Periodontal Disease

[Drsumitra]

Alendronate (ALN), an aminobisphosphonate, has been shown to inhibit osteoclastic bone resorption and is proposed to have osteostimulative properties. A study that explored the efficacy of 1% ALN gel as a local drug delivery system adjunctive to scaling and root planing (SRP) for the treatment of intrabony defects in subjects with chronic periodontitis was published recently in the Journal of Periodontology by Drs. Anuj Sharma and A. R. Pradeep. The study involved 66 intrabony defects which were treated either with 1% ALN gel or a placebo gel. ALN gel was prepared by adding ALN into carbopol-distilled water mixture. Clinical parameters of modified sulcus bleeding index, plaque index, probing depth (PD), and periodontal attachment level (PAL) were recorded at baseline, 2 months, and 6 months; radiographic parameters were recorded at baseline and 6 months. Defect fill at baseline and at 6 months was calculated on standardized radiographs using image analysis software. The study found that mean PD reduction and mean PAL gain were greater in the ALN group than the placebo group, both at 2 months and at 6 months. Significantly greater mean percentage of bone fill was found in the ALN group (40.4 ± 11.71%) compared to placebo group (2.5 ± 1.02%). The study concluded that local delivery of 1% ALN into periodontal pockets as an adjunct to SRP stimulated a significant increase in PD reduction, PAL gain, and improved bone fill as compared to placebo gel. These results could provide a new direction in the field of periodontal healing, according to the authors.

 

        

[Drsumitra]

Scientists are trying to open a new front in the battle against gum disease, the leading cause of tooth loss in adults and sometimes termed the most serious oral health problem of the 21st century. They described another treatment approach for the condition in a report at the 244th National Meeting & Exposition of the American Chemical Society in Philadelphia August 20

 

"Our technology uses controlled-release capsules filled with a protein that would be injected in the pockets between the gums and the teeth," said Steven Little, Ph.D., who reported on the research. "That’s ground-zero for periodontal disease ― ‘gum disease’ ― the place where bacteria breed and inflammation occurs. The capsules dissolve over time, releasing a protein that acts as a homing beacon. It guides immune cells to the diseased area, reducing inflammation, creating an environment that fights the disease process and even could create conditions favorable for gum tissue to regrow."
Little and colleagues, who are with the University of Pittsburgh, have evidence from laboratory experiments with mice ― stand-ins for humans in early research of this kind that cannot be done with actual patients ― that the approach does foster healing and regrowth of gum tissue damaged by periodontal disease.
A bacterial infection causes periodontal disease. It first appears as mild tenderness and bleeding of the gums. It leads to inflammation and, if left untreated, can damage the gums so that they recede and lose their attachment to the teeth. It may progress even further and damage bone and other tissues that hold teeth firmly in place. Surprisingly, gum disease has a number of deleterious effects outside the mouth, with some studies linking inflammation in the gums to an increased risk of heart disease, stroke and preterm delivery in pregnant women.
Treatment includes scaling, root planing and other procedures to remove the plaque and bacteria that have accumulated in pockets between the teeth and gums. Dentists may combine this with antibiotics to fight the bacteria involved in gum disease.
Many scientists are seeking alternative treatments that kill the bacteria. Little’s group is taking an entirely different approach. They are targeting the inflammation process. "Although bacteria start the disease, inflammation is what keeps it going and causes progressive damage," Little explained.
To reduce inflammation at the gums, Little and colleagues designed injectable controlled-release capsules containing a protein encased inside a plastic-like polymer material. The polymer is already used in medicine in dissolvable sutures. After the capsules are injected, the polymer slowly breaks down, releasing the protein encapsulated inside. The protein, termed a chemokine, is already produced by the body’s existing cells in order to summon specialized white blood cells to a specific site. Scientists previously tried to keep those cells, termed lymphocytes, away from the gums so as to block inflammation from occurring in the first place.
"It seems counterintuitive to lure in a lymphocyte, which is traditionally thought of as an inflammatory cell, if there’s inflammation," Little pointed out. "But remember that a certain level of natural inflammation is required to fight off an infection. Inflammation is inherently a good thing, but too much of it is a bad thing. That’s why we aim to restore the immune balance, or homeostasis."
Little’s team injected the capsules into mice and discovered evidence that disease symptoms are dramatically reduced and that proteins and other substances involved in regrowth of gum tissue had appeared. Little said that this finding offers encouragement that the treatment could not only rebalance the immune system, but also prompt regrowth of lost gum and bone tissue in the mouth.
The researchers acknowledged funding from the Arnold and Mabel Beckman Foundation, the Wallace H. Coulter Foundation and the National Institute of Dental and Craniofacial Regeneration of the NIH (1R01DE021058-01).

 

        

[Drsumitra]

A University of Louisville scientist discovered a way to stop the inflammation and bone loss that come from gum disease.

The researcher, David Scott, successfully accomplished this by blocking the natural signaling pathway of the enzyme GSK3b. This enzyme is a key factor in leading the immune response.

