Periodontal Disease

[drmithila]

 

Periodontal Probes

The periodontal probe continues to be one of the more useful diagnostic tools to determine the presence and severity of periodontal lesions. An ideal periodontal probe should possess specific characteristics:

1. It should be tissue-friendly and not traumatize periodontal tissues during probing.

2. It should be suitable as a measuring instrument.

3. It should be standardized to ensure reproducibility, particularly with respect to recommended pressure.

4. It should be suitable both for use in the clinical setting where precise data documentation is required on an individual patient basis, and for screening purposes, as in epidemiology.

5. It should be easy and simple to use and read.

Over the years, the shape, design, and function of probes have changed to enhance accuracy and reproducibility. Three generations of probes have been suggested by Philström¹⁹: first generation—conventional handheld instruments; second generation—force application during measurement; third generation—force application using automated measurement and computerized data capture. The conventional handheld probes most commonly are preferred for their ease and simplicity in application. However, the use of second- and third-generation probes also is common, especially in the field of research where variables such as pressure or force on probing, reproducibility, and accuracy are investigated. Various studies considering these different probes and their characteristics also are found in the literature. Samuel et al²⁰ have published an in vitro study testing the accuracy and reproducibility of automated and conventional probes. In that study automated probes were reported to offer increased accuracy over conventional probes, and the reproducibility of both Florida pocket-depth and disk probes was found to be comparable with that of the conventional probes. Buduneli et al²¹ in an in vitro model investigated the accuracy and reproducibility of two manual probes and concluded that overall accuracy was higher with the WHO probe compared with the Williams probe. This study also revealed better reproducibility percentages for the WHO probe in comparison with the Williams probe.

Probe Characteristics

Characteristics of the probe, such as its diameter at the tip and the calibration, can influence PPD measurement. Different probes, such as Michigan, Williams, Marquis, Goldman-Fox, and Nabers probes, have different dimensions and a different diameter at the tip. The tip diameters range from 0.28 mm for the Michigan “O” probe to 0.7 mm for the Williams probe. Moreover, the widths of probe markings in the painted bands differ by as much as 0.7 mm between probes because of manufacturing errors. Figure 3 illustrates different manual probes. Van der Zee et al⁵ evaluated the accuracy of probe markings in a variety of probes and noted that probes from the same batch from the same production line could differ by more than 0.5 mm in calibration and the mean tip diameter ranged from 0.28 mm to 0.7 mm. They concluded that probe-tip diameter and calibration should be considered in addition to other variables of periodontal probing. Standardization of tine characteristics and avoidance of the use of different types or batches in a single study should enhance the accuracy and reproducibility of periodontal probe-dependent measurements.

Atassi et al²² compared a parallel-sided probe to a tapered probe (Figure 4). Results indicated that the parallel-sided tine tended to yield a deeper reading when a difference occurred. Garnick and Silverstein²³reviewed the effect of the probe-tip diameter on accurate probe placement and recommended a probe-tip diameter of 0.6 mm and a 20-g force to measure a reduction in the clinical probing depth after therapy. Quirynen et al²⁴ found interexaminer variability was dependent upon probe type. The study compared a conventional periodontal probe with an automatic, computerized, constant-force, electronic probe in vivo and found that PPD measurements recorded with the manual probe were consistently deeper than those recorded with the electronic probe. Wang et al⁴ evaluated intra- and interexaminer reproducibility for conventional and electronic probes and found that reproducibility may not necessarily be higher with an electronic, force-controlled periodontal probe than with a conventional manual probe. In an attempt to overcome some of the technical challenges associated with conventional manual periodontal probes, numerous electronic periodontal probes have been developed that permit probe insertion with a controlled force.⁹

The controlled-force probe that has achieved the most widespread use is the Florida Probe^® (Florida Probe Corp, Gainesville, FL) (Figure 5A and Figure 5B). This computer-linked device has in vitro resolution of 0.1 mm and is capable of recording probing depths and relative attachment levels.^25-31 Clinical measurements obtained with conventional manual probes are consistently greater than those obtained with controlled-force probes.^24,32-37 One of the possible reasons for this is reduced tactile sensitivity associated with the use of controlled-force probes. This is especially true in patients with untreated periodontitis for whom the presence of subgingival calculus can interfere with probe insertion. With conventional probes, it generally is easier for the operator to manipulate the probe tip past subgingival calculus deposits. A definite advantage of computer-linked probes is that they can record probe readings automatically. Some systems allow voice-activated data entry.³⁸ The usefulness of controlled-force probes in day-to-day clinical practice has not yet been demonstrated.⁹

One possible reason for the lack of widespread acceptance of controlled-force electronic probes by practitioners might be increased patient discomfort when these devices are used, particularly around the anterior teeth. During probing with conventional manual probes, the operator can decrease the insertion force rapidly if the patient shows any early signs of discomfort. With controlled-force probes, this patient–dentist feedback is not possible because the probe is inserted into the pocket in one motion and with fixed or predetermined force

        

[Drsumitra]

 If a pregnant woman is a MRSA carrier, there is no research evidence that her pregnancy will be compromised. In general, MRSA screening is not done routinely during pregnancy. However, if a woman has been diagnosed previously with MRSA, and if she is having a planned C-section, has a high risk for complications, has a MRSA-positive household member, or has been hospitalized in the last three months, she may be screened for MRSA. Some clinicians will offer treatment to suppress the bacteria; other clinicians may not, depending on the mother’s circumstances. Pregnant women who get MRSA infections are treated with antibiotics; if they pass MRSA to their infant, the baby can also be treated. Fortunately, serious MRSA infections in infants are rare. Pregnant women with MRSA infections should be treated by specialists, usually a team consisting of an ob-gyn and infectious-disease consultant, since careful choices in antibiotics and close follow-up yield the best outcomes for the mother and baby.

