Position Paper: Diagnosis of Periodontal Diseases

Salivary microbiome and biomarker characteristics of diabetics with periodontitis

OBJECTIVE

To examine the characteristics of the salivary microbiome in Type 2 diabetes mellitus (T2DM) patients with or without periodontitis.

BACKGROUND

Periodontitis has been identified as clear sequelae of T2DM. This chronic oral disease also impacts the management of the clinical features of diabetes. The oral microbiome characteristics in T2DM with and without periodontitis, as well as the response of this oral microbiome to nonsurgical therapy have not been well described. Knowledge of key oral biological features could help address the observed poorer clinical presentation of T2DM patients.

METHODS

The oral microbiome in saliva of adult cohorts periodontally healthy/non-diabetic (non-periodontitis; NP; n = 31), T2DM without periodontitis (DWoP; n = 32), and T2DM with periodontitis (DWP; n = 29) were characterized by microbial molecular analysis using V3-V4 sequencing and Luminex or ELISA techniques for salivary host analytes.

RESULTS

Phyla distribution showed DWP with significantly lower levels of Firmicutes and Actinobacteria and higher levels of Fusobacteria and Spirochetes compared to the healthier groups. Approximately 10% of the detected microbial species showed significant differences in frequency and level of colonization among the DWP, DWoP, and NP samples. A subset of bacteria were significantly correlated with clinical disease features, as well as a specific repertoire of salivary analytes, in particular matrix metalloproteinase (MMP)8/MMP9, interleukin-1ß, B-cell activating factor, and resistin differed between the groups and were related to specific taxa. Principal component analysis that identified a majority of the DWP subjects microbiome was unique based upon an array of 27 taxa out of up to 255 detected in the saliva samples.

CONCLUSION

T2DM patients with periodontitis show unique oral microbiome and salivary analyte composition compared to diabetics or non-diabetic persons without periodontitis. Specific members of the oral microbiome relate directly to the clinical disease features and/or salivary biomolecules in T2DM individuals.

Salivary features of periodontitis and gingivitis in type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) is associated with cellular abnormalities, tissue and organ dysfunctions, and periodontitis. This investigation examined the relationship between the oral microbiome and salivary biomarkers in T2DM patients with or without periodontitis. This cohort (35-80 years) included systemically healthy non-periodontitis (NP; n = 31), T2DM without periodontitis (DWoP; n = 32) and T2DM with periodontitis (DWP; n = 29). The oral microbiome [Operational Taxonomic Units (OTUs)] (16 s rRNA sequencing) and targeted host salivary biomarkers (immunoassays) were assessed. We identified 47 OTUs that were significantly different in abundance between NP samples and any disease subset or between disease subgroups. The most unique microbiome patterns were observed in the DWP group. Differences in genera/species abundance were also observed when T2DM patients were stratified by extent of periodontal inflammation and disease (i.e., generalized versus localized gingivitis/periodontitis). Salivary biomarkers showed significant elevations in MMP-8, MMP-9, resistin, IL-1β, IL-6, IFNα, and BAFF (THFSR13b) comparing generalized to localized periodontitis. Salivary analytes showed significant positive correlations with specific microbiome members, predominantly in DWP patients. Odds ratio analyses reinforced that a panel of biologic markers (IL-6, MMP-8) and bacteria (e.g., Bacteroidetes, Fusobacteria, Spirochaetes) discriminated the severity and extent of periodontal disease in this diabetic population.

Thermosensitive hydrogel doped with osteoconductive fillers for the treatment of periodontitis periapicalis chronica: from synthesis to clinical trial

Herein, a chitosan-based thermosensitive hydrogel (CH) containing hydroxyapatite (HAp), poly(lactic acid) (PLDLLA) or their mixture is proposed as an innovative, biomimetic composition with antimicrobial and bone-forming properties for guided bone regeneration. The modified hydrogels were synthesized and characterized to verify their suitability for the treatment of periodontitis periapicalis chronica. Compared to the unmodified hydrogel, both CH_HAp and CH_PLDLLA revealed improved mechanical properties, as evidenced by rotational rheology. FTIR analysis proved that no chemical interplay existed between the components. All the tested samples displayed no cytotoxicity against osteoblast-like cell culture and confirmed antimicrobial features, both crucial from an application perspective. Radiation sterilization dosage was tailored for the tested samples to maintain sterility for a minimum of 8 weeks of storage and limit crosslinking of the samples. Finally, the hydrogel was used in a clinical trial to treat a patient with chronic inflammation of periapical tissues in teeth 26 and 27. The medical procedure proved the safety, nontoxicity, non-allergenicity, and, most importantly, bone-forming properties of the hydrogel formulation. The kinetics of new bone formation was analyzed in-depth using graphical cross-sections of anatomical structures obtained from pre- and post-operative CBCT scans.

Small Extracellular Vesicles and Oral Mucosa: The Power Couple in Regenerative Therapies?

Although ongoing debates persist over the scope of phenomena classified as regenerative processes, the most up-to-date definition of regeneration is the replacement or restoration of damaged or missing cells, tissues, organs, or body parts to full functionality. Despite extensive research on this topic, new methods in regenerative medicine are continually sought, and existing ones are being improved. Small extracellular vesicles (sEVs) have gained attention for their regenerative potential, as evidenced by existing studies conducted by independent research groups. Of particular interest are sEVs derived from the oral mucosa, a tissue renowned for its rapid regeneration and minimal scarring. While the individual regenerative potential of both sEVs and the oral mucosa is somewhat understood, the combined potential of sEVs derived from the oral mucosa has not been sufficiently explored and highlighted in the existing literature. Serving as a broad compendium, it aims to provide scientists with essential and detailed information on this subject, including the nature of the materials employed, isolation and analysis methodologies, and clinical applications. The content of this survey aims to facilitate the comparison of diverse methods for working with sEVs derived from the oral mucosa, aiding in the planning of research endeavors and identifying potential research gaps.

Metronidazole Modified-Release Therapy Using Two Different Polymeric Systems Gels or Films: Clinical Study for the Treatment of Periodontitis

This study evaluated the efficacy of semisolid systems (gels) and films containing a combination of metronidazole (MTZ) and metronidazole benzoate after scaling and root-planing (SRP) for periodontitis. In total, 45 patients with stage I or II periodontitis were enrolled and divided into 3 groups: 1-SRP-control; 2-SRP + Film with MTZ; 3-SRP + Gel with MTZ. The pH of gingival crevicular fluid (GCF) before/after treatments, MTZ concentrations, and drug release using high-performance liquid chromatography were investigated. The effects were evaluated by longitudinal monitoring of clinical parameters (probing depth-PD, clinical attachment level-CAL, and bleeding on probing-BP). MTZ and MTZ-benzoate concentrations in the periodontal pocket and pH showed no statistical difference after application. SRP + Gel presented the lowest CAL values. For SRP + Film and SRP + Gel, higher PD values were observed at T0 compared to all groups. A relevant reduction in BP was observed in SRP + Film and SRP + Gel groups at all times compared to T0. Both therapies improved periodontal health compared to SRP alone, reducing PD and BP, and increasing CAL for the gel group, suggesting they are promising for periodontal disease treatment.

Menopause and Oral Health: Clinical Implications and Preventive Strategies

Menopause, occurring typically between the ages of 45 and 55 years, marks the end of a woman's reproductive years and is characterized by the cessation of menstruation and a significant decline in estrogen and progesterone production. These hormonal changes impact various aspects of health, including oral health. This review explores the clinical implications of menopause on oral health and outlines preventive strategies. Hormonal changes during menopause can lead to xerostomia (dry mouth), periodontal disease, burning mouth syndrome (BMS), oral mucosal changes, altered taste sensation, and osteoporosis-related oral health issues. Xerostomia results from decreased salivary flow, increasing the risk of dental caries and oral infections. Periodontal disease is exacerbated by estrogen deficiency, leading to bone loss and increased tooth mobility. BMS, characterized by a chronic burning sensation, and oral mucosal atrophy are linked to hormonal fluctuations. In addition, altered taste perception and osteoporosis further complicate oral health management. Effective prevention and management strategies include regular dental checkups, good oral hygiene practices, and tailored treatments such as fluoride treatments, saliva substitutes, and hormone replacement therapy. Nonpharmacological approaches such as stress management and lifestyle modifications also play a role. This review emphasizes the importance of a multidisciplinary approach, involving dental and medical professionals, to address the complex oral health challenges faced by menopausal women. Understanding the underlying mechanisms and implementing evidence-based preventive measures can significantly enhance the oral health and overall well-being of menopausal women.

Data-driven prediction model for periodontal disease based on correlational feature analysis and clinical validation

Objectives

This study aimed to investigate the performance and reliability of data-driven models employing correlational feature analysis and clinical validation for predicting periodontal disease.