The information appears on the Internet in the journal Molecular Medicine.

This research may not only be pivotal in stopping periodontal disease but it may also be helpful when it comes to other chronic inflammatory diseases. Since GSK3b is associated with numerous inflammatory signaling pathways, it also is a factor in many other diseases. Further tests are being conducted to determine its importance in Alzheimer’s disease, Type II diabetes and some forms of cancer.

This approach differs from the normal approach in handling periodontal disease because instead of preventing plaque at the gumline, this method targets the natural mechanism to limit inflammation.

SB216763 is the enzyme that stopped the inflammation process and eventual bone loss that normally stems from GSK3b.

The next part of this study includes whether or not SB216763 has any side effects or if something else needs to be discovered to thwart GSK3b.

 

        

[drmithila]

More adults in the United States have gum disease than one would think.

A new study shows that about 50 percent of American adults age 30 and older have gum disease. The study appears in a recent issue of the Journal of Dental Research.

Periodontitis is a major problem and leads to tooth loss in many cases.

To compile the data for this study, a research team looked through data from a previous study involving 3,700 adults age 30 and older. There were 47 percent of the people who had periodontitis—9 percent had mild gum disease, 30 percent suffered from moderate gum disease and 8.5 percent had severe gum disease. According to this information, roughly 65 million American adults have gum disease.

The research also concluded that 64 percent of adults age 65 and older had some type of periodontitis that could at least be considered moderate. This estimation is much larger than previous studies have indicated, according to the lead author Paul Eke.

The study also showed that the gum disease rates were highest for males, Mexican Americans, adults with less than a high school education, adults whose income would be considered below the poverty line and people that currently smoke.

There are several warning signs for gum disease, including swollen, tender, or bleeding gums. Chronic bad breath is another sign of gum disease.

 

        

[Drsumitra]

Dr. Carla Martins et al studied whether dental calculus formation is higher among patients with chronic kidney disease un­der­going hemodialysis than among controls. Also evaluated were the links between dental calculus formation and den­tal plaque, variables that are related to renal disease and/or sal­iva composition. The renal group included 30 pa­tients un­dergoing hemodialysis; the control group included 30 clinically healthy patients. Stim­ulated whole saliva and parot­id saliva were collected. Salivary flow rate and calcium and phosphate con­centrations were determined. The saliva col­lection was carried out before and af­ter a hemodialysis session for renal pa­tients. Both patient groups received in­traoral exams, or­al hygiene in­struc­tions, and dental scaling. The dental calculus was measured 3 months later by the Volpe-Man­hold method to de­ter­mine the rate of formation. It was found that the renal group presented a higher rate of formation (P < .01). Cor­relation was ob­served between the rate of dental calculus formation and whole saliva flow rate in the renal group after a hemodialysis session (r = .44, P < .05). The presence of dental calculus was as­sociated with phosphate concentration in whole saliva from the renal group (P < .05). In conclusion, patients undergoing hemodialysis presented accelerated dental calculus formation, probably due to salivary variables.

 

        

[Drsumitra]

People with chronic gum disease seem to be slightly more likely to develop the skin condition psoriasis, according to a new study.

Taiwanese researchers found that in a group of more than 230,000 people, those with gum disease were 54 percent more likely to get psoriasis over five years.

The study is among the first to investigate the link between the two conditions and doesn’t necessarily mean gum disease can cause psoriasis.

"We don’t know very much about what the risk factors are for chronic inflammatory diseases like psoriasis," said Dr. Joel Gelfand, a dermatologist at the University of Pennsylvania in Philadelphia, who was not involved in the new research.

"This study points in a potentially new direction for a potential risk factor that – in theory – could be modified and thus lower the risk of psoriasis in the future," he told Reuters Health. "That being said, this finding needs to be confirmed by more-rigorous, more-controlled studies to determine if the findings are real."

Psoriasis is thought to be caused by a mistaken immune reaction directed at the body’s own cells, leading to inflamed patches of red, scaly skin.

It’s not the first time the condition has been linked to other health problems. Earlier this year, a study of people evaluated for heart disease found 84 percent of patients with psoriasis had coronary artery disease, compared to 75 percent of patients without the skin condition. (See Reuters Health article from January 10, 2012.)

Oral health has also been tied to other conditions, with two studies from this year finding links to heart disease and dementia. (See Reuters Health articles from April 19 and 21, 2012.)

But until now only one other study had looked at the link between psoriasis and chronic periodontitis, the advanced stage of the gum disease gingivitis.

For the new research, published in the British Journal of Dermatology, Dr. Joseph J. Keller from Taipei Medical University and his colleague turned to a database of Taiwan’s national health system.

They identified 115,365 people with gum disease, and then selected the same number of people without the condition. The researchers then looked through the database to see how many people in each group developed gum disease over the next five years.

In the group with gum disease, 1,082 developed psoriasis, while 706 did in the comparison group. That works out to about 1.9 in 1,000 people versus 1.2 in 1,000, respectively.

