The Harvard Medical School Family Health Guide
Teeth, Mouth, and Gums
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Preventive Dentistry

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Periodontitis and Heart Disease
The question of whether gum disease is associated with heart disease is controversial. The first research to suggest a connection, published in 1989, found that even after controlling for such cardiovascular disease risk factors as smoking and diabetes, heart-attack patients had significantly worse dental health than control subjects. Since then, several studies have also suggested a link, but the nature of the relationship — is it causative or coincidental? — remains in question.

In 2001, researchers sought an answer to this question, examining data from 4,027 people who participated in the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. During 17 years of follow-up, there were 1,238 cases of heart disease, 538 of which proved fatal. The rate of heart disease was three times higher in those with periodontitis than in those with healthy gums.

However, the connection became less prominent once investigators adjusted the numbers to account for other risk factors for cardiovascular disease — smoking, cholesterol levels, high blood pressure, and diabetes. After this adjustment, the heart disease risk among people with and without chronic dental infections was similar.

In fact, even those people who had eliminated any potential of dental infection through extraction of all teeth didn't have a lower heart disease risk when compared to those diagnosed with periodontitis (inflammation of the gums). The risk of developing CHD didn't decrease over time among those with no dental infections or increase over time among people with periodontitis.

A higher rate of other heart-disease risk factors among people with periodontitis might explain this relationship between gum disease and heart disease. For example, those with periodontitis were more likely to have high blood pressure and diabetes, and to smoke cigarettes.

These findings support the theory that the presence of periodontitis may occur coincidentally with increased cardiovascular risk but it is not its cause.
March 2002 Update

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Early versus Later Orthodontic Treatment in Children
Which approach works best for children who need orthodontic care: early two-phase treatment (which begins when a child still has all or most of his or her "baby" teeth) or later single-phase treatment (which is implemented when most, or all, of the permanent teeth are in)? Proponents of early two-phase orthodontic treatment argue that it is better able to modify the patient's skeletal growth and improve the patient's self-esteem. They also believe this approach achieves a better and more stable result and reduces the need for extensive therapy later. A University of North Carolina study, however, reports early two-phase orthodontic treatment is not necessarily superior to later single-phase treatment, nor does it always achieve all the goals some orthodontists claim it does.

Most people do not have perfect teeth, however, malocclusion is a condition where the jaws are misaligned. In very severe forms of malocclusion, the misalignment may interfere with the ability to speak or eat. The children in the North Carolina trial did not have such extreme misalignment. These children were determined to have moderate-to-severe Class II malocclusion. Children with a Class II malocclusion have some jaw misalignment. In addition, teeth may be crowded, abnormally spaced, or misaligned. This type of malocclusion can also involve upper teeth that protrude excessively or front teeth that do not meet. Malocclusion usually becomes apparent between ages 6 and 14, when the teeth and jaw are growing and often runs in families.

In this study, researchers randomly assigned children who still had most of their baby teeth to one of three groups: headgear treatment (fixed-appliance therapy), bionator therapy (removable-appliance therapy), or to an observational group that received no treatment. Seventy-five percent of the children in both the headgear and bionator therapy groups showed improvement in jaw alignment (although there was significant variation across all three groups).

The second phase of the study was to see whether the improvements achieved in the first phase of the study truly represented long-term results. Once the children's permanent teeth came in, study investigators randomly assigned members of all three groups to receive fixed-appliance therapy. Researchers discovered that the skeletal changes resulting from early treatment did not last. In addition, skeletal relationships, as well as the relationship between the upper and lower jaws, did not differ significantly between the groups that received the early two-phase treatment and the group that received later single-phase treatment. Neither the length of treatment nor the severity of the malocclusion was an important influence on the end result. Individual skeletal growth patterns, however, did play an important role.

One of the conclusions from this study is that the success of Class II correction does not depend on when treatment begins as long as it begins while the child is still growing. If the criterion for success of Class II correction is a better, more stable result, the later single-phase treatment would be preferable because treatment time is shorter. However, if the criteria for success include better self-esteem, then it may be preferable to start treatment earlier. It is important to keep in mind that early treatment is not the only way to correct malocclusion. A Class II correction can be achieved early or later with equally beneficial results. Other studies have been conducted that support these findings among children with more severe occlusions and other orthodontic problems.

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