Abstract
Objectives
To evaluate the impacts of obstructive adenotonsillar disease on periodontal health and to assess the efficacy of adenotonsillectomy in the prevention of chronic periodontitis in children.
Methods
This prospective and controlled clinical study was conducted between August 2012 and February 2013 with 35 pediatric patients who had permanent anterior dentition. The study group included twenty patients (n = 20) who had complaints of chronic mouth breathing and snoring and were diagnosed with obstructive adenotonsillar disease. These patients underwent adenoidectomy with or without tonsillectomy. We performed periodontal examinations to assess the periodontal health status in these children before and two months after surgery. The periodontal measures included plaque index (PI), pocket depth (PD) and gingival index scores (GI). Subsequently, these periodontal measures were compared with healthy control group who had no adenotonsillar disease (n = 15).
Results
Among the study group six patients underwent adenoidectomy and 14 patients underwent adenoidectomy combined with either tonsillectomy or tonsillotomy. The preoperative PI, PD and GI scores of the study group were 1.27 ± 0.39, 1.34 ± 0.31 and 0.97 ± 0.37 respectively. These scores were significantly higher compared to the control group (p < 0.001). These periodontal index scores were significantly improved after surgery (p = 0.008 for PI and p < 0.001 for both PD and GI). In addition, we found no difference in postoperative values of PD and GI between the study group and control group.
Conclusion
We concluded that obstructive adenotonsillar disease adversely affects periodontal health in children and surgical management of obstruction improves the clinical findings. However, more comprehensive research is required to elucidate the association between adenotonsillar hypertrophy and periodontal disease.
1
Introduction
Periodontal disease is the inflammation of gingiva, supporting connective tissue attachments and alveolar bone which eventually causes loss of dentition . Although it is regarded as a local oral infection, the inflammation of periodontal tissues may also induce bacteremia and endotoxemia with elevation of serum proinflammatory cytokines (IL-1, IL-6 and TNF-α). In recent studies, these mediators were shown to have a causal relation with various systemic diseases such as hyperlipidemia, diabetes mellitus, cardiovascular disease and even preterm delivery . Furthermore, the periodontal disease has profound negative impacts on patients’ oral health related quality of life .
Gingivitis and dental plaque formation are the most common and early indicators of periodontal disease in children and adolescents . Subsequently, the disease progresses to aggressive periodontitis with pocket formation and bone dectruction if these early signs are underestimated in children . There are various local and systemic risk factors which cause the development of periodontitis in children such as gingival calculus, improper dental restorations, orthondontic appliances, malocclusion, xerostomia, hormonal changes with puberty, leukemia, neutropenia, drug influenced, vitamin C defiency, diabetes mellitus, genetic disorders and smoking . In addition, chronic mouth breathing and lack of lip closure at rest are among the other risk factors which particularly affect palatal surfaces of maxillary anterior teeth .
Tonsils and adenoid are mucosa associated lymphoid organs which contribute to the formation of the Waldeyer lymphatic ring. Their main function is to synthesize immunoglobulins in response to exogenous pathogens and they work as guardians at the gate of the aerodigestive tract . In children, both the recurrent infections and natural growth of lymphoid tissues by genetic factors play a role in the enlargement of these organs. The sustained enlargement of adenotonsillar tissues eventuates with upper airway obstruction. Subsequently, chronic mouth breathing is established in these children as a consequence of airway obstruction . We argue that chronic mouth breathing in these children may influence periodontal disease.
Thus the aims of this study are to evaluate the association between obstructive adenotonsillar hypertrophy and periodontal disease and also to assess the efficacy of adenotonsillectomy for the prevention of clinical periodontitis in children.
2
Material and methods
This prospective, controlled and observer blinded clinical study was conducted at the University of Uludag Department of Otolaryngology between August 2012 and January 2013. Forty-six patients who were admitted to the otolaryngology outpatient clinic with the complaints of chronic mouth breathing, snoring, and nasal obstruction and had the diagnosis of obstructive adenoid or adenotonsillar hypertrophy were enrolled in the study. The inclusion criteria were as follows: i) age between 8 and 16 years ii) presence of permanent upper anterior dentition, iii) no chronic systemic disease or immunodeficiency, iv) tonsillar hypertrophy with size III + or IV +, v) adenoid hypertrophy with > 80% obstruction at nasopharyngeal airway vi) no other local risk factors. Finally, 20 patients who fulfilled above criteria were included in the study. The patients in healthy control group (n = 15) were selected from individuals who had no adenotonsillar hypertrophy at similar age. The study was approved by the ethical committee of Uludag University Medical School and an informed consent form was obtained from all the participants.
All patients underwent a general otolaryngological examination including nasopharyngoscopy and also periodontal examination by the same periodontologist (B.C.). Periodontal status was assessed by three periodontal measures including; plaque index (PI), pocket depth (PD) and gingival index (GI) scores. This examination requires the presence of upper anterior permanent dentition in order to prevent any measurement bias regarding gingival pocket depth. The standard periodontal probe was inserted into the gingival pocket with a probing force not exceeding 20 g. The depth of invasion was measured on the scale of the probe (in mm) at six sites per tooth (mesio-buccal, mid-buccal, disto-buccal, disto-lingual, mid-lingual and mesio-lingual). In addition, the number of bleeding sites after probing and the grade of plaque formation on three surfaces (mesial, distal and mid) were evaluated. Finally, the mean score for each periodontal index was analysed. In particular, higher scores in these periodontal indices indicate worse periodontal health. The periodontologist did not give oral hygiene advice at first assessment.
The periodontal examinations were repeated 2 months following surgical interventions; adenoidectomy with/without tonsillectomy in order to compare the changes in index score for the study group. Since one patient did not attend the control examination, the study was completed with 19 patients in the study group. Furthermore, a control group of 15 patients with no adenotonsillar disease underwent a similar periodontological examination. The periodontology colleague was blinded to the patient’s group status.
Statistical analysis was carried out using IBM SPSS Statistics 20. Shapiro–Wilk test was used to test the normality of continuous variables. Normally distributed variables were presented as mean (SD). Otherwise median (range) values were given. Independent samples t-test was and paired t-test were used for comparing independent and dependent two groups, respectively. Mann Whitney’s U test was used for comparing non-normally distributed variables between two independent groups. Categorical variables were given as n and percentages, and Fisher’s exact or chi-square tests were used for categorical variables. Significance level was considered to be alpha 0.05.
2
Material and methods
This prospective, controlled and observer blinded clinical study was conducted at the University of Uludag Department of Otolaryngology between August 2012 and January 2013. Forty-six patients who were admitted to the otolaryngology outpatient clinic with the complaints of chronic mouth breathing, snoring, and nasal obstruction and had the diagnosis of obstructive adenoid or adenotonsillar hypertrophy were enrolled in the study. The inclusion criteria were as follows: i) age between 8 and 16 years ii) presence of permanent upper anterior dentition, iii) no chronic systemic disease or immunodeficiency, iv) tonsillar hypertrophy with size III + or IV +, v) adenoid hypertrophy with > 80% obstruction at nasopharyngeal airway vi) no other local risk factors. Finally, 20 patients who fulfilled above criteria were included in the study. The patients in healthy control group (n = 15) were selected from individuals who had no adenotonsillar hypertrophy at similar age. The study was approved by the ethical committee of Uludag University Medical School and an informed consent form was obtained from all the participants.
All patients underwent a general otolaryngological examination including nasopharyngoscopy and also periodontal examination by the same periodontologist (B.C.). Periodontal status was assessed by three periodontal measures including; plaque index (PI), pocket depth (PD) and gingival index (GI) scores. This examination requires the presence of upper anterior permanent dentition in order to prevent any measurement bias regarding gingival pocket depth. The standard periodontal probe was inserted into the gingival pocket with a probing force not exceeding 20 g. The depth of invasion was measured on the scale of the probe (in mm) at six sites per tooth (mesio-buccal, mid-buccal, disto-buccal, disto-lingual, mid-lingual and mesio-lingual). In addition, the number of bleeding sites after probing and the grade of plaque formation on three surfaces (mesial, distal and mid) were evaluated. Finally, the mean score for each periodontal index was analysed. In particular, higher scores in these periodontal indices indicate worse periodontal health. The periodontologist did not give oral hygiene advice at first assessment.
The periodontal examinations were repeated 2 months following surgical interventions; adenoidectomy with/without tonsillectomy in order to compare the changes in index score for the study group. Since one patient did not attend the control examination, the study was completed with 19 patients in the study group. Furthermore, a control group of 15 patients with no adenotonsillar disease underwent a similar periodontological examination. The periodontology colleague was blinded to the patient’s group status.
Statistical analysis was carried out using IBM SPSS Statistics 20. Shapiro–Wilk test was used to test the normality of continuous variables. Normally distributed variables were presented as mean (SD). Otherwise median (range) values were given. Independent samples t-test was and paired t-test were used for comparing independent and dependent two groups, respectively. Mann Whitney’s U test was used for comparing non-normally distributed variables between two independent groups. Categorical variables were given as n and percentages, and Fisher’s exact or chi-square tests were used for categorical variables. Significance level was considered to be alpha 0.05.
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