Reduction of hsCRP levels following an Oral Health Education Program combined with routine dental treatment

OBJECTIVES

The present study aimed to determine the effect of a personalised oral health education program, in combination with routine dental treatment, on serum biomarkers of systemic disease compared to dental treatment alone in a population from a low-socioeconomic community with poor oral health.

METHODS

This secondary analysis of a randomised clinical trial involved 295 participants (mean age, 45.4 ± 11 years) assigned to two groups. One group received dental treatment combined with the Oral Health Education Program (OHEPDT), while the second group (DT) received dental care without the Education Program. Serum levels of high-sensitivity C-reactive protein (hsCRP), lipid profile (total cholesterol, triglycerides, and high- and low-density lipoprotein cholesterol), and HbA1c levels were analysed at baseline and after 12 months. Changes in diet, smoking and alcohol consumption were also determined.

RESULTS

No intergroup differences were observed for the lipid profile and HbA1c levels. A reduction in the hsCRP levels at the 12-month follow-up was observed in the OHEPDT group, which was significantly different from the DT group (p = 0.01). Multivariate modelling indicated that baseline hsCRP levels (p = 0.000), baseline body mass index (p = 0.000), and higher consumption of vegetables (p = 0.021) predicted a reduction in hsCRP levels.

CONCLUSIONS

This study demonstrated that personalised oral health education combined with routine dental treatment was associated with a significant reduction in hsCRP levels subsequent to dietary behavioural changes. These findings suggest that personalised oral health education in combined with routine dental treatment may have beneficial effects on general health.

CLINICAL SIGNIFICANCE

The strategy for developing an oral health program that involves education of the modifiable common risk factors for general health has beneficial effects and should be one of the priority components of these programs to improve oral and general health, particularly for at-risk communities.

The in vitro effect of VEGF receptor inhibition on primary alveolar osteoblast nodule formation

BACKGROUND

Vascular endothelial growth factor (VEGF) is a master regulator and is required for the effective coupling of angiogenesis and osteogenesis supporting both skeletal development and postnatal bone repair. A direct role for VEGF in intramembranous-derived osteoblast growth and differentiation is not clear. We investigated the expression of primary alveolar osteoblast VEGF receptors and the subsequent effects on mineralization and nodule formation in vitro following VEGFR inhibition.

METHODS

Primary human alveolar osteoblasts (HAOBs) were cultured in the presence of VEGF receptor inhibitors, exogenous VEGF or the bisphosphonate, zoledronic acid. VEGF, VEGFR1 and VEGFR2 mRNA expression and nodule formation following 21 days of culture. VEGFR1 protein expression was examined using immunofluorescence after 48 h.

RESULTS

The HAOBs expressed high levels of VEGF and VEGFR1 protein but VEGFR2 was not detected. The VEGFR1/2 inhibitors, ZM306416 and KRN633, lead to a dose-dependent decrease in mineralization. Treatment with zoledronic acid showed no difference in HAOB VEGF receptor expression.

CONCLUSION

VEGF/VEGFR1 pathway appears to be important for intramembranous-derived osteoblast differentiation and maturation in vitro.

Effects of zoledronic acid and geranylgeraniol on angiogenic gene expression in primary human osteoclasts

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a serious complication associated with bisphosphonate treatment. Zoledronic acid (ZA) is a commonly used bisphosphonate due to its effectiveness in increasing bone density and reducing skeletal events, with evidence that it alters angiogenesis. Replacement of the mevalonate pathway using geranylgeraniol (GGOH) was studied to determine the effects of ZA on angiogenic gene expression in primary human osteoclasts. Osteoclast cultures were generated from peripheral blood mononuclear cells of three patients using the peripheral blood mononuclear cell isolation. These cells were phenotyped by phase-contrast microscopy, tartrate-resistant acid phosphatase staining, and pit assays. Primary osteoclasts were found to express a number of key angiogenic molecules at very high levels. Gene expression levels for 84 human angiogenic factors were determined using PCR arrays. Three genes with significant fold regulation (FR) in response to ZA were as follows: tumor necrosis factor (FR = +2.57, P = 0.050), CXCL9 (FR = +39.48, P = 0.028), and CXCL10 (FR = +18.52, P = 0.0009). The co-addition of geranylgeraniol with ZA resulted in the significant down-regulation of these three genes along with CCL2, TGFBR1, ENG, and CXCL1. GGOH reversed the gene changes induced by ZA and may offer a promising treatment for BRONJ.

Feasibility of the salivary transcriptome as a novel biomarker in determining disease susceptibility

BACKGROUND AND OBJECTIVE

The salivary transcriptome may present as a readily available and non-invasive source of potential biomarkers. The development of chronic periodontitis is determined by individual patient susceptibility; hence, the aim of this study was to determine the potential of the salivary transcriptome as a biomarker of disease susceptibility using chronic periodontitis as an example.

