Experimental gingivitis in relation to susceptibility to periodontal disease. (I.) Clinical observations

Melatonin and oral diseases: possible therapeutic roles based on cellular mechanisms

Oral diseases, including periodontal disorders, oral cancer, periodontitis, and mucositis are the major challenges for both patients and healthcare providers. These conditions often involve inflammation, oxidative stress, and impaired cellular processes, leading to symptoms ranging from discomfort to severe debilitation. Conventional treatments for such oral diseases exhibit constraints, prompting the investigation of innovative therapeutic approaches. Considering the anti-inflammatory, anti-oxidant, and anti-cancer effects of melatonin, this study was carried out to investigate the potential protective effects of melatonin in mitigating the severity of oral diseases. Studies indicate that melatonin influences the differentiation of periodontal stem cells, inhibits oral cancer progression, reduces inflammation associated with periodontitis, and alleviates the severity of oral mucositis. Melatonin has demonstrated potential efficacy in both preclinical and clinical investigations; however, findings are frequently heterogeneous and contingent upon contextual factors. This review provides a comprehensiveoverview of current state of knowledge in this domain, elucidating the multifaceted role that melatonin may assume in combatingoral diseases. Further research should be directed toward determining the most effective dosing, timing, and administration methods for melatonin-based therapies for oral diseases.

Clinical, immunological and microbiological evaluation of experimental peri-implant mucositis and gingivitis in subjects with Grade C, stage III/IV periodontitis background

AIM

To compare individuals with a periodontitis background (Grade C, stage III/IV-formerly generalized aggressive periodontitis) (H-GAP) with periodontally healthy subjects (H-Health) in terms of molecular changes (immunological/microbiological) accompanying experimental peri-implant mucositis and gingivitis.

MATERIALS AND METHODS

H-GAP and control (H-Health) subjects were recruited, and experimental mucositis/gingivitis was induced around a single screw-retained implant and one contralateral tooth. Participants refrained from oral hygiene for 21 days in the selected areas, followed by professional prophylaxis and hygiene instructions for 21 days. Clinical parameters, immunological markers (multiplex analysis) and microbial data (16S rRNA gene sequencing) were collected at baseline, during induction (7, 14 and 21 days) and following remission (42 days).

RESULTS

Clinically, no significant differences were observed between the groups (n = 10/each group) (H-GAP vs. H-Health) (p > .05, Mann-Whitney test) and the type of site (tooth vs. implant) (p > .05, Wilcoxon test) at the time of onset and resolution, or severity of gingival/mucosal inflammation. H-GAP displayed lower concentrations of the cytokines interleukin (IL)-1B, IL-4, IL-17, tumor necrosis factor-α and interferon-γ around implants than H-Health at baseline and during induction of mucositis (p < .05, Mann-Whitney test). In both groups, implants showed significantly higher inflammatory background at baseline and all subsequent visits when compared with teeth (p < .05, Wilcoxon test). Alpha and β-diversity metrics showed a significant shift in the microbiome composition and abundances of core species during induction and resolution of peri-implant mucositis and gingivitis (p < .05, restricted maximum likelihood method of Shannon and Bray-Curtis indices, respectively). Differences were not significant for these parameters between the H-Health and H-GAP groups when the periodontal and peri-implant microbiomes were compared separately; however, at each time point, the peri-implant microbiome differed significantly from the periodontal microbiome.

CONCLUSIONS

Within the limitations of this pilot study (e.g. low power), it can be concluded that different microbial shifts contribute to the onset and progression of inflammatory responses around teeth and implants and that history of periodontal disease experience plays an additional role in modulating the immune response of peri-implant and periodontal tissues to biofilm accumulation.

Adjunctive Effect of Green Tea Mouthwash Prepared at Different Steeping Temperatures on Gingivitis: A Triple-Blind Randomized Controlled Clinical Trial

PURPOSE

To compare the effect of green tea mouthwashes prepared at different steeping temperatures as adjuncts to mechanical plaque control on gingivitis.

METHODS

Forty-five women with gingivitis participated in this 4-week randomized controlled clinical trial. They received professional mechanical plaque control and rinsed daily with either warm green tea, hot-cold green tea or placebo. Dental plaque control record (PCR) and gingival bleeding indices (GBI) were recorded at baseline and 7, 14 and 28 days after.

RESULTS

Participants' mean age was 20.7 ± 2 years. The mean scores for the PCR and GBI at baseline were 82.4 ± 19 and 85.8 ± 7, respectively. All groups showed significant reduction in PCR and GBI between Days 0 and 28 (p < 0.01). No significant differences in PCR were observed between the groups at any of the examinations (p > 0.01). The warm green tea group demonstrated significantly lower GBI at all examinations compared to the hot-cold group (p < 0.01).

CONCLUSIONS

Within study limits, green tea-made mouthwashes significantly reduced plaque and gingivitis when used as adjuncts to mechanical plaque control. The green tea mouthwash prepared in warm water demonstrated significantly higher efficacy in lowering gingivitis compared to that prepared in hot water followed by ice.

Local Drug Delivery Based Treatment Approaches for Effective Management of Periodontitis

Background:

Periodontal disease is an immuno-inflammatory condition of tissues that surround and hold the teeth. It is the disease which succeeds in all races, groups and both genders. Almost 10 to15% of the global population gets suffered from severe periodontitis as per WHO reports. Periodontal disease may likely cause other systemic diseases such as cardiovascular disease and pre-term low birth weight infants. Mechanical removal of plaques and calculus deposits from supra and subgingival environment is the backbone of periodontal treatment till date whereas complete elimination of these deleterious agents is quite unrealistic as the pocket depth increases.