        

[Drsumitra]

Flap surgery is a subspecialty of plastic and reconstructive surgery. Various types of flaps are performed, and the indications for them are even more diverse.

Rather than discuss all the different types of flaps ever used, this article aims to outline the broad classification of flaps and to provide basic principles to remember when preparing for the operating room. For more details on particular flap procedures, please see the Flaps section of the Plastic Surgery journal.

Flap Definition, History, and Classification
A flap is a unit of tissue that is transferred from one site (donor site) to another (recipient site) while maintaining its own blood supply.

Flaps come in many different shapes and forms. They range from simple advancements of skin to composites of many different types of tissue. These composites need not consist only of soft tissue. They may include skin, muscle, bone, fat, or fascia.

How does a flap differ from a graft? A flap is transferred with its blood supply intact, and a graft is a transfer of tissue without its own blood supply. Therefore, survival of the graft depends entirely on the blood supply from the recipient site.

History of flap surgery
The term flap originated in the 16th century from the Dutch word flappe, meaning something that hung broad and loose, fastened only by one side. The history of flap surgery dates as far back as 600 BC, when Sushruta Samita described nasal reconstruction using a cheek flap. The origins of forehead rhinoplasty may be traced back to approximately 1440 AD in India. Some reports suggest flap surgeries were being performed before the birth of Christ.

The surgical procedures described during the early years involved the use of pivotal flaps, which transport skin to an adjacent area while rotating the skin about its pedicle (blood supply). The French were the first to describe advancement flaps, which transfer skin from an adjacent area without rotation. Distant pedicle flaps, which transfer tissue to a remote site, also were reported in Italian literature during the Renaissance period.

Subsequent surgical flap evolution occurred in phases. During the First and Second World Wars, pedicled flaps were used extensively. The next period occurred in the 1950s and 1960s, when surgeons reported using axial pattern flaps (flaps with named blood supplies). In the 1970s, a distinction was made between axial and random flaps (unnamed blood supply) and muscle and musculocutaneous (muscle and skin) flaps. This was a breakthrough in the understanding of flap surgery that eventually led to the birth of free tissue transfer.

In the 1980s, the number of different tissue types used increased significantly with the development of fasciocutaneous (fascia and skin) flaps (which are less bulky than muscle flaps), osseous (bone) flaps, and osseocutaneous (bone and skin) flaps.

The most recent advancement in flap surgery came in the 1990s with the introduction of perforator flaps. These flaps are supplied by small vessels (previously thought too small to sustain a flap) that typically arise from a named blood supply and penetrate muscle, muscle septae, or both to supply the overlying tissue. An example of this is the deep inferior epigastric perforator (DIEP) flap, which has now become the criterion standard in breast reconstruction. Noncontrast MRI is now used for preoperative mapping of perforator flaps.[1]

Classification of flaps
Most classification systems have been designed for the sole purpose of aiding communication with peers by being familiar with the correct vocabulary to use. However, the crucial point for any physician to remember is that communication with the patient is of foremost importance. The patient must be able to picture, with the surgeon’s guidance, what the surgeon is planning.

Many different methods have been used to classify flaps. Furthermore, these classification systems are often complex and varied in principle.

To improve the reader’s understanding of flap classification, the author has summarized the most commonly used classifications into 3 simplified categories: type of blood supply, type of tissue to be transferred, and location of donor site.

Blood supply

Like any living tissue, flaps must receive adequate blood flow to survive. A flap can maintain its blood supply in 2 main ways.

If the blood supply is not derived from a recognized artery but, rather, comes from many little unnamed vessels, the flap is referred to as a random flap. Many local cutaneous (skin) flaps fall into this category. If the blood supply comes from a recognized artery or group of arteries, it is referred to as an axial flap. Most muscle flaps have axial blood supplies.

Because of the complexity and variation observed in axial blood supply, a further subclassification (axial types I-V) was made by Mathes and Nahai and is readily used in plastic and reconstructive surgery literature to describe different types of muscle flaps (see the image below).[2]

Patterns of muscle flap vascular anatomy. Type I – One vascular pedicle. Type II – Dominant pedicle(s) and minor pedicle(s). Type III – Two dominant pedicles. Type IV – Segmental vascular pedicles. Type V – One dominant pedicle and secondary segmental pedicles.
The classification of flaps based on blood supply, including the Mathes and Nahai subclassification, can be summarized as follows:

Random (no named blood vessel)
Axial (named blood vessel) Mathes and Nahai classification
One vascular pedicle (eg, tensor fascia lata)
Dominant pedicle(s) and minor pedicle(s) (eg, gracilis)
Two dominant pedicles (eg, gluteus maximus)
Segmental vascular pedicles (eg, sartorius)
One dominant pedicle and secondary segmental pedicles (eg, latissimus dorsi)
Tissue to be transferred

In general, flaps may comprise in part or in whole almost any component of the human body, as long as an adequate blood supply to the flap can be ensured once the tissue has been transferred.

