Therapy-resistant periodontitis (II). Compliance and general and dental health experiences

Clinical outcomes of using erythritol powder by means of air polishing with ultrasonic debridement in the treatment of initial periodontal pockets in hand of dental students: A split-mouth, randomized, comparative, controlled study. Part I

OBJECTIVE

The purpose of this trial was to evaluate the clinical efficacy and patient acceptance of using the erythritol powder air polishing with mechanical debridement in non-surgical periodontal therapy.

METHODS

The trial was conducted as a split-mouth design study of 6 weeks' duration including 13 patients with gingivitis and stage I periodontitis with grade A. Each patient received ultrasonic debridement and polishing (UD+P) on one side, whereas the contralateral side was treated by erythritol powder air polishing and ultrasonic instrumentation (EPAP+UI) when required. Clinical variables were as follows: papillary bleeding index (PBI), bleeding on probing (BOP), full mouth plaque index (FMPI), calculus index (CI), modified gingival index (MGI), probing pocket depth (PPD), the time needed and rate the pain for each group.

RESULTS

The FMPI, MGI, CI, PBL and BOP parameters improved significantly for both treatment procedures; however, there were no statistically significant differences between the two groups at any of the examinations intervals, except for MGI and CI which showed a significant reduction at 2 weeks compared with baseline. PPD was significantly decreased in EPAP+UI group. Perceived pain intensity was lower for EPAP+UI group than UD+P group without any significant difference during follow-up periods between the two groups. Seven patients favoured air polishing. The treatment's time was (24.92 ± 9.260 and 34.08 ± 9.106) minutes for the test and control side, respectively.

CONCLUSION

This study generally revealed no significant differences in clinical outcomes between two groups for gingivitis and stage I periodontitis treatment. However, EPAP+UI had higher patient's preference and less time-consuming compared with UD+P.

Predictive factors for tooth loss during supportive periodontal therapy in patients with severe periodontitis: a Japanese multicenter study

Background

Supportive periodontal therapy (SPT) must take individual patient risk factors into account. We conducted a multicenter joint retrospective cohort study to investigate the value of modified periodontal risk assessment (MPRA) and therapy-resistant periodontitis (TRP) assessment as predictive factors for tooth loss due to periodontal disease in patients with severe periodontitis during SPT.

Methods

The subjects were 82 patients from 11 dental institutions who were diagnosed with severe periodontitis and continued SPT for at least 1 year (mean follow-up = 4.9 years) between 1981 and 2008. The outcome was tooth loss due to periodontal disease during SPT. The Cox proportional hazards model was used to analyze sex, age, diabetes status, smoking history, number of periodontal pockets measuring ≥6 mm, rate of bleeding on probing, bone loss/age ratio, number of teeth lost, MPRA, and TRP assessment as explanatory variables.

Results

Univariate analysis showed that loss of ≥8 teeth by the start of SPT [hazard ratio (HR) 2.86], MPRA score indicating moderate risk (HR 8.73) or high risk (HR 11.04), and TRP assessment as poor responsiveness to treatment (HR 2.79) were significantly associated with tooth loss (p < 0.05). In a model in which the explanatory variables of an association that was statistically significant were added simultaneously, the HR for poor responsiveness to treatment and ≥8 teeth lost was significant at 20.17 compared with patients whose TRP assessment indicated that they responded favorably to treatment and who had lost <8 teeth by the start of SPT.

Conclusion

MPRA and TRP assessment may be useful predictive factors for tooth loss due to periodontal disease during SPT in Japanese patients with severe periodontitis. Additionally, considering the number of teeth lost by the start of SPT in TRP assessment may improve its predictive accuracy.

Clinical and microbiological effects of the supplementary use of an erythritol powder air-polishing device in non-surgical periodontal therapy: a randomized clinical trial

Purpose

This study was undertaken to evaluate the clinical and microbiological effects of an erythritol powder air-polishing device (EPAP) as a supplement to scaling and root planing (SRP) therapy in patients with moderate chronic periodontitis.

Methods

Clinical and microbiological evaluations were performed at 21 sites treated with SRP (control) and 21 sites treated with SRP+EPAP (test). All examinations were performed before treatment, 1 month after treatment, and 3 months after treatment.

Results

There were no significant clinical differences between the test group and the control group. Microbiological analysis revealed that the relative expression level of Porphyromonas gingivalis was significantly lower in the test group than in the control group at 1 month after treatment. Clinical and microbiological results showed improvements at 1 month compared to baseline; in contrast, the results at 3 months after treatment were worse than those at 1 month after treatment.

Conclusions

In this study, both SRP and SRP+EPAP were clinically and microbiologically effective as non-surgical periodontal treatments. In particular, the SRP+EPAP group showed an antimicrobial effect on P. gingivalis, a keystone bacterium associated with the onset of chronic periodontitis, in a short-term period. Periodic periodontal therapy, at intervals of at least every 3 months, is important for sustaining the microbiological effects of this treatment.

