Seattle Periodontics and Implant Dentistry

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Economic burden of periodontitis in the United States and Europe: An updated estimation

"Periodontal disease is a major public health problem with significant socio-economic impacts" Evaluation of the most recent comprehensive data (2018) from the US and Europe estimated this loss to be $154.06Bn for the US and €158.64Bn for Europe. "A reliable estimation of the economic burden with a disease is also an estimation of the maximum amount of resources" that would be available "if the disease were partially or totally eradicated"

Methods:
Costs were divided into direct and indirect costs. Direct costs relate to the cost in providing treatment for periodontal disease and indirect costs reflect productivity loss due to absenteeism and other impacts such as root caries as part of periodontal disease, edentulism and reconstruction. Data sets accessed were the following: WHO Global Health Expenditure Database, Annual GDP from the various countries and information from the International Labor Organization also the Organization for Economic Co-operation and Development (OECD). Germany's numbers were used as a standard. It estimates that 3.45 % of the cost of dental treatment go towards periodontal therapy. The hope is that, in the future more accurate numbers will be readily available from all countries.

Focus Points:

Estimate cost of periodontal disease across US is ~ $154.06Bn and €158.64Bn
Majority of costs are indirect costs (perio disease, edentulism, absenteeism)
Direct costs of treatment of periodontal disease are $3.49Bn in the US and €2.52 Bn in Europe
As % of GDP the US spends x2 as much as Europe on health
Indirect cost of periodontal disease is lower in the US than in Europe
The economic cost, both direct and indirect, is very significant and prevention efforts should ongoing so that these resources can be redirected to other areas of need

Economic burden of periodontitis in the United States and Europe: An updated estimation, João Botelho et al, J Periodontol. 2022;93:373-379

WHO recognizes oral health as a global health priority.

A resolution introduced earlier this year has been endorsed by the World Health Assembly (June '21). It recognizes the burden of poor oral health and its impact on overall health and well-being. It urges member states "move towards a preventive promotional approach with risk identification for timely comprehensive and inclusive care". This task requires development of a strategy that addresses key risk factors for poor oral health and the associated disease burden both orally and systemically. (June 2021)

https://apps.who.int/gb/ebwha/pdf_files/EB148/B148_R1-en.pdf

COVID19 infection of the oral cavity and saliva

"These data show the oral cavity is an important site for SARS-CoV-2 infection an implicate saliva as a potential route of SARS-CoV-2 transmission"

A recently reported study which looked at oral tissue samples of COVID-19 patients, found that the virus can access and infect the cells of the mouth. In addition, they found that the saliva of both symptomatic and asymptomatic patients can be infectious suggesting a route of transmission to the lungs and the GI tract. These findings may explain that loss of taste and smell often reported by COVID-19 patients. (April 2021)

SARS-CoV-2 infection of the oral cavity and saliva. Huang, N. et al (2021) Nature Medicine

Population Health

"Oral Health professionals can improve population health"

This article discusses the crucial role that oral health professionals can play transforming the healthcare landscape to improve the overall health of the population. (January 2021)

The ability of oral health professionals to significantly influence improving overall health Mays, K (2020) Journal of Dental Education

Oral Systemic Connection NEW!

"Effect of an intensive antiplaque regimen on microbiome outcomes after nonsurgical periodontal therapy"

Our understanding of the compositional trajectory of periodontal microbial communities in health and disease, continues to evolve in the field of periodontics. This study sought to evaluate the response of the microbiome in terms of composition after professional nonsurgical periodontal therapy alone (SRP) or with the addition of an intensive "at home" antiplaque routine with interproximal aids and mouthrinse (SRP +P + S). There was a greater tendency for the SRP + P + S group to achieve modestly healthier microbiome however considerable variability was observed in both groups. Statistical analysis of the data suggested that the initial microbiome composition has a noticeable influence on outcomes of treatment with respect to achieving "eubiosis".

The research offers the following:

Although clinical improvements were noted in both groups, there was only a modest move in the direction of a "health like" microbiome. The addition of an "at home" intensive antiplaque regimen did help achieve a healthier microbial profile
Considerable variation in the response was noted in both groups
The baseline microbial composition appeared to have a greater influence on the relative success in terms of achieving eubiosis
A personalized approach to care seems indicated

Effect of an intensive antiplaque regimen on microbiome outcomes after nonsurgical periodontal therapy
Li, Lu, Hayashi-Okada, Yoshiko, Falkner, KL, Shimizu, Y, Zambon, JJ, Kirkwood, KL, Schifferle, RE, Genco, RJ, Diaz, PI. J Periodontol. 2025;96:241-254

"Performing SRP and placing a patient in a periodontal maintenance program without reevaluation is unacceptable...There is a need for formal guidelines from organized dentistry that call for a thorough reevaluation of initial periodontal therapy and provide guidance for subsequent therapy based on clinical findings at the time of reevaluation"

This commentary was recently published in JADA. It highlights the fact that it is hard to definitively achieve the treatment endpoint of an inflammatory free state in the tissues that we equate with health and stability or indeed its surrogate endpoints of no bleeding on probing (BOP) and/or pocketing ≤4 mm. The question posed is - What should we do if after initial therapy (SRP), bleeding on probing persists with the tissues red and swollen, consistent the with presence of ongoing inflammation?

