralfistula, or osteolysis extending to theinferior border

Treatment Strategies

No treatment required

Patient education about BRONJrecommended

Antibacterial mouth rinse

Quarterly clinical follow-up

Patient education

Assessment of indications for continuedbisphosphonate therapy

Symptomatic treatment with broad-spectrumoral antibiotics

Antibacterial mouth rinse and pain control

Superficial debridement to relieve soft tissueirritation

Antibacterial mouth rinse

Antibiotic therapy and pain control

Surgical debridement/resection to addresslonger term infection and pain

BRONJ Staging and Treatment Strategies

Adapted from the American Association of Oral and M axillofacial Surgeons Position Paper, 20063

page 7

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References

1. Marx RE. Pamidronate (Aredia) andzoledronate (Zometa) induced avascular

necrosis of the jaws: A growing epidemic. J Oral

Maxillofac Surg 2003;61(9):1115-1117.

2. Ruggiero SL, Mehrotra B, Rosenberg TJ,

Engroff SL. Osteonecrosis of the jaws associated

with the use of bisphosphonates: A review of 63

cases. J Oral Maxillofac Surg 2004;62(5):527-

534.

3. American Association of Oral and Maxillofacial

Surgeons. Position paper on bisphosphonate-

related osteonecrosis of the jaws. 2006.

http://www.aaoms.org/docs/position_papers/

osteonecrosis.pdf (Accessed 2 Oct 2007).

patients with BRONJ, response tothe surgical treatment algorithms

used for osteomyelitis orosteoradionecrosis is lesspredictable. Surgical debridementis variably effective; it is difficult toobtain a surgical margin with viablebleeding bone because of thebisphosphonate exposure. Electivedentoalveolar surgery should beavoided in these patients.Extraction of symptomatic teethwithin exposed, necrotic boneshould be considered because it isunlikely that this will exacerbatethe necrotic process.3OC

The Colgate Oral Care Reportwelcomes its new

continuing education partner

The Forsyth InstituteFounded in 1910, The Forsyth Institute is the worlds

leading independent organization dedicated to scientificresearch, clinical, and educational programs in oral and

related biomedical science. Forsyth is honored to now serve

as the continuing education sponsor of the Oral Care Report.

ORALCAREREPORT

page 8

for patients who have taken oralbisphosphonates for more than

three years, discontinuation ofbisphosphonate therapy (drugholiday) for at least three monthsprior to the oral surgeryifsystemic conditions permitisrecommended.3

Patients with Established

BRONJ

Treatment objectives are toeliminate pain, control infection,and minimize the progression oroccurrence of bone necrosis. In

THE

A Summary Journal of Advances in Dentistry and Oral Health Care

ORALCAREREPORT

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Many countries are facingfinancial strains as the pressure forspending is affecting governmentappropriations for health-relatedprograms. Previous policies inmany countries have favored eldersand children, but the demographictrends are starting to show greatergrowth in the aging populationcompared to children. Adding tothe strain, the number of childrenboth in the United States and

globally is increasing at a rate thatis outpacing the current level ofchildcare programs.

The recent attempt in the U.S.to extend greater dental coverageto children came in the form of theState Childrens Health InsurancePlan (SCHIP). And while it failedto override a presidential veto byonly a few votes, it failednonetheless. Regrettably, there wastoo much pressure favoring other

budgetary items to allow inclusionof oral health for children into thenations health care policy.

Unfortunately, this may not bean isolated case as we look into thefuture. Many countries areexperiencing an increase in thenumbers of low income children.European, African, Asian, andPacific Rim countries, for example,are all showing demographicgrowth in their lower-income childpopulations.

Are we witnessing the dawn ofan era of declining oral health for

large minority sections of ourglobal societies? Not if we dontwant to ... We can decide to not let

this happen. But to do so, theprimary public policy emphasis must beon prevention. The dentalprofession, schools, government,and educators must raise the valueof prevention in their day-to-dayactivities. If we wait for dentaldisease to occur, there are simplynot enough dentists in the U.S.,Europe, Asia, and elsewhere torepair the damage.

Dental health policy forchildren must stress prevention the

world over.

Prevention for children cancome in many forms, includingcommunity- and school-basedprograms, dental professionactivities, or engagement of themedical and allied healthproviders. Schools andgovernments will need tocooperate and participate. We willneed all the help we can get if weare going to give the children ofthe world a chance for lifelong oralhealth.OC

Editor-in-Chief Dominick P. DePaola,

DDS, PhD; U.S.A.President and CEOThe Forsyth Instiute

2007 Colgate-Palmolive Company.All rights reserved.Printed on Recycled PaperThe Oral Care Report(ISSN 1520-0167) is supported bythe Colgate-Palmolive Companyfor oral care professionals. TheProfessional Continuing EducationProgram is sponsored by The ForsythInstitute and underwritten by a grant

from the Colgate-Palmolive Company.The Forsyth Institute does not endorsethe products of any company. Medicalwriting by BioMedCom Consultants,inc., Montral, QC (Canada).

Published by Professional AudienceCommunications, Inc., Yardley, PA(U.S.A.).Address comments, queries andaddress changes to:

The Oral Care ReportColgate Continuing Education

Services CoordinatorThe Forsyth Instiute140 The FenwayBoston, MA 02115 USAe-mail:colgateoralcarereport@forsyth.org.

