Periodontal disease and dental caries comprise the two most significant dental findings affecting most patients. As general practitioners, the majority of our day-to-day encounters with patients involve some aspect of treating and educating our patients on periodontal health and the cause of dental caries. It is important to realize patient personal and medical history plays a major role in the diagnosis, prevention, and treatment of dental issues. This paper will take a glance at the trends in periodontal disease and dental caries among different ethnicities, patients with special needs, and Down syndrome patients.
Periodontal Disease and Dental Caries Status Among Various Ethnicities
Working with such a broad patient population, it is important to recognize the link between patients and their predisposition to certain oral health issues to improve patient care. An NYU College of Dentistry research team, headed by Dr. Gustavo Cruz, found that an immigrant’s ethnicity and country of origin predisposes them to caries and periodontal disease. They analyzed the caries and periodontal disease rates in over 1,500 Chinese, Haitian, Indian, West Indian, and Puerto Rican, Dominican, and Central and South American immigrants of Hispanic origin living in New York City. Significant differences were found among the ethnic groups: Puerto Ricans, Haitians, and Indians, for example, were more likely to have periodontal disease, while Hispanics were more likely to have dental caries. These differences can be connected to an immigrant's country of origin, where early cultural influences can lead to oral health problems later in life.1
The study found some ethnic groups are more prone to tooth decay because their traditional diet is high in refined carbohydrates, while refined carbohydrates are almost absent from the diet of other groups. Lack of fluoridated water to strengthen enamel also plays a role. 1 More recently, research has shown that heredity is important because some ethnic groups may be more susceptible to decay-causing oral bacteria. The relationship between heredity and oral health has shown evidence that variations in risk and protection against dental caries have a strong genetic component. 2
Rates of tooth decay and periodontal disease can also be linked to ethnicity and country of origin even among immigrants who have lived for many years in the United States and have increased income and education levels. 1 Mexican Americans and African Americans are more likely to develop periodontitis than patients of European descent. This increased risk may be due to many factors, including frequency of dental visits or different inflammatory responses in different ethnicities. 3
Ethnicity is also significant in immune response among smokers or patients suffering from systemic health conditions that are known to contribute to oral infections. One study examined whether race/ethnicity, income, and education are independently associated with periodontitis before and after adjusting for selected morbidities, such as smoking and diabetes. The researchers found that the overall prevalence of periodontal disease was 3.6%. The prevalence data broke down along racial/ethnic lines: African Americans - 7.2%, Mexican Americans - 4.4%, and Caucasians - 3.0%. According to the authors, race/ethnicity, education, and income were independently associated with periodontal disease. The study concluded that ways by which race/ethnicity and socioeconomic indicators, separately or together, lead to health or disease should be investigated. 4 There should be more clinical and scientific research to identify whether patients are being educated about their oral hygiene and which factors (genetics, systemic diseases, etc.) should be targeted, respectively. This will help develop preventive measures, such as diagnostic tools, that discover the presence of harmful oral bacteria that may be more common in certain ethnic groups.
Periodontal Disease and Dental Caries Status Among Special Needs Patients
Through new medicine and technology, longevity of special needs patients has increased, making their dental needs especially important. These patients include those who have physical, mental, sensory, behavioral, cognitive, emotional and chronic medical conditions requiring health care beyond that considered routine. Special needs patients can be challenging to work with, therefore maintaining their periodontal status and controlling dental caries becomes even more significant.