Recent Approaches:

Recently controlled local drug delivery application is more encouraging in comparison to systemic approach as it mainly targets to enhance the therapeutic efficacy by maintaining site-specificity, avoiding first pass metabolism, reduction in gastrointestinal (GI) side effects and decreasing the dose. Several drugs such as antiseptics and antibiotics alongwith various carriers are being formulated as local drug delivery systems for effective management of the disease. Various local delivery systems reported are fibers, films, strips, compacts, injectables, microparticles, vesicular carriers, gels and nanoparticles. These local carriers provide effective prolonged treatment at the site of infection at reduced doses. This review enlightens detailed pathophysiology and various phases of periodontitis, challenges in treatment of disease and various antimicrobial agents (along with their marketed formulations) used. The main emphasis of the review is to cover all carrier systems developed so far for local delivery application in the effective management of periodontitis, as a patient compliant drug therapy.

The subgingival periodontal microbiota of the aging mouth

Different mechanisms have been hypothesized to explain the increase in prevalence and severity of periodontitis in older adults, including shifts in the periodontal microbiota. However, the actual impact of aging on the composition of subgingival biofilms remains unclear. In the present article, we provide an overview of the composition of the subgingival biofilm in older adults and the potential effects of age on the oral microbiome. In particular, this review covers the following topics: (i) the oral microbiota of an aging mouth; (ii) the effects of age and time on the human oral microbiome; (iii) the potential impact of inflammaging and immunosenescence in the host-oral microbiota interactions; and (iv) the relationship of the aging oral microbiota and Alzheimer's disease. Finally, we present analyses of data compiled from large clinical studies that evaluated the subgingival microbiota of periodontally healthy subjects and patients with periodontitis from a wide age spectrum (20-83 years of age).

Triphala, a New Herbal Mouthwash for the Treatment of Gingivitis: A Randomized Controlled Clinical Trial

BACKGROUND

An antiplaque agent with minimal side effects that can be used as an effective adjunct to mechanical plaque control is needed. The current study is designed to evaluate efficacy of triphala (TRP) mouthwash in reduction of plaque and gingivitis.

METHODS

Ninety individuals with chronic generalized gingivitis were randomly assigned to three groups: 1) group I, placebo mouthwash; 2) group II, TRP mouthwash; and 3) group III, chlorhexidine (CHX) mouthwash. All individuals were instructed to rinse with their respective mouthwash twice daily. 1) Plaque index (PI); 2) gingival index (GI); 3) oral hygiene index-simplified (OHI-S); and 4) microbiologic colony counts were recorded at baseline and at 7, 30, and 60 days.

RESULTS

All three groups showed gradual reduction in PI, GI, and OHI-S levels from baseline to 7, 30, and 60 days. There was also significant reduction in microbial counts in all groups at all time intervals except in group I. A significant difference was noticed with respect to reduction in PI, GI, OHI-S, and microbiologic counts in group I compared with groups II and III. However, no significant differences were found between groups II and III for any parameters at any time intervals.

CONCLUSIONS

TRP mouthwash was found to decrease inflammatory parameters from baseline to follow-up intervals. Because improvement in gingivitis was comparable with that of CHX mouthwash, TRP mouthwash can be considered a potential therapeutic agent in the treatment of gingivitis.

Comparison of red autofluorescing plaque and disclosed plaque-a cross-sectional study

Objectives

The aim of this cross-sectional study was to assess the correlation between dental plaque scores determined by the measurement of red autofluorescence or by visualization with a two-tone solution. Clinical photographs were used for this study.

Materials and methods

Overnight plaque from the anterior teeth of 48 participants was assessed for red fluorescence on photographs (taken with a QLF-camera) using a modified Quigley & Hein (mQH) index. A two-tone disclosing solution was applied. Total disclosed plaque was clinically assessed using the mQH index. In addition, total and blue disclosed plaque was scored on clinical photographs using the mQH index.

Results

A strong correlation was observed between the total disclosed plaque scored on photographs and the clinical scores (r = 0.70 at site level; r = 0.88 at subject level). The correlation between red fluorescent plaque and total plaque, as assessed on the photographs, was moderate to strong and significant (r = 0.50 at the site level; r = 0.70 at the subject level), with the total plaque scores consistently higher than the red fluorescent plaque scores. The correlation between red fluorescent plaque and blue disclosed plaque was weak to moderate and significant (r = 0.30 at the site level; r = 0.50 at the subject level).

Conclusions

Plaque, as scored on white-light photographs, corresponds well with clinically assessed plaque. A weak to moderate correlation between red fluorescing plaque and total disclosed plaque or blue disclosed plaque was found.

Clinical relevance

What at present is considered to be matured dental plaque, which appears blue following the application of a two-tone disclosing solution, is not in agreement with red fluorescent dental plaque assessment.

Learned and unlearned concepts in periodontal diagnostics: a 50-year perspective

In the past 50 years, conceptual changes in the field of periodontal diagnostics have paralleled those associated with a better scientific understanding of the full spectrum of processes that affect periodontal health and disease. Fifty years ago, concepts regarding the diagnosis of periodontal diseases followed the classical pathology paradigm. It was believed that the two basic forms of destructive periodontal disease were chronic inflammatory periodontitis and 'periodontosis'- a degenerative condition. In the subsequent 25 years it was shown that periodontosis was an infection. By 1987, major new concepts regarding the diagnosis and pathogenesis of periodontitis included: (i) all cases of untreated gingivitis do not inevitably progress to periodontitis; (ii) progression of untreated periodontitis is often episodic; (iii) some sites with untreated periodontitis do not progress; (iv) a rather small population of specific bacteria ('periodontal pathogens') appear to be the main etiologic agents of chronic inflammatory periodontitis; and (v) tissue damage in periodontitis is primarily caused by inflammatory and immunologic host responses to infecting agents. The concepts that were in place by 1987 are still largely intact in 2012. However, in the decades to come, it is likely that new information on the human microbiome will change our current concepts concerning the prevention, diagnosis and treatment of periodontal diseases.

