The effect of long-term aspirin intake on the outcome of non-surgical periodontal therapy in smokers: a double-blind, randomized pilot study

The role of non-steroidal anti-inflammatory drugs as adjuncts to periodontal treatment and in periodontal regeneration

Periodontitis is the sixth most prevalent chronic disease globally and places significant burdens on societies and economies worldwide. Behavioral modification, risk factor control, coupled with cause-related therapy have been the "gold standard" treatment for managing periodontitis. Given that host inflammatory and immunological responses play critical roles in the pathogenesis of periodontitis and impact treatment responses, several adjunctive strategies aimed at modulating host responses and improving the results of periodontal therapy and maintenance have been proposed. Of the many pharmacological host modulators, we focused on non-steroidal anti-inflammatory drugs (NSAIDs), due to their long history and extensive use in relieving inflammation and pain and reducing platelet aggregation. NSAIDs have been routinely indicated for treating rheumatic fever and osteoarthritis and utilized for the prevention of cardiovascular events. Although several efforts have been made to incorporate NSAIDs into the treatment of periodontitis, their effects on periodontal health remain poorly characterized, and concerns over the risk-benefit ratio were also raised. Moreover, there is emerging evidence highlighting the potential of NSAIDs, especially aspirin, for use in periodontal regeneration. This review summarizes and discusses the use of NSAIDs in various aspects of periodontal therapy and regeneration, demonstrating that the benefits of NSAIDs as adjuncts to conventional periodontal therapy remain controversial. More recent evidence suggests a promising role for NSAIDs in periodontal tissue engineering and regeneration.

Causes of Emergency Bleeding after Nonsurgical Periodontal Therapy in Adult Periodontitis Patients: A Retrospective Analysis

Background

Emergency gingival uncontrollable bleeding after nonsurgical periodontal therapy (NSPT) could be caused by a variety of factors; local oral factors are the main cause of gingival bleeding in most patients. Because the doctor will do a good job of evaluating the patient's physical condition before nonsurgical periodontal therapy. This study is subjected to evaluate the possible factors associated with emergency uncontrollable bleeding within 24-48 hours after NSPT. Material and Methods. A total of fifty-eight patients with emergency bleeding after NSPT in the past four years were enrolled. The related factors in patients, such as age, gender, clotting function, systemic diseases, and baseline periodontitis severity, were analyzed. The site-related factors, such as tooth type, tooth distribution, and alveolar bone resorption at the bleeding site, were compared. The possible relationship of the parameters to the causes of emergency bleeding with NSPT was also evaluated.

Results

Gingival bleeding after NSPT was registered. In this retrospective study, a total of 58 patients were selected. There were 29 males and 29 females, aged from 20 to 67 years old, with an average age of 35.21 ± 10.09 years. Among them, 8.6% were over 50 years old, and 91.4% were under 50 years old. Completed evaluations were performed in 15.5% gingivitis and 84.5% periodontitis. The causes of emergency bleeding after nonsurgical periodontal therapy in this study were residual subgingival calculus or granulation tissue in 63.79% of cases: severe gingival inflammation, 29.32%; gum trauma, 3.45%; and poor compliance, 3.45%. The therapy method before bleeding includes supragingival scaling accounted for 72.4% and subgingival scaling accounted for 27.6%. 23 cases of horizontal absorption at the bleeding site accounted for 39.66%, and 35 cases of angular absorption accounted for 60.34%. Bleeding of maxillary posterior teeth accounted for 34.48%; mandibular anterior teeth accounted for 15.52%; mandibular anterior teeth accounted for 8.62%; and mandibular posterior teeth accounted for 18.97%; multiple sites accounted for 22.41%; eliminating residual subgingival calculus and granulation tissue were the main and most effective hemostatic methods, 86.21%.

Conclusion

Residual subgingival calculus or granulation tissue and severe gingival inflammation were the main causes of emergency gingival bleeding after nonsurgical periodontal therapy. Severe gingival inflammation causing emergency bleeding was more common in maxillary posterior teeth areas. Angular alveolar bone resorption was more likely to cause bleeding than horizontal resorption. Careful debridement of residual subgingival calculus and granulation tissue was the main hemostatic method.

