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Dental Tribune Middle East & Africa Edition | 2/2016 hygiene tribune 2 ◊Page1 ditional oral hygiene products. Fur- thermore, full mouth plaque scores had to be measured using the most frequently used indices (Silness & Loe,Quigley&Hein,andNavy). After screening 2,119 articles, 120 were reviewed. Of these, 59 ar- ticles involving 212 separate brush- ing experiments ultimately met the inclusion criteria. No studies were detected which evaluated the ef- ficacy with the use of the Silness & Loe plaque index. The plaque score reduction was 30% if measured us- ing the Quigley & Hein index and if the NAVY-index had been used, the plaquescorereductionwas53%. In summary, the overall weight- ed mean plaque score reduction after a single manual brushing ex- ercise was 42%. A sub-analysis of the various bristle designs revealed that the most frequently recommended manualtoothbrush–onewitha‘flat- trim’ bristle design – numerically re- movedlessplaquethanatoothbrush with multi-level bristles. Based on an estimated weighted mean Navy Index plaque score reduction of 61%, the most effective toothbrush was onewithangledbristles. In conclusion, the mean plaque score reduction efficacy following a single brushing exercise being 42% is influenced by the duration of brushing and bristle design. From a practical perspective, if only ap- proximately40%oftheplaquescore is reduced this means that there is room for improvement. This could be partly achieved by increasing the awareness of brushers with indi- vidually tailored instructions, for ex- ample, through their use of disclos- ing agents and a mirror. Motivating brushers to improve their brushing technique and to brush for a suf- ficient length of time is also impor- tant.Instudieswhereitwaspossible, ananalysisoftheinfluenceofbrush- ing duration on brushing efficacy re- vealed the plaque score was reduced by27%afteroneminuteofbrushing. With two minutes of brushing, the reductionalmostdoubledto41%. Article published in RDH, Feb 2013; adapted from article in Neder- landseVerenigingvoorParodontolo- gienewsletter,2012. “...reductionof61%, themosteffective toothbrushwasone withangledbristles...” Coronary heart disease patients with no teeth have nearly double risk of death ByDentalTribuneU.S. Coronary heart disease patients with no teeth have nearly double the risk of death as those with all of their teeth, according to research recently published in the European Journal of Preventive Cardiology.1 The study with more than 15,000 patients from 39 countries found that levels of tooth loss were linearly associated withincreasingdeathrates. “The relationship between dental health, particularly periodontal dis- ease, and cardiovascular disease has received increasing attention over the past 20 years,” said lead author Dr. Ola Vedin, cardiologist at Upp- salaUniversityHospitalandUppsala Clinical Research Center in Uppsala, Sweden. “However it has been in- sufficiently investigated among patients with established coronary heart disease who are at especially highriskofadverseeventsanddeath and in need of intensive prevention measures.” Analysis included 15,456 pa- tients from 39 countries on fivecontinents This was the first study to prospec- tively assess the relationship be- tween tooth loss and outcomes in patients with coronary heart disease (CHD). The results are from a sub- study of the STABILITY trial2, which evaluated the effects of the Lp-PLA2 inhibitor darapladib versus placebo inpatientswithCHD. Theanalysisincluded15,456patients from 39 countries on five conti- nents from the STABILITY trial.2 At the beginning of the study, patients completed a questionnaire about lifestyle factors (smoking, physical activity, etc), psychosocial factors and number of teeth in five catego- ries (26-32 [considered all teeth re- maining],20-25,15-19,1-14andnone). Patients were followed for an aver- ageof3.7years.Associationsbetween tooth loss and outcomes were calcu- lated after adjusting for cardiovascu- lar risk factors and socioeconomic status. The primary outcome was major cardiovascular events (a com- posite of cardiovascular death, myo- cardialinfarctionandstroke). Patients with a high level of tooth loss were older, smokers, female, less active and more likely to have dia- betes, higher blood pressure, higher body mass index and lower educa- tion. During follow up there were 1,543 major cardiovascular events, 705 cardiovascular deaths, 1,120 deaths fromanycauseand301strokes. After adjusting for cardiovascu- lar risk factors and socioeconomic status, every increase in category of tooth loss was associated with a 6 percent increased risk of major cardiovascular events, 17 percent in- creased risk of cardiovascular death, 16 percent increased risk of all-cause death and 14 percent increased risk ofstroke. 