Flaps may be composed of just one type of tissue or several different types of tissue. Flaps composed of one type of tissue include skin (cutaneous), fascia, muscle, bone, and visceral (eg, colon, small intestine, omentum) flaps. Composite flaps include fasciocutaneous (eg, radial forearm flap), myocutaneous (eg, transverse rectus abdominis muscle [TRAM] flap), osseocutaneous (eg, fibula flap), tendocutaneous (eg, dorsalis pedis flap), and sensory/innervated flaps (eg, dorsalis pedis flap with deep peroneal nerve).

Therefore, another way of classifying flaps is by describing the different types of tissue that are being used in the flap.

Location of donor site

Tissue may be transferred from an area adjacent to the defect. This is known as a local flap. It may be described based on its geometric design, be advanced, or both. Pivotal (geometric) flaps include rotation, transposition, and interpolation. Advancement flaps include single pedicle, bipedicle, and V-Y flaps.

Tissue transferred from an noncontiguous anatomic site (ie, from a different part of the body) is referred to as a distant flap.

Distant flaps may be either pedicled (transferred while still attached to their original blood supply) or free. Free flaps are physically detached from their native blood supply and then reattached to vessels at the recipient site. This anastomosis typically is performed using a microscope, thus is known as a microsurgical anastomosis. Visible light spectroscopy can be used to measure tissue oxygenation in free flap reconstruction.[3]

Principles of flap surgery
Now that the main ways of classifying flaps have been introduced, the remaining sections of this article are devoted to the most important principles to remember before performing flap surgery. Like any surgical procedure, flap surgery is not devoid of risk. Complications such as complete flap loss can be catastrophic. Considering the following basic principles before any flap surgery serves patients well by optimizing outcome and decreasing operative morbidity.

Principle I: Replace Like With Like
This is a particularly important principle. When filling in a defect, replace like with like. Ralph Millard once said, "when a part of one’s person is lost, it should be replaced in kind, bone for bone, muscle for muscle, hairless skin for hairless skin, an eye for an eye, a tooth for a tooth."

If this cannot be accomplished, use the next most similar tissue substitute. For example, the surgeon can use scalp to replace a beard or skin from the forehead to cover a nose wound. The goal is to camouflage the reconstruction as much as possible. Everyone can learn from Mother Nature’s blending tricks. The surgeon’s goal is to create an effect as subtle as a chameleon changing colors as it moves through its surroundings.

An example of this can be found in the treatment of any eyelid injury. The best course of action when faced with a full-thickness defect is to use eyelid skin from the contralateral eye. If this is not possible, the next best substitute is a full-thickness posterior auricular skin graft. This provides the most similar substitute tissue, with a satisfactory color match and minimal tendency toward contracture.

If the surgeon’s work can pass unnoticed, he is to be congratulated as having accomplished his task as a reconstructive surgeon.

Principle II: Think of Reconstruction in Terms of Units
According to Millard, human beings may be divided into 7 main parts: the head, neck, body, and extremities. Each of these body parts can be further subdivided into units. The head, for example, is composed of several regional units: scalp, face, and ears. Consider that each of these units has its own unique features, and each feature has, in turn, multiple subunits with their own special shapes. All of these different units and subunits must be considered and reproduced during reconstruction.

As emphasized by Millard, "The most important aspects of a regional unit are its borders, which are demarcated by creases, margins, angles and hair liners." Taking this a step further, perhaps the most important principle is the way in which the borders between units come together and interact rather than just the borders themselves.

Adherence to these natural borders during reconstruction is important. Most often, it is better to convert a defect that covers only a partial unit to a whole-unit defect prior to reconstruction. According to Millard, "If possible make the defect fit the flap or graft to that unit!"

Principle III: Always Have a Pattern and a Back-up Plan
As with all surgery, comparing the pros and cons of each surgical option is of the utmost importance. The reconstructive ladder is a mental exercise that provides the surgeon with options ranging from the simplest to most complex. Usually, things should be kept as simple as possible. This benefits both the surgeon and the patient; the simplest plan is often the safest.

However, physicians should not sell themselves or patients short. Avoid settling for the simplest procedure just for the sake of simplicity. More complex problems may require more complex solutions, and the simplest approach may be, frankly, inadequate. A sound plan must provide restoration of function and aesthetic form; these are the fundamental goals of plastic and reconstructive surgery.

A nose, breast, or finger reconstruction should be designed to fit its use and location, rather like the philosophy used by architects when designing buildings. In 1949, a pioneer of 20th-century architecture, Frank Lloyd Wright, said, "Form and function thus become one in design and execution if the nature of materials and methods and purposes are all in unison." Several years earlier, Wright had been asked to build a hotel in Tokyo. As Japan was in an earthquake zone, Wright designed the hotel to withstand shocks using a sea of mud to support the foundations. Following the Japanese earthquake of 1923, Wright’s hotel was apparently the only building left standing in Tokyo.

Once a plan has been determined, rehearse it. Trace the defect or cut a pattern to fit the defect. Transpose the pattern and experiment with it to decide on the best donor area and orientation. Omitting this step is akin to Wright building his hotel without a blueprint, and his materials were much cheaper than the surgeon’s.

