Periodontal Disease in Patients with Ankylosing Spondylitis: myth or reality?

2017 ◽  
Vol 68 (7) ◽  
pp. 1660-1664
Author(s):  
Cristina Iordache ◽  
Rodica Chirieac ◽  
Eugen Ancuta ◽  
Cristina Pomirleanu ◽  
Codrina Ancuta
Keyword(s):  
Ankylosing Spondylitis ◽  
Periodontal Disease ◽  
Systemic Inflammation ◽  
Periodontal Pocket ◽  
Pocket Depth ◽  
Clinical Attachment Loss ◽  
Attachment Loss ◽  
Inflammatory Parameters ◽  
Periodontal Inflammation ◽  
The Impact

Although the relation between periodontitis (PD) and systemic disorders (e.g. cardiovascular diseases, diabetes and rheumatoid arthritis) is widely accepted, the association with ankylosing spondylitis (AS) is inconsistently mentioned. We prospectively examined the relationship between periodontal disease and AS, focusing on the rate and course of PD, factors associated with severity and the impact of anti-TNF-a treatment on inflammatory status. Standard assessments performed twice (week 0, week 24) included an extensive dental evaluation (plaque index, gingival index, bleeding on probing, periodontal pocket depth, clinical attachment loss), inflammatory parameters and AS activity scores (BASDAI, ASDAS-CRP). More than half of AS presented with impaired periodontal health at baseline (mild to moderate PD) meaning increased sites with dental plaque, abnormal bleeding, increased periodontal pocket depth and clinical attachment loss. Significant positive correlation between presence and severity of PD, AS activity and systemic inflammation (CRP) was reported at baseline (p[0.05). A final analysis performed at 24 weeks revealed significant improvement in periodontal status, inflammatory parameters and AS activity, suggesting efficacy of TNF inhibitors directed not only against systemic, but also on local (articular, periodontal) inflammation (p[0.05). Patients with AS are at risk to develop periodontal disease, particularly those with high levels of systemic inflammation. Benefits of anti-TNFa therapy in the particular settings of AS patient and concomitant periodontal disease should be validated through further studies in larger cohorts.

TNF Inhibitors and Periodontal Inflammation in Psoriatic Arthritis

2017 ◽  
Vol 68 (8) ◽  
pp. 1914-1918
Author(s):  
Codrina Ancuta ◽  
Eugen Ancuta ◽  
Rodica Chirieac ◽  
Carmen Anton ◽  
Zenaida Surlari ◽  
...  
Keyword(s):  
Psoriatic Arthritis ◽  
Periodontal Disease ◽  
Periodontal Diseases ◽  
Tnf Inhibitors ◽  
Periodontal Pocket ◽  
Pocket Depth ◽  
Clinical Attachment Loss ◽  
Periodontal Status ◽  
Inflammatory Parameters ◽  
Periodontal Inflammation

The link between immune mediated rheumatic disorders and oral health, particularly periodontal disease, is widely accepted, based on shared immune and inflammatory processes as well as local (articular, gingival) damage mediated by similar pro-inflammatory cytokine and destructive mediators. We aimed to evaluate periodontal status in psoriatic arthritis (PsA) before and after 24-weeks treatment with TNF inhibitors and to identify potential relation between disease activity, inflammatory parameters, therapeutic response and chronic periodontitis. Patients were prospectively assessed according to a standard protocol comprising a complex rheumatologic (PsA activity, inflammatory prolife) and dental evaluation (plaque and gingival index, bleeding on probing, periodontal pocket depth, clinical attachment level). Up to one third PsA presented with moderate to severe periodontitis at baseline, with high prevalence of sites with dental plaque, abnormal bleeding, increased periodontal pocket depth and clinical attachment loss. Higher levels of inflammatory parameters were described in the subset of PsA presenting with aggressive periodontal diseases, while significant correlation between dental pathology and CRP (p[0.05). A significant improvement in both PsA-related parameters and periodontal status was demonstrated after 24 weeks of anti-TNF therapy (p[0.05). Periodontal disease may develop in PsA and should be commonly evaluated, particularly patients with active disease. Benefits of TNF inhibitors, with significant response in articular and periodontal parameters, suggest common inflammatory pathways in both entities.