The Effect of Acknowledged and Novel Anti-Rheumatic Therapies on Periodontal Tissues-A Narrative Review

Rheumatoid arthritis (RA) and periodontal disease (PD) are chronic complex inflammatory diseases with several common susceptibility factors, especially genetic and environmental risk factors. Although both disorders involve a perturbation of the immune–inflammatory response at multiple levels, one major difference between the two is the different locations in which they develop. RA is triggered by an exaggerated autoimmune response that targets joints, while periodontal disease occurs as a consequence of the subgingival periodontopathogenic microbiota. Current treatment models in both pathologies involve the stratification of patients to allow therapeutic individualization according to disease stage, complexity, progression, lifestyle, risk factors, and additional systemic diseases. Therapeutic guidelines for RA comprise of five main classes of drugs: non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, glucocorticoids, and disease-modifying anti-rheumatic drugs (DMARDs): biologic and non-biologic. Although various treatment options are available, a definitive treatment remains elusive, therefore research is ongoing in this area. Several alternatives are currently being tested, such as matrix metalloproteinases (MMP) inhibitors, toll-like receptors (TLR) blockers, pro-resolution mediators, anti-hypoxia inducing factors, stem cell therapy, NLRP3 inhibitors and even natural derived compounds. Although the link between PD and rheumatoid arthritis has been investigated by multiple microbiology and immunology studies, the precise influence and causality is still debated in the literature. Furthermore, the immunomodulatory effect of anti-rheumatic drugs on the periodontium is still largely unknown. In this narrative review, we explore the mechanisms of interaction and the potential influence that anti-rheumatoid medication, including novel treatment options, has on periodontal tissues and whether periodontal health status and treatment can improve the prognosis of an RA patient.

Pocket closure and residual pockets after non-surgical periodontal therapy: A systematic review and meta-analysis

Aim

To analyse the efficacy of non‐surgical therapy (NST) in terms of pocket closure (PC) and changes in percentage and number of pockets.

Materials and Methods

Three databases (PubMed, EMBASE, and Scopus) were searched up to January 2020. Prospective studies with a minimum follow‐up of 12 months and presenting data in terms of PC or number or percentage of pocket depths (PDs) before and after NST on systemically healthy patients were included. Random‐effect meta‐analyses were performed.

Results

After screening 4610 titles and abstracts, 27 studies were included. Of these, 63.9% of PC was reported by one study. The percentage of PDs ≤3 mm changed from 39.06% to 64.11% with a weighted mean difference (WMD) of 26.14% (p < .001). This accounted for a relative increase of healthy sites of 64.13%. The mean percentage of PD ≥5 mm was 28.23% and 11.71% before and after treatment, respectively, with a WMD of 15.50% (p < .001). The WMD in the number of PDs ≥5 mm before and after treatment was 24.42 (p = .036). The mean number of residual PPD ≥5 after NST was 14.13.

Conclusions

NST is able to eradicate the majority of the pockets. However, residual pockets after NST may remain and should be considered cautiously for further treatment planning.

Effectiveness of a nutraceutical agent in the non-surgical periodontal therapy: a randomized, controlled clinical trial

OBJECTIVE

Nutraceutical agents have been demonstrated as adjuncts for the treatment of several inflammatory diseases. The present study analyzed and compared new nutraceutical agent as an adjunct to Scaling and root planing (SRP) versus SRP alone for the treatment of periodontitis.

MATERIALS AND METHODS

Sixty-six patients with moderate periodontitis were enrolled. Through a randomized design, the patients were randomly assigned to SRP + nutraceutical agent (test group) or SRP alone (control group). Patients were regularly examined the clinical, inflammatory mediators and visual analogue scale (VAS) changes over a 6-month period. Clinical attachment level (CAL) was the primary outcome variable chosen. Gingival crevicular fluid (GCF) inflammatory mediator change and the impact of treatment on VAS were evaluated through a linear regression model.

RESULTS

Both treatments demonstrated an improvement in periodontal parameters compared with baseline. After 6 months of treatment, compared with the control group, the test group determined a significant probing depth (PD) (p = 0.003) and bleeding on probing (BOP) reduction (p < 0.001), while CAL gain was significantly obtained at 30 and 60 days after treatment (p < 0.05). In the test group, the level of inflammatory mediators was significantly reduced compared with the control group (p < 0.05). The linear regression analysis demonstrated that the nutraceutical agent exerted, in the test group, a significant influence on VAS at 6, 12, 24, and 48 h after treatment (p < 0.05).

