The Chairside Periodontal Diagnostic Toolkit: Past, Present, and Future

Periodontal disease and emerging point-of-care technologies for its diagnosis

Periodontal disease (PD), a chronic inflammatory disorder that damages the tooth and its supporting components, is a common global oral health problem. Understanding the intricacies of these disorders, from gingivitis to severe PD, is critical for efficient treatment, diagnosis, and prevention in dental care. Periodontal biosensors and biomarkers are critical in improving oral health diagnostic skills. Clinicians may accomplish early identification, tailored therapy, and efficient tracking of periodontal diseases by using these technologies, ushering in a new age of accurate oral healthcare. Traditional periodontitis diagnostic methods frequently rely on physical probing and visual examinations, necessitating the development of point-of-care (POC) devices. As periodontal disorders necessitate more precise and rapid diagnosis, incorporating novel innovations in biosensors and biomarkers becomes increasingly crucial. These innovations improve our capacity to diagnose, monitor, and adapt periodontal therapies, bringing in the next phase of customized and effective dental healthcare. The review discusses the characteristics and stages of PD, clinical treatment techniques, prominent biomarkers and infection-associated factors that may be employed to determine PD, biomedical sensing, and POC appliances that have been created so far to diagnose stages of PD and its progression profile, as well as predicting future developments in this field.

Intraoral ultrasonography image registration for evaluation of partial edentulous ridge: A methodology and validation study

OBJECTIVES

Ultrasound (US) reveals details for diagnosing soft- and hard-tissue dimensions around teeth, implants, and the edentulous ridge, not seen in 2D radiographs. Co-registering free-hand US scans with other 3D modalities presents reliability challenges. This study first aims to develop and validate a registration method to longitudinally reproduce US images of the jawbone on a simulator. In addition, it also evaluates the degree of the anatomical match in humans between US images acquired by the proposed registration method and the commonly used freehand acquisitions in comparison to cone beam computed tomography (CBCT) and intra-oral optical scan (IOS), used as references.

METHODS

A previously introduced ultrasound phantom was employed as a CBCT-US hybrid, suitable for training and technique development of US guides in edentulous ridges. After establishing feasibility in the phantom, the methodology was validated in a cohort of 24 human subjects (26 cases). Soft tissues were delineated on US and IOS, and hard tissues on US and CBCT. US accuracy and repeatability from both guided and freehand scans (non-guided) was assessed as the average distance between US and the references.

RESULTS

Guided US images resembled the references more closely than freehand (non-guided) scans. Notably, delineation of soft and hard tissues was significantly more accurate when employing guides. In the phantom, guided scans exhibited an absolute mean deviation of 81.8 µm for gingiva and 90.4 µm for bone, whereas non-guided scans showed deviations of 150.4 µm and 177.2 µm, respectively. Similarly, in vivo, guided US outperformed non-guided US, with gingiva deviations of 125 µm and 196 µm, and bone deviations of 354 µm and 554 µm, respectively.

CONCLUSIONS

By using a registration method, guided US scans improved repeatability and accuracy of mapping hard and soft tissue of the edentulous ridge when compared to non-guided scans.

CLINICAL RELEVANCE

This guided US imaging method could lay the foundation for longitudinal evaluation of tissue behavior and dimensional changes with improved accuracy.

Conventional diagnostic criteria for periodontal diseases (plaque-induced gingivitis and periodontitis)

This narrative review addresses conventional diagnostic criteria used in clinical practice to discriminate between periodontal health, gingivitis, and periodontitis. Visual examination of the color and texture of the periodontal tissues, assessment of plaque deposits, periodontal probing assessments, and diagnostic imaging enable the collation of information to make a periodontal diagnosis, followed by an appropriate treatment plan. The periodontal probe is an essential diagnostic tool to assess probing pocket depth, clinical attachment level, bleeding on probing, and the degree of furcation involvement at multirooted teeth. When clinical signs and symptoms of periodontitis are identified, diagnostic imaging enables evaluation of the level and extent of bone destruction and bone defect morphology. The diagnostic process requires clinicians who are trained to evaluate, record, and interpret these measures. This narrative review focuses on conventional clinical diagnostic parameters which, despite their limitations, are considered the current standard of care.