They authors contend that the research offers the following:

After SRP, >1/3 of initially moderate to deep pockets (>5mm & ≥7mm) still show BOP and have probing depths >4mm, sometimes even after multiple rounds of SRP
Long-term studies indicate that in patients with moderate to advanced disease, SRP limits deterioration but not progression
Studies show that source of the persistent inflammation, generally indicates the presence of subgingival calculus
If inflammation persists, additional therapy is needed. "...periodontal maintenance should not be the next step"

When is periodontal maintenance not enough? - The need for clinical guidance
Harrel, SK, Rethman, MP, Cobb, CM, Sottosanti, JS, Lee, SN. Journal of the American Dental Association
jada.ada.org/article/S0002-8177(22)00794-2

"We found that periodontal care was associated with more after AMI (acute myocardial infarction) visits"

Findings from previous studies have indicated that patients with periodontitis are at increased risk of hospitalization for AMI. In this study, analysis of data from insurance databases was conducted regarding patients who had an AMI in 2017. It pointed to a correlation between the need for periodontal care and an increase in post AMI visits.

Overall health and oral health are interrelated and "early intervention to ensure stable periodontal health in patients with risk factors for AMI could reduce downstream hospital resource use

Association between periodontal care and hospitalization with acute myocardial infarction, Romesh P. Nalliah et al, Journal of the American Dental Association (2022)

"Database studies focusing on epidemiologic research and post-mortem studies show that periodontal pathogens may play a role in the pathogenesis of AD" (Alzheimer's Disease)

The review provided the following comments:

AD is the most common form of dementia. Its etiology includes age, genetic factors, neuropathology and infection
Studies suggest that active periodontitis plays a role in cognitive decline over time
Epidemiology studies have demonstrated that periodontitis is related to AD although the link is still unclear
Serology studies have shown that AD is related to a high inflammatory state and elevated levels of antibodies to periodontal bacteria
The etiology of early onset AD may differ from that of late onset AD. Early onset is more related to genetic factors rather than an inflammatory state, which seems to be the case for late onset

Association of periodontitis and oral microbiomes with Alzheimer's disease: A narrative systematic review. Mao, Samantha et al, Journal of Dental Sciences, July, 2022

Preventive dental care is strongly associated with significant savings for diabetes and CAD (coronary artery disease) patients and such savings were higher for diabetes + CAD patients

This was a Mayo Clinic-led study that retrospectively looked at the connection between costs savings and the adoption of preventive dental care regimens in diabetic and coronary artery disease patient cohorts.

Those patients with diabetes or CAD, who regularly received preventive dental services, had reduced health care costs
The likelihood of their need for hospitalization was also decreased
The association was significant for those with either condition and even greater for patients with both diabetes and CAD

Association between preventive dental care and healthcare cost for enrollees with diabetes or coronary artery disease: 5-year experience, Bijan J. Borah, PhD et al, Compendium of Continuing Education in Dentistry, Volume 43, Issue 3

Maintenance of Good Oral Health and Regular Access to Dental Care Are Considered More Important to Prevent VGS IE than AP for a Dental Procedure

The American Heart Association confirms ongoing support for the 2007 guidelines that limits the use of preventive antibiotics for dental procedures to 4 specific high-risk types of patients and reiterated the significance of good oral health in the prevention of infective endocarditis.

"We continue to recommend VGS IE (Viridans Group Streptococcal Infective Endocarditis) prophylaxis only for categories of patients at highest risk for adverse outcome while emphasizing the critical role of good oral health and regular access to dental care for all."

The following 4 patient groups are deemed to be high risk and would benefit from AP prevention of IE

Prosthetic cardiac valve or prosthetic material used for cardiac valve repair or other implantable cardiac devices, such as transcatheter aortic valve implantation
Previous, relapse or recurrent IE
Congenital heart disease
Cardiac transplant recipients

Key Findings:

VGS IE is much more likely to develop as a result of transient VGS bacteremia attributable to routine daily activities such as chewing food and toothbrushing than a dental procedure
An exceedingly small number of cases of VGS IE could be prevented by AP for a dental procedure, even if prophylaxis is 100% effective
If AP for a dental procedure is effective in preventing a very small number of cases of VGS IE, it should be suggested only for those patients with the highest risk of adverse outcome for VGS IE
There is no convincing evidence of an increased frequency of morbidity or mortality from VGS IE in patients at low, moderate, or high risk of adverse outcome since publication of the 2007 doc
AP for a dental procedure is not suggested solely on the basis of an increased lifetime risk of acquisition of VGS IE