CONCLUSIONS

Nutraceutical agent resulted in a more significant reduction in clinical, inflammatory mediators and short-term pain compared with SRP alone.

CLINICAL RELEVANCE

Nutraceutical agent, when combined with SRP, was demonstrated to be effective in reducing periodontal parameters and controlling the levels of inflammatory mediators and pain in patients with periodontitis.

Fine-tuning multilevel modeling of risk factors associated with nonsurgical periodontal treatment outcome

This retrospective study evaluated the influence of known risk factors on nonsurgical periodontal treatment (NSPT) response using a pocket depth fine-tuning multilevel linear model (MLM). Overall, 37 patients (24 males and 13 females) with moderate-to-severe chronic periodontitis underwent NSPT. Follow-up visits at 3, 6, and 12 months included measurements of several clinical periodontal parameters. Data were sourced from a previously reported database. In a total of 1416 initially affected sites (baseline PD ≥ 4 mm) on 536 teeth, probing depth (PD) and clinical attachment loss (CAL) reductions after NSPT were evaluated against known risk factors at 3 hierarchical levels (patient, tooth, and site). For each post-treatment follow-up, the variance component models fitted to evaluate the 3-level variance of PD and CAL decrease revealed that all levels contributed significantly to the overall variance (p < 0.001). Patients who underwent NSPT and were continually monitored had curative results. All 3 hierarchical levels included risk factors influencing the degree of PD and CAL reduction. Specifically, the type of tooth, surfaces involved, and tooth mobility site-level risk factors had the strongest impact on these reductions and were highly relevant for the success of NSPT.

Establishing an osteoimmunomodulatory coating loaded with aspirin on the surface of titanium primed with phase-transited lysozyme

BACKGROUND

To improve osseointegration and enhance the success rate of implanted biomaterials, the surface modification technology of bone implants has developed rapidly. Intensive research on osteoimmunomodulation has shown that the surfaces of implants should possess favorable osteoimmunomodulation to facilitate osteogenesis.

METHODS

A novel, green and efficient phase-transited lysozyme (PTL) technique was used to prime titanium discs with a positive charge. In addition, sodium hyaluronate (HA) and self-assembled type I collagen containing aspirin (ASA) nanoparticles were decorated on PTL-primed Ti discs via electrostatic interaction.

RESULTS

The behaviors of bone marrow stromal cells (BMSCs) on the Ti disc surfaces containing ASA were analyzed in different conditioned media (CM) generated by macrophages. Additionally, the secretion of inflammation-related cytokines of macrophages on the surfaces of different Ti discs was investigated in in vitro experiments, which showed that the Ti surface containing ASA not only supported the migration, proliferation and differentiation of BMSCs but also reduced the inflammatory response of macrophages compared with Ti discs without surface modification. After implantation in vivo, the ASA-modified implant can significantly contribute to bone formation around the implant, which mirrors the evaluation in vitro.

CONCLUSION

This study highlights the significant effects of appropriate surface characteristics on the regulation of osteogenesis and osteoimmunomodulation around an implant. Implant modification with ASA potentially provides superior strategies for the surface modification of biomaterials.

The Effect of Tobacco Smoking on Musculoskeletal Health: A Systematic Review

This systematic review explored associations between smoking and health outcomes involving the musculoskeletal system. AMSTAR criteria were followed. A comprehensive search of PubMed, Web of Science, and Science Direct returned 243 articles meeting inclusion criteria. A majority of studies found smoking has negative effects on the musculoskeletal system. In research on bones, smoking was associated with lower BMD, increased fracture risk, periodontitis, alveolar bone loss, and dental implant failure. In research on joints, smoking was associated with increased joint disease activity, poor functional outcomes, and poor therapeutic response. There was also evidence of adverse effects on muscles, tendons, cartilage, and ligaments. There were few studies on the musculoskeletal health outcomes of secondhand smoke, smoking cessation, or other modes of smoking, such as waterpipes or electronic cigarettes. This review found evidence that suggests tobacco smoking has negative effects on the health outcomes of the musculoskeletal system. There is a need for further research to understand mechanisms of action for the effects of smoking on the musculoskeletal system and to increase awareness of healthcare providers and community members of the adverse effects of smoking on the musculoskeletal system.