Individuals with special health care needs have been reported to have poorer oral hygiene and periodontal status, more untreated caries and fewer remaining teeth. Treating special needs patients usually involves specialized knowledge, increased awareness, attention and accommodation. Oral health status may be influenced by age, severity of impairment and living conditions. Individuals with special needs may have great limitations in oral hygiene performance due to their decreased motor, sensory and intellectual disabilities and with lack of support they will be prone to poor oral health. 5
One study surveyed the dental health status of patients with cerebral palsy, mentally disabled and visual disorders. The study included 170 individuals, between 6 and 15 years old, who were attending four special schools in Athens, Greece. Dental health status found that treatment needs are extremely high in all individuals. The oral hygiene status is in general, moderate to low-grade, especially in the individuals with mental retardation. The highest rate of malocclusion is observed in the group of individuals with cerebral palsy. 6 Typical oral health problems of these patients include decreased salivation, root-surface caries, poor oral hygiene, a high prevalence of periodontal disease and dental caries. These patients would benefit from parental/supervisor education on diet modification such as using fluoride tablets, adding Xylitol in their regimen to help prevent caries, improvement of oral hygiene practices and regular dental visits. 7
Periodontal Disease and Dental Caries Status Among Down Syndrome Patients
Down syndrome (DS), also known as Trisomy 21, a congenital defect resulting in an extra chromosome, was found to exacerbate periodontal disease. This syndrome leads toward a critical discussion because the total number of DS cases at birth in the US increased by 24.2% from 1979-1983 to 1999-2003 in certain regions. This can be attributed to fact that the number of infants born with DS was almost 5 times higher among births to older mothers (38.6 per 10,000) than among births to younger mothers.8 Many orofacial characteristics are associated with this disease such as macroglossia, angular cheilitis, delayed eruption of teeth, poor oral hygiene, and a low-caries rate.9 One article studied the prevalence of dental caries and treatment needs of Down syndrome children in the South Indian city of Chennai. A total of 130 Down syndrome children, ages 15 and younger, were examined. Dental status was determined and recorded using the WHO oral assessment criteria. Results found that oral prophylaxis, restorative treatment, fluoride application, orthodontics were needed in all groups, but the older age groups needed fluoride, orthodontics, and extractions much more than the younger children. There were no significant difference between dental needs among males and females. Also, this study found 29.4% of the patients to be caries-free. This is lower than previous similar studies and could be due to lack of awareness of dental visits, irregular dietary habits, poor oral hygiene, lack of fluoridated water, high-sugar foods, parental neglect, and lack of preventative care. 9
Current research has studied the importance of periodontal disease and dental caries among Down syndrome patients. Previous studies found a high association of periodontal disease and Down syndrome, and the objective of a recent study in particular was to update the prevalence of periodontal disease and its relation to the quality of life of these patients. The 93 Down syndrome patients examined were between the ages of 6-20. Periodontal probing, plaque index, and periodontal clinical parameters (bleeding on probing (BOP), probing depth, and attachment loss) were recorded. The mothers of the Down syndrome patients were also interviewed to evaluate the consequences of periodontal disease on the quality of life of these patients. Sample questions included discomfort caused by bleeding gums, halitosis, discomfort caused by appearance of gums, and problems with mastication and deglutition, to name a few. Results indicated that the prevalence of gingivitis was 91%, and periodontal disease was found in 33% of the patients. Oral hygiene of 68% of the individuals was classified as bad or extremely bad, and bleeding on probing was seen in 91% of the patients. BOP, high probing depths, and attachment loss caused negative impacts in daily life and the results go further to say that quality of life deteriorates as the periodontal status worsens, in example from moderate to severe periodontitis. In conclusion, these studies place significance on patient/caregiver education and stresses preventative dental care since oral prophylaxis and fluoride were the most needed treatments by all the Down syndrome patients.10
Overall, caries prevention and early periodontal monitoring in all patients is necessary to ensure better oral health. This is also linked to educating the caregivers, if any, since they are the primary messenger between the dentist and the patient. These studies have strengthened the obligation that general dentists have so they can obtain a better understanding of their patient’s background, from social history to varying health problems. An awareness of diverse patient populations will prepare the general practitioner to better manage these patients in order to lead the way in preventing and treating oral diseases.
1 Tooth Decay And Gum Infections Linked To Ethnicity And Country Of Origin. Science Daily. New York University. March 2007. http://www.sciencedaily.com/releases/2007/03/070325111747.htm
2Defining the Contribution of Genetics in the Etiology of Dental Caries. Wright, J Tim.
J DENT RES November 2010 89: 1173-1174.
3 Destructive Periodontal Disease in Adults 30 Years of Age and Older in the United States, 1988-1994. Dr. J.M. Albandar, J.A. Brunelle, and A. Kingman
Journal of Periodontology 1999 70:1, 13-29
4 Social disparities in periodontitis among United States adults 1999-2004.
Borrell LN, Crawford ND. Community Dent Oral Epidemiol. 2008 Oct;36(5):383-91.
5 Oral health status and treatment needs of children and young adults attending a day center for individuals with special health care needs.
Folakemi A, Oredugba, Akindayomi, Y. BMC Oral Health 2008, 8:30. 22 October 2008
6Oral health status in Greek children and teenagers, with disabilities.
J Clin Pediatr Dent. 2001 Fall;26(1):111-8.
7Xylitol in the prevention of oral diseases.
Kitchens, D. H. Spec Care Dentist. 2005 May-Jun; 25(3): 140–144.
8Prevalence of Down Syndrome Among Children and Adolescents in 10 Regions of the United States. Pediatrics December 2009 (124:6);1565-1571.
9Dental caries prevalence and treatment needs of Down syndrome children in Chennai, India. Asokan S, Muthu MS, Sivakumar N. Indian J Dent Res, 2008: 19, 224-229.
10The impact of periodontal disease on the quality of life of individuals with Down syndrome. Loureiro ACA, Costa FO, da Costa JE. Down Syndrome Research and Practice,2007: 12, 50-54.