Periodontal disease in patients with ankylosing spondylitis

2009 ◽  
Vol 69 (01) ◽  
pp. 34-38 ◽  
Author(s):  
N Pischon ◽  
T Pischon ◽  
E Gülmez ◽  
J Kröger ◽  
P Purucker ◽  
...  
Keyword(s):  
New York ◽  
Ankylosing Spondylitis ◽  
Alcohol Consumption ◽  
Periodontal Disease ◽  
Inflammatory Diseases ◽  
Stepwise Logistic Regression ◽  
Tissue Destruction ◽  
Pocket Depth ◽  
Clinical Attachment Loss ◽  
Attachment Loss

Objective:Ankylosing spondylitis (AS) and periodontal disease (PD) are characterised by dysregulation of the host inflammatory response, resulting in soft and hard connective tissue destruction. AS has been related to other inflammatory diseases, however, there is a paucity of data on whether AS is associated with inflammatory PD.Methods:The association between AS and PD was examined in 48 patients with AS and 48 healthy controls, matched for age and gender. AS was diagnosed according to the modified New York criteria. Periodontal examination included probing pocket depth (PPD), clinical attachment loss (CAL), plaque index (PI) and bleeding on probing (BOP). Potential risk factors of PD such as smoking, low education, alcohol consumption, body mass index (BMI), as well as chronic diseases associated with PD and AS were assessed through questionnaires.Results:In stepwise logistic regression, including AS status, age, gender, education, smoking, alcohol consumption and BMI, only AS status, age and education remained significant predictors of PD. Patients with AS had significant 6.81-fold increased odds (95% CI 1.96 to 23.67) of PD (defined as mean attachment loss >3 mm) compared to controls. The strength of the association was attenuated but remained statistically significant after further adjustment for plaque accumulation (odds ratio (OR) 5.48, 95% CI 1.37 to 22.00).Conclusions:The present study shows that patients with AS have a significantly higher risk of PD, strongly suggesting the need for close collaboration between rheumatologists, periodontists and dental hygienists when treating patients with AS.

Relationship Between Body Mass Index and Chronic Periodontitis

2021 ◽  
Vol 5 (1) ◽  
pp. 7-10
Author(s):  
Shreeya Aryal ◽  
Ameena Pradhan ◽  
Shilu Shrestha ◽  
Surendra Man Shrestha
Keyword(s):  
Body Mass Index ◽  
Periodontal Disease ◽  
Body Mass ◽  
Disease Status ◽  
Periodontal Pocket ◽  
Potential Threat ◽  
Predisposing Factor ◽  
Clinical Attachment Loss ◽  
Cross Sectional ◽  
Attachment Loss

Introduction: Obesity is regarded as unnecessary body fat in ratio to lean body mass. Besides being an established risk factor for cardiovascular and other systemic diseases, obesity has been suggested to be a potential threat for periodontitis as well. Objective: The objective of the study was to learn relationship between body mass index (BMI) and periodontal disease. Methods: This analytical cross-sectional study was conducted at People’s Dental College from February 16 to April 15, 2021 after ethical approval. Seventy-two participants were selected conveniently who, on the basis of calculation of weight and height were allocated into two groups: Group A: participants with normal BMI, Group B: Obese/ overweight individuals. Plaque index, gingival index, periodontal pocket, and clinical attachment loss were recorded in both the groups to assess the periodontal disease status. On basis of findings, the two groups were statistically compared. Results: The result showed clinical attachment loss was significantly higher (P <0.001) in overweight/obese group than in normal BMI group (P =0 .001). Conclusion: The findings of this study suggest that obesity and overweight can be a possible predisposing factor for periodontal disease.

scholarly journals Determinants of periodontitis according to the immunological and virological profiles of HIV-infected patients in Yaoundé, Cameroon

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Joseph Fokam ◽  
Buolikeze Kuoh Nji Geh ◽  
Samuel Martin Sosso ◽  
Desire Takou ◽  
Ezechiel Semengue Ngufack ◽  
...  
Keyword(s):  
Periodontal Diseases ◽  
Protective Role ◽  
Sub Saharan Africa ◽  
Periodontal Pocket ◽  
Pocket Depth ◽  
Clinical Attachment Loss ◽  
Attachment Loss ◽  
Cd8 Cells ◽  
Reference Centre ◽  
Increased Risk