According to the researchers, their findings may challenge some of what is known about psoriasis’s underlying cause, but they caution their study has some limitations.

Specifically, they were not able to account for certain factors that could have played a role, such as cigarette smoking. And until the findings are confirmed, Gelfand said, people with gum disease should not be alarmed.

 

        

[drmithila]

November is American Diabetes Month, and the New Jersey Society of Periodontists (NJSP) is spreading awareness about the link between periodontal disease and diabetes.
“If you have diabetes, you are at higher risk for developing infections, including periodontal disease,” said Scott Zirkin, DDS, president of the NJSP. “These infections can impair the ability to process and/or utilize insulin, which may cause your diabetes to be more difficult to control and your infection to be more severe than a person [without] the disease.”

People with diabetes are more likely to have periodontal disease than people without diabetes, most likely because they are more susceptible to contracting infections, according to the NJSP. In fact, periodontal disease is often considered the sixth complication of diabetes, and those people who don’t have their diabetes under control are especially at risk.

“We are very much aware of the link between periodontal disease and diabetes and understand the importance of the collaborative care of a periodontist and a physician,” said Gina Murdoch, executive director of American Diabetes Association, New Jersey Area, in an NJSP news release.

        

[drsushant]

– Mass spectrometry presents a unique method for analyzing gingival crevicular fluidas a source of biomarkers for predicting periodontal disease progression, according to a new study in the Journal of Periodontal Research (October 11, 2012).

Researchers from the University of Melbourne used mass spectrometry to examine the relationship between the relative amounts of proteins and peptides in gingival crevicular fluid and their relationship with clinical indices and periodontal attachment loss in periodontal maintenance patients.

They followed 41 periodontal maintenance subjects over a one-year period, with clinical measurements taken at baseline and three-month intervals thereafter. Gingival crevicular fluid was collected from the subjects at each visit and was analyzed using matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry.

Samples were classified based upon pocket depth, modified gingival index (MGI), plaque index, and attachment loss. A genetic algorithm was used to create a model based on pattern analysis to predict sites undergoing attachment loss.

Using this method, the study authors analyzed 385 gingival crevicular fluid samples. Twenty-five sites under observation in 14 patients exhibited attachment loss of more than 2 mm over the 12-month period, they reported. They found that clinical indices pocket depth, MGI, plaque levels, and bleeding on probing were poor discriminators of gingival crevicular fluid mass spectra. However, models generated from the gingival crevicular fluid mass spectra were able to predict site-specific attachment with high specificity (97% recognition capability and 67% cross-validation), they noted.

“The use of algorithm-generated models based on gingival crevicular fluid mass spectra may provide utility in the diagnosis of periodontal disease,” the researchers concluded.

        

[Drsumitra]

Written by Debra Seidel-Bittke, RDH, BS

Periodontal disease is an inflammatory disease that affects the soft and hard tissues that support the teeth. The early stage of this disease is gingivitis. In later stages, the teeth may become loose, and the bone surrounding the teeth can degenerate. The most advanced stage of periodontitis is termed chronic periodontitis.1 Major risk factors for this disease include an inherited or a genetic predisposition, smoking, lack of routine home care, age, diet, certain systemic diseases, and various medications.2

Any time bleeding is present, pathological change is occurring in your patient’s mouth that needs to be evaluated and appropriately treated sooner rather than later. When periodontal disease is present, the potential for bone loss has already begun. Depending upon the patient’s risk factors, bone loss can occur quickly and become aggressive very easily. In patients with few or no risk factors, periodontal disease can be reversed with early nonsurgical intervention.3 With this knowledge, a patient will be much more likely to say yes to your treatment plan.

Phase 1 treatment is complete after the patient undergoes scaling and root planing, followed by a successful postoperative report from the 6-week re-evaluation appointment. This 6-week re-evaluation appointment is the first of the SPT appointments. During the early stage of periodontal disease and at the end of phase 1, the periodontium has the best chance to reverse the diseased state and, in many cases, halt the progression of further oral and systemic disease. Patients need to know, however, that this is not the end of the story. After phase 1 therapy is complete, a patient is now and forever considered a periodontal patient, which means regular SPT is a must to prevent active disease. A regular prophy just won’t do. If your patient were to ask, alternating prophylaxis appointments with SPT appointments is not appropriate and should not be considered as an appropriate phase for future treatment. Bone loss is not reversible, and it is imperative that patients understand this. Removal of the biofilm and microbiological factors also becomes very important for future health of the patient.4

For years, we have understood that periodontal disease is episodic. Make sure your patients understand what that means. It is another key point to use when explaining why regular periodontal maintenance is crucial. Periodontal pathogens will repopulate a healthy and recently scaled sulcus as early as 9 to 12 weeks post-scaling.5 That means a patient can brush and floss all day long, or even see the dental hygienist every 3 months; yet this may not be enough to prevent the return of periodontal pathogens. Without these pathogens removed, bone loss is likely to continue. Other clinical studies have shown that even with the supragingival environment as the single source for colonizing bacteria, a complex subgingival microbiota can develop within one week.6