The Association between Salivary Metabolites and Gingival Bleeding Score in Healthy Subjects: A Pilot Study

Periodontal diseases, including gingivitis and periodontitis, are among the most prevalent diseases in humans. Gingivitis is the mildest form of periodontal disease, characterized by inflammation of the gingiva caused by the accumulation of dental plaque. Salivary diagnostics are becoming increasingly popular due to the variation in saliva composition in response to pathological processes. We used a metabolomics approach to investigate whether a specific saliva metabolic composition could indicate preclinical stage of gingivitis. 1H-NMR spectroscopy was used to obtain the salivary metabolite profiles of 20 healthy subjects. Univariate/multivariate statistical analysis evaluated the whole saliva metabolite composition, and the Full-Mouth Bleeding Score (FMBS) was employed as a classification parameter. Identifying a signature of specific salivary metabolites could distinguish the subjects with high FMBS scores but still within the normal range. This set of metabolites may be due to the enzymatic activities of oral bacteria and be associated with the early stages of gingival inflammation. Although this analysis is to be considered exploratory, it seems feasible to establish an FMBS threshold that distinguishes between the absence and presence of early inflammatory alterations at the salivary level.

The Suitability of Trabecular Patterns in the Assessment of Dental Implant Osseointegration Process through 2D Digital and 3D CBCT Radiographs

OBJECTIVE

 The research aims to determine the suitability of the trabecular pattern in the assessment of the dental implant osseointegration process through two-dimensional (2D) digital and three-dimensional (3D) cone-beam computed tomography (CBCT) radiographs.

MATERIALS AND METHODS

 This is a correlation description that explains the relationship between variables. The population consisted of 24 data points on 3D CBCT and 2D digital radiographs from the procedure after dental implants were inserted into the tibia of a New Zealand white rabbit (Oryctolagus cuniculus) on days 3, 14, and 28. The radiograph was selected based on the region of interest (ROI), which covers the peri-implant area with a width of 1 mm and length following the height of the implant. The ROI was analyzed for trabecular thickness (Tb.Th), separation (Tb.Sp), number (Tb.N), and fractal dimension.

STATISTICAL ANALYSIS

 The intraclass correlation coefficient (ICC) was used to statistically test the data to assess the consistency of intraobserver measurements and the r value (Pearson's correlation coefficient). This determines the correlation between trabecular patterns in both radiographic modalities and the Bland-Altman plot to observe the limits of acceptable discrepancies.

RESULTS

 The ICC test showed high intraobserver consistency in trabecular pattern measurements on 2D digital radiographs and 3D CBCT. The trabecular space pattern and number showed an r value of 0.88 with radiographic modalities of 0.72 mm and 0.018, respectively. Additionally, the trabecular thickness and fractal dimension had an insignificant correlation, with an r value of 0.22, and the mean of the 2D radiograph was lower than that of CBCT.

CONCLUSION

 The 2D radiograph and 3D CBCT showed correlations in the trabecular number and space results but had no correlation in the trabecular thickness and fractal dimension results. Based on intraclass correlation analysis, 3D CBCT appeared to be more reliable for measuring trabecular patterns (Tb.Th, Tb.Sp, Tb.N, and fractal dimension) than 2D radiograph.

The use of digital technologies in peri-implant soft tissue augmentation - A narrative review on planning, measurements, monitoring and aesthetics

OBJECTIVE

To identify the different uses and modalities of digital technologies to diagnose, plan and monitor peri-implant soft tissue conditions and aesthetics.

METHODS

A comprehensive narrative review of pertinent literature was conducted, critically appraising key digital technologies that may assist peri-implant soft tissue augmentation and assessment. An electronic search on four databases including studies published prior to 1st July 2023 was performed and supplemented by a manual search.