MATERIAL AND METHODS

Using an Oragene^® RNA kit, the total RNA was purified from the saliva of 10 patients with chronic periodontitis and 10 patients without chronic periodontitis. The quantity and quality of the total RNA was determined, and a measure of gene expression via cDNA was undertaken using the Affymetrix microarray system. The microarray profiling result was further validated by real-time quantitative polymerase chain reaction.

RESULTS

Spectrophotometric analysis showed the total RNA purified from each participant ranged from 0.92 μg/500 μL to 62.85 μg/500 μL. There was great variability in the quantity of total RNA obtained from the 2 groups in the study with a mean of 10.21 ± 12.71 μg/500 μL for the periodontitis group and 15.97 ± 23.47 μg/500 μL for the control group. Further the RNA purity (based on the A₂₆₀ /A₂₈₀ ratio) for the majority of participants (9 periodontitis and 6 controls) were within the acceptable limits for downstream analysis (2.0 ± 0.1). The study samples, showed 2 distinct bands at 23S (3800 bp) and 16S (1500 bp) characteristic of bacterial rRNA. Preliminary microarray analysis was performed for 4 samples (P2, P6, H5 and H9). The percentage of genes present in each of the 4 samples was not consistent with about 1.8%-18.7% of genes being detected. Quantitative real-time polymerase chain reaction confirmed that the total RNA purified from each sample was mainly bacterial RNA (Uni 16S) with minimal human mRNA.

CONCLUSION

This study showed that minimal amounts of human RNA were able to be isolated from the saliva of patients with periodontitis as well as controls. Further work is required to enhance the extraction process of human mRNA from saliva if the salivary transcriptome is to be used in determining individual patient susceptibility.

Effects of environmental tobacco smoke on the oral health of preschool children

AIMS

This study investigated the association between the prevalence of oral health problems (caries, gingivitis, mucosal pigmentation and enamel defects in one to 5 year-old children exposed and not exposed to environmental tobacco smoke before and/or after birth. Exposure to environmental tobacco smoke (ETS) in childhood may have significant health effects.

METHODS

A structured questionnaire was used to collect data on a child's current and previous illnesses, oral health behaviours, dietary habits, parental smoking behaviours and parents' dental history. The intraoral examination recorded dental caries (dmfs), enamel defects, gingival health, melanin pigmentation and soft tissue health. Stimulated saliva was collected. Total sIgA levels were quantified using indirect competitive ELISA with a SalimetricsTM kit.

RESULTS

The 44 children (aged 15-69 months) recruited were divided into two groups: ETS and non-ETS (control). There were 22 children in each: 16 who were exposed to ETS during and after gestation were identified as the ETSB subgroup. Participants exposed to ETS were more likely to have had upper respiratory tract and middle ear infections during the neonatal period and had higher mean dmft, mean dmfs, mean percent of surfaces with demarcated opacities and mean GI than the non-ETS participants. The children exposed to ETS before and after birth had the highest occurrence of enamel opacities showed a higher risk for dental caries even though more children in this group used the recommended fluoride toothpaste (1000 ppm fluoride). Mothers who smoked either never breastfed their children or breastfed their children for less than the recommended period of 6 months. Children exposed to ETS were shown to have higher mean total sIgA (μg/ml) than the children in the control group.

CONCLUSIONS

Associations between ETS exposure before and after gestation and oral health, including salivary changes in young children were shown in the present study. Dental health professionals should include a question about household smoking in children's dental histories, which would allow opportunities to discuss the impact of smoking on child oral health. Longitudinal oral health studies should include a history of maternal smoking during pregnancy and afterwards.

Natural history of periodontitis: Disease progression and tooth loss over 40 years

OBJECTIVES

To assess long-term attachment and periodontitis-related tooth loss (PTL) in untreated periodontal disease over 40 years.

MATERIAL AND METHODS

Data originated from the natural history of periodontitis study in Sri Lankan tea labourers first examined in 1970. In 2010, 75 subjects (15.6%) of the original cohort were re-examined.

RESULTS

PTL over 40 years varied between 0 and 28 teeth (mean 13.1). Four subjects presented with no PTL, while 12 were edentulous. Logistic regression revealed attachment loss as a statistically significant covariate for PTL (p < .004). Markov chain analysis showed that smoking and calculus were associated with disease initiation and that calculus, plaque, and gingivitis were associated with loss of attachment and progression to advanced disease. Mean attachment loss <1.81 mm at the age of 30 yielded highest sensitivity and specificity (0.71) to allocate subjects into a cohort with a dentition of at least 20 teeth at 60 years of age.

CONCLUSIONS

These results highlight the importance of treating early periodontitis along with smoking cessation, in those under 30 years of age. They further show that calculus removal, plaque control, and the control of gingivitis are essential in preventing disease progression, further loss of attachment and ultimately tooth loss.