Methods

The 7th Korea National Health and Nutrition Examination Survey (n = 10,654) was used for correlation analysis to identify significant risk factors for periodontitis. Periodontal prediction models were developed with the selected factors and database, followed by internal validation with 5-fold cross-validation and 1000 bootstrap resampling. External validation was conducted with clinical data (n = 120) collected through self-reported questionnaires, clinical periodontal parameters, and radiographic image analysis. Predictive performance was assessed for logistics regression, support vector machine, random forest, XGBoost, and neural network algorithms using the area under the receiver operating characteristic curves (AUC) and other performance metrics.

Results

Correlation analysis identified 16 features from over 1000 potential risk factors for periodontitis. The best data-driven model (XGBoost) showed AUC values of 0.823 and 0.796 for internal and external validations, respectively. Modeling with clinical data revealed those same measures to be 0.836 and 0.649, respectively. In addition, the data-driven model could predict other clinical periodontal parameters including severe bone loss (AUC = 0.813), gingival bleeding (AUC = 0.694), and tooth loss (AUC = 0.734). A patient case study about prognostic predictions revealed that the probability of periodontitis can be reduced by 6.0 % (stop smoking) and 0.6 % (stop drinking) on average.

Conclusions

Data-driven models for predicting periodontitis and other periodontal parameters were developed from 16 risk factors, demonstrating enhanced prediction performance and reproducibility in internal-external validations.

Progression from healthy periodontium to gingivitis and periodontitis: Insights from bioinformatics-driven proteomics - A systematic review with meta-analysis

AIM

The current study aimed to: (1) systematically review the published literature regarding the proteomics analyses of saliva and gingival crevicular fluid (GCF) in healthy humans and gingivitis and/or periodontitis patients; and (2) to identify the differentially expressed proteins (DEPs) based on the systematic review, and comprehensively conduct meta-analyses and bioinformatics analyses.

METHODS

An online search of Web of Science, Scopus, and PubMed was performed without any restriction on the year and language of publication. After the identification of the DEPs reported by the included human primary studies, gene ontology (GO), the Kyoto encyclopedia of genes and genomes pathway (KEGG), protein-protein interaction (PPI), and meta-analyses were conducted. The risk of bias among the included studies was evaluated using the modified Newcastle-Ottawa quality assessment scale.

RESULTS

The review identified significant differences in protein expression between healthy individuals and those with gingivitis and periodontitis. In GCF, 247 proteins were upregulated and 128 downregulated in periodontal diseases. Saliva analysis revealed 79 upregulated and 70 downregulated proteins. There were distinct protein profiles between gingivitis and periodontitis, with 159 and 31 unique upregulated proteins in GCF, respectively. Meta-analyses confirmed significant upregulation of various proteins in periodontitis, including ALB and MMP9, while CSTB and GSTP1 were downregulated. AMY1A and SERPINA1 were upregulated in periodontitis saliva. HBD was upregulated in gingivitis GCF, while DEFA3 was downregulated. PPI analysis revealed complex networks of interactions among DEPs. GO and KEGG pathway analyses provided insights into biological processes and pathways associated with periodontal diseases.

CONCLUSION

The ongoing MS-based proteomics studies emphasize the need for a highly sensitive and specific diagnostic tool for periodontal diseases. Clinician acceptance of the eventual diagnostic method relies on its ability to provide superior or complementary information to current clinical assessment procedures. Future research should prioritize the multiplex measurement of multiple biomarkers simultaneously to enhance diagnostic accuracy and large study cohorts are necessary to ensure the validity and reliability of research findings.

Radiographic diagnosis of periodontal diseases - Current evidence versus innovations

Accurate diagnosis of periodontal and peri-implant diseases relies significantly on radiographic examination, especially for assessing alveolar bone levels, bone defect morphology, and bone quality. This narrative review aimed to comprehensively outline the current state-of-the-art in radiographic diagnosis of alveolar bone diseases, covering both two-dimensional (2D) and three-dimensional (3D) modalities. Additionally, this review explores recent technological advances in periodontal imaging diagnosis, focusing on their potential integration into clinical practice. Clinical probing and intraoral radiography, while crucial, encounter limitations in effectively assessing complex periodontal bone defects. Recognizing these challenges, 3D imaging modalities, such as cone beam computed tomography (CBCT), have been explored for a more comprehensive understanding of periodontal structures. The significance of the radiographic assessment approach is evidenced by its ability to offer an objective and standardized means of evaluating hard tissues, reducing variability associated with manual clinical measurements and contributing to a more precise diagnosis of periodontal health. However, clinicians should be aware of challenges related to CBCT imaging assessment, including beam-hardening artifacts generated by the high-density materials present in the field of view, which might affect image quality. Integration of digital technologies, such as artificial intelligence-based tools in intraoral radiography software, the enhances the diagnostic process. The overarching recommendation is a judicious combination of CBCT and digital intraoral radiography for enhanced periodontal bone assessment. Therefore, it is crucial for clinicians to weigh the benefits against the risks associated with higher radiation exposure on a case-by-case basis, prioritizing patient safety and treatment outcomes.

Non-invasive assessment of periodontal inflammation by continuum-removal hemodynamic spectral indices

BACKGROUND

Hyperspectral techniques have aroused great interest in non-invasively measuring periodontal tissue hemodynamics. However, current studies mainly focused on three typical inflammation stages (healthy, gingivitis and periodontitis) and practical approaches for using optical spectroscopy for early and precisely detection of periodontal inflammation at finer disease stages have not been well studied.

METHODS

This study provided novel spectroscopic insights into periodontitis at different stages of disease, and developed six simple but physically meaning hemodynamic spectral indices (HSIs) including four spectral absorption depths of oxyhemoglobin ( D HbO 2 ), deoxyhemoglobin ( D Hb ), total hemoglobin ( t Hb ) and tissue water ( D water ), and two normalized difference indices of oxyhemoglobin( N D HbO 2 I ) and deoxyhemoglobin ( N D Hb I ) from continuum-removal spectra (400-1700 nm) of periodontal tissue collected from 47 systemically healthy subjects over different severities from healthy, gingivitis, slight, moderate to severe periodontitis for early and precision diagnostics of periodontitis. Typical statistical analyses were conducted to explore the effectiveness of the proposed HSIs.

RESULTS

D Hb and t Hb exerted significant increasing trends as inflammation progressed, whereas D HbO 2 exhibited significant difference (P < 0.05) from the healthy sites only at moderate and severe periodontitis and D water presented unstable sensitives to disease severity. By contrast, N D HbO 2 I and N D Hb I showed more steadily downward trends as severity increased, and demonstrated the highest correlations with clinical gold standard parameters. Particularly, the proposed normalized HSIs ( N D HbO 2 I and N D Hb I ) yielded high correlations of - 0.49 and - 0.44 with probing depth, respectively, far outperforming results achieved by previous studies. The performances of the HSIs were also confirmed using the periodontal therapy group.

CONCLUSIONS

These results indicated great potentials of combination optical spectroscopy and smart devices to non-invasively probe periodontitis at earlier stages using the simple and practical HSIs. Trial registration This study was retrospectively registered in the Chinese Clinical Trial Registry on October 24, 2021, and the clinical registration number is ChiCTR2100052306.

Changes in Oral Health and Dental Esthetic in Smokers Switching to Combustion-Free Nicotine Alternatives: Protocol for a Multicenter and Prospective Randomized Controlled Trial

BACKGROUND

Although the detrimental effects of conventional combustible cigarettes on oral health and dental esthetics are well known, there is limited information about the long-term impact of combustion-free nicotine alternatives (C-F NA) such as e-cigarettes or heated tobacco products.

OBJECTIVE

This multicenter, prospective, 3-parallel-arm randomized controlled trial will investigate whether switching from combustible cigarettes to C-F NA will lead to measurable improvements in oral health parameters and dental esthetics over 18 months in adult smokers with limited gum disease.

METHODS

Regular smokers not intending to quit and without clinical signs of periodontitis will be randomly assigned (1:4 ratio) to either standard of care with brief cessation advice (control group; arm A) or C-F NA use (intervention group; arm B). The study will also include a reference group of never smokers (reference group; arm C). The primary end point is the change in the Modified Gingival Index (MGI) score from baseline between the control arm (arm A) and the intervention arm (arm B) at the 18-month follow-up. In addition, the study will analyze the within- and between-group (arms A, B, and C) changes in MGI assessment, plaque imaging, dental shade quantitation, tooth stain scores, and oral health-related quality of life questionnaires measured at each study time point. All participants will attend a total of 7 clinic visits: screening, enrollment, and randomization (visit 0); baseline visit-day 14 (visit 1); day 90 (visit 2); day 180 (visit 3); day 360 (visit 4); and day 540 (visit 5). This multicenter study will be conducted in 4 dental clinics in 4 countries. The statistical analysis will involve descriptive statistics for continuous and categorical data. Primary end points will undergo tests for normality and, based on distribution, either a 2-sided t test or Mann-Whitney U test. Linear mixed model with random factors center and study arms by center will also be applied. Secondary end points, including MGI assessment and quality of life, will be subjected to similar tests and comparisons. Only if one value of the parameter MGI is missing after day 1, the last available observation will be carried forward. The analysis will be performed on the substituted data. Secondary parameters will not have missing value replacement.

RESULTS

Participant recruitment began in October 2021, and enrollment was completed in June 2023. Results will be reported in 2025.

CONCLUSIONS

This will be the first study to provide key insights into oral health benefits or risks associated with using C-F NA in smokers who are seeking alternatives to cigarette smoking.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04649645; https://clinicaltrials.gov/ct2/show/NCT04649645.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53222.

Coronary atherosclerosis and periodontitis have similarities in their clinical presentation

Background

Periodontitis (PE) and coronary heart disease (CHD) possess multiple mechanisms for a putative association. This case-control study compared the periodontal status among CHD subjects to controls without CHD, while also investigating atheroma invasion by known periodontal pathogens.

Methods

161 subjects participated in this study were divided into three CHD groups: No CHD, chronic CHD, acute CHD. Additional analysis involved grouping subjects according to number of atheromas: no atheroma, 1-4 atheromas, 5-18 atheromas. Data were collected from medical records, periodontal examinations, and questionnaires that included demographic, behavioral, and oral health variables. Angiographic catheterizations were analyzed according to the number of atheroma lesions, lesion size, lesion location, and atheroma lesion stability. Lipoprotein profile, inflammatory markers and cells were analyzed. The microbiological branch added 30 individuals who had their atheroma lesion and subgingival plaque analyzed using polymerase chain reaction probes against the 16 s region, red complex and Aggregatibacter actinomycetemcomitans' DNA.

Results

Subjects with CHD had high levels of systemic inflammatory markers and low levels of high-density lipoproteins compared to subjects without CHD. Subjects without CHD and clear coronaries had a prevalence of mild CAL, while individuals with more atheroma lesions had advanced CAL and more active PE. Subjects with more advanced CAL were 4 times more likely to have CHD compared to subjects with less, which is comparable to smoking. Only 4 subjects had the screened pathogens detected in atheroma, although these subjects also have the screened pathogens in subgingival plaque. However, 80% of atheromas had bacteria.

Conclusions

CHD and PE showed similarities in progression while active PE led to more atheroma lesions that also tended to be larger in size.

The influence of periodontitis case definition on the association between periodontal disease and glycaemic status

OBJECTIVE

The association between periodontitis and glycaemic control is complex, and often described as 'bidirectional'. Although epidemiological studies have examined this relationship extensively, a disagreement on periodontitis case definition still exists. This study aimed to assess the influence of case definition on the association between periodontal disease and glycaemic status.

METHODS

The study is a secondary analysis of data from the United States National Health and Nutrition Examination Survey (NHANES), 2009-2014 cycles. The association between periodontitis and glycated haemoglobin (HbA1c) was assessed using different periodontitis case definitions: the definition by the Centers for Disease Control and Prevention and the American Academy of Periodontology (CDC/AAP), Community Periodontal Index (CPI), ≥1 site with ≥3 mm clinical attachment loss (CAL) and ≥4 mm probing depth (PD), ≥1 site with ≥4 mm CAL and ≥4 mm PD, the 5th European Workshop definitions, Machtei et al. 'established periodontitis', the 2017 World Workshop classification, and self-reported periodontitis. The associations between periodontitis and HbA1c were compared across the case definitions.

RESULTS

There was substantial variability in prevalence estimates of periodontitis, and in the strength of association between periodontitis and HbA1c when different case definitions were applied. The CDC/AAP and stage III/IV periodontitis were consistently significantly associated with elevated HbA1c. For stage III/IV, the adjusted odds ratios of prediabetes and diabetes HbA1c were 1.19 and 1.76, respectively.

CONCLUSION

Comprehensive periodontitis case definitions that account for CAL and PD, such as the CDC/AAP and the 2017 classification, seem to better detect the association between periodontal disease and HbA1c.

Comparing gingivitis diagnoses by bleeding on probing (BOP) exclusively versus BOP combined with visual signs using large electronic dental records

The major significance of the 2018 gingivitis classification criteria is utilizing a simple, objective, and reliable clinical sign, bleeding on probing score (BOP%), to diagnose gingivitis. However, studies report variations in gingivitis diagnoses with the potential to under- or over-estimating disease occurrence. This study determined the agreement between gingivitis diagnoses generated using the 2018 criteria (BOP%) versus diagnoses using BOP% and other gingival visual assessments. We conducted a retrospective study of 28,908 patients' electronic dental records (EDR) from January-2009 to December-2014, at the Indiana University School of Dentistry. Computational and natural language processing (NLP) approaches were developed to diagnose gingivitis cases from BOP% and retrieve diagnoses from clinical notes. Subsequently, we determined the agreement between BOP%-generated diagnoses and clinician-recorded diagnoses. A thirty-four percent agreement was present between BOP%-generated diagnoses and clinician-recorded diagnoses for disease status (no gingivitis/gingivitis) and a 9% agreement for the disease extent (localized/generalized gingivitis). The computational program and NLP performed excellently with 99.5% and 98% f-1 measures, respectively. Sixty-six percent of patients diagnosed with gingivitis were reclassified as having healthy gingiva based on the 2018 diagnostic classification. The results indicate potential challenges with clinicians adopting the new diagnostic criterion as they transition to using the BOP% alone and not considering the visual signs of inflammation. Periodic training and calibration could facilitate clinicians' and researchers' adoption of the 2018 diagnostic system. The informatics approaches developed could be utilized to automate diagnostic findings from EDR charting and clinical notes.

Correlation of Serum and Gingival Crevicular Fluid Levels of Caspase-3 and Milk Fat Globule-Epidermal Growth Factor 8 on Gingival Health

AIM

This study aimed to estimate and correlate the serum and gingival crevicular fluid (GCF) levels of caspase-3 and milk fat globule-epidermal growth factor 8 (MFG-E8) in healthy, gingivitis and generalised chronic periodontitis subjects.

MATERIALS AND METHODS

A total of 24 subjects were selected and divided into three groups. After recording the periodontal parameters (plaque index (PI), modified gingival index (MGI), probing depth (PD) and clinical attachment level (CAL)), the serum and GCF samples were collected and the levels of caspase-3 and MFG-E8 were estimated using enzyme-linked immunoassay (ELISA).

RESULTS

The mean values of PI, MGI, PD and CALs were significantly higher in group III when compared to group II and group I. The mean value of serum and GCF caspase-3 increased with increasing disease severity, whereas the mean serum and GCF values of MFG-E8 decreased with increasing severity of disease. Spearman's correlation showed a strong positive correlation between the serum and GCF levels of caspase-3 and periodontal parameters, whereas serum and GCF levels of MFG-E8 showed a strong negative correlation with the periodontal parameters.

CONCLUSION

The findings of this study are suggestive that the serum and GCF levels of caspase-3 and MFG-E8 could serve as a potential biomarker for the role of apoptosis in periodontal disease. However, further studies are required to explore the mechanism and understand the relationship between these apoptotic markers and periodontitis.

Machine learning techniques for periodontitis and dental caries detection: A narrative review

OBJECTIVES

In recent years, periodontitis, and dental caries have become common in humans and need to be diagnosed in the early stage to prevent severe complications and tooth loss. These dental issues are diagnosed by visual inspection, measuring pocket probing depth, and radiographs findings from experienced dentists. Though a glut of machine learning (ML) algorithms has been proposed for the automated detection of periodontitis, and dental caries, determining which ML techniques are suitable for clinical practice remains under debate. This review aims to identify the research challenges by analyzing the limitations of current methods and how to address these to obtain robust systems suitable for clinical use or point-of-care testing.

METHODS

An extensive search of the literature published from 2015 to 2022 written in English, related to the subject of study was sought by searching the electronic databases: PubMed, Institute of Electrical and Electronics Engineers (IEEE) Xplore, and ScienceDirect.

RESULTS

The initial electronic search yielded 1743 titles, and 55 studies were eventually included based on the selection criteria adopted in this review. Studies selected were on ML applications for the automatic detection of periodontitis and dental caries and related dental issues: Apical lessons, Periodontal bone loss, and Vertical root fracture.

CONCLUSION

While most of the ML-based studies use radiograph images for the detection of periodontitis and dental caries, few pieces of the literature revealed that good diagnostic accuracy could be achieved by training the ML model even with mobile photos representing the images of dental issues. Nowadays smartphones are used in every sector for different applications. Training the ML model with as many images of dental issues captured by the smartphone can achieve good accuracy, reduce the cost of clinical diagnosis, and provide user interaction.

