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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Parents with periodontitis drive the early acquisition of dysbiotic microbiomes in their offspring

AIM

To evaluate the microbial colonization in different dentition phases on individuals from 0 to 18 years of age belonging to families with a history of periodontitis compared to descendants of periodontally healthy parents.

MATERIALS AND METHODS

The offspring of subjects with periodontitis ('Perio' group) and the offspring of periodontally healthy subjects ('Healthy' group), matched for gender and age, were included in this cross-sectional study and divided according to the dentition phase: pre-dentate, primary, mixed and permanent. The patients were clinically assessed, and their saliva was collected. DNA was extracted, and V1-V3 and V4-V5 regions of the 16S rRNA gene were sequenced.

RESULTS

Fifty children of parents with periodontitis and 50 from healthy parents were included in the study and divided according to the dentition phase: pre-dentate (n = 5/group), primary dentition (n = 15/group), mixed dentition (n = 15/group) and permanent dentition (n = 15/group) in each group. The microbiome composition was different between dentitions for both groups. Children of the Perio group presented a microbial diversity different from that of the Healthy group in mixed and permanent dentitions. The more intense shift in the community occurred between primary and mixed dentition in the Perio group, while the transition between mixed and permanent dentition was the period with greater changes in the microbiome for the Healthy group. Furthermore, a pathogen-rich environment-higher prevalence and abundance of periodontitis-associated species such as Prevotella spp., Selenomonas spp., Leptotrichia spp., Filifactor alocis, Prevotella intermedia, Treponema denticola and Tannerella forsythia- was observed in the Perio group.

CONCLUSIONS

The parents' periodontal status significantly affects the microbiome composition of their offspring from an early age. The mixed dentition was the phase associated with establishing a dysbiotic and pathogen-rich microbiome in descendants of parents with periodontitis.

AB0696 Prevalence and clinical associations of different autoantibodies in the Reuma.pt systemic sclerosis cohort: is it all really set in stone?

Background

Different autoantibodies (Ab) have been associated with distinct systemic sclerosis (SSc) phenotypes. Most of these associations have not been confirmed in Portuguese patients.

Objectives

To evaluate SSc immuno-clinical associations in the Rheumatic Diseases Portuguese Register (Reuma.pt) cohort.

Methods

Multicentre open cohort study including adult SSc patients registered in Reuma.pt up to February 2021. The associations between Ab expression and clinical data were established using Chi-Square, Fischer’s Exact or Mann-Whitney U tests. The Bonferroni correction for multiple comparisons was applied to get α≤0.05. Definite associations were defined by p≤0.002, and likely associations by p≤0.05.

Results

1080 patients were included, with a mean age and disease duration of 60.2±14.6 and 12.4±10.0 years, respectively. Most were females (87.5%) and had white European ancestry (WEA, 93.2%). The most common disease subtypes were limited cutaneous (lcSSc, 57.4%), diffuse cutaneous (dcSSc, 17.7%), and very early diagnosis of SSc (VEDOSS, 12.3%). Most patients expressed antinuclear Ab (ANA, 93.4%), and the most frequent were anti-centromere (ACA, 54.6%), anti-topoisomerase I (Scl70, 21.8%), and anti-Pm/Scl Ab (PmScl, 4.7%).

ACA had definite positive associations with female sex, older age at diagnosis, lcSSc, lower modified Rodnan skin score (mRSS, median 0 vs 4), and isolated sclerodactyly, and likely associations with a higher diagnosis delay, WEA and VEDOSS. ACA had definite inverse associations with flexion contractures (FC), myositis, digital ulcers (DU), and interstitial lung disease (ILD), and likely inverse associations with pitting scars (PS) and oesophageal involvement (OI).

Scl70 had definite positive associations with male sex, dcSSc, higher mRSS, FC, DU, PS, ILD, and OI, and likely associations with younger age at diagnosis, tendon friction rubs, active scleroderma pattern in capillaroscopy, and heart involvement.

PmScl had a definite association with myositis and likely associations with male sex, calcinosis, joints involvement, and ILD. Anti-U1RNP Ab had definite associations with younger age at diagnosis, MCTD and myositis, and likely associations with a lower diagnosis delay, African ancestry and joint involvement. Anti-RNA polymerase III Ab (RP3) had likely associations with higher mRSS and renal involvement. Anti-U3RNP Ab had a definite association with dcSSc and likely associations with calcinosis and renal involvement. Anti-Th/To Ab had likely associations with male sex and myositis. Anti-Ku Ab had likely associations with systemic lupus erythematosus and mixed connective tissue disease (MCTD) overlap syndromes.

Conclusion

There was a higher prevalence of ACA and PmScl compared to other cohorts, most likely due to the high proportion of WEA patients. Most immuno-clinical associations described in the literature apply, including ACA with lcSSc and Scl70 with dcSSc, DU, PS and ILD. However, Scl70+ patients did not have an increased risk of renal involvement, and ACA+ patients did not have an increased risk for calcinosis, PAH or OI, contrary to what was described in the literature. New findings included the association of PmScl with ILD and Scl70 with an active pattern in capillaroscopy. Also, anti-U3RNP+ and Th/To+ patients did not have an increased risk of ILD or PAH, contrarily to what was previously reported. These nuances may be specific to the Portuguese SSc population or signal previously reported associations as geographically specific.

Disclosure of Interests

None declared

POS0564 SHOULD WE USE PHYSICIAN’S GLOBAL TO DEFINE REMISSION IN RHEUMATOID ARTHRITIS AND CONSIDER A SEPARATE PATIENT-CENTRED TARGET?

Background

The definitions of remission play a crucial role in the treat-to-target strategy in rheumatoid arthritis.The patient’s and physician’s global assessment (PGA|PhGA) of disease activity are considered in current definitions, but PGA has been criticized for its poor relationship with actual disease activity. This leads to a considerable risk of overtreatment in patients who are otherwise in remission but fail this target solely because of PGA: PGA-near-remission. A dual-target strategy, excluding PGA from the definition of biological remission and the creation of a second target focused on disease impact has been proposed.1 Another proposal is to substitute PGA by PhGA with the purpose of strengthening the definition with a fourth variable capable of conveying relevant unaccounted factors, such as comorbidity.2

Objectives

To assess the relationship of PGA and PhGA with objective measures of disease activity (DAS3v) and their impact upon near-remission and risk of overtreatment.

Methods

This is a cross-sectional analysis of data from RAID.PT, an observational, prospective and multicenter study, including adult patients fulfilling RA classification criteria. Tender (TJC28) and swollen (SJC28) 28 joint counts, C-Reactive Protein (CRP), Pain score, Health Assessment Questionnaire (HAQ), the Rheumatoid Arthritis Impact of Disease (RAID) total score, Hospital Anxiety and Depression Scale (HADS) scores, PGA and PhGA were collected. Disease Activity Score (DAS28-3v-CRP) was calculated and taken as the reference measure of current disease activity. Correlation between PGA and PhGA with other continuous variables was evaluated through Pearson´s Correlation Coefficient and variables with p<0.10 in univariate analysis were included in multivariable linear regression models.

Results

We included 299 patients, 81.3% women, mean age of 57.4±12.0 years and disease duration 9.4±9.5 years. Average DAS28-3v-PCR 2.4 (±1.9).

DAS3v-CRP is the strongest factor associated with PhGA, explaining 45% of its variance. Inversely, it only explains 2% of the variance of PGA, which is more affected by disease impact.

In this clinical cohort, 13% of patients were in full Boolean remission and 41% in PGA-near-remission. Only 49 of 123 patients in the latter group had a PhGA >1.

Considering PhGA instead of PGA in the Boolean definition of remission would increase the proportion of remission from 13 to 37.5% of the whole cohort.

Table 1.

Factors Associated with PGA and PhGA in multivariate regression analysis

PGAPhGA(β, 95% CI)(β, 95% CI)(β, 95% CI)ΔR2ΔR2DAS28-3v-CRP3.7 (1.9-5.5)10.9 (9.4 to12.5)0.020.45RAID7.7 (6.7-8.8)3.4 (2.5 to 4.3)0.610.09HAQ5.6 (1.0-8.1)-3.4 (-6.4 to -0.4)0.010.01R20.64*0.55*

DAS28-3v-CRP: Disease Activity Score-3 variables C-Reactive Protein. PGA: Patient global assessment; PhGA: Physician Global Assessment; HAQ (health assessment questionnaire); RAID: Rheumatoid Arthritis Impact Disease score. ΔR2 change of R2associated with the inclusion of the variable in the model. *p<0,01

Conclusion

PhGA is a closer representation of actual disease activity than PGA, thus providing a more valid basis for treatment decisions aimed at disease activity. These observations support the substitution of PGA by PhGA in the Boolean definition of remission as it would strengthen the representation of disease activity and significantly reduce the risk of overtreatment in comparison to current definitions. The consequences of this change upon the prediction of long-term function and structural stability warrant evaluation. The patient’s perspective will remain central to disease management in the form of a distinct target.

References

[1]Ferreira et al. Ann Rheum Dis 2019 Oct;78(10):e109.doi: 10.1136/annrheumdis-2018-214199

[2]Pazmino et al. J Rheumatol. 2021 Feb;48(2):174-178.doi: 10.3899/jrheum.200758

Disclosure of Interests

None declared.

Oral Dysbiosis in Severe Forms of Periodontitis Is Associated With Gut Dysbiosis and Correlated With Salivary Inflammatory Mediators: A Preliminary Study

Inflammation is a driven force in modulating microbial communities, but little is known about the interplay between colonizing microorganisms and the immune response in periodontitis. Since local and systemic inflammation may play a whole role in disease, we aimed to evaluate the oral and fecal microbiome of patients with periodontitis and to correlate the oral microbiome data with levels of inflammatory mediator in saliva. Methods: Nine patients with periodontitis (P) in Stage 3/Grade B and nine age-matched non-affected controls (H) were evaluated. Microbial communities of oral biofilms (the supra and subgingival from affected and non-affected sites) and feces were determined by sequencing analysis of the 16SrRNA V3-V4 region. Salivary levels of 40 chemokines and cytokines were correlated with oral microbiome data. Results: Supragingival microbial communities of P differed from H (Pielou's evenness index, and Beta diversity, and weighted UniFrac), since relative abundance (RA) of Defluviitaleaceae, Desulfobulbaceae, Mycoplasmataceae, Peptostreococcales-Tissierellales, and Campylobacteraceae was higher in P, whereas Muribaculaceae and Streptococcaceae were more abundant in H. Subgingival non-affected sites of P did not differ from H, except for a lower abundance of Gemellaceae. The microbiome of affected periodontitis sites (PD ≥ 4 mm) clustered apart from the subgingival sites of H. Oral pathobionts was more abundant in sub and supragingival biofilms of P than H. Fecal samples of P were enriched with Acidaminococcus, Clostridium, Lactobacillus, Bifidobacterium, Megasphaera, and Romboutsia when compared to H. The salivary levels of interleukin 6 (IL-6) and inflammatory chemokines were positively correlated with the RA of several recognized and putative pathobionts, whereas the RA of beneficial species, such as Rothia aeria and Haemophilus parainfluenzae was negatively correlated with the levels of Chemokine C-C motif Ligand 2 (CCL2), which is considered protective. Dysbiosis in patients with periodontitis was not restricted to periodontal pockets but was also seen in the supragingival and subgingival non-affected sites and feces. Subgingival dysbiosis revealed microbial signatures characteristic of different immune profiles, suggesting a role for candidate pathogens and beneficial organisms in the inflammatory process of periodontitis.