Site-level progression of periodontal disease during a follow-up period

Periodontal disease is assessed and its progression is determined via observations on a site-by-site basis. Periodontal data are complex and structured in multiple levels; thus, applying a summary statistical approach (i.e., the mean) for site-level evaluations results in loss of information. Previous studies have shown the availability of mixed effects modeling. However, clinically beneficial information on the progression of periodontal disease during the follow-up period is not available.

We conducted a multicenter prospective cohort study. Using mixed effects modeling, we analyzed 18,834 sites distributed on 3,139 teeth in 124 patients, and data were collected 5 times over a 24-month follow-up period. The change in the clinical attachment level (CAL) was used as the outcome variable. The CAL at baseline was an important determinant of the CAL changes, which varied widely according to the tooth surface. The salivary levels of periodontal pathogens, such as Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans, were affected by CAL progression. “Linear”- and “burst”-type patterns of CAL progression occurred simultaneously within the same patient. More than half of the teeth that presented burst-type progression sites also presented linear-type progression sites, and most of the progressions were of the linear type. Maxillary premolars and anterior teeth tended to show burst-type progression. The parameters identified in this study may guide practitioners in determining the type and extent of treatment needed at the site and patient levels. In addition, these results show that prior hypotheses concerning "burst" and "linear" theories are not valid.

Impact of Yoga on Periodontal Disease and Stress Management

Background

Yoga is considered to be one of the most important, effective, and valuable tools available for man to overcome various physical and psychological problems. Stress contributes significantly to the pathogenesis of periodontal diseases; hence, it becomes important to reduce the level of stress for prevention and management of diseases.

Aims and Objectives

The present study was aimed: (1) To understand and analyze the possibilities of employing yogic practices in the treatment of periodontal disease along with conventional dental therapy, (2) to understand the effect of stress on periodontal treatment outcome, (3) to evaluate the efficacy of yoga in the management of periodontal disease with reference to stress.

Materials and Methods

An outpatient department-based parallel group randomized study was performed with standard treatment for periodontal disease yoga therapy as Group II and only standard treatment as Group I. Periodontal health status was recorded using indices of modified plaque index (PI), bleeding on probing (BOP), probing depth, and clinical attachment loss (CAL). The Cohen's perceived stress questionnaire was also used to determine stress severity. The yogic intervention consists of lectures and practical sessions on asanas, pranayama, kriyas, and meditation.

Results

Repeated measure analysis of variance revealed a significant difference (P < 0.001) in all the outcome variables with respect to time in both groups. It was observed that mean PI score reduced by 1.35 in Group II as compared to 0.54 in Group I, mean probing pocket depth reduced by 1.60 in Group II as compared to only 0.68 in Group I, and mean CAL score reduced by 1.60 in Group II as compared to 0.68 in Group I. Similarly, Cohen's perceived stress scale score also reduced by 18.76 points in Group II as compared to only 2.58 points in Group I, BOP also shows better improvement in Group II with a reduction of 0.68 as compared to reduction of only 0.08 in Group I. The results obtained ascertained the role of yoga in stress reduction in periodontal disease.

Conclusion

Although yoga does not play a direct role in improving periodontal disease, it accelerates the treatment outcomes by combating the stress which is a major factor affecting the treatment of periodontal disease.

Approximal plaque and gingival sulcus bleeding in routine dental care patients: relations to life stress, somatization and depression

OBJECTIVES

Previous research on relations between life stress and periodontal conditions was often based on indicators of periodontal destruction history and stimulus-specific measures of life stress. The present study was undertaken to compare patients showing different degrees of gingival sulcus bleeding with patients without signs of bleeding, using an instrument measuring cognitive impacts of events and assessing reported symptoms of depression and somatization. Additionally the patient groups were compared with regard to dental status and dental visiting behaviour. Analog comparisons were conducted in patients with different degrees of approximal plaque.

MATERIALS AND METHODS

140 routine dental care patients attending a private dental practice were examined. Measurement devices were the sulcus bleeding index (SBI), the approximal plaque index (API), the Dental Avoidance Scale, the Life Experience Survey (LES), the Impact of Event Scale with the subtests cognitive intrusion and cognitive avoidance, and the SCL-90-R subscales somatization and depression.

RESULTS

Patients with high API scores differed from their zero-score counterparts in dental avoidance and time since last visit only. By contrast, subjects scoring high in the SBI not only had more missing teeth and reported more dental avoidance than their zero-score counterparts but also had elevated scores in intrusive and avoidant thoughts related to a stressful event as well as in symptoms of somatization and depression. No difference was found for the measure of stimulus specific recent life events (LES).

CONCLUSIONS

The results suggest that cognitive preoccupation with adverse events and the presence of somatization and depression symptoms might play a role in gingival inflammation.

Effect of Restraint Stress on the Progression of Experimental Periodontitis in Rats

BACKGROUND

A hypothesis of an increased risk for destructive periodontal diseases due to psychological stress has long been promoted. However, the research on stress and periodontal disease is still in its infancy. One of the reasons is thought to be that there is no suitable animal model for investigating the relationship.

METHODS

One hundred male Wistar rats were included. A nylon ligature was placed around the second right maxillary molars. The animals were then divided into group S, exposed to a restraint stress for 12 hours/day for up to 10 days, and group N, controls. Ten animals were sacrificed on days 2, 4, 6, 8, and 10. Blood samples were taken, and the blood glucose level and the concentrations of adrenocorticotropic hormone, corticosterone, and adrenaline were measured as the markers of stress. The atrophies of the thymus and the spleen were measured. The furcation area of the second maxillary molars was examined histologically and histometrically.

RESULTS

In group S, all values of stress markers were increased, and the thymus and the spleen were atrophied. Whereas group N showed only slight alveolar bone resorption, a marked alveolar bone resorption occurred in group S between days 8 and 10. An increase in beaded nerve terminals occurred around the vessels in the furcation area of group S.

CONCLUSION

The results of the present study suggest that the restraint stress modulates the progression of periodontal inflammation and that this rat model is suitable for investigating the association between stress and periodontal disease.

Presence of cortisol in gingival crevicular fluid. A pilot study

Cortisol is one of the primary mediators of the stress response, in the main having immunosuppressive effects. An important component of the host response in periodontal inflammation is gingival crevicular fluid (GCF), with constituents mainly derived from serum. Cortisol, like many other steroids, is present in saliva but its occurrence in GCF does not seem to be documented. Unstimulated whole saliva was collected and GCF was sampled on filter disks. The samples were analysed by a modified RIA method for serum in such a way that small volumes and low concentrations could be measured. Our findings suggest that the total concentration of cortisol in GCF might be estimated to levels below 1/10 of that in serum. However, what appears as a distinctive feature is the considerable variation of the cortisol concentrations for individual teeth. To our knowledge, this is the first time cortisol has been measured in gingival crevicular fluid, and this opens the prospects for further in vivo research.

Oral hygiene and gingivitis in a Swedish adult population 1973, 1983 and 1993

The periodontal condition of the inhabitants of Jönköping County, Sweden was followed for 20 years by means of 3 cross-sectional investigations performed in 1973, 1983, and 1993. The study comprised individuals in the age groups 20, 30, 40, 50, 60, and 70 years. The number of dentate individuals was 537 in 1973, 550 in 1983, and 552 in 1993. All individuals participating in the studies were examined clinically and radiographically. They also filled out a questionnaire about dental care habits, socio-economic status, and general health. A clear reduction in the plaque score was seen between 1973 and 1983 in all age groups. With one exception, no further significant change in plaque levels was found between 1983 and 1993: the increase in plaque among the 20-year-olds was significant. In 1993 the mean % of surfaces with plaque was between 30% and 40% in all age groups. Gingivitis values corresponded well with the values of dental plaque; the same pattern with a clear reduction in gingivitis score was seen in all age groups between 1973 and 1983, and an increase in the mean frequency of gingival inflammation between 1983 and 1993 was seen in the 20-year age group. 30% of the individuals in this age group had more than 50% gingivitis in 1993 compared with 9% of the individuals in 1983. The 20-year-olds were further analyzed in a linear regression model using gingivitis as a dependent variable against some socio-economic, general health, and dental care variables associated with poor oral hygiene and gingivitis. In 1993, the most important explanatory variable was gender: significantly more males than females had higher gingivitis scores. The second most important explanatory variable was toothbrushing habits. Together they explained 10.9% of the variance. The multivariate analysis did not reveal approximal cleaning habits to be significant, probably due to their strong connection to gender and toothbrushing habits. In the 1983 sample, no significant explanatory variables were found. It was concluded from this data that it is important not only to renew but also to direct preventive guidelines more towards young adults who have no previous extensive experience of oral disease so that they will not be excluded from dental care and their dental health thereby jeopardised. In addition to preventive programmes aimed at the population as a whole, individual programmes based on risk targeting are also necessary to reduce the number of people developing dental disease and to increase the quality of dental care.

Therapy-resistant periodontitis. Psychosocial characteristics

This study investigated the perspective of a stress system disorder in the pathogenesis of therapy-resistant periodontitis. The goal was to find indications that the stress-behaviour-immune system model holds as an explanatory model for the understanding of periodontal disease. 2 patient-groups were compared: one group classified as responding well to periodontal treatment (responsive-group, R-group, n=11); the other group was classified as responding less well to treatment (non-responsive-group, NR-group, n=11). Somatic and psychological factors were described as obtained by interviews and psychological testings. These findings were related to clinical data documented during the treatment of the patients. An exact logistic multivariate regression analysis was performed on a model based on variables selected by bivariate analysis (variable versus group). The results indicated that the NR-group patients displayed indications of more psychosocial strain and a more passive-dependent personality. The R-group patients displayed a more rigid personality and possibly a less stressful psychosocial situation in the past. The report highlights the possible contribution of stress factors in the context of therapy resistant periodontal disease, and the results seem to be understandable within the context of a stress system disorder perspective.