Peri-implant clinicoradiographic status among betel-quid chewers and controls

The aim of the present case-control observational study was to evaluate the peri-implant clinicoradiographic status among betel-quid chewers and controls. Self-reported betel-quid chewers and controls were included. Participants were categorized into 3 groups: Group-1: Individuals chewing betel-quid with tobacco; Group-2: Individuals chewing betel-quid without tobacco; and Group-3: Controls (individuals not using tobacco in any form). Demographic data was collected using a questionnaire. Periodontal and peri-implant clinicoradiologic parameters (plaque and gingival indices [PI and GI], probing depth [PD] and crestal bone loss/marginal bone loss [CBL/MBL]) were assessed. Clinical attachment loss (AL) around teeth was also assessed. Group comparisons were done using the one-way analysis of variance and Bonferroni Post-hoc adjustment tests. Correlation of periodontal and peri-implant inflammatory parameters with the duration of betel-quid chewing habit and duration of placement in the mouth were assessed using logistic regression analysis. P<0.05 was considered statistically significant. Thirty, 30 and 30 patients were included in groups 1, 2 and 3, respectively. Full-mouth PI (P<0.01), GI (P<0.01), clinical AL (P<0.01), PD (P<0.01) and mesial and distal MBL (P<0.01) were higher in groups 1 and 2 than Group-3. Peri-implant mPI (P<0.01), mGI (P<0.01), PD (P<0.01) and MBL/CBL (P<0.01) were significantly higher in groups 1 and 2 than Group-3 with no significant difference in groups 1 and 2. Betel-quid chewing habit either with or without tobacco is a risk-factor of peri-implant soft-tissue inflammation and CBL.

The Effect of Locally Applied Simvastatin on Clinical Attachment Level and Alveolar Bone in Periodontal Maintenance Patients: Randomized Clinical Trial

BACKGROUND

The purpose of this double-masked, randomized, controlled trial was to determine if the local application of simvastatin (SIM), combined with minimally invasive papilla reflection and root preparation (PR/RP), is effective in improving clinical attachment level (CAL), probing depth (PD) reduction, and increasing interproximal bone height (IBH) in persistent 6-9 mm periodontal pockets in patients receiving periodontal maintenance therapy (PMT).  METHODS: : Fifty patients with Stage III, Grade B periodontitis presenting with a 6-9 mm interproximal PD with a history of bleeding on probing (BOP) were included in the study. Experimental [PR/RP+SIM/methylcellulose (MCL); n=27] and control (PR/RP + MCL; n=23) therapies were randomly assigned.  Root surfaces were accessed via reflection of interproximal papillae, followed by root planing assisted with endoscope evaluation, acid etching, and SIM/MCL or MCL application.  CAL, PD, BOP, plaque presence and IBH (using standardized vertical bitewing radiographs) were evaluated at baseline and 12 months. Measurements were compared by group and time using Chi-square, Wilcoxon rank sum, and t-tests.

RESULTS

Both PR/RP+SIM/MCL and PR/RP+MCL, respectively, resulted in improvements in clinical outcomes (CAL: -1.9 ± 0.3 mm, p<0.0001; -1.0 ± 0.3 mm, p<0.003; PD:  -2.3 mm ± 0.3, p<0.0001; -1.3 mm ± 0.3, p<0.0001; BOP: -58.7%; -41.7%, p<0.05) and stable IBH (-0.2 ± 0.12, -0.4 ± 0.2, p=0.22) from baseline to 12 months post-therapy. PR/RP+SIM/MCL had more improvement in CAL (p=0.03), PD (p=0.007), and BOP (p=0.047).

CONCLUSIONS

The addition of SIM/MCL to PR/RP improved CAL, PD, and BOP compared to PR/RP alone in periodontal maintenance patients. This article is protected by copyright. All rights reserved.

Use of the deep learning approach to measure alveolar bone level

AIM

The goal was to use a deep convolutional neural network to measure the radiographic alveolar bone level to aid periodontal diagnosis.

MATERIALS AND METHODS

A deep learning (DL) model was developed by integrating three segmentation networks (bone area, tooth, cemento-enamel junction) and image analysis to measure the radiographic bone level and assign radiographic bone loss (RBL) stages. The percentage of RBL was calculated to determine the stage of RBL for each tooth. A provisional periodontal diagnosis was assigned using the 2018 periodontitis classification. RBL percentage, staging, and presumptive diagnosis were compared with the measurements and diagnoses made by the independent examiners.

RESULTS

The average Dice Similarity Coefficient (DSC) for segmentation was over 0.91. There was no significant difference in the RBL percentage measurements determined by DL and examiners ( p = .65 ). The area under the receiver operating characteristics curve of RBL stage assignment for stages I, II, and III was 0.89, 0.90, and 0.90, respectively. The accuracy of the case diagnosis was 0.85.

CONCLUSIONS

The proposed DL model provides reliable RBL measurements and image-based periodontal diagnosis using periapical radiographic images. However, this model has to be further optimized and validated by a larger number of images to facilitate its application.

Leptin Aggravates Periodontitis by Promoting M1 Polarization via NLRP3

Periodontitis is characterized by periodontal pocket formation, loss of attachment, and alveolar bone resorption. Both innate and adaptive immunity are involved in the pathogenesis of this oral chronic inflammatory disease. Accumulating evidence indicates a critical role of leptin in periodontal diseases. However, the mechanism by which leptin promotes periodontitis pathogenesis remains unclear. In the present study, we observed an elevated expression of leptin in the serum of periodontitis mice compared to that in healthy controls. There was a higher extent of M1 phenotype macrophage infiltration in mice periodontitis samples than in healthy controls. A positive correlation was observed between the serum leptin levels and M1 macrophages. Treatment with leptin increased M1 macrophage polarization and decreased M2 macrophage polarization in RAW 264.7 cells. Moreover, leptin facilitated lipopolysaccharide (LPS)-induced M1 phenotype macrophage polarization in RAW 264.7 cells. In bone marrow-derived macrophages (BMDMs) generated from leptin-deficient obese (ob/ob) mice, M1 macrophage polarization was significantly attenuated after LPS stimulation compared to the healthy controls. With regards to the molecular mechanism, we found that leptin activated the NOD-like receptor family pyrin domain containing 3 (NLRP3) inflammasome and promoted M1 polarization via the NLRP3 inflammasome in vitro. In BMDMs generated from Nlrp3^-/- mice, M1 macrophage polarization was significantly attenuated after synchronous stimulation with leptin and LPS compared with BMDMs produced by healthy controls. The NLRP3 inhibitor MCC950 also prevented leptin-mediated M1 macrophage polarization in RAW 264.7 cells. Nlrp3^-/- periodontitis models indicated that leptin aggravates the periodontal response to the ligature by promoting M1 macrophage polarization via the NLRP3 inflammasome. Taken together, we show that leptin promotes the progression of periodontitis via proinflammatory M1 macrophage skewing, and targeting leptin/NLRP3 signaling may be a feasible approach for treating periodontitis.

Periodontitis in Ischemic Stroke Patients: Case Definition Challenges of the New Classification Scheme (2018)

The identification of the associative relationships between ischemic stroke (IS) and risk factors such as advanced age and periodontitis is essential to design real screening protocols and to address them using primary and secondary preventive policies. This study primarily aimed to evaluate the diagnostic performance of the 2018 European Federation of Periodontology/American Academy of Periodontology (EFP/AAP) case definition in detecting periodontitis against the 2012 Centers for Disease Control and Prevention/American Academy of Periodontology (CDC/AAP) case definition in a group of IS patients. Secondarily, we report the periodontal status of IS patients and the associative relationship with respect to some risk factors. Patients with their first IS were assessed based on demographic data, medical, oral risk factors and periodontal parameters. The two case definitions were applied to identify the periodontitis burden. The agreement between the two case definition systems, as well as the misclassification ratio, were calculated. A total of 141 patients were included. According to the 2012 CDC/AAP and the 2018 EFP/AAP case definitions, a frequency of periodontitis of 98.5% and 97.8% based on two modalities of inclusion of cases in the severity groups, sensitivity values of 98.54% or 100%, and specificity values of 25% or 14.7% were calculated. Thus, the new case definition system has a higher capacity to detect periodontitis, especially the well-established forms.

[Dental imaging procedures in the Unified Health System and the expansion of secondary care: series between 2000-2016]

The scope of this paper was to analyze the time series of dental procedures performed between 2000 and 2016 in the Brazilian Unified Health System (SUS). The data were obtained from the Outpatient Information System of the SUS (SIA-SUS). The influence of the 2004 National Oral Health Policy of Ordinance No. 600/2006 (which instituted the financing of Dental Specialty Centers - CEOs), and Ordinance No. 1,234/2013 (Financial incentive for the Program for Enhancement of Quality and Access - PMAQ-CEO) were analyzed. Descriptive analyses of the initial and final years of the time series were presented, assessing trends and seasonality in seven types of imaging procedures. The time series of rates of periapical/bitewing radiographic exams revealed a trend of moderate increase and was the only area in which the impact of the financial implementation policy of the CEOs was observed, though not of the PMAQ-CEO. Extraoral imaging exams, such as panoramic radiography, facial CT/TMJ and TMJ MRI revealed a strong upward trend, despite the very low rates. The conclusion reached is that between 2000 and 2016, the policy of expansion of secondary care increased the use of periapical/bitewing imaging exams.

Periodontal disease inequities among Indigenous populations: A systematic review and meta-analysis

The prevalence of periodontal disease varies considerably between Indigenous and general populations. The aim of this systematic review was to assess the global prevalence of periodontal disease among Indigenous populations in comparison with non-Indigenous populations. A systematic electronic search of databases and grey literature sources was conducted of all records through to February 2021. Study selection criteria included original data that reported the prevalence of periodontal diseases among an Indigenous population and compared with a non-Indigenous population, without any restriction on age, sex, language or geographical location. Critical appraisal was conducted with the Joanna Briggs Institute (JBI) tool for prevalence studies. A random-effects model using standardised mean difference (SMD) as the effect measure was used to estimate the pooled prevalence of periodontitis. Subgroup analysis of study location and publication source was also performed. Publication bias was assessed using Egger's test, and funnel plots were used for visualisation. A total of 19 articles were included for descriptive and meta-analysis. The overall prevalence of periodontitis was 35% (95% CI: 0.18, 0.52) higher among the Indigenous population than the non-Indigenous population. The pooled prevalence of periodontitis was consistently higher among the Indigenous populations when stratified according to periodontitis definition employed, study location and publication source. Indigenous populations have a higher prevalence of periodontitis than non-Indigenous populations. To decrease oral health inequities, more emphasis should be given to oral health promotion and specific culturally safe interventions working in partnership with Indigenous populations.

Periodontal disease in seropositive rheumatoid arthritis: scoping review of the epidemiological evidence

The link between periodontal disease (PD) and rheumatoid arthritis (RA) has been hypothesized to lie in the anti-cyclic citrullinated protein antibody (ACPA) molecules present in seropositive RA. This review aimed to discuss how RA and specifically ACPA-positive RA link to PD, and appraise the epidemiological evidence on the relationship between ACPA-positive RA and PD. Articles were searched following the PRISMA guideline across the MEDLINE, Web of Science, Scopus and Cochrane Library databases. A total of 21 articles met the inclusion criteria of reporting the epidemiological data on the different ACPA status of the subjects with RA and PD (or periodontitis) parameters. A discrepancy is noted in the epidemiological evidence on the difference in the prevalence and severity of PD between ACPA-positive and ACPA-negative RA patients. Although the link between RA and PD is mostly discussed in terms of ACPA, reports on the different manifestations of PD between the two RA subsets remains inconclusive.

Resolving the Contradictory Functions of Lysine Decarboxylase and Butyrate in Periodontal and Intestinal Diseases

Periodontal disease is a common, bacterially mediated health problem worldwide. Mastication (chewing) repeatedly traumatizes the gingiva and periodontium, causing traces of inflammatory exudate, gingival crevicular fluid (GCF), to appear in crevices between the teeth and gingiva. Inadequate tooth cleaning causes a dentally adherent microbial biofilm composed of commensal salivary bacteria to appear around these crevices where many bacteria grow better on GCF than in saliva. We reported that lysine decarboxylase (Ldc) from Eikenella corrodens depletes the GCF of lysine by converting it to cadaverine and carbon dioxide. Lysine is an amino acid essential for the integrity and continuous renewal of dentally attached epithelium acting as a barrier to microbial products. Unless removed regularly by oral hygiene, bacterial products invade the lysine-deprived dental attachment where they stimulate inflammation that enhances GCF exudation. Cadaverine increases and supports the development of a butyrate-producing microbiome that utilizes the increased GCF substrates to slowly destroy the periodontium (dysbiosis). A long-standing paradox is that acid-induced Ldc and butyrate production support a commensal (probiotic) microbiome in the intestine. Here, we describe how the different physiologies of the respective tissues explain how the different Ldc and butyrate functions impact the progression and control of these two chronic diseases.

The new periodontal disease classification: Level of agreement on diagnoses and treatment planning at various dental education levels

PURPOSE/OBJECTIVES

Using the periodontal diseases classification published in 2018, this study evaluated the level of agreement among predoctoral and postgraduate students of different education levels and specialties in the diagnosis and treatment planning of periodontal conditions.

METHODS

Second-year (D2) and fourth-year (D4) dental students, postgraduate orthodontic students (OS), and periodontology students (PS) were presented with an anonymous survey of 10 cases, each with five choices of diagnosis and seven therapeutic approaches. The cases included a patient summary, photographs, radiographs, periodontal charting, and ranged from health to periodontitis. Consensus diagnosis, used as a gold standard, was established between two experienced periodontists. Diagnosis and treatment choices for each case were compared across educational groups using Fisher's exact test. The level of agreement among educational groups was assessed using a multirater kappa coefficient.

RESULTS

The survey was completed in 2020 with a 72.4% overall response rate (57-D2, 45-D4, 17-OS, and 12-PS). The overall level of agreement on diagnosis was fair (κ = 0.24, p <.0001) with PS showing the most agreement (κ = 0.55, p <.0001). There were tendencies to prioritize stage over grade and extent in assigning diagnoses and to overdiagnose disease severity and underdiagnose localized periodontitis. Nonsurgical periodontal therapies had the highest overall agreement (κ = 0.63 for scaling/root planing and κ = 0.44 for maintenance, p <.0001). Response distribution per case and per level of education indicated that PS more consistently agreed with the gold standard than any other group.

CONCLUSIONS

OS, D2, and D4 students demonstrated inferior agreement levels compared to PS, successfully recognized health from disease, suggested appropriate treatment plans, and tended to overdiagnose milder periodontal conditions.

Periodontitis Is Associated With Risk of Conventional Stent Restenosis: Pilot Case-Control Study

Objectives: Percutaneous coronary angioplasty with stent implantation has been established as the main form of treatment of atherosclerosis. However, 16 to 44% of patients may evolve with stent restenosis. Periodontitis is an inflammatory condition associated with bacterial infection, that may lead to periodontal tissue destruction and tooth loss. This study aimed to evaluate the association between stent restenosis and periodontitis.

Materials and Methods: Coronary angiography exams presenting stent imaging with and without restenosis were analyzed. Patients meeting the inclusion and exclusion criteria were selected and allocated in 2 groups: case (restenosis) and control (without restenosis). We evaluated if systemic and periodontal variables were predictors of restenosis (primary outcome) using a multivariable stepwise logistic regression. Additionally, we compared clinical and periodontal conditions between the control and case groups (secondary outcomes) using Chi-square test and ANOVA test.

Results: Data from 49 patients (case n = 15; control n = 34) were analyzed. The results showed that stages III and IV periodontitis and lack of physical activity were significant predictors of stent restenosis (OR 5.82 and 5.98, respectively). Comparisons regarding the diagnosis of periodontal conditions between control and case groups did not present significant differences in the incidence of periodontitis and alveolar bone loss.

Conclusion: Stages III and IV periodontitis increased the incidence of stent restenosis. These findings suggest that advanced stages of periodontal disease might lead to the occurrence of negative outcomes after coronary angioplasty with stent placement.

The adult orthodontic patient over 40 years of age: association between periodontal bone loss, incisor irregularity, and increased orthodontic treatment need

Objectives

Adult orthodontic treatment, especially in patients over 40 years, is steadily increasing. One causal factor for the treatment need in this age group is periodontal breakdown. The aim of this study was to detect correlations between periodontal problems and orthodontic parameters in interdisciplinary patients.

Methods

This observational, cross-sectional study included 118 patients over 40 years (51 men/67 women; mean age, 58.03 years) classified into three groups according to periodontal breakdown (group I, controls; group II, moderate periodontitis; group III, severe periodontitis). Clinical periodontal and orthodontic parameters as well as the index of orthodontic treatment need (IOTN) were assessed and compared between the groups.

Results

A gradual deterioration of all periodontal and orthodontic parameters according to periodontal bone loss (lowest values in group I; highest values in group III) was observed. Especially groups I and III differed significantly regarding the overjet (p < 0.001) and the little indices of the maxilla (p < 0.001) and mandible (p < 0.010). The IOTN was highest in group III: 90% of the patients with severe periodontitis were classified to have moderate to very great treatment need.

Conclusions

The higher the degree of periodontal breakdown was, the more severe were overjet, overbite, irregularity of the anterior teeth, and the orthodontic treatment need.

Clinical relevance

Adult patients over 40 years represent a challenge for an orthodontic/periodontal treatment approach with high incidence of pathologic tooth migration, orthodontic treatment need, and periodontal breakdown. Therefore, this special patient collective requires a focus in clinical orthodontics and research.

Periodontitis Prevalence, Severity, and Risk Factors: A Comparison of the AAP/CDC Case Definition and the EFP/AAP Classification

BACKGROUND

This cross-sectional study evaluated the utility of the 2018 European Federation of Periodontology/American Academy of Periodontology (EFP/AAP) classifications of epidemiological studies in terms of periodontitis severity, prevalence and associated risk factors and the 2012 American Academy of Periodontology/Centers for Disease Control and Prevention (AAP/CDC) case definitions.

METHODS

We included 488 participants aged 35-74 years. Measurements were recorded at six sites per tooth by two qualified examiners. The evaluated parameters included pocket depth (PD), clinical attachment loss (CAL) and bleeding on probing (BOP). Periodontitis prevalence and severity were reported using the 2018 EFP/AAP classification and the AAP/CDC case definitions. The data were stratified by recognized risk factors (age, diabetes and smoking status).