You can strengthen your case for preventive care even more when your patient is aware that oral health affects the whole body. Countless studies have emerged during recent years suggesting a strong link between periodontal health and systemic health. For example, when patients with Crohn’s disease receive the appropriate treatment for periodontal disease, research reports a decrease in the enzymes that would normally increase inflammation in the sulcus—and the body.7 In addition, much research states that when a patient with type 2 diabetes mellitus is diagnosed with periodontal disease, nonsurgical periodontal therapy was associated with improved glycemic control.8 The role of the dental hygienist becomes extremely valuable when patients’ teeth are not merely "cleaned." Scaling, root planing, and various adjunct chemotherapeutic intervention along with lasers can improve a patient’s oral health8,9 and thus may actually help a patient live a longer, healthier life.

Your chances of getting a yes to nonsurgical periodontal therapy and routine SPT appointments will increase when patients understand the vital link between their oral health and systemic health. On that note, what’s even more effective is to share science’s good news. Decades of research and advances in periodontal therapy have proven that the majority of patients who receive routine preventive care can retain their dentition throughout their lifetimes.10 Many patients who do routine, long-term, supportive, nonsurgical therapy can maintain optimal gingival health that is free from reinfection.

If you have your patients’ attention at this point, they will probably want to know how often they need to come in for periodontal therapy. Although each patient will need an individualized treatment plan, dental hygiene appointments for routine preventive care will ideally range from 2- to 6-month intervals.11 Presenting the scientific evidence to patients takes good communication, and their understanding will leap forward, giving them a reason to sit up, listen, and take action, saying, "Yes!" to case acceptance of nonsurgical periodontal treatment.

LEAVE A LASTING IMPRESSION WITH STELLAR PATIENT EDUCATION
Now, you must bridge the gap between the hard science and your patients. So that you don’t overwhelm patients with heaps of unorganized scientific facts from your stream of consciousness, use a 3-step approach to present the information in support of your argument to partake in routine supportive periodontal therapy.

First, give patients the disease facts, focusing on tooth/bone loss and systemic health. This is also a good time to discuss risk factors for periodontal disease. Effectively communicate using words your patients will understand when you talk about the periodontal disease process. Not only is tooth loss a fact in their future, but also their health and longevity is at stake if they do not follow the appropriate treatment plan. Back up your facts with brochures, posters, iPad apps, etc, to show patients the importance of optimal oral health in relationship to their total overall health. Mention the risk factors and systemic disease links and highlight their specific risk factors in the information they will take home with them. Explain the complications that arise when periodontal health declines—and explain how easily this can happen without proper treatment and regular supportive periodontal therapy.

Second, when a diagnosis is established that calls for something other than a prophy, take the time to describe the treatment plan with your patients. Outline the treatment process with patients, step by step. You might even share with them a visual aid that shows the drastic difference between a prophy and periodontal therapy, or healthy versus diseased gums, such as the chart12 in Table 2 (Figures 1 to 13). To enhance an engaging communication process, ask open-ended questions, such as, "How do you feel about this treatment approach?" and "What are your concerns?" Then, invite the patient to ask questions. This is all part of the buy-in.

Finally, explain that periodontal disease is episodic and what that means.13 Tell patients that from this point forward, they need to return every 12 weeks, or at frequent, appropriate intervals when SPT is required. Explain that patients may appear healthy for many years after completing scaling and root planing, but the disease process can return at any time. Occasionally, patients may need to go from supportive periodontal therapy back to scaling and root planing. This is an example of the episodic process of periodontal disease, specifically when patients have certain risk factors.

Even with a 3-step approach, talking science isn’t always easy, but there are some creative ways to deliver a powerful message to your patients. Begin by sitting down as a team to discuss and understand the various personality styles of your patients. Then, develop scripts and practice a dialogue between the hygienist and various types of patients. Understand what words are important to your various types of patients and what may be considered hot buttons for your patients. For example, words such as "irreversible," "tooth loss," "bone loss," "pus," etc, are likely to grab their attention. Remember to take out words such as "cleaning" from your vocabulary with patients, and use words such as "preventive care," "supportive therapy," or "periodontal maintenance." Know the various types of words you can use with your individual patients, their health IQ, and their different personality styles when you communicate with them.

Know what motivates your patients. For instance, cosmetic issues are a huge motivator for many. If these patients understand that tooth loss or unsightly teeth and gums are in store for them, they might ask you to schedule an appointment right away. Other patients are motivated by health issues, so one of your scripts might be for the "health-conscious person." Another example is the patient motivated by money. At first, suggesting periodontal therapy may sound counter-productive to this kind of patient, but if you take a preventive angle, you can explain that the patient will save a lot of money in the long run by avoiding costly surgeries and other systemic health complications that may require numerous doctor appointments, pharmaceuticals, and even hospital visits.