OP0293 OPTIMIZING A TOOL TO IDENTIFY LUPUS FLARES IN DAILY CLINICAL PRACTICE: SLE-DAS FLARE VERSUS SELENA FLARE INDEX

Background:

In the management of patients with Systemic Lupus Erythematosus (SLE), it is of utmost importance to accurately identify lupus flares. There is a conceptual consensus definition of lupus flares [1]; however, the instruments used to identify flares in clinical trials, such as the SELENA Flare Index (SFI) are too cumbersome to apply in daily clinical practice. The SLE disease activity score (SLE-DAS) is a validated continuous measure of disease activity with higher sensitivity to change and validity in predicting damage accrual when compared to SLEDAI-2K. SLE-DAS is quickly scored with its online calculator. An increase in SLE-DAS ≥1.72 was validated as a clinically meaningful worsening of SLE disease activity. [2]

Objectives:

To compare the performance of SLE-DAS, classic SFI (c-SFI), revised SFI (r-SFI) and SLEDAI-2K in the identification of lupus flares in a real-life clinical setting.

Methods:

We included patients with SLE fulfilling classification criteria [ACR (1997) and/or SLICC and/or EULAR/ACR], followed at an academic lupus clinic from January 2017 to June 2020, and presenting with lupus low disease activity score (LLDAS) at baseline.

Flares occurring after baseline were identified as fulfillment of the conceptual definition of flare, as assessed by the senior lupus expert at time of each outpatient visit. For each flare event, we evaluated the fulfillment of flare criteria according to c-SFI, r-SFI, SLEDAI-2K (score increase ≥4 points from baseline), and SLE-DAS (score increase ≥1.72 from baseline). As control visits without flare, we considered the first visit after baseline, where we assessed the four tools, excluding those where a flare was identified by the gold-standard expert evaluation. Sensitivity and specificity of the four flare tools were estimated and McNemar’s test applied to assess differences with the gold-standard flare definition. The inter-instrument agreement with the gold-standard was assessed through Cohen’s Kappa.

Results:

We included 297 patients (female: 86.2%; mean age: 48.9±14.6 years, mean disease duration: 12.5±9.0 years). At baseline, all patients were in LLDAS, receiving ongoing antimalarials, immunosuppressants, and/or glucocorticoids in 91.0%, 43.8% and 33.6%, respectively. During follow-up, 22.2% developed flares. The analysis included 92 flares [musculoskeletal (40.2%); renal (23.9%), mucocutaneous (18.5%), haematological (5.9%), serositis (3.3%); multisystemic (8.7%)], with increase or change of treatment in 80.4% of these episodes, and 292 visits without flare considered as control.

There was no statistically significant difference between either SLE-DAS flare or c-SFI and the gold-standard expert flare definition (p=0.41 and p=0.82, respectively), while r-SFI and SLEDAI-2K flare were different from the gold-standard (Table 1). There was a strong agreement between SLE-DAS flare, c-SFI, r-SFI and the expert definition (Cohen’s kappa, Table 1).

Table 1.

Performance of the flare tools for the gold-standard flare definition.

Sensitivity (%)Specificity (%)McNemar’s§§Kappa§SLE-DAS flare90.195.0n.s.0.836c-SFI flare91.196.5n.s.0.869r-SFI flare93.492.9p<0.010.820SLEDAI-2K flare51.698.6p<0.00010.590

§§ McNemar’s test: significant difference from gold-standard if p<0.05; § Cohen’s kappa agreement (0-1) with the gold-standard flare definition; n.s.: non-significant

Conclusion:

The c-SFI and SLE-DAS showed the best performance in identifying SLE flares. The SLE-DAS flare definition is easier to apply and hence might be considered as an optimal tool to be used in daily clinical practice.

References:

[1]Ruperto N, Hanrahan LM, Alarcón GS, et al. International consensus for a definition of disease flare in lupus. Lupus. 2011;20(5):453-62.

[2]Jesus D, Matos A, Henriques C, et al. Derivation and validation of the SLE Disease Activity Score (SLE-DAS): a new SLE continuous measure with high sensitivity for changes in disease activity. Ann Rheum Dis 2019; 78:365-71.

Disclosure of Interests:

None declared.

POS0496 YOUNG VERSUS LATE-ONSET RHEUMATOID ARTHRITIS: A PROSPECTIVE 12 MONTH-FOLLOW-UP COHORT STUDY IN AN EARLY ARTHRITIS COHORT

Background:

Rheumatoid Arthritis (RA) is a chronic inflammatory arthropathy that can present at any age. Data regarding differences in the clinical course and outcome in Late-Onset Rheumatoid Arthritis (LORA) comparing to Young-Onset RA (YORA) are conflicting. Some studies suggested that LORA may represent a more benign form of RA (1), while others have shown a poorer prognosis in these patients (2,3). Only a few publications have included patients with early disease (3).

Objectives:

To compare demographic and clinical features between LORA and YORA patients, and clinical activity at baseline and after 12 months of initial therapy, in patients with early disease.

Methods:

We conducted a prospective cohort study of 12 months of follow-up based on an early arthritis clinic. Consecutive patients with early RA – less than 12 months duration – fulfilling ACR/EULAR 2010 and/or ACR 1987 RA classification criteria, were included and classified in LORA (disease onset ≥60 years) and YORA groups. Variables were collected from patients’ registries at first appointment after symptoms onset and after 12 months of treatment, according to a treat-to-target strategy. Independent t-test and chi-square test were performed to compare variables between groups.

Results:

We included 72 patients (40 (55.6%) YORA; 32 (44.4%) LORA), mean age at diagnosis 44.9±1.78 and 72.5± 1.34 years, respectively. In LORA group, the symptoms duration at first observation was shorter (17.0±2.26 vs. 23.8±2.45 weeks; p=0.046) and rheumatoid factor (RF)/ anti-citrullinated protein antibodies (ACPA) positivity was lower (28.1% vs 65.0%; p= 0.002; 31.3% vs 72.5%; p<0.001). At baseline, LORA had higher mean number of tender joints (9.76±1.29 vs 6.50±0.67; p=0.021), erythrocyte sedimentation rate (ESR) (45.7±4.98 vs. 29.3±3.74; p=0.011), C-reactive protein (CRP) (4.63±0.91 vs 2.22±0.46; p=0.022) and disease activity using DAS28-3V (5.11±0.28 vs 4.42±0.19; p=0.046), CDAI (33.7±3.39 vs 23.6±2.18; p=0.015) and SDAI (37.4±3.43 vs 26.3±2.57; p=0.015). At the end of follow-up, there were no statistically significant differences between LORA and YORA groups regarding treatment, disease activity and patient-reported outcomes at 12 months (Table 1).

Table 1.

Clinical variables assessment at 12 months of follow-up.

EORAYORAp-valueTreatment, % users Corticosteroids93.397.4p= 0.576 Methotrexate76.774.4p=0.825 Hydroxychloroquine43.346.2p= 0.815 Sulfasalazine10.015.4p=0.722 Leflunomide3.305.10p=1.000 TNF blockers3.305.10p=0.717DAS28-3V, mean (SD)1.99±0.152.22±0.15p=0.286SDAI, mean (SD)4.64±1.357.68±1.39p=0.128CDAI, mean (SD)4.15±1.176.56±1.32p=0.180Swollen joints, mean (SD)1.29±0.491.03±0.25p=0.613Tender joints, mean (SD)0.32±0.131.28±0.53p=0.084ESR, mean (SD)10.6±1.799.43±1.14p=0.585CRP, mean (SD)0.44±0.090.50±0.15p=0.730PtGA, mean (SD)21.8±5.9029.2±6.11p=0.387PhGA, mean (SD)10.6±3.2613.1±3.11p= 0.593Pain intensity (VAS), mean (SD)20.7±5.8232.7±6.30p=0.169HAQ, mean (SD)0.23±0.0890.54±0.13p=0.060

Legend: DMARD- disease-modifying anti-rheumatic drug; TNF- tumoral necrosis factor; SDAI-simplified disease activity score; CDAI- clinical disease activity score; PtGA/ PhGA – patient’s/ physician’s global assessment of general health; VAS- visual analogic scale; HAQ- health assessment questionnaire.

Conclusion:

LORA patients presented with higher disease activity manifested by higher joint counts and laboratory inflammatory markers but lower RF and ACPA positivity proportion. Despite the more aggressive clinical presentation, the clinical and functional outcomes at 12 months were similar between LORA and YORA patients.

References:

[1]Deal et al. Arthritis Rheum 1985;28(9):987-94.

[2]Arnold et al. Rheumatology (Oxford) 2014; 53:10751086.

[3]Romão et al. Semin Arthritis Rheum 2020;0(4):735-743.

Disclosure of Interests:

None declared

POS0105 PREDICTORS OF FLARE IN SLE PATIENTS ATTAINING LUPUS LOW DISEASE ACTIVITY STATE: A REAL-LIFE COHORT STUDY OF 292 PATIENTS WITH 36-MONTH FOLLOW-UP

Background:

Lupus Low Disease Activity State (LLDAS) is a target for management of patients with SLE, that should be maintained in the long-term by preventing flares. Stratification of flare risk would be useful to optimize management.

Objectives:

To identify predictors of flare in SLE patients attaining LLDAS.