Suggestions:

AP for a dental procedure that involves manipulation of the gingival tissues, periapical region of teeth, or perforation of the oral mucosa is suggested only for patients with the highest risk of adverse outcome from VGS IE

Maintenance of good oral health and regular access to dental care are considered more important to prevent VGS IE than AP for a dental procedure

Shared decision making is important between patients and health care providers. Patients need to be adequately informed of the risk and benefits of AP for a dental procedure so that an informed decision can be made

Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From the American Heart Association, Walter R. Wilson, MD, et al, Circulation. 2021;143:e963-e978

Scaling and root planing (SRP) is still critical in the treatment of periodontal disease

"SRP involving deep probing depths (≥ 5mm) and root surfaces with anatomical and surface irregularities, regardless of the type of instrumentation, requires time, exceptional skill and perseverance, and patient compliance with periodontal maintenance."

The authors outline some conclusions based on an extensive review of the literature

SRP aims to remove calculus and biofilm to achieve a biologically compatible root surface
Biofilm coats the subgingival calculus and its compositional bacteria can invade the surface defects on the root surface. Removal of such deposits requires root planing
Endotoxins released by the biofilm can soak into the cementum, dentin and calculus
The presence of calculus is strongly associated with periodontal destruction
Effective removal of calculus may be hampered by increased pocket depths, furcations, anatomical irregularities etc, dictating the need for surgical intervention

A re-evaluation of scaling and root planing, Charles M. Cobb and John S. Sottosanti, Journal of Periodontology Volume 92, Issue 10, p.1370-1378

Tooth loss may affect ability to carry out everyday tasks

"We know from previous studies that tooth loss is associated with reduced functional capacity but, this study is the first to provide evidence about the causal effect of tooth of tooth loss on the instrumental activities of daily living (IADL) among older adults"

The researchers suggest that retaining a functional dentition can be linked to a delay in the development of disability and death. Tooth loss can limit social interactions which is linked to a poorer quality of life and result in a poorer diet with less nutritional options. (June 2021)

Causal Effect of Tooth Loss on Functional Capacity in Older Adults in England: A Natural Experiment, Yusuke Matsuyama et al, Journal of the American Geriatrics Society (2021)

Oral Systemic Connections

"Periodontitis is linked to higher systolic blood pressure in otherwise healthy individuals"

A recent study from University College London, UK, is another paper connecting oral health to systemic health. The exact nature of the connection between the chronic inflammatory state of severe gum disease and high blood pressure is still under investigation but "promotion of periodontal and systemic health strategies" from both dental and medical care settings is recommended. (March 2021)

Association between periodontitis and blood pressure highlight in systemically healthy individuals, Munoz Aguilera, E. (2021) Hypertension

Did You Know?

Did you know?

15 Fun Facts about Teeth and Dentistry
How well do you know the world of teeth?

The average American spends 38.5 total days brushing over a lifetime.
If you don't floss, you miss cleaning 40% of your tooth surfaces.
Tooth enamel is the hardest substance in the human body.
The average woman smiles 62 times a day. The average man smiles about 8 times a day.
Every year, kids in North America spend close to half a million dollars on chewing gum.
More people use blue toothbrushes than red ones.
Like fingerprints, everyone's tongue print is different.
More than 300 types of bacteria make up dental plaque.
Kids laugh around 400 times a day, adults just 15 times a day.
78% of Americans have had at least 1 cavity by age 17.
Giraffes only have bottom teeth.
1882 was the year commercial floss was first manufactured.
A snail's mouth is no larger than the head of a pin, but it can have over 25,000 teeth!
The average person only brushes for 45 to 70 seconds a day, the recommended amount of time is 2-3 minutes.
Dogs have 42 teeth, cats have 30 teeth, pigs have 44 teeth, and an armadillo has 104 teeth.

Since 2007 antibiotics prophylaxis have been recommended for 4 types of cardiac patients at risk for Infective Endocarditis (IE) - those with

Prosthetic heart or aortic valve
History of infective endocarditis or recurrent IE
Congenital heart disease
Cardiac transplant recipients

This recent paper reaffirms the recommendation of "IE prophylaxis only for categories of patients at highest risk of adverse outcome while emphasizing the critical role of good oral health and regular access to dental care for all"..."Because routine daily activities result in transient VGS bacteremia at a much higher frequency than a single dental procedure, optimizing oral health has a major impact on preventing VGS IE" (April 2021)

Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From the American Heart Association Wilson, Walter R. et al (2021) Circulation

"Blood donors with periodontitis are considerably more likely to donate blood contaminated with bacteria". This is a recently reported finding of a Danish group of researchers. Currently, in the USA, the blood samples are screened for many infectious diseases but periodontal disease is not one of them. This is likely to change. (February 2021)

Periodontitis increases risk of viable bacteria in freshly drawn blood donations Damgaard C. et al (2021) Blood Transfusion