RESULTS

Predominantly, tools such as cone beam computed tomography (CBCT), intraoral scanning (iOS), intraoral ultrasonography and digital spectrophotometry were commonly to assess and monitor peri-implant soft tissues. The main clinical and research applications included: (i) initial assessment of mucosal thickness, supra-crestal tissue height and keratinized mucosa width, (ii) evaluation of peri-implant soft tissue health and inflammation, (iii) monitoring profilometric changes and midfacial mucosal margin stability over time and (iv) aesthetic evaluation through colour assessment. While evidence for some digital tools may be limited, the integration of digital technologies into peri-implant soft tissue management holds great promise. These technologies offer improved precision, comfort and speed in assessment, benefiting both patients and clinicians.

CONCLUSION

As digital technologies progress, their full potential in peri-implant soft tissue augmentation and their value will become more evident with ongoing research. Embracing these innovations and their potential benefits is recommended to ensure that during progress in implant dentistry, patient care is not hindered.

Personalized antibiotic selection in periodontal treatment improves clinical and microbiological outputs

Introduction

Periodontitis is a biofilm-mediated disease that is usually treated by non-surgical biofilm elimination with or without antibiotics. Antibiotic treatment in periodontal patients is typically selected empirically or using qPCR or DNA hybridization methods. These approaches are directed towards establishing the levels of different periodontal pathogens in periodontal pockets to infer the antibiotic treatment. However, current methods are costly and do not consider the antibiotic susceptibility of the whole subgingival biofilm.

Methods

In the current manuscript, we have developed a method to culture subgingival samples ex vivo in a fast, label-free impedance-based system where biofilm growth is monitored in real-time under exposure to different antibiotics, producing results in 4 hours. To test its efficacy, we performed a double-blind, randomized clinical trial where patients were treated with an antibiotic either selected by the hybridization method (n=32) or by the one with the best effect in the ex vivo growth system (n=32).

Results

Antibiotic selection was different in over 80% of the cases. Clinical parameters such as periodontal pocket depth, attachment level, and bleeding upon probing improved in both groups. However, dental plaque was significantly reduced only in the group where antibiotics were selected according to the ex vivo growth. In addition, 16S rRNA sequencing showed a larger reduction in periodontal pathogens and a larger increase in health-associated bacteria in the ex vivo growth group.

Discussion

The results of clinical and microbiological parameters, together with the reduced cost and low analysis time, support the use of the impedance system for improved individualized antibiotic selection.

DAMPs and alarmin gene expression patterns in aging healthy and diseased mucosal tissues

Introduction

Periodontitis is delineated by a dysbiotic microbiome at sites of lesions accompanied by a dysregulated persistent inflammatory response that undermines the integrity of the periodontium. The interplay of the altered microbial ecology and warning signals from host cells would be a critical feature for maintaining or re-establishing homeostasis in these tissues.

Methods

This study used a nonhuman primate model (Macaca mulatta) with naturally-occurring periodontitis (n = 34) and experimental ligature-induced periodontitis (n = 36) to describe the features of gene expression for an array of damage-associate molecular patterns (DAMPs) or alarmins within the gingival tissues. The animals were age stratified into: ≤3 years (Young), 7-12 years (Adolescent), 12-15 years (Adult) and 17-23 years (Aged). Gingival tissue biopsies were examined via microarray. The analysis focused on 51 genes representative of the DAMPs/alarmins family of host cell warning factors and 18 genes associated with tissue destructive processed in the gingival tissues. Bacterial plaque samples were collected by curette sampling and 16S rRNA gene sequences used to describe the oral microbiome.

Results

A subset of DAMPs/alarmins were expressed in healthy and naturally-occurring periodontitis tissues in the animals and suggested local effects on gingival tissues leading to altered levels of DAMPs/alarmins related to age and disease. Significant differences from adult healthy levels were most frequently observed in the young and adolescent animals with few representatives in this gene array altered in the healthy aged gingival tissues. Of the 51 target genes, only approximately ⅓ were altered by ≥1.5-fold in any of the age groups of animals during disease, with those increases observed during disease initiation. Distinctive positive and negative correlations were noted with the DAMP/alarmin gene levels and comparative expression changes of tissue destructive molecules during disease across the age groups. Finally, specific correlations of DAMP/alarmin genes and relative abundance of particular microbes were observed in health and resolution samples in younger animals, while increased correlations during disease in the older groups were noted.