RESULTS

The 2018 EFP/AAP classification indicated that all patients suffered from periodontitis. When CAL served as the main criterion, the frequency of patients with severe (Stages III-IV) periodontitis was 54%. When the AAP/CDC case definitions were applied, the prevalence of periodontitis was 61.9% and that of severe periodontitis 16.8%. Age was the most significant risk factor, regardless of the chosen case definition.

CONCLUSION

It is essential to employ a globalized standard case definition when monitoring periodontitis and associated risk factors.

Comparative assessment of conventional periodontal probes and CEJ handpiece of electronic probes in the diagnosis and primary care of periodontal disease

Objectives:

Conventional probes (CPs) have been considered acceptable as diagnostic tools to measure probing pocket depth (PPD) and clinical attachment level (CAL) but are affected by multiple variables. Electronic probes (EPs) provide controlled force, digital readout and data storage in computers. The objectives were to compare the reproducibility in the measurement of PPD and CAL by CP and the newly introduced CEJ handpiece of EP and intra-examiner and inter-examiner errors done in two phases.

Methods and Material:

Selected 720 periodontal sites in 1^st molar of 30 persons with chronic periodontitis ≤4 mm and >4 mm pockets were analysed by two trained investigators in two phases at 2 hours difference by CP and CEJ handpiece of EP. Standard deviation, mean difference, correlation coefficient, P value and student 't' test were done to analyse data.

Results:

The intra- examiner and inter-examiner analyses revealed that Pearson's correlation coefficient was above 0.080 and 0.722 in the ≤4 mm and >4 mm pockets, respectively. Mean difference was not statistically significant in both groups except in the intra- examiner findings in the 2^nd phase. Interprobe analysis depicted a standard error of mean of <0.03 in ≤4 mm pockets, whereas it varied from 0.047–0.056 in >4 mm pockets.

Conclusion:

In conclusion, EP is advantageous for research purposes by providing automatic recording and long-term maintenance of data storage without the need of an assistant and patient education and motivation, whereas CP appears to be more useful in routine periodontal examination.

Feasibility of oral health evaluation by intraoral digital photography: a pilot study

Objectives

This study investigated the accuracy and duration of intraoral digital photograph examination (IDPE) for evaluating oral health status and explored the feasibility of remote oral health assessment.

Methods

Thirty-one healthy college students underwent evaluations of oral health status via clinical examination (CE) combined with panoramic X-ray assessment at baseline, followed by IDPE 1 month later using photos taken at baseline. Methods for evaluation of gingival health included the Modified Gingival Index (MGI) and Plaque Index (PI). Examinations of caries status included the decayed, missing, and filled teeth and surfaces indexes (DMFT and DMFS indexes, respectively). The duration of each evaluation was also recorded.

Results

There were significant differences in MGI and PI between CE and IDPE. There were no significant differences in DMFT and DMFS indexes between CE and IDPE, and there were positive correlations between CE and IDPE for each of the two indexes (DMFT index: r=0.56; DMFS index: r=0.69). The IDPE duration was shorter than the CE duration.

Conclusions

The feasibility of caries status assessment via IDPE is promising. Digital oral health evaluation merits further clinical consideration.

Trial registration

Xiamen University Training Program of Innovation and Entrepreneurship for Undergraduates, project number: 2018X0583. Registered 1 April 2018; http://cxw.xmu.edu.cn/admin/Innovation/NewInnovationDetail?id=6ce0a415-6131-496b-891a-6a1ae44e556d

Possible association between periodontitis and prostatitis: A pilot study

Introduction: Prostatitis is one of the most chronic diseases which is often associated with periodontitis. The serum Prostate Specific Antigen (PSA) levels can be elevated in a non-malignant condition such as symptomatic and asymptomatic prostatitis. Similarity in the inflammatory etiopathogenesis of these diseases is evident through the presence of Gram negative bacteremia, which in turn may be the possible link between these two conditions. Aim: To estimate the possible association between chronic periodontitis and prostatitis, evaluating the PSA levels in patients with moderate and severe periodontitis. Material and methods: 40 patients with prostatitis and elevated Prostate Specific Antigen (PSA) levels (≥ 4ng/ml) that participated in the study were hospitalized at the University Urology Clinic at the Faculty of Medicine in Skopje. Patients were divided into two groups on the basis of the levels of periodontal clinical attachment. First group of 20 patients with Clinical attachment level (CAL) ≥ 3mm, moderate periodontitis and other group of 20 patients with CAL ≥ 5mm, severe periodontitis. Dental plaque index (DPI), Index of gingival inflammation (IGI), Gingival bleeding index (GBI) and Clinical attachment level (CAL) were recorded and an assessment of PSA values was done and correlation to periodontal parameters, respectively. Differences in means, as statistically significant, were analyzed using Student's ttest. The relationship between PSA scores with all clinical parameters was done using Pearson's correlation coefficient technique. Results: Statistically significant differences were noted, (p<0.05) between periodontal index values (DPI, IGI, GBI, CAL) and PSA levels within the two examined groupsHigher PSA levels were recordedin patients with severe periodontitis than inthose with moderate periodontitis. Pearson coefficient test among these periodontal indices (DPI, IGI, GBI and CAL) and PSA levels in two examined groups showed no statistically significant correlation. Conclusion: Patients with severe periodontitis were found to have higher PSA levels than those with moderate periodontitis. The clinical parameters of periodontitis and elevated PSA levels indicated a probable link between the two diseases.

Diagnostic Accuracy of Oral Fluids Biomarker Profile to Determine the Current and Future Status of Periodontal and Peri-Implant Diseases

Severe periodontitis is ranked as the sixth most prevalent disease affecting humankind, with an estimated 740 million people affected worldwide. The diagnosis of periodontal diseases mainly relies upon assessment of conventional clinical parameters. However, these parameters reflect past, rather than current, clinical status or future disease progression and, likely, outcome of periodontal treatment. Specific and sensitive biomarkers for periodontal diseases have been examined widely to address these issues and some biomarkers have been translated as point-of-care (PoC) tests. The aim of this review was to provide an update on PoC tests for use in the diagnosis and management of periodontal diseases. Among the PoC tests developed so far, active matrix metalloproteinase-8 has shown promising results in terms of diagnostic and prognostic values. However, further studies are required to increase the sensitivity and specificity via combining more than one biomarker and merging these test kits with periodontal risk assessment tools. Furthermore, the validity of these test kits needs to be investigated by applying the results in further independent studies and the impact on these test kits', together with the results of risk factors for periodontal diseases, such as diabetes and smoking, also needs to be examined.

Possible association of periodontal disease with oral cancer and oral potentially malignant disorders: a systematic review

Background: Periodontitis has been associated with several systemic diseases and medical conditions, including oral cancer (OC). However, most studies reporting an association between OC and periodontal disease have used different clinical and radiographic criteria to define periodontal disease. This review aimed to evaluate the currently available evidence to determine an association between periodontal disease (extension and severity), OC, and oral potentially malignant disorders (OPMDs).Material and methods: A systematic search of studies published up to August 2018 was performed following the PRISMA guidelines in the electronic databases MEDLINE (PubMed) and COCHRANE (OVID). A methodological evaluation was made using the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist.Results: Eight studies (case-control, cross-sectional and cohort) were included. An increased clinical attachment loss, plaque index, bleeding on probing, and radiographic bone loss was found in patients with OC and OPMDs. Differences in the methodological characteristics, case definition used for periodontal diseases, and OC location did not allow estimating the odds ratio required to conduct a meta-analysis.Conclusion: Some studies suggest a positive relationship between periodontal disease, OC, and OPMDs; however, the currently available evidence is insufficient to draw solid conclusions.

Effect of section thickness on cone beam computed tomography-based measurements of intrabony defects compared with clinical measurements

BACKGROUND

It is unknown whether cone beam computed tomography (CBCT) image reconstruction characteristics, including section thickness, may affect linear bone measurements of periodontal intrabony defects. The aim of this study was to compare intrasurgical and CBCT-based linear measurements of intrabony defects focusing on CBCT section thickness.

METHODS

Sixty-six intrabony defects were assessed in 21 patients with chronic generalized severe periodontitis. Linear measurements of alveolar bone (radiographic bone level [rBL]), assessed in CBCT images at diverse section thicknesses: 0.25 mm (voxel size), 1 mm, and 3 mm, were compared with clinical bone level (cBL) measurements obtained intrasurgically. To provide identical reference points for rBL and cBL measurements, individually adjusted grooves on the reference stent were prepared for each periodontal defect site. CBCT measurements were performed in two rounds by two trained observers. Observer agreement was assessed by intraclass correlation coefficients (ICC). ANOVA assessed the difference among cBL and rBL at different section thicknesses.

RESULTS

Intra- and inter-observer agreement was excellent (ICC >0.99) and highly significant independent of the observer, evaluation round, and CBCT section thickness. Mean rBL in the diverse CBCT section thicknesses was very close to that measured clinically (cBL). There was no statistically significant difference between cBL and rBL for any section thickness, neither for the overall evaluated sites, nor the maxilla or mandible separately.