Also take time with your team to list all the possible reasons a patient might say no. Then, brainstorm creative ways to counter the argument from your patient. Brainstorm as many personality types as you can, what motivates them, and push those buttons with them. After writing your scripts, practice with each other before you begin this new method of effective communication.

Alongside your script writing, brush up on your scientific knowledge and your ability to deliver it in everyday language. Have each member of the hygiene team bring in information about periodontal disease, risk factors, the oral health-systemic link, etc, and present a few key findings in 5 minutes or less, without looking at notes. Remember, you’re practicing for face time with a patient in a conversational situation. If you have only one hygienist, ask other teammates to participate in this exercise. Set a goal for everyone on the team to understand and embrace how treatment of periodontal disease can benefit a patient and mitigate various risk factors.

Many patients relate well to understanding the science. Some patients will want to know all the details about the disease, the treatment, and cause of this oral health challenge. Because of this, it can be valuable to have the hygiene team educate the entire team about subgingival recolonization of bacteria. Your team may want to spend some time with your local periodontist to learn about how subgingival microflora changes over time. At the same time, you can learn what your local periodontist expects from your office, when to refer, and when the periodontist wants to see a patient. This is another relationship-building opportunity. Set a goal for everyone on the team to truly understand the science and the oral-systemic link. Bottom line: every team member needs to be able to effectively explain the periodontal process and treatment goals to patients.

In addition, take time with your team to discuss your current patient needs. Create various scenarios, including real-life patient situations, and role play as a team. In this exercise, evaluate and discuss your team’s strengths and weaknesses in communicating the appropriate information. Practice until you are certain your communication skills will help patients understand what they need to do to be healthy and what it takes to get a yes to case acceptance.

The takeaway: You can educate your patients to a higher oral health IQ when you follow these suggestions—and you will get more patients to answer yes to the correct treatment plan. As a result, you will spend less time doing nonproductive scaling and have more time for other services that add profits to the practice and wow your patients. This is the true value of a dental hygiene appointment and providing more than "just a cleaning."

 

        

[drmithila]

Because periodontal disease is not evenly distributed in the mouth, prevalence estimates from surveys using PMPE protocols may have underestimated the severity of the disease within the U.S. population by as much as 50%, the American Academy of Periodontology (AAP) noted in a press release. The 2009-2010 NHANES survey collected measurements from six sites per tooth for all teeth (except third molars) in U.S. adults.

The AAP has been working closely with the CDC since 2003 to determine the extent, severity, and prevalence of periodontal disease in the U.S.

“This is the most accurate picture of periodontal disease in the U.S. adult population we have ever had.”
— Pamela McClain, DDS, president, American Academy of Periodontology
“We know that periodontal disease can be very site-specific, so unless you look at the entire mouth and assess each tooth, you could miss severe disease,” Pamela McClain, DDS, president of the American Academy of Periodontology (AAP) and a practicing periodontist in Aurora, CO, told DrBicuspid.com. “Unless you are doing a comprehensive exam where you are probing at least six sites on every tooth, you are not getting an accurate picture of that patient’s periodontal health.”

The AAP collaborated with the CDC to help the agency develop a more accurate assessment of periodontal disease, she added.

“We now have a precise measure of the prevalence of periodontal disease and can better understand the true severity and extent of periodontal disease in our country,” Dr. McClain said. “This is the most accurate picture of periodontal disease in the U.S. adult population we have ever had.”

Disparities among certain populations

The data in the JDR study indicate prevalence disparities among certain segments of the U.S. population. Periodontal disease is higher in men than women (56.4% versus 38.4%) and is highest in Mexican-Americans (66.7%) compared with other races. Other segments with high prevalence rates include current smokers (64.2%); those living below the federal poverty level (65.4%); and those with less than a high school education (66.9%).

“We have demonstrated a high burden of periodontal disease in the adult U.S. population, especially among adults 65 and older,” said lead study author Paul Eke, MPH, PhD, a CDC epidemiologist, in an AAP press release. “Periodontal disease is associated with age, and as Americans live longer and retain more of their natural teeth, periodontal disease may take on more prominence in the oral health of the U.S adult population.”

Co-author Robert Genco, DDS, PhD, a distinguished professor at the State University of New York at Buffalo and past president of the American Association for Dental Research and the International Association for Dental Research, believes these findings elevate periodontal disease as a public health concern.

“We now know that periodontal disease is one of the most prevalent noncommunicable chronic diseases in our population, similar to cardiovascular disease and diabetes,” he said.

The 2009-2010 NHANES periodontal disease data support the need for comprehensive periodontal evaluations performed annually by a member of the dental team, including a dentist, dental hygienist, or periodontist, Dr. McClain added. This includes examining every tooth and measuring both attachment loss and probing depth to get the most accurate assessment of periodontal disease.

“Many of our patients have periodontal disease and do not know it,” she stated. “As dental professionals, it is more important than ever that we provide patients with a comprehensive periodontal evaluation annually to determine their disease status.”

