|Year : 2015 | Volume
| Issue : 4 | Page : 429-434
Comparison of various risk indicators among patients with chronic and aggressive periodontitis in davangere population
Kharidhi Laxman Vandana, Rahul Dilip Nadkarni, Kaveri Guddada
Department of Periodontics, College of Dental Sciences, Davangere, Karnataka, India
|Date of Submission||10-Mar-2014|
|Date of Acceptance||16-Mar-2015|
|Date of Web Publication||11-Aug-2015|
Kharidhi Laxman Vandana
Department of Periodontics, College of Dental Sciences, Davangere, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The aim of the present study was to compare various risk indicators of chronic periodontitis (CP) and aggressive periodontitis (AP) among patients of Davangere population. Methods: Totally, 89 CP and 90 AP patients were selected from outpatient Department of Periodontics, College of Dental Sciences, Davangere. Various clinical parameters proven to be risk indicators were determined for each patient such as age, gender, occupation, oral hygiene habits, personal habits, income, level of education, place of residence, frequency of dental visits, various oral hygiene indices, gingival status, wasting diseases, malocclusion, laboratory investigations, and the results were subjected to statistical analysis. Results: This study demonstrated that AP is manifested early in life in susceptible individuals. Proven risk indicators for AP and CP in the present study population included young age, place of residence, income and education levels, frequency of dental visits. Patients with AP had better oral hygiene habits and oral hygiene index results than patients with CP. Paan chewing and smoking could be considered as risk factors, both in CP and AP cases. The similar association of plaque scores but higher bleeding tendency in AP patients supported the fact of higher susceptibility of AP patients to periodontal breakdown. Malocclusion being present in the majority of cases could also be put forth as a risk factor for AP and CP. Conclusion: This study identifies the different risk indicators for CP and AP and demonstrates the need for constructing nationwide oral health promotion programs to improve the level of oral health awareness and standards in Indian population.
Keywords: Aggressive periodontitis, chronic periodontitis, Davangere, risk factors, risk indicators
|How to cite this article:|
Vandana KL, Nadkarni RD, Guddada K. Comparison of various risk indicators among patients with chronic and aggressive periodontitis in davangere population. J Indian Soc Periodontol 2015;19:429-34
|How to cite this URL:|
Vandana KL, Nadkarni RD, Guddada K. Comparison of various risk indicators among patients with chronic and aggressive periodontitis in davangere population. J Indian Soc Periodontol [serial online] 2015 [cited 2020 May 27];19:429-34. Available from: http://www.jisponline.com/text.asp?2015/19/4/429/156879
| Introduction|| |
Periodontitis is a multifactorial disease with microbial dental plaque as an initiator but is influenced by a wide variety of factors including subject characteristics, social and behavioral factors, systemic factors, genetic factors, tooth level factors, microbial composition of dental plaque. 
Periodontitis was classified by the international workshop of classification of periodontal disease in 1999 as chronic periodontitis (CP), aggressive periodontitis (AP), and periodontal manifestations of systemic diseases.  CP is the most common form of destructive periodontal disease and shows a slow disease progression characterized by bursts of disease activity separated by quiescent periods of varying durations. AP encompasses, rapidly progressive forms of periodontitis, often commencing during adolescence and early adulthood, hence classified as early-onset periodontitis. 
CP and AP though different diseases have numerous similarities and differences. Comparing these entities is difficult as many details of etiology and pathogenesis of periodontal infections are unknown. In addition, studies dealing with these diseases often use different terminology and case definitions, thereby complicating any attempt at effective analysis of the existing literature. 
In recent years, it has become apparent that the pathogenesis of periodontal diseases is more complex than the presence of virulent microorganisms. Several risk factors are thought to be causal for the disease. A risk factor can be defined as an occurrence or characteristic that has been associated with the increased rate of a subsequently occurring disease. The term risk factor denotes a greater weight of evidence supporting an association than does the term risk indicator. 