Abstract Background HIV infection is associated to different oral manifestations (including periodontal diseases), which have decreased with the advent of antiretroviral therapy (ART). Yet, the occurrence of periodontitis is still consistent among patients with HIV living in sub Saharan-Africa, with limited evidence on the driven factors and mitigating measures in these settings. We aimed at evaluating the occurrence of periodontitis and its associated immunological and virological factors in patients with HIV living in Yaoundé, Cameroon. Methods We included 165 (44 ART-naïve and 121 ART-experienced) patients > 18 years old attending the Yaoundé Central Hospital and the Chantal BIYA International Reference Centre, from January-April 2018. The periodontal status was assessed by measuring the clinical attachment loss, periodontal pocket depth, plaques index and gingival bleeding index. CD4+/CD8+ cells and viremia were measured using the fluorescence-activated cell sorting method (FACS Calibur) and the Abbott m2000 RT HIV-1 RNA kit respectively. A standard-questionnaire concerning participants’ medical records and oral hygiene methods was filled. Data was analyzed and p < 0.05 considered statistically significant. Results There was a significantly high prevalence of periodontitis in the ART-naïve (53.2%) compared to the ART-experienced group (37.3%), with a twofold increased risk of the ART-naïve population presenting with periodontitis than the ART-experienced population (OR 2.06, p = 0.03). More importantly, ART-naïve, patients with CD4 < 200 cells presented with higher risk of having periodontitis compared to those with higher CD4-values, with a threefold difference (OR 3.21). Worth noting, males presented with a higher risk of having clinical attachment loss (OR 6.07). There was no significant association between the occurrence of periodontitis and the CD8 (p = 0.45) or viremia (p = 0.10). Conclusion In the Cameroonian context, a considerable number of adults infected with HIV suffer from periodontitis regardless of their treatment profile. Nonetheless, ART-naïve patients have a higher risk, indicating the protective role of ART. Interestingly, severely immune-compromised patients and men are vulnerable to periodontitis, thereby highlighting the need for clinicians to refer patients for regular periodontal screening especially male patients and those with low CD4. Such measures could greatly improve the quality of life of the population living with HIV in Cameroon.

scholarly journals CORRELATION BETWEEN PERIODONTAL DISEASE INDICES AND LUNG CANCER IN GREEK ADULTS: A CASE — CONTROL STUDY

2016 ◽  
Vol 38 (1) ◽  
pp. 49-53 ◽  
Author(s):  
N A Chrysanthakopoulos
Keyword(s):  
Lung Cancer ◽  
Periodontal Disease ◽  
Case Control Study ◽  
Case Control ◽  
Pocket Depth ◽  
Clinical Attachment Loss ◽  
Bleeding On Probing ◽  
Attachment Loss ◽  
Probing Pocket Depth ◽  
Control Study

Aim: The aim of the present case — control study was to examine the possible associations between periodontal disease indices and the risk of lung cancer development in a sample of Greek out-patients referred to a medical and a dental private practice. Materials and Methods: A total of 200 individuals were interviewed and underwent an oral clinical examination, and 64 of them were suffered from several histological types of lung cancer. The estimation of the possible associations between lung cancer as a dependent variable and periodontal disease indices as independent ones was carried out by using a multiple regression analysis model. Results: Probing pocket depth (odds ratio (OR) = 2.72, 95% confidence interval (CI) 1.05–7.06), clinical attachment loss (OR = 3.51, 95% CI 1.30–9.47) bleeding on probing (OR = 1.93, 95% CI 0.98–3.81) were significantly associated with the risk of developing lung cancer. Smoking (OR = 2.49, 95% CI 1.20–5.17) was significantly associated with the mentioned risk, whereas it was consisted as a confounder regarding the estimated associations between moderate/severe clinical attachment loss and presence of bleeding on probing with the risk of developing lung cancer. Conclusion: Probing pocket depth as an index for periodontal disease severity was statistically significantly associated with the risk of developing lung cancer.

scholarly journals Role of gender & age in chronic periodontal disease

2021 ◽  
Vol 6 (2) ◽  
pp. 117-125
Author(s):  
Ashish Jain ◽  
Neeta V Bhavsar
Keyword(s):  
Periodontal Disease ◽  
Hospital Setting ◽  
Screening Tools ◽  
Pocket Depth ◽  
Cross Sectional ◽  
Diagnostic Strategies ◽  
Periodontal Inflammation ◽  
Chronic Periodontal Disease ◽  
Significant Difference ◽  
The Impact

There is lot of literature suggesting a gender based heterogeneity in many human chronic diseases including periodontal disease. To analyze and compare the clinical periodontal disease parameters & serum biochemical markers of periodontal inflammation in systemically healthy age stratified adult male and female patients suffering from chronic destructive periodontal disease. Cross sectional observational study in a hospital setting A total of 300 subjects, both genders were enrolled based on predefined criteria and were categorized in 6 groups of 50 subjects each. Complete medical and dental history was taken to screen before enrollment. All subjects underwent complete periodontal examination, including evaluation of Plaque index (PI), Probing pocket depth (PPD) and Clinical attachment level (CAL), Bleeding on Probing (BOP). Blood samples were taken for analysis of inflammatory biomarkers viz interleukin (IL)-1β, osteoprotegrin (OPG), matrix metalloproteinase (MMP)- 8 & interleukin (IL)- 6. IBM SPSS STATISTICS (version 22.0) Clinical parameters of periodontal status were higher in females as compared to males except BOP. However, only PPD and CAL showed significant difference. Higher serum levels of IL-1β, OPG and Il-6 were observed in females (2.10 + 26.82, 168.18 + 49.84 , 29.17 + 99.20 pg/ml) than males (1.90 + 7.27 , 145.00 + 39.60 , (25.83 + 189.09pg/ml) respectively, but significant difference was observed only for OPG. A statistically significant higher level of MMP-8 was observed in males (3003.33 + 772.33 pg/ml) as compared to females (1398.33 + 1218.10 pg/ml). The findings of current investigation has identified significant differences in the clinical and specific biochemical mediators(IL-1β, IL-6, OPG, MMP-8) across groups and subgroups of the population To ascertain the impact of gender and age in the causation and pathogenesis of inflammatory periodontal disease, further well designed prospective investigations are needed . The study findings point towards the identification of specific biomarkers in individual subgroup/group based on age and gender. These shall pave path to develop predictive models, screening tools and early diagnostic strategies for chronic periodontal disease for Indian population.

Non-Surgical Periodontal Therapy Decreases Periodontal Pocket Depth and Clinical Attachment Loss of Rheumatoid Arthritis Patients

2021 ◽  
Vol 15 (11) ◽  
pp. 3376-3377
Author(s):  
Marryam Riaz ◽  
Sohaib Shujaat ◽  
Ayesha Fahim ◽  
Shamail Zafar ◽  
Mariyah Javed ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Gingival Recession ◽  
Periodontal Therapy ◽  
Periodontal Pocket ◽  
P Value ◽  
Pocket Depth ◽  
Clinical Attachment Loss ◽  
Public And Private ◽  
Attachment Loss ◽  
Before And After

Objective: The objective of the present study was to determine the effect of non-surgical periodontal therapy on the disease severity in rheumatoid arthritis patients. Methods: Five hundred and twenty arthritis patients were included in the study, using consecutive non-probability sampling from the outpatient department of various public and private hospitals of Pakistan. Patients with periodontitis along with systemic Rheumatoid Arthritis (RA) were included in the study. Clinical parameters taken for the severity of periodontitis were the Gingival recession (GV), Periodontal Pocket Depth (PPD) and Clinical Attachment Loss (CAL). Independent sample t-test was used for significance before and after non-surgical periodontal therapy. Data was presented with mean (standard deviation). Results: The PPD and CAL of Rheumatoid Arthritis patients were found to be decreased significantly following non-surgical periodontal treatment (p value < 0.05), unlike the gingival recession, which did not decrease significantly (p value > 0.05). Conclusion: The PPD and CAL values of periodontal patients with rheumatoid arthritis were significantly reduced after giving non-surgical Periotherapy along with oral hygiene instruction. Keywords: arthritis; gingiva; periodontitis; periodontal pocket

A Novel Systemic Indicator of Periodontal Tissue Damage: Ischemia Modified Albumin

2018 ◽  
Vol 21 (8) ◽  
pp. 544-549 ◽  
Author(s):  
Mahmure A. Tayman ◽  
Canan Önder ◽  
Şivge Kurgan ◽  
Muhittin A. Serdar ◽  
Meral Günhan
Keyword(s):  
Periodontal Disease ◽  
Inflammatory Diseases ◽  
Periodontal Therapy ◽  
Periodontal Pocket ◽  
Oxidative Stress Marker ◽  
Pocket Depth ◽  
Ischemia Modified Albumin ◽  
Nonsurgical Periodontal Therapy ◽  
Before And After ◽  
The Impact

Background: Ischemia-modified albumin (IMA) is a systemic indicator of inflammatory diseases and is suggested as an oxidative stress marker. Objective: To determine the IMA and high-sensitivity C-reactive protein (hsCRP) serum levels for patients with chronic periodontitis (CP) and to evaluate the impact of non-surgical periodontal therapy on serum IMA and hsCRP levels. Methods: Twenty one systemically healthy patients with CP and 15 systemically and periodontally healthy controls (C) were enrolled in the study. Periodontal pocket depth (PPD), bleeding on probing (BOP) and attachment loss (AL) were recorded at the time of diagnosis and 6 weeks after the nonsurgical periodontal therapy. Blood samples were obtained before and after treatment from all groups, and serum IMA and hsCRP levels were evaluated by ELISA method. Results: All of the clinical findings were found to be elevated in the CP group in comparison to C group (p<0.05). Levels of IMA and hsCRP were higher in the CP group (p<0.05) and decreased after non-surgical periodontal therapy (p<0.05). Positive correlations were determined between PPD, BOP and hsCRP (p<0.05) as well as between PPD, AL, BOP and IMA levels (p<0.01) before treatment. A significant positive correlation was also observed between hsCRP and IMA (p<0.01) before and after treatment. Conclusion: IMA is a marker indicating systemic inflammation during periodontal disease, and is significantly reduced as a result of non-surgical periodontal therapy. Therefore, IMA might be suggested as a useful indicator of periodontal disease.

scholarly journals Estimation of periodontal pocket surface area in small to medium dogs: a proof-of-concept study

2022 ◽  
Vol 18 (1) ◽  
Author(s):  
Kazuya Tamura ◽  
Masako Tokuzen-Tai ◽  
Yasir Dilshad Siddiqui ◽  
Hitomi Tamura-Naito ◽  
Yoshiharu Nagahara ◽  
...  
Keyword(s):  
Body Weight ◽  
Periodontal Disease ◽  
Surface Area ◽  
Periodontal Pocket ◽  
Regression Equations ◽  
Serum Globulin ◽  
Pocket Depth ◽  
Epithelial Surface ◽  
Periodontal Inflammation ◽  
Systemic Health

Abstract Background Periodontal disease is the most common dental disease in dogs. Although the systemic effects of periodontal disease have not been clarified in veterinary science, it is necessary to evaluate the effects of periodontal disease in clinical trials in the future. There have been a few clinical attempts made, however, to assess the severity of periodontal inflammation and its impact on the systemic health of dogs. Meanwhile, in the field of dentistry for humans, the periodontal inflamed surface area (PISA) and periodontal epithelial surface area (PESA) have been used to quantitatively assess the degree of periodontal disease affecting a single tooth as well as the overall extent of periodontitis. Recent studies have also suggested the use of these assessments to examine the relationship between periodontal inflammation and systemic health. Results The estimation formula for a dog’s periodontal pocket surface area (PPSA), an alternative to PISA and PESA in humans, was established using body weight and periodontal pocket depth. Actual values were measured using extracted teeth from various dog breeds and sizes (2.3–25.0 kg of body weight) to obtain universal regression equations for PPSA. Altogether, 625 teeth from 73 dogs of 16 breeds were extracted and subsequently analyzed for morphological information. PPSA was measured in 61 dogs of 10 breeds with periodontal disease using the established estimation formulas, and the correlation between PPSA and preoperative blood chemistry data was analyzed accordingly. A strong correlation was found between PPSA and serum globulin (r = 0.71) while moderate correlations were found for C-reactive protein (r = 0.54) and serum albumin (r = -0.51). Conclusions Estimation formulas using body weight and the 6-point probing depth were established for determining PPSA. Direct correlations between PPSA and several blood test results were observed in the study sample. Taken together, these results suggest that PPSA could be useful for evaluating the effects of periodontitis on systemic conditions in dogs.

scholarly journals POS0581 PERIODONTAL DISEASE IN RHEUMATOID ARTHRITIS: RESULTS FROM A COHORT AT TREATMENT WITH BIOLOGICAL, CLASSICAL AND TARGETED SYNTHETIC DMARDs

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 524.1-524
Author(s):  
R. Dos-Santos ◽  
F. Otero ◽  
E. Perez-Pampín ◽  
A. Mera Varela
Keyword(s):  
Rheumatoid Arthritis ◽  
Oral Health ◽  
Periodontal Disease ◽  
Disease Activity ◽  
Health Problem ◽  
Multivariable Analysis ◽  
Testing Time ◽  
Univariable Analysis ◽  
Clinical Attachment Loss ◽  
Attachment Loss

Background:Periodontal disease (PD) has been widely studied in the pathogenesis of rheumatoid arthritis (RA). As well, its relationship with severity and disease activity, has also been investigated with ambiguous results. It has been suggested that the improvement of oral health could enhance disease activity scores.1 PD prevalence worldwide stands around 60% in older adults (>65 years) and its frequency increases with aging.2Objectives:To asses oral health in RA patients and to identify predictors of PD in this population.Methods:Patients diagnosed of RA at treatment with biological, classical or targeted synthetic disease modifying anti-rheumatic drugs (b/cs/tsDMARDs) in the aforementioned hospital during 2020 performed a dental review with a specialized periodontal odontologist. Oral health patterns were given for all patients, following criteria of American Academy of Periodontology, and reevaluation of disease activity was made 2 months later.Clinical, demographic and treatment data were collected from participants.Univariable logistic regression was performed to identify predictors of PD. Variables with p<0.20 were selected for multivariable analysis.Stata 15.1 was used to perform statistical analysis.Results:81 patients were recruited. 82.72% were female. Mean age was 56.17 years (SD 14.15) and mean time since diagnosis was 15.58 years (SD 8.17). 25% were current or past smokers. 21 patients had comorbidities (arterial hypertension the most frequent). 66.67% were rheumatoid factor (RF) positive and 72.73% anti-citrullinated peptide autoantibody (ACPA) positive. Median erythrocyte sedimentation rate (ESR) was 12 mm (IQR 6;23) and mean C-reactive protein (CRP) was 0.48 mg/dl (SD 1.18). Mean disease activity score (DAS28-VSG) at the testing time was 2.62 (SD 1.21) and after 2 months was 2.39 (SD 0.97). 96.30% of patients were at treatment with csDMARDs, 64.20% with glucocorticoids, 96.30% with bDMARDs and 6 patients with tsDMARDs.Univariable analysis identified higher age, at least one autoantibody positive and ESR/CRP as potential predictors of medium/severe PD (p<0.20). Multivariable testing including these variables pointed out higher age, lower ESR and at least one autoantibody positive (OR 1.09 [CI95% 1.04-1.14] p=0.001, OR 0.18 [CI95% 0.04-0.95] p=0.044 and OR 0.94 [CI95% 0.88-1.00] p=0.042, respectively) as predictors of medium or severe PD (≥3 mm interdental clinical attachment loss).Univariable analysis identified higher age, the presence of any comorbidity and anti tumour-necrosis factor alpha treatment (anti-TNF) as potential predictors of severe PD (p<0.20). Multivariable testing including these variables pointed out higher age (OR 1.15 [CI95%1.02-1.30] p=0.026) as predictor of severe PD (≥5 mm interdental clinical attachment loss).Conclusion:Periodontal disease is still an extended health problem among the entire population. Its prevalence in RA is increased, therefore higher age and RF or ACPA positive are risk factors for developing severe PD. This analysis might suggest that an aggressive management of PD could implement better responses in DAS28. Also anti-TNF treatment could delimit a “penumbra” group of patients at risk of developing severe PD, where intensive manage could modify the final outcome.References:[1]C O Bingham, M Moni. Periodontal disease and rheumatoid arthritis: the evidence accumulates for complex pathobiologic interactions. Curr Opin Rheumatol. 2013;25(3):345-353.[2]P Carvajal. Periodontal disease as a public health problem: the challenge for primary health care. Rev Clin Periodoncia inplantol. 2016;9(2):177-183.Disclosure of Interests:None declared

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