746 patients had a myocardi- alinfarctionduringthestudy Comparedwiththosewithalloftheir teeth, after adjusting for risk factors andsocioeconomicstatus, thegroup with no teeth had a 27 percent in- creased risk of major cardiovascular events, 85 percent increased risk of cardiovascular death, 81 percent in- creased risk of all-cause death and 67 percentincreasedriskofstroke. “Theriskincreasewaslinear,withthe highestriskinthosewithnoremain- ing teeth,” said Vedin. “For example, the risks of cardiovascular death and all-cause death were almost double to those with all teeth remaining. Heart disease and gum disease share many risk factors such as smoking and diabetes, but we adjusted for these in our analysis and found a seemingly independent relationship betweenthetwoconditions. “Many patients in the study had lost teeth so we are not talking about a few individuals here,” continued Ve- din. “Around 16 percent of patients hadnoteethandroughly40percent weremissinghalfoftheirteeth.” Duringthestudyperiod,746patients had a myocardial infarction. There was a numerically increased risk of myocardial infarction for every in- crease in tooth loss, but this was not significant after adjustment for risk factors and socioeconomic status. Vedinsaid,“Wefoundnoassociation between number of teeth and risk of myocardial infarction. This was puzzling (because) we had robust as- sociations with other cardiovascular outcomes,includingstroke.” Tooth loss could identify patients whoneedmorepreventionefforts Gumdiseaseisoneofthemostcom- moncausesoftoothloss.Theinflam- mationfromgumdiseaseisthought to trigger the atherosclerotic process and may explain the associations observed in the study. Poor dental hygiene is one of the strongest risk factorsforgumdisease. “This was an observational study so we cannot conclude that gum dis- ease directly causes adverse events in heart patients,” Vedin said. “But tooth loss could be an easy and in- expensivewaytoidentifypatientsat Researchers connect levels of tooth loss (due primarily to poor dental hygiene that leads to periodontal disease) with increasing rates of death and stroke Cumulative incidence rates by tooth loss level: (a) Major adverse cardiovascu- lar events (MACEs) (cardiovascular death (CV dth), myocardial infarction (MI), orstroke);(b)cardiovasculardeath;(c)stroke;and(d)all-causedeathfrom0to 1,400 days from randomization, stratified by tooth loss level (26–32, 20–25, 15–19, <15, or no teeth). Chart/Provided by European Journal of Preventive Cardiology higher risk who need more intense prevention efforts. While we can’t yet advise patients to look after their teeth to lower their cardiovascular risk, the positive effects of brushing and flossing are well established. The potential for additional positive ef- fects on cardiovascular health would beabonus.” About the European Journal ofPreventiveCardiology The European Journal of Preventive Cardiology describes itself as being the world’s leading preventive cardi- ology journal, playing a pivotal role in reducing the global burden of car- diovasculardisease. About theEuropeanSociety ofCardiology The European Society of Cardiology represents more than 90,000 car- diology professionals across Europe and worldwide. Its mission is to re- duce the burden of cardiovascular diseaseinEurope. References 1. Vedin O, Hagström E, Budaj A, DenchevS,HarringtonRA,KoenigW, Soffer J, Sritara P, Stebbins A, Stewart RHA, Swart HP, Viigimaa M, Vinere- anu D, Wallentin L, White HD, Held C onbehalfoftheSTABILITYInvestiga- tors. Tooth loss is independently as- sociated with poor outcomes in sta- blecoronaryheartdisease.European Journal of Preventive Cardiology. 2015;OI:0.1177/2047487315621978 2.TheStabilizationofAtherosclerotic Plaque by Initiation of Darapladib Therapy (STABILITY) study evaluat- ed the efficacy of darapladib, an oral inhibitor of lipoprotein-associated phospholipase A2, compared to pla- cebo. Patients were eligible to par- ticipate if they had coronary heart disease, defined as prior myocardial infarction, prior coronary revascu- larisation, or multivessel coronary heart disease without revascularisa- tion. (Sources: European Society of Cardiol- ogyandEuropeanJournal ofPreventiveCardiology) “746patientshada myocardialinfarction duringthestudy”