Differential gender effects of a reduced-calorie diet on systemic inflammatory and immune parameters in nonhuman primates

BACKGROUND AND OBJECTIVE

Dietary manipulation, including caloric restriction, has been shown to impact host response capabilities significantly, particularly in association with aging. This investigation compared systemic inflammatory and immune-response molecules in rhesus monkeys (Macaca mulatta).

MATERIAL AND METHODS

Monkeys on continuous long-term calorie-restricted diets and a matched group of animals on a control ad libitum diet, were examined for systemic response profiles including the effects of both gender and aging.

RESULTS

The results demonstrated that haptoglobin and alpha1-antiglycoprotein levels were elevated in the serum of male monkeys. Serum IgG responses to Campylobacter rectus, Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis were significantly elevated in female monkeys. While only the antibody to Fusobacterium nucleatum was significantly affected by the calorie-restricted diet in female monkeys, antibody levels to Prevotella intermedia, C. rectus and Treponema denticola demonstrated a similar trend.

CONCLUSION

In this investigation, only certain serum antibody levels were influenced by the age of male animals, which was seemingly related to increasing clinical disease in this gender. More generally, analytes were modulated by gender and/or diet in this oral model system of mucosal microbial challenge.

Refining exposure definitions for studies of periodontal disease and systemic disease associations

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 > or = 45).

RESULTS

In men and women, percent of sites with attachment loss (AL) > or =6 mm and tooth loss both revealed the highest correlation with HbA1c (rho = 0.11; several other definitions related similarly), while the strongest fibrinogen correlation was observed with percent of sites with pocket depth > or =3 mm (rho = 0.19). Findings for c-IMT among men were strongest for percent of sites with AL > or =6 mm (rho = 0.14; several other definitions related similarly) while among women, percent of sites with pocket depth > or =5 or 6 mm had the highest observed correlation (rho = 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.

Gingivitis susceptibility and its relation to periodontitis in men

The objective of this cross-sectional study was to evaluate whether gingivitis susceptibility is associated with periodontitis. We analyzed data of 462 men in the VA Dental Longitudinal Study aged 47 to 92 years who had never smoked or had quit smoking 5+ years previously. Multiple logistic regression models, with tooth-level bleeding on probing at sites with attachment loss<or=2 mm as the dependent variable, were derived with adjustment for plaque, calculus, crown coverage, age, income, education, marital status, body mass index, diabetes, and vitamin C intake, and stratification by age (<65, 65+ years). Periodontitis and mean attachment loss were positively associated with bleeding on probing, with stronger associations among men<65 years old (for periodontitis, OR 2.1; 95% CI 1.5, 3.1) than men 65+ years of age (OR 1.2; 95% CI 0.9, 1.6). Our results suggest that among never and former smokers, gingivitis susceptibility is higher among men with periodontitis compared with that in men without periodontitis.

Modulation of clinical expression of plaque-induced gingivitis: response in aggressive periodontitis subjects

AIM

The aim of this study was to characterize the gingival inflammatory response to de novo plaque accumulation in subjects treated for aggressive periodontitis (AP). The gingival inflammatory response of the AP subjects was retrospectively compared with that of periodontally healthy individuals (PH) matched for exposure to plaque and of periodontally healthy subjects previously identified as "high responders" (HR) and "low responders" (LR).

MATERIALS AND METHODS

13 AP subjects and 26 matched PH subjects participated in a 21-day experimental gingivitis trial. Plaque index (PlI), Gingival index (GI), gingival crevicular fluid volume (GCF) and angulated bleeding score (AngBS) were recorded at days 0, 7, 14 and 21. Cumulative plaque exposure (CPE), i.e. PlI over time, was also calculated.

RESULTS

GCF was significantly higher in AP compared with PH group at each observation interval (p< or =0.001). In addition, GCF was significantly higher in AP group compared with either LR or HR groups at each observation interval (p<0.001).

CONCLUSIONS

These results suggest that susceptibility to gingival inflammation in response to de novo plaque accumulation may be related to susceptibility to periodontitis.

Periodontal diseases

The periodontal diseases are highly prevalent and can affect up to 90% of the worldwide population. Gingivitis, the mildest form of periodontal disease, is caused by the bacterial biofilm (dental plaque) that accumulates on teeth adjacent to the gingiva (gums). However, gingivitis does not affect the underlying supporting structures of the teeth and is reversible. Periodontitis results in loss of connective tissue and bone support and is a major cause of tooth loss in adults. In addition to pathogenic microorganisms in the biofilm, genetic and environmental factors, especially tobacco use, contribute to the cause of these diseases. Genetic, dermatological, haematological, granulomatous, immunosuppressive, and neoplastic disorders can also have periodontal manifestations. Common forms of periodontal disease have been associated with adverse pregnancy outcomes, cardiovascular disease, stroke, pulmonary disease, and diabetes, but the causal relations have not been established. Prevention and treatment are aimed at controlling the bacterial biofilm and other risk factors, arresting progressive disease, and restoring lost tooth support.

Host response to microbial challenge following resective/non-resective periodontal therapy

BACKGROUND

The host response to microbial challenge depends on the recruitment of homing leucocytes and may be related to the experience to infectious insults over years.

PURPOSE

The aim of this study was to investigate the soft tissue reactions to de novo plaque formation at sites treated with either open flap debridement or with the use of resective means during periodontal therapy.