        

[Drsumitra]

Numerous studies have shown that pregnant women are susceptible to periodontal disease. Now new research (Archives of Gynecology and Obstetrics, May 3, 2011) finds that dentists can target those at high risk by asking a simple question: Do you have tooth mobility and/or swollen gums?
Pregnant and postpartum women are at higher risk of developing periodontal diseases because elevated levels of progesterone and estrogen during pregnancy enhance inflammatory response, altering the gingival tissue, according to lead author Alessandro Villa, DDS, from the department of medicine, surgery, and dentistry at the University of Milan.

Dr. Villa first became interested in this research when reports came out of a possible association between periodontal disease and adverse pregnancy outcomes.

"We thought that this was a new, interesting world to explore," Dr. Villa said. "In addition, we thought that it would be interesting to investigate oral hygiene levels and practices among pregnant women."

To understand oral hygiene practices and periodontal symptoms among postpartum women and assess whether self-reported periodontal symptoms are correlated with a clinical diagnosis of periodontal disease, Dr. Villa and her colleagues developed a questionnaire to assess socio-demographic information, oral hygiene habits, and frequency of dental visits. Additional questions included information on self-reported periodontal symptoms.

The authors looked at data collected from 409 postpartum women between the ages of 20 and 44 who were approached on the postnatal ward of the Hospital Policlinico, Mangiagalli and Regina Elena in Milan.

Relevant data on pregnancy care and outcome were sourced from the medical records of each woman and her infant. Finally, all women received a full-mouth dental and periodontal examination.

Among the study findings:

More than 99% of the participants brushed their teeth every day.
Approximately 15% of women brushed their teeth for more than three minutes per day, 64% from one to three minutes, and 21% for one minute.
Participants most frequently reported going to the dentist annually (59.9%), although a relatively high proportion attended only when in pain (34.7%).
Periodontal disease was present in about 61% of women.
Patients with gum swelling and tooth mobility were almost twice as likely to have periodontal disease.
No associations were found between periodontal disease, gum swelling PTB, and/or LBW.
"We found that only around 50% of the women brushed their teeth more than once a day and 35% seek oral care from a dentist only when they experience pain, thus making prevention less possible," Dr. Villa noted.

At a minimum, healthcare providers should advise pregnant women about proper oral care, she added.

"It was interesting to note that self-reported gum swelling and tooth mobility during pregnancy may correspond to the presence of periodontal disease," Dr. Villa said. "Both dentists and prenatal medical care providers may target pregnant women who might be at higher risk for periodontitis by asking whether they have swollen gums and/or tooth mobility."

This simple question may be useful to promote oral health and good oral hygiene practices among women, she said.

The study authors evaluated previous studies that collected data on periodontal symptoms and found that none of them asked the pregnant women if they had experienced tooth mobility or reported a sensation of swollen gums.

Medical care providers are in a good position to play a major role in preventing periodontal diseases, Dr. Villa said. For example, they could help their patients develop behavioral patterns such that they brush teeth more often and visit a dentist regularly for preventative measures.

"Even though we did not find any association, past research has tied poor dental health to increased risk of adverse pregnancy outcome," the authors concluded. "[Thus], in the absence of definitive data on the association between periodontitis and adverse pregnancy outcome, clinicians should educate pregnant women about the importance of maintaining a good standard for oral health."

 

        

[drmithila]

A new study in the Journal of Periodontology (June 15, 2012) has added clinical support to recent publications suggesting a need for standardizing the terminology used in diagnosing periodontitis.
“An issue in periodontitis diagnosis is the lack of a single consensus document where all the information needed to form a diagnosis is contained,” the study authors wrote. “Hence, a ‘gold standard’ for diagnosis of periodontitis is lacking.”

The idea for the study arose from discussions with periodontal thought leaders, study author Frederick Curro, DMD, a clinical professor at the New York University College of Dentistry, told DrBicuspid.com.

“The study was initiated to assess the consistency of periodontal diagnosis by general practitioners,” he explained.

Randomized case presentation

The randomized case presentation study consisted of 10 case scenarios ranging from periodontal health and gingivitis to mild, moderate, and severe periodontitis, and included 130 members of the Practitioners Engaged in Applied Research and Learning (PEARL) network, in which member dentists conduct practice-based research pertaining to clinical issues of everyday practice.

Standard information for each case included probing depth, bleeding upon probing, bone loss, furcation involvement, mobility, clinical attachment loss, and presence of inflammation. For each case, participants were asked to signify their diagnosis from periodontal health, gingivitis, and mild, moderate, and severe periodontitis, or, alternatively, referral to a specialist for the diagnosis.

“This finding points to a need for consensus in diagnostic terminology in dentistry.”
— Frederick Curro, DMD
After respondents were asked for their diagnosis of the described cases, the diagnoses were compared with two existing classifications of periodontal disease status.