MEMBERPUBLICATION

AMERICANASSOCIATION OFDENTAL EDITORS

HEALTH CARE TRENDSHEALTH CARE TRENDSGUAM

The dental profession, schools,government, and educatorsmust raise the value of

prevention in their day-to-dayactivities.

If we wait for dental diseaseto occur, there are simply notenough dentists in the U.S.,Europe, Asia, and elsewhereto repair the damage.

Dental health policy forchildren must stress preventionthe world over if we are goingto give the children of theworld a chance to havelifelong good oral health.

page 10

Access to Dental Care for Children

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PROFESSIONAL CONTINUING EDUCATION PROGRAMTHE FORSYTH INSTITUTE

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CONTINUING EDUCATIO

ANSWER SHEET AND

ENROLLMENT FORM

VOLUME 17 NO. 4

Name _____________________________

Title _____________________________[General Dentist, Specialty (type), RDH, o

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This quiz can be taken interactively online via www.colgateprofessional.com

1. In a study on renal disease and periodontitis,lower glomerular filtration rates were reported

to be associated witha) a high titer of antibodies against P. gingivalis, S.

noxia, A. actinomycetemcomitans, T. denticola, andV. parvula.

b) a higher level of interproximal attachment loss.c) a higher total bacterial load.d)All of the above

2. Which of the following is true?a)A study of diabetic patients showed no

correlation between periodontitis and renalfailure.

b)A study of diabetic patients with renalinsufficiency reported that periodontitis ispredictive of the development of overtnephropathy and end-stage renal disease.

c) Diabetic patients are not considered at risk ofdeveloping periodontitis.

d) Mild periodontitis was strongly associated withrenal disease in diabetic patients.

3. Which of the following statements about studieson periodontitis and renal disease is false?a) Overall, studies show a correlation between the

severity of periodontal disease and renalinsufficiency.

b) Renal transplant patients with severeperiodontitis had more carotid atherosclerosisthan those with no or moderate periodontitis.

c) Renal failure causes periodontitis.d) Patients on hemodialysis had more severe

periodontitis than those with pre-dialysischronic kidney disease.

4. Effective periodontal therapy maya) reduce periodontal disease.b) improve systemic inflammation.c) lead to better renal disease and cardiovascular

outcomes.d)All of the above

5. Which one of the following is not a modifier ofthe effectiveness of flossing?a)Administration of topical fluoridesb) Protein consumptionc)Assessment of complianced) Caries risk in the population

6. Professional flossing, performed in school onfirst-grade children with poor oral hygiene andlow exposure to fluorides, was reported to reducecaries risk bya) 0%b) 20%c) 40%d) 60%

7. Controlled clinical trials to support the role offlossing in the prevention of interproximal cariesexist fora) unsupervised flossing by school-age children.b) professional flossing to school-age children.c) self-performed flossing by adults.d)All of the above

8. Which substances are produced by bacteria andassociated with halitosis?

a) Insoluble proteinsb) Ethanol mixturesc) Nucleic acidsd)Volatile sulfur compounds

9. Which modern laboratory technique has allowedthe identification of additional strains of bacteriainfecting the human oral cavity?a)Automated cell cultureb) Polymerase chain reactionc) Rapid breath testd)Antibody binding assays

10. How many distinct bacterial strains are currentlyestimated to infect the human oral cavity?a) 100b) 400c) 800

d) 120011. Which bacterial species was found ONLY in

subjects with halitosis in two recent clinicalstudies?a) Streptococcus salivariusb) Cryptobacteium curtumc) Solobacterium mooreid) Neisseria flavescens

12. BRONJ may be diagnosed if patients demonstratea) current or previous treatment with a

bisphosphonate.b) exposed bone in the maxillofacial region

persisting more than eight weeks.c) no history of radiation therapy to the jaws.d)All of the above

13. Compared with bisphosphonates of lower potencyand taken for shorter durations, those with greaterpotency and taken for longer duration areassociated witha) greater risk for BRONJ.b) equal risk for BRONJ.c) lower risk for BRONJ.d) greater risk for BRONJ when bisphosphonates are

orally administered.

14. Which of the following statements is false?a) Few patients receiving bisphosphonates develop

BRONJ spontaneously; it is most often acomplication that arises following dentoalveolarsurgery.

b) If systemic conditions permit, initiation ofbisphosphonate therapy should be delayed untildental health is optimized.

c) No delays in planned surgeries are required forindividuals who have taken oral bisphosphonatesfor less than three years.

d) None of the above.

15. Which of the following statements regardingpatients with established BRONJ is true?a) Response to the surgical treatment algorithms

commonly used for osteomyelitis orosteoradionecrosis is less predictable in patientswith BRONJ.

b) Elective dentoalveolar surgery should be avoidedin patients with established BRONJ.

c) Extraction of symptomatic teeth within exposed,necrotic bone is unlikely to exacerbate thenecrotic process.

d)All of the above

This continuing education (CE) program is offered by The Forsyth Institute. Each volume of the Oral Care Report(OCR) consists of 4 issues, each of which contains multiple-choice, two credit

hour (CE) examinations sponsored by The Forsyth Institute, an ADA Continuing Education Recognition Program(CERP) provider.

Participants who have passed an examination will receive a Verification of Participation letter awarding two (2) CEcredits from The Forsyth Institute continuing education program.

Quizzes may be submitted at any time for credit. Refund requests related to the automated payment process will be honored.

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A Summary Journal of Advances in Dentistry and Oral Health Care

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