MATERIAL AND METHODS

Fifteen patients, who had been treated for periodontal disease (severe generalized chronic periodontitis), participated in the study. Surgical therapy was performed using either gingivectomy (GV) or open flap debridement (OFD) procedures in a split mouth design. After 6 months of healing (day 0), two gingival biopsies were obtained, one from the GV- and one from the OFD-treated sites. The experimental gingivitis model was applied and plaque accumulation was allowed for 3 weeks. New biopsies were obtained from the remaining quadrants on day 21 of plaque formation. The biopsies were snap frozen and prepared for immunohistochemical analysis.

RESULTS

Following 3 weeks of plaque accumulation, the size of the lesion in OFD sites was more than twice as large than that in GV sites (0.42 versus 0.19 mm2). In the GV units, the lesion was characterized by almost similar proportions of T cells (CD3+, 6.0%) and B cells (CD19+, 6.6%), while the ICT in OFD sites was dominated by B cells (13.8%). During the 3-week period of plaque formation the increase in cell densities of T and B cells was three times larger in OFD than in GV sites. The proportion of ELAM-1 (CD62+ cells) decreased in GV (-0.4%) and increased in OFD (0.9%) sites.

CONCLUSIONS

The host response that occurred in the gingival sites treated with OFD was more pronounced than the reaction that under similar experimental conditions took place in the regenerated gingiva at sites treated by resective means.

The salivary microbiota as a diagnostic indicator of oral cancer: a descriptive, non-randomized study of cancer-free and oral squamous cell carcinoma subjects

Background

The purpose of the present investigation was to determine if the salivary counts of 40 common oral bacteria in subjects with an oral squamous cell carcinoma (OSCC) lesion would differ from those found in cancer-free (OSCC-free) controls.

Methods

Unstimulated saliva samples were collected from 229 OSCC-free and 45 OSCC subjects and evaluated for their content of 40 common oral bacteria using checkerboard DNA-DNA hybridization. DNA counts per ml saliva were determined for each species, averaged across subjects in the 2 subject groups, and significance of differences between groups determined using the Mann-Whitney test and adjusted for multiple comparisons. Diagnostic sensitivity and specificity in detection of OSCC by levels of salivary organisms were computed and comparisons made separately between a non-matched group of 45 OSCC subjects and 229 controls and a group of 45 OSCC subjects and 45 controls matched by age, gender and smoking history.

Results

Counts of 3 of the 40 species tested, Capnocytophaga gingivalis, Prevotella melaninogenica and Streptococcus mitis, were elevated in the saliva of individuals with OSCC (p < 0.001). When tested as diagnostic markers the 3 species were found to predict 80% of cancer cases (sensitivity) while excluding 83% of controls (specificity) in the non-matched group. Diagnostic sensitivity and specificity in the matched group were 80% and 82% respectively.

Conclusion

High salivary counts of C. gingivalis, P. melaninogenica and S. mitis may be diagnostic indicators of OSCC.

Evaluation of additional amine fluoride/stannous fluoride-containing mouthrinse during supportive therapy in patients with generalized aggressive periodontitis. A randomized, crossover, double-blind, controlled trial

OBJECTIVES

The objective of the present randomized controlled trial was to evaluate the efficacy of a mouthrinse containing a combination of AmF/SnF2 in controlling supragingival plaque accumulation and gingival inflammation during a 12-week period in patients affected by generalized aggressive periodontitis (GAP).

METHODS

Eighteen subjects, six males and 12 females, mean age: 32.2 years, were evaluated. One-half of the patients was either prescribed an AmF/SnF2-containing mouthrinse (test mouthrinse) or a control mouthrinse in addition to mechanical plaque control for 12 weeks. After a 2-week wash-out period, the patients received the alternative mouthrinse. Before and after treatment plaque index (PlI), gingival index (GI), angulated bleeding index (AngBI), tooth stain (GMSI), and tongue stain were recorded.

RESULTS

Test mouthrinse resulted in a statistically significant decrease in PlI (p = 0.029) and GI (p = 0.017). After treatment, PlI was significantly lower in test compared to control mouthrinse (p = 0.027). GMSI significantly increased post-treatment for both mouthrinse regimens (p < 0.001), a significantly higher score being observed for the test compared to control mouthrinse (p = 0.002).

CONCLUSIONS

The 12-week use of a AmF/SnF2-containing mouthrinse as an adjunct to conventional mechanical oral hygiene procedures in GAP patients was effective in controlling the amount of supragingival plaque deposits.

Modulation of clinical expression of plaque-induced gingivitis. I. Background review and rationale

OBJECTIVES

The purpose of this article is to provide the necessary background and rationale for the accompanying studies, which are ultimately aimed at identifying genetic and environmental factors determining gingivitis susceptibility.

MATERIALS AND METHODS

The literature on factors reported to modify the clinical expression of gingivitis, i.e., factors that determine individual variability in gingival inflammatory response to plaque, is presented.

RESULTS

Clinical evidence suggests that the gingival inflammatory response to plaque accumulation may differ substantially among individuals. However, most of the available studies are of small scale and not purposely designed to address the issue. Systemic factors implicated in modulation of the clinical expression of gingivitis include metabolic, genetic, environmental and other factors. The significance of such factors in designing and conducting a large-scale experimental gingivitis trial and means to account for them are discussed.

CONCLUSION

Although several factors have been implicated, genetic or environmental factors underlying differences in gingivitis expression are not fully elucidated. The accompanying studies aim to identify and characterize, among participants in a specifically designed large-scale experimental gingivitis trial, subjects that differ significantly in their gingival inflammatory response to plaque. This is the first step in an effort to determine genetic or environmental factors underlying such differences.

Effects of periodontitis and smoking on the microbiota of oral mucous membranes and saliva in systemically healthy subjects

BACKGROUND/AIM

To examine the differences in the proportions of 40 bacterial species in samples from eight oral soft-tissue surfaces and saliva in systemically healthy adult subjects with and without periodontitis and in smokers and nonsmokers.