Finally, the surgeon should ask him or herself "what do I do next if this fails?" Proceed to the operating room only after answering this question definitively. Once in the operating room, keep an open mind and be ready to adjust the surgical plan as the situation dictates.

Principle IV: Steal From Peter to Pay Paul
Apply the "Robin Hood" principle: steal from Peter to pay Paul, but only when Peter can afford it. Using what the body has to reconstruct a deficit is essentially "robbing the bank." The goal to achieve is ultimate efficiency, or, according to Millard, "getting something for almost nothing." Examples of local flaps illustrating Millard’s point are shown in the images below.

An interpolated flap. The donor site is separated from the recipient site, and the pedicle of the flap must pass above or beneath the tissue to reach the recipient area. (A) Flap is outlined and elevated. (B) Donor site is closed. (C) Pedicle is divided once the flap is revascularized. (D) Insetting of the flap is completed.

A rotation flap. Movement is in the direction of an arc around a fixed point and primarily in one plane. This is a semicircular flap.

A transposition flap. The rectangular flap is rotated on a pivot point. The more the flap is rotated, the shorter the flap becomes.

An advancement flap. Advancement flaps are moved primarily in a straight line from the donor site to the recipient site. No rotational or lateral movement is applied. Triangles y (Burrow triangles) have been removed lateral to the base equal to the distance of the advancement (x = y). Incisions are made into the base of the flap to assist in the advancement.

A bipedicle flap with incisions parallel to the advancement.

A V-Y advancement flap.
Do not make the naive mistake of merely advancing tissue to the deficient area unless this can be accomplished completely without tension. Tension compromises the blood supply of the advanced tissue and, ultimately, results in flap failure. Tension is to be feared the most. It must be recognized and prevented or else used to the surgeon’s advantage.

Principle V: Never Forget the Donor Area
Surgeons once believed in treating the primary defect without worrying about the secondary defect. Plastic surgery has since progressed. Plastic and reconstructive surgeons now realize the importance of considering both defects equally.

The reality is that it is not possible to get something for nothing; a price usually must be paid following reconstruction of a primary defect. The significance of providing coverage of a defect with minimal deformity and disability is one of the foremost principles on which the reconstructive surgery specialty is based.

If reconstruction of the primary defect is too costly in terms of resultant deformity or disability, reevaluate and use another reconstructive option.

Remember that donor areas are not limitless. One cannot continuously use tissue without paying back in some way. Carelessness or overuse of a donor area eventually causes damage that may be far greater than the original defect.

 

        

[Drsumitra]

The study, published in Nature Immunology, reveals that the deterioration in gum health which often occurs with increasing age is associated with a drop in the level of a chemical called Del-1.
The researchers say that understanding more about Del-1 and its effects on the body’s immune system could help in the treatment or prevention of serious gum disease.
Periodontitis is a disease of the gums which causes bleeding and bone loss which can, over time, lead to loss of teeth. It affects about 20 per cent of the UK population and is caused by an over-active immune response to bacteria that grow in the mouth.
As people age they are more likely to suffer from inflammatory diseases, including gum disease.
The new research investigated gum disease in young and old mice and found that an increase in gum disease in the older animals was accompanied by a drop in the level of Del-1. This protein is known to restrain the immune system by stopping white blood cells from sticking to and attacking mouth tissue.
Mice that had no Del-1 developed severe gum disease and elevated bone loss and researchers found unusually high levels of white blood cells in the gum tissue.
When they treated the gums of the mice with Del-1, the number of white blood cells dropped, and gum disease and bone loss were reduced.
The researchers say their findings could be the basis for a new treatment or prevention of gum disease.
Mike Curtis is Professor of Microbiology at Queen Mary, University of London, Director of the Blizard Institute and the lead on the microbiological studies in the research. He said: "Periodontitis is an extremely common problem and we know that the disease tends to be more common as we get older.
"This research sheds some light on why aging makes us more susceptible and understanding this mechanism is the first step to an effective treatment."

 

        

[drmithila]

While we may brush and floss tirelessly and our dentists may regularly scrape and pick at our teeth to minimize the formation of plaque known as tartar or dental calculus, anthropologists may be rejoicing at the fact that past civilizations were not so careful with their dental hygiene.
University of Nevada, Reno researchers G. Richard Scott and Simon R. Poulson discovered that very small particles of plaque removed from the teeth of ancient populations may provide good clues about their diets. Scott is chair and associate professor of anthropology in the College of Liberal Arts. Poulson is research professor of geological sciences in the Mackay School of Earth Sciences and Engineering.
Scott obtained samples of dental calculus from 58 skeletons buried in the Cathedral of Santa Maria in northern Spain dating from the 11th to 19th centuries to conduct research on the diet of this ancient population. After his first methodology met with mixed results, he decided to send five samples of dental calculus to Poulson at the University’s Stable Isotope Lab, in the off chance they might contain enough carbon and nitrogen to allow them to estimate stable isotope ratios.
"It’s chemistry and is pretty complex," Scott explained. "But basically, since only protein has nitrogen, the more nitrogen that is present, the more animal products were consumed as part of the diet. Carbon provides information on the types of plants consumed."
Scott said that once at the lab, the material was crushed, and then an instrument called a mass spectrometer was used to obtain stable carbon and nitrogen isotope ratios.
"It was a long shot," he said. "No one really thought there would be enough carbon and nitrogen in these tiny, 5- to 10- milligram samples to be measurable, but Dr. Poulson’s work revealed there was. The lab results yielded stable carbon and nitrogen isotope ratios very similar to studies that used bone collagen, which is the typical material used for this type of analysis."
Scott explained that the common practice of using bone to conduct such research is cumbersome and expensive, requiring several acid baths to extract the collagen for analysis. The process also destroys bone, so in many instances, it isn’t permitted by museum curators.
As for using hair, muscle and nails for such research, Scott said, "They are great, when you can find them. The problem is, they just don’t hold up very well. They decompose too quickly. Dental calculus, for better or for worse, stays around a very long time."
Scott said that although additional work is necessary to firmly establish this new method of using dental calculus for paleodietary research, the results of this initial study indicate it holds great potential.
"This is groundbreaking work," Scott said. "It could save a lot of time and effort, and also allow for analysis when things like hair, muscle and nails are no longer available.

