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Pocket Depth (pocket + depth)
Kinds of Pocket Depth Selected AbstractsPeriodontal disease among indigenous people in the Amazon rain forestJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 11 2001Mauricio Ronderos Abstract Background: People are not all equally susceptible to periodontitis. To understand the epidemiology and natural history of this disease, it is important to study populations with varying genetic backgrounds and environmental exposures. Aim: Characterize the periodontal condition of a sample of indigenous adults in a remote region of the Amazon rain forest and determine the association of periodontal disease with various demographic, behavioral and environmental factors. Methods: A cross-sectional evaluation of 244 subjects aged 20,70 years was conducted. Pocket depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), plaque and calculus were assessed for the Ramfjord index teeth. Results: These people had high levels of plaque, calculus and BOP. The mean PD was rather shallow (2.45 mm in 20,29 year-olds to 2.73 mm in 50+ year-olds) and did not increase significantly with age. Mean CAL (0.57 mm in 20,29 year-olds and 2.26 mm in 50+ year-olds) and mean location of the free gingival margin in relation to the cemento-enamel junction changed significantly with age (p<0.0001). Multivariate analysis revealed that increasing age, bleeding on probing and calculus scores were positively associated with mean CAL (p<0.01). Sex, ethnicity, level of modern acculturation, use of coca or tobacco paste, frequency of dental visits and plaque were not associated with mean CAL. Conclusions: Periodontal disease in these people was mainly associated with gingival recession rather than deep pockets. Most people had clinical attachment loss but despite poor oral hygiene and extensive gingival inflammation, they did not have very severe periodontal destruction. [source] Refining exposure definitions for studies of periodontal disease and systemic disease associationsCOMMUNITY DENTISTRY AND ORAL EPIDEMIOLOGY, Issue 6 2008Ryan T. Demmer Abstract,,, Background:, Substantial variation exists in reported associations between periodontal infections and cardiovascular disease. Imprecise periodontal exposure definitions are possible contributors to this variability. We studied appropriate exposure definitions for studying associations between clinical periodontal disease (PD) and systemic disease. Methods:, Data originate from men and women aged 20,79 enrolled in the Study of Health in Pomerania (SHIP) from 1997,2001. Age and sex-adjusted correlation analysis identified PD definitions with the highest cross-sectional associations with three subclinical markers of systemic disease: plasma fibrinogen (n = 3481), serum hemoglobin A1c (HbA1c) (n = 3480), and common carotid artery intima-media thickness (c-IMT) (n = 1745, age , 45). Results:, In men and women, percent of sites with attachment loss (AL) ,6 mm and tooth loss both revealed the highest correlation with HbA1c (, = 0.11; several other definitions related similarly), while the strongest fibrinogen correlation was observed with percent of sites with pocket depth ,3 mm (, = 0.19). Findings for c-IMT among men were strongest for percent of sites with AL ,6 mm (, = 0.14; several other definitions related similarly) while among women, percent of sites with pocket depth ,5 or 6 mm had the highest observed correlation (, = 0.13). Conclusions:, A range of near optimal definitions varied according to gender and whether the systemic disease marker reflected an acute or chronic situation. Pocket depth was more strongly correlated with the acute marker fibrinogen while attachment and tooth loss tended to be more strongly correlated with the chronic markers, HbA1c, and c-IMT. These findings can be useful in designing future studies investigating the association between PD and systemic disease. [source] Longitudinal study on periodontal conditions in healthy elderly people in JapanCOMMUNITY DENTISTRY AND ORAL EPIDEMIOLOGY, Issue 6 2002Toshinobu Hirotomi Abstract , Objectives: A strategy for the control of periodontal disease progression is required to prevent tooth loss in older people. However, detailed epidemiological data on periodontal conditions in elderly people is limited. The purpose of the present study is to describe the natural history of periodontal disease and to evaluate the intraoral factors relating to the disease progression in systemically healthy elderly people. Methods: In the cross-sectional study, 599 and 162 subjects aged 70 and 80 years, respectively, were examined. Of those subjects aged 70 years, 436 (73%) participated in the 2-year longitudinal study. Pocket depth (PD) and attachment level (AL) were measured for all functioning teeth at six sites per tooth. In the cross-sectional study, AL of 4 mm or greater and 7 mm or greater were defined as moderate and severe disease, respectively. In the longitudinal study, a change in AL of 3 mm or greater at each site was defined as periodontal disease progression. Results: In the cross-sectional study, 97.1% of the subjects had at least one site of AL of 4 mm or greater (4+ mm). The prevalence of AL of 7 mm or greater (7+ mm) was 47.9%, with 2.8 affected teeth per person in those with AL 7+ mm. These findings reveal that periodontal disease is extremely widespread in the elderly population. However, very few had many teeth with severe periodontal conditions. In the longitudinal study, 75.1% experienced attachment loss of 3 mm or greater (3+ mm) during the 2-year study period. Of those subjects who experienced attachment loss, a mean of 4.7 teeth exhibited attachment loss. Multivariate logistic regression showed that both the highest AL in each tooth at baseline and abutment teeth for removable partial dentures were significantly related to periodontal disease progression as well as tooth loss incidence. Conclusions: These results suggest that teeth with poor periodontal conditions as well as abutment teeth for removable partial dentures were significant intraoral factors relating to periodontal disease progression as well as tooth loss. [source] Bone resorbing activity and cytokine levels in gingival crevicular fluid before and after treatment of periodontal diseaseJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 6 2004Anders Holmlund Abstract Background: The aim of the present study was to investigate bone resorption activity (BRA), interleukin-1, (IL-1,), IL-1, and interleukin-1 receptor antagonist (IL-1ra) in gingival crevicular fluid (GCF) in sites with no signs of periodontol disease and in sites with horizontal or angular loss of periodontal bone. These assessments were performed before and after periodontal treatment. Methods: GCFs were collected from 10 individuals with filter strips from two healthy sites and four sites with deep pathological periodontal pockets, two of which showed horizontal bone loss and two with angular bone loss. All diseased pockets were treated with flap surgery and systemic Doxyferm®. Twelve months later GCF was collected again and treatment outcome evaluated. BRA in GCFs was assessed in a bone organ culture system by following the release of 45Ca from neonatal mouse calvariae. The amounts of IL-1,, IL-1, and IL-1ra in GCFs were quantified by enzyme-linked immunosorbent assay (ELISA). Results: Treatment resulted in reduction of pocket depths with 3.5±0.5 mm in sites with angular bone loss and 2.8±0.3 mm in sites with horizontal bone loss. Initially, BRA, IL-1,, IL-1, and IL-1ra were significantly higher in GCFs from diseased sites compared with healthy sites. No differences in BRA and cytokine levels were seen between GCFs from pockets with horizontal and angular bone losses. The levels of IL-1,, IL-1, and IL-1ra were significantly reduced after treatment of diseased pockets. Pocket depths were significantly correlated to BRA only in pre-treatment sites with angular bone loss. BRA was correlated to Il-1,, IL-1,, but not to IL-1ra, in diseased sites with angular bone loss, before and after treatment. The reductions of BRA in the individual sites, seen after treatment, were not correlated to the reductions of Il-1,, IL-1, or IL-1ra. Conclusions: These data show that BRA and cytokine levels are increased in GCFs from sites with periodontal disease and that periodontal treatment results in reduction of the cytokines. Our findings further indicate that IL-1, and IL-1, play important roles for the BRA present in GCFs, but that other factors also contribute to this activity. [source] The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: a systematic reviewINTERNATIONAL JOURNAL OF DENTAL HYGIENE, Issue 4 2008DE Slot Abstract:, Aim:, The aim of the study was to asses the effect of the use of interdental brushes (IDB) in patients as an adjunct to toothbrushing compared with toothbrushing alone or other interdental oral hygiene devices on plaque and the clinical parameters of periodontal inflammation. Material and methods:, MEDLINE,PubMed and the Cochrane Central register of controlled trials (CENTRAL) were searched through November 2007 to identify appropriate studies. Clinical parameters of periodontal inflammation such as plaque, gingivitis, bleeding and pockets were selected as outcome variables. Results:, Independent screening of the titles and abstracts of 218 MEDLINE,PubMed and 116 Cochrane papers resulted in nine publications that met the eligibility criteria. Mean values and standard deviations were collected by data extraction. Descriptive comparisons are presented for brushing alone or brushing and woodsticks; meta-analyses were also performed for the floss comparison. Conclusion:, As an adjunct to brushing, the IDB removes more dental plaque than brushing alone. Studies showed a positive significant difference using IDB with respect to the plaque scores, bleeding scores and probing pocket depth. The majority of the studies presented a positive significant difference in the plaque index when using the IDB compared with floss. [source] The effect of the Vector® scaler system on human teeth: a systematic reviewINTERNATIONAL JOURNAL OF DENTAL HYGIENE, Issue 3 2008DE Slot Abstract:, Aim:, To review the available literature, considering the effect of instrumentation with the Vector® ultrasonic scaler on human teeth in vitro and in vivo compared to conventional ultrasonic instruments and/or hand instrumentation. The assessed effects are calculus removal, time of instrumentation, root surface aspects, cell attachment, patients' perception, bleeding upon probing, pocket depth, clinical attachment loss and microbiological effects. Materials and methods:, MEDLINE,PubMed and the Cochrane Central register of controlled trials (CENTRAL) were searched up through January 2008 to identify appropriate studies. Results:, Independent screening of the titles and abstracts of 270 MEDLINE,PubMed and 15 Cochrane papers resulted in 15 suitable publications. The studies differed in design and outcome, so this review summarizes the outcomes in a descriptive manner. Comparisons are presented against conventional ultrasonic system and scaling and root planing. Conclusion:, The Vector® ultrasonic scaler provided comparable clinical and microbiological periodontal healing results as scaling and root planing and conventional ultrasonic system in moderately deep pockets. The Vector® ultrasonic scaler may be used as a gentle root debridement device for supportive periodontal therapy, as an alternative to other conventional ultrasonic system. The operator should however consider the extra time needed for instrumentation. [source] Oral hygiene practices, periodontal conditions, dentition status and self-reported bad mouth breath among young mothers, TanzaniaINTERNATIONAL JOURNAL OF DENTAL HYGIENE, Issue 4 2006EGS Mumghamba Abstract:,Objectives:,To determine the oral hygiene practices, periodontal conditions, dentition status and self-reported bad mouth breath (S-BMB) among young mothers. Study participants and methods:,This was a cross-sectional descriptive study conducted at Muhimbili National Hospital, Dar es Salaam, Tanzania. A total of 302 postpartum mothers, aged 14,44 years, were interviewed on oral hygiene practices and S-BMB using structured questionnaire. Oral hygiene, dentition and periodontal status were assessed using the Community Periodontal Index probe and gingival recessions (GR) using Williams Periodontal probe. Results:,Tooth brushing practice was 99%; tongue brushing (95%), plastic toothbrush users (96%), chewing stick (1%), wooden toothpicks (76%), dental floss (<1%); and toothpaste (93%). The prevalence of plaque and gingival bleeding on probing was 100%, gum bleeding during tooth brushing (33%), calculus (99%), probing periodontal pocket depth (PPD) 4,5 mm (27%), PPD 6+ mm (3%), GR 1+ mm (27%) and tooth decay (55%). The prevalence of S-BMB was 14%; the S-BMB had higher mean number of sites with plaque compared to the no S-BMB group (P = 0.04). Factors associated with S-BMB were gum bleeding on tooth brushing (OR = 2.4) and PPD 6+ mm (OR = 5.4). Conclusion:,Self-reported bad mouth breath is a cause of concern among young mothers, and associated significant factors were gum bleeding on tooth brushing and deep periodontal pockets of 6+ mm. Further research involving clinical diagnosis of bad mouth breath and intervention through oral health promotion and periodontal therapy are recommended. Clinical relevance:,This study provides baseline information on oral health status and the complaint on bad mouth breath which necessitates in the future need for objective assessment, diagnosis and management of bad mouth breath for enhanced social and professional interaction without embarrassments. [source] Serum levels of interleukin-10 and tumour necrosis factor- , in chronic periodontitisJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 10 2010Anna Passoja Passoja A, Puijola I, Knuuttila M, Niemelä O, Karttunen R, Raunio T, Tervonen T. Serum levels of interleukin-10 and tumour necrosis factor- , in chronic periodontitis. J Clin Periodontol 2010; 37: 881,887. doi: 10.1111/j.1600-051X.2010.01602.x Abstract Aims: To investigate, using a cross-sectional study design, whether the extent of periodontal inflammation associates with the serum levels of cytokine interleukin (IL)-10 and tumour necrosis factor (TNF)- , and their ratio. Material and Methods: The study group consisted of 61 subjects with chronic periodontitis and 30 control subjects with minimally inflamed periodontal tissues. Probing pocket depth (PD), bleeding on probing (BOP) and periodontal attachment level (AL) were measured. The serum IL-10 (pg/ml) and TNF- , (U/l) levels were analysed using enzyme-linked immunosorbent assays. After categorization of the subjects, associations between serum IL-10 and TNF- , levels and the extent of periodontal inflammation were studied using linear regression models adjusted for age, gender, body mass index and smoking. Results: A negative, partly dose-dependent association existed between the extent of BOP, PD4 mm and AL4 mm and serum IL-10 level. The subjects in the periodontitis group presented significantly higher serum TNF- , levels and their TNF- ,/IL-10 ratio was approximately threefold when compared with the ratio in the control group. Conclusions: The significantly higher serum TNF- ,/IL-10 ratio in the subjects with chronic periodontitis when compared with the ratio in the controls is indicative of a stronger systemic pro-inflammatory state in chronic periodontitis. [source] Metabolic syndrome, insulin resistance, and periodontitis: a cross-sectional study in a middle-aged French populationJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 7 2010Catherine Benguigui Benguigui C, Bongard V, Ruidavets J-B, Chamontin B, Sixou M, Ferrières J, Amar J. Metabolic syndrome, insulin resistance and periodontitis: a cross-sectional study in a middle-aged French population. J Clin Periodontol 2010; 37: 601,608. doi: 10.1111/j.1600-051X.2010.01571.x. Abstract Aim: Metabolic syndrome consists of a cluster of clinical and biological abnormalities, influenced by insulin resistance and promoting cardiovascular diseases. We examined the relationships between metabolic syndrome, its various components, insulin resistance, and periodontitis. Materials and Methods: The study included 276 subjects (35,74 years) recruited within a cross-sectional survey on cardiovascular risk factors. Twenty-one were excluded because of infectious risk or total tooth loss. Clinical attachment loss (CAL), probing pocket depth (PD), gingival and plaque indexes were recorded. Periodontitis was classified into moderate and severe forms. Results: The mean age was 58, 41% of the subjects had moderate and 39% had severe periodontitis. In univariate comparisons, periodontitis was associated with metabolic syndrome (p=0.050), most of its components, and HOMA index (homoeostasis model assessment of insulin resistance). After adjustment for confounders, only HOMA index remained associated with severe periodontitis (odds ratio [OR]=3.97 [95% confidence interval: 1.22,12.9], OR=3.78 [1.14,12.5] for third and fourth versus the first quartile of the HOMA index, respectively). The HOMA index was also associated with the number of periodontal sites with CAL4 mm, CAL5 mm, or PD4 mm (greater number for higher HOMA-index values). This relationship disappeared in never-smokers. Conclusions: Our data support the relationships between metabolic disturbances and periodontitis, with a central role of insulin resistance. [source] Salivary interleukin-1, concentration and the presence of multiple pathogens in periodontitisJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 11 2009Ulvi Kahraman Gursoy Abstract Aim: This study aimed to find salivary enzymes and/or cytokines that would reflect periodontitis, alone or in combination with salivary microbial markers. Material and Methods: The salivary concentrations of elastase, lactate dehydrogenase, interleukin-1, (IL-1,), interleukin-6, and tumour necrosis factor- ,, and the presence of five periodontal pathogens, Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythia, and Treponema denticola, were analysed from salivary specimens of 165 subjects, a subpopulation of Health 2000 Health Examination Survey in Finland; 84 of the subjects had probing pocket depth (PPD) of 4 mm at 14 or more teeth (the advanced periodontitis group), while 81 subjects had no teeth with PPD of 4 mm (the control group). All subjects had at least 20 teeth and no systemic diseases. Results: Among the salivary cytokines and enzymes tested, IL-1, was the only biomarker associated with periodontitis. An association was also found with the presence of multiple periodontal pathogens. Salivary IL-1, and the presence of multiple periodontal pathogens were associated with periodontitis at the same magnitude, when they were in the logistic regression model individually or together. Conclusion: We suggest that salivary IL-1, and the presence of multiple periodontal pathogens in saliva should be studied more thoroughly as markers of periodontitis. [source] Partial least squares path modelling for relations between baseline factors and treatment outcomes in periodontal regenerationJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 11 2009Yu-Kang Tu Abstract Background: Some clinical outcome variables in periodontal research are mathematically coupled, and it is not feasible to include all the mathematically coupled variables in an ordinary least squares (OLS) regression analysis. The simplest solution to this problem is to drop at least one of the mathematically coupled variables. However, this solution is not satisfactory when the mathematically coupled variables have distinctive clinical implications. Material and Methods: Partial least squares (PLS) methods were used to analyse data from a study on guided tissue regeneration. Relationships between characteristics of baseline lesions and treatment outcomes after 1 year were analysed using PLS, and the results were compared with those from OLS regression. Results: PLS analysis suggested that there were multiple dimensions in the characteristics of baseline lesion: vertical dimension was positively associated with probing pocket depth (PPD) reduction and clinical attachment level (CAL) gain, whilst horizontal dimension was negatively associated with the outcome. Baseline gingival recession had a negative association with PPD reduction but a small positive one with CAL gain. Conclusion: PLS analysis provides new insights into the relationships between baseline characteristics of infrabony defects and periodontal treatment outcomes. The hypothesis of multiple dimensions in baseline lesions needs to be validated by further analysis of different datasets. [source] Dose,response relationship between periodontal inflamed surface area and HbA1c in type 2 DiabeticsJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 4 2009Willem Nesse Abstract Background: A dose,response relationship between the amount of inflamed periodontal tissue and HbA1c level, might be indicative for a causal association between periodontitis and type 2 diabetes. Aim: To assess a dose,response relationship between the periodontal inflamed surface area (PISA), as a measure of the amount of inflamed periodontal tissue, and HbA1c levels in type 2 diabetics. Material and Methods: Forty consecutive dentate type 2 diabetics attending their general practitioner for regular check-up, underwent full-mouth probing pocket depth and bleeding on probing assessment. From these data PISA was calculated. HbA1c levels were retrieved from patients' medical files. The dose,response relationship between PISA and HbA1c levels was assessed using multiple linear regression analyses, controlling for factors that might influence PISA or HbA1c levels. Results: The higher the PISA of type 2 diabetics was, the higher their HbA1c levels were. On a group level, an increase of PISA with 333 mm2 was associated with a 1.0 percentage point increase of HbA1c, independent of the influence of other factors. Conclusion: On a group level, there is a dose,response relationship between PISA and HbA1c in type 2 diabetics. This might be an indication of a causal relationship between type 2 diabetes and periodontitis. [source] IL-6,174 genotype associated with the extent of periodontal disease in type 1 diabetic subjectsJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 1 2009Taina Raunio Abstract Aim: The aim of this study was to investigate whether genetic polymorphism in certain cytokine and receptor molecule genes and diabetic status associate with the extent of periodontal disease in type 1 diabetes mellitus (DM). Material and Methods: Eighty patients with type 1 DM participated. Visible plaque, bleeding on probing (BOP), probing pocket depth (PD) and attachment level (AL) were examined clinically and glycosylated haemoglobin (HbA1c) levels were used to assess the glycemic control of DM. CD-14, IL-6, TNF- ,, IL-10, IL-1,, IL-1, and TLR-4 gene polymorphisms were studied using the polymerase chain reaction (PCR). Results: The 3-year HbA1c was good (<7.5%) in 16%, acceptable (7.5,8.5%) in 36% and poor (>8.5%) in 48% of the subjects. IL-6,174 genotype and 3-year GHbA1c associated significantly with BOP and PD4 mm, subjects with the GG genotype of the IL-6,174 exhibiting more severe periodontal disease than those with the GC/CC genotype. After stratification by IL-6 genotype, associations between the extent of periodontal disease and 3-year HbA1c levels remained significant in subjects carrying the GC/CC but not the GG genotype. Conclusions: In addition to the HbA1c level, the IL-6,174 genotype is a significant susceptibility factor for periodontal disease among type 1 diabetics. [source] Effect of partial recording protocols on severity estimates of periodontal diseaseJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 8 2008Albert Kingman Abstract Objectives: The study aim was to assess bias magnitudes of periodontal disease severity estimates for specific partial recording protocols (PRPs) in epidemiological studies. Material and Methods: Estimates of mean clinical attachment loss (MCAL) and mean probing pocket depth (MPPD) were derived for 20 different PRPs using full-mouth periodontal data from 1437 dentate Brazilian subjects 14,103 years old having at least four teeth. Biases, relative biases and intra-class correlations for all PRPs were evaluated. Graphical methods were used to assess how well the PRP-based estimates agreed with full-mouth scores across levels of disease. Results: Slightly higher levels of disease were evidenced on lingual than on buccal sites. Seven multi-site PRPs and the Ramfjörd PRP produced small biases in MPPD (,0.17 to 0.04 mm) and MCAL with relative biases under 8% and 4% in absolute value for MPPD and MCAL, respectively. Biases for full- and random half-mouth-based PRPs were similar. The three-site random half-mouth MB,B,DL and the Ramfjörd PRPs produced the smallest biases, with relative biases <3% in absolute value for MPPD and MCAL. Conclusions: Bias for MPPD or MCAL estimates varies by site type, number of sites per tooth and number of quadrants included in the PRP. [source] Clinical changes in periodontium during pregnancy and post-partumJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 7 2008Mervi Gürsoy Abstract Background and Aim: Pregnancy has been presented to increase susceptibility to gingival inflammation. It is unclear whether pregnancy gingivitis exposes or proceeds to periodontitis. We examined longitudinally the severity of periodontal changes during pregnancy and post-partum, and compared the findings with an age-matched group of non-pregnant women. Material and Methods: Thirty generally healthy, non-smoking women at an early phase of their pregnancy and 24 non-pregnant women as controls were recruited. The pregnant group was examined three times during pregnancy and twice during post-partum, and the non-pregnant group three times, once per subsequent month. At each visit, visible plaque index (VPI), bleeding on probing (BOP), probing pocket depth (PPD), and clinical attachment level (CAL) were measured from six sites per tooth. Results: In the pregnant group, BOP and PPD increased simultaneously without relation to plaque between the first and second trimesters, and thereafter decreased during subsequent visits. No changes were detected in CAL during the study period. In the non-pregnant group, BOP stayed invariable during the follow-up and correlated with the amount of plaque. Neither periodontal pocket formation nor significant changes in attachment levels were observed. Conclusion: Based on this study, changes in clinical parameters during pregnancy are reversible, indicating that pregnancy gingivitis does not predispose or proceed to periodontitis. [source] Bleeding on probing differentially relates to bacterial profiles: the Oral Infections and Vascular Disease Epidemiology StudyJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 6 2008Ryan T. Demmer Abstract Aim: Various bacterial species are differentially prevalent in periodontal health, gingivitis or periodontitis. We tested the independent associations between three bacterial groupings and gingival inflammation in an epidemiological study. Material and Methods: In 706 Oral Infections and Vascular Disease Epidemiology Study (INVEST) participants 55 years, bleeding on probing (BoP), pocket depth (PD) and subgingival plaque samples (n=4866) were assessed in eight sites per mouth. Eleven bacterial species were quantitatively assayed and grouped as follows: (i) aetiologic burden (EB, Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Treponema denticola, Tannerella forsythia); (ii) putative burden (PB, Campylobacter rectus, Eikenella corrodens, Fusobacterium nucleatum, Micromonas micros, Prevotella intermedia); (iii) health-associated burden (HAB, Actinomyces naeslundii, Veillonella parvula). Results: After mutual adjustment for EB, PB and HAB, the BoP prevalence increased by 45% ( p<0.0001) across increasing quartiles of EB while BoP decreased by 13% ( p<0.0001) across increasing quartiles of HAB. Mean PD increased 0.8 mm and decreased 0.3 mm from the first to fourth quartiles of EB (p<0.0001) and HAB ( p<0.0001), respectively. Among 1214 plaque samples with fourth quartile EB, 60% were collected from sites with PD 3 mm. Conclusion: Bacterial species believed to be aetiologically related to periodontitis were associated with BoP in sites with minimal PD and/or attachment level (AL). Species presumed to be associated with periodontal health demonstrated inverse associations with BoP. [source] Subgingival microbial profiles in chronic periodontitis patients from Chile, Colombia and SpainJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 2 2008David Herrera Abstract Aim: To investigate the subgingival microbiota of distinct periodontitis patient populations, in Chile, Colombia and Spain, using identical clinical and bacteriological methods. Material and Methods: In this multicentre study, 114 chronic periodontitis patients were selected. Patients were examined using an identical clinical protocol and pooled subgingival samples were obtained from each patient. Samples were processed in the three laboratories by means of culturing under identical clinical and microbiological protocols. Total anaerobic counts and frequency of detection and proportions of nine periodontal pathogens were calculated. Variables were analysed by means of anova, ,2, Kruskal,Wallis and Dunn's multiple comparison tests. Results: The Colombian population demonstrated greater severity of periodontitis, with significantly deeper mean probing pocket depth, and had a significantly lower percentage of current smokers. When comparing samples from the three patient populations, the total counts were significantly higher in the Colombian patients. The numbers of putative pathogens differed among groups. Tannerella forsythia was found less frequently in Chilean samples, while Parvimonas micra and enteric rods differed significantly among the three population groups. Conclusion: Significant differences among Chile, Colombia and Spain existed regarding the frequency and proportions of specific periodontal pathogens in the subgingival microbiota of periodontitis patients. [source] The extent of periodontal disease and the IL-6,174 genotype as determinants of serum IL-6 levelJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 12 2007Taina Raunio Abstract Aim: To study the extent of periodontal disease and the IL-6,174 genotype as determinants of serum and mouthwash IL-6 concentration in subjects with moderate to severe periodontal disease. Material and Methods: Fifty-two generally healthy subjects volunteered to participate. Probing pocket depth (PD) and periodontal attachment level (AL) were clinically examined and alveolar bone level (BL) was measured on orthopantomographs. IL-6 concentrations in mouthwash, collected by rinsing with 3 ml saline for 30 s and in serum, obtained by venipuncture, were measured using ELISA. IL-6,174 polymorphism was studied using a polymerase chain reaction. Results: Eleven subjects carried the GG genotype, and 41 subjects, carried the CG/CC genotype. The mean (± SD) concentration of IL-6 in serum was 1.6 (± 1.5) pg/ml and, 2.8 (± 5.04) pg/ml in mouthwash. The serum concentration of IL-6 was higher in subjects with the GG genotype than with the CG/CC genotype. In regression analyses the percentages of sites with PD6 mm, AL6 mm and BL8 mm, the IL-6,174 genotype, body mass index and gender associated significantly with serum IL-6 concentration. Conclusions: The extent of moderate to severe periodontal disease and the IL-6,174 genotype contribute significantly to serum IL-6 concentration. [source] Incomplete adherence to an adjunctive systemic antibiotic regimen decreases clinical outcomes in generalized aggressive periodontitis patients: a pilot retrospective studyJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 10 2007Adrian Guerrero Abstract Aim: The objective of this study was to explore the effect of incomplete adherence to the prescribed antibiotic regimen, amoxicillin and metronidazole, in the non-surgical treatment of generalized aggressive periodontitis (GAP). Methods: This retrospective study included 18 GAP subjects who received a conventional course of full-mouth non-surgical periodontal treatment using machine-driven and hand instruments and an adjunctive course of systemic antibiotics (500 mg amoxicillin and 500 mg metronidazole three times a day for 7 days). Clinical parameters were collected at baseline and at 2 months post-treatment. Self-reported adherence to the prescribed medication regimen was recorded at 2 months. Results: All clinical parameters, except for the mean clinical attachment level (CAL) in sites with initial probing pocket depth (PPD) 3 mm, improved at 2 months in all subjects. PPD reduction was 3.7 mm [95% confidence interval (CI) 3.2, 4.3 mm] in deep pockets (7 mm) and 2.2 mm (95% CI 1.9, 2.4 mm) in moderate pockets (4,6 mm), while CAL gain was 2.2 mm (95% CI 1.7, 2.6 mm) and 1.2 mm (95% CI 0.8, 1.5 mm), respectively. However, only 11 subjects (61.1%) reported full adherence to the medication. In deep pockets (7 mm), the difference between an adherent and non-adherent/partially adherent subject was 0.9 mm (95% CI 0.1, 1.7 mm, ancova, p=0.027) in PPD reduction and 0.8 mm (95% CI ,0.2, 1.9, p=0.129) in CAL gain at 2 months. In moderate pockets (4,6 mm) this difference was smaller in magnitude: 0.4 mm (95% CI 0.1, 0.9 mm, p=0.036) in PPD reduction and 0.2 mm (95% CI ,0.3, 0.9 mm, p=0.332) in CAL gain. Conclusions: Within the limits of this design, these data suggest that incomplete adherence to a 7-day adjunctive course of systemic metronidazole and amoxicillin is associated with decreased clinical outcomes in subjects with generalized aggressive periodontitis. [source] Comparison of gingival blood flow during healing of simplified papilla preservation and modified Widman flap surgery: a clinical trial using laser Doppler flowmetryJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 10 2007M. Retzepi Abstract Aim: This prospective randomized-controlled clinical trial compared the gingival blood flow responses following simplified papilla preservation (test) versus modified Widman flap (control). Materials and Methods: Twenty contra-lateral upper sites with pocket depth 5 mm after initial treatment in 10 chronic periodontitis patients were randomly assigned to either test or control treatment, using a split-mouth design. Laser Doppler flowmetry recordings were performed pre-operatively, following anaesthesia, immediately post-operatively and on days 1, 2, 3, 4, 7, 15, 30 and 60, at nine selected sites per flap. Results: Significant ischaemia was observed at all sites following anaesthesia and immediately post-operatively. At the mucosal flap basis, a peak hyperaemic response was observed on day 1, which tended to resolve by day 4 at the test sites, but persisted until day 7 at the control sites. The buccal and palatal papillae blood perfusion presented the maximum increase on day 7 in both groups and returned to baseline by day 15. Both surgical modalities yielded significant pocket depth reduction, recession increase and clinical attachment gain. Conclusions: Periodontal access flaps represent an ischaemia,reperfusion flap model. The simplified papilla preservation flap may be associated with faster recovery of the gingival blood flow post-operatively compared with the modified Widman flap. [source] Gingival crevicular fluid levels of RANKL and OPG in periodontal diseases: implications of their relative ratioJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 5 2007Nagihan Bostanci Abstract Aim: Receptor activator of NF-,B ligand (RANKL) and osteoprotegerin (OPG) are a system of molecules that regulate bone resorption. This study aims to compare the levels of RANKL, OPG and their relative ratio in gingival crevicular fluid (GCF) of healthy and periodontal disease subjects. Material and Methods: GCF was obtained from healthy (n=21), gingivitis (n=22), chronic periodontitis (n=28), generalized aggressive periodontitis (n=25) and chronic periodontitis subjects under immunosuppressant therapy (n=11). RANKL and OPG concentrations in GCF were measured by enzyme-linked immunosorbent assays. Results: RANKL levels were low in health and gingivitis groups, but increased in all three forms of periodontitis. OPG levels were higher in health than all three periodontitis, or gingivitis groups. There were no differences in RANKL and OPG levels between chronic and generalized aggressive periodontitis groups, whereas these were lower in the immunosuppressed chronic periodontitis group. The RANKL/OPG ratio was significantly elevated in all three periodontitis forms, compared with health or gingivitis, and positively correlated to probing pocket depth and clinical attachment level. Conclusion: GCF RANKL and OPG levels were oppositely regulated in periodontitis, but not gingivitis, resulting in an enhanced RANKL/OPG ratio. This ratio was similar in all three periodontitis groups and may therefore predict disease occurrence. [source] Gingival blood flow changes following periodontal access flap surgery using laser Doppler flowmetryJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 5 2007M. Retzepi Abstract Aim: To investigate the pattern of gingival blood flow changes following periodontal access flap surgery by laser Doppler flowmetry (LDF). Material and methods: Fourteen patients with chronic periodontitis presenting upper anterior sites with pocket depth 5 mm after initial treatment were included in the study. Periodontal access flap surgery was performed on the experimental areas and LDF recordings were taken at baseline, following anaesthesia, immediately postoperatively and on days 1, 2, 3, 4, 7, 15, 30 and 60 of healing, at nine predetermined sites per flap. Results: Significant ischaemia was observed at all flap sites following anaesthesia and immediately postoperatively. At the alveolar mucosal sites, a peak increase of the gingival blood flow was observed on postoperative day 1 (p<0.001), which persisted until day 7 (p=0.012) and resolved by day 15. The mucosal sites close to the flap periphery presented higher blood perfusion compared with the sites located centrally in the flap. The microcirculatory perfusion of the buccal and palatal papillae was maximum on postoperative day 7 (p=0.013 and <0.001, respectively) and returned to baseline by day 15. Conclusion: Topographically distinct areas of the periodontal access flap consistently present different patterns of microvascular blood flow alterations during the wound-healing period. [source] Gingival crevicular fluid interleukin-1,, prostaglandin E2 and periodontal status in a community populationJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 4 2007Y. Zhong Abstract Aim: Interleukin-1 , (IL-1,) and prostaglandin E2 (PGE2) are key inflammatory mediators involved in periodontal disease. The purposes of this molecular cross-sectional epidemiological study were to investigate relationships in a community sample between mean concentrations of IL-1, and PGE2 in gingival crevicular fluid (GCF) and (1) clinical periodontal signs and (2) risk factors of host inflammatory response and/or periodontal disease. Material and Methods: The sample comprised 6277 community-dwelling adults aged 52,74 years enrolled in the Atherosclerosis Risk in Communities (ARIC) study. IL-1, and PGE2 concentrations were measured using enzyme-linked immunosorbent assay. Person-level summary variables were computed for maximum pocket depth (MaxPD), maximum clinical attachment level (MaxCAL) and presence/absence of bleeding on probing (BOP). Mean GCF IL-1, and PGE2 concentrations were dependent variables in multiple linear regression models with periodontal measures and covariates as explanatory variables. Results: Both GCF IL-1, and PGE2 were positively related to MaxPD and BOP in multiple regression models (p<0.01). Increased levels of IL-1, and PGE2 were associated with body mass index 30 kg/m2. Conclusion: Higher levels of GCF IL-1, and PGE2 were significantly associated with clinical signs of periodontal disease and independently related to patient-based anthropomorphic measures, behaviours and exposures in community-dwelling adults. [source] Periodontal conditions in male adolescents using smokeless tobacco (moist snuff)JOURNAL OF CLINICAL PERIODONTOLOGY, Issue 12 2006Ulrika Montén Abstract Aim: The aim of this study was to evaluate the potential association of the use of smokeless tobacco (moist snuff) on the periodontal conditions of adolescents. Material and methods: A subject sample of one hundred and three 19-year-old male individuals (33 snuff users, 70 controls) living in Göteborg, Sweden, were clinically examined with regard to oral hygiene, gingivitis, probing pocket depth (PPD), clinical attachment loss (CAL) and gingival recession. Bitewing radiographs were obtained for assessments of alveolar bone level. Information about tobacco and oral hygiene habits was obtained by a structured questionnaire. Student 's t -test, ,2 -test and logistic regression analysis were used for statistical analysis. Results: The mean plaque and gingivitis scores in snuff-users were 59% (SD 21.0) and 47% (18.6), respectively, and in controls 64% (22.4) and 50% (18.3), respectively. The average PPD and CAL in snuff-users amounted to 2.3 mm (0.3) and 0.2 mm (0.1), respectively, and in controls 2.4 mm (0.3) and 0.1 mm (0.1) (p>0.05), respectively. The mean bone level was 1.3 mm (0.2) in both groups. The prevalence of subjects showing recession was 42% among snuff-users and 17% among controls (p=0.006). In snuff users, an average of 4% (0.9) of the teeth showed recession, compared with 1% (0.3) in controls (p<0.001). Limiting the analysis to the maxillary anterior tooth region, 33% of the snuff-users and 10% of the controls presented recessions (p=0.002). The use of snuff entailed an OR=5.1 to have gingival recessions. Conclusion: In the present population sample of adolescents, the use of smokeless tobacco (moist snuff) was not associated with the presence of periodontal disease except for a significantly high prevalence of gingival recessions. [source] Adjunctive benefits of systemic amoxicillin and metronidazole in non-surgical treatment of generalized aggressive periodontitis: a randomized placebo-controlled clinical trialJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 10 2005Adrian Guerrero Abstract Background: The objective of this study was to assess the adjunctive clinical effect of the administration of systemic amoxicillin and metronidazole in the non-surgical treatment of generalized aggressive periodontitis (GAP). Methods: Forty-one systemically healthy subjects with GAP were included in this 6-month double-blind, placebo-controlled, randomized clinical trial. Patients received a course of full-mouth non-surgical periodontal treatment delivered over a 24 h period using machine-driven and hand instruments. Test subjects received an adjunctive course of systemic antibiotic consisting of 500 mg amoxicillin and 500 mg metronidazole three times a day for 7 days. Clinical parameters were collected at baseline, and at 2 and 6 months post-treatment. Results: In both the test and the placebo groups, all clinical parameters improved at 2 and 6 months. In deep pockets (7 mm), the test treatment resulted in an additional 1.4 mm (95% confidence interval 0.8, 2.0 mm) in full-mouth probing pocket depth (PPD) reduction and 1 mm (0.7, 1.3 mm) of life cumulative attachment loss (LCAL) gain at 6 months. In moderate pockets (4,6 mm), the adjunctive benefit was smaller in magnitude: PPD reduction was 0.4 mm (0.1, 0.7 mm) and LCAL gain was 0.5 mm (0.2, 0.8 mm). In addition, the 6-month data showed LCAL gains 2 mm at 25% of sites in test patients compared with 16% in placebo (p=0.028). Similarly, PPD reductions of 2 mm or more were observed in 30% of sites in test and 21% of sites in placebo patients. Seventy-four percent of pockets with PPD 5 mm at baseline were 4 mm or shallower at 6 months in the test group. This compared with 54% in the placebo group (p=0.008). Disease progression at 6 months was observed at 1.5% of test and 3.3% of sites in test and placebo, respectively (p=0.072). Conclusions: These data indicate that a 7-day adjunctive course of systemic metronidazole and amoxicillin significantly improved the short-term clinical outcomes of full-mouth non-surgical periodontal debridement in subjects with GAP. [source] A chlorhexidine varnish implemented treatment strategy for chronic periodontitisJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 7 2005Short-term clinical observations Abstract Objectives: The aim of this study was to investigate the clinical outcome of a subgingivally applied chlorhexidine varnish when used as an adjunct to scaling and root planing (SRP) in the treatment of chronic periodontitis. Material and methods: A randomized controlled, single blind, parallel trial was conducted on the basis of 16 volunteers suffering from chronic periodontitis. The control group received oral hygiene instructions and was scaled and root planed in two sessions. The test group received the same instructions and treatment, however, all pockets were additionally disinfected using a chlorhexidine varnish. The gingival index, plaque index, bleeding on probing, probing pocket depth (PPD) and clinical attachment level (CAL) were recorded at baseline and subsequently after 1 and 3 months. Results: Both treatment strategies showed significant reductions in PPD and CAL at both follow-up visits by comparison with baseline levels (p<0.001). Yet, at study termination, combination therapy resulted in additional pocket reductions between 0.73 and 1.23 mm (p<0.02), and clinical attachment gains between 0.63 and 1.09 mm (p<0.02). Conclusions: These findings suggest that a varnish-implemented strategy may improve the clinical outcome for the treatment of chronic periodontitis in comparison with SRP alone. [source] Periodontal dressing (Vocopac®) influences outcomes in a two-step treatment procedureJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 4 2005B. W. Sigusch Abstract Objectives: It is not clear if periodontal dressing influences the long-term results in a non-surgical treatment procedure. Material and Methods: The periodontal parameters (pre-baseline) of 36 patients with aggressive periodontitis were obtained before the patients were treated initially (1st step) by a dental hygienist, who completely removed the supra- and subgingival concrements. Baseline parameters were raised 3 weeks after the 1st step, before the 2nd therapy step was conducted. It consisted of a non-surgical procedure, which comprised a closed full-mouth manual root curettage (root planing), immediate systemic application of metronidazole, and the placement of a periodontal dressing (Vocopac®, Voco). The patients were randomized to two test groups having their periodontal packs removed after 3,4 days (group 1, n=12) and 7,8 days (group 2, n=12), respectively and a control group (n=12) without periodontal dressing. Clinical parameters were raised again after 6 and 24 months. Results: Six and 24 months later, changes in probing pocket depth (PPD) and probing attachment level (PAL) were observed in all three groups compared with baseline, but the difference was significant in group 2 only. In addition, group 2 showed a greater reduction in mean PPD and also a significantly greater gain of attachment in comparison with the controls. Conclusion: Wound dressing has a positive effect on clinical long-term results using a two-step non-surgical procedure. Moreover, removing the dressing after 7,8 days leads to clearly better results than removing it earlier. [source] Evaluation of the relationship between smoking during pregnancy and subgingival microbiotaJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 1 2005Nurcan Buduneli Abstract Background: Numerous studies have shown that smoking negatively affects periodontal health. Hormonal changes, which occur during pregnancy have also been reported to have adverse effects on the periodontal tissues or indirectly through alterations in the subgingival bacterial flora. At present, no knowledge exists concerning possible effects of smoking on the composition of subgingival plaque in pregnancy. The purpose of the present study was to evaluate the effects of smoking during pregnancy on the subgingival plaque bacteria most commonly associated with periodontal disease. Methods: A total number of 181 women were examined within 72 h post-partum. Smoking status was recorded by means of a self-reported questionnaire and the study population was divided into three groups; non-smokers, light smokers, and heavy smokers. In each woman, two subgingival plaque samples were obtained from mesio- or disto-buccal aspect of randomly selected one molar and one incisor tooth by sterile paperpoints. Clinical periodontal recordings comprising presence of dental plaque, bleeding on probing (BOP), and probing pocket depth (PPD) were performed at six sites per each tooth at all teeth. Plaque samples were analysed by checkerboard DNA,DNA hybridization with respect to 12 bacterial species. In all analyses, the individual subject was the computational unit. Thus, mean values for all clinical parameters were calculated and bacterial scores from each individual sample were averaged. Statistical methods included ,2 test, Kruskal,Wallis test and Mann,Whitney U -test. Results: Mean ages were similar in the study groups. Plaque, BOP and PPD recordings were lower in the heavy-smoker group, but the differences were not statistically significant (p>0.05). The detection rates and bacterial loads of the specific subgingival bacteria exhibited no significant differences between the groups. No correlation could be found between smoking status and detection rates and bacterial loads of various bacterial species. Conclusion: The present findings suggest that smoking during pregnancy does not have a significant effect on the composition of subgingival plaque bacteria. [source] Long-term stability of periodontal conditions achieved following guided tissue regeneration with bioresorbable membranes: case series results after 6,7 yearsJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 11 2004Andreas Stavropoulos Abstract Objectives: To evaluate the results of guided tissue regeneration (GTR) treatment of intrabony defects with bioresorbable membranes after 6,7 years, and to disclose factors that may influence the long-term outcome of the treatment. Methods: Twenty-five defects in 19 patients were treated by means of polylactic acid/citric acid ester copolymer bioresorbable membranes. At baseline and after 1 and 6,7 years, the following parameters were recorded: (1) probing pocket depth (PPD), (2) gingival recession (REC), (3) probing attachment level (PAL)=PPD+REC, (4) presence/absence of plaque (PI), (5) presence/absence of bleeding on probing (BOP). Smoking habits and frequency of dental-control visits were also recorded. Significance of differences between categorical variables was evaluated with McNemar's test, and between numerical variables with the t -test for paired observations. Generalized linear models were constructed to evaluate the influence of various factors on PAL gain and PPD changes from 1 to 6,7 years. Association of smoking, frequency of dental controls, oral hygiene, and BOP with sites losing 2 mm in PAL was evaluated with Fisher's exact test. Results: At baseline, a mean PPD of 8.7±1.1 mm and a mean PAL of 9.8±1.5 mm was recorded. Statistically significant clinical improvements were observed at 1 and 6,7 years after GTR treatment. An average residual PPD of 3.8±1.1 mm and a mean PAL gain of 3.8±1.4 mm were observed after 1 year. After 6,7 years the corresponding values were 4.7±1.3 and 3.6±1.4 mm, respectively. There were no statistically significant differences between the 1- and the 6,7-year values. At the 6,7-year control, only 16% of the sites had lost 2 mm (maximum 3 mm), of the PAL gain obtained 1 year after GTR treatment. None of the sites had lost all of the attachment gained 1 year after treatment. Smoking, frequency of dental controls, oral hygiene, and BOP did not seem to influence the change of PPD and PAL gain, or the stability of PAL gain (i.e. losing PAL or not) from 1 to 6,7 years from treatment. Conclusion: Clinical improvements achieved by GTR treatment of intrabony defects by means of bioresorbable membranes can be maintained on a long-term basis. [source] Subgingival microbiota of chronic periodontitis subjects from different geographic locationsJOURNAL OF CLINICAL PERIODONTOLOGY, Issue 11 2004A. D. Haffajee Abstract Background: Most clinical studies assume that the subgingival microbiota is similar from one geographic location to another. The purpose of the present investigation was to examine the composition of the subgingival microbiota in chronic periodontitis subjects from four countries. Method: Subjects with chronic periodontitis (N, Sweden=101; USA=115; Brazil=58; Chile=26) were recruited. Subjects were measured at baseline for plaque, gingivitis, bleeding on probing (BOP), suppuration, pocket depth (PD) and attachment level (AL) at six sites per tooth. Subgingival plaque samples taken from the mesial aspect of each tooth at baseline were individually analyzed for their content of 40 bacterial species using checkerboard DNA,DNA hybridization (total samples=6036). % DNA probe counts comprised by each species was determined for each site and averaged across sites in each subject. Significance of differences in proportions of each species among countries was determined using ancova adjusting for age, mean pocket depth, gender and smoking status. p- Values were adjusted for multiple comparisons. Results: On average, all species were detected in samples from subjects in the four countries. Thirteen species differed significantly in adjusted mean proportions among countries even after adjusting for multiple comparisons. Porphyromonas gingivalis, one species that differed in proportions among countries, comprised adjusted means of 7.5, 11.9, 1.6 and 6.6% of the microbiota in subjects from Brazil, Chile, Sweden and USA (p<0.001), while mean proportions of Treponema denticola were 6.7, 4.2, 0.8 and 2.3, respectively (p<0.001). In contrast, a key periodontal pathogen, Tannerella forsythensis, exhibited mean proportions ranging from 6.2,8.5% and did not differ significantly among countries. Besides these species, prominent species in Brazil were Actinomyces naeslundii genospecies 1 and 2 (8.4%, 7.2%) and Prevotella intermedia (6.5%); in Chile, Prevotella melaninogenica (6.4%) and Neisseria mucosa (5.3%); in Sweden A. naeslundii genospecies 2 (8.4%), Capnocytophaga gingivalis (7.1%) and Peptostreptococcus micros (5.0%); in USA A. naeslundii genospecies 2 (7.5%), P. intermedia (6.8%) and C. gingivalis (6.1%). Conclusions: The microbial profiles of subgingival plaque samples from chronic periodontitis subjects in four countries showed surprisingly marked differences. These differences persisted after adjusting for age, mean pocket depth, gender and smoking status. [source] | ||||||||||||||||||||||||||||