METHODS

Saliva and microbial samples were taken from eight oral soft-tissue surfaces in 229 systemically healthy subjects stratified by periodontal and smoking status. Subjects included 84 periodontally healthy and 145 periodontitis individuals. Of these, there were 182 nonsmokers and 47 smokers. Soft-tissue samples were taken using a "buccal brush" and saliva was taken by expectoration. All samples were individually evaluated for their content of 40 bacterial species using checkerboard DNA-DNA hybridization. The percentage of total DNA probe count was determined for each species at each sample location and averaged across subjects. The significance of differences among the proportions of the 40 test species at different sample locations was sought in these populations using the Kruskall-Wallis test and adjusted for multiple comparisons.

RESULTS

When stratified for periodontal status or smoking status, microbial profiles at most sites did not differ significantly. Generally, periodontal pathogens were found at higher levels on the soft tissues of periodontitis subjects than in periodontally healthy subjects, and at higher levels in smokers than nonsmokers. Few significant differences were found, although trends in the populations were noted.

CONCLUSIONS

Small differences in the proportions of bacterial species were observed on soft tissues and in saliva comparing periodontally healthy and periodontitis subjects. Somewhat greater differences between smokers and nonsmokers were found; however, these were not statistically significant.

Periodontal diseases: current and future indications for local antimicrobial therapy

The microbial etiology of gingivitis and periodontitis provides the rationale for use of adjunctive antimicrobial agents in the prevention and treatment of periodontal diseases. Although mechanical removal of supra- and subgingival calcified and non-calcified plaque deposits has been proved effective to control the gingival inflammatory lesions as well as to halt the progression of periodontal attachment loss, some patients may experience additional benefits from the use of systemic or topical antimicrobial agents. Such agents are able to significantly affect supra- and subgingival plaque accumulation and/or suppress or eradicate periodontal pathogenic microflora. Currently, properly selected local antiseptic and systemic antibiotic therapies can provide periodontal treatment that is generally effective, low-risk and affordable. This paper will briefly review the host-related conditions in which the periodontal preventive and therapeutic approaches may be effectively assisted by a local antimicrobial regimen. Potential future indications for adjunctive local antimicrobial therapy will also be discussed.

Maintenance of periodontal attachment levels in prosthetically treated patients with gingivitis or moderate chronic periodontitis 5-17 years post therapy

OBJECTIVES

The present retrospective analysis was performed to evaluate the long-term results of initial periodontal and fixed prosthodontic treatment in patients with gingivitis or moderate chronic periodontitis during post-therapeutic irregular maintenance of 5-17 years.

MATERIAL AND METHODS

Thirty-four patients participated in the study. Baseline data were taken from the patients' records when the periodontal and the prosthetic treatment was finished. A follow-up examination was performed in conjunction with the radiographic examination including assessment of plaque, bleeding on probing, probing pocket depth, recession and probing attachment loss. Information regarding the oral hygiene habits of the subjects as well as the amount of dental and initial therapy received between the observation time was obtained from the patients' records.

RESULTS

The results from the clinical trial revealed that during the mean examination period of 11 years only 31 teeth were lost. The remaining restored and non-restored teeth did not show any significant differences in attachment loss (from 2.9 mm to 3.0 mm) in spite of a higher plaque value at the follow-up examination (from 42% to 48%). The BoP remained stable in the same time period and scored 31% to 28%.

CONCLUSIONS

The periodontal attachment levels were maintained during a prolonged period despite irregular maintenance care. This indicates that in a population of obviously decreased susceptibility to chronic periodontitis, it is possible that fixed reconstructions will not - even under suboptimal supportive care - jeopardize the periodontal status.

Preventive strategies and supportive treatment

There is a preponderance of evidence in the literature that periodontal and other oral diseases, such as caries, can be treated and controlled by thorough mechanical plaque removal by the patient, the use of antimicrobial agents and antibiotics when necessary, and participation with the therapist in a well monitored, long-range program of supportive periodontal therapy. Recent evidence suggests that the control and prevention of oral disease, especially periodontitis, is especially important for patients with various systemic conditions that can be impacted by oral infections. It is far better for patients and therapists to practice primary and even secondary prevention with effective plaque control and regular, consistent supportive periodontal therapy, than having to rely on tertiary prevention for disease that has progressed to a level that requires costly treatment, is time-consuming and carries a greater risk of morbidity.

Longitudinal association between plaque and gingival bleeding in smokers and non-smokers

BACKGROUND/AIMS

Whereas accumulation of dentogingival plaque inevitably leads to inflammatory reactions in the adjacent gingival tissue, there is limited information with regard to factors influencing naturally occurring fluctuation between gingival health and disease. The major aims of the present study were to investigate site-specific associations between plaque and gingivitis as well as transition dynamics of naturally occurring gingivitis in smoking and non-smoking young adults.

METHODS

65 systemically healthy young adults, 19 to 30 years old, participated. 33 volunteers smoked at least 20 cigarettes per day, whereas 32 subjects were non-smokers. Clinical periodontal conditions were assessed four times within a time period of 6 months. An ecological approach in data analysis as well as site-specific analyses considering the correlated structure of data were performed.

RESULTS

At the outset and after 6 months, smokers had significantly more supragingival plaque than non-smokers. At the final examination, bleeding upon probing as well as calculus were more prevalent in smokers. A site-by-site analysis revealed that smokers tended to have a weaker association between supragingival plaque and bleeding on probing than non-smokers (median Mantel-Haenszel's common odds ratio 1.91 vs. 2.89, p=0.07). Multiple logistic regression analyses adjusted for periodontal probing depth, plaque and calculus identified smoking status to significantly increase the risk for the first transition of non-bleeding to bleeding upon probing by 86% (p<0.01). In contrast, recovery of bleeding sites was positively influenced by female gender, but not smoking.

CONCLUSIONS

In multivariate analyses adjusted for probing depth, plaque and calculus, smokers appeared to be at higher risk for the transition from non-bleeding to bleeding on probing. Weaker associations between plaque and naturally occurring gingivitis in smokers may have important consequences for preventive strategies for gingivitis.

A comparison of the efficacy of 2 powered toothbrushes in affecting plaque accumulation, gingivitis, and gingival bleeding

BACKGROUND

The purpose of this 30-day blinded, parallel-design study was to compare the effect of 2 powered toothbrushes, the Rowenta MH700 and the Braun Plak Control Ultra, on reducing plaque accumulation, gingivitis, and gingival bleeding in a cohort of 60 healthy adults.

METHODS

After baseline evaluation of plaque, gingivitis, and gingival bleeding, subjects were randomly assigned to one of the experimental groups, provided written and verbal toothbrushing instructions, and had their teeth polished. At 2 weeks (follow-up 1) and 4 weeks (follow-up 2), all clinical parameters were again evaluated.

RESULTS

The Braun group demonstrated a nearly significant reduction in gingival index (GI) and a significant reduction in GI at follow-up 2. The Rowenta group demonstrated significant reductions in GI, plaque index (PI), and bleeding index (GBI) at both follow-up 1 and 2 examinations. At follow-up 1, the Braun group demonstrated a nearly significant reduction in GI, a significant reduction in PI, and a non-significant reduction in GBI. At follow-up 2, the Braun group demonstrated a significant reduction in GBI, but not a significant reduction in PI. The reduction in GI for the Rowenta group was significantly greater (P values of 0.0001 and 0.0001, respectively) than that demonstrated in the Braun group. However, the Rowenta group did not demonstrate a significantly greater reduction in PI (P values of 0.7135 and 0.3184 for follow-up 1 and follow-up 2, respectively) or GBI than the Braun group at either examination (P values of 0.0663 and 0.3397 for follow-up 1 and 2, respectively).

CONCLUSIONS

The results of this study support the findings of numerous other studies that powered toothbrushes have great potential to remove plaque and improve gingival health and that the improvement can be demonstrated in a relatively short period of time.

Experimental gingivitis in periodontitis-susceptible subjects

The purpose of this study was to evaluate clinical, microbiological, and gingival crevicular fluid (GCF) profiles in periodontitis-resistant and periodontitis-susceptible subjects during 4 weeks of experimental gingivitis. Experimental groups of similar ages were defined as gingivitis controls (GC; n = 10) and history of rapidly progressive periodontitis (RPP; n = 10), respectively. Prior to baseline, all subjects achieved good plaque control (plaque index (P1I) approximately 0) and gingival health (gingival index (GI) = 0), and had probing depths < or = 4 mm on experimental teeth. For 4 weeks after baseline, oral hygiene around maxillary 2nd premolar and 1st molar teeth was inhibited by a plaque guard. The plaque guard was removed weekly for GCF sampling to determine interleukin (IL)-1 beta and prostaglandin (PG)E2 amounts by ELISAs. In addition, P1I, GI, probing depth, and gingival recession measurements were made. Subgingival plaque darkfield microscopy and DNA probe analysis also were performed. Results indicated that clinical signs of inflammation, microbiological patterns and GCF profiles progressed similarly in both groups. However, plaque accumulated more rapidly in the susceptible subjects. P1I in RPP at 4 weeks was 2.1 +/- 0.1 compared to 1.5 +/- 0.2 in GC, with an incidence of P1I > of 100% versus 50%, respectively (logistic regression; p < 0.0001). Hence, the clinical, microbiological and host factors selected for this study were unrelated to previous susceptibility to periodontitis when evaluated in the experimental gingivitis model. However, the increased rate of plaque accumulation, following thorough plaque removal, in RPP patients suggests a potential factor in disease recurrence in these susceptible subjects.

The effect of age on the development of gingivitis. Clinical, microbiological and histological findings

In the present "experimental gingivitis" study, the response of the marginal gingiva to plaque formation was studied in one group of young subjects, 20-25 years of age, and in one group of older subjects, aged 65-80 years. During a 4-week period, all subjects received a series of professional tooth cleaning to establish healthy gingival conditions. A baseline examination (Day 0) included assessments of plaque and gingivitis. Sites that were examined (the experimental sites) included the mesio-palatal, palatal, and disto-palatal surfaces of all teeth present in the 15 ... 25 tooth region. Among the experimental sites, microbial sampling and gingival fluid assessment were performed and one gingival biopsy harvested from each subject. Following the baseline examination, the participants abolished mechanical tooth cleaning measures in the palatal and approximal surfaces of 15 ... 25. The clinical examination and the gingival fluid measurement were repeated on days 7, 14 and 21 of no oral hygiene. The microbiological sampling and the biopsy procedure were repeated on days 7 and 21. The data collected demonstrated that old subjects, during a 3-week period of oral hygiene abstention, formed similar amounts of plaque as the young subjects, but developed more gingivitis than young subjects. Thus, the clinical gingivitis assessments, the gingival fluid measurements and morphometric determinations made in the biopsy samples documented that the gingival lesion which formed in the old individuals was more pronounced and contained more inflammatory cells than the corresponding lesion in the young subject sample.

Gingivitis in young and old dogs

The aim of the investigation was to study the development of gingivitis in young and old dogs. 10 beagle dogs were used. 5 of the dogs were 1 year old and 5 dogs were between 8 and 9 years of age. On day 0, all the teeth of all 10 dogs were scaled and polished. A 6-week period of plaque control was initiated. On day 42, a clinical examination was performed, microbial samples from the gingival sulcus were harvested and biopsies obtained from tooth regions 3P and 4P. The tooth-cleaning measures were abandoned following biopsy and the animals were during the subsequent 3 weeks allowed to form plaque. On day 63, i.e., day 21 of plaque formation, the clinical examination, sampling of the subgingival plaque and harvesting of biopsies were repeated in the contralateral premolar regions (P3 and P4). The histological analysis revealed that the cellular infiltrate (the lesion) of inflamed gingiva was larger and extended more apically in the old than in the young dogs. The lesion in the old dogs contained significantly more plasma cells but less macrophages, lymphocytes and PMN cells than the infiltrate in the young dogs.

A 2-year follow-up on the clinical and microbiological conditions of periodontium in teenagers

87 teenagers were included in a 2-year follow-up study on clinical and microbiological conditions of the periodontium. The clinical status was determined according to the Community Periodontal Index of Treatment Needs (CPITN) for subjects under 20 years of age. 59% of the subjects had at least 3 healthy sextants at the baseline and 68% at the 2-year examination. The microbiological conditions were assessed by using direct dark-field microscopy, and the culture of Actinobacillus actinomycetemcomitants (A.a.). Subgingival bacterial samples were taken, 2 for the microscopy and 2 for the culture, from the mesial surfaces of the first molars of each subject. The presence of gingival bleeding after probing was separately recorded from the 2 sites sampled for dark-field microscopy. No gingival bleeding at these 2 sites was found at the 2-year examination in 55% of those subjects who were non-bleeding at baseline, in 46% of the subjects initially with 1 bleeding site and in 13% of the subjects with both sites bleeding at baseline. 55% of the subjects with neither fusiforms, motile rods nor spirochetes at baseline maintained their healthy flora for 2 years. A.a. was recovered in 4 subjects at baseline and in 5 subjects 2 years later, in 3 of them at both examinations. Longer follow-up periods are needed to reveal the significance of the constant recovery of A.a. from the same subjects.

The effect of mechanical oral hygiene procedures on bleeding on probing

The purpose of the present study was to investigate the effect of mechanical oral hygiene procedures on bleeding on probing in relation to age and periodontal status. The study was carried out on 49 individuals divided into 7 experimental groups according to age and having been either treated for destructive periodontal disease or having an intact healthy periodontium. In order to eliminate any pre-existant gingival inflammation, all subjects received a carefully controlled oral hygiene program. At the start of the experiment, all subjects were instructed to abstain from oral hygiene procedures for 24 h. Thereafter, clinical baseline measurements were carried out, including bleeding on probing (BOP) using a standardized probing pressure. Next, all subjects cleaned their teeth according to their normal oral home care protocol using a multitufted toothbrush, toothpicks and interdental brushes. BOP scores were again assessed 30 min after completed tooth cleaning procedures. The results revealed a significant increase in BOP after the mechanical oral hygiene procedures in every individual in all experimental groups (p less than 0.05). Further analysis showed that the increase in BOP was independent of the periodontal status of the subjects. However the BOP scores after mechanical oral hygiene procedures were higher in the young age groups. It was concluded that the diagnostic predictability of BOP in the treatment of periodontal diseases might be affected by temporarily elevated BOP scores shortly after mechanical oral hygiene procedures.

The effect of health beliefs on the compliance of periodontal patients with oral hygiene instructions

Problems of patient compliance in periodontics are evident. This study explored factors which may contribute to the degree of adherence. Using the "Health Belief Model" a questionnaire was constructed and administered to 120 patients of the Department of Periodontology, University of Frankfurt Dental School. Compliance of these patients during the hygienic phase was assessed using a bleeding index. The data set for statistical evaluation comprised 96 patients. The loss was due to missing of appointments and incomplete questionnaires. There was no significant correlation between patient compliance on the one hand and sociodemographic variables (age, sex, family status), disease parameters, and the health beliefs "susceptibility," "barriers," "dentist-patient-relationship," and "experience with therapy" on the other hand. "Motivation," "seriousness," "benefits," "experience with affected organ," and tooth-loss-index were significant predictors with Spearman correlation coefficients running from 0.17 to 0.32. When the predictor variables were combined the coefficient was 0.59. This study further supports the assumption that health beliefs play a significant role in the determination of health related behavior.

Experimental gingivitis in relation to age in individuals not susceptible to periodontal destruction

The purpose of the present investigation was to study the effect of age on the rate of development of gingival inflammation in individuals not susceptible to periodontal destruction. 7 younger (mean age 37 years) and 7 older (mean age 58 years) individuals were selected on the basis of the presence of at least 18 teeth, no evidence of extraction due to periodontal destruction, no loss of attachment, shallow pockets, gross amounts of plaque and a history of no interdental cleaning. All individuals were subjected to a carefully controlled oral hygiene program and experimental gingivitis was induced in 1 quadrant of the mouth during a period of 33 days. The amount of plaque, redness and swelling of the gingiva, and bleeding on probing were assessed before, during and after the experiment. At day 33, supra-gingival plaque samples were taken for bacteriological examination and gingival biopsies were taken for histopathological and immunohistochemical investigation. Results showed no differences between the 2 age groups with regard to the amount of plaque accumulation and the rate of development of gingival inflammation. Furthermore phase-contrast microscopy of plaque samples showed no differences between the 2 age groups. Neither histological nor immunohistochemical investigation showed any differences between the 2 age groups. All biopsies diffusely showed presence of IgG, whereas in most biopsies, IgA plasma cells and in one biopsy IgM plasma cells were found. Neither IgD, IgE nor complement deposits were found. It was concluded that age is of minor importance in the development of experimentally-induced gingivitis in individuals not susceptible to periodontal destruction.

Probing considerations in relation to susceptibility to periodontal breakdown

Both epidemiological and clinical studies indicate that not all individuals are equally susceptible to periodontal breakdown. Therefore, the clinical differences were investigated between subjects highly susceptible and subjects insusceptible to periodontal breakdown. The highly susceptible group consisted of patients with a diagnosis of juvenile periodontitis. The insusceptible group consisted of older individuals with gross amounts of plaque and no periodontal breakdown. Results indicated that a high value of the bleeding/plaque ratio may possibly act as a prognostic indicator for periodontal breakdown. However, longitudinal data are indispensable for substantiation of this hypothesis. Since longitudinal research takes many years, the experimental gingivitis model was chosen for further investigation. 4 groups of individuals were selected on the basis of a different history of inflammatory periodontal disease: 2 younger age groups without periodontal breakdown, having either a low or a high bleeding/plaque ratio--a hypothetically susceptible and a hypothetically insusceptible group, respectively; one older age group with presence of gross amounts of plaque, no periodontal breakdown and a low bleeding/plaque ratio--an insusceptible group; and an adult group who previously suffered from severe periodontal disease--a susceptible group. Results of the experimental gingivitis studies indicated that the older insusceptible group developed only small amounts of bleeding, whereas the younger hypothetically insusceptible group developed a comparable low bleeding index. The younger hypothetically susceptible group developed a much higher bleeding index comparable to that of the susceptible group, the periodontal patients. In conclusion, comparison of the results of the experimental gingivitis studies in subjects with differing histories of inflammatory periodontal disease supports the concept that the bleeding/plaque ratio may act as a prognostic indicator for periodontal breakdown.

Bleeding/plaque ratio and the development of gingival inflammation

In a recent publication, it was hypothesized that the ratio between bleeding and plaque scores may act as a prognostic indicator for periodontal breakdown. Furthermore, it was found that the rate of development of gingival inflammation in terms of bleeding on probing during experimental gingivitis is more rapid in patients susceptible to periodontal breakdown than in subjects insusceptible to periodontal breakdown. The purpose of the present investigation was to compare the gingival reaction to dental plaque in an experimental gingivitis study in individuals without periodontal breakdown, having either a low or a high bleeding/plaque ratio. A group of 8 volunteers (18-23 years) with a low bleeding/plaque ratio and 7 volunteers (19-22 years) with a high bleeding/plaque ratio were selected. In both groups, an experimental gingivitis study of 23 days duration was carried out. Results showed that individuals with a high bleeding/plaque ratio developed significantly more clinical inflammation in terms of bleeding and swelling of the gingiva than individuals with a low bleeding/plaque ratio. After 23 days of plaque accumulation, gingival biopsies as well as supragingival plaque samples were taken from both groups. Phase-contrast microscopy of the plaque samples showed no significant differences between the 2 groups. Low %s of spirochetes and motile rods were found. Stereologic point-counting procedures showed equal amounts of infiltrated connective tissue in both groups. However, significant differences in composition of the infiltrate appeared to be present. The high ratio group showed more IgA producing plasma cells and complement activation than the low ratio group.(ABSTRACT TRUNCATED AT 250 WORDS)

Experimental gingivitis in relation to susceptibility to periodontal disease. II. Phase-contrast microbiological features and some host-response observations

In the present investigation, a number of histological and immunohistochemical characteristics of periodontal tissues as well as the phase-contrast microscopy of dental plaque were studied after experimentally-induced gingival inflammation in relation to susceptibility to periodontal disease. The study included a younger (mean age 34.1 years) and an older age group (mean age 48 years) with a reduced but healthy periodontium. Both age groups had the same amount of loss of attachment which may suggest that they had different degrees of susceptibility to periodontal disease. At the start of the experiment, each patient was instructed to abstain from oral hygiene in one quadrant of the mouth for a period of 18 days. At the end of the 18-day period, supra-gingival plaque and gingival tissue samples were taken. As determined by phase-contrast microscopy, the plaque samples of both age groups contained relatively high proportions of spirochetes. This may indicate that the patients are at risk for recurrence of periodontal breakdown. The general histopathologic picture of the gingival tissue samples of both age groups was similar to the so-called 'early lesion'. However, IgA-producing plasma cells were found in most tissue samples of both age groups. The first part of this study showed that the younger, in comparison to the older, patients developed inflammation in terms of bleeding on probing more rapidly. These clinical results cannot be explained by the host-parasite parameters investigated in the present study.

Effect of age on healing following periodontal therapy

The present investigation was performed in order to analyze the effect of age on healing of the periodontal tissues following treatment. The patients included in the present analysis consisted of 2 different samples. One group of 62 patients (sample A) was examined and treated between 1980 and 1982. 13 of these subjects were less than 40 years of age, 26 subjects were 40-49 years of age and 23 subjects were greater than 49 years old. The patients were subjected to periodontal surgery using the modified Widman flap procedure. During the active phase of treatment and for the subsequent 6 months of healing, all 62 patients were subjected to professional tooth cleaning. Instruction in proper oral hygiene measures was repeated and scaling was carried out when indicated. Sample B consisted of 21 subjects treated for advanced periodontal disease in 1969. Six of these patients were between 26 and 29 years of age at the start of treatment and 15 were at least 60 years old. The criterion for acceptance for the study in 1969 was that the patient should have lost 50% or more of his/her periodontal tissues. Following an initial examination, all patients were subjected to scaling and root planing and surgical elimination of pathologically deepened pockets. After the termination of active treatment, the patients were placed in a maintenance care program which included recall appointments every 3-6 months. Once a year after the completion of active treatment, all patients in this sample were examined regarding probing depths and clinical attachment levels. The findings from the present retrospective analyses failed to demonstrate that the age of patients with moderately advanced or advanced forms of periodontal tissue breakdown had an influence on the results of periodontal therapy. If anything, the younger patients appeared to heal with a higher frequency of shallow pockets and more gain of probing attachment than older patients.