Periodontal disease activity: a critical assessment

Therapeutic Strategies and Genetic Implications for Periodontal Disease Management: A Systematic Review

The objective of this review is to identify the microbiological alterations caused by various therapy modalities by critically analyzing the current findings. We limited our search to English-language papers published between 1 January 2004 and 7 May 2024 in PubMed, Scopus, and Web of Science that were relevant to our topic. In the search approach, the Boolean keywords "microbio*" AND "periodontitis" were used. A total of 5152 papers were obtained from the databases Web of Science (2205), PubMed (1793), and Scopus (1154). This resulted in 3266 articles after eliminating duplicates (1886), and 1411 entries were eliminated after their titles and abstracts were examined. The qualitative analysis of the 22 final articles is included in this study. Research on periodontal disease shows that periodontitis alters the oral microbiome and increases antibiotic resistance. Treatments like scaling and root planing (SRP), especially when combined with minocycline, improve clinical outcomes by reducing harmful bacteria. Comprehensive mechanical debridement with antibiotics, probiotics, EMD with bone grafts, and other adjunctive therapies enhances periodontal health. Personalized treatment strategies and advanced microbial analyses are crucial for effective periodontal management and antibiotic resistance control.

Quantification and comparison of salivary neutrophils in periodontal health and disease

Background

Neutrophils continuously migrate into the oral cavity from various sources like gingival crevicular fluid and saliva both in health and in inflammation. The migration of the neutrophils into the various tissues and into the oral cavity occurs when the host microbial interplay tips the balance favoring the initiation of the inflammatory and immune reactions which depending on the amount of the microbial load results in the development of acute and chronic infections in the susceptible host.

Aim

The present study was designed to quantify and compare the oral salivary neutrophil levels in patients with gingivitis and chronic and aggressive periodontitis as well as in healthy controls, before and after scaling and root planing (SRP) and to compare the difference within the selected study groups.

Materials and Methods

Forty subjects were classified into four groups, that is, healthy controls, gingivitis, and chronic and aggressive periodontitis. Oral rinse samples were collected using Hank's balanced salt solution from each patient before and after phase I periodontal therapy. Cells in the rinse samples were stained with Acridine orange, and neutrophil counts were carried out using a fluorescence microscope and a hemocytometer.

Results

Baseline oral salivary neutrophil levels were maximum in the chronic periodontitis group followed by the aggressive group and then the gingivitis group. Oral salivary neutrophil levels also positively correlated to probing pocket depth, plaque index, calculus index, and gingival index in all four study groups. Maximum reduction in the oral salivary neutrophil levels after phase I periodontal therapy was seen in the gingivitis group.

Conclusion

From our study, we conclude that the oral salivary neutrophil levels decreased significantly after SRP. Estimation of changes in the oral salivary neutrophil levels has the potential to aid in monitoring treatment outcomes. Thus, it suggests that it could be used as a simple, noninvasive laboratory technique to monitor the periodontal status and disease progression.

Effectiveness of a Therapeutic Educational Oral Health Program for Persons with Schizophrenia: A Cluster Randomized Controlled Trial and Qualitative Approach

BACKGROUND

The oral health of people with schizophrenia (PWS) is very poor, suggesting a need for oral health promotion programmes with a high level of evidence. The aim of the EBENE study (Clinicaltrials.gov: NCT02512367) was to develop and evaluate the effectiveness of a multidisciplinary therapeutic educational programme in oral health (TEPOH) for PWS.

METHODS

A multicentre cluster randomised controlled trial, with outpatient psychiatry centres as the unit of randomisation, was designed to compare the effectiveness of TEPOH (intervention group) versus standard care (control group). The trial was conducted in 26 outpatient psychiatry centres in France (14 in the intervention group, 12 in the control group). Eligible patients with a diagnosis of schizophrenia were enroled between 2016 and 2020 and followed for 6 months. The TEPOH group received a multicomponent intervention (comprising an introductory session, three educational sessions, and a debriefing session). The primary endpoint was the evaluation of periodontal disease as a community periodontal index (CPI) score ≥ 3 at Month 6. The trial was completed using a qualitative approach based on semi-structured interviews with caregivers conducted between July 2018 and December 2019. The trial was stopped early due to difficulties in recruiting patients.

RESULTS

Overall, 81 patients (of 250 planned) were included, and 54 patients completed the trial: 40 in the TEPOH group and 14 in the control group. At baseline, the percentage of CPI ≥ 3 was 42.5% in the TEPOH group and 9.1% in the control group. At Month 6, the percentage of CPI ≥ 3 was 20% in the TEPOH group and 14.3% in the control group. The qualitative evaluation underlined that the professionals emphasised the "seriousness" and "assiduity" of the patients' participation in this programme and that the TEPOH reinforced carers' investment in oral hygiene. It also highlighted structural factors (lack of resources for professionals, lack of teeth in PWS, COVID-19 pandemic) that may have exacerbated the difficulties with enrolment and follow-up.

CONCLUSIONS

The effectiveness of this TEPOH, developed for PWS as part of the EBENE study, has not been demonstrated. Certain aspects of the programme's content and implementation need to be reconsidered. In particular, an adapted subjective measurement scale should be developed.

The adjunctive effect of probiotics to nonsurgical treatment of chronic periodontitis: A randomized controlled clinical trial

Background:

Probiotics catch more attention as adjunctive periodontal therapy. This study was conducted to assess the benefit of locally delivered Lactobacillus reuteri (L. reuteri) probiotic as an adjunctive to scaling and root planing (SRP) in the treatment of chronic periodontitis clinically and microbiologically.

Materials and Methods:

Bacterial cultures and clinical evaluation were recorded in 20 sites of chronic periodontitis in 12 patients and followed up at 3 and 6 months from the start of intervention using clinical attachment level, probing pocket depth, plaque index (PI), bleeding on probing, and microbiologically for Porphyromonas gingivalis (P. gingivalis) load. Patients meeting the inclusion criteria were scheduled within 1 week for two sessions of SRP. After SRP, oral hygiene measures were reassured, and sites were divided randomly into two groups 10 sites each. Group I received SRP only, while Group II received SRP and subgingival delivery of 1 ml of probiotic L. reuteri suspension at baseline and 1, 2, and 4 weeks using a blunt syringe. A periodontal pack was applied after the placement of the drug.

Results:

We found noticeable variation between the two groups in all evaluation aspects at 3 and 6-month follow-up periods except PI at 6 months in which there was no significant difference between both groups.

Conclusions:

The results proved the antimicrobial benefit of L. reuteri probiotic as a promising adjunctive therapy in improving periodontal parameters. However, further long-term studies with large sample size are needed to evaluate the extent of the added value of L. reuteri suspension.

Clarithromycin as an adjunct to periodontal therapy: a systematic review and meta-analysis

OBJECTIVE

To collate the literature evaluating the efficacy of clarithromycin as an adjunct to non-surgical periodontal therapy and conduct meta-analyses for changes in probing pocket depth (PPD) and clinical attachment level (CAL).

METHODS

Five electronic databases were searched from inception to May 2020 (PubMed, Cochrane CENTRAL, EMBASE via OVID, Web of Science and OpenGrey). Clinical outcomes were extracted, pooled and meta-analyses conducted using mean difference with standard deviations.