The oral microbiome of patients with axial spondyloarthritis compared to healthy individuals

Background. A loss of mucosal tolerance to the resident microbiome has been postulated in the aetiopathogenesis of spondyloarthritis, thus the purpose of these studies was to investigate microbial communities that colonise the oral cavity of patients with axial spondyloarthritis (AxSpA) and to compare these with microbial profiles of a matched healthy population.

Methods. Thirty-nine participants, 17 patients with AxSpA and 22 age and gender-matched disease-free controls were recruited to the study. For patients with AxSpA, disease activity was assessed using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). All participants underwent a detailed dental examination to assess oral health, including the presence of periodontal disease assessed using probing pocket depth (PPD). Plaque samples were obtained and their bacterial populations were profiled using Ion Torrent sequencing of the V6 region of the 16S rRNA gene.

Results.Patients with AxSpA had active disease (BASDAI 4.1 ± 2.1 [mean ± SD]), and a significantly greater prevalence of periodontitis (PPD ≥ 4 mm at ≥4 sites) than controls. Bacterial communities did not differ between the two groups with multiple metrics of α and β diversity considered. Analysis of operational taxonomic units (OTUs) and higher levels of taxonomic assignment did not provide strong evidence of any single taxa associated with AxSpA in the subgingival plaque.

Discussion. Although 16S rRNA gene sequencing did not identify specific bacterial profiles associated with AxSpA, there remains the potential for the microbiota to exert functional and metabolic influences in the oral cavity which could be involved in the pathogenesis of AxSpA.

A comparison of salivary IgA in children with Down syndrome and their family members

The aim of this study was to compare total IgA in the whole saliva of children with Down syndrome with levels in sibling and parent groups. IgA measurements were presented as the concentration in saliva (μg/ml) and also adjusted for salivary flow rate (SFR; μg/min). Twenty children with Down syndrome, ten siblings and twenty parents were recruited. Stimulated whole saliva was collected from the participants and SFR calculated. The measurement of salivary IgA (sIgA) was carried out using an indirect competitive Enzyme-Linked Immunosorbent Assay. The difference in the mean SFR between children with Down syndrome, parents and siblings were not statistically significant. The mean salivary concentration of IgA was higher in children with Down syndrome (95.1 μg/ml) compared with siblings (48.3 μg/ml; p=0.004). When adjusted for SFR children with Down syndrome had mean sIgA levels of 98.8 μg/min and the siblings 48.6 μg/min (p=0.008). The children with Down syndrome had sIgA levels similar to those of the parents (92.5 μg/ml; 93.2 μg/min). There was a positive correlation between age and sIgA concentration in the siblings (p=0.008) but not for children with Down syndrome (p=0.363). This suggests that under similar environmental influences, the levels of sIgA in children with Down syndrome are higher than in the siblings, from a very young age.

Influence of a triclosan toothpaste on periodontopathic bacteria and periodontitis progression in cardiovascular patients: a randomized controlled trial

BACKGROUND AND OBJECTIVE

Triclosan/copolymer toothpaste is effective in controlling plaque and gingivitis and in slowing the progression of periodontitis. This study describes its influence on microbiological and clinical outcomes, over a 5-year period, in patients with established cardiovascular disease (CVD).

MATERIAL AND METHODS

Four-hundred and thirty-eight patients were recruited from the Cardiovascular Unit at The Prince Charles Hospital, Brisbane, Australia, and randomized to triclosan or placebo groups. Six sites per tooth were examined annually for probing pocket depth and loss of attachment. These outcomes were analysed, using generalized linear modelling, in 381 patients who had measurements from consecutive examinations. Concurrent load of the periodontal pathogens Aggregatibacter actinomycetemcomitans, Fusobacterium nucleatum, Tannerella forsythia and Porphyromonas gingivalis was determined, using quantitative real-time PCR, in 437 patients with baseline plaque samples. Group comparisons were expressed as geometric means. The chi-square test was used to test for differences between the two groups of patients with regard to the proportion of patients with different numbers of bacterial species.

RESULTS

There was no difference in general health or periodontal status between the groups at baseline. There was a significant reduction in the number of interproximal sites showing loss of attachment between examinations, by 21% on average (p < 0.01), in the triclosan group compared with the placebo group. The prevalence of patients with F. nucleatum and A. actinomycetemcomitans was high and remained relatively constant throughout the 5 years of the study. In contrast, the prevalence of T. forsythia and P. gingivalis showed more variability; however, there was no significant difference between the groups, at any time point, in the prevalence of any organism. A significant difference in the geometric means for P. gingivalis (p = 0.01) was seen at years 1 and 4, and for F. nucleatum (p = 0.01) and in the total bacterial load (p = 0.03) at year 2; however, these differences were not statistically significant following a Bonferroni correction for multiple comparisons. There was no difference between the groups in the geometric means for each organism at year 5.

CONCLUSION

Within the limitations of the study, these data suggest that the use of triclosan/copolymer toothpaste significantly slowed the progression of periodontitis in patients with CVD but that it had little influence on key subgingival periodontopathic bacteria in these patients over the 5 years of the study.

An overview of systematic reviews on the effectiveness of periodontal treatment to improve glycaemic control

Several systematic reviews with meta-analyses on the effectiveness of periodontal treatment to improve glycaemic control have been published. So far no overview of these systematic reviews has been performed. The main objective of this report was to assess critically these systematic reviews to provide the reader with a high-level synthesis of research evidence. MEDLINE (via PubMed) and EMBASE databases were searched independently and in duplicate to identify systematic reviews with meta-analyses of clinical studies that assessed the relationship between diabetes mellitus and periodontitis. The last database search was performed on 10 March 2015. The reference lists of included systematic reviews were also scrutinized for further publications. The methodological quality of the included systematic reviews was assessed independently with two validated checklists (AMSTAR and OQAQ) by two authors. Disagreements in the assessment were resolved by consensus. A total of 226 potential publications were initially retrieved. Eleven systematic reviews with meta-analyses were finally included. Glycosylated haemoglobin A1c (HbA1c) was the most commonly used clinical endpoint. Meta-analytic estimates from systematic reviews generated an average reduction of 0.46% (median 0.40%) of HbA1c in patients with diabetes mellitus who received periodontal treatment. These meta-analyses had, nevertheless, methodological limitations such as inclusion of trials with different types of risk of bias that hinder more robust conclusions. A recent meta-analysis that included recently published large randomized controlled trials did not show significant change in the level of HbA1c at the 6 mo follow-up. The AMSTAR checklist generated results that were more conservative than OQAQ. Findings from this overview do not support the information that periodontal treatment may improve glycaemic control. Methodological issues described in this overview may guide further research on this topic.

Effects of zoledronic acid and geranylgeraniol on the cellular behaviour and gene expression of primary human alveolar osteoblasts

INTRODUCTION

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a serious complication of bisphosphonate therapy. The mechanism underlying BRONJ pathogenesis is poorly understood.

OBJECTIVES

To determine the effects of zoledronic acid (ZA) and geranylgeraniol (GGOH) on the mevalonate pathway (MVP) in osteoblasts generated from the human mandibular alveolar bone in terms of cell viability/proliferation, migration, apoptosis and gene expression.

MATERIALS AND METHODS

Primary human osteoblasts (HOBs) isolated from the mandibular alveolar bone were phenotyped. HOBs were cultured with or without ZA and GGOH for up to 72 h. Cellular behaviour was examined using a CellTiter-Blue® viability assay, an Ibidi culture-insert migration assay, an Apo-ONE® Homogeneous Caspase-3/7 apoptosis assay and transmission electron microscopy (TEM). Quantitative real-time reverse transcriptase polymerase chain reaction (qRT²-PCR) was used to determine the simultaneous expression of 168 osteogenic and angiogenic genes modulated in the presence of ZA and GGOH.

RESULTS

ZA decreased cell viability and migration and induced apoptosis in HOBs. TEM revealed signs of apoptosis in ZA-treated HOBs. However, the co-addition of GGOH ameliorated the effect of ZA and partially restored the cells to the control state. Twenty-eight genes in the osteogenic array and 27 genes in the angiogenic array were significantly regulated in the presence of ZA compared with those in the controls at one or more time points.

CONCLUSION

The cytotoxic effect of ZA on HOBs and its reversal by the addition of GGOH suggests that the effect of ZA on HOBs is mediated via the MVP.

CLINICAL RELEVANCE

The results suggest that GGOH could be used as a possible therapeutic/preventive strategy for BRONJ.

The bisphosphonate zoledronic acid regulates key angiogenesis-related genes in primary human gingival fibroblasts

BACKGROUND

Osteonecrosis of the jaws is recognised as a serious complication for patients receiving bisphosphonates. The anti-angiogenic effects of bisphosphonates have been implicated in the pathogenesis of bisphosphonate-related osteonecrosis of the jaw (BRONJ). The purpose of this study was to determine the effects of zoledronic acid on cultured human gingival fibroblasts in relation to the modulation of genes associated with angiogenic regulation.

METHODS

Primary cultures of fibroblasts were developed from gingival tissues excised during crown-lengthening surgery from three patients. Cells were cultured with and without 30μM zoledronic acid for 6, 12 and 24h and cellular proliferation and migration investigated using CellTiter-Blue and scratch wound assays, respectively. Gene expression was determined using semi-quantitative PCR array technology that allowed the analysis of 84 pathway-focused genes known to be important in the regulation of angiogenesis.

RESULTS

Zoledronic acid increased the proliferation of the gingival fibroblasts in a dose dependent manner with 12 and 24h of exposure. Scratch wounding of the human gingival fibroblasts and treatment with increasing doses and time exposure to zoledronic acid (ZA) inhibited their migration. Statistically significant increases in gene expression were found for RHOB, VEGFA, CD55 and BMP2 (p≤0.05) in response to 30μM zoledronic acid. CCL2 and IL6 genes were significantly downregulated (p≤0.05).

CONCLUSIONS

The regulation of the prenylated protein RHOB in this study was consistent with the known effects of zoledronic acid on the mevalonate pathway. The down regulation of CCL2 and IL6 and the upregulation of CD55 may be associated with suppression of inflammation. An increase in VEGFA and BMP2 gene expression suggests that fibroblasts respond to zoledronic acid by producing a proangiogenic environment.

The influence of a triclosan toothpaste on adverse events in patients with cardiovascular disease over 5-years

Adverse effects of long-term usage of triclosan-containing toothpaste in humans are currently unknown. We assessed the effect of long-term use of 0.3% triclosan-toothpaste on serious adverse events (SAEs) in patients with cardiovascular disease (CVD). 438 patients with a history of stable CVD were entered into the 5-year longitudinal Cardiovascular and Periodontal Study at Prince Charles Hospital, Brisbane, Australia and randomised into test (triclosan) or placebo groups. There were no significant differences in demographics or clinical features between the groups. Patients were examined at baseline, and annually for 5-years. SAEs were classified according to the System Organ Classes defined by MedDRA (Medical Dictionary for Regulatory Activities). Results were analysed using chi square and Kaplan Meier analysis. Overall, 232 patients (123 in the triclosan group; 109 in the placebo group) experienced 569 SAEs (288 in the triclosan group and 281 in the placebo group). There was no significant difference between the groups in numbers of patients experiencing SAEs (p=0.35) or specific cardiovascular SAEs (p=0.82), nor in time to the first SAE or first cardiovascular SAE, irrespective of gender, age or BMI after adjusting for multiple comparisons (p>0.05). The adjusted odds of experiencing an SAE were estimated to increase by 2.7% for each year of age (p=0.02) and the adjusted odds of experiencing a cardiovascular SAE were estimated to increase by 5.1% for each unit increase in BMI (p=0.02). Most cardiovascular events were related to unstable angina or myocardial infarcts, 21 were associated with arrhythmia and 41 were vascular events such as aortic aneurysm and cerebrovascular accident. Within the limitations of the present study the data suggest that the use of triclosan-toothpaste may not be associated with any increase in SAEs in this CVD population. The long-term impact of triclosan on hormone-related disease, such as cancer, in humans remains to be determined.

Zoledronic acid and geranylgeraniol regulate cellular behaviour and angiogenic gene expression in human gingival fibroblasts

The mevalonate pathway (MVP) and the anti-angiogenic effect of bisphosphonates have been shown to play a role in the pathogenesis of bisphosphonate-related osteonecrosis of the jaw (BRONJ). This study determined the effect of the bisphosphonate, zoledronic acid and the replenishment of the MVP by geranylgeraniol on human gingival fibroblasts. Cell viability, apoptosis, morphological analysis using transmission electron microscopy, and gene expression for vascular endothelial growth factor A, bone morphogenic protein 2, ras homologue gene family member B, epiregulin and interferon-alpha were conducted. Results showed cellular viability was decreased in the presence of zoledronic acid and the co-addition of zoledronic acid with geranylgeraniol restored cell viability to control levels. Caspase 3/7 was detected in zoledronic-acid-treated cells indicating apoptosis. Transmission electron microscopy revealed dilation of the rough endoplasmic reticulum with zoledronic acid and the appearance of multiple lipid-like vesicles following the addition of geranylgeraniol. Zoledronic acid significantly (P < 0.05, FR > ± 2) up-regulated vascular endothelial growth factor A, bone morphogenic protein 2, ras homologue gene family member B and epiregulin at one or more time points but not interferon-alpha. Addition of geranylgeraniol resulted in a reduction in the expression of all five genes compared with zoledronic-acid-treated human gingival fibroblasts. The study concluded geranylgeraniol partially reversed the effects of zoledronic acid in human gingival fibroblasts both at the cellular and genetic levels, suggesting the regulation of these genes is mediated via the mevalonate pathway.

Periodontal diseases in an Omani adult population: a preliminary study

BACKGROUND

Data on the periodontal status of the adult population in the Arab world are scarce. The aim of this pilot study is to assess the prevalence, extent, and severity of periodontal diseases in an adult group from Oman.

METHODS

This is a cross-sectional study of 319 teachers who were randomly sampled from the list of teachers from the Muscat region schools in Oman. Dental caries, tooth loss, and periodontal attachment loss (AL) were recorded for each of the participants. A questionnaire collected data on participants' sociodemographic characteristics, dental-care characteristics, self-rated periodontal status, and self-rated well-being.

RESULTS

A total of 99% of participants had at least one site with probing depth (PD) or clinical AL of ≥ 3 mm. More than one third (36%) of participants had at least one site with AL ≥ 5 mm, and 12% had at least one site with AL ≥ 6 mm; for PD, the prevalence estimates were 26% and 8%, respectively, and a gradient by age group was evident across the different thresholds. Regarding the extent of disease, 17.6% of sites had PD ≥ 3 mm, and 21% of sites had AL ≥ 3 mm.

CONCLUSIONS

The prevalence, extent, and severity of periodontitis were higher than estimates reported from industrialized countries, such as Australia, New Zealand, and the United States. This is of concern, especially when considering the relatively young age of the study population. Because of this high prevalence, investigation of periodontitis in a national sample of Omanis is desirable to confirm the findings of this study.

Oral hygiene behaviours and readiness to change using the TransTheoretical Model (TTM)

OBJECTIVE

The aim of this pilot study was to investigate the Transtheoretical Model (TTM) in relation to measures of readiness to change oral hygiene behaviours.

RESEARCH DESIGN

Participants (N = 105) were recruited from a dental hygiene patient waiting list. A self-administered questionnaire was designed; it included four measures related to inter-dental cleaning used for TTM staging, confidence and frequency measures of future interdental cleaning and toothbrushing, together with items seeking demographic details. Data collection occurred before a dental hygiene appointment where oral health advice was offered, and then at three and six months afterwards, in order to measure readiness to change post-intervention.

RESULTS

All three questionnaires were returned by 91.4% of participants. The confidence measures for maintaining toothbrushing twice per day and for interdental cleaning were associated with TTM staging at baseline (respective correlation coefficients of 0.200; P = 0.042 and 0.584; P < 0.001). Participants were likely to be in a higher TTM stage at 3 months after attendance at the dental hygiene clinic and then decline to a lower TTM stage by 6 months (baseline to 3 months and 6 months: Wilcoxon signed rank tests of p= 0.024 and p = 0.627). Of the 31 participants (33%) who improved their TTM staging between baseline and 3 months, 11 (35%) fell back to a lower category between 3 months and 6 months, 14 (45%) maintained their improvement, and 6 (19%) improved further.

CONCLUSIONS

Understanding a person's readiness to change could improve the way in which oral hygiene interventions and advice are given in the clinical setting. The TTM staging measurement tool used here provides insight into people's readiness to change their oral hygiene behaviours, and its use would aid practitioners in the delivery of oral health messages. The initial improvement in TTM stage and subsequent regression was consistent with the TTM's relapse phenomenon and reinforces the concept that on-going support is crucial to maintaining behaviour change.

Periodontal pathogen load and increased antibody response to heat shock protein 60 in patients with cardiovascular disease

AIM

To determine the relationship between periodontal pathogen load and anti-human heat shock protein 60 (hHSP60) antibodies in patients with established cardiovascular disease (CVD).

MATERIALS AND METHODS

Participants were cardiovascular patients (n = 74) with a previous hospital admission for myocardial infarction. Concurrent periodontal pathogen load of Porphyromonas gingivalis, Fusobacterium nucleatum, Tannerella forsythia and Aggregatibacter actinomycetemcomitans was determined using quantitative real-time PCR. Serum antibodies to these pathogens, GroEL and hHSP60 were determined using an ELISA.

RESULTS

There was a trend for increasing anti-hHSP60 antibody as the number of bacterial species increased. The strongest positive correlations were found between anti-hHSP60 levels and numbers of T. forsythia (r = 0.43; p < 0.001) and between anti-hHSP60 and anti-GroEL levels (r = 0.39; p = 0.001). Patients with extensive periodontal pocketing (≥4 mm) had higher numbers of P. gingivalis and T. forsythia (p < 0.05) and a higher subgingival pathogen load (p < 0.05) than patients with minimal pocketing (≤1 site ≥ 4 mm). They also had significantly elevated anti-hHSP60 levels (p < 0.05). Overall, the highest anti-hHSP60 levels were seen in patients with extensive periodontal pocketing and all four bacterial species.

CONCLUSIONS

In cardiovascular patients, a greater burden of subgingival infection with increased levels of P. gingivalis and T. forsythia is associated with modestly higher anti-hHSP60 levels.

An exploratory study of the acceptability of delivering oral health information in community pharmacies

OBJECTIVE

The community pharmacy is an accessible service which, with further training and support, could be used to deliver oral health messages. This is important especially for those with systemic diseases such as diabetes mellitus and cardiovascular disease, where the oral environment may have a negative impact. This qualitative study assessed the feasibility of pharmacists delivering oral health messages in community pharmacies.

DESIGN AND METHODS

Semi-structured interviews were conducted with 49 pharmacists in Dunedin and Auckland, New Zealand, with a focus on the pharmacists' current knowledge, attitudes and possibilities for providing oral health information to patients with diabetes and cardiovascular disease.

FINDINGS

There is potential for community pharmacists to provide oral health information to patients, dependent on the approach of the pharmacist and the patient response. The majority of pharmacists agreed that providing oral health advice was within their role; however, few did so proactively. They highlighted a lack of available resources relating to oral health and systemic disease. Further training relating to oral health and systemic disease would be necessary to provide the knowledge to support any resources. The preferred option by pharmacists for such training was an evening course or workshop.

Long term use of triclosan toothpaste and thyroid function

The long term effects of usage of triclosan-containing toothpaste on thyroid function are currently unknown. Triclosan is structurally similar to thyroid hormones and reductions in serum thyroid hormone levels have been observed in animal studies following oral administration of triclosan. Therefore, an assessment of thyroid function over 4 years was undertaken in a subset of individuals in a randomised, placebo controlled clinical trial comparing the effects of 0.3% triclosan toothpaste with placebo toothpaste in subjects with coronary heart disease. Thyroid stimulating hormone (TSH), free thyroxine (fT4), free triiodothyronine (fT3), antithyroglobulin antibody (anti-TGab) and antithyroid peroxidase antibody (TPOab) were measured. Paired serum samples at year 1 and year 5 from 132 subjects (64 triclosan group, 68 placebo group) were analysed. At year 1 there were no significant differences in thyroid function between the groups: mean (SD) TSH 1.4 (0.8) and 1.6 (0.9) mU/L, triclosan and placebo groups respectively, fT4 15.8 (2.2) and 15.2 (2.1) pmol/L; fT3 4.8 (0.5) and 4.8 (0.5) pmol/L. Similarly, for antithyroid antibodies there were no group differences at year 1. Median (25th, 75th percentile) for anti-TGab, 38 (34, 42) and 37 (30, 42) U/mL triclosan and placebo groups respectively; anti-TPOab, 15 (10, 22) and 18 (10, 24) U/mL. At year 5, fT4 was the only measure to show a significant difference between groups (mean and 95% Confidence Interval) 15.6 (15.1, 16.1) and 14.7 (14.2, 15.1) pmol/L triclosan and placebo respectively (p=0.01). This reflects reduced levels in the placebo group but no change in the triclosan group. In conclusion, over 4 years triclosan toothpaste had no detectable effect on thyroid function. The data support the view that 0.3% triclosan in toothpaste is safe and free of significant thyroid adverse effects.

Why should a doctor be interested in oral disease?

Oral health has been implicated in systemic disease throughout the ages; however, the understanding of the relationship between oral disease and systemic diseases such as cardiovascular disease and Type 2 diabetes mellitus is still emerging today. Chronic periodontal disease is widespread in the general population and a significant proportion of adults suffer from the most severe form of the disease. Dental plaque biofilm is necessary for the development of chronic periodontal disease with genetic and environmental factors contributing towards the pathogenesis. The putative biological mechanisms of the association between oral disease and atherogenesis are discussed, although there is insufficient evidence to establish causality at this time. Regardless of a direct causal relationship between oral disease and cardiovascular disease, treatment of oral disease leads to both a reduction in the systemic inflammatory burden as reflected in inflammatory markers and an improvement in endothelial function and hence improved overall health outcomes. A brief overview of periodontal disease including etiology, pathogenesis, screening and therapeutic implications is presented.

Diabetes, periodontitis, and the subgingival microbiota

Both type 1 and type 2 diabetes have been associated with increased severity of periodontal disease for many years. More recently, the impact of periodontal disease on glycaemic control has been investigated. The role of the oral microbiota in this two-way relationship is at this stage unknown. Further studies, of a longitudinal nature and investigating a wider array of bacterial species, are required in order to conclusively determine if there is a difference in the oral microbiota of diabetics and non-diabetics and whether this difference accounts, on the one hand, for the increased severity of periodontal disease and on the other for the poorer glycaemic control seen in diabetics.

Periodontal disease and systemic health: current status

The relationship between poor oral health and systemic diseases has been increasingly recognized over the past two decades. Indeed, the clichés "You cannot have good general health without good oral health", "The mouth is part of the body" and "Floss or die", are gaining an increasing momentum. A large number of epidemiological studies have now linked poor oral health with cardiovascular diseases, poor glycaemic control in diabetics, low birthweight preterm babies and a variety of other conditions. The majority have shown an association, although not always strong. As a result, a number of meta-analyses have been conducted and have confirmed the associations and at the same time cautioned that further studies are required, particularly with regard to the effect of periodontal treatment in reducing risk. A number of biologically plausible mechanisms have been put forward to explain the association and there is accumulating evidence in support of them, although at this stage, insufficient to establish causality. Nevertheless, the relationship between poor oral health and systemic diseases has become a significant issue, such that adult oral health can no longer be ignored in overall health strategies. This review provides an update on current understanding of the contribution of poor oral health to systemic diseases, the possible mechanisms involved and the relevance of this for general dental practitioners.

Immediate placement or immediate restoration/loading of single implants for molar tooth replacement: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis assessed the survival of immediately placed single implants in fresh molar extraction sites and immediately restored/loaded single molar implants in healed molar sites.

MATERIALS AND METHODS

A search of the main electronic databases, including the Cochrane Oral Health Group's Trials Register, was conducted up to November 1, 2008. The meta-analysis was prepared in accordance with the guidelines of the Academy of Osseointegration Workshop on the State of the Science on Implant Dentistry. The data were analyzed with statistical software.

RESULTS

For immediately placed molar implants, nine studies describing 1,013 implants were included to support a survival rate of 99.0%. There were no significant differences between immediate and delayed loading/restoration in molar sites (relative risk of 0.30, 95% confidence interval 0.05 to 1.61; P = .16). For immediate restoration/loading of single implants in healed molar sites, seven studies with 188 single implants were identified. In this case, the implant survival rate was 97.9%, with no difference between immediate and delayed loading (relative risk of 3.0, 95% confidence interval: 0.33 to 27.16; P = .33). Favorable marginal bone level changes in the immediate loading group were detected at 12 months (mean difference of -0.31, 95% confidence interval: -0.53 to -0.096; P = .005).

CONCLUSIONS

The protocols of immediate placement and immediate restoration/loading of single implants in mandibular molar regions showed encouraging results.

Dental stem cells and their potential role in apexogenesis and apexification

Injury to an immature permanent tooth may result in cessation of dentine deposition and root maturation leaving an open root apex and thin dentinal walls that are prone to fracture. Endodontic treatment is often complicated and protracted with an uncertain prognosis frequently resulting in premature tooth loss. Postnatal stem cells, which are capable of self-renewal, proliferation and differentiation into multiple specialized cell lineages have been isolated and identified within the dental pulp, apical papilla and periodontal ligament. The ability of these cells to produce pulp-dentine and cementum-periodontal ligament complexes in vivo suggest potential applications involving stem cells, growth factors and scaffolds for apexification or apexogenesis. Similar protein expression amongst dental stem cells possibly implicates a common origin; however, the dominant cells to repopulate an open apex will be directed by local environmental cues. A greater understanding of the structure and function of cells within their environment is necessary to regulate and facilitate cellular differentiation along a certain developmental path with subsequent tissue regeneration. This review focuses on development of the apical tissues, dental stem cells and their possible involvement clinically in closing the open root apex. MEDLINE and EMBASE computer databases were searched up to January 2009. Abstracts of all potentially relevant articles were scanned and their contents identified before retrieval of full articles. A manual search of article reference lists as well as a forward search on selected authors of these articles was undertaken. It appears that dental stem cells have the potential for continued cell division and regeneration to replace dental tissues lost through trauma or disease. Clinical applications using these cells for apexogenesis and apexification will be dependent on a greater understanding of the environment at the immature root end and what stimulates dental stem cells to begin dividing and then express a certain phenotype.

Relationship between periodontal infections and systemic disease

Oral conditions such as gingivitis and chronic periodontitis are found worldwide and are among the most prevalent microbial diseases of mankind. The cause of these common inflammatory conditions is the complex microbiota found as dental plaque, a complex microbial biofilm. Despite 3000 years of history demonstrating the influence of oral status on general health, it is only in recent decades that the association between periodontal diseases and systemic conditions such as coronary heart disease and stroke, and a higher risk of preterm low birth-weight babies, has been realised. Similarly, recognition of the threats posed by periodontal diseases to individuals with chronic diseases such as diabetes, respiratory diseases and osteoporosis is relatively recent. Despite these epidemiological associations, the mechanisms for the various relationships remain unknown. Nevertheless, a number of hypotheses have been postulated, including common susceptibility, systemic inflammation with increased circulating cytokines and mediators, direct infection and cross-reactivity or molecular mimicry between bacterial antigens and self-antigens. With respect to the latter, cross-reactive antibodies and T-cells between self heat-shock proteins (HSPs) and Porphyromonas gingivalis GroEL have been demonstrated in the peripheral blood of patients with atherosclerosis as well as in the atherosclerotic plaques themselves. In addition, P. gingivalis infection has been shown to enhance the development and progression of atherosclerosis in apoE-deficient mice. From these data, it is clear that oral infection may represent a significant risk-factor for systemic diseases, and hence the control of oral disease is essential in the prevention and management of these systemic conditions.

Radiographic study of ethnic variation in alveolar bone height among New Zealand dental students

BACKGROUND

The aim of this study was to determine anatomical variations in the radiographic distance between the cemento-enamel junction and the alveolar crest with respect to ethnic heritage and gender in New Zealand dental students.

METHODS

Digitized bitewing films of 123 second-year New Zealand dental students were examined with a computer imaging program on a desktop computer screen. The race of parents and grandparents was obtained by questionnaire.

RESULTS

The mean distance from the cemento-enamel junction to the alveolar crest across the sample was 0.97 mm. Eighteen (14.6%) of the participants had measurements >2 mm, of whom 17 were Asians. Asians had a significantly larger mean distance than did non-Asians (1.10 mm compared to 0.83 mm; P <0.001). Gender was not a significant variable.

CONCLUSIONS

Students of Asian origin had a significantly greater distance between the cemento-enamel junction and the alveolar crest. It remains to be determined whether this is anatomical or disease related.