Guided bone regeneration with asymmetric collagen-chitosan membranes containing aspirin-loaded chitosan nanoparticles

Introduction

Membranes allowing the sustained release of drugs that can achieve cell adhesion are very promising for guided bone regeneration. Previous studies have suggested that aspirin has the potential to promote bone regeneration. The purpose of this study was to prepare a local drug delivery system with aspirin-loaded chitosan nanoparticles (ACS) contained in an asymmetric collagen-chitosan membrane (CCM).

Methods

In this study, the ACS were fabricated using different concentrations of aspirin (5 mg, 25 mg, 50 mg, and 75 mg). The drug release behavior of ACS was studied. Transmission electron microscopy (TEM) and scanning electron microscopy (SEM) were used to examine the micromorphology of ACS and aspirin-loaded chitosan nanoparticles contained in chitosan-collagen membranes (ACS-CCM). In vitro bone mesenchymal stem cells (BMSCs) were cultured and critical-sized cranial defects on Sprague-Dawley rats were made to evaluate the effect of the ACS-CCM on bone regeneration.

Results

Drug release behavior results of ACS showed that the nanoparticles fabricated in this study could successfully sustain the release of the drug. TEM showed the morphology of the nanoparticles. SEM images indicated that the asymmetric membrane comprised a loose collagen layer and a dense chitosan layer. In vitro studies showed that ACS-CCM could promote the proliferation of BMSCs, and that the degree of differentiated BMSCs seeded on CCMs containing 50 mg of ACS was higher than that of other membranes. Micro-computed tomography showed that 50 mg of ACS-CCM resulted in enhanced bone regeneration compared with the control group.

Conclusion

This study shows that the ACS-CCM would allow the sustained release of aspirin and have further osteogenic potential. This membrane is a promising therapeutic approach to guiding bone regeneration.

Commentary: Targeting Underlying Biologic Mechanisms in Selecting Adjunctive Therapies to Improve Periodontal Treatment in Smokers: A Commentary

Despite well-established evidence that cigarette smoking is the largest modifiable risk factor for periodontal disease and has many deleterious health effects, treatment of periodontal disease in smokers remains a challenge of periodontal therapy. A recent meta-analysis revealed that adjunctive use of local delivery of antimicrobials, but not systemic antibiotic usage, with non-surgical periodontal therapy resulted in improvement in clinical periodontal parameters. Further evaluation of the current literature reveals that host modulation therapy may also result in clinical benefit in smokers. These findings may be tied to the underlying pathophysiology of periodontal disease progression in smokers and suggest that focused therapies that target known mechanisms of action are critical to the success of proposed treatments.

Decision Making in the Treatment of Patients With Rheumatoid Arthritis and Periodontitis: Scientific Evidence and Clinical Experience

Focused Clinical Question: What are the key considerations for coordination of care for a patient with rheumatoid arthritis (RA) and chronic periodontitis (CP), and what are the clinical implications of RA on periodontal health? Summary: Both RA and CP involve hyper-immune response and osseous destruction. However, despite emerging evidence that RA and CP may have common etiologies and patients with RA have increased risk of CP, periodontal evaluation and treatment remain largely similar for patients with and without RA. More fully assessing inflammatory burden in patients with RA and CP may allow practitioners to more accurately assess the risk profile of a patient for RA and periodontal disease progression and to better evaluate adequate end points to periodontal therapy. Furthermore, coordination of care for patients with RA and CP with their rheumatologist or treating physician could allow for advanced screening and prophylactic care that may prevent disease development or progression. Conclusion: For patients with RA and CP, evaluation of their rheumatoid disease activity score and periodontal inflamed surface area score, rather than traditional periodontal clinical measurements, along with additional biologic sampling methods may be appropriate measures to more accurately assess inflammatory burden in these susceptible patients.

Lower dosage of aspirin promotes cell growth and osteogenic differentiation in murine bone marrow stromal cells

Background/purpose

The effect of aspirin on bone regeneration remains controversial. This study aimed to determine the effect of various concentrations of aspirin on cell viability, osteogenic differentiation, cell cycle, and apoptosis on ST2 cells to find an effective range of aspirin for bone regeneration induction.