RESULTS

Systemic delivery: 0.65 mm (95% CI: 0.02 to 1.27 mm) mean additional PPD reduction was observed at 3 months and 0.28 mm (95% CI: -0.32 to 0.87 mm) at 6 months. 0.41 mm (95% CI: -0.12 to 0.95 mm) mean additional CAL gain was observed at 3 months, and 0.16 mm (95% CI: -0.41 to 0.74 mm) at 6 months. Increased risk of adverse events was observed; RR: 5.13 (95% CI: 0.63 to 41.98). Local delivery: 1.01 mm (95% CI: 0.84 to 1.17 mm) mean additional PPD reduction was observed at 3 months, and 1.20 mm (95% CI: 0.76 to 1.64 mm) at 6 months. 0.56 mm (95% CI: 0.46 to 0.66 mm) mean additional CAL gain was observed at 3 months, and 0.83 mm (95% CI: 0.65 to 1.02 mm) at 6 months. No adverse events were observed.

CONCLUSIONS

The use of locally delivered clarithromycin significantly improves treatment outcomes.

Indocyanine green-mediated antimicrobial photodynamic therapy as an adjunct to periodontal therapy: a systematic review and meta-analysis

Objectives

The aim of this systematic review and meta-analysis was to evaluate the efficacy of indocyanine green–mediated photodynamic therapy (ICG-PDT) as an adjunct to non-surgical periodontal therapy (NSPT), in the management of chronic periodontitis.

Materials and methods

Four electronic databases (PubMed, Cochrane Central Register of Controlled Trials, Embase via OVID, Web of Science) were searched for randomised controlled trials comparing NSPT with ICG-PDT to NSPT without laser therapy. Primary outcome measures were changes in probing pocket depth (PPD) and clinical attachment level (CAL). Clinical outcomes were extracted and pooled from 7 eligible trials and meta-analyses conducted using mean difference with standard deviations.

Results

For PPD, adjunctive ICG-PDT resulted in a mean additional reduction of 1.17 mm (95% CI: 0.67–1.66 mm) at 3 months and a mean additional reduction of 1.06 mm (95% CI: 0.54–1.57 mm) at 6 months. For CAL, adjunctive ICG-PDT resulted in a mean additional gain of 0.70 mm (95% CI: 0.17–1.23 mm) at 3 months and a mean additional gain of 1.03 mm (95% CI: 0.83–1.24 mm) at 6 months. No adverse events were reported in any studies.

Conclusions

The adjunctive use of ICG-PDT in NSPT results in improved treatment outcomes at 3 and 6 months post-therapy. Further investigation is needed to evaluate variables such as different photosensitiser concentrations and adjusting parameters associated with the light source.

Clinical relevance

Indocyanine green–based photosensitisers may be a novel, clinically efficacious agent for use in the management of periodontitis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00784-021-03871-2.

Boric acid as an adjunct to periodontal therapy: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy of boric acid as an adjunct to non-surgical periodontal therapy, in comparison with a placebo adjunct, in terms of changes in probing pocket depth (PPD) and clinical attachment level (CAL), in patients with periodontitis.

METHODS

Four electronic databases were searched from inception to May 2020 (PubMed, Cochrane CENTRAL, EMBASE via OVID and Web of Science). Clinical outcomes were extracted, pooled and meta-analyses conducted using mean difference with standard deviations.

RESULTS

For PPD, a mean additional reduction of 0.58 mm (95% CI: -0.03-1.19 mm, p = 0.06) was observed at 3 months and a mean additional reduction of 1.18 mm (95% CI: 0.97-1.40 mm, p < 0.05) at 6 months, compared with placebo. For CAL, a mean additional gain of 0.62 mm (95% CI: -0.07-1.32 mm, p = 0.08) was observed at 3 months and a mean additional gain of 1.24 mm (95% CI: 0.89-1.58 mm, p < 0.05) at 6 months, compared with placebo. No adverse events were reported in any studies.

CONCLUSIONS

The adjunctive use of boric acid in non-surgical periodontal therapy results in improved treatment outcomes at 3 and 6 months, with no adverse events reported.

Clinical periodontal, bacterial, and immunological outcomes of antimicrobial photodynamic therapy in orthodontic treatment-induced gingival enlargement

AIM

The aim of the present clinical trial is to evaluate the clinical, bacterial, and immunological outcomes of photodynamic therapy (PDT) in adolescent patients with orthodontic treatment-induced gingival enlargement (OTGE).

MATERIALS AND METHODS

A total of 26 adolescent patients, 16 girls and 10 boys, of mean age 16.8 years, undergoing fixed orthodontic treatment for at least 6 months (mean duration in months, 8.3 ± 1.9) and presenting with GE were included in the clinical trial. All patients undergoing fixed orthodontic treatment with clinical diagnosis of OTGE were divided into two groups: Patients receiving full-mouth periodontal debridement (FMPD) 'Group-FMPD' and 'Group-PDT' included participants receiving methylene blue-assisted PDT in the selected area along with FMPD. Clinical periodontal assessments included the evaluation of plaque scores (PS), bleeding on probing (BOP), probing depth (PD) and hyperplastic index (HI). The total bacterial counts of Porphyromonas gingivalis (P. gingivalis), Treponema denticola (T. denticola), and Tannerella forsythia (T. forsythia) were estimated and expressed as log CFU/mL of each bacteria. Cytokines including interleukin (IL)-1β and IL-6 were analyzed using enzyme-linked immunosorbent assay (ELISA) kit.

RESULTS

The mean percentage of PS and BOP statistically significantly reduced with both FMPD and PDT from baseline to 4 weeks (p < 0.05). Although mean PD significantly reduced in both the groups at all time points, there was significantly higher reduction with PDT as compared to FMPD at 2 weeks post treatment (p < 0.05). Inter-group comparison showed PDT demonstrated significantly higher HI at 2- and 4-weeks post treatment (p < 0.05). The mean log CFU/mL of P. gingivalis and T. forsythia showed statistically significantly higher reduction with PDT than FMPD (p < 0.05) at both 2-and 4-weeks follow-up. T. denticola reported significantly reduced levels at 2 weeks follow-up period only with PDT (p < 0.05). No statistically significant difference appeared when both treatment modalities were compared with one another (p > 0.05). Four weeks after periodontal treatment, IL-6 significantly reduced with PDT compared to FMPD (p < 0.05).

CONCLUSION

PDT assisted in reducing bacterial counts and improving hyperplastic index in OTGE.

Comparative Evaluation of Boric Acid Gel versus Chlorhexidine Gel in the Treatment of Chronic Periodontitis: Randomized, Placebo-Controlled Clinical Study

Background:

Over the years, various antimicrobials have been tried and tested in the treatment of periodontitis. Chlorhexidine (CHX) has emerged as the gold standard. In recent years, trend has shifted toward the use of agents with antibacterial, anti-inflammatory, and osteoblastic activity. Boric acid (BA) is one such agent which possess all such properties and thus been evaluated in the treatment of periodontitis.

Aim and Objective:

The aim of the study is to compare and evaluate the efficacy of 0.75% BA gel versus 1% CHX gel as an adjunct to scaling and root planing in patients with chronic periodontitis both clinically and microbiologically.

Materials and Methods:

The present study was a randomized, placebo-controlled clinical trial where 45 systemically healthy patients with chronic periodontitis were included in the study. About 15 patients each were divided into three groups, that is, Group I received BA gel, Group II received CHX gel, and Group III received placebo gel as a local drug delivery agent. Clinical parameters such as gingival index, plaque index, modified sulcus bleeding index, probing pocket depth, and clinical attachment level were evaluated at baseline and 6-month follow-up. Microbiological analysis to check for mixed anaerobic flora was done using subgingival plaque samples at baseline and 3 months after treatment.

Results:

Significant reduction was seen in all clinical parameters in both BA and CHX gel groups as compared to control group (P < 0.05). However, on comparing BA gel group with CHX gel, the results were statistically insignificant (P > 0.05).