Conclusions

Thus, using this human-like preclinical model of induced periodontitis, we demonstrated the dynamics of the activation of the DAMP/alarmin warning system in the gingival tissues that showed some specific differences based on age.

Alpha-Defensin 1: An Emerging Periodontitis Biomarker

Background: Research on the development of reliable diagnostic targets is being conducted to overcome the high prevalence and difficulty in managing periodontitis. However, despite the development of various periodontitis target markers, their practical application has been limited due to poor diagnostic accuracy. In this study, we present an improved periodontitis diagnostic target and explore its role in periodontitis. Methods: Gingival crevicular fluid (GCF) was collected from healthy individuals and periodontitis patients, and proteomic analysis was performed. The target marker levels for periodontitis were quantified in GCF samples by enzyme-linked immunosorbent assay (ELISA). Mouse bone marrow-derived macrophages (BMMs) were used for the osteoclast formation assay. Results: LC-MS/MS analysis of whole GCF showed that the level of alpha-defensin 1 (DEFA-1) was higher in periodontitis GCF than in healthy GCF. The comparison of periodontitis target proteins galactin-10, ODAM, and azurocidin proposed in other studies found that the difference in DEFA-1 levels was the largest between healthy and periodontitis GCF, and periodontitis was more effectively distinguished. The differentiation of RANKL-induced BMMs into osteoclasts was significantly reduced by recombinant DEFA-1 (rDEFA-1). Conclusions: These results suggest the regulatory role of DEFA-1 in the periodontitis process and the relevance of DEFA-1 as a diagnostic target for periodontitis.

Potential Impact of Prosthetic Biomaterials on the Periodontium: A Comprehensive Review

The success of a prosthetic treatment is closely related to the periodontal health of the individual. The aim of this article was to review and present the importance of prosthetic restorative materials on the condition of the periodontium, the changes that occur in the composition of the subgingival microbiota and the levels of inflammatory markers in gingival crevicular fluid. Articles on the influence of different prosthetic restorative materials on subgingival microbiota and proinflammatory cytokines were searched for using the keywords "prosthetic biomaterials", "fixed prosthesis", "periodontal health", "subgingival microbiota", "periodontal biomarkers" and "gingival crevicular fluid" in PubMed/Medline, Science Direct, Scopus and Google Scholar. The type of material used for prosthesis fabrication together with poor marginal and internal fit can result in changes in the composition of the subgingival microbiota, as well as increased accumulation and retention of dentobacterial plaque, thus favoring the development of periodontal disease and prosthetic treatment failure. Biological markers have helped to understand the inflammatory response of different prosthetic materials on periodontal tissues with the main purpose of improving their clinical application in patients who need them. Metal-free ceramic prostheses induce a lower inflammatory response regardless of the fabrication method; however, the use of CAD/CAM systems is recommended for their fabrication. In addition, it is presumed that metal-ceramic prostheses cause changes in the composition of the subgingival microbiota producing a more dysbiotic biofilm with a higher prevalence of periodontopathogenic bacteria, which may further favor periodontal deterioration.

Salivary Biomarkers in Periodontitis Post Scaling and Root Planing

OBJECTIVES

This study was conducted to evaluate the levels of salivary uric acid and arginase in patients with periodontitis, generalized gingivitis, and in healthy individuals. Then, the effects of non-surgical periodontal therapy on levels of salivary arginase and uric acid were also investigated.

METHODS

A total of 60 subjects were divided into three groups based on periodontal health: group I comprised 20 healthy individuals; group II comprised 20 subjects who had generalized gingivitis; group III comprised 20 subjects who had generalized periodontitis. On day 0, the clinical examination of periodontal status was recorded, following which saliva samples were collected. Group II and group III subjects underwent non-surgical periodontal therapy. These patients were recalled on day 30 to collect saliva samples. The periodontal parameters were reassessed on day 90, and saliva samples were collected for analysis of salivary arginase and uric acid levels.

RESULTS

Group II and group III showed improvement in clinical parameters following non-surgical periodontal therapy on the 90th day. The MGI score, PPD, and CAL showed improvement. On day 0, at baseline, salivary arginase levels in group III and group II were higher than those in healthy subjects, whereas on day 0, salivary uric acid levels in group III and group II were lower than those in healthy subjects. Both on day 0 and day 90, the salivary arginase level showed a positive correlation with the periodontal parameters, whereas the salivary uric acid level was positively correlated with the periodontal parameters on day 90.

CONCLUSION

the level of salivary arginase was a pro-inflammatory marker and a raised level of salivary uric acid was an anti-inflammatory marker following periodontal therapy, suggesting their pivotal role in assessing periodontal status and evaluation of treatment outcome.

Determination of the Accuracy of Salivary Biomarkers for Periodontal Diagnosis

Background: We aimed to investigate the accuracy of salivary matrix metalloproteinases (MMP)-8 and -9, and tissue inhibitor of metalloproteinase (TIMP)-1 in diagnosing periodontitis and in distinguishing periodontitis stages (S)1 to S3. Methods: This study was a case–control study that included patients with periodontitis S1 to S3 and subjects with healthy periodontia (controls). Saliva was collected, and then, clinical parameters were recorded, including plaque index, bleeding on probing, probing pocket depth, and clinical attachment level. Diagnosis was confirmed by assessing the alveolar bone level using radiography. Salivary biomarkers were assayed using an enzyme-linked immunosorbent assay. Results: A total of 45 patients (15 for each stage) and 18 healthy subjects as controls were included. The levels of all salivary biomarkers and clinical parameters were significantly higher in periodontitis subjects than in the controls. The ROC curve showed that MMP-8, MMP-9, TIMP-1, MMP-8/TIMP-1, and MMP-9/TIMP-1 had statistically significant diagnostic accuracy, with areas under the curve (AUCs) of 0.892, 0.844, 0.920, 0.986, and 1.000, respectively, when distinguishing periodontitis from the controls. Similarly, these biomarkers showed significant diagnostic accuracy in the differentiation of S1 periodontitis from the controls (AUC range from 0.902 to 1.000). Conclusions: This study suggested that salivary biomarkers exhibited high diagnostic accuracy in distinguishing periodontal health from periodontitis in general as well as S1 periodontitis. Furthermore, TIMP-1 could differentiate S1 from S3.

Clinical Assessment of the Hyperbaric Oxygen Therapy Efficacy in Mild to Moderate Periodontal Affections: A Simple Randomised Trial

Background and Objectives: Gum disease represents the condition due to the dental plaque and dental calculus deposition on the surfaces of the teeth, followed by ulterior destruction of the periodontal tissues through the host reaction to the pathogenic microorganisms. The aim of study was to present aspects regarding the efficacy of hyperbaric oxygen therapy (HBOT) as an adjuvant therapy for the treatment of periodontal disease, started from the already certified benefits of HBOT in the general medicine specialties. Materials and Methods: The participant patients in this study (71) required and benefited from specific periodontal disease treatments. All patients included in the trial benefited from the conventional therapy of full-mouth scaling and root planing (SRP) within 24 h. HBOT was performed on the patients of the first group (31), in 20 sessions, of one hour. The patients of the control group (40) did not benefit from HBO therapy. Results: At the end of study, the included patients in HBOT group presented significantly better values of oral health index (OHI-S), sulcus bleeding index (SBI), dental mobility (DM), and periodontal pocket depth (PD) than the patients of the control group. Conclusions: HBOT had beneficial effects on the oral and general health of all patients, because in addition to the positive results in periodontal therapy, some individual symptoms of the patients diminished or disappeared upon completion of this adjuvant therapy.