During the past decade, many risk factors have been identified for the periodontal diseases.  Prominent and confirmed risk factors or risk predictors for periodontitis in adults include smoking, diabetes, race, porphyromonas gingivalis, prevotella intermedia, low education, infrequent dental attendance, and genetic influences.  A review of longitudinal studies ranging from 2 months to 28 years noted that tobacco use, specific subgingival bacterial species, low education, infrequent dental visits, male sex, lack of flossing, and race (African-American) were statistically significant risk factors for clinical attachment loss. 
A study conducted to determine risk indicators of AP in Jordanian population concluded that young age, smoking, reduced oral hygiene measures, income <625 euro/month, urban residency, and regular attendance to dental clinics are associated with increasing risk of AP.  Another study aiming to assess the prevalence of AP and to investigate the association between demographic, socioeconomic, and behavioral risk indicators with AP in an untreated and isolated young population in South-eastern Brazil concluded that this population presented a high prevalence of AP with local plaque-retaining factors playing a major role. 
Studies conducted in India have been mainly directed toward the determination of epidemiology of periodontitis. A review in 2010 reveals that 43 studies were conducted determining prevalence of periodontitis in different regions of India from 1990 to 2009.  Furthermore, WHO in 2007 conducted an epidemiological survey in seven Indian states determining the prevalence of periodontitis in five different age groups.  However, Medline search reveals no study comparing the prevalence of risk indicators among patients with AP and CP in Indian population.
The aim of the present study was to compare the effects of various risk indicators such as age, gender, occupation, income, place of residence, level of education, oral hygiene habits and status, frequency of dental visits, smoking, alcohol, malocclusion, and other parameters related to periodontal disease such as oral hygiene indices, gingival status, deleterious habits, malocclusion, wasting diseases of teeth, and laboratory investigations in patients diagnosed with CP and AP attending the outpatient Department of Periodontics, College of Dental Sciences, Davangere, Karnataka, India.
| Materials and Methods|| |
In the present study, patients were diagnosed as having CP and AP according to the 1999 criteria of American Academy of Periodontology classification. Patients excluded from the study were those having systemic problems, patients who had received periodontal treatment or had taken antibiotic therapy within last 3 months. 89 patients with CP and 90 patients with AP were selected from the outpatient department of periodontics, College of Dental Sciences. The study was conducted over a period of 3 years and was in accordance with the specifications of Rajiv Gandhi University of Health Sciences, Bangalore and ethical clearance was granted for the study.
A complete case history was taken along with detailed clinical examination and blood investigations. Various clinical parameters proven to be risk indicators were included in the proforma drawn up to be filled for each patient such as age, gender, occupation, oral hygiene habits, personal habits, income, level of education, place of residence, frequency of dental visits, various oral hygiene indices, gingival status, wasting diseases, malocclusion. Analysis results were subjected to statistical analysis. Mean values and standard deviation were calculated, and Chi-square test was used for comparison. SPSS software, version 19 manufactured by IBM, Chicago Illinois USA corporation was used to carry out the statistical analysis. A statistical value of <0.05 was deemed to be significant.
| Results|| |
Mean age of patients with AP was 23.90 and CP was 43.98. This difference between AP and CP groups was statistically significant. Among patients with CP, there were 59 males and 30 females. Among the patients with AP, there were 60 males and 30 females. 54.4% cases of AP belonged to the student category, and 35.6% belonged to working class whereas in CP, 67.4% belonged to working class. Most of the population, 63.3% in AP and 59.6% in CP cases came from rural areas, and the majority of them visited the dental clinics only in cases of emergency. Education levels were high in patients with AP as majority belonged to the student population, (71.1%) [Table 1].
|Table 1: Sociodemographic characteristics of the study population and frequency of dental visits |
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Oral hygiene habits
In AP, 94.4% patients used a soft or medium brush whereas 44.9% patients with CP used a hard brush. Furthermore, 43.3% AP patients brushed twice daily compared to 15.7% patients with CP. Smoking was more prevalent in CP patients at 49.4% compared to 30% in AP [Table 2].
Oral hygiene indices
The plaque control record scores were not statistically significant however for a similar plaque score, the gingival bleeding scores showing 60-100% bleeding sites was greater in AP (56.5%) compared to CP (47.2%) [Table 3].
Gingival recession was significantly greater in the CP group (41.6%) compared to AP group (20%) [Table 4].
Hard tissue evaluation
Wasting disease of teeth was greater in CP group with the prevalence of attrition, abrasion and erosion being 29.5%, 39.3%, and 24.7%. Similar parameters in AP group showed the results 26.7%, 24.4% and 17.8%, respectively. Only the results for erosion were statistically significantly in CP patients (24.7%) than AP patients (17.8%) [Table 5].
Majority of the cases of both CP and AP groups had Class I Malocclusion (53.6% and 43.6% respectively). But the prevalence of Class II and III types of malocclusion was low in both groups ranging from 0.6% to 5%. Lip seal was present in 63.3% cases of AP and 40.4% cases of CP group. Tongue thrusting was present in 42.7% cases of CP whereas only 4.4% cases of AP showed tongue thrusting. These results showed that deleterious habits were significantly more in CP patients as compared to AP patients [Table 6].
Blood picture (red blood cells, white blood cell, hemoglobin, blood test, and computed tomography)
There were no significant findings among both CP and AP groups [Table 7].
| Discussion|| |
Comparison of the mean age of subjects in both test groups shows that AP is manifested earlier in life than CP similar to findings of Albandar 2005 in the American population [Table 1].  A study in West Bengal population reported that the mean number of edentulous sextants and sextants affected by Score four of community periodontal index of treatment needs, index shows a steady rise with age.  Another study demonstrated that AP was highly prevalent among young individuals of an isolated and untreated Brazilian population.  In the present study, the percentage of males affected by AP and CP was about 66% and 60% respectively which is in agreement with a study which concluded according to NHANES (National Health and Nutrition Examination Survey) findings that among adult Americans, males had higher prevalence of periodontitis than females, regardless of age .  A study conducted in Trivandrum population attending dental college concluded that females have better periodontal condition than males.  However, another study found a higher prevalence of AP in females in a NHANES survey in America. 
Majority of AP population was of student category and CP population among the working population. Most of the population from both groups fell in the low or medium income groups [Table 1]. Greater proportion of CP patients (25.8%) belonged to the low-income group compared to AP patients (11.1%). A study conducted in West Bengal stated that the maximum number of subjects with periodontitis came from lower income group (9728 subjects) and lower middle-income group (6057 subjects).  Literature also presents other studies with similar findings . , Similar percentage of the study patients (about 60%) in both groups belonged to rural areas which are in accordance with findings of a study in Jordanian population and in West Bengal population. , Education levels were high in AP patients and low in CP patients similar to a study on North Carolina population which concluded that persons who attained fewer than 12 years of education had from 1.3 to 2.0 times higher incidence of attachment loss compared to those who attained 12 or more years of education.  The differences in working status, income, and education levels among the 2 test groups could also be attributed to the age difference between the two groups. Majority of the population in both groups visited dental clinics only in cases of emergency.
Patients with AP had better oral hygiene habits with regards to type of toothbrush and frequency of brushing compared to patients with CP [Table 2] in accordance with findings of a study conducted in 1999 which stated that AP patients were associated with good oral hygiene and oral hygiene habits which could not be correlated to the amount of attachment loss.  Another study concluded that higher proportion of AP patients reported brushing their teeth regularly when compared to CP patients.  Paan chewers were greater in CP patients, and the difference was statistically significant. A study conducted in Pune, India checked 300 patients (150 Paan chewers and 150 with no habits) for periodontal status. Paan with tobacco chewers was found to have seven times more risk of loss of attachment compared to patients with no habits. 
In the present study, oral hygiene parameters were poorer in CP compared to AP [Table 3] in accordance to the consensus report of World Workshop of Periodontology 1999 where it was stated that poor oral hygiene has been proven to be a major risk factor for disease progression in CP, but amount of deposits is inconsistent with severity of disease in AP. A study done to determine the progression of periodontal attachment loss in male Sri-Lankan tea laborers over a 20 year period concluded that gingival index, calculus index, and time were significantly associated with progression of periodontitis.  Another study reported that susceptibility to experimental gingivitis (in terms of development of bleeding on probing) differs between two groups of patients with apparently different susceptibility to periodontitis.  A study showed 13 AP subjects and 26 matched periodontally healthy subjects participated in a 21 days experimental gingivitis trial. Gingival crevicular fluid was significantly higher in AP compared to periodontally healthy group at each observation interval which suggests that susceptibility to gingival inflammation in response to de novo plaque accumulation may be related to susceptibility to periodontitis. 