Conclusion:

BA gel and CHX gel both were equally effective in improving the clinical and microbiologic parameters in patients with chronic periodontitis when used as a local drug delivery agent.

Assessment of interleukin-1beta and interleukin-6 in the crevicular fluid around healthy implants, implants with peri-implantitis, and healthy teeth: a cross-sectional study

Objectives

This study aimed to assess and compare the levels of interleukin-1beta (IL-1β) and interleukin-6 (IL-6) in the crevicular fluid around healthy implants, implants with peri-implantitis, and healthy teeth.

Materials and Methods

This study evaluated 16 dental implants in 8 patients (4 males and 4 females). These patients had at least one healthy implant and one implant with peri-implantitis next to healthy teeth. The crevicular fluid was collected using absorbent cones and transferred to the laboratory. Specimens were evaluated by ELISA for interleukin levels. Data were analyzed using repeated measures ANOVA and Bonferroni tests (P<0.05).

Results

Levels of IL-1β in the crevicular fluid around implants with peri-implantitis were significantly higher than around healthy implants (P=0.002); the latter was significantly higher than around healthy teeth (P=0.015). A significant difference was found in the level of IL-6 in the crevicular fluid around implants with peri-implantitis and healthy implants (P=0.049) and also between implants with peri-implantitis and healthy teeth (P<0.001).

Conclusion

Within the limitations of this study, significant differences exist in the levels of IL-1β and IL-6 in the crevicular fluid of implants with peri-implantitis, healthy implants, and healthy teeth. More studies with larger sample sizes in different populations are necessary.

To estimate salivary aspartate aminotransferase levels in chronic gingivitis and chronic periodontitis patients prior to and following non-surgical periodontal therapy: A clinico-biochemical study

Context:

Saliva can be used as a diagnostic fluid in dentistry. Various enzymes have been proposed as markers for periodontal destruction. One of them is aspartate aminotransferase, for which salivary analysis can offer a cost-effective approach for monitoring the disease. Changes in enzymatic activity reflect metabolic changes in the gingiva and periodontium in inflammation.

Aims:

The purpose of this study was to assess the aspartate aminotransferase levels in saliva prior to and following scaling and root planning (SRP) at 1 month and 3 month interval and correlating it with the clinical parameters in generalized chronic gingivitis and chronic periodontitis patients.

Materials and Methods:

Thirty patients with generalized chronic gingivitis and 30 with generalized chronic periodontitis were selected. The activity of aspartate aminotransferase levels in saliva were assessed biochemically before and after SRP at 1 month and 3 months. The aspartate aminotransferase levels were correlated with clinical parameters (gingival index and probing depth).

Statistical Analysis Used:

A paired t test was done.

Results:

A decrease in gingival index, probing depth, and aspartate aminotransferase levels were seen in both the groups at 1 and 3 months which was found to be statistically highly significant (P value 0.00). Aspartate aminotransferase levels were statistically significantly correlated with the clinical parameters at baseline (P < 0.05) but at 3 months, a positive correlation was seen in both the groups which was statistically insignificant (P > 0.05).

Conclusions:

Elevated salivary aspartate aminotransferase levels were seen in generalized chronic gingivitis and chronic periodontitis patients, with higher values recorded in generalized chronic periodontitis correlating to the tissue destruction taking place in these conditions.

Effect of local application of tea tree (Melaleuca alternifolia) oil gel on long pentraxin level used as an adjunctive treatment of chronic periodontitis: A randomized controlled clinical study

Background:

Conventional non-surgical periodontal therapy has been proven to be an effective treatment for patients with chronic periodontitis. Tea tree oil (TTO) can be used as adjunct to conventional periodontal therapy in patient with chronic periodontitis. The aim of this study was to evaluate the effectiveness of adjunctive treatment of TTO on the clinical parameters and the level of pentraxin-3 (PTX3) in chronic periodontitis.

Materials and Methods:

A total of 40 patients with moderate to severe chronic periodontitis were divided into two groups, Group I received scaling and root planing (SRP) only, Group II received SRP and TTO gel. Clinical parameters were recorded and gingival crevicular fluid (GCF) samples were collected from each subject for measuring PTX3 levels at baseline, 1, 3 and 6 months after treatment.

Results:

In all evaluation periods, there was statistically significant reduction in each of the studied clinical parameters and PTX3 level in Group II as compared with Group I.

Conclusions:

The local delivery of TTO gel in case of chronic periodontitis may have some beneficial effects to augment the results of the conventional periodontal therapy. Moreover, it places a focus on the value of monitoring GCF levels of PTX3 as a marker of periodontal tissue healing.

Commentary: prognosis revisited: a system for assigning periodontal prognosis

Prognosis is an integral part of the periodontal practice because it directly influences treatment planning. However, there is limited direct evidence in the literature regarding the assignment of periodontal prognosis. There are several important concepts to consider in developing a system of periodontal prognosis. Traditional systems are based on tooth loss and may have limited use for patient management. On the other hand, prognosis can be based on stability of the periodontal supporting apparatus, which is influenced by more evidence-based factors and may be more useful for patient management. Other important concepts include the timing of the projection (short and long term) and the consideration of individual teeth versus the overall dentition. Historically, several authors have formulated and investigated their own prognostication systems. Results were variable, but they generally showed that systems based on tooth loss were unpredictable over the long term. Therefore, the purpose of this report is to review relevant literature and propose a new periodontal prognostication system.

Characterization of Patients Presenting for Treatment to a University Refractory Periodontal Diseases Unit: Three Case Reports

BACKGROUND

Of the many forms of periodontal disease, refractory periodontal diseases are the least characterized. They are defined as the continued degeneration of the periodontium despite adequate management. This has led to the suggestion that there may be a systemic component that is a contributing factor to the development of this condition. The objectives of this report were to follow the progression of clinical changes associated with periodontal disease over a number of years in this unique population and review various hematologic and microbiologic factors that may be contributing to the disease progression.

METHODS

Three subjects were profiled. They were referred to the Refractory Periodontal Disease Unit at the University of Toronto by periodontists or general practitioners in the Southern Ontario region. Complete medical and dental histories were obtained along with baseline clinical measurements. Periodontal examinations were facilitated with the use of a computer-assisted periodontal probe. A microbiologic analysis using immunofluorescence techniques was able to detect Prevotella intermedia, Porphyromonas gingivalis, Tannerella forsythia, and Actinobacillus actinomycetemcomitans and spirochetes. A hematologic analysis, including a complete blood count (CBC), immune profile, and glycosylated hemoglobin assay, was also performed.

RESULTS

The clinical presentation revealed that patients receiving adequate maintenance therapy and with good to excellent oral hygiene demonstrated sites with continual loss of attachment. Few periodontal pathogens were detected. However, the most significant finding appeared to be the report elevated levels of CD8+ cells within this group of patients compared to normal laboratory ranges.

CONCLUSIONS

This report is an attempt at characterizing a unique population within the periodontal realm. The long-term monitoring of these patients allowed for an assessment of factors that may be involved in the continued decline of the periodontal health of these patients. Based on the immune profile, it is possible that a hyperresponsive state may be the primary feature of this population. Future assessments, including full-mouth interleukin (IL)-1 and matrix metalloproteinase (MMP)-8 levels, may assist in characterizing this population further, with the goal of producing markers that will assist clinicians in predicting treatment outcome.

Nonsurgical periodontal therapy in 2000: a literature review

BACKGROUND

This article addresses the advantages and limitations of nonsurgical periodontal therapies to treat patients with mild-to-moderate chronic periodontitis.

TYPES OF STUDIES REVIEWED

Controlled clinical trials were selected that assessed the efficacy of the following treatment methods: mechanical instrumentation, ultrasonic débridement, supragingival irrigation, subgingival irrigation, local drug delivery, administration of systemic antibiotics and host-response modulation. Evidently, data with regard to alterations of probing depth, clinical attachment levels and inflammatory status were evaluated.

RESULTS

Comparison of the data from test and control groups revealed the following results. Manual and ultrasonic débridement can be used to treat most patients with mild-to-moderate chronic periodontitis. Patients who do not practice optimal plaque control can enhance their personal hygiene procedures by using supragingival irrigation. Subgingival irrigation usually does not provide any benefit beyond that achieved with root planing. Systemic and locally delivered antimicrobial agents appear to be most beneficial among patients who do not respond to conventional treatment. Host modulation may enhance root planing modestly.

CLINICAL IMPLICATIONS

The data indicate that most patients with mild-to-moderate periodontitis can be treated with nonsurgical therapies. However, clinicians need to be aware of the limitations of each technique with regard to the magnitude of improvement that it can induce at specific sites.

Use of a fluorogenic septapeptide matrix metalloproteinase assay to assess responses to periodontal treatment

BACKGROUND

Quantification of gingival crevicular fluid matrix metalloproteinase activity may provide improved assessment of periodontal disease status and response to treatment. A fluorogenic matrix metalloproteinase substrate assay (FSA) has been developed using a methoxycoumarin-containing septapeptide analog of the alpha2(I) collagen cleavage site. This substrate exhibits increased fluorescence following cleavage by many matrix metalloproteinases, and the enzyme activity can be readily estimated with a fluorimeter. Here we compared this assay with classical methods of periodontal assessment including bleeding on probing, crevicular fluid flow, and probing depth to assess its utility as an indicator of changes in periodontal status and treatment response.

METHODS

Complete measurements of probing depth were obtained for Ramfjord teeth on subjects who had been previously treated for periodontitis. Subjects were subsequently divided into groups based on existing periodontal disease severity: gingivitis (n = 21), stable periodontitis (n = 41), and severe periodontitis (n = 50). Crevicular fluid volume, bleeding on probing, and FSA were measured at each Ramfjord tooth or substitute. After baseline measurements, subjects received subgingival scaling and prophylaxis; 3 months later, they were reassessed.

RESULTS

FSA measurements were positively associated with severity of disease at baseline. After treatment there were substantial reductions of FSA in gingivitis (approximately 51%; P <0.01) and severe periodontitis (approximately 45%; P <0.001), but not in stable periodontitis (13%; P >0.2). All groups showed a positive association between FSA measurements and higher bleeding scores at individual sites. FSA measurements were also positively associated with crevicular fluid flow at baseline, but after treatment there was a approximately 67% decrease (P <0.01) in the highest crevicular fluid flow class. There were significant reductions of FSA at follow-up for sites with probing depths between 0 to 3 mm (23%; P <0.05) and 4 to 6 mm (31%; P <0.05). However, the largest reduction was for sites with probing depth between 7 to 9 mm (49%; P <0.001).

CONCLUSIONS

These results indicate that monitoring patients by measurement of matrix metalloproteinase levels in gingival crevicular fluid with the quenched fluorescent substrate assay provides estimates of inflammatory status, periodontal destruction, and response to treatment, especially in more severe periodontitis lesions.

Human gingival crevicular fluid contains MRP8 (S100A8) and MRP14 (S100A9), two calcium-binding proteins of the S100 family

Human gingival crevicular fluid contains unidentified proteins which might play a role as markers in periodontal diseases. Therefore, low-molecular-weight proteins found in human gingival crevicular fluid (GCF), but absent from serum, were identified in the present study by means of two-dimensional electrophoresis (2-D PAGE) analysis. GCF, serum, and whole saliva were collected from periodontitis and healthy subjects, as well as from edentulous and newborn subjects. Protein samples were separated by two-dimensional polyacrylamide gel electrophoresis, stained with silver, and compared with reference protein maps in the SWISS-2D PAGE database. In GCF and saliva from periodontitis patients and healthy subjects, four dominant low-molecular-mass (from 8 to 14 kDa) acidic spots were observed. They were not found in serum and were less visible in saliva from edentulous and newborn subjects. From N-terminal amino acid sequencing, the two 2-D protein spots of 8 kDa and isoelectric points between 6.5 and 7.0 were both identified as protein MRP8 (SI00A8), a member of the S100 family of calcium-binding proteins. Using peptide mass fingerprinting and matrix-assisted laser desorption ionization time of flight mass spectrometry (MALDI-TOF-MS), we identified the other two protein spots, with mass of 14 kDa and isoelectric points between 5.5 and 6.0, as protein MRP14 (S100A9), also belonging to the S100 family. The presence of MRP8 and MRP14 in GCF was confirmed by Western blot, with monoclonal antibodies. The two polypeptides, MRP8 and MRP14, identified in GCF represent the major difference between the 2-D PAGE patterns of serum and GCF, and we hypothesize that they may play an important role in the gingival sulcus and could represent possible markers for periodontal diseases.

Relationship of the subgingival microbiota to a chairside test for aspartate aminotransferase in gingival crevicular fluid

BACKGROUND

The aim of the present study was to evaluate the association between the occurrence of certain specific periodontal pathogens and aspartate aminotransferase (AST) levels in gingival crevicular fluid (GCF).

METHODS

Thirty systemically healthy subjects with moderate to advanced periodontitis were selected. Within each subject, the AST contents of GCF from sites with probing depth between 5 mm and 7 mm were measured using a chairside colorimetric test. AST-positive site refers to one that had an AST level > or = 800 microIU. Subgingival plaque samples from one AST-positive and one negative site were collected for microbiological examination. One site with probing depth < or = 3 mm and no gingival inflammation was selected as a healthy control. Clinical parameters of the chosen sites, including the plaque index and gingival index scores, probing depth, and clinical attachment level were measured. Culture and immunofluorescence (IF) were used for detecting common periodontal pathogens, including Actinobacillus actinomycetemcomitans, Peptostreptococcus micros, Campylobacter rectus, Eikenella corrodens, Fusobacterium nucleatum, Capnocytophaga species, Prevotella intermedia, Prevotella melaninogenica, and Porphyromonas gingivalis. Logistic regression was used to analyze the correlation between the AST test and certain specific pathogens.

RESULTS

The GCF scores and total cultivable bacterial counts were higher in AST-positive sites than either AST-negative or healthy sites. The prevalence and proportions of specific periodontal pathogens such as C rectus, E. corrodens, F. nucleatum, Capnocytophaga species, P. intermedia, and P. gingivalis were significantly higher in positive than in negative sites. In analyzing the correlation of the proportion of 6 pathogens with the AST test by logistic regression, only P. gingivalis showed a significant positive correlation. The odds ratio of having a high proportion of P. gingivalis in the presence of a positive AST test was 1.21.

CONCLUSIONS

The present study showed that at AST-positive sites, there is a higher prevalence and higher proportion of certain periodontal pathogens. Although only the correlation of P. gingivalis and AST values was statistically significant, the results imply that certain periodontal pathogens may be associated with elevation of AST levels in GCF.

High levels of soluble intercellular adhesion molecule-1 (ICAM-1) in crevicular fluid of periodontitis patients with plaque

The intercellular adhesion molecule-1 (ICAM-1) is a membrane-bound molecule involved in cell-cell adhesive interactions which is upregulated on inflammatory epithelial cells. The levels of soluble ICAM-1 (sICAM-1) shed into the gingival crevicular fluid (GCF) were studied in healthy patients and patients with gingivitis, adult periodontitis or rapidly progressive periodontitis, using an ELISA technique. Clinical parameters including plaque index, gingival index, probing depth, and bleeding on probing were recorded following careful sampling of GCF with standardised filter strips. In GCF, sICAM-1 levels were higher for patients with plaque (p=0.04) and for patients with inflammation (p=0.02), but did not correlate with disease classifications. These results suggest that elevated GCF sICAM-1 levels may represent increased shedding of this molecule in the interstitial fluid as a result of membrane-bound ICAM-1 upregulation on ICAM-1 gingival-bearing cells in relation with plaque accumulation and inflammation.

Contemporary interpretation of probing depth assessments: diagnostic and therapeutic implications. A literature review

This paper addresses the diagnostic and therapeutic implications of increased probing depths. In general, in untreated and treated patients, when deep and shallow probing depths are compared, the data indicate that deep sites are associated with increased bleeding upon probing, elevated subgingival temperatures, higher levels of pathogens, more probing errors, a greater amount of infiltrated connective tissue, reduced ability to remove subgingival deposits with root planing, and diminished effectiveness of oral hygiene to alter the subgingival microbiota. Clinical trials demonstrate that probing depth is not a good predictor of future disease progression. However, deep sites are at greater risk of disease progression than shallow sites in untreated and treated patients. Furthermore, the deeper the probing depth, the greater the risk of future disease progression. Overall, the preponderance of evidence indicates that it is advantageous, but not always necessary, for patients to have shallow probing depths. With regards to surgical reduction of probing depths beyond that attained with non-surgical therapy, clinicians need to consider the advantages (e.g., ease of maintenance, reduced risk of disease progression) and disadvantages (e.g., root sensitivity, cosmetic defects) of treatment procedures. Since numerous variables require consideration (e.g., response to root planing, goals of therapy, acceptable level of risk for future disease progression), treatment decisions will vary depending on the patient and the desired clinical outcome at specific sites.

Attachment loss with postmenopausal age and smoking

To determine whether postmenopausal bone loss and factors associated with osteoporosis affect tooth retention, we examined vertebral and proximal femoral (postcranial) bone mineral density in relation to tooth loss and attachment loss in a cross-sectional study of 135 postmenopausal women (age range 41-70 yr). Women had at least 10 teeth and no evidence of moderate or severe periodontal disease. Full-mouth attachment loss measurements were made using a pressure-sensitive probe, and bone density was determined by dual-energy X-ray absorptiometry. Attachment loss was correlated with tooth loss (number of remaining teeth, radiologically determined), but not with vertebral or proximal femur bone density. Multivariate analysis showed current smoking (p = 0.01), years since menopause (p = 0.02) and the interaction of age and current smoking (p < 0.01), to be statistically significant predictors of attachment loss in our study population.

Is the chemical prevention of gingivitis necessary to prevent severe periodontitis?

Gingival inflammation seldom causes discomfort, social embarrassment or loss of function. As most sites with gingival inflammation do not progress to severe periodontal disease, gingivitis should not be considered a public health problem. Periodontitis is always preceded by gingivitis. But most gingivitis remains stable for years without progressing to periodontitis. The number of gingivitis sites that do convert is small. The levels of oral cleanliness achieved by the majority of populations in industrialized countries are below the threshold for severe destructive periodontal disease of personal and public health concern. Because methods of measuring the progression of periodontal disease are unreliable, definitive answers regarding conversion of gingivitis to severe periodontitis are lacking. Gingival inflammation frequently remains contained; most gingivitis remains stable for years without progressing to periodontitis. Decreasing gingivitis does reduce shallow pocketing, but the effect on severe periodontitis is not clear. Although the underlying justification for the reduction of plaque is to reduce gingival inflammation to prevent or reduce severe periodontitis and tooth loss, the basis for the approach is equivocal. A reasonably high level of plaque appears to be compatible with acceptably low levels of periodontal disease. Reducing nonspecific plaque levels to such levels is therefore a rational goal. The conventional methods of controlling periodontal disease involve mechanical removal of plaque and calculus. A complimentary ecological approach, using chemicals, would be to alter the environment of the pocket to prevent growth of putative pathogens. Any ecological approach should be sensitive to the dangers of disrupting the natural ecology of dental plaque. Some antimicrobial and antimetabolic agents such as fluoride, chlorhexidine and triclosan and zinc citrate can selectively suppress certain organisms or inhibit bacterial proteases implicated in tissue damage. The uncertainties about factors that convert gingival inflammation into periodontitis and periodontitis into severe periodontitis coupled with insufficient data from controlled clinical trials on the effectiveness of chemical reduction of gingivitis to prevent severe periodontitis leads one to conclude that more research is required before the need for the chemical prevention of gingivitis to prevent severe periodontitis can be justified.

Design and implementation of clinical trials of antimicrobial drugs and devices used in periodontal disease treatment

The design and implementation of clinical trials (CTs) carried out to evaluate antimicrobial and anti-infective drugs and devices are one of the most difficult challenges in contemporary periodontal research and product development. The overwhelming amount of evidence which has established a microbial etiology for periodontitis is the basis for developing and testing antimicrobial treatments. Well-designed antimicrobial CTs start with a carefully crafted hypothesis and a protocol which explicitly integrates the requirements of the patient, the clinician, the sponsor, and regulatory authorities. Surrogate variables for effectiveness must be clinically relevant, scientifically sound, and statistically valid. Currently, clinical attachment level measurements and alveolar bone assessments are accepted as proof of effectiveness. Indication and claim support of the antimicrobial product guide the design and implementation of the CT. Adverse microbiologic consequences, such as lack of antimicrobial susceptibility, wrong spectrum, incorrect dosage, non-compliance, and drug interference, must be monitored. Successful CTs balance a large group of variables used to screen, randomize, and assign subjects to experimental and control groups to ensure that prognostic and risk factors are properly accounted for.

A longitudinal study of various crevicular fluid components as markers of periodontal disease activity

In order to examine the relationship of possible crevicular biochemical parameters to attachment loss (ALOSS), 330 sites from 8 untreated adult patients were monitored longitudinally at 3-month intervals, for up to 1 year. Attachment levels were measured with a force-sensing probe and an acrylic stent in duplicates at each study point. Crevicular samples were collected and used for the determination of the following 11 markers: number of polymorphonuclear leukocytes (PMNs), prostaglandin E2 (PGE2), osteocalcin (OC), alkaline phosphatase (ALP), collagenase (COL), beta-glucuronidase (BG), antigenic and functional elastase (AEL and FEL), alpha-1 antitrypsin (a1AT), alpha-2 macroglobulin (a2M) and aspartate aminotransferase (AST). 10 sites with ALOSS of > or = 1.5 mm per 3 months (active sites) and 43 sites with negligible changes (inactive sites) were identified. Total amounts of ALP, BG and COL were found to be significantly higher in active as compared to inactive sites, prior to significant ALOSS, without any significant differences in crevicular fluid volume and clinical indices. When biochemical parameters were expressed as ratios to the number of PMNs, PGE2/ PMNs was significantly elevated in active sites. The capacity of such individual parameters to distinguish between active and inactive sites was limited. However, linear discriminant analysis using total amounts of PGE2, COL, ALP, a2M, OC and AEL showed more significant diagnostic values (sensitivity: 80%, specificity: 91%). These findings suggest that the combination of several biochemical parameters in crevicular fluid could give more information to predict future clinical ALOSS.

The relationship between gingival crevicular fluid cathepsin B activity and periodontal attachment loss in chronic periodontitis patients: a 2-year longitudinal study

This study aims to determine whether gingival crevicular fluid (GCF) cathepsin B levels, total activity (TA) and concentration (EC) predict progressive attachment loss (AL). Seventy-five previously untreated patients with moderate periodontitis were recruited. GCF was collected from 16 molar and premolar mesiobuccal sites and probing attachment level (PAL) and probing depth (PPD) were measured with an electronic probe. Gingival, gingival bleeding and plaque indices were then scored. Prior to baseline patients were given basic periodontal treatment after which the above procedures were repeated. Carefully localized radiographs were taken of the test teeth and repeated annually. Patients were seen 3-monthly for 2 yr and the procedures were repeated. One hundred and twenty-one AL sites, 90 rapid AL (RAL) and 31 gradual AL (GAL), in 49 patients were detected. Cathepsin B levels (TA & EC) at RAL sites were significantly higher (p < 0.0001) than paired control sites at the attachment loss time (ALT) and prediction time (PT). Mean levels (TA & EC) over the study period at GAL sites were significantly higher (p < 0.0001) than paired control sites. Using a critical value (CV) of 7.5 microU/30 s (TA) and 30 microU/microL (EC) showed a sensitivity of 100% and specificity of 99.83% (TA) and 100% and 99.75%(EC) at both ALT & PT. Mean cathepsin B levels (TA & EC) were significantly higher (p < 0.0001) at RAL and GAL sites than non-attachment loss (NAL) sites in AL patients in intrapatient comparisons and mean patient levels were significantly higher (p < 0.0001) in AL patients than NAL patients in interpatient comparisons. These results indicate that GCF cathepsin B may serve as a predictor of attachment loss.

Correlation between gingivain/gingipain and bacterial dipeptidyl peptidase activity in gingival crevicular fluid and periodontal attachment loss in chronic periodontitis patients. A 2-year longitudinal study

The aim of this study is to determine whether either gingival crevicular fluid (GCF) bacterial gingivain/gingipain or dipeptidyl peptidase (DPP) levels, total activity (TA) and concentration (EC), predict progressive attachment loss (AL) in 75 patients with moderate periodontitis. GCF was collected from 16 molar and premolar mesiobuccal sites and then clinical attachment level (CAL) and probing depth (PD) were measured with an electronic constant pressure probe. Lastly, gingival, gingival bleeding, and plaque indices were scored. Prior to the baseline visit, patients were given basic periodontal treatment after which the above procedures were repeated. In addition, carefully localized radiographs were taken of the test teeth and repeated annually. Patients were then seen every 3 months for 2 years and the clinical measurements repeated at each visit. In 48 patients, 124 AL sites, 91 rapid AL (RAL), and 33 gradual AL (GAL) were detected. Gingivain/gingipain and bacterial DPP levels (TA and EC) at RAL sites were significantly higher (P < or = 0.0001) than at paired control sites at the attachment loss time (ALT) and prediction time (PT). Mean levels over the study period of both proteases (TA and EC) at GAL sites were significantly higher (P < or = 0.0001) than those at paired control sites. The GCF levels of gingivain/gingipain were always higher than those of DPP. Critical values (CV) of 5 microU/30 seconds (TA) and 30 microU/microL (EC) for both proteases showed high sensitivity and specificity values for TA and EC, which were the same at both ALT and PT. The positive predictive values were higher for gingivain/ gingipain. Mean site levels, over the course of the study, of both proteases (TA and EC) were significantly higher (P < or = 0.0001) at AL, RAL, and GAL sites than non-attachment loss (NAL) sites in AL patients and mean patient levels were significantly higher (P < or = 0.0001) in AL, RAL, and GAL patients than NAL patients. These results indicate that both of these bacterial proteases in GCF may be predictors of periodontal attachment loss.

A 2-year longitudinal study of elastase in human gingival crevicular fluid and periodontal attachment loss

The purpose of this study is to determine whether gingival crevicular fluid (GCF) elastase total activity (TA) and concentration (EC) correlate with and predict progressive attachment loss (AL). 75 previously untreated patients with moderate periodontitis were recruited. GCF was collected from 16 molar and premolar mesiobuccal sites and probing attachment loss (PAL), probing depth (PPD), gingival index (GI), gingival bleeding index (GBI) and plaque index (Pl.I) were measured. PAL and PPD were measured with an electronic, constant pressure probe. Patients were given basic periodontal treatment prior to baseline when the above procedures were repeated. In addition, carefully localised radiographs were taken of the test teeth and repeated annually. Patients were seen at 3 months intervals to 2 years and the procedures were repeated. 119 AL sites were detected and 89 of these were rapid AL sites (RAL) and 30 were gradual AL sites (GAL). Elastase levels (TA & EC) at RAL sites were significantly higher (p < or = 0.0001) than paired control sites in the same patient at both the attachment loss time (ALT) and the prediction time (PT). The mean levels (TA & EC) over the study period at GAL sites were significantly higher (p < or = 0.0001) than paired control sites in the same patient. Using a critical value (CV) of 125 micronsU/30 s (TA) and 400 micronsU/micronsL (EC) in 2 x 2 contingency tables showed a sensitivity of 100% and specificity of 99.95% (TA) and a sensitivity of 100% and specificity of 99.91% (EC) at the PT with very similar values at the ALT. Patient level comparisons showed that the mean elastase levels (TA & EC) were significantly higher (p < or = 0.0001) at RAL and GAL sites than non-attachment loss (NAL) sites in AL patients and that the mean levels were significantly higher (p < or = 0.0001) in AL patients than NAL patients. All these results indicate that these CVs for GCF elastase activity may serve as a predictors of future attachment loss.

Oral fluid elastase as an indicator of periodontal health

The study was designed to find out whether oral elastase activity could be used as a simple biochemical indicator of periodontal health. Both stimulated whole saliva and water rinse samples were collected from subjects with different degrees of adult periodontitis, gingivitis or healthy periodontium. In both sample types, elastase was mostly bound to insoluble fraction and preferred valine containing synthetic substrate, similar to neutrophil elastase. The elastase measurement required very little manipulation or time and its reproducibility was found to be good. The elastase levels were found to be negligible in edentulous subjects and usually very low in subjects with healthy periodontium. In about 85% of periodontitis cases having at least 1 deep periodontal pocket ( > or = 6 mm), clearly elevated elastases levels were detected in both the saliva and r rinse samples. In advanced periodontitis cases, the colour reaction took place in 0.5 to 2 h. In localized periodontitis cases, 2- to 18-h incubations were required for positive reaction. There was a good correlation between the elastase activity and the number of deep periodontal pockets and the average community periodontal index of the subjects. Elastase activity was not a good indicator of gingivitis. About 45% of gingivitis cases were positive with the elastase test, and the enzyme values were not significantly increased in experimental gingivitis. In a longitudinal study on advanced periodontitis cases, elastase levels dropped dramatically as a result of clinically successful therapy, close to the values of healthy subjects. The oral elastase test could serve as a valuable adjunct in periodontal screening and assessment of treatment efficacy.

Correlation between gingival crevicular fluid dipeptidyl peptidase II and IV activity and periodontal attachment loss. A 2-year longitudinal study in chronic periodontitis patients

OBJECTIVE

The aim of this study is to determine whether gingival crevicular fluid (GCF) dipeptidyl peptidase (DPP) II or IV levels, total activity (TA) and concentration (EC), predict progressive attachment loss (AL).

SUBJECTS AND METHODS

Seventy five patients with moderate periodontitis were recruited. GCF was first collected from 16 molar and premolar mesiobuccal sites and then probing attachment level (PAL) and probing pocket depth (PPD) were measured with an electronic probe. Finally, gingival index, gingival bleeding and plaque indices were scored. Patients were given basic periodontal treatment prior to baseline after which the above procedures were repeated. Patients were seen 3 monthly for 2 years and the procedures were repeated. Carefully localised radiographs were taken of the test teeth annually.

RESULTS

One hundred and twenty AL sites, 88 rapid AL (RAL) and 32 gradual AL (GrAL), in 48 patients were detected. DPP II and IV levels (TA and EC) at RAL sites were significantly higher (P < or = 0.0001) than paired control sites at the attachment loss time (ALT) and prediction time (PT). Mean levels over the study period of both proteases (TA and EC) at GrAL sites were significantly higher (P < or = 0.0001) than other paired control sites. The GCF levels of DPP IV were always slightly higher than those of DPP II. Critical values (CV) of 5 microU per 30 s (TA) and 25 microU microL(-1) (EC) for both proteases showed high sensitivity and specificity values for TA and EC and these were the same at both ALT and PT. The positive predictive values were slightly higher for DPP II. Mean site DPP II and IV levels (TA and EC) in intra-patient comparisons were significantly higher (P < or = 0.0001) at RAL and GrAL sites than non-attachment loss (NAL) sites in AL patients and mean patient levels were significantly higher (P < or = 0.0001) in AL patients than NAL patients in inter-patient comparisons.

CONCLUSIONS

These results indicate that both GCF DPP II and IV may be predictors of periodontal attachment loss.

Effect of gingival wall on resistance to probing forces

This study was conducted to determine whether the gingival tissue lateral to the periodontal sulcus contributes resistance to the advancement of a periodontal probe tip into the sulcus under different applied pressures. An electromechanical device was used to advance a probe tip 0.6 mm in diameter into the facial sulcus at a constant speed until resisting forces of 0.70 N were encountered. The device registered the resisting force and probe advancement simultaneously. The gingiva of all 2nd incisors, 2nd premolars, and 1st molars of 4 young adult male beagle dogs were tested. After the first measurement, the buccal gingiva of experimental sites were incised mesiodistally from the gingival margin to the alveolar crest and the sulcus was reprobed. 2 experimental and control quadrants were selected randomly resulting in 6 sets of both experimental and control data from each animal. The data were analyzed with analysis of variance. The analysis demonstrated significant variation from site to site, and dog to dog; therefore, only changes between the 1st and 2nd probings at the same sites could be compared. Less variability of probing distance in different animals occurred at higher forces; however, the incision had a significant effect on probing distance at these forces. The pressure at which probing distance had less variability among animals and least affected when the gingival sulcular wall was incised was estimated to be 106 N/cm2. This corresponds to 30 g force on the 0.6 mm diameter probe.

Understanding diagnostic testing for periodontal diseases

Probability computations are used to characterize new periodontal diagnostic tests and are an integral facet of risk assessment for periodontal diseases. However, misinterpretation of these data can result in confusion and erroneous conclusions regarding the relationship of test results to the presence or absence of disease in a subject, or to episodes of periodontal destruction at specific sites. This paper was written to provide clinicians with a primer to help in understanding calculations used to evaluate diagnostic tests and risk assessment.

A 6-month multi-center evaluation of adjunctive tetracycline fiber therapy used in conjunction with scaling and root planing in maintenance patients: clinical results

The purpose of this study was to compare the efficacy of scaling and root planing (S and RP) alone versus tetracycline fiber therapy used adjunctively with S and RP in the treatment of localized recurrent periodontitis sites in maintenance patients. A total of 113 patients receiving regular supportive periodontal therapy (SPT) were treated with whole mouth S and RP. Two non-adjacent sites in separate quadrants were selected in each patient for monitoring based on criteria that the sites were 5 to 8 mm deep and had a history of bleeding on probing. The chosen sites were randomly assigned to one of the two treatment groups. Probing depth (PD), bleeding on probing (BOP), and clinical attachment level (CAL) were measured at baseline and 1, 3, and 6 months. At 1, 3 and 6 months, adjunctive fiber therapy was significantly better in reducing PD (P < 0.05) and reducing BOP (P < 0.05) than S and RP alone. At 6 months, fiber therapy was significantly better in promoting clinical attachment gain (P < 0.05) than S and RP alone. Overall, these results indicate that fiber therapy significantly enhanced the effectiveness of S and RP in the management of localized recurrent periodontitis sites, in patients receiving regular supportive periodontal treatment.

Association of clinical risk factors with treatment outcomes

A patient's decision to accept treatment recommended by his dental health care provider will be strongly influenced by the quality of the information he is given. Estimates of prognosis and treatment predictability must be based on the evidence available from the literature and the practitioners' own experience. Thorough, accurate, and relevant clinical and adjunctive diagnostic data will be a major influence in the development of the patient's individualized treatment strategy. Some clinical findings such as severity of disease for age, deepening pockets accompanied by loss of clinical attachment, frequent bleeding on probing, and bone loss can be considered as risk and prognosis factors. "Hard" data implicating specific clinical or diagnostic findings as risk factors or markers are difficult to find because there are few randomized longitudinal trials available. A new approach which attempts to focus on reducing the risk of undesirable outcomes while improving the probability of successful outcomes following treatment has been referred to as the Treatment Predictability Model. A key feature of this approach is the focus on individual patient circumstances and preferences through the use of decision analysis techniques. A large scale, long-term project utilizing a practice-based research network (PBRN) provided some descriptive information about factors that could distinguish between responders and nonresponder patients undergoing treatment for advanced periodontitis. Bacterial colonization, level of post-treatment plaque control, and smoking were major predictive variables in this group of periodontitis patients. The predictive treatment approach may be one way to develop evidence that will improve the predictability of outcomes for individual patients.

Type I collagen carboxyterminal telopeptide in human gingival crevicular fluid in different clinical conditions and after periodontal treatment

A total of 126 gingival crevicular fluid (GCF) samples were collected from 20 adults using paper strips. Patients were divided into a periodontitis-affected group (13 subjects) and a periodontitis-free group (7 subjects) by pocket depth and radiological bone loss. 4 subjects from the periodontitis-affected group received a single episode of periodontal treatment (scaling, root planing and curettage) and GCF samples were collected 2, 5, 10, 20 and 40 days after treatment. Type I collagen carboxyterminal telopeptide (ICTP) in GCF was extracted into saline solution and determined by a radioimmunological method. Mean GCF ICTP concentration was 425 micrograms/l (SEM 45) in periodontitis patients and 148 micrograms/l (SEM 25) in periodontitis-free subjects, i.e., GCF ICTP concentrations were about 100 x higher than serum reference values. Significant positive correlations were found between GCF ICTP total amount per site and plaque index (R = 0.362), papilla bleeding index (R = 0.259), pocket depth (R = 0.464) and radiological bone loss (R = 0.418). Periodontal treatment decreased GCF ICTP concentration to the level seen in healthy subjects. However, large variations were seen between subjects and sites. ICTP levels below the detection limit were often found in deep pockets, as well as high values in periodontitis-free subjects. It was concluded that GCF ICTP reflects the local type I collagen degradation in periodontal tissues, and probably gives information about the tissue destruction process beyond the reach of the clinical parameters.

Differential periodontal temperature measurements in the assessment of periodontal disease activity: an experimental and clinical study

The difference in surface temperatures between the bottom of periodontal pockets and the attached gingiva adjacent to the openings of the pockets were determined both in monkeys with experimental marginal periodontitis, and clinically in patients with marginal periodontitis. For this purpose a custom-made, temperature-measuring device was developed which enabled immediate recording of temperature differences as well as periodontal pocket depths, bleeding, and attachment levels. The measurements were performed periodically. The differential temperature measurements were correlated to change in periodontal attachment over time. It was shown that differential periodontal temperatures are well correlated to change in periodontal attachment over time. It was furthermore concluded that differential periodontal temperature measurements have the potential of serving as a predictor of activity of marginal periodontitis. However, more extensive data are required to assess the sensitivity and specificity of the method.

Role of suspected periodontopathogens in microbiological monitoring of periodontitis

Periodontal disease is the clinical result of a complex interaction between the host and plaque bacteria. Although a specificity to some degree is found for Actinobacillus actinomycetemcomitans in localized juvenile periodontitis (LJP), it has been difficult to obtain evidence for a specific etiological role of the bacteria associated with periodontal disease in adults. What we see is the net result of host-parasite interactions which in an unpredictable moment accumulate and exceed the threshold of tissue integrity. This hypothesis is concomitant with the view of periodontal disease as a polymicrobial infection, predominantly anaerobic, which occurs commonly in the oral cavity or elsewhere in the body. Some micro-organisms (risk markers) occur more frequently than others and may significantly determine the outcome of this host-parasite interaction. Microbiological sampling and analysis seem to be of limited value in risk assessment; however, they can be used as tools in diagnosis in LJP patients and acute infections, and in treatment decision and therapy control in "refractory" patients. Suspected pathogens (risk markers) are Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and some species of spirochetes, while the roles of Prevotella intermedia, Bacteroidesforsythus, Fusobacterium nucleatum, Campylobacter rectus, and Peptostreptococcus micros are more uncertain. The presence of periodontopathogens as well as enterics, Staphylococcus aureus and Candida especially, should be considered in patients with systemic individual disorders--e.g., diabetes mellitus, neutropenia, agranulocytosis, and AIDS--or with implants.

Subgingival minocycline hydrochloride ointment in moderate to severe chronic adult periodontitis: a randomized, double-blind, vehicle-controlled, multicenter study

The safety and efficacy of subgingivally-applied 2% minocycline ointment was evaluated in a randomized, double-blind study of 103 adults with moderate to severe periodontitis. Two groups were compared; one received the test minocycline ointment and the other a vehicle control. Both groups had scaling and root planing at baseline, after which the test or control ointments were applied with an applicator into the periodontal pockets at baseline, and at 2, 4, and 6 weeks. Assessment of clinical response was made by measuring probing depth and probing attachment level and gingival bleeding. These measurements were made at baseline prior to scaling and root planing, and at weeks 4 and 12. Microbiological assessment of the subgingival flora was carried out with DNA probes at baseline, and at weeks 2, 4, 6, and 12 to identify and quantify Porphyromonas gingivalis, Prevotella intermedia, and Actinobacillus actinomycetemcomitans. Subgingival minocycline ointment resulted in statistically significantly greater reduction of P. gingivalis at weeks 2, 4, 6, and 12; P. intermedia at weeks 2, 4, 6, and 12; and A. actinomycetemcomitans at weeks 6 and 12. Probing depth reductions were seen for both groups at weeks 4 and 12; however, this reduction was statistically significantly greater in subjects treated with minocycline ointment. Reduction in gingival index and probing attachment gain were seen in both groups, however, the differences between the groups were not statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Periodontal health in free-ranging baboons of Ethiopia and Kenya

Frontal and lateral intraoral photographs of 19 baboons from the Awash National Park, Ethiopia and 37 baboons from Amboseli National Park, Kenya, were used to assess periodontal health. The Awash baboons, and two groups (Alto's and Hook's) at Amboseli, fed entirely from natural sources, but baboons from the third Amboseli group (Lodge) fed largely on food refuse from one of the park's lodges. Juveniles and adults were evaluated separately. Intraoral photographs were seriated based on visual appraisals of periodontal health. In both age groups, the best periodontal health was seen in Awash animals; Alto's and Hook's animals were intermediate, and the poorest health was seen in the Lodge sample. The periodontal health decreased with age in adult baboons, as reported in humans. Geochemistry, genetics, age, and diet (particularly variations in bacterial flora) were considered as factors contributing to the intergroup differences. Although it is not possible at present to exclude any of these as a contributing cause, we consider that diet in the broad sense (including food, water, and contamination by oral bacteria of human origin) probably plays a major role.

The host response in gingival crevicular fluid: potential applications in periodontitis clinical trials

Traditional clinical variables of periodontal pathology have only limited value as indicators for future disease progression in patients with adult periodontitis. Consequently, other aspects of the periodontal lesion are being examined for their diagnostic utility. Analysis of the host response in gingival crevicular fluid (GCF) is among the most intensely studied of these new diagnostic approaches. Specific indicators of the humoral immune response, cellular immune response, and acute inflammatory response have been identified in GCF. The relationship of indicators of the humoral immune response to active periodontal disease is equivocal. Specific indicators of the cellular immune response in GCF may ultimately prove to be important diagnostically, but the relationship of any specific marker to active periodontal disease has not been reported. In contrast, the acute inflammatory response in GCF has been extensively studied and a number of factors appear to be associated with an increased risk for future disease progression. Indicators of enhanced polymorphonuclear leukocyte activity, (lysosomal beta-glucuronidase, lysosomal collagenase), prostaglandin E2, and an indicator of acute tissue destruction (the cytoplasmic enzymes aspartate aminotransferase) have been associated with the occurrence of clinical attachment loss. An example of the application of a GCF marker in a periodontitis clinical trial is provided by describing the relationship of lysosomal beta-glucuronidase in GCF at baseline and 2 weeks following root planing and scaling to the occurrence of disease activity during the following 6 months. Persistently elevated levels of this enzyme were related to clinical attachment loss. The positive, negative, and total predictive values for beta-glucuronidase as an identifier of clinical attachment loss were 86%, 71%, and 76%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical effect of subgingival chlorhexidine irrigation on gingivitis in adolescent orthodontic patients

Twenty-three adolescent orthodontic patients with gingivitis affecting all banded first molars volunteered for the study. Three measures associated with gingivitis (papilla bleeding index, plaque index, and probing depth) were recorded at four sites for all four molars. A single application of subgingival irrigation with 0.12% chlorhexidine digluconate or isotonic saline was performed for 5 seconds at each site. As determined by coin toss, the first molars on the right or left side of the mouth received either chlorhexidine or saline irrigation. The papilla bleeding index, plaque index, and probing depth were recorded before the treatment and subsequently at 2 weeks and then 4 weeks. The gingival bleeding as determined by papilla bleeding index, was virtually eliminated in 4 weeks by a single application of subgingival irrigation with either chlorhexidine or saline. However, there was no significant reduction in pocket depth or plaque index. In addition, no significant difference between the effect of chlorhexidine or saline was found for any of the outcome measures.

Report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

Subjects of the past decade in the dental literature are reflected in this year's Committee report. We note the decrease in the prevalence of caries, the influence of dental implants, the advancements in dental materials, and the continued efforts to control adhesive events in the oral cavity. This year we included comments from and about many significant review articles published this past year. The Committee continues to be concerned about the quality of some of the work reported and the quality of the reporting. We have attempted to select the distinguished work, that which provides new information to our profession. The subjects covered include pulp biology, caries prevention, periodontics, implants, craniomandibular function and dysfunction, occlusion, and dental materials.