The clinical course of chronic periodontitis. IV. Gingival inflammation as a risk factor in tooth mortality

Non-surgical retreatment versus papillary preservation flap surgery for residual pockets: A randomized controlled trial with clinical and patient-reported outcomes

AIM

To compare the efficacy of non-surgical re-instrumentation (NSR) and papillary preservation flap (PPF) surgery at single-rooted teeth with residual pockets.

MATERIALS AND METHODS

Patients with at least a residual pocket depth (PD ≥ 5 mm) after Steps I and II were enrolled and randomly assigned to receive NSR or PPF surgery. The primary outcome was PD reduction, and secondary outcomes were clinical attachment level (CAL) change and patient-reported outcome measures (PROMs). Outcome variables were measured at baseline, 3 and 6 months. The examiner was blinded. Statistical analysis, one site for each patient, included descriptive statistics and analysis of covariance.

RESULTS

Forty-six participants were enrolled, and one patient dropped out in the PPF group. After 6 months, both treatments resulted in significant PD reduction (1.3 ± 1.2 mm, p = .009 NSR; 2.0 ± 0.7 mm, p < .001 PPF) and CAL gain (1.0 ± 2.4 mm, p = .031 NSR; 1.4 ± 0.8 mm, p < .001 PPF). PD reduction between groups was not statistically significant (diff: 0.6 mm; 95% confidence interval [CI] [-0.3 to 1.5]; p = .167). Pocket closure was 61% NSR versus 86% PPF (p = .091). Smoking was associated with less PD reduction of almost 1 mm in both treatments. Treatment time was longer for PPF surgery, but PROMs and post-operative pain were similar between groups.

CONCLUSIONS

Both NSR and PPF reduced PD without significant difference between treatments at 6 months. PPF surgery may offer faster PD reduction, but smoking habits reduce treatment efficacy.

Fracture resistance, marginal and internal adaptation of innovative 3D-printed graded structure crown using a 3D jet printing technology

PURPOSE

This in vitro study aimed to create a graded structured dental crown using 3D printing technology and investigate the fracture resistance and the adaptation of this new design.

MATERIALS AND METHODS

A dental crown with a uniform thickness of 1.5 mm was designed, and the exported stereolithography file (STL) was used to manufacture 30 crowns in three groups (n = 10), solid (SC), bilayer (BL), and multilayer (ML) crowns using  3D jet printing technology. Marginal and internal gaps were measured using the silicone replica technique. Crowns were then luted to a resin die using a temporary luting agent and the fracture resistance was measured using a universal testing machine. One-way ANOVA and Tukey post hoc tests were used to compare the fracture resistance and the adaptation of crowns at a significance level of 0.05.

RESULTS

Mean marginal and internal gap of the ML group were 80 and 82 mm, respectively; which were significantly (p < 0.05) smaller than BL (203 and 183 mm) and SC (318 and 221 mm) groups. The SC group showed the highest mean load at fracture (2330 N) which was significantly (p < 0.05) higher than the BL (1716 N) and ML (1516 N) groups.

CONCLUSION

3D jet printing technology provides an opportunity to manufacture crowns in a graded structure with various mechanical properties. This study provided an example of graded structured crowns and presented their fracture resistance. SC group had the highest fracture resistance; however, ML had the best marginal and internal adaptation.

Auxiliary Diagnosis of Dental Calculus Based on Deep Learning and Image Enhancement by Bitewing Radiographs

In the field of dentistry, the presence of dental calculus is a commonly encountered issue. If not addressed promptly, it has the potential to lead to gum inflammation and eventual tooth loss. Bitewing (BW) images play a crucial role by providing a comprehensive visual representation of the tooth structure, allowing dentists to examine hard-to-reach areas with precision during clinical assessments. This visual aid significantly aids in the early detection of calculus, facilitating timely interventions and improving overall outcomes for patients. This study introduces a system designed for the detection of dental calculus in BW images, leveraging the power of YOLOv8 to identify individual teeth accurately. This system boasts an impressive precision rate of 97.48%, a recall (sensitivity) of 96.81%, and a specificity rate of 98.25%. Furthermore, this study introduces a novel approach to enhancing interdental edges through an advanced image-enhancement algorithm. This algorithm combines the use of a median filter and bilateral filter to refine the accuracy of convolutional neural networks in classifying dental calculus. Before image enhancement, the accuracy achieved using GoogLeNet stands at 75.00%, which significantly improves to 96.11% post-enhancement. These results hold the potential for streamlining dental consultations, enhancing the overall efficiency of dental services.

Relationship between 1-, 3-, and 6-Month Gingival Bleeding Outcomes

INTRODUCTION

Results from systematic reviews and meta-analyses show generally consistent antigingivitis effects between 3- and 6-mo observation time points with twice-daily use of stannous fluoride (SnF2) dentifrice. However, the relationship between 1-, 3-, and 6-mo gingivitis responses has not been investigated.

METHODS

This pooled analysis was conducted to understand the relationship of 1-, 3-, and 6-mo gingival bleeding outcomes. Number of bleeding sites, derived from Löe-Silness Gingival Index (LSGI) or Gingival Bleeding Index, was identified as the primary end point of the analysis for the biological and clinical relevance. Randomized, double-blinded, controlled clinical studies meeting the following predefined selection criteria were identified: 1) published and unpublished gingivitis clinical trials conducted from 1995 to 2022 comparing efficacy of 0.454% SnF2 dentifrices to negative controls (sodium fluoride or sodium monofluorophosphate dentifrice) and 2) studies with a 3-mo assessment and at least a 1- or 6-mo assessment.

RESULTS

The search resulted in ten 6-mo and fourteen 3-mo studies meeting selection criteria. A mixed-effects model was performed on the pooled data to assess gingival bleeding outcomes across time. The bleeding efficacy significantly increased between months 1 and 3 (P < 0.0001) and plateaued between months 3 and 6 (P = 0.007), supporting the fact that bleeding reduction relative to control established by 1 mo will increase and be maintained through 3 and 6 mo (R2 = 0.857). In addition, gingival bleeding and gingivitis efficacy, as measured by LSGI, were found to be highly correlated (R2 = 0.874).

CONCLUSION

A clear relationship has been demonstrated between 1-, 3-, and 6-mo gingival bleeding outcomes in gingivitis clinical studies comparing SnF2 dentifrice to negative control dentifrice. These findings have important implications to the dental practice and scientific research as antigingivitis efficacy evaluations can be observed as early as 1 mo and are consistent with those seen at 3 or 6 mo.

KNOWLEDGE TRANSFER STATEMENT

Outcomes from this investigation indicate that the clinical evaluation of antigingivitis efficacy at 1 mo is predictive of that at 3 and 6 mo, supporting studies of 1-mo duration as a viable method of knowledge acquisition. This more efficient, expedited research design has positive implications for patient care, clinical practice guidelines, protocols, and policies.

The effect of a multicomponent oral care regimen on gingival inflammation: A randomized controlled clinical trial

BACKGROUND

Oral care regimens can be explored to improve oral health in patients with gingivitis. This study aimed to evaluate the efficacy of a multicomponent oral care regimen with a dual zinc plus arginine (DZA) toothpaste and cetylpyridinium chloride with zinc lactate (CPC + Zn) mouthwash in reducing gingival bleeding in patients with gingivitis.

METHODS

This randomized clinical trial included 94 participants with gingivitis who were randomized into two groups: the DZA/CPC + Zn group, which used a 1450-ppm fluoride toothpaste containing 0.96% zinc plus 1.5% arginine and a fluoride-containing mouthwash with 0.075% CPC and 0.28% zinc lactate, and the control group, which used a 1450-ppm fluoride toothpaste and a placebo mouthwash for 6 months. All participants were examined by a blinded examiner who measured the gingival index, plaque index, and gingival severity index. Data were analyzed using paired t test, independent t test, and analysis of covariance (ANCOVA).

RESULTS

Both groups presented statistically significant reductions in all clinical parameters compared to baseline. The DZA/CPC + Zn group exhibited significantly greater reductions in gingival index, gingival severity index, proximal gingival index, plaque index and proximal plaque index compared to the control group at 1, 3, and 6 months. Furthermore, DZA/CPC + Zn significantly decreased the percentage of patients with generalized gingivitis over a 6-month follow-up period. However, differences between the DZA/CPC + Zn and the control groups were not maintained after both groups established similar regimens with fluoride toothpaste.

CONCLUSION

The multicomponent oral care regimen consisting of DZA toothpaste and CPC + Zn mouthwash is effective in reducing gingival inflammation and supragingival biofilm in patients with gingivitis.

Natural history of periodontal disease: The original Sri Lanka and Oslo studies

Susceptibility to periodontal disease depends on individual factors within the host response to the bacterial challenge. The study of these factors requires longitudinal studies of an undisturbed development of the disease process. On the basis of the original longitudinal studies on the natural histology of periodontal disease staged in Sri Lanka and Oslo/Norway, several analyses of periodontal parameters and tooth status have been performed. The main findings were that in the first 20 years of complete absence of oral hygiene practices or preventive services attachment was lost at various rates. Three groups of subjects could be identified: rapidly progressing (RP) (8%), moderately progressing (MP) (81%), and subjects with no disease progression (NP) (11%). In the second two decades, the RP subjects have lost most of their teeth and no NP patients were identified anymore. The progression rate in these two decades was much slower, and the tooth mortality decreased. It could be predicted that subjects who had lost more than 2 mm at age 30 would not maintain a functional dentition at age 60. The corresponding control population in Oslo was used to study the influence of gingival inflammation on the initiation and progression of periodontal disease. The pattern and rates of attachment loss were identified in a population that was exposed to optimal and regular preventive services from age 3 onward. In the observation period of 26 years, it could be demonstrated that gingival inflammation varied little throughout adult life and always bleeding sites occurred consistently in 10% to 20%. The role of ongoing gingivitis in the pathogenesis of attachment loss was identified and also reflected stability whenever it was absent. Tooth mortality was only found in subjects with ongoing gingivitis. After 50 years of tooth age, 63% of the teeth were still maintained, while 99.8% were maintained after 50 years when gingival inflammation had been absent. Consequently, continuous gingivitis represented a risk factor for tooth loss.

Identification of a new genetic variant (G231N, E232T, N235D) of peptidylarginine deiminase from P. gingivalis in advanced periodontitis

Chronic periodontitis (CP), an inflammatory disease of periodontal tissues driven by a dysbiotic subgingival bacterial biofilm, is also associated with several systemic diseases, including rheumatoid arthritis (RA). Porphyromonas gingivalis, one of the bacterial species implicated in CP as a keystone pathogen produces peptidyl arginine deiminase (PPAD) that citrullinates C-terminal arginine residues in proteins and peptides. Autoimmunity to citrullinated epitopes is crucial in RA, hence PPAD activity is considered a possible mechanistic link between CP and RA. Here we determined the PPAD enzymatic activity produced by clinical isolates of P. gingivalis, sequenced the ppad gene, and correlated the results with clinical determinants of CP in patients from whom the bacteria were isolated. The analysis revealed variations in PPAD activity and genetic diversity of the ppad gene in clinical P. gingivalis isolates. Interestingly, the severity of CP was correlated with a higher level of PPAD activity that was associated with the presence of a triple mutation (G231N, E232T, N235D) in PPAD in comparison to W83 and ATCC 33277 type strains. The relation between mutations and enhanced activity was verified by directed mutagenesis which showed that all three amino acid residue substitutions must be introduced into PPAD expressed by the type strains to obtain the super-active enzyme. Cumulatively, these results may lead to the development of novel prognostic tools to assess the progress of CP in the context of associated RA by analyzing the ppad genotype in CP patients infected with P. gingivalis.

Clinical parameters and inflammatory biomarkers among patients with multibracket appliances: a prospective clinical trial

BACKGROUND

Aim of the presented study was to investigate changes in clinical parameters and active matrix metalloproteinase-8 (aMMP-8) levels in gingival crevicular fluid of patients before and during treatment with multibrackets appliances.

METHODS

Fifty-five adolescents scheduled for the treatment were included. Clinical parameters and subgingival samples were obtained at six time points: 1 week before appliance insertion (T0), 3 (T1), 6 (T2) weeks, 3 (T3), 6 (T4) months, and 1 year (T5) after that. Gingival index and plaque index were assessed to evaluated changes on the clinical status. Subgingival samples were collected to analyze changes in aMMP-8.

RESULTS

Scores for gingival and plaque index increased after bracket insertion. The gingival index increased from T2 (p < 0.05) until T5 (p < 0.0001). Plaque index also increased, reaching its maximum peak at T3 (p < 0.05). Moreover, an increase of aMMP-8 levels (p < 0.05) was noted. There was no significant between upper and lower jaws.

CONCLUSIONS

Treatment with multibracket appliances in adolescents favors dental plaque accumulation and may transitionally increase gingival and plaque index and aMMP-8 levels leading to gingival inflammation, even 1 year after therapy began.

TRIAL REGISTRATION

This study was approved by the Ethics Committee of the dental medical association Rheiland-Pfalz, Germany (process no. 837.340.12 (8441-F)), and followed the guidelines of Good Clinical Practices.

An evaluation of 910 premolars transplanted in the anterior region-A retrospective analysis of survival, success, and complications

AIM

The aim this retrospective analysis was to evaluate the survival, success and possible complications of transplanted premolars to the anterior region subdivided in development stage and patient's age.

MATERIALS AND METHODS

The material comprised patients that underwent a tooth transplantation between April 2004 and December 2021. A total of 910 premolars were transplanted in 707 patients. Tooth mobility, oral hygiene, and periodontal parameters were clinically evaluated. Standardized radiographs were used to evaluate pulpal and periodontal healing and root formation. The cumulative survival rate was calculated using the Kaplan-Meier method.

RESULTS

The data were subdivided in three groups based on the stage of root development and patient's age. The average age at surgery was 16 years. The main indication for transplantation was trauma, followed by agenesis and other indications. Two premolars were lost during the whole observation period. The overall survival and success in the immature premolars group after an observation period of 10 years was 99.8%. The 10-year survival and success rate when fully developed premolars were transplanted in the anterior region in adolescents were 100% and 96.3%, respectively. In adults, the 10-year survival and success rate were 87.5%.

CONCLUSION

Transplantation of premolars with developing and fully developed roots to the anterior region in children, adolescents, and adults is a predictable treatment modality.

Neutrophils' Contribution to Periodontitis and Periodontitis-Associated Cardiovascular Diseases

Neutrophils represent the primary defense against microbial threats playing a pivotal role in maintaining tissue homeostasis. This review examines the multifaceted involvement of neutrophils in periodontitis, a chronic inflammatory condition affecting the supporting structures of teeth summarizing the contribution of neutrophil dysfunction in periodontitis and periodontal-related comorbidities. Periodontitis, a pathological condition promoted by dysbiosis of the oral microbiota, is characterized by the chronic inflammation of the gingiva and subsequent tissue destruction. Neutrophils are among the first immune cells recruited to the site of infection, releasing antimicrobial peptides, enzymes, and reactive oxygen species to eliminate pathogens. The persistent inflammatory state in periodontitis can lead to aberrant neutrophil activation and a sustained release of proinflammatory mediators, finally resulting in tissue damage, bone resorption, and disease progression. Growing evidence now points to the correlation between periodontitis and systemic comorbidities. Indeed, the release of inflammatory mediators, immune complexes, and oxidative stress by neutrophils, bridge the gap between local and systemic immunity, thus highlighting neutrophils as key players in linking periodontal inflammation to chronic conditions, including cardiovascular diseases, diabetes mellitus, and rheumatoid arthritis. This review underscores the crucial role of neutrophils in the pathogenesis of periodontitis and the complex link between neutrophil dysfunction, local inflammation, and systemic comorbidities. A comprehensive understanding of neutrophil contribution to periodontitis development and their impact on periodontal comorbidities holds significant implications for the management of oral health. Furthermore, it highlights the need for the development of novel approaches aimed at limiting the persistent recruitment and activation of neutrophils, also reducing the impact of periodontal inflammation on broader health contexts, offering promising avenues for improved disease management and patient care.

Developing Automated Computer Algorithms to Track Periodontal Disease Change from Longitudinal Electronic Dental Records

OBJECTIVE

To develop two automated computer algorithms to extract information from clinical notes, and to generate three cohorts of patients (disease improvement, disease progression, and no disease change) to track periodontal disease (PD) change over time using longitudinal electronic dental records (EDR).

METHODS

We conducted a retrospective study of 28,908 patients who received a comprehensive oral evaluation between 1 January 2009, and 31 December 2014, at Indiana University School of Dentistry (IUSD) clinics. We utilized various Python libraries, such as Pandas, TensorFlow, and PyTorch, and a natural language tool kit to develop and test computer algorithms. We tested the performance through a manual review process by generating a confusion matrix. We calculated precision, recall, sensitivity, specificity, and accuracy to evaluate the performances of the algorithms. Finally, we evaluated the density of longitudinal EDR data for the following follow-up times: (1) None; (2) Up to 5 years; (3) > 5 and ≤ 10 years; and (4) >10 and ≤ 15 years.

RESULTS

Thirty-four percent (n = 9954) of the study cohort had up to five years of follow-up visits, with an average of 2.78 visits with periodontal charting information. For clinician-documented diagnoses from clinical notes, 42% of patients (n = 5562) had at least two PD diagnoses to determine their disease change. In this cohort, with clinician-documented diagnoses, 72% percent of patients (n = 3919) did not have a disease status change between their first and last visits, 669 (13%) patients' disease status progressed, and 589 (11%) patients' disease improved.

CONCLUSIONS

This study demonstrated the feasibility of utilizing longitudinal EDR data to track disease changes over 15 years during the observation study period. We provided detailed steps and computer algorithms to clean and preprocess the EDR data and generated three cohorts of patients. This information can now be utilized for studying clinical courses using artificial intelligence and machine learning methods.

Clinical and microbiological effects of a single application of sodium hypochlorite gel during subgingival re-instrumentation: a triple-blind randomized placebo-controlled clinical trial

OBJECTIVES

The aim of this study is to assess the clinical and microbiological effects of a single subgingival administration of sodium hypochlorite gel (NaOCl) and compare it with 1% chlorhexidine (CHX) gel and a placebo gel following mechanical re-instrumentation during supportive periodontal therapy (SPT).

MATERIALS AND METHODS

Sixty-two patients who had been treated for stage III-IV periodontitis and enrolled in SPT were included in the study based on following criteria: (1) active periodontal therapy completed at least 6 months before enrollment in the study, (2) presence of at least 4 non-adjacent sites with probing pocket depths (PPDs) ≥ 4 mm with bleeding on probing (BOP), or presence of 5-8 mm PPDs with or without BOP. All sites presenting PPD ≥ 4 mm and BOP at baseline and 3-, 6-, and 9-month follow-up timepoints were subgingivally re-instrumented with ultrasounds. Selected patients were randomly assigned into three groups and treated additionally with a single subgingival administration of NaOCl gel (group A); 1% CHX gel (group B); and placebo gel (group C). Main outcome variable was pocket closure at 12 months. Secondary outcome variables were changes in mean PPD, BOP, and clinical attachment level (CAL) along with changes in the numbers of the following five keystone bacterial pathogens: Aggregatibacter actinomycetemcomitans (A.a.), Porphyromonas gingivalis (P.g.), Prevotella intermedia (P.i.), Tannerella forsythia (T.f.), and Treponema denticola (T.d.).

RESULTS

At 12 months, pocket closure was obtained in 77.5% in the NaOCl treated sites. The reduction in PPD was higher with CHX than with NaOCl, although a statistically significant adjunctive effect for NaOCl (P = 0.028) was only observed in comparison with placebo only. Mean CAL improved in all groups and at all timepoints, compared to the baseline (P < 0.05). However, after 6 months, CAL gain was statistically significantly higher in the NaOCl treated group than following application of CHX (P = 0.0026).

CONCLUSION

In SPT patients, a single adjunctive use of a NaOCl gel may provide benefits in controlling inflammation and residual pockets.

TRIAL REGISTRATION

ISRCTN Registry of Clinical Trials (ISRCTN11387188).

CLINICAL RELEVANCE

A baseline single application of NaOCl gel in conjunction with mechanical debridement may achieve substantial pocket closure in patients enrolled in SPT; treatment time, cost, and applicability considerations should be taken into account when selecting this therapy.

Treatment of gingivitis is associated with reduction of systemic inflammation and improvement of oral health-related quality of life: A randomized clinical trial

AIM

To compare the level of inflammatory markers, oral health-related quality of life (OHRQoL) and gingival parameters 1 month after introduction of electric toothbrush and intensive oral hygiene maneuvers adaptation (OHI) versus routine habits (no-OHI) in patients affected by generalized gingivitis.

METHODS

140 subjects with generalized gingivitis were randomized to receive either OHI or no-OHI. Full-mouth plaque/bleeding scores (FMPS/FMBS), serum high-sensitivity C-reactive protein (hs-CRP), interleukin-6- (IL-6) and an Oral health impact profile-14 questionnaire (OHIP-14) were collected at baseline and at 1-month follow-up visit.

RESULTS

In the OHI, a significant FMPS and FMPBS reduction (p<0.01), a significant intragroup decrease in hs-CRP and IL-6 (p<0.01) and a significant improvement of OHRQoL (p<0.01) was noted at 1-month. In the no-OHI, lower-magnitude differences were noted only for oral parameters. Resolution of gingivitis varied between OHI and no-OHI (89% versus 7% respectively, p<0.01). A Logistic multivariate regression suggested that FMBS ≤8% was associated with odds ratio of 13 of having both CRP and IL-6 below the selected threshold for healthy young adults (p=0.04).

CONCLUSIONS

Gingivitis resolution determined important reductions of gingival inflammation and plaque levels, as well as systemic inflammatory markers and an improvement of quality of life (NCT03848351).

Association of periodontitis, missing teeth, and oral hygiene behaviors with the incidence of hypertension in middle-aged and older adults in Korea: A 10-year follow-up study

BACKGROUND

The relationship between periodontitis and hypertension remains controversial. This study aimed to investigate the association of periodontitis, missing teeth, and oral hygiene behaviors with the incidence of hypertension.

METHODS

A total of 104,349 participants were selected from the National Health Insurance System-Health Screening cohort. Incident hypertension and periodontitis were diagnosed based on the patients' clinical records and health examinations. A multivariable Cox proportional hazards regression analysis was performed after adjusting for socioeconomic factors, coexisting disease, and health behaviors.

RESULTS

The mean age of the participants was 51.1 years (range, 40-79 years) at baseline, and 55.1% were men. A total of 52,855 incident hypertension cases were identified during the median follow-up period of 9.6 years. Among the participants, periodontitis (hazard ratio [HR]: 1.02, 95% confidence interval [95% CI]: 1.00-1.04), number of missing teeth (for ≥15 group, HR: 1.40, 95% CI: 1.29-1.52), dental scaling (HR: 0.93, 95% CI: 0.91-0.95), and tooth brushing frequency (for ≥3 group, HR: 0.85, 95% CI: 0.83-0.88) were significantly associated with incident hypertension after full adjustments for covariates. While periodontitis was significantly associated with incident hypertension (HR: 1.04, 95% CI: 1.02-1.06) in the middle-aged group (40-64 years), the effect was insignificant in the older group (≥65 years).

CONCLUSION

Oral inflammation could contribute to the incidence of hypertension; thus, efforts to reduce oral inflammation should be encouraged. Future intervention studies are warranted to determine whether oral health care could be beneficial in the management of hypertension. This article is protected by copyright. All rights reserved.

Recent Development of Active Ingredients in Mouthwashes and Toothpastes for Periodontal Diseases

Periodontal diseases like gingivitis and periodontitis are primarily caused by dental plaque. Several antiplaque and anti-microbial agents have been successfully incorporated into toothpastes and mouthwashes to control plaque biofilms and to prevent and treat gingivitis and periodontitis. The aim of this article was to review recent developments in the antiplaque, anti-gingivitis, and anti-periodontitis properties of some common compounds in toothpastes and mouthwashes by evaluating basic and clinical studies, especially the ones published in the past five years. The common active ingredients in toothpastes and mouthwashes included in this review are chlorhexidine, cetylpyridinium chloride, sodium fluoride, stannous fluoride, stannous chloride, zinc oxide, zinc chloride, and two herbs—licorice and curcumin. We believe this comprehensive review will provide useful up-to-date information for dental care professionals and the general public regarding the major oral care products on the market that are in daily use.

Endpoints of active periodontal therapy

Aim

Position paper on endpoints of active periodontal therapy for designing treatment guidelines. The question was as follows: How are, for an individual patient, commonly applied periodontal probing measures—recorded after active periodontal therapy—related to (a) stability of clinical attachment level, (b) tooth survival, (c) need for re‐treatment or (d) oral health‐related quality of life.

Methods

A literature search was conducted in Ovid MEDLINE(R) and Epub Ahead of Print, In‐Process & Other Non‐Indexed Citations and Daily <1946 to 07 June 2019>.

Results

A total of 94 papers were retrieved. From the literature search, it was found that periodontitis patients with a low proportion of deep residual pockets after active periodontal therapy are more likely to have stability of clinical attachment level over a follow‐up time of ≥1 year. Other supporting literature confirms this finding and additionally reports, at the patient level, that probing pocket depths ≥6 mm and bleeding on probing scores ≥30% are risks for tooth loss. There is lack of evidence that periodontal probing measures after completion of active periodontal treatment are tangible to the patient.

Conclusions

Based on literature and biological plausibility, it is reasonable to state that periodontitis patients with a low proportion of residual periodontal pockets and little inflammation are more likely to have stability of clinical attachment levels and less tooth loss over time. Guidelines for periodontal therapy should take into consideration (a) long‐term tangible patient outcomes, (b) that shallow pockets (≤4 mm) without bleeding on probing in patients with <30% bleeding sites are the best guarantee for the patient for stability of his/her periodontal attachment, (c) patient heterogeneity and patient changes in immune response over time, and (d) that treatment strategies include lifestyle changes of the patient. Long‐term large population‐based and practice‐based studies on the efficacy of periodontal therapies including both clinical and patient‐reported outcomes (PROs) need to be initiated, which include the understanding that periodontitis is a complex disease with variation of inflammatory responses due to environment, (epi)genetics, lifestyle and ageing. Involving people living with periodontitis as co‐researchers in the design of these studies would also help to improve their relevance.

Polyamine biomarkers as indicators of human disease

The significant increase of periodontitis, chronic kidney disease (CKD), Alzheimer's disease and cancer can be attributed to an ageing population. Each disease produces a range of biomarkers that can be indicative of disease onset and progression. Biomarkers are defined as cellular (intra/extracellular components and whole cells), biochemical (metabolites, ions and toxins) or molecular (nucleic acids, proteins and lipids) alterations which are measurable in biological media such as human tissues, cells or fluids. An interesting group of biomarkers that merit further investigation are the polyamines. Polyamines are a group of molecules consisting of cadaverine, putrescine, spermine and spermidine and have been implicated in the development of a range of systemic diseases, in part due to their production in periodontitis. Cadaverine and putrescine within the periodontal environment have demonstrated cell signalling interfering abilities, by way of leukocyte migration disruption. The polyamines spermine and spermidine in tumour cells have been shown to inhibit cellular apoptosis, effectively prolonging tumorigenesis and continuation of cancer within the host. Polyamine degradation products such as acrolein have been shown to exacerbate renal damage in CKD patients. Thus, the use of such molecules has merit to be utilized in the early indication of such diseases in patients.

Do periodontal defects affect periodontal inflammation and destruction? Histological/microbiological changes and gene expression profiles of a pilot study in beagle dogs

BACKGROUND

The present study focused on the inflammatory disease progress after periodontal defect induction and aimed to specifically determine periodontal tissue responses following dental plaque accumulation by ligatures on a site with/without standardized periodontal defect induction.

METHODS

After 1 month from extraction of the adjacent teeth, semi-circumferential defects were surgically created in the unilateral second and fourth premolars (test group), whereas no defects were being induced at the contralateral sites (control group). One week later, silk was used to ligate the tooth cervix at both sites to encourage the accumulation of dental plaque. Four weeks later, the tissue samples were collected for histological/histomorphometric and microarray analysis. Microbiological analysis was performed before defect induction and at ligatures, and after 4 weeks of dental plaque accumulation.

RESULTS

Remarkable inflammation was clinically and histologically observed in both groups after plaque accumulation, and the intrabony type of periodontal defect exaggerated inflammatory cell infiltration into the connective tissue layer. Expression of genes related to inflammation such as IL-1 was highly up-regulated in test sites. However, these inflammatory infiltrations did not invade to a boundary of periodontal ligament and connective tissue attachment in both groups, and histomorphometric results corresponds to these observational results. Bacterial findings also showed no significant differences in detected microbiome compositions between control and test groups at three-time points.

CONCLUSION

Intrabony defect might exaggerate the plaque-induced inflammation in the aspect of inflammatory cell infiltration and the related gene expression, but both dental plaque and the pre-existing periodontal defect negligibly disrupt periodontal attachment and the underlying alveolar bone.

Association between Periodontal Disease and Levels of Triglyceride and Total Cholesterol among Korean Adults

Although the correlation between periodontal condition and hyperlipidemia was shown by previous researches, it remains disputed. This study was based on data from the seventh Korea National Health and Nutrition Examination Survey 2016-2018. Data included 14,068 subjects' demographic characteristics, total cholesterol levels, triglyceride levels, and periodontal conditions. We analyzed the correlation between periodontal disease and blood lipid levels using complex-sample chi square tests and complex-sample logistic regression. The results of chi square tests showed a significant difference in demographic characteristics according to total cholesterol level and triglyceride level. The results of logistic regression, adjusted for the subjects' demographic characteristics such as age, gender, house income, marital status, home ownership, number of persons living together, health insurance coverage, and economic activity, showed that prevalence of periodontal disease was 1.048-fold (confidence interval (CI) 0.827-1.133) higher in the high-total-cholesterol group and 1.499-fold (CI 1.576-1.983) higher in high-triglyceride group. We found that not high total cholesterol but high triglyceride level was connected with periodontal disease. Therefore, management of triglyceride level could be a possible precaution of periodontal disease.

Exploring the putative interactions between chronic kidney disease and chronic periodontitis

Chronic kidney disease (CKD) and chronic periodontitis (CP) are both common diseases, which are found disproportionately comorbid with each other and have been reported to have a detrimental effect on the progression of each respective disease. They have an overlap in risk factors and both are a source of systemic inflammation along with a wide selection of immunological and non-specific effects that can affect the body over the lifespan of the conditions. Previous studies have investigated the directionality of the relationship between these two diseases; however, there is a lack of literature that has examined how these diseases may be interacting at the localized and systemic level. This review discusses how oral microorganisms have the ability to translocate and have distal effects and provides evidence for microbial involvement in a systemic disease. Furthermore, it summarizes the reported local and systemic effects of CKD and CP and discusses how the interaction of these effects may be responsible for directionality associations reported.

Non-Surgical Periodontal Therapy - Evidence and Opinion

Effective non-surgical periodontal therapy is fundamental to achieve and maintain periodontal health, particularly in individuals who are susceptible to periodontitis. This article aims to highlight current evidence and published guidance, together with personal insights and suggestions from the author's clinical experience to help with management of patients utilising this common treatment modality.

The effects of bioavailable gluconate chelated stannous fluoride dentifrice on gingival bleeding: Meta-analysis of eighteen randomized controlled trials

AIM

To estimate gingivitis effects of a bioavailable gluconate chelated 0.454% stannous fluoride (SnF2 ) family of dentifrices in adult subjects versus positive (triclosan) and negative (NaF or MFP) controls when used ≤3 months.

MATERIALS AND METHODS

A meta-analysis evaluated bioavailable gluconate chelated SnF2 dentifrices versus a negative or positive control for gingival bleeding.

RESULTS

In 18 randomized controlled trials (RCTs) with 2,890 subjects assessing SnF2 paste versus a negative or positive control, the average number of bleeding sites was reduced by 51% and 31%, respectively. The average change (95% CI) in number of bleeding sites was -16.3 (-27.8, -4.9) versus the negative control and -3.6 (-5.4, -1.8) versus the positive control. Subjects with localized or generalized gingivitis had 3.7 times better odds (95% CI [2.8, 5.0]) of shifting to generally healthy using SnF2 versus a negative control and 2.8 times better odds (95% CI [2.1, 3.9]) of shifting to generally healthy using SnF2 versus a positive control. The individual study risk of bias was deemed to be low in all categories of bias.

CONCLUSION

This meta-analysis demonstrates significant gingivitis benefits of bioavailable SnF2 dentifrices when used ≤3 months versus positive (triclosan) and negative (NaF or MFP) controls.

Association between regular walking and periodontitis according to socioeconomic status: a cross-sectional study

Physical activity reduces the risk and mortality risk of inflammatory diseases. This study aimed to examine the relationship between regular walking and periodontitis in a Korean representative sample of adults according to socioeconomic status. Data acquired by the Sixth Korea National Health and Nutrition Examination Survey in 2014 and 2015 were used. The survey was completed by 11,921 (5,175 males; 6,746 females) participants (≥19 years). Individuals without values on periodontitis were excluded, and 9,728 participants remained. Multivariable logistic regression analysis was done using socio-demographic characteristics (age, gender, income, education), oral health-related variables (flossing, interdental brushing, community periodontal index), oral and general health status and behaviour (smoking, diabetes mellitus), and regular walking. In all models, subjects who walked regularly had significantly lower risks of periodontitis. After adjusting for age, gender, income, education, smoking, diabetes mellitus, flossing, and interdental brushing, the odds ratio for periodontitis in subjects who walked regularly was 0.793 (95% Confidence interval: 0.700-0.898). Non-regular walking groups showed similar social gradients. Risk of low socioeconomic status was not significant in the regular walking group after adjusting for age, gender, income, and education. This study found that regular walking is associated to lower prevalence of periodontitis and can attenuate the relationship between periodontitis and low socioeconomic status.

Ten-year clinical evaluation of posterior fixed-movable resin-bonded fixed partial dentures

OBJECTIVES

Two-unit cantilevered resin-bonded fixed partial dentures (RBFPDs) offer long-term retention for anterior and premolar-sized spans. At this center, molar and longer spans have been restored with fixed-movable (FM) RBFPDs to overcome the lower retention rates of fixed-fixed RBFPDs. This retrospective study aimed to evaluate the long-term longevity and the patient-reported outcomes of posterior FM-RBFPDs.

METHODS

Posterior FM-RBFPDs that had been inserted at least five years were reviewed. Survival was "retention of the original prosthesis in mouth" and success was "survival of prosthesis and absence of complications requiring treatment intervention". Prosthesis location, number of units, insertion year, tooth/teeth replaced and operator experience were collected. Patients' acceptance to FM-RBFPDs were assessed using prosthesis satisfaction questionnaire and Oral Health Impact Profile (OHIP-49). Results were analyzed using log-rank and cox-regression tests at significance level α = 0.05.

RESULTS

One-hundred-and-one prostheses were examined. The mean observation time was 126.4 ± 32.2 months. Thirty-six (35.6%) and 63 (62.4%) FM-RBFPDs were rated as success and survival respectively. Prostheses inserted after year 2001 (n = 69) experienced 42.0% (n = 29) success and 75.4% (n = 52) survival, and its survival rate was significantly better than those inserted in or before 2001 (p = 0.01). Five- and ten-year cumulative survival probability of FM-RBFPDs inserted after year 2001 were 82.3% and 74.1% respectively. The most frequent complications were debonding among 34 (33.7%) prostheses. Patients' acceptance were high.

CONCLUSIONS

More recently inserted prostheses showed improved longevity and patients' acceptance to posterior FM-RBFPDs were high.

CLINICAL SIGNIFICANCE

Fix-Movable RBFPDs are a viable tooth replacement option in the posterior region.

Long-term impact of powered toothbrush on oral health: 11-year cohort study

Aims

This study aimed to assess 11‐year longitudinal effects of powered toothbrush on periodontal health, caries and tooth loss in an adult population.

Materials and Methods

Participants of Study of Health in Pomerania (SHIP) cohort with dental examinations and interview data at SHIP‐1, SHIP‐2 or SHIP‐3 examinations were included. Mixed‐effects linear regression models were constructed between the exposure (manual versus powered toothbrush) and outcome variables (periodontal status using mean probing depth (PD) and mean clinical attachment loss (CAL), caries status using DMFS and DFS scores, and tooth loss), adjusting for potential baseline covariates.

Results

Final baseline (SHIP‐1) study sample comprised of 2,819 participants. Powered toothbrush users increased from 18.3% (SHIP‐1) to 36.9% (SHIP‐3); were younger; had significantly less mean PD [β: −0.09 (95% CI: −0.16; −0.02)] and mean CAL [β: −0.19 (95% CI: −0.32; −0.07)] progressions; and had 17.7% less DMFS progression and 19.5% more teeth retained than the manual toothbrushers.

Conclusions

In the long‐term, powered toothbrush seems to be effective in reducing mean PD and mean CAL progressions, besides increasing the number of teeth retained.

MicroRNA expression profiling of nicotine-treated human periodontal ligament cells

Cigarette smoking is a lifestyle-related risk factor involved in the causation and progression of periodontal disease. Nicotine is a key toxic component of tobacco. However, the mechanisms underlying nicotine-induced periodontitis have not yet been fully elucidated. The present study investigated the microRNA (miRNA) expression profile of human periodontal ligament cells (PDLCs) treated with nicotine. Using differential analysis of miRNA array data, several differentially expressed miRNAs were identified in nicotine-treated PDLCs. Quantitative real-time PCR was employed to verify the accuracy of the miRNA array, and the targets of these dysregulated miRNAs were further analyzed. Function and pathway enrichment of differentially expressed miRNAs suggested that several important signaling pathways, such as the Toll-like receptor signaling pathway, nicotine addiction, the transforming growth factor-beta signaling pathway, and the hypoxia inducible factor-1 signaling pathway, are potentially responsible for nicotine-induced periodontitis. This study has helped to clarify the epigenetic mechanisms of nicotine-induced periodontitis, highlighting novel biomarkers and therapeutic targets.

Visualization and Quantification of the Oral Hygiene Effects of Brushing, Dentifrice Use, and Brush Wear Using a Tooth Brushing Simulator

Approaches that reproduce dental hygiene regimens under controlled conditions have applications in preclinical research. We have applied standardized, reproducible brushing regimes to typodonts coated in simulated or biological plaques to assess the effects on tooth cleaning of toothbrush/dentifrice regimens. Replicated typodonts were coated with Occlude^TM or Glogerm^TM indicators to simulate plaque, and brushed reproducibly using a mechanical brushing simulator to compare the cleaning of occlusal surfaces before and after brushing with water or a dentifrice. An in vitro model using salivary inocula to cultivate oral biofilms on typodont surfaces was then developed to evaluate removal of disclosed plaque by new toothbrushes in comparison to toothbrushes with wear equivalent to 3 months of use. Analyses of typodonts brushed under controlled conditions significantly (p < 0.01) distinguished between brushed and unbrushed surfaces and between the use of water vs. dentifrice for the removal of simulated interproximal plaque (p < 0.05). New toothbrushes removed significantly (p < 0.05) more biological plaque from typodont surfaces than brushes that had been worn by repeated brushing. Through controlled and defined brushing of typodonts with simulated and biological plaques, the effectiveness of dental hygiene regimens was compared under reproducible conditions. Data indicate that the cleaning effectiveness of brushing was augmented by the addition of dentifrice and that new brushes were significantly more effective than brushes with substantial wear from previous use. Whilst we have focussed on the occlusal surfaces of molars and worn brushes, the method could be applied to a range of other tooth surfaces and oral hygiene regimens.

WITHDRAWN: Flossing for the management of periodontal diseases and dental caries in adults

BACKGROUND

Good oral hygiene is thought to be important for oral health. This review is to determine the effectiveness of flossing in addition to toothbrushing for preventing gum disease and dental caries in adults.

OBJECTIVES

To assess the effects of flossing in addition to toothbrushing, as compared with toothbrushing alone, in the management of periodontal diseases and dental caries in adults.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 17 October 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4), MEDLINE via OVID (1950 to 17 October 2011), EMBASE via OVID (1980 to 17 October 2011), CINAHL via EBSCO (1980 to 17 October 2011), LILACS via BIREME (1982 to 17 October 2011), ZETOC Conference Proceedings (1980 to 17 October 2011), Web of Science Conference Proceedings (1990 to 17 October 2011), Clinicaltrials.gov (to 17 October 2011) and the metaRegister of Controlled Clinical Trials (to 17 October 2011). We imposed no restrictions regarding language or date of publication. We contacted manufacturers of dental floss to identify trials.

SELECTION CRITERIA

We included randomised controlled trials conducted comparing toothbrushing and flossing with only toothbrushing, in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias for the included studies and extracted data. We contacted trial authors for further details where these were unclear. The effect measure for each meta-analysis was the standardised mean difference (SMD) with 95% confidence intervals (CI) using random-effects models. We examined potential sources of heterogeneity, along with sensitivity analyses omitting trials at high risk of bias.

MAIN RESULTS

Twelve trials were included in this review, with a total of 582 participants in flossing plus toothbrushing (intervention) groups and 501 participants in toothbrushing (control) groups. All included trials reported the outcomes of plaque and gingivitis. Seven of the included trials were assessed as at unclear risk of bias and five were at high risk of bias.Flossing plus toothbrushing showed a statistically significant benefit compared to toothbrushing in reducing gingivitis at the three time points studied, the SMD being -0.36 (95% CI -0.66 to -0.05) at 1 month, SMD -0.41 (95% CI -0.68 to -0.14) at 3 months and SMD -0.72 (95% CI -1.09 to -0.35) at 6 months. The 1-month estimate translates to a 0.13 point reduction on a 0 to 3 point scale for Loe-Silness gingivitis index, and the 3 and 6 month results translate to 0.20 and 0.09 reductions on the same scale.Overall there is weak, very unreliable evidence which suggests that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 or 3 months.None of the included trials reported data for the outcomes of caries, calculus, clinical attachment loss, or quality of life. There was some inconsistent reporting of adverse effects.

AUTHORS' CONCLUSIONS

There is some evidence from twelve studies that flossing in addition to toothbrushing reduces gingivitis compared to toothbrushing alone. There is weak, very unreliable evidence from 10 studies that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 and 3 months. No studies reported the effectiveness of flossing plus toothbrushing for preventing dental caries.

Severe periodontitis is more common in HIV- infected patients

OBJECTIVE

To assess periodontitis prevalence and severity in HIV infected patients as compared to controls. Furthermore, to assess whether HIV infection characteristics are associated with periodontitis.

DESIGN

cross-sectional controlled study.

METHODS

We assessed prevalence and severity of periodontitis in 258 HIV-infected patients and 539 historical controls with the Dutch Periodontal Screening Index (DPSI). HIV characteristics were collected from medical charts. Age-related diseases and oral care were assessed with questionnaires.

RESULTS

Severe periodontitis (DPSI 4) was more prevalent in HIV-infected patients than in controls (66% vs. 36%, p = 0.002). HIV-infection, increasing age and male sex were significant risk factors for severe periodontitis. In particular, older male HIV patients have a higher risk of severe periodontitis. Clinical, immunological and virologic characteristics, and antiretroviral therapy were not associated with periodontitis prevalence or severity. HIV-infected patients rate the importance of their oral health as high, although many do not disclose their HIV infection to their dentists.

CONCLUSIONS

Prevalence and severity of periodontitis are higher in HIV-infected patients compared to controls, particularly in older males. Awareness of the increased prevalence of periodontitis associated with HIV-infection among patients and health-care professionals could significantly improve oral health and quality of life of HIV-infected patients.

Chlorhexidine mouthrinse as an adjunctive treatment for gingival health

BACKGROUND

Dental plaque associated gingivitis is a reversible inflammatory condition caused by accumulation and persistence of microbial biofilms (dental plaque) on the teeth. It is characterised by redness and swelling of the gingivae (gums) and a tendency for the gingivae to bleed easily. In susceptible individuals, gingivitis may lead to periodontitis and loss of the soft tissue and bony support for the tooth. It is thought that chlorhexidine mouthrinse may reduce the build-up of plaque thereby reducing gingivitis.

OBJECTIVES

To assess the effectiveness of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for the control of gingivitis and plaque compared to mechanical oral hygiene procedures alone or mechanical oral hygiene procedures plus placebo/control mouthrinse. Mechanical oral hygiene procedures were toothbrushing with/without the use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment.To determine whether the effect of chlorhexidine mouthrinse is influenced by chlorhexidine concentration, or frequency of rinsing (once/day versus twice/day).To report and describe any adverse effects associated with chlorhexidine mouthrinse use from included trials.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 28 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 28 September 2016); MEDLINE Ovid (1946 to 28 September 2016); Embase Ovid (1980 to 28 September 2016); and CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 28 September 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials assessing the effects of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for at least 4 weeks on gingivitis in children and adults. Mechanical oral hygiene procedures were toothbrushing with/without use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. We included trials where participants had gingivitis or periodontitis, where participants were healthy and where some or all participants had medical conditions or special care needs.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference (MD) and 95% confidence interval (CI). We combined MDs where studies used the same scale and standardised mean differences (SMDs) where studies used different scales. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. Due to anticipated heterogeneity we used random-effects models for all meta-analyses.

MAIN RESULTS

We included 51 studies that analysed a total of 5345 participants. One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however, this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect. Gingivitis After 4 to 6 weeks of use, chlorhexidine mouthrinse reduced gingivitis (Gingival Index (GI) 0 to 3 scale) by 0.21 (95% CI 0.11 to 0.31) compared to placebo, control or no mouthrinse (10 trials, 805 participants with mild gingival inflammation (mean score 1 on the GI scale) analysed, high-quality evidence). A similar effect size was found for reducing gingivitis at 6 months. There were insufficient data to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 (moderate or severe levels of gingival inflammation). Plaque Plaque was measured by different indices and the SMD at 4 to 6 weeks was 1.45 (95% CI 1.00 to 1.90) standard deviations lower in the chlorhexidine group (12 trials, 950 participants analysed, high-quality evidence), indicating a large reduction in plaque. A similar large reduction was found for chlorhexidine mouthrinse use at 6 months. Extrinsic tooth staining There was a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 4 to 6 weeks. The SMD was 1.07 (95% CI 0.80 to 1.34) standard deviations higher (eight trials, 415 participants analysed, moderate-quality evidence) in the chlorhexidine mouthrinse group. There was also a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 7 to 12 weeks and 6 months. Calculus Results for the effect of chlorhexidine mouthrinse on calculus formation were inconclusive. Effect of concentration and frequency of rinsing There were insufficient data to determine whether there was a difference in effect for either chlorhexidine concentration or frequency of rinsing. Other adverse effects The adverse effects most commonly reported in the included studies were taste disturbance/alteration (reported in 11 studies), effects on the oral mucosa including soreness, irritation, mild desquamation and mucosal ulceration/erosions (reported in 13 studies) and a general burning sensation or a burning tongue or both (reported in nine studies).

AUTHORS' CONCLUSIONS

There is high-quality evidence from studies that reported the Löe and Silness Gingival Index of a reduction in gingivitis in individuals with mild gingival inflammation on average (mean score of 1 on the 0 to 3 GI scale) that was not considered to be clinically relevant. There is high-quality evidence of a large reduction in dental plaque with chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for 4 to 6 weeks and 6 months. There is no evidence that one concentration of chlorhexidine rinse is more effective than another. There is insufficient evidence to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 indicating moderate or severe levels of gingival inflammation. Rinsing with chlorhexidine mouthrinse for 4 weeks or longer causes extrinsic tooth staining. In addition, other adverse effects such as calculus build up, transient taste disturbance and effects on the oral mucosa were reported in the included studies.

Long-Term Effect of Surface Roughness and Patients' Factors on Crestal Bone Loss at Dental Implants. A Systematic Review and Meta-Analysis

Publications from 2011 to 2015 were selected to evaluate effect of implant surface roughness on long-term bone loss as surrogate for peri-implantitis risk. 87 out of 2,566 papers reported the mean bone loss after at least 5 years of function. Estimation of the proportion of implants with bone loss above 1, 2, and 3 mm as well as analysis the effect of implant surface roughness, smoking, and history of periodontitis was performed. By means of the provided statistical information of bone loss (mean and standard deviation) the prevalence of implants with bone loss ranging from 1 to 3 mm was estimated. The bone loss was used as a surrogate parameter for "peri-implantitis" given the fact that "peri-implantitis" prevalence was not reported in most studies or when reported, the diagnostic criteria were unclear or of dubious quality. The outcome of this review suggests that peri-implant bone loss around minimally rough implant systems was statistically significant less in comparison to the moderately rough and rough implant systems. No statistically significant difference was observed between moderately rough and rough implant systems. The studies that compared implants with comparable design and different surface roughness, showed less average peri-implant bone loss around the less rough surfaces in the meta-analysis. However, due to the heterogeneity of the papers and the multifactorial cause for bone loss, the impact of surface roughness alone seems rather limited and of minimal clinical importance. Irrespective of surface topography or implant brand, the average weighted implant survival rate was 97.3% after 5 years or more of loading. If considering 3 mm bone loss after at least 5 years to represent the presence of "peri-implantitis," less than 5% of the implants were affected. The meta-analysis indicated that periodontal history and smoking habits yielded more bone loss.

A Randomized Double-Masked Clinical Trial Comparing Four Periodontitis Treatment Strategies: 5-Year Tooth Loss Results

BACKGROUND

Tooth loss is the ultimate negative consequence of periodontitis, and reports of the extent to which different treatment strategies may influence long-term tooth loss are hard to find. This study aims to test the hypothesis that there is no difference in 5-year clinical outcome of therapy in terms of tooth mortality between groups of patients treated with conventional scaling and root planing (SRP) over weeks or same-day full-mouth disinfection (FDIS), with or without adjunctive metronidazole (MET).

METHODS

One hundred eighty-four patients with moderate-to-severe periodontitis were randomly allocated to one of four treatment groups: 1) FDIS+MET; 2) FDIS+placebo; 3) SRP+MET; and 4) SRP+placebo. Total 161 patients (88%) completed the 5-year follow-up examination, and data on number and timing of tooth extractions as well as pre-extraction diagnoses and reasons for extractions were analyzed.

RESULTS

No differences were observed between groups with regard to number of, reasons for, or time of extractions in the four groups at baseline and 1, 3, and 5 years after treatment.

CONCLUSION

If extraction or retention of teeth is regarded as a measure of failure or success 5 years after completion of periodontal therapy, none of the four strategies produced an end result better than the other.

The impact of smoking on marginal bone loss in a 10-year prospective longitudinal study

OBJECTIVES

The aim of this epidemiologic study was to determine the impact of smoking on marginal bone loss in a subsample derived from an original randomly selected adult sample, after adjusting for oral and general factors.

METHODS

The number of participants at baseline in this 10-year longitudinal study was 616 (mean age: 42 years, range 21-63 years). The participants underwent a full-mouth radiographic survey. After recall in 2003, 473 (77%) of the participants accepted and completed an identical survey. In 2008, the survey was repeated, and 301 (48.9%) individuals were included in this study. The marginal bone level of each tooth was measured in mm. Age, gender, smoking habits, number of teeth, apical periodontitis, crowns and initial marginal bone level were also recorded for each individual. Only individuals who did not report a change in smoking habits during the 10-year period were included in the study. Multiple regression analyses were used to evaluate crude and adjusted associations between smoking and marginal bone loss.

RESULTS

At the first, radiographic survey smokers had a statistically significantly more reduced marginal bone level (in average 0.9 mm) than nonsmokers. After 10 years, a progression of a mean marginal bone loss of > 2 mm was statistically significantly more common in smokers than in nonsmokers (7.1% and 0%, respectively). Furthermore, a marginal bone loss of 1-2 mm was observed in 29% of the smokers and 19% of the nonsmokers, and ≤ 1 mm marginal bone loss was found in 69% of smokers and 81% of nonsmokers. Even after adjusting for initial marginal bone level, gender, age, and also presence of apical periodontitis and crowns, the difference in progression of marginal bone loss was still statistically higher in smokers (on average 0.36 mm).

CONCLUSIONS

The smokers started out with a more reduced marginal bone level than nonsmokers. However, even after adjusting for the initial marginal bone level, the progression of marginal bone loss in smokers was more pronounced than in nonsmokers. This shows that smoking is a factor with significant impact on the marginal bone level and can be assumed to be a true risk factor for marginal bone loss.

Epidemiology of gingivitis in schoolchildren in Bucharest, Romania: a cross-sectional study

BACKGROUND AND OBJECTIVE

Gingivitis is the most prevalent oral disease in children, being strongly associated to social gradients. Many studies have reported different results concerning the extent and intra-oral distribution of gingivitis in children. The aim of this study was to investigate the epidemiologic parameters and socio-related risk factors of gingivitis in the 10-17-year-old Bucharest schoolchildren population and to analyze its intra-oral distribution.

MATERIAL AND METHODS

Cross-sectional data were obtained from 1595 schoolchildren, social condition being assigned using a simple questionnaire. Classes of students were used as clusters in a single-stage cluster sampling method. An intra-oral exam was performed for all the children included in this study. Silness and Löe scores, prevalence and the extent of gingivitis were calculated.

RESULTS

The gingival scores showed a mild inflammation and the prevalence of gingivitis was 91%. Boys had a higher gingival (0.19 vs. 0.18; p < 0.05) and plaque scores (0.71 vs. 0.59; p < 0.01) than girls. Children who did not live in overcrowded households, whose parents had a better education and those who had direct access to school dental services displayed better gingival conditions (p < 0.05). Gingivitis was more severe on the upper teeth, with the maximum score being reached at the right upper lateral incisor (0.63 on distal surface).

CONCLUSIONS

Gingival condition in Bucharest schoolchildren population was associated to social gradients. School dental services are also another factor that seems to be related with gingivitis.

Patient-Specific Variations in Biomarkers across Gingivitis and Periodontitis

This study investigates the use of saliva, as an emerging diagnostic fluid in conjunction with classification techniques to discern biological heterogeneity in clinically labelled gingivitis and periodontitis subjects (80 subjects; 40/group) A battery of classification techniques were investigated as traditional single classifier systems as well as within a novel selective voting ensemble classification approach (SVA) framework. Unlike traditional single classifiers, SVA is shown to reveal patient-specific variations within disease groups, which may be important for identifying proclivity to disease progression or disease stability. Salivary expression profiles of IL-1ß, IL-6, MMP-8, and MIP-1α from 80 patients were analyzed using four classification algorithms (LDA: Linear Discriminant Analysis [LDA], Quadratic Discriminant Analysis [QDA], Naïve Bayes Classifier [NBC] and Support Vector Machines [SVM]) as traditional single classifiers and within the SVA framework (SVA-LDA, SVA-QDA, SVA-NB and SVA-SVM). Our findings demonstrate that performance measures (sensitivity, specificity and accuracy) of traditional classification as single classifier were comparable to that of the SVA counterparts using clinical labels of the samples as ground truth. However, unlike traditional single classifier approaches, the normalized ensemble vote-counts from SVA revealed varying proclivity of the subjects for each of the disease groups. More importantly, the SVA identified a subset of gingivitis and periodontitis samples that demonstrated a biological proclivity commensurate with the other clinical group. This subset was confirmed across SVA-LDA, SVA-QDA, SVA-NB and SVA-SVM. Heatmap visualization of their ensemble sets revealed lack of consensus between these subsets and the rest of the samples within the respective disease groups indicating the unique nature of the patients in these subsets. While the source of variation is not known, the results presented clearly elucidate the need for novel approaches that accommodate inherent heterogeneity and personalized variations within disease groups in diagnostic characterization. The proposed approach falls within the scope of P4 medicine (predictive, preventive, personalized, and participatory) with the ability to identify unique patient profiles that may predict specific disease trajectories and targeted disease management.

Defining periodontal health

Assessment of the periodontium has relied exclusively on a variety of physical measurements (e.g., attachment level, probing depth, bone loss, mobility, recession, degree of inflammation, etc.) in relation to various case definitions of periodontal disease. Periodontal health was often an afterthought and was simply defined as the absence of the signs and symptoms of a periodontal disease. Accordingly, these strict and sometimes disparate definitions of periodontal disease have resulted in an idealistic requirement of a pristine periodontium for periodontal health, which makes us all diseased in one way or another. Furthermore, the consequence of not having a realistic definition of health has resulted in potentially questionable recommendations. The aim of this manuscript was to assess the biological, environmental, sociological, economic, educational and psychological relationships that are germane to constructing a paradigm that defines periodontal health using a modified wellness model. The paradigm includes four cardinal characteristics, i.e., 1) a functional dentition, 2) the painless function of a dentition, 3) the stability of the periodontal attachment apparatus, and 4) the psychological and social well-being of the individual. Finally, strategies and policies that advocate periodontal health were appraised.

I'm not sick but I'm not well,

and it's a sin to live so well.

Flagpole Sitta, Harvey Danger

Targeted salivary biomarkers for discrimination of periodontal health and disease(s)

Generally, clinical parameters are used in dental practice for periodontal disease, yet several drawbacks exist with the clinical standards for addressing the needs of the public at large in determining the current status/progression of the disease, and requiring a significant amount of damage before these parameters can document disease. Therefore, a quick, easy and reliable method of assessing and monitoring periodontal disease should provide important diagnostic information that improves and speeds treatment decisions and moves the field closer to individualized point-of-care diagnostics.

OBJECTIVE

This report provides results for a saliva-based diagnostic approach for periodontal health and disease based upon the abundance of salivary analytes coincident with disease, and the significant progress already made in the identification of discriminatory salivary biomarkers of periodontitis.

METHODS

We evaluated biomarkers representing various phases of periodontitis initiation and progression (IL-1ß, IL-6, MMP-8, MIP-1α) in whole saliva from 209 subjects categorized with periodontal health, gingivitis, and periodontitis.

RESULTS

Evaluation of the salivary analytes demonstrated utility for individual biomarkers to differentiate periodontitis from health. Inclusion of gingivitis patients into the analyses provided a more robust basis to estimate the value of each of these analytes. Various clinical and statistical approaches showed that pairs or panels of the analytes were able to increase the sensitivity and specificity for the identification of disease.

CONCLUSIONS

Salivary concentrations of IL-1ß, IL-6, MMP-8, MIP-1α alone and in combination are able to distinguish health from gingivitis and periodontitis. The data clearly demonstrated a heterogeneity in response profiles of these analytes that supports the need for refinement of the standard clinical classifications if we are to move toward precision/personalized dentistry for the twenty-first century.

Should retention of a tooth be an important goal of dentistry? How do you decide whether to retain and restore a tooth requiring endodontic treatment or to extract and if possible replace the tooth?

Whether a questionable tooth should be treated endodontically or extracted, is still a dilemma clinicians encounter every day. With advances in technology such as implantology, deciding whether or not to save a tooth is still not clear. Local site-specific factors and patient-related factors that may affect the longevity of a particular tooth should be considered in preparing the treatment plan. Long-term success rates for root canal therapy and implant-supported crowns demonstrate similar outcomes. A choice between these alone is not sufficient in the decision-making process. Only following a systematic evaluation of the reasons for and against tooth retention as directed by each individual case, can the best option be decided.

Lessons learned and unlearned in periodontal microbiology

Periodontal diseases are initiated by bacterial species living in polymicrobial biofilms at or below the gingival margin and progress largely as a result of the inflammation elicited by specific subgingival species. In the past few decades, efforts to understand the periodontal microbiota have led to an exponential increase in information about biofilms associated with periodontal health and disease. In fact, the oral microbiota is one of the best-characterized microbiomes that colonize the human body. Despite this increased knowledge, one has to ask if our fundamental concepts of the etiology and pathogenesis of periodontal diseases have really changed. In this article we will review how our comprehension of the structure and function of the subgingival microbiota has evolved over the years in search of lessons learned and unlearned in periodontal microbiology. More specifically, this review focuses on: (i) how the data obtained through molecular techniques have impacted our knowledge of the etiology of periodontal infections; (ii) the potential role of viruses in the etiopathogenesis of periodontal diseases; (iii) how concepts of microbial ecology have expanded our understanding of host-microbe interactions that might lead to periodontal diseases; (iv) the role of inflammation in the pathogenesis of periodontal diseases; and (v) the impact of these evolving concepts on therapeutic and preventive strategies to periodontal infections. We will conclude by reviewing how novel systems-biology approaches promise to unravel new details of the pathogenesis of periodontal diseases and hopefully lead to a better understanding of their mechanisms.

Economics of periodontal care: market trends, competitive forces and incentives

The adoption of new technologies for the treatment of periodontitis and the replacement of teeth has changed the delivery of periodontal care. The objective of this review was to conduct an economic analysis of a mature periodontal service market with a well-developed workforce, including general dentists, dental hygienists and periodontists. Publicly available information about the delivery of periodontal care in the USA was used. A strong trend toward increased utilization of nonsurgical therapy and decreased utilization of surgical periodontal therapy was observed. Although periodontal surgery remained the domain of periodontists, general dentists had taken over most of the nonsurgical periodontal care. The decline in surgical periodontal therapy was associated with an increased utilization of implant-supported prosthesis. Approximately equal numbers of implants were surgically placed by periodontists, oral and maxillofacial surgeons, and general dentists. Porter's framework of the forces driving industry competition was used to analyze the role of patients, dental insurances, general dentists, competitors, entrants, substitutes and suppliers in the periodontal service market. Estimates of out-of-pocket payments of self-pay and insured patients, reimbursement by dental insurances and providers' earnings for various periodontal procedures and alternative treatments were calculated. Economic incentives for providers may explain some of the observed shifts in the periodontal service market. Given the inherent uncertainty about treatment outcomes in dentistry, which makes clinical judgment critical, providers may yield to economic incentives without jeopardizing their ethical standards and professional norms. Although the economic analysis pertains to the USA, some considerations may also apply to other periodontal service markets.