Methods:

Patients with SLE fulfilling classification criteria [ACR (1997) and/or SLICC and/or EULAR/ACR], followed at an academic lupus clinic from January 2017 to March 2020 were eligible. Baseline for each patient was the first visit with LLDAS within the study period. Patients never fulfilling LLDAS were excluded. Flares were identified as change from baseline by 3 instruments: revised SELENA flare index (r-SFI); SLEDAI-2K; Systemic Lupus Erythematosus Disease Activity Score (SLE-DAS). Time to first flare up to 36 months was identified separately for each instrument. Predictors of flare were sought through survival analysis, with distinct models for each of the three definitions of flare. Univariate analysis was performed using Kaplan-Meir curves and Log-Rank tests. Tested variables at baseline were: gender; age at time of SLE diagnosis; disease duration; cumulative SLE organ involvement (arthritis; mucocutaneous; renal; neurologic; haematological; anti-phospholipid syndrome); cumulative immunological features (anti-dsDNA; anti-Sm; anti-RNP, anti-phospholipid antibodies; hypocomplementemia); ongoing treatment (hydroxychloroquine; prednisone; immunosuppressants). Variables with p<0.1 were further tested in multivariate Cox regression models. Hazard ratios (HR) were determined with 95% confidence intervals (95%CI).

Results:

From 322 patients in this SLE cohort, 292 (90.7%) fulfilled LLDAS and were included in the analyses (female: 87.3%; mean age: 46.2±14.5 years; previous lupus nephritis: 36.0%; receiving ongoing antimalarials, immunosuppressants, glucocorticoids: 92.8%, 34.6% and 29.8%, respectively. Over follow-up, the proportion of patients with flares according to each definition were: 28.4% (r-SFI), 24.7% (SLE-DAS) and 13.4% (SLEDAI-2K). The r-SFI flares were moderate in 28.9% and severe in 9.6% of the cases. From all patients, 54.1% maintained stable glucocorticoid-free control of the disease, without flares during follow-up. In the multivariate models, the following parameters were independent predictors of flare, as defined by any of the definitions (Table 1): anti-RNP+; oral glucocorticoids; immunosuppressants.

Conclusion:

Patients attaining LLDAS but requiring ongoing treatment with immunosuppressants and/or glucocorticoids present a higher risk of flare and thus might need a tighter clinical monitoring. Anti-RNP+ was newly identified as a potential biomarker for higher risk of flares. Glucocorticoid-free, stable low disease activity is an achievable target.

References:

[1]Mathian A, Pha M, Haroche J, Cohen-Aubart F, Hié M, Pineton de Chambrun M, et al. Withdrawal of low-dose prednisone in SLE patients with a clinically quiescent disease for more than 1 year: a randomised clinical trial. Ann Rheum Dis. 2020;79(3):339-46.

[2]Inês L, Duarte C, Silva RS, Teixeira AS, Fonseca FP, da Silva JA. Identification of clinical predictors of flare in systemic lupus erythematosus patients: a 24-month prospective cohort study. Rheumatology (Oxford). 2014;53(1):85-9.

Table 1.

Predictors of flare in multivariate Cox regression according to each of the flare definitions (r-SFI; SLE-DAS; SLEDAI-2K)

r-SFISLE-DASSLEDAI-2KAnti-RNP+2.11 (1.30-3.42)2.39 (1.44-3.95)2.22 (1.11-4.42)Immunosuppressants1.96 (1.22-3.15)2.32 (1.38-3.88)2.26 (1.12-4.54)Prednisone*1.93 (1.19-3.14)1.99 (1.18-3.35)2.17 (1.07-4.38)Blood cytopenias§2.08 (1.03-4.17)n.s.n.s.Arthritis§n.s.n.s.2.23 (1.12-4.44)

* Prednisone ≤7.5 mg/day as required by LLDAS. § Blood cytopenias; arthritis: cumulative SLE features up to baseline. Risk for each predictor reported as Hazard Ratio (95% Confidence Interval); n.s.: non-significant

Disclosure of Interests:

None declared

AB0147 OLDER AGE AT ONSET AND NOT DISEASE ACTIVITY IS ASSOCIATED WITH FUNCTIONAL DISABILITY AT RA DIAGNOSIS: RESULTS FROM AN EARLY ARTHRITIS COHORT

Background:

Rheumatoid Arthritis (RA) is a chronic inflammatory arthropathy that potentially leads to loss of function and disability early in the disease course. (1) Optimizing physical function is one of the primary goals of RA treatment (2). Several demographic, psychosocial and clinical factors may influence the impact of RA upon physical capacity, and understanding their relative contribution to disability at disease diagnosis is key to an effective treatment approach.

Objectives:

To evaluate functional disability at the time of disease diagnosis and identify its demographic and clinical correlates in an early RA cohort.

Methods:

We conducted a cross-sectional study based on a Rheumatology centre early arthritis cohort. Consecutive patients with early RA – less than 12 months duration– fulfilling ACR/EULAR 2010 and/or ACR 1987 RA classification criteria, were included. Variables were collected from patients’ registries at the first rheumatology appointment after symptom’s onset. Functional disability was assessed using the Health Assessment Questionnaire- Disability Index (HAQ-DI) (range 0 to 3, higher values indicating greater disability). Independent t-test, one way-ANOVA and Pearson’s correlation coefficient were performed to evaluate differences between groups. Variables with p<0.1 were included in a stepwise multiple linear regression analysis to assess the independent association of variables with the HAQ-DI at baseline.

Results:

We included 71 patients (63.4% female, mean age 57.2 ±2.01 years). Mean HAQ-DI score was 1.42±0.08. Sociodemographic and clinical variables are described in Table 1. There was a significant difference in HAQ-DI scores between rheumatoid factor (RF) positive (mean 1.24±0.11) and RF negative (1.61±0.113) patients. HAQ-DI was positively weakly correlated with age (r=0.48; p<0.001), CDAI (r=0.43; p=0.038), SDAI (r=0.49; p=0.015), and moderately with DAS28-3V (r=0.60; p<0.001) and DAS28-3V-CRP (r=0.60; p<0.001). The number of tender (r=0.35; p=0.024) and swollen joints (r=0.42; p= 0.005), ESR (r=0.46; p=0.001), CRP (r=0.35; p=0.018), HADS-depression (r=0.46; p=0.023) and educational level (r= -0.48; p=0.002) were also associated with HAQ-DI in univariate analyses. After multivariate regression analysis, age at disease diagnosis (β= 0.022 [95 CI 0.010 to 0.034]; p= 0.001) was the only independent predictor of HAQ-DI (R2= 0.46, p=0.001).

Table 1.

Patients’ baseline sociodemographic and clinical characteristics.

Age at diagnosis (years), mean (SD)57.2±2.01Educational level (years), mean (SD)7.37±0.59Employment: full-time, %42.4Employment: partial-time, %3.00Employment: retired, %48.4Employment: absenteeism in the last month, %1.50Unemployed, %4.50Disease duration at presentation (weeks), mean (SD)20.4±1.70Morning stiffness >30 minutes, %83.0RF positivity, %47.9ACPA positivity, %53.5Fibromyalgia, %6.60DAS28-3V, mean (SD)4.72±0.17CDAI, mean (SD)29.2±2.28SDAI, mean (SD)32.4±2.42PtGA, mean (SD)66.8±3.73PhGA, mean (SD)54.7±3.08Pain intensity (VAS), mean (SD)67.7±3.75EQ-5D score, mean (SD)0.26±0.039HADS-depression, mean (SD)7.17±0.87

Legend: ACPA- anti-citrullinated protein antibodies; ESR- erythrocyte sedimentation rate; CRP- c-reactive protein; DAS- disease activity score; CDAI- clinical disease activity score; SDAI-simplified disease activity score; PtGA/ PhGA – patient’s/physician’s global assessment of general health; VAS- visual analogic scale; EQ-5D- EuroQoL 5-Dimensional Descriptive System; HADS-Hospital Anxiety and Depression Scale.

Conclusion:

Older age at disease onset is associated with greater functional impairment at diagnosis, assessed by HAQ-DI, in this cohort of early RA patients, irrespective of disease activity and other clinical variables. This result suggests that older newly diagnosed RA patients may deserve special attention regarding physical function.

References:

[1]Wolfe F et al. Arthritis Res Ther. 2010; 12(2): R35.

[2]Smolen JS et al. Ann Rheum Dis. 2010; 69:631-637.

Disclosure of Interests:

None declared

The effect of a toothpaste containing oleanolic acid in reducing plaque and gingivitis: a proof-of-concept randomized trial

OBJECTIVES

To assess the safety and efficacy of an oleanolic acid (OA)-containing toothpaste in reducing gingival inflammation and plaque in patients with gingivitis.

METHODS

This proof-of-concept parallel, double-blind, randomized controlled clinical trial included 99 patients. Following a 1-week washout, patients were randomized into three groups: OA group (fluoride toothpaste containing 0.1% OA and placebo mouthwash); negative control (fluoride toothpaste and placebo mouthwash); and CHX group (fluoride toothpaste and 0.12% chlorhexidine mouthwash). Patients were clinically assessed at inclusion, pre-washout visit, baseline and after 4 days, 1 week and 2 weeks of twice-daily use of the products. Patients received a diary for documentation of bleeding on brushing and provided unstimulated saliva samples.

RESULTS

After two weeks, all groups showed significant reductions in all clinical parameters. The CHX group exhibited significantly greater reductions in gingival index and interproximal gingival index scores at week 2, as compared to patients in the negative control (p = 0.04). In contrast, reductions in gingival index scores did not differ between CHX and OA groups and between OA and negative control groups at week 2. The CHX group had significantly greater reductions in plaque index scores at day-4, 1-week and 2-week evaluations, as compared to the negative control and OA groups. The frequency of adverse events was similar among the groups. None of the groups reduced salivary transferrin levels. Finally, the OA group had the lowest percentage of self-reported bleeding events.

CONCLUSION

OA toothpaste failed to provide antiplaque and antigingivitis effects superior to those of a fluoride toothpaste after 2 weeks of use.

Periodontopathogenic bacteria in subglottic samples from patients undergoing elective intubation for general anesthesia: A pilot study

BACKGROUND

Translocation of periodontal pathogens into the respiratory tract could either cause pneumonia or disrupt local defense mechanisms, predisposing the host to infection by respiratory pathogens. The objective of this pilot study was to evaluate the levels of periodontopathogenic bacteria in subglottic samples of intubated and mechanically ventilated patients and the impact of oral decontamination with chlorhexidine (CHX) on subglottic levels of these microorganisms.

METHODS

Patients scheduled to undergo elective surgical procedures requiring endotracheal intubation and mechanical ventilation for at least 3 hours were included. Following full-mouth periodontal examination, patients were randomly assigned to groups that rinsed preoperatively with 0.12% CHX or 0.9% saline (control). After 3 hours of orotracheal intubation, subglottic contents were collected. Quantification of Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans), Porphyromonas gingivalis (P. gingivalis), and Tannerella forsythia (T. forsythia) in subglottic samples was determined using quantitative real-time polymerase chain reaction. Data were analyzed by Fisher Exact Probability, unpaired Student's t and Mann-Whitney tests.