CONCLUSIONS

No statistically significant difference between clinical and radiographic bone level for 0.25-, 1-, and 3-mm CBCT section thicknesses were observed when assessing intrabony periodontal defects.

The correspondence of 3D supporting bone loss and crown-to-root ratio to periodontitis classification

AIM

Assessing the application of three-dimensional clinical attachment loss (3D-CAL), 3D supporting bone loss (3D-SBL), supracrestal tissue attachment (STA), and crown-to-root ratio (CRR) in evaluating the 2017 periodontitis classification.

MATERIALS AND METHODS

We analysed ninety single-rooted human premolars with micro-computed tomography. The amount of 3D-SBL, linear radiographic bone loss (RBL), and CRR corresponding to various periodontitis stages as well as the statistical significance was investigated.

RESULTS

From a 3D perspective, the premolars with a 21% of 3D-SBL at 2.0 mm coronal root length (RL) and 15% RBL corresponded to the periodontitis stage I. Premolars with a 44% of 3D-SBL at coronal 4.2-4.4 mm RL and 33% RBL accorded with the periodontitis stage II. Excluding the consideration of STA, CRR = 5:6 and 4:3 were associated with the levels at 15% and 33% RBL, respectively.

CONCLUSIONS

A greater percentage of 3D-CAL than that of 2D-CAL is significant at evaluated levels. It is feasible to correlate the 3D-SBL, 3D-CAL, and STA parameters to evaluate the stages of periodontitis severity. However, the current use of RBL and CAL as applied for staging in the 2017 classification might be inconsistent with the evaluated premolar roots length, when STA dimensions are considered.

Estudo in vitro e in vivo de sondas periodontais do tipo Williams disponíveis no mercado brasileiro

Resumo Introdução A sonda periodontal é a melhor ferramenta para o diagnóstico clínico da doença periodontal, porém o desenho da sonda pode influenciar nos resultados. Objetivo Avaliar as características estruturais de sondas periodontais do tipo Williams disponíveis no mercado brasileiro e avaliar sua utilização clínica durante a sondagem periodontal. Material e método Os grupos de sondas foram divididos em: 1) Hu-Friedy® (n = 15); 2) Trinity® (n = 15); 3) Fava® (n = 15); 4) Millennium® (n = 15). Foram avaliados in vitro: peso (g), diâmetro da ponta ativa (mm), diâmetro do cabo (mm) e milimetragem das sondas (mm). Para o estudo in vivo, foram selecionados 10 participantes que apresentavam pelo menos quatro dentes com periodontite. As marcas de sondas foram codificadas em A, B, C e D para o cegamento do examinador. Resultado Verificou-se um diâmetro da ponta ativa sugestivo de forma tridimensional cônica para as marcas Trinity®, Hu-Friedy® e Millennium®, com conicidade crescente, enquanto a marca Fava® revelou forma tridimensional cilíndrico/paralelo. A sonda Fava® apresentou os maiores diâmetros nos terços inicial e médio, enquanto a Hu-Friedy® revelou menor diâmetro no terço inicial. Todas as sondas apresentaram milimetragem similar. No estudo clínico, verificou-se que a sonda Fava® resultou em menor média de profundidade de sondagem do que às demais. Conclusão As sondas periodontais apresentam diferenças estruturais que devem ser consideradas durante a seleção do instrumento, sendo que as sondas cônicas apresentam resultados mais confiáveis à prática clínica, pois o desenho da sonda interfere diretamente no diagnóstico clínico da doença periodontal.

Role of gingival mesenchymal stem cell exosomes in macrophage polarization under inflammatory conditions

OBJECTIVE

Exosomes have been shown to play a strong role in intercellular communication. While GMSCs have been extensively studied, less research exists on exosomes derived from GMSCs, especially on how exosomes affect macrophages. This study aimed to investigate the impact of GMSC-derived exosomes on macrophage polarization and phenotype under inflammatory conditions.

METHODS

Exosomes were isolated from GMSCs-conditioned media by ultracentrifugation (UC) and characterized by transmission electron microscopy (TEM), nanoparticle tracking analysis (NTA) and western blot (WB). In vitro, GMSC-derived exosomes were co-incubated with macrophages for 24 h in the absence or presence of M1 polarizing conditions in the six-well plate. The protein and mRNA expression levels of M1 and M2 macrophage markers were detected and the supernatants were collected for an enzyme-linked immunosorbent assay (ELISA).

RESULTS

Exosomes were successfully isolated from GMSCs. Macrophages co-cultured with exosomes showed significantly decreased levels of the M1 markers Tumor Necrosis Factor-α (TNF-α), Interleukin-12 (IL-12), CD86 and Interleukin-1β (IL-1β). By contrast, M2 marker Interleukin-10 (IL-10) levels moderately increased. Meanwhile, similar results were acquired in the cell culture supernatants.

CONCLUSION

GMSC-derived exosomes may promote M1 macrophage transformation into M2 macrophages, reducing the pro-inflammatory factors produced by M1 macrophages.

Placental colonization with periodontal pathogens: the potential missing link

Observational studies demonstrate that women with severe periodontitis have a higher risk of adverse pregnancy outcomes like preterm birth and low birthweight. Standard treatment for periodontitis in the form of scaling and root planing during the second trimester failed to reduce the risk of preterm or low birthweight. It is premature to dismiss the association between periodontitis and adverse pregnancy outcomes because one explanation for the failure of scaling and root planing to reduce the risk of adverse pregnancy outcomes is that periodontal pathogens spread to the placental tissue prior to periodontal treatment. In the placenta, orally derived organisms could cause direct tissue damage or mediate a maternal immune response that impairs the growth of the developing fetus. Sequencing studies demonstrate the presence of organisms derived from the oral microbiome in the placenta, but DNA-based sequencing studies should not be the only technique to evaluate the placental microbiome because they may not detect important shifts in the metabolic capability of the microbiome. In humans, polymerase chain reaction and histology have detected periodontal pathogens in placental tissue in association with multiple adverse pregnancy outcomes. We conclude that both placental and oral microbiomes may play a role in periodontitis-associated adverse pregnancy outcomes. However, the measure to determine the association between periodontal pathogens in the placenta and adverse pregnancy outcomes should be the amount and prevalence, not the mere presence of such microorganisms. Placental colonization with periodontal pathogens thus potentially represents the missing link between periodontitis and adverse pregnancy outcomes.

Periodontal disease in Chinese patients with rheumatoid arthritis: A case-control study

OBJECTIVE

To evaluate the prevalence and severity of periodontal disease in Chinese rheumatoid arthritis patients.

SUBJECTS AND METHODS

This cross-sectional study included 128 RA and 109 healthy controls. Two dentists conducted periodontal status including Plaque index (PI), Gingival index (GI), pocket probing depths (PPDs), Clinical attachment level (CAL) and Bleeding on probing (BOP) independently. Sociodemographic, lifestyle, clinical parameters and use of medication were assessed. Data were analyzed by Student's t test, χ² test, Wilcoxin-Mann- Whitney's test, Correlational Analysis, univariate or multivariate logistic regression.

RESULTS

The periodontal status was significantly worse in RA, especially the condition of dental and gingival status. RA had 4.68-fold. After adjusted potential risk factors, RA had 10.26-fold. The independent variable related to GI was DAS28 (p = .05) negatively, to the contrary, ESR (p = .013) was positively associated; the independent variable positively and related to periodontitis was educational level (p = .021) and anti-CCP positivity (p = .002). Through multivariate logistic regression, age and swollen joint were the independent variable related to periodontitis of RA (OR 1.087, p = .044) and (OR 1.560, p = .008) respectively.

CONCLUSIONS

Chinese RA patients show higher odds of PD. It is important to take early interventions in combination with medical therapy.

Levels of Cadmium in Human Mandibular Bone

Cadmium (Cd) is an environmental toxicant that accumulates in bone and alters bone turnover and metabolism. Periodontal disease is characterized by tooth loss and tissue destruction, specifically, loss of supporting bone around the teeth. We have previously shown that Cd causes loss of dental alveolar (tooth supporting) bone in a rodent model of long-term Cd poisoning. The overall goal of this study was to determine the possible association between levels of Cd in alveolar bone and evidence of periodontal disease in human cadavers. The extent of Cd accumulation in human mandible samples was analyzed. Levels of Cd in mandibular alveolar bone were compared to those in basal bone as well as the renal cortex in samples obtained from the cadavers. Alveolar bone contained significantly higher levels of Cd when compared to basal bone (p < 0.01). Cd levels in mandibular bone were significantly higher in female compared to male cadavers (p < 0.05). The kidney cortex had greater than 15-fold higher Cd levels compared to mandible bone. Additional analyses showed a possible association between levels of Cd in basal bone and the presence of periodontal disease in cadavers from which the samples were obtained. This study shows that Cd accumulates to relatively high levels within alveolar bone as compared to basal bone in the mandible and thus may have a significant and direct effect in the progression of changes in bone associated with periodontal disease.

Optical coherence tomography follow-up of patients treated from periodontal disease

Optical coherence tomography (OCT) is one of the most important imaging modalities for biophotonics applications. In this work, an important step towards the clinical use of OCT in dental practice is reported, by following-up patients treated from periodontal disease (PD). A total of 147 vestibular dental sites from 14 patients diagnosed with PD were evaluated prior and after treatment, using a swept-source OCT and two periodontal probes (Florida probe and North Carolina) for comparison. The evaluation was performed at four stages: day 0, day 30, day 60 and day 90. Exceptionally one patient was evaluated 1-year after treatment. It was possible to visualize in the two-dimensional images the architectural components that compose the periodontal anatomy, and identify the improvements in biofilm and dental calculus upon treatment. In the follow-up after the treatment, it was observed in some cases decrease of the gingival thickness associated with extinction of gingival calculus. In some cases, the improvement of both depth of probing with the traditional probes and the evidence in the images of the region was emphasized. The study evidenced the ability of OCT in the identification of periodontal structures and alterations, being an important noninvasive complement or even alternative for periodontal probes for treatment follow-up. OCT system being used in a clinical environment. Above OCT image (left) prior treatment and (right) 30 days after treatment.

Leptin levels in gingival crevicular fluid during canine retraction: in vivo comparative study

OBJECTIVE

To evaluate and compare the leptin levels in gingival crevicular fluid (GCF) and rate of canine retraction using an elastomeric chain and nickel-titanium (NiTi) closed coil spring.

DESIGN

In vivo, clinical study.

SETTING

Orthodontic department at ITS Centre for Dental Studies and Research, Ghaziabad, India.

PARTICIPANTS

Twenty-seven patients reported to the Department of Orthodontics at ITS Centre for Dental Studies and Research.

METHODS

Twenty-seven patients were included in the study in which canine retraction was carried out with an elastomeric chain and NiTi closed coil spring on either side of the arch applying 150 g of force on both sides. GCF samples were collected before the commencement of canine retraction, on the first, seventh and 21st day after application of force and were analysed for leptin levels by the ELISA technique. Impressions for the study model were taken at baseline and after 21 days to measure the rate of tooth movement bilaterally with an electronic digital calliper.

RESULTS

The results obtained within both groups showed a significant decrease in leptin levels from baseline to 21 days ( P = 0.0001). There was no significant difference in leptin levels between both groups, but leptin levels decreased more in the NiTi closed coil spring group. The rate of tooth movement is not significantly different between both groups, but space closure is faster in the NiTi closed coil spring group.

CONCLUSIONS

Leptin levels in GCF showed a significant decrease during canine retraction using an elastomeric chain and NiTi coil spring; there was no significant difference in the rate of tooth movement between both the groups.

Embracing Personalized Medicine in Dentistry

Aim:

The aim of this systematic review was to evaluate the number of articles in the area of personalized medicine specific to dentistry.

Materials and Methods:

Electronic search using three databases was performed using PubMed, Embase, and Scopus search.

Results:

Results suggest that there is a definite need for more awareness and research pertaining to this specific area.

Conclusion:

With this background, the authors have written a comprehensive review on applications of personalized medicine in various branches of dentistry.

Periodontal pathogens and the association between periodontitis and rheumatoid arthritis in Korean adults

Purpose

Periodontitis and rheumatoid arthritis (RA) share a similar inflammatory pathogenesis. Porphyromonas gingivalis (Pg) can induce anticyclic-citrullinated peptide autoantibodies (anti-CCP antibodies), a key factor in the development of RA. This study aimed at evaluating the relationships between the 2 diseases and identifying the clinical implications thereof, with a focus on periodontal pathogens in Korean adults.

Methods

A total of 260 RA patients and 86 age- and sex-matched control patients without arthritis were enrolled in this prospective cross-sectional study. Periodontal indices and the prevalence and amount of periodontal pathogens were compared between the groups. Correlations between periodontal and RA indices were examined, as were correlations between 9 periodontal pathogens and RA indices.

Results

The RA group had significantly higher values than the control group for all investigated periodontal indices (P<0.05) except the number of teeth. The gingival index (GI) was correlated with the disease activity score 28 (DAS28) (r=0.125, P=0.049), RA disease duration (r=0.253, P<0.001), erythrocyte sedimentation rate (ESR) (r=0.162, P=0.010), and anti-CCP antibody titer (r=0.205, P=0.004). Probing pocket depth (PPD) was correlated with ESR (r=0.139, P=0.027) and anti-Pg antibody titer (r=0.203, P=0.001). Bleeding on probing (BOP) was correlated with DAS28 (r=0.137, P=0.030), RA disease duration (r=0.202, P=0.001), ESR (r=0.136, P=0.030), anti-Pg antibody titer (r=0.177, P=0.005), and anti-CCP antibody titer (r=0.188, P=0.007). Clinical attachment level (CAL) and periodontitis severity were correlated with anti-Pg antibody titer (the former r=0.201, P=0.002; the latter r=0.175, P=0.006). The quantity of Pg was positively correlated with the serum anti-Pg antibody titer (r=0.148, P=0.020).

Conclusions

The GI, BOP, and PPD showed positive relationships with several RA indices. The anti-Pg antibody titer had positive relationships with PPD, BOP, CAL, and periodontitis severity. Thus, increasing values of periodontal indices could be used as a risk indicator of disease development in RA patients, and an increasing anti-Pg antibody titer could be considered as a warning sign in RA patients suffering with periodontitis.

Differential profiles of soluble and cellular toll like receptor (TLR)-2 and 4 in chronic periodontitis

Chronic periodontitis is a common inflammatory disease initiated by a complex microbial biofilm and mediated by the host response causing destruction of the supporting tissues of the teeth. Host recognition of pathogens is mediated by toll-like receptors (TLRs) that bind conserved molecular patterns shared by large groups of microorganisms. The oral epithelial cells respond to most periodontopathic bacteria via TLR-2 and TLR-4. In addition to the membrane-associated receptors, soluble forms of TLR-2 (sTLR-2) and TLR-4 (sTLR-4) have been identified and are thought to play a regulatory role by binding microbial ligands. sTLR-2 has been shown to arise from ectodomain shedding of the extracellular domain of the membrane receptor and sTLR-4 is thought to be an alternate spliced form. Many studies have previously reported the presence of elevated numbers of viable exfoliated epithelial cells in the saliva of patients with chronic periodontitis. The objective of this study was to investigate the potential value of salivary sTLR-2 and sTLR-4 together with the paired epithelial cell-associated TLR-2/4 mRNA as diagnostic markers for chronic periodontitis. Unstimulated whole saliva was collected after obtaining informed consent from 40 individuals with either periodontitis or gingivitis. The sTLR-2 and sTLR4 in saliva was measured by enzyme-linked immunosorbent assay. The TLR-2 and TLR-4 transcript in the epithelial cells in saliva was measured by real time polymerase chain reaction. While levels of sTLR-2 exhibited an inverse correlation, sTLR-4 positively correlated with clinical parameters in the gingivitis cohort. Interestingly, both correlations were lost in the periodontitis cohort indicating a dysregulated host response. On the other hand, while the sTLR-2 and the paired epithelial cell associated TLR-2 mRNA exhibited a direct correlation (r2 = 0.62), that of sTLR4 and TLR-4 mRNA exhibited an inverse correlation (r2 = 0.53) in the periodontitis cohort. Collectively, assessments of salivary sTLR2 and sTLR4 together with the respective transcripts in the epithelial cells could provide clinically relevant markers of disease progression from gingivitis to periodontitis.

Peri-Implantitis and Peri-Implant Mucositis Case Definitions in Dental Research: A Systematic Assessment

The aim of this review was to determine the most common peri-implant mucositis and peri-implantitis case definitions used worldwide in the implant dentistry literature. A systematic assessment of peri-implant disease classification was conducted using all publications in MEDLINE, EMBASE, SCOPUS, and Google Scholar between 1994 and November 2017. Screening of eligible studies and data extraction were conducted in duplicate and independently by 2 reviewers. The search protocol identified 3049 unique articles, of which 2784 were excluded based on title and abstract. In total, 265 full texts were screened, 106 of which met the eligibility criteria. Of these, 41 defined peri-implant mucositis. Eight (19.6%) used bleeding on probing (BOP) only; 8 (19.6.7%) used a combination of probing depth (PD), BOP, and radiograph; and 5 (12.3%) used PD and BOP. Cases with crestal bone loss of ≤2 mm in the first year and ≤0.2 mm in each subsequent year were considered as peri-implant mucositis. Ninety-three articles defined peri-implantitis; 28 (30.1%) used a combination of PD with suppuration, BOP, and radiograph, followed by 25 (26.9%) using a combination of PD, BOP, and radiograph. The main criteria in most of the studies were considered to be BOP, PD, and radiograph. Cases of crestal bone loss of ≥2 mm and PD ≥3 mm are considered peri-implantitis. Different peri-implant disease case definitions may affect disease prevalence and treatment strategies. We need to standardize case definitions to avoid discrepancies in case diagnosis and prognosis.