 

        

[Drsumitra]

The potential role of periodontitis, an inflammatory disease of the gums, in the risk of cardiovascular disease, particularly ischemic stroke, has received growing attention during the last decade. A new study is the first prospective cohort study to use clinical measures of periodontitis to evaluate the association between this disease and the risk of cerebrovascular disease.
Led by Thomas Dietrich of the University of Birmingham School of Dentistry, and Elizabeth Krall of the Boston VA and the Boston University School of Dental Medicine, the study analyzed data from 1,137 men in the VA Normative Aging and Dental Longitudinal Study, an ongoing study begun in the 1960s with healthy male volunteers from the greater Boston area. A trained periodontist conducted dental exams every three years that included full mouth X-rays and periodontal probing at each tooth. Cerebrovascular disease was defined as a stroke or transient ischemic attack (TIA) and follow-up lasted an average of 24 years.
The results showed a significant association between periodontal bone loss and the incidence of stroke or TIA, independent of cardiovascular risk factors. This association was much stronger among men younger than 65 years old.
There are several possible pathways that could explain the association found in the study. There could be direct or indirect effects of the periodontal infection and the inflammatory response, or some people may have an increased pro-inflammatory susceptibility that could contribute to both cerebrovascular disease and periodontal disease.
The study found that only periodontal bone loss, which would indicate a history of periodontal disease, not probing depth, which would indicate current inflammation, was associated with the incidence of cerebrovascular disease. Also, the stronger association in younger men seen in this and other studies may indicate a pro-inflammatory susceptibility in some men that is reflected in periodontal destruction at a younger age.
The authors note that if periodontitis caused cerebrovascular disease, it could be an important risk factor, given its relatively high prevalence and the strength of the association in younger men. It is also possible that people with periodontitis may pay less attention to health in general (e.g., they may not take medications as regularly). The authors conclude: "Large epidemiologic studies using molecular and genetic approaches in various populations are necessary to determine the strength of the association between periodontitis and cerebrovascular disease and to elucidate its biologic basis."
This study is published in Annals of Neurology

 

        

[Drsumitra]

Objectives: To study whether the amount of dental
plaque, which indicates poor oral hygiene and is
potential source of oral infections, associates with
premature death from cancer.
Design: Prospective cohort study.
Participants: 1390 randomly selected healthy young
Swedes followed up from 1985 to 2009. All subjects
underwent oral clinical examination and answered
a questionnaire assessing background variables such
as socioeconomic status and smoking.
Outcome measures: Causes of death were recorded
from national statistics and classified according to the
WHO International Classification of Diseases. Unpaired
t test, c

tests and multiple logistic regressions were
used.
Results: Of the 1390 participants, 4.2% had died
during the follow-up. Women had died at a mean age
of 61.0 (62.6 SD) years and men at the age of 60.2
(62.9 SD) years. The amount of dental plaque
between those who had died versus survived was
statistically significant (p<0.001). In multiple logistic
regression analysis, dental plaque appeared to be
a significant independent predictor associated with
1.79 times the OR of death (p<0.05). Age
increased the risk with an OR of 1.98 (p<0.05) and
gender (men) with an OR of 1.91 (p<0.05). The
malignancies were more widely scattered in men, while
breast cancer was the most frequent cause of death in
women.
Conclusions: This study hypothesis was confirmed by
showing that poor oral hygiene, as reflected in the
amount of dental plaque, was associated with
increased cancer mortality.
INTRODUCTION
Dental plaque is a bacterial biofilm formed
on dental surfaces. It plays a role in the
aetiology of oral diseases such as caries and
periodontal disease but may also associate
with systemic health and diseases due to
direct or hematogenic spread of microorganisms with subsequent upregulation of
cytokines and inflammatory mediators.

The
dento-gingival region is a natural habitat for
a magnitude of oral bacteria. The average
total microscopic count of bacteria from the
dental plaque has been calculated to be up to
2.1310

/mg wet weight.

Paster et al

estimated that there are 415 species of nonspecific bacteria in the subgingival plaque,
while pyro-sequencing techniques analysing
dental plaque and saliva have shown that
even thousands of microbial species may
inhabit the oral cavity.

Carcinogenesis is a multi-step process in
which cells accumulate changes in their
genetic material giving rise to alterations
of function.

These metabolic cascades can
also be triggered byinfection and inflammation which, in fact, have been estimated to
play a role in 15%e20% of all malignancies.

Because oral infections, and periodontitis
in particular, are highly prevalent in populations, there has been interest in studyingthe eventual link between oral infections and the prevalence of cancer. Smoking is a common risk factor both
for periodontitis and in many types of malignancies;
thus, smoking needs always to be taken into account in
this context.

Our group published a study in 2007
showing that patients with periodontitis and missing
molars seem to be at increased risk for premature death
by life-threatening diseases, such as neoplasms and
diseases of the circulatory and digestive systems.
We have recently also published a study showing an
association between periodontal disease and breast
cancer, with an OR of 2.36.
The putative mechanisms
involved in the association have been further reviewed by
Meurman and Bascones-Martinez.
Considering these
observations, the hypothesis of the present study was that
dental plaque is associated with premature death in
cancer. A high amount of dental plaque indicates poor
oral hygiene and, subsequently, was thought to be
a surrogate for increased risk for dental infections.
These, in turn, by triggering systemic reactions were
thought to lead to malignant transformation in a variety
of tissues. The specific aim of this study was to investigate
the underlying causes of death in malignancies among
1390 randomly selected young Swedes who had been
clinically investigated and followed up from 1985 to
2009. The Swedish national hospital admission and
death registers were used to record cancer. Death from
cancer was considered the end point of the study.

 

        

[drmithila]

 Got a case in the clinic today where a 40 year old lady showed generalised gingivitis

But her chief complaint was that there was a slightly more inflammed area of gingiva in area of upper left lateral incisor.

this area is causing her a lot of discomfort.Local application of Gum paint was advised for few days,  but no effect was seen

The tooth is absolutely healthy

As per the planned treartment we have scheduled to perform a sub gingival currettage 

Also the patient has been informed that in case of relapse we shal perform a gingivectomy

Ant suggestions that you can give are more than welcome

        

[drmithila]

 

        

[drmithila]

By Jacqueline Russo, RN, DDS

The oral-systemic link has irrefutably been documented. As dental professionals we are all aware that the inflammation from periodontal disease is not a localized event but one with life-threatening global consequences.

So the question that confounds us is how to incorporate the research into our practices as clinical protocol. Traditional therapies alone are frustratingly ineffective at resolving periodontal disease long term. The fact that periodontal disease exacerbates every inflammatory process in our body mandates that if we want to move our patients to long term health we must address the patient systemically.

Screening for inflammatory biomarkers and oral pathogens, treating sleep apnea and having protocols for smoking cessation are lifesaving services that should be offered by dentists. Nutritional screening and counseling is another essential piece of the oral-systemic equation that cannot be ignored if we want to provide optimal care for our patients.

There is increasing evidence that the link between periodontal and other inflammatory diseases is being driven by reactive oxygen species (ROS). The presence of periodontal pathogens leads to a hyper-inflammatory state and the formation of ROS. A leading hypothesis of aging is based on the free radical theory of aging by Harman(1) who argued that oxygen-free radicals produced cumulative damage to molecules which progressively leads to loss of functionality of the organism. These same free radicals create oxidative stress induced damage to gingiva, periodontal ligament and alveolar bone.(2) There is extensive research showing that antioxidants play a vital role in minimizing oxidative damage caused by free radicals.

Iain Chappel recently published research in the JADA that stated: “Higher serum antioxidant concentrations were associated with lower odds ratios for severe periodontal disease.”Antioxidants are micronutrients sourced from our food from colorful fruits and vegetables and pharmaceutical grade supplements. A list of the best 20 food sources for antioxidants follows:

1. Small red beans

2. Wild blueberries

3. Kidney beans

4. Pinto beans

5. Blueberries

6. Cranberries

7. Artichokes

8. Blackberries

9. Prunes

10. Raspberries

11. Strawberries

12. Red Delicious, GS apples

13. Pecans

14. Sweet cherries

15. Black plums

16. Russet potatoes

17. Black beans

18. Plums

19. Gala apples

20. Walnuts

The nutrients from these foods limit oxidative tissue damage by neutralizing free radicals or ROS and preventing the oxidation of our cells. By preventing cellular and DNA damage from free radicals, we reduce the inflammatory burden on the entire body and effectively enhance immune function, and improve our patients overall health.

 

        

[drmithila]

Periodontal infection with P. gingivalis in rheumatoid arthritis (RA) patients
By M. De Smit, E. Brouwer, A. Vissink, B. Doornbos-Van Der Meer, J. Westra, A.J. Van Winkelhoff, Groningen/Netherlands

Aim: Because of the hypothesized pathogenic role of periodontal infection with P. gingivalis in RA, this study aimed to assess clinical, microbiological and serological features of both diseases in RA patients.

Material and Methods: In 95 dentate RA patients, periodontal condition was examined using the validated Dutch Periodontal Screening Index (DPSI). RA disease activity was scored with DAS28. Subgingival plaque samples were tested for presence of P. gingivalis by culture technique. Serum was investigated for IgG- and IgM- antibody titers to P. gingivalis, antibodies specific for RA (rheumatoid factor (IgM-RF) and anti-citrullinated protein antibodies (anti-CCP), and CRP levels by ELISA. Serum and subgingival plaque measures were compared to an identical control group without RA or other systemic diseases (n=44).

Results: RA patients with severe periodontitis had higher DAS28 scores (p<0.001), CRP levels (p<0.05), IgG- anti P. gingivalis titers (p<0.05) and age (p<0.01) than RA patients with no or moderate periodontitis. No differences were seen in RA disease duration, IgM-RF, anti-CCP, and IgM-anti P.gingivalis titers. Subgingival prevalence of P. gingivalis was not different in RA patients compared to the control group. RA patients with severe periodontitis showed higher IgM- and IgG- anti P. gingivalis titers (p<0.01 resp. p<0.05) compared to severe periodontitis patients without RA. There was a significant difference between P. gingivalis culture positive and negative RA patients concerning IgM- and IgG- anti P. gingivalis titers (p<0.01 resp. p<0.001), but not in controls.

Conclusion: RA patients with periodontitis have higher RA disease activity, and a more pronounced antibody response against P. gingivalis compared to non-RA patients.Effect of Periodontal Intervention on Periodontal Disease and Type 2 Diabetes Mellitus
By T.B. Taiyeb-Ali, R.P.C. Raman, R.D. Vaithilingam, S.P. Chan, Kuala Lumpur/Malaysia

Aim: To investigate effects of non-surgical periodontal intervention on metabolic control and systemic inflammatory challenge in Type 2 diabetics.

Material and Methods: Randomized, controlled clinical trial of 40 Type 2 Diabetes Mellitus (T2DM) patients with moderate-to-severe PD who were randomly distributed to either test group, receiving oral hygiene instructions (OHI) and full mouth scaling/root planing, or control group receiving OHI only. Periodontal parameters, glycosylated haemoglobin (HbA1c) and high sensitivity C-Reactive Protein (hs-CRP) were evaluated atmbaseline, 2- and 3-month intervals.

Results: All periodontal parameters improved significantly in both groups except for GBI in control group at 3-month interval. Both groups recorded a decrease in HbA1c levels but only test group had statistically significant change (p=0.038). More participants were categorized as having good metabolic control at the end of study (53.3% for test and 58.8% for control). Participants who recorded an improvement in HbA1c levels of ≥ 1% recorded statistically significant reductions in means of PI, GBI and PPD (p=0.001, p=0.008 and p=0.005, respectively). Likewise, participants who recorded good response to periodontal therapy (in terms of reduction in PPD) showed significant reductions of HbA1c and hs-CRP levels (p=0.004 and p=0.012). A reduction in s-CRP levels recorded in test group, however, did not reach statistical significance, while in control group minimal change was observed.

Conclusion: Periodontal therapy contributed to improved metabolic control in Type 2 diabetics and overall reduction of systemic inflammatory challenge. The converse was also observed. It is advocated that in approach to management of either T2DM or PD, interdisciplinary care should be considered

 

        

[drmithila]

American adults of normal weight with new-onset diabetes are more likely to die than overweight and obese adults with the same disease, according to a new study.

The study, published in the August 7 issue of JAMA, finds that normal-weight participants experienced both significantly higher total and noncardiovascular mortality than overweight or obese participants.

Normal-weight adults with type 2 diabetes have been understudied because those who typically develop the disease are overweight or obese. In this study, about 10 percent of those with new-onset diabetes were at a normal weight when they found out they had the disease.

Being overweight is a risk factor for developing this disease, but other risk factors such as family history, ethnicity, and age may play a role.

“It could be that this is a very unique subset of the population who are at a particularly high risk for mortality and diabetes, and it is possible that genetics is a factor with these individuals,” says Mercedes R. Carnethon, associate professor of preventive medicine at Northwestern University Feinberg School of Medicine and first author of the study.

Older adults and nonwhite participants are more likely to experience normal-weight diabetes, according to the study.

“Many times physicians don’t expect that normal-weight people have diabetes when it is quite possible that they do and could be at a high risk of mortality, particularly if they are older adults or members of a minority group,” Carnethon said. “If you are of a normal weight and have new-onset diabetes, talk to your doctor about controlling your health risks, including cardiovascular risk factors.”

Researchers analyzed data from five cohort studies and identified 2,625 American men and women older than 40 who were found to have diabetes at the start of the studies. Some of these individuals already knew they were diabetic, and others found out through their participation in the studies.

Diabetes determination was based on a fasting glucose of 126 mg/dL or greater or newly initiated diabetes medication with concurrent measurements of body mass index (BMI). A participant of normal weight had a BMI of 18.5 to 24.99, while overweight/obese participants had a BMI of 25 or greater.

With the aging and diversification of the population, cases of normal weight diabetes likely will be on the rise, Carnethon says. Future studies should focus on factors such as fat distribution and genetic types in normal-weight people with diabetes, she said.

This research is funded by the National Institute of Diabetes and Digestive and Kidney Disease, a part of the National Institutes of Health.

 

        

[drmithila]

The oral-systemic link has irrefutably been documented. As dental professionals we are all aware that the inflammation from periodontal disease is not a localized event but one with life-threatening global consequences.

So the question that confounds us is how to incorporate the research into our practices as clinical protocol. Traditional therapies alone are frustratingly ineffective at resolving periodontal disease long term. The fact that periodontal disease exacerbates every inflammatory process in our body mandates that if we want to move our patients to long term health we must address the patient systemically.

Screening for inflammatory biomarkers and oral pathogens, treating sleep apnea and having protocols for smoking cessation are lifesaving services that should be offered by dentists. Nutritional screening and counseling is another essential piece of the oral-systemic equation that cannot be ignored if we want to provide optimal care for our patients.

There is increasing evidence that the link between periodontal and other inflammatory diseases is being driven by reactive oxygen species (ROS). The presence of periodontal pathogens leads to a hyper-inflammatory state and the formation of ROS. A leading hypothesis of aging is based on the free radical theory of aging by Harman(1) who argued that oxygen-free radicals produced cumulative damage to molecules which progressively leads to loss of functionality of the organism. These same free radicals create oxidative stress induced damage to gingiva, periodontal ligament and alveolar bone.(2) There is extensive research showing that antioxidants play a vital role in minimizing oxidative damage caused by free radicals.

Iain Chappel recently published research in the JADA that stated: “Higher serum antioxidant concentrations were associated with lower odds ratios for severe periodontal disease.Antioxidants are micronutrients sourced from our food from colorful fruits and vegetables and pharmaceutical grade supplements. A list of the best 20 food sources for antioxidants follows:

1. Small red beans

2. Wild blueberries

3. Kidney beans

4. Pinto beans

5. Blueberries

6. Cranberries

7. Artichokes

8. Blackberries

9. Prunes

10. Raspberries

11. Strawberries

12. Red Delicious, GS apples

13. Pecans

14. Sweet cherries

15. Black plums

16. Russet potatoes

17. Black beans

18. Plums

19. Gala apples

20. Walnuts

The nutrients from these foods limit oxidative tissue damage by neutralizing free radicals or ROS and preventing the oxidation of our cells. By preventing cellular and DNA damage from free radicals, we reduce the inflammatory burden on the entire body and effectively enhance immune function, and improve our patients overall health.(6)

So how do we implement nutrition into our already busy practices?

We need to be able to measure nutritional levels in the body. We could assume that everyone is nutritional deficient, and probably be right most of the time, but that is not science. Traditionally, obtaining a biomarker for nutrition has been expensive and invasive, only blood or tissue sampling was available. However, obtaining an inexpensive and non-invasive measurement of antioxidant status is now possible with a device called the Biophotonic Scanner. This technology inexpensively and more accurately than blood serum testing can measure antioxidant status in the body in 90 seconds.

It is critical in dentistry or medicine to have a way to measure effectiveness of therapies. Up until now there have been limited ways to monitor our patients’ nutritional status so many practitioners have not understood how effective nutritional intervention can be. This technology was recently introduced on the Dr. Oz show as the ultimate nutritional lie detector test. He told the audience he was astounded by the results and the technology completely blew his mind. See the video at http://www.doctoroz.com/videos/cancer-fighting-antioxidants-pt-1.

The ability to measure and monitor nutritional status will enable us to make nutritional recommendations that will enhance our treatment outcomes and improve our patients lives. We see our patients on a more regular basis than any other health care provider. In fact, in some cases, we might be the ONLY health care provider they see. We have a unique opportunity to influence our patients to live their very best lives.
By Jacqueline Russo, RN, DDS

 

        

[Drsumitra]

A new method may be used to help treat gum disease.

A technology that utilizes controlled-release capsules filled with protein could be injected in the area between the gums and teeth. This would serve to battle the disease and limit its effects while also enabling the gum tissue to regrow. The technology was unveiled at the 244th National Meeting and Exposition of the American Chemical Society in Philadelphia.

Steven Little and the rest of the University of Pittsburgh research team experimented with this technology on mice. The results indicated that technology did promote regrowth of gum tissue.

A bacterial infection causes periodontal disease. It first shows up as tenderness and bleeding of the gums.

Many scientists are looking at alternative ways to eliminate bacteria. This technology, however, focuses on the inflammation process, which makes it unique compared to most other studies.

To successfully inject the controlled-release capsules in the gums, the research team developed protein encased in a type of plastic polymer material. The polymer releases the protein inside after breaking down. The protein is produced by the body to lure specialized white blood cells to a specific site. In prior studies, the researchers attempted to keep the cells away from the gums in an attempt to block the inflammation.

 

        

[drmithila]

A study reviewing the effect of cigarette smoking on the clinical outcomes of periodontal surgical procedures was published in the Ameri­can Journal of the Medical Sciences. Data­bases were searched from 1968 to May 2010 using various combinations of the following key words: inflammation, mu­co­­periosteal flap, perio­dontal surgery, smoking, and tobacco. The inclusion criteria included all levels of available evidence. Articles published only in the En­glish language were evaluated, and unpublished data were not sought. The study identified 24 clinical studies that met the criteria. The duration of smoking habit ranged from at least 5 years to 27.8 years. Sixteen studies showed that reductions in probing depth and gains in clinical attachment levels were compromised in smokers in comparison with nonsmokers. Three studies showed re­sidual recession after periodontal surgical interventions to be significantly higher in smokers compared with nonsmokers. Three case reports showed periodontal healing to be uneventful in smokers. The authors conclude that, based on the studies re­viewed, cigarette smoking has a negative effect on periodontal wound healing after surgical interventions.

 

        

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