Materials and methods

Cell viability was measured with MTT assay after being stimulated with aspirin for 1 day, 2 days, 3 days, 5 days, and 7 days. Alkaline phosphatase (ALP) activity was measured after cells were treated for 1 day, 3 days, and 7 days. Expression of runt-related transcription factor 2 (Runx-2) was evaluated using Western-blot analysis at 3 days and 7 days. Flow cytometry was used for cell cycle and apoptosis measurement after cells were treated for 48 hours.

Results

Lower concentrations of aspirin (1μΜ and 10μM) promoted cell growth and increased ALP levels and Runx-2 expression, while higher concentrations (100μΜ and 1000μΜ) inhibited cell growth (P < 0.05), and lost their effect on ALP activity after 3 days, while even showing an inhibitory effect on the expression of Runx-2. Aspirin at a concentration of 100μM promoted cell mitosis from the S phase to the G2/M phase, and 1000μM arrested the cell cycle in the resting phase G0/G1 (P < 0.05). Parallel apoptosis/necrosis studies showed the percentage of cells in apoptosis decreased dramatically at any dose of aspirin.

Conclusion

A lower dosage of aspirin could promote ST2 cell growth, osteogenic differentiation, and inhibit their apoptosis which indicates that aspirin can be used as an alternative for bone regeneration.

Omega-3 fatty acids as an adjunct for periodontal therapy-a review

OBJECTIVES

The aim of this article is to present an overview of omega-3 fatty acids, their anti-inflammatory properties and potential use as an adjunct for periodontal therapy.

MATERIALS AND METHODS

A general literature search was conducted to provide an overview of omega-3 fatty acids, their metabolism and anti-inflammatory properties. A more specific literature search of PubMed and EMBASE was conducted to identify articles dealing studies investigating the effects of omega-3 fatty acids in the treatment of periodontitis in animals and humans and included cross-sectional, longitudinal and intervention designs.

RESULTS

To date, there is good emerging evidence that dietary supplementation with fish oil may be of some benefit and this is enhanced if combined with aspirin. All clinical intervention studies to date have been on small sample sizes, and this indicates there is need for larger and more robust clinical trials to verify these initial findings.

CONCLUSIONS

Dietary supplementation with fish oil could be a cost-effective adjunctive therapy to the management of periodontal disease.

CLINICAL RELEVANCE

The host modulatory properties of omega-3 fatty acids warrant further assessment of their use as an adjunct in the management of periodontitis.

Peptidylarginine deiminase from Porphyromonas gingivalis contributes to infection of gingival fibroblasts and induction of prostaglandin E2 -signaling pathway

Porphyromonas gingivalis (P. gingivalis) expres-ses the enzyme peptidylarginine deiminase (PPAD), which has a strong preference for C-terminal arginines. Due to the combined activity of PPAD and Arg-specific gingipains, P. gingivalis on the cell surface is highly citrullinated. To investigate the contribution of PPAD to the interaction of P. gingivalis with primary human gingival fibroblasts (PHGF) and P. gingivalis-induced synthesis of prostaglandin E2 (PGE2 ), PHGF were infected with wild-type P. gingivalis ATCC 33277, an isogenic PPAD-knockout strain (∆ppad) or a mutated strain (C351A) expressing an inactive enzyme in which the catalytic cysteine has been mutated to alanine (PPAD(C351A) ). Cells were infected in medium containing the mutants alone or in medium supplemented with purified, active PPAD. PHGF infection was assessed by colony-forming assay, microscopic analysis and flow cytometry. Expression of cyclo-oxygenase 2 (COX-2) and microsomal PGE synthase-1 (mPGES-1), key factors in the prostaglandin synthesis pathway, was examined by quantitative reverse transcription polymerase chain reaction (qRT-PCR), while PGE2 synthesis was evaluated by enzyme immunoassay. PHGF were infected more efficiently by wild-type P. gingivalis than by the ∆ppad strain, which correlated with strong induction of COX-2 and mPGES-1 expression by wild-type P. gingivalis, but not by the PPAD activity-null mutant strains (Δppad and C351A). The impaired ability of the Δppad strain to adhere to and/or invade PHGF and both Δppad and C351A to stimulate the PGE2 -synthesis pathway was fully restored by the addition of purified PPAD. The latter effect was strongly inhibited by aspirin. Collectively, our results implicate PPAD activity, but not PPAD itself, as an important factor for gingival fibroblast infection and activation of PGE2 synthesis, the latter of which may strongly contribute to bone resorption and eventual tooth loss.