RESULTS

Of the 69 patients included, 43 completed study participation. There were no differences between control and CHX groups in subglottic detection rates and abundance levels of P. gingivalis (P = 0.59), T. forsythia (P = 0.83) and A. actinomycetemcomitans (P = 0.07). Moreover, our data indicate that periodontal health has no impact on subglottic levels of P. gingivalis, T. forsythia, and A. actinomycetemcomitans.

CONCLUSIONS

Periodontal pathogens were detected in subglottic samples of intubated and mechanically ventilated patients. Moreover, a single CHX rinse prior to endotracheal intubation may have no effect on subglottic contamination by P. gingivalis, T. forsythia, and A. actinomycetemcomitans.

Oral and Fecal Microbiome in Molar-Incisor Pattern Periodontitis

In order to improve our understanding on the microbial complexity associated with Grade C/molar-incisor pattern periodontitis (GC/MIP), we surveyed the oral and fecal microbiomes of GC/MIP and compared to non-affected individuals (Control). Seven Afro-descendants with GC/MIP and seven age/race/gender-matched controls were evaluated. Biofilms from supra/subgingival sites (OB) and feces were collected and submitted to 16S rRNA sequencing. Aggregatibacter actinomycetemcomitans (Aa) JP2 clone genotyping and salivary nitrite levels were determined. Supragingival biofilm of GC/MIP presented greater abundance of opportunistic bacteria. Selenomonas was increased in subgingival healthy sites of GC/MIP compared to Control. Synergistetes and Spirochaetae were more abundant whereas Actinobacteria was reduced in OB of GC/MIP compared to controls. Aa abundance was 50 times higher in periodontal sites with PD≥ 4 mm of GC/MIP than in controls. GC/MIP oral microbiome was characterized by a reduction in commensals such as Kingella, Granulicatella, Haemophilus, Bergeyella, and Streptococcus and enrichment in periodontopathogens, especially Aa and sulfate reducing Deltaproteobacteria. The oral microbiome of the Aa JP2-like+ patient was phylogenetically distant from other GC/MIP individuals. GC/MIP presented a higher abundance of sulfidogenic bacteria in the feces, such as Desulfovibrio fairfieldensis, Erysipelothrix tonsillarum, and Peptostreptococcus anaerobius than controls. These preliminary data show that the dysbiosis of the microbiome in Afro-descendants with GC/MIP was not restricted to affected sites, but was also observed in supragingival and subgingival healthy sites, as well as in the feces. The understanding on differences of the microbiome between healthy and GC/MIP patients will help in developing strategies to improve and monitor periodontal treatment.

P53 in skin cancer: From a master player to a privileged target for prevention and therapy

The increasing incidence of skin cancer (SC) is a global health concern. The commonly reported side effects and resistance mechanisms have imposed the pursuit for new therapeutic alternatives. Moreover, additional preventive strategies should be adopted to strengthen prevention and reduce the rising number of newly SC cases. This review provides relevant insights on the role of p53 tumour suppressor protein in melanoma and non-melanoma skin carcinogenesis, also highlighting the therapeutic potential of p53-targeting drugs against SC. In fact, several evidences are provided demonstrating the encouraging outcomes achieved with p53-activating drugs, alone and in combination with currently available therapies in SC. Another pertinent perspective falls on targeting p53 mutations, as molecular signatures in premature phases of photocarcinogenesis, in future SC preventive approaches. Overall, this review affords a critical and timely discussion of relevant issues related to SC prevention and therapy. Importantly, it paves the way to future studies that may boost the clinical translation of p53-activating agents, making them new effective alternatives in precision medicine of SC therapy and prevention.

THU0090 AGREEMENT BETWEEN REFERRING PHYSICIANS AND RHEUMATOLOGISTS AND PREDICTORS OF INFLAMMATORY ARTHRITIS: ANALYSIS BASED ON 8 YEARS OF EXPERIENCE IN AN EARLY ARTHRITIS CLINIC

Background:

Early recognition of patients with arthritis is a crucial opportunity for optimal outcome. The Early Arthritis Clinic (EAC) of our department was created in 2012 to ensure a prompt access of these patients to efficient medical care. Patients may be referred based on a set of clinical criteria with less than 12 months duration and laboratory parameters: arthritis, inflammatory arthralgias, squeeze test, morning stiffness > 30 minutes, rheumatoid factor (RF), erythrocyte sedimentation rate (ESR)>30mm/h and C-reactive-protein>0.5mg/dL (CRP).

Objectives:

To assess the level of agreement between the referring physician and the rheumatologist, regarding the presence of each of the six referral criteria and to identify predictors of inflammatory arthritis.

Methods:

Cross sectional study including patients aged ≥ 18-year-old observed in the EAC between January 2012 and October 2019. Subjects who were referred to the EAC by a rheumatologist and those without available referral letter/medical records from the first visit to the EAC were excluded. Demographic data, provenience, referral criteria (presence/absence) and the final diagnosis [presence or not of an inflammatory rheumatic disease (IRD)] were collected from medical records. For the six referral criteria, the agreement between the referring physician and the rheumatologist was assessed using the Cohen’s Kappa. The presence of each referral criteria was compared between patients with and without an IRD using χ2 tests. Variables with p<0.1 or clinically relevant were included in forward stepwise multivariable logistic regression analysis to identify possible predictors for IRD. The statistical analysis was performed using SPSS® v21 andp<0.05 was considered statistically significant.

Results:

376 patients (70% female; mean age (±SD) 56.3±16.2 years) were included. Most patients were referred from primary care (84%); the remaining 16% include those referred from emergency department and other hospital specialties. We diagnosed an inflammatory arthritis in 62% (n = 232) of the patients. Table 1 shows the level of agreement between the referring physician and the rheumatologist, regarding the presence of the referral criteria.

Table 1.

Agreement between the referring physician and the rheumatologist, regarding the presence of the referral criteria.

Referral criteriaKappapArthritis0.230.05Squeeze test0.090.04Inflammatory arthralgias0.110.04Morning stiffness0.180.04RF0.270.04ESR0.260.04CRP0.250.04ANA0.020.47

ANA- antinuclear antibodies; CRP- C-reactive-protein; ESR-erythrocyte sedimentation rate; RF-Rheumatoid factor

In univariable analysis (IRD Vs non-IRD), inflammatory arthralgias (74% Vs 93%, p=0.01), squeeze test (24% Vs 55%, p=0.01), morning stiffness (49% Vs 63%, p=0.05), ESR (63% Vs 46%, p=0.01), CRP (62% Vs 48%, p=0.04) were associated to IRD. In multivariable analysis, only ESR (OR 5.0 [95% CI 1.9-13.0], p < 0.05) and inflammatory arthralgias (OR 0.15 [95% CI 0.04-0.52], p < 0.05) remained as predictors of IRD.

Conclusion:

Agreement between the referring physicians and the rheumatologist regarding then presence/absence of the referral criteria was poor in all clinical criteria and fair in laboratory criteria. Elevated ESR was an independent predictor of IRD and the description of inflammatory arthralgias was negatively correlated with IRD. These findings suggest the need to clarify the referral criteria used and to improve education among the physicians referring patients to the EAC.

Disclosure of Interests:

Luisa Brites: None declared, LILIANA SARAIVA: None declared, Ana Rita Cunha: None declared, Helena Assunção: None declared, Tânia Santiago: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

AB0223 PHYSICIAN’S GLOBAL ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS IS A RELIABLE AND RESPONSIVE TOOL IN CLINICAL practice

Background:

Physician’s global assessment of disease activity (PhGA) is highly influential upon treatment decisions taken by rheumatologists, surpassing the impact of DAS28. [1, 2]. However, data regarding its psychometric properties are scarce.

Objectives:

To evaluate the reliability and responsiveness of PhGA.

Methods:

We included two consecutive visits of RA patients followed in a Tertiary Rheumatology Department. Socio-demographic (age and gender) and clinical data were collected including tender (TJ28) and swollen (SJC28) joints in 28 count, C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), Disease activity Score (DAS28-3v-CRP, DAS28-3v-ESR, DAS28-4v-CRP, DAS28-4v-ESR), PhGA and Patient Global Assessment of disease Activity (PGA) through a Visual Analogic Scale (VAS) 0-100mm. Changes (Δ) between the two visits were calculated. Only patients without missing data were included. Correlations between ΔPhGA and change of other variables were assessed using Pearson’s correlations. Reliability was evaluated through Intraclass Correlation Coefficient (ICC) between two consecutive appointments in a subgroup of patients with stable disease activity (Δ DAS28-4vESR [-0.6 to 0.6]. An ICC above 0.8 was considered indicative of excellent reliability. Sensitivity to change was assessed in the subgroup of patients who improved their disease activity at least 0.6 on DAS28-4V-ESR, through Standardized Response Mean (SRM). The respective intervals of confidence were obtained through bootstrapping procedures. SRM above 0.8 were considered large. Independent factors associated with ΔPhGA were identified through multivariate linear regression analysis. p<0.05 was considered statistically significant

Results:

121 RA patients (84.3% female and 64.0±12.6 years) were included. Δ PhGA was weakly correlated with ΔCRP (r=0.23), Δ PGA (r=0.31) and Δ pain (r=0.37). Moderate to strong correlations were observed with Δ DAS28-3V-ESR (r=0.55), Δ SJC28 (r=0.56), Δ DAS28-3V-CRP (r=0.58), Δ DAS28-3V-CRP (r=0.60), Δ TJ28 (r=0.62) and Δ DAS28-4V-CRP (r=0.63). ICC between two consecutive visits was 0.7, [95%CI:0.47-0.83] and SRM was -1.01 [95%CI:-1.26-(-0.73)]. In the multivariate regression analysis, ΔSJC28 (β=4.01; 95% CI:3.07 to 4.96) and Δ Pain (β=0.18; 95%CI: 0.07 to 0.28) remained as independent factors associated with ΔPhGA (R2:0.49, p<0.01)

Conclusion:

In this study, PhGA showed a high reliability and sensitivity to change regarding disease activity, in clinical practice. Changes in SJC had the strongest association with change in PhGA scoring, but Δ Pain was also significantly correlated (graph 1).

Figure 1.

Graph 1 – Explicative model to variations on PhGA

References:

[1]Choy T et al. Rheum (Oxford, England). 2014;53(3):482-90.

[2]Rohekar G et al. Jour Rheum. 2009;36(10):2178.

Disclosure of Interests:

LILIANA SARAIVA: None declared, Luisa Brites: None declared, Ana Rita Cunha: None declared, Helena Assunção: None declared, Ana Rita Prata: None declared, Mariana Luis: None declared, Flavio Costa: None declared, Pedro Freitas: None declared, Marlene Sousa: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

AB0749 COMPARING PATIENT-PHYSICIAN DISCORDANCE IN RA AND PsA PATIENTS

Background:

Patient global Assessment (PGA) of disease activity is considered a key patient reported outcome in Rheumatoid Arthritis (RA) and Psoriatic Arthritis (PsA), both being included in combined indices of disease activity. However, patients and physicians frequently disagree in their assessment.

Objectives:

This study aimed at comparing the degree of this discrepancy and its determinants in RA and PsA.

Methods:

Cross sectional study including 100 patients with RA (ACR/EULAR 2010 criteria) and 100 patients with PsA with predominant peripheral joint involvement (CASPAR criteria), aged ≥18 years, randomly selected from the electronic registry Reuma.pt. Data were collected from the most recent rheumatology visit during the last year: sociodemographic data, disease duration (years), tender and swollen joint counts 0-28 (TJC and SJC), disease activity (DAS28 3V-PCR), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), patient’s pain assessment, PGA and physician global assessment (PhGA). The discrepancy between patients and physicians (ΔPPhGA) was defined as PGA minus PhGA, and a difference > |20mm| was taken as “discordance”. Categorical variables are presented as proportions and continuous variables as mean (±SD). Patient and clinical characteristics were compared between patients with RA and PsA using t- test and χ2 test, as adequate. Variables with p<0.05 or clinically relevant were included in multivariable logistic regression analysis to identify correlates for ΔPPhGA in the whole sample. A p≤0.05 was considered statistically significant.

Results:

Compared to PsA, patients with RA were more often female (90% Vs 49%,p< 0.05), older (66.7 ± 10.7 Vs 58.3 ± 12.2 years,p< 0.05) and had a shorter disease duration (18.2 ± 9.8 Vs 19.9 ± 9.7 years,p= 0.202). Regarding disease activity, the RA and PsA groups were comparable: DAS28 3V-PCR (2.3 ± 0.9 Vs 2.4 ± 1.0,p= 0.34). Patients with RA had a higher mean ΔPPhGA (30.4 ± 30.6 Vs 25.4 ± 27.5,p< 0.05), and were more frequently discordant to the physician (69% Vs 51%,p< 0.05). In univariable analysis, having RA, higher patient’s pain assessment and higher ESR were associated to patient-physician discordance. In multivariable analysis, only patient’s pain assessment (OR 1.04 [95% CI 1.03-1.06], p = 0.00) and TJC (OR 0.82 [95% CI 0.68-0.97], p = 0.02) remained as predictors of discordance.

Conclusion:

Despite comparable disease activity scores in RA and PsA patients, RA patients tend to have a worst self-perception of their disease activity compared to their physician´s. Patient’s pain assessment and TJC were the only predictors of patient-physician discordance, irrespective of the disease.

Disclosure of Interests:

Luisa Brites: None declared, LILIANA SARAIVA: None declared, Flavio Costa: None declared, João Dinis de Freitas: None declared, Mariana Luis: None declared, Ana Rita Prata: None declared, Helena Assunção: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, João Rovisco: None declared, Catia Duarte: None declared

THU0111 PHYSICIAN’S GLOBAL ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS: WHAT DO WE REALLY MEAN?

Background:

Physician’s global assessment of disease activity (PhGA) is included in some scores of disease activity and, demonstrably, plays a major role upon treatment decisions in rheumatoid arthritis (RA) [1, 2, 3]. Therefore, understanding the reasons underlying the physician´s assessment is crucial.

Objectives:

To understand the reasons underlying the physician´s assessment.

Methods:

Cross-sectional study, including consecutive RA patients followed in a Tertiary Rheumatology Department. Socio-demographic (age and gender) and clinical data were collected through a standardized protocol, including 28 tender (TJ28) and swollen (SJC28) joints count, C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), Disease activity Score (DAS28-4v-CRP and DAS28-4v-ESR), PhGA and Patient Global Assessment of disease Activity (PGA) through a Visual Analogic Scale (VAS) 0-100mm, Health Assessment Questionnaire (HAQ), European Quality of Life-5 Dimensions (EQ-5D) and Hospital Anxiety and Depression Scale (HADS). Correlation between PhGA and other continuous variables was evaluated through Pearson´s Correlation Coefficient and variables with p<0.05 in univariate analysis were included in multivariable linear regression (stepwise model).

Results:

392 RA patients (80.6% female, 65.3±12.6 years) were included. PhGA was weakly correlated with CRP (r=0.23), TJC28 (r=0.35), PGA (r=0.26), HAQ (r=0.31) and EQ5D (r=-0.21). Moderate correlations were observed with SJC28 (r=0.45) and DAS-4V-CRP (r=0.48). In multivariable analysis, SJC28 (β=4.14, 95%CI:3.16-5.12), CRP (β=0.22; 95%CI: 0.02-0.03), HAQ (β=4.46, 95%CI:1.50-7.42) and PGA (β=0.08; 95%CI:0.00-0.16) remained as independent correlates of PhGA (R2=0.27, p<0,05).

Conclusion:

In this study, PhGA was associated with SJC28, CRP, HAQ and PGA, suggesting that physicians adopt a comprehensive reading of the disease into account. However, a large proportion of the variance of PhGA remains unexplained. Given its driving role in treatment decisions, the need to standardize and better understand PhGA seems to deserve a closer attention.

References:

[1]Ward MM, et al. Art Car Res. 2017;69(8):1260-5.

[2]Desthieux C, et al. Art Car Res (Hoboken). 2016;68(12):1767-73.

[3]Kaneko Y, et al. Mod Rheumatol. 2018;28(6):960-7.

Disclosure of Interests:

LILIANA SARAIVA: None declared, Luisa Brites: None declared, Ana Rita Cunha: None declared, Helena Assunção: None declared, Ana Rita Prata: None declared, Mariana Luis: None declared, Flavio Costa: None declared, Pedro Freitas: None declared, Marlene Sousa: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

FRI0229 THE IMPACT OF SYSTEMIC SCLEROSIS ON BODY IMAGE PATIENTS

Background:

Satisfaction with body image has a major impact in quality of life. Systemic sclerosis (SSc) is a can result in disfiguring physical changes.

Objectives:

Our aim was to determine the impact of systemic sclerosis on body image using the Satisfaction with Appearance Scale (SWAP). (1)

Methods:

Cross-sectional study including patients satisfying the 2013 American College of Rheumatology criteria for SSc diagnosis, aged ≥ 18 years, treated in a tertiary Rheumatology Department. Demographic and clinical data were collected from Reuma.pt and clinical records. All patients provided informed consent and fulfilled SWAP questionnaire, which consists of 14 questions in 4 subscales: satisfaction with facial appearance, satisfaction with non-facial appearance, social discomfort due to appearance and perceived social impact of appearance. Patients rate each item on a numerical rating scale from 1 (strongly disagree) to 7 (strongly agree). Scores for the facial and non-facial appearance range from 0-24 and scores for the social discomfort and perceived social impact subscales range from 0-18. Total SWAP score can range from 0-84 and higher values indicate greater dissatisfaction with appearance and poorer body image. A descriptive analysis was used to summarize demographic and clinical data; categorical variables were described using frequencies; and continuous data using mean and standard deviation. Correlation between variables [Rodnan, age, disease duration, Hospital Anxiety and Depression Scale (HADS) and Short Form Health Survey (SF36)] and SWAP score was tested with Pearson or Spearman coefficient, as appropriated. Scores of SWAP and its subscales in preclinical, limited and diffuse forms of SSc were compared using ANOVA test. Analyses were performed with SPSS Statistics, V.21 andp<0.05 was considered statistically significant.

Results:

We enrolled 38 patients, 84.2% (n=32) female, with mean age 60.3±14.5 years and mean disease duration 13.3±6.5 years. All but one were caucasian. Fifty percent (n=19) had a limited form, 26.3% (n=10) had preclinical scleroderma and 23.7% (n=9) had a diffuse form of SSc. Regarding the autoantibody profile: 63.2% (n=24) had anti-centromere antibodies, 28.9% (n=11) had anti-Scl-70 antibodies, 5.3% (n=2) had anti-PM antibodies and 2.6% (n=1) had no positive antibodies. The median of Rodnan scores was 4 (IQR 0-9). The total mean SWAP score was 44.8±12.5 with worse results at “Satisfaction with facial appearance” subscale (mean score 14.4±6.1). There is no statistically significant difference in the SWAP score (or its subscales) between the three diagnosis subtypes. No statistically significant correlation was found between the total and subscale SWAP scores and any of the continuous variables considered and no statistically significant difference was found between the different forms of SSc.

Conclusion:

We found no significant differences between preclinical, limited or diffused SS. SWAP scores were not significantly correlated with the total Rodnan score, age or disease duration. Contrary to our expectations SWAP did not show any relationship with depression, anxiety (HADS) or quality of Life (SF-36) However, our sample is too small to support definite conclusions. Further studies assessing body image in SSc and its impact in quality of life are warranted to support the holistic care of these patients.

References:

[1]doi:10.3899/jrheum.141482.;

[2]10.1037/0278-6133.22.2.130;

[3]10.3899/jrheum.141482.

Disclosure of Interests:

Luisa Brites: None declared, Flavio Costa: None declared, LILIANA SARAIVA: None declared, Ana Rita Cunha: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Tânia Santiago: None declared, Maria Joao Salvador: None declared

SAT0029 PATIENT-PHYSICIAN DISCORDANCE IN ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS

Background:

In rheumatoid arthritis (RA), global disease activity is commonly assessed, from the patient’s and the physician’s perspective, through a 100mm VAS. Previous studies have commonly shown a considerable discrepancy between the patient’s and physician’s assessment.

Objectives:

This study aimed evaluating patient-physician discordance in the assessment of disease activity and to explore its determinants.

Methods:

Cross sectional study including RA patients (ACR/EULAR 2010 classification criteria), aged ≥ 18 years, followed in a single tertiary centre. Data were collected from the most recent evaluation including sociodemographic features, disease duration (years), disease activity (DAS 28 3V-PCR), tender and swollen joint count 0-28 (TJC and SJC), VAS-pain-patient, patient and physician global assessment (PGA and PhGA respectively), erythrocyte sedimentation rate (ESR), C-reactive protein (CPR), Health assessment questionnaire (HAQ) and EuroQol five-dimension scale (EQ5D). The discrepancy between patients and physicians (ΔPPhGA) was defined as PGA minus PhGA, and a difference > |20mm| was considered as “discordant”. A descriptive analysis was performed and variables described as proportions or means (+/- SD), as adequate. Correlation between ΔPPhGA and other variables was assessed through Pearson’s correlation and comparison between groups through t-test. Variables with p<0.05 or otherwise considered clinically relevant were included in multiple linear regression analysis to identify predictors for ΔPPhGA. A p≤0.05 was considered statistically significant.

Results:

In total, 467 patients with RA were included (81.2% female; mean age 63.9% ± 12.2 years). PGA and PhGA were discordant in 61.7% of the cases, the patient scoring higher than the physician in 95% of these cases. The proportion of concordance increased (p< 0.01) when considering only patients in remission (DAS 28 3V <2.6), (Graph 1). ΔPPhGA was moderately correlated with VAS-pain-patient (r = 0.59) and weakly correlated with SJC (r = -0.12), HAQ (r= 0.27), EQ5D (r = -0.28) and age (r = 0.21); all p<0.01. In multivariate analysis, VAS-pain-patient (β 0.74, 95% CI 0.62-0.88, p=0.00) and TJC (β 0.16, 95% CI 0.45-0.48, p=0.02) remained associated with a higher ΔPPhGA.

Conclusion:

Our study confirmed that a significant discrepancy between patients and physicians in the assessment of global disease activity is frequent in clinical practice, probably due to valorization of different parameters. This was much less pronounced among patients in remission. Higher VAS-pain-patient and TJC were independent predictors of greater discrepancy between patients and physician’s assessment.

Disclosure of Interests:

Luisa Brites: None declared, Flavio Costa: None declared, João Dinis de Freitas: None declared, Mariana Luis: None declared, Ana Rita Prata: None declared, Helena Assunção: None declared, LILIANA SARAIVA: None declared, Marlene Sousa: None declared, Ana Rita Cunha: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

Immunological and microbiological periodontal profiles in isolated growth hormone deficiency

BACKGROUND

Growth hormone (GH) has been identified as an important regulator of the immune response. We have previously shown that adults with isolated GH deficiency (IGHD) due to a mutation in the GH releasing hormone receptor (GHRHR) gene, have a greater chance of having periodontitis. However, the interaction of GH with periodontal tissues is still unknown, and this population has emerged as a unique model to investigate this issue. Therefore, we evaluated the microbiological and immunological periodontal profiles of such individuals.

METHODS

Nineteen IGHD and 19 controls matched by age, sex, diabetes, and smoking status, were enrolled in this case-control study. Periodontal clinical parameters (probing depth [PD] and clinical attachment loss [AL]) were measured at six sites per tooth. Immune mediators (C-reactive protein, matrix metalloproteinase [MMP]-8, MMP-9, interleukin [IL]-1α, IL-6, IL-8, tumor necrosis factor [TNF]-α, adiponectin, and leptin) were analyzed by enzyme-linked immunosorbent assay (ELISA) in the gingival crevicular fluid (GCF) in four non-adjacent sites for each participant (two with PD ≤3 mm [shallow sites] and two with PD ≥7 mm or the worst PD found in the mouth [deep sites]). Bacterial quantification (Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythia) of subgingival biofilm samples collected from these same sites was performed by quantitative real-time polymerase chain reaction (qPCR).

RESULTS

IGHD individuals presented higher values of PD and AL, and increased levels of CRP, IL-8, MMP-8, and adiponectin in the GCF. Bacterial quantification did not identify differences between the two groups.

CONCLUSION

IGHD alters the local immune response in periodontal pockets leading to greater attachment loss, and GH stands out as an important hormone to be evaluated in the pathogenesis of periodontitis.

A systematic review and meta-analysis of the survival rate of implants placed in previously failed sites

The aim of this study was to conduct a systematic review and meta-analysis to assess the clinical outcomes of dental implants placed in previously early and late implant failed sites. An electronic literature search was conducted in several databases for articles published up to February 2018. Human clinical trials that received at least one implant in a previously failed site were included. Hence, the PICO question that was aimed to be addressed was: Do patients undergoing implant replacement (second and third attempts) in previous failed sites have survival rates similar to implants placed at first attempts? A random effects model was used to calculate survival weighted means and corresponding 95% Confidence Intervals (CI) among studies. Eleven studies of low to moderate methodological quality were included in this review. Implants placed in sites with history of one and two implant failures had a weighted survival rate (SR) of 88.7% (95%CI 81.7-93.3) and 67.1% (95%CI 51.1-79.9), respectively. Implants placed in sites with a previous early failure revealed a weighted SR of 91.8% (95%CI 85.1-95.6). First implants presented higher SR than implants placed in sites with one or two previous implant failures. In contrast, implants placed in sites with one and two implant failures had similar SR. Within its limitations, this review suggests that replacement implants have moderate SR. Larger prospective studies with well-defined criteria for early and late implant failure are necessary to confirm and expand on these results.

The ideal time of systemic metronidazole and amoxicillin administration in the treatment of severe periodontitis: study protocol for a randomized controlled trial

Background

The combination of systemic metronidazole (MTZ) and amoxicillin (AMX) with scaling and root planing (SRP) has shown to be an effective periodontal treatment. However, some essential issues associated with the use of these antibiotics remain unanswered, such as the ideal time of administration during the course of periodontal treatment. Although these agents are often prescribed after the healing phase of the SRP procedure, there is biological plausibility to support its use in conjunction with the mechanical treatment. However, to date, no placebo controlled randomized clinical trial (RCT) has directly compared these two protocols. Therefore, the aim of this RCT is to compare the clinical, microbiological and immunological effects of the adjunctive systemic MTZ + AMX administered in different phases of the treatment of severe periodontitis.

Methods

Subjects with severe periodontitis (n = 180) are being randomly assigned into three groups (n = 60/group): (i) SRP-only (control group), SRP in combination with 400 mg MTZ + 500 mg AMX, starting (ii) at the first SRP session (active phase group), or (iii) after 3 months of its completion (healing phase group). All volunteers are receiving clinical and microbiological evaluation at baseline, 3, 6 and 12 months, and immunological assessment at baseline and 12 months post-therapy. Nine subgingival biofilm samples are being collected per subject and analyzed for counts and proportions of 40 bacterial species by checkerboard DNA-DNA hybridization, and six gingival crevicular fluid samples are being collected and analyzed for the levels of 20 chemokines by multiplex immunoassay. The primary outcome variable is the number of volunteers reaching the clinical endpoint for treatment (≤ 4 sites with probing depth ≥5 mm) at 1 year post-therapy. Differences in clinical, microbiological and immunological parameters among groups and over time will be evaluated using analysis of variance, analysis of covariance and the Chi-square and Tukey tests. Microbiological and immunological analyses will be performed using adjustments for multiple comparisons. Statistical significance will be set at 5%.

Trial registration

ClinicalTrials.gov, NCT02954393. Registered on 3 November 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2540-8) contains supplementary material, which is available to authorized users.

Influence of Piezosurgery on Bone Healing around Titanium Implants: A Histological Study in Rats

The aim of this study was to evaluate histomorphometrically the influence of two techniques of dental implant site preparation on bone healing around titanium implants. Fifteen male Wistar rats (±300 g) were used in the study. Each tibia was randomly assigned to receive the implant site preparation either with a conventional drilling technique (control - DRILL group) or with a piezoelectric device (PIEZO group). The animals were sacrificed after 30 days and then the following histomorphometric parameters were evaluated (percentage) separately for cortical and cancellous regions: proportion of mineralized tissue (PMT) adjacent to implant threads (500 μm adjacent); bone area within the threads (BA) and bone-implant contact (BIC). The results demonstrated that there were no statistically significant differences between both groups for cancellous BIC (p>0.05) and cortical PMT (p>0.05). On the other hand, a higher percentage of BA was observed in the PIEZO group in the cortical (71.50±6.91 and 78.28±4.38 for DRILL and PIEZO groups, respectively; p<0.05) and cancellous regions (9.62±4.06 and 19.94±14.18 for DRILL and PIEZO groups, respectively; p<0.05). The piezosurgery also showed higher PMT values in the cancellous zone (9.35±5.54 and 18.72±13.21 for DRILL and PIEZO groups, respectively; p<0.05). However, the DRILL group presented better results for BIC in cortical region (80.42±10.88 and 70.25±16.93 for DRILL and PIEZO groups, respectively; p<0.05). In conclusion, for the implant site preparation, the piezosurgery was beneficial to bone healing rates in the cancellous bone region, while the drill technique produced better results in the cortical bone.

PAR-2 expression in the gingival crevicular fluid reflects chronic periodontitis severity

Recent studies investigating protease-activated receptor type 2 (PAR-2) suggest an association between the receptor and periodontal inflammation. It is known that gingipain, a bacterial protease secreted by the important periodontopathogen Porphyromonas gingivalis can activate PAR-2. Previous studies by our group found that PAR-2 is overexpressed in the gingival crevicular fluid (GCF) of patients with moderate chronic periodontitis (MP). The present study aimed at evaluating whether PAR-2 expression is associated with chronic periodontitis severity. GCF samples and clinical parameters, including plaque and bleeding on probing indices, probing pocket depth and clinical attachment level, were collected from the control group (n = 19) at baseline, and from MP patients (n = 19) and severe chronic periodontitis (SP) (n = 19) patients before and 6 weeks after periodontal non-surgical treatment. PAR-2 and gingipain messenger RNA (mRNA) in the GCF of 4 periodontal sites per patient were evaluated by Reverse Transcription Polymerase Chain Reaction (RT-qPCR). PAR-2 and gingipain expressions were greater in periodontitis patients than in control group patients. In addition, the SP group presented increased PAR-2 and gingipain mRNA levels, compared with the MP group. Furthermore, periodontal treatment significantly reduced (p <0.05) PAR-2 expression in patients with periodontitis. In conclusion, PAR-2 is associated with chronic periodontitis severity and with gingipain levels in the periodontal pocket, thus suggesting that PAR-2 expression in the GCF reflects the severity of destruction during periodontal infection.

Effects of periodontal treatment on primary sjȫgren's syndrome symptoms

The aim of this longitudinal prospective study was to evaluate the effects of periodontal treatment on the clinical, microbiological and immunological periodontal parameters, and on the systemic activity (ESSDAI) and subjective (ESSPRI) indexes in patients with primary Sjögren's Syndrome (pSS). Twenty-eight female patients were divided into four groups: pSS patients with or without chronic periodontitis (SCP, SC, respectively), and systemically healthy patients with or without chronic periodontitis (CP, C, respectively). Periodontal clinical examination and immunological and microbiological sample collection were performed at baseline, 30 and 90 days after nonsurgical periodontal treatment (NSPT). Levels of interleukin IL-1β, IL-8 and IL-10 in saliva and gingival crevicular fluid (GCF) were evaluated by ELISA, as well as the expression of Porphyromonas gingivalis (Pg), Aggregatibacter actinomycetemcomitans, (Aa) Tannerella forsythia (Tf), and Treponema denticola (Td), by qPCR. Systemic activity and pSS symptoms were evaluated by ESSDAI and ESSPRI. NSPT resulted in improved periodontal clinical parameters in both SCP and CP groups (p>0.05). Pg, Aa, and Tf levels decreased after NSPT only in CP patients (p<0.05). Significantly greater levels of IL-10 in GCF were verified in both SCP and CP groups (p<0.05). SCP patients showed increased salivary flow rates and decreased ESSPRI scores after NSPT. In conclusion, NSPT in pSS patients resulted in improved clinical and immunological parameters, with no significant effects on microbiological status. pSS patients also showed increased salivary flow and lower ESSPRI scores after therapy. Therefore, it can be suggested that NSPT may improve the quality of life of pSS patients.

Validity and reliability of a pictorial instrument for assessing perceived motor competence in Portuguese children

BACKGROUND

It is important to assess young children's perceived Fundamental Movement Skill (FMS) competence in order to examine the role of perceived FMS competence in motivation toward physical activity. Children's perceptions of motor competence may vary according to the culture/country of origin; therefore, it is also important to measure perceptions in different cultural contexts. The purpose was to assess the face validity, internal consistency, test-retest reliability and construct validity of the 12 FMS items in the Pictorial Scale for Perceived Movement Skill Competence for Young Children (PMSC) in a Portuguese sample.

METHODS

Two hundred one Portuguese children (girls, n = 112), 5 to 10 years of age (7.6 ± 1.4), participated. All children completed the PMSC once. Ordinal alpha assessed internal consistency. A random subsamples (n = 47) were reassessed one week later to determine test-retest reliability with Bland-Altman method. Children were asked questions after the second administration to determine face validity. Construct validity was assessed on the whole sample with a Bayesian Structural Equation Modelling (BSEM) approach. The hypothesized theoretical model used the 12 items and two hypothesized factors: object control and locomotor skills.

RESULTS

The majority of children correctly identified the skills and could understand most of the pictures. Test-retest reliability analysis was good, with an agreement ration between 0.99 and 1.02. Ordinal alpha values ranged from acceptable (object control 0.73, locomotor 0.68) to good (all FMS 0.81). The hypothesized BSEM model had an adequate fit.

CONCLUSIONS

The PMSC can be used to investigate perceptions of children's FMS competence. This instrument can also be satisfactorily used among Portuguese children.

Hydrogen peroxide-induced secondary necrosis in conidia of Aspergillus fumigatus

Aspergillus fumigatus conidia have been linked to severe aspergillosis in immunocompromised patients. Recently, the cytotoxic effect of secondary metabolites from A. fumigatus conidia was reported. In the present work, a methodology used to detect cell death markers in fungal hyphae was adapted to study conidia cell death. Additionally, the mechanism of H2O2-induced cell death was studied in A. fumigatus conidia for the first time. Data presented in this work reveal that the H2O2-induced conidial cell death was associated with a marked increase of TUNEL- and PI-positive cells. It is therefore suggested that conidia cell death occurs in a dose-dependent manner through a secondary necrosis mechanism. The knowledge of conidia cell death machinery may provide insights into the molecular mechanism of conidia-mediated toxicity to the respiratory tract and may pave the way for improved therapeutic approaches against A. fumigatus conidia-mediated diseases.

Gingival crevicular fluid levels of protease-activated receptors type 1 and type 2 in diabetic patients with periodontitis

BACKGROUND AND OBJECTIVE

Protease activated receptor type 1 (PAR1 ) seems to play a role in periodontal repair, while PAR2 is associated with periodontal inflammation. As diabetes is a known risk factor for periodontal disease, the aim of this study was to evaluate the influence of type 2 diabetes on PAR1 and PAR2 mRNA expression in the gingival crevicular fluid of patients with chronic periodontitis before and after non-surgical periodontal treatment.

MATERIAL AND METHODS

Gingival crevicular fluid samples and clinical parameters consisting of measuring probing depth, clinical attachment level, bleeding on probing and plaque index were collected from systemically healthy patients and patients with type 2 diabetes and chronic periodontitis, at baseline and after non-surgical periodontal therapy. PAR1 and PAR2 , as well as the presence of the proteases RgpB gingipain and neutrophil proteinase-3 were assessed by quantitative polymerase chain reaction in the gingival crevicular fluid.

RESULTS

The periodontal clinical parameters significantly improved after periodontal therapy (p < 0.01). Diabetes led to increased expression of PAR1 in gingival crevicular fluid, and in the presence of chronic periodontitis, it significantly decreased the expression of PAR1 and PAR2 (p < 0.05). Moreover, non-surgical periodontal treatment in diabetics resulted in increased expression of PAR1 and PAR2 (p < 0.05), and decreased expression of RgpB gingipain and proteinase-3 (p < 0.05).

CONCLUSION

The present data demonstrated that diabetes was associated with an altered expression of PAR1 and PAR2 in the gingival crevicular fluid cells of subjects with chronic periodontitis. Future studies are necessary to elucidate the effects of PAR1 upregulation in periodontally healthy sites and PAR2 downregulation in chronic periodontitis sites on the increased susceptibility and severity of periodontitis in diabetes.

Phlebotomine sand flies (Diptera: Psychodidae) and Leishmania infection in Gafanhoto Park, Divinópolis, Brazil

The potential of Gafanhoto Park as an American cutaneous leishmaniasis (ACL) focus was evaluated by examination of sand fly vectors of the Leishmania parasite. This forest remnant is located in a periurban area of Divin6polis, Brazil, where autochthonous cases of ACL have been reported. Sand fly populations were monitored over a 2-yr period (2006-2008) by using light traps (HP and Shannon). During systematic collections with HP traps, 824 specimens in total (342 males and 482 females) of 21 species were captured. Most prevalent species were as follows: Brumptomyia brumpti (Larrouse), Lutzomyia aragaoi (Costa Lima), Lutzomyia lutziana (Costa Lima), Lutzomyia sordellii (Shannon & Del Ponte), and Lutzomyia whitmani (Antunes & Coutinho). Using Shannon traps, 257 specimens representing 15 species were collected (159 females and 98 males), with a high prevalence of L. whitmani and Lutzomyia neivai (Pinto), both vectors of Leishmania braziliensis (Vianna). To ascertain the level of natural infection, a sample of females captured in Shannon traps was assayed for the presence of Leishmania by using polymerase chain reaction-restriction fragment length polymorphism, where 39% of insects were positive. The most infected species was L. whitmani (29 sand flies; 18.2%), followed by L. neivai (21; 13.2%), Lutzomyia christenseni (Young & Duncan) (five; 3.1%), Lutzomyia pessoai (Coutinho & Barreto) (three; 1.9%), L. aragaoi (one; 0.6%), Lutzomyia fischeri (Pinto) (one; 0.6%), Lutzomyia lenti (Mangabeira) (one; 0.6%), L. lutziana (one; 0.6%), and Lutzomyia monticula (Costa Lima) (one; 0.6%). The finding of potential and incriminated vectors naturally infected with Leishmania reinforces the need of epidemiologic surveillance in the area.

Gingival overgrowth among patients medicated with cyclosporin A and tacrolimus undergoing renal transplantation: a prospective study

BACKGROUND

The aim of this study is to make a longitudinal evaluation of the incidence and severity of gingival overgrowth (GO) induced by immunosuppressive agents, such as tacrolimus (Tcr) and cyclosporin A (CsA), in the absence of calcium channel blockers in patients undergoing renal transplantation (RT).

METHODS

This longitudinal study is conducted in 49 patients with RT who were divided into a CsA group (n = 25) and Tcr group (n = 24). The individuals were assessed at four time intervals: before transplant and 30, 90, and 180 days after RTs. Demographic data and periodontal clinical parameters (plaque index, cemento-enamel junction to the gingival margin, probing depth, clinical attachment level, bleeding on probing [BOP], and GO) were collected at all time intervals.

RESULTS

The mean GO index was significantly lower in the Tcr group compared to the CsA group after 30 (P = 0.03), 90 (P = 0.004), and 180 (P = 0.01) days of immunosuppressive therapy. One hundred eighty days after RTs, a clinically significant GO was observed in 20.0% of individuals in the CsA group and 8.3% of individuals in the Tcr group. However, this difference was not statistically significant (P = 0.41). There was a reduction in periodontal clinical parameters regarding the time of immunosuppressive therapy for PI and BOP (P <0.001) in both groups.

CONCLUSION

Although there was no statistical difference in the incidences of clinically significant GO after 180 days of immunosuppressive therapy, it was observed that GO occurred later in the Tcr group, and the severity of GO in this group was lower than in patients who used CsA.

Selective activation of protein kinase C-delta and -epsilon by 6,11,12,14-tetrahydroxy-abieta-5,8,11,13-tetraene-7-one (coleon U)

6,11,12,14-tetrahydroxy-abieta-5,8,11,13-tetraene-7-one (coleon U) is a diterpene compound isolated from Plectranthus grandidentatus with an antiproliferative effect on several human cancer cell lines. Herein, we studied the modulatory activity of coleon U on individual isoforms of the three protein kinase C (PKC) subfamilies, classical (cPKC-alpha and -betaI), novel (nPKC-delta and -epsilon) and atypical (aPKC-zeta), using a yeast PKC assay. The results showed that, whereas the PKC activator phorbol-12-myristate-13-acetate (PMA) activated every PKC tested except aPKC, coleon U had no effect on aPKC and cPKCs. Besides, the effect of coleon U on nPKCs was higher than that of PMA. This revealed that coleon U was a potent and selective activator of nPKCs. The isoform-selectivity of coleon U for nPKC-delta and -epsilon was confirmed using an in vitro PKC assay. Most importantly, while PMA activated nPKCs inducing an isoform translocation from the cytosol to the plasma membrane and a G2/M cell cycle arrest, coleon U induced nPKCs translocation to the nucleus and a metacaspase- and mitochondrial-dependent apoptosis. This work therefore reconstitutes in yeast distinct subcellular translocations of a PKC isoform and the subsequent distinct cellular responses reported for mammalian cells. Together, our study identifies a new isoform-selective PKC activator with promising pharmacological applications. Indeed, since coleon U has no effect on cPKCs and aPKC, recognised as anti-apoptotic proteins, and selectively induces an apoptotic pathway dependent on nPKC-delta and -epsilon activation, it represents a promising compound for evaluation as an anti-cancer drug.

Incidence of tacrolimus-induced gingival overgrowth in the absence of calcium channel blockers: a short-term study

AIM

The aim of this study was to determine the incidence and severity of gingival overgrowth (GO) induced by tacrolimus (Tcr) compared with ciclosporin A (CiA) in the absence of calcium channel blockers (CCB) in renal transplant recipients.

METHODS

Forty patients (20 Tcr and 20 CiA) were evaluated before and 30 and 90 days after kidney transplantation. Demographic (age, gender) and periodontal parameters were recorded for all patients. Patients taking CCB at any time during the study were excluded from the investigation.

RESULTS

The mean GO score was significantly lower (p=0.014) in the Tcr group (6.4%) compared with the CiA group (17.9%) after 90 days of immunosuppressive therapy. At 90 days post-transplant, clinically significant GO was observed in four patients of the CiA group and in two of the Tcr group. This difference was not statistically significant (0.66).

CONCLUSION

No significant difference in the incidence of clinically significant GO was observed between the CiA and Tcr groups up to 90 days of immunosuppressive therapy.

Efficacy of a herbal toothpaste on patients with established gingivitis--a randomized controlled trial

The aim of this randomised, double blind controlled trial was to verify the efficacy of a herbal dentifrice on the reduction of plaque and gingivitis. Forty eight volunteers with established gingivitis were randomly assigned to either a test group (herbal dentifrice) or positive control group (dentifrice with triclosan and fluoride). The dentifrices were distributed in plain white tubes by an independent pharmacy, which revealed the contents of each tube only after the experimental period. Plaque and gingivitis assessments were carried out on baseline and after 28 days of product use. All examinations were conducted by the same calibrated investigator. Subjects were instructed to brush their teeth three times daily using their assigned dentifrice for 28 days. There was a significant reduction in plaque levels in both the test and control groups. However, there was no significant difference between the groups. A significant reduction in gingivitis was observed in both groups, although there was no significant difference between them. No adverse reactions were reported. The authors concluded that both dentifrices were effective in reducing plaque and gingivitis in subjects with established gingivitis.

Evaluation of subgingival bacterial plaque changes and effects on periodontal tissues in patients with renal transplants under immunosuppressive therapy

OBJECTIVE

The purpose of this study was to identify the presence of periodontal microrganisms in 35 renal transplant patients before the transplant procedure.

STUDY DESIGN

At each time point, clinical parameters were recorded and subgingival plaque samples were collected from 4 different sites at days 30 and 90 after surgery. Samples were plated onto selective and nonselective media to determine total colony counts and the presence of putative periodontal pathogens. After transplant surgery, patients received immunosuppressive therapy.

RESULTS

Statistical analysis of the microbiologic data showed significant changes between time points. An increase in total counts of microrganisms was observed on day 90 after surgery. As a side effect of cyclosporine, 14 patients developed gingival overgrowth. Beta-hemolytic Streptococcus was more frequently detected in patients who did not present gingival overgrowth 90 days after surgery.

CONCLUSION

Quantitative and qualitative changes of the subgingival microflora can occur 90 days after transplant surgery, while patients are still under immunosupressive drugs.

Relationship of Subgingival and Salivary Microbiota to Gingival Overgrowth in Heart Transplant Patients Following Cyclosporin A Therapy

BACKGROUND

Severe gingival overgrowth (GO) is induced in patients taking cyclosporin A (CsA) following organ transplantation. Determining which patient will develop GO is still not possible. The purpose of this study was to establish an association between CsA and gingival overgrowth in heart transplant patients taking into account periodontal and microbiological conditions.

METHODS

Thirty patients (10 female, 20 male; range: 13 to 67 years; mean age: 44.89) undergoing CsA treatment were evaluated using the gingival index (GI), plaque index (PI), probing depth (PD), and clinical attachment level (CAL). Subgingival samples collected from the deepest site of each quadrant and saliva samples were submitted to microbial analysis. All patients had at least 12 teeth. Exclusion criteria were the use of antibiotics and/or having undergone periodontal treatment 6 months prior to the study. Patients were divided in two groups: with gingival (GO+) and without gingival overgrowth (GO-).

RESULTS

There were no statistically significant differences between the GO+ and GO- groups when CsA dosage, time since transplant, GI, PI, PD, and CAL were compared. Microbiological examination of the subgingival samples detected the following microorganisms: Actinobacillus actinomycetemcomitans (23%), Porphyromonas gingivalis (36%), Prevotella intermedia (93%), Fusobacterium sp. (66%), Campylobacter rectus (30%), Micromonas micros (66%), enteric rods (0%), and yeasts (30%). A positive association between M. micros and the GO+ group was found (P < 0.001). Yeasts were detected in 30% of the subgingival and saliva samples.

CONCLUSIONS

Clinical parameters were not sufficient to determine which patients would develop GO. However, colonization by M. micros might play a role in the etiology of GO.

Superinfecting microorganisms in patients under treatment with cyclosporin-A and its correlation to gingival overgrowth

The aim of this study was to identify the presence of superinfecting microorganisms (Gram-negative enteric rods and Candida sp.) in heart transplant patients and correlate this with gingival overgrowth. Thirty patients (10 females, 20 males--mean age 45 years) were examined. All were under cyclosporin-A (CsA) therapy. Patients who had taken any antibiotics 3 months prior the study or had been submitted to periodontal therapy were not enrolled. Patients were required to have at least 6 teeth. The plaque index (PI), gingival index (GI), pocket depth (PD) and clinical attachment level (CAL) were recorded. Microbiological samples were taken from sulcus/pocket (s/p) and from stimulated saliva (ss) and submitted to analysis. Patients were divided into two groups: the ones with gingival overgrowth (GO) and those without gingival overgrowth (WGO). After statistical analysis (chi-square test, Student's t-test, Fisher test, p < or = 0.05), we concluded that there was no statistical difference between groups in the parameters of gender, CsA dosage, time since transplantation, PI, GI, PD and CAL. Gram-negative rods from either the sulcus/pocket or saliva samples were not found. Candida sp. was detected (s/p-30% and ss-30%). Stimulated saliva samples analysis determined that the presence of Candida sp. was associated with patients without gingival overgrowth.

Differential activation by daphnetoxin and mezerein of PKC-isotypes alpha, beta I, delta and zeta

Daphnetoxin, a mezerein derivative, was isolated from the stem bark of Daphne gnidium. Mezerein is a PKC activator that exhibits antileukemic properties. However, daphnetoxin and its analogue 12-hydroxydaphnetoxin were described as being devoid of this effect. In the present study daphnetoxin and mezerein were compared as PKC activators on classical (alpha and beta I), novel (delta) and atypical (zeta) isoforms, using an alternative in vivo yeast phenotypic assay. The aim was to clarify if daphnetoxin is a PKC activator and if the differences between the antiproliferative effect of mezerein and of its analogue daphnetoxin may be ascribed to differences on their potency or selectivity as PKC activators. Yeast samples expressing each of the mammalian PKC isoforms tested were incubated with daphnetoxin or mezerein. Growth inhibition caused by these drugs was assumed to be due to PKC activation since it did not occur when expression was not induced. Mezerein inhibited the growth of yeast expressing PKC alpha (IC(50) = 1190 +/- 237 nM; n = 20), PKC beta I (IC(50) = 908 +/- 46 nM; n = 20), and PKC delta (IC(50) = 141 +/- 25 nM; n = 20) but not of yeast expressing PKC zeta. Daphnetoxin also inhibited the growth of yeast expressing isoforms alpha, beta I and delta, being more potent than mezerein on PKC alpha (IC(50) = 536 +/- 183 nM; n = 20; P < 0.05), as potent as mezerein on PKC beta I (IC(50) = 902 +/- 129 nM; n = 20) and less potent than mezerein upon PKC delta (IC(50) = 3370 +/- 492 nM; n = 20; P < 0.05). These results show that daphnetoxin is a potent PKC activator but with a selectivity different from that of mezerein. It is suggested that the lack of antileukemic and antiproliferative effects of daphnetoxin may be due to its lower potency to activate PKC delta.

Phonomechanocardiographic findings in endomyocardial fibrosis

Endomyocardial fibrosis (EMF) is a severe restrictive cardiomyopathy characterized by the formation of fibrous tissue on the endocardium and to a lesser extent in the myocardium of one or both ventricles. The disease results in endocardial rigidity, atrioventricular valve dysfunction and progressive obliteration of the ventricular cavity. The clinical and pathological findings of EMF have been well established and definitive diagnosis can be made by selective cineangiocardiography. However, there are few reports concerning the phonomechanocardiographic (PMCG) patterns in this condition. In this paper we describe the PMCG findings in 12 patients with EMF which is now recognized with increasing frequency in the Northeast of Brazil.

Surgical treatment of endomyocardial fibrosis

Thirty patients with endomyocardial fibrosis were submitted to endocardial decortication and atrioventricular valve replacement between December, 1977, and October, 1981. There were 26 female and four male patients, ranging in age from 14 to 48 years (mean 32). Thirteen patients had biventricular disease, 14 had the right-sided form, and three had endomyocardial fibrosis confined to the left ventricle. All were in Functional Class III or IV (New York Heart Association classification). The hospital mortality was 20% (six cases). Among the survivors (mean follow-up 13 months), 23 of 24 were improved clinically. Postoperative hemodynamic and angiographic studies were performed in 15 patients. Two (6.6%) have definitive atrioventricular heart block. There were five (16.6%) late deaths. Operation for endomyocardial fibrosis should be considered a palliative procedure. Possible limitations include the need for a valve prosthesis, cardiac conduction disturbances secondary to endocardiectomy of the right ventricle, and the possibility of recurrence of the endocardial fibrosis. However, at present, operation seems to be the treatment of choice for this condition because (1) endomyocardial fibrosis is characterized by a grave prognosis and medical therapy is ineffective; (2) endomyocardial fibrosis is a disease in which only the heart is affected, lesions in other organs being the result of passive congestion; (3) systolic performance of the heart is usually only slightly depressed; and (4) the surgical procedure is easily performed, so that the mortality is acceptable.

Endomyocardial fibrosis: report of 6 patients and review of the surgical literature

Six patients with endomyocardial fibrosis were treated by endocardium decortication and atrioventricular valve replacement. There were 5 female patients and 1 male patient ranging from 14 to 48 years old (mean, 30 years). Four patients had involvement of the right ventricle, 1 patient had involvement of the left ventricle, and 1 patient had biventricular disease. There was 1 operative death due to low cardiac output state (the patient with biventricular endomyocardial fibrosis), and there was 1 late noncardiac death. The surgical literature, which describes 19 previously reported cases, was reviewed. On the basis of the results of this series and those of the reported cases, it is concluded that surgical treatment of endomyocardial fibrosis is feasible and provides good clinical improvement.