Present study showed smoking more prevalent in CP patients whereas alcohol consumption was greater in AP [Table 2] . A study conducted in Stockholm, Sweden concluded that smokers exhibit greater bone loss and attachment loss, as well as more pronounced frequencies of periodontal pockets than nonsmokers. Smoking, thus, considerably increases the risk for destructive periodontal disease .  A study examined 200 smokers and 200 nonsmokers in the age group of 18-65 years attending the Himachal dental college, Sundernagar and concluded that the positive association was observed between periodontal disease and cigarette smoking.  A longitudinal study in Boston, USA concluded that alcohol consumption is an independent modifiable risk factor for periodontitis.  The gingival status of both test groups was similar apart from gingival recession which was found to be significantly greater in CP patients compared to AP, which could be due to the higher mean age of CP patients.
Present study had more than 50% of patients in both groups exhibiting Malocclusion [Table 6]. A study concluded that teeth with occlusal discrepancies were found to have deeper initial probing depths, significantly worse prognosis and more mobility than teeth without occlusal discrepancies even when patients with good oral hygiene are considered. Tongue thrusting and lip incompetence were more in CP patients whereas mouth breathing, bruxism, and pathological migration were not statistically significant.  A study in San Antonio, USA determined that pathologic migration was found in almost one-third of the patients (n = 343) studied with moderate to severe periodontitis over a period of 5 years. Teeth affected by pathologic migration had significantly more attachment loss than contralateral teeth without pathologic migration.  A study investigating the prevalence of tongue thrusting and the incidence of periodontal disorders associated with this habit among patients in Tehran concluded that tongue thrusting was seen in 27.3%of patients, whereas 29.8% and 33.8% of them showed an increase in periodontal pocket depths in their upper and lower jaws, respectively.  A study in Japanese population showed that children with severely incompetent lip seal showed significantly higher plaque score and inflammatory score of papillary gingiva than those with competent lip seal.  A study conducted in 240 students in Amritsar concluded that gingival index was found to be higher in the mouth breathers than in the normal breathers in the subjects with incompetent lip seal.  The blood picture (red blood cell, white blood cell, Hemoglobin, blood test, computed tomography) of the population under study [Table 7] demonstrated no significant difference between CP and AP patients.
Periodontal disease and its risk factors were known to mankind several years ago, but the lack of uniform criteria to evaluate and interpret data are major drawbacks in the literature. There is an urgent need to initiate and implement universally accepted protocols throughout the globe to generate data pertaining to different races and population.
| Conclusion|| |
This study has demonstrated that AP is manifested early in life in individuals who are susceptible to the disease. We can suggest that risk indicators for AP and CP in the present study include young age, place of residence, income and education levels, frequency of dental visits. The results suggest that patients with AP have better oral hygiene habits and oral hygiene indices results than patients with CP. Furthermore, Paan chewing and smoking can be considered as risk factors both in CP and AP cases. The similar association of plaque scores but higher bleeding tendency in AP patients supports the fact of higher susceptibility of AP patients to periodontal breakdown. Malocclusion being present in the majority of cases can also be put forth as a risk factor for AP and CP.
Nationwide studies with definite and uniform criteria to diagnose AP and CP are needed to determine the risk factors in other regions of India and globally. Further studies to cover different age groups and a larger population are needed to identify risk indicators of CP and AP in Davangere population. In addition, further longitudinal and intervention studies are needed to determine whether the identified risk factors are true risk factors for AP and CP in Davangere population. Furthermore, this study has demonstrated the great need for constructing nationwide oral health promotion programs in order to improve the level of oral health awareness and standards in Indian population.
| Acknowledgement|| |
We acknowledge the work of Dr. Vivekanda M.R in data collection, Dr. Bhagyajyothi and Dr. Umesh Wadgave for their help in statistical analysis.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]