The authors found “demonstrable variations” in periodontal assessment among the 130 PEARL general practitioners who participated in the survey. The range of agreement among dentists for all 10 case presentations was 55% to 88% representing the cases described from health to severe periodontitis. The highest agreement for diagnosis among dentists (88%) was for severe periodontitis. The highest percentage of variation was found in cases with health and gingivitis.

“Our findings suggest that the lack of consensus in the definitions of periodontitis may have contributed to the variation in diagnosis by the practitioners,” the authors wrote.

This variation may affect treatment outcomes, they cautioned.

Dr. Curro expressed surprise at these findings and said he and his co-authors were expecting more agreement on cases.

“This finding points to a need for consensus in diagnostic terminology in dentistry,” he said.

The variation in terminology has been noted in recent literature reviews on periodontal disease, but no direct clinical study data exist about the effects of this on practicing dentists, he added. This is the first clinical data demonstrating potential impact of the variation in terminology.

PEARL dentists are screened prior to becoming members and represent a percentage of dentists who would be more engaged in the profession, which means the data in this study represent the most favored presentation, Dr. Curro noted.

A coding disconnect

The historical basis for this variation of a periodontal diagnosis is based on the coding of dental procedures for reimbursement purposes, the study authors wrote. Dentists are required to treatment plan using the Code on Dental Procedures and Nomenclature (CDT Code), Dr. Curro noted.

While diagnosis occurs as part of the decision to treat, it is not required to be documented, he added. However, medicine requires diagnosis codes for every oral health encounter.

An oral health diagnosis for a hospital or medical encounter is made using the International Classification of Disease, the study authors wrote. Dentistry currently has a disconnect between procedure codes (CDT) and diagnosis codes (ICD), which only confounds the issue of terminology.

“Being aware of the systems used in medicine, as well as the professional association guidelines is good practice,” Dr. Curro concluded. “This study will hopefully give practitioners the background to understand the dilemma they may face due to variation in terminology that exists in dentistry.”

A consensus of standardized terms related to periodontal health states, risk assessment, and diagnosis codes may increase diagnosis accuracy, which could result in additional health and cost savings, he and his co-authors concluded.

“If a patient is treated for periodontitis when they merely have gingivitis, this may have significant costs associated with it,” they wrote. “Alternatively if a patient is treated for gingivitis when they have periodontitis, this may be associated with adverse oral health outcomes.”

        

[Drsumitra]

Scientists from the University of Pennsylvania have demonstrated the ability to both prevent periodontitis from developing and halt the progression of the disease once it has developed, according to study in the Journal of Immunology, (December 1, 2012, Vol. 189:11, 5442-5448).

In the study, led by Toshiharu Abe, a postdoctoral researcher in the department of microbiology in Penn’s School of Dental Medicine, the researchers impacted periodontitis by blocking a molecular receptor that bacteria normally target to cause the disease in a mouse model.

In previous research, Abe’s colleagues showed that Porphyromonas gingivalis, the bacterium responsible for many periodontitis cases, acts to "hijack" a receptor on white blood cells called C5aR. The receptor is part of the complement system, a component of the immune system that helps clear infection but can trigger damaging inflammation if improperly controlled.

By hijacking the receptor, P. gingivalis subverts the complement system and handicaps immune cells, rendering them less able to clear infection from the gum tissue, according to the researchers. As a result, numbers of P. gingivalis and other microbes rise and create severe inflammation. According to a study published last year by the Penn researchers, mice bred to lack C5aR did not develop periodontitis.

Meanwhile, other studies by the Penn group and others have shown that Toll-like receptors (TLRs) — a set of proteins that also activate immune cell responses — may act in concert with the complement system. In addition, mice lacking one form of TLR called TLR2 do not develop bone loss associated with periodontitis, just like the C5aR-deficient mice.

In the new study, the Penn team wanted to determine if the synergism seen by other scientists between the complement system and TLRs was also at play in this inflammatory gum disease. To find out, they injected two types of molecules, one that activated C5aR and another that activated TLR2, into the gums of mice.

When only one type of molecule was administered, a moderate inflammatory response was apparent a day later, but when both were injected together, inflammatory molecules increased dramatically — soaring to levels higher than would have been expected if the effect of activating both receptors was merely additive.

This finding suggested to the scientists that the Toll-like receptor signaling was somehow involved in "cross talk" with the complement system, serving to augment the inflammatory response. They wondered whether blocking just one of these receptors could effectively halt the inflammation that allows P. gingivalis and other bacteria to thrive and cause disease.

Testing this hypothesis, the researchers synthesized and administered a molecule that blocks the activity of C5aR, to see if it could prevent periodontitis from developing. They gave this receptor "antagonist," known as C5aRA, to mice that were then infected with P. gingivalis. The C5aRA injections were able to stave off inflammation to a large extent, reducing inflammatory molecules by 80% compared with a control and completely stopping bone loss.

And when the mice were given the antagonist two weeks after being infected with P. gingivalis, the treatment was still effective, reducing signs of inflammation by 70% and inhibiting nearly 70% of periodontal bone loss.

Regardless of whether the researchers administered the C5a receptor antagonist before the development of the disease or after it was already in progress, their results showed that they were able to inhibit the disease either in a preventive or a therapeutic mode, they noted.

The results are significant for extending these findings to a potential human treatment, as treatments would most likely be offered to those patients already suffering from gum disease.

 

        

[Drsumitra]

A new systematic review has found that pregnant women who are at high risk for preterm birth and have periodontal disease may be able to lower their risk by getting scaling and root planing (SRP) treatment (Journal of Periodontology, December 2012, Vol. 83:12, pp. 1508-1519).

While previous studies have shown an association between preterm labor and periodontitis in pregnant women, the relationship is still under investigation, and a link has not been clearly established, noted the study authors, from the Harvard School of Dental Medicine, Dartmouth Medical School, and Dartmouth Institute for Health Policy and Clinical Practice.

If prenatal treatment of periodontitis is effective for preventing prematurity, increased availability of treatment could result in significant healthcare cost savings, they added.

"The connection between periodontitis and general health is of great interest," study author Nadeem Karimbux, DMD, an associate professor in the department of oral medicine, infection, and immunity at the Harvard School of Dental Medicine, told DrBicuspid.com. "A study like this captures all that is known about the topic to date."

Benefits outweigh potential harm

Dr. Karimbux and his colleagues performed a systematic review and meta-analysis of randomized controlled trials to evaluate the efficacy of SRP in reducing preterm birth and the risk of low birth weight. They also analyzed key subgroups and further explored heterogeneity and bias risks in the pooled studies.

They searched the Cochrane Library (from 1990 to September 2011), Medline (from 1950 to September 2011), Cumulative Index to Nursing and Allied Health Literature (CINAHL, from 1980 to September 2011), the University of Michigan School of Dentistry’s Dentistry and Oral Sciences database (from 1990 to September 2011), conference proceedings, and the ClinicalTrials.gov database. The final search update was performed on September 19, 2011.

After abstract review, 12 studies were identified by the search, and 11 were included in the main meta-analysis. Overall quality and design of included studies were fair or good.

Selection criteria included randomized controlled trials that reported preterm-birth risk (less than 37 weeks) outcomes, compared SRP treatment to either placebo or no treatment in pregnant patients with periodontitis, and had a probing depth of more than 4 mm or clinical attachment loss greater than 2 mm for one or more sites. Studies followed all participants through delivery or loss of pregnancy. Infant gestational age was a required outcome.

The researchers found that the clinical benefits of treating chronic periodontitis in pregnant women who are at a high risk of preterm delivery outweigh the potential harms.

"Although periodontal treatment is not universally effective, there is little indication of clinically significant harms from treatment or, at least generally, no excessive overall attrition or statistically increased preterm birth in any study," the study authors wrote.

The main implication of these findings is that, for the general population undergoing pregnancy, there is not sufficient evidence to support the need for periodontitis treatment to reduce the risk of preterm birth, they noted.

However, a posthoc subgroup analysis of the study findings indicated a statistically significant association between the treatment of periodontitis and reduction in the risk of preterm birth for groups with high risks of preterm birth, they added.

The fact that women who have other risk factors for preterm or low-birth-weight babies and also have chronic periodontitis can lower that risk by having scaling and root planing is new information that has not been reported before, according to Dr. Karimbux.

"Dentists can use these findings in their everyday practice to educate their pregnant patients, as well as their fellow physicians, and maybe improve the systemic health of some patients," he added.

Additional research

Another recent systematic review that evaluated whether maternal periodontal disease treatment can reduce preterm birth and/or low-birth-weight incidence found that treatment did not decrease risk (Journal of Periodontology, October 2011, Vol. 38:10, pp. 902-914).

Of the 13 randomized controlled trials that provided data, only five were considered to be at a low risk of bias. And although the results of eight studies showed that treatment may reduce risk, the meta-analysis showed contrasting results. The influence of specific aspects such as disease diagnosis, extension and severity, and the success of treatment should be evaluated further, wrote the authors of that study.

Meanwhile, the authors of the current review noted that their analysis indicates a statistically significant effect in reducing risk of preterm birth for SRP in pregnant women with periodontitis for groups with a high risk of preterm birth only.

"Future research should attempt to confirm these findings and further define groups in which risk reduction may be effective," they concluded.

 

        

[drmithila]

A new diagnostic platform enables the pathogens to be detected quickly, enabling dentists to act swiftly to initiate the right treatment.
Bleeding gums during tooth brushing or when biting into an apple could be an indication of periodontitis, an inflammatory disease of the tissues that surround and support the teeth. Bacterial plaque attacks the bone, meaning teeth can loosen over time and in the worst case even fall out, as they are left without a solid foundation to hold them in place. Furthermore, periodontitis also acts as a focal point from which disease can spread throughout the entire body: If the bacteria, which can be very aggressive, enter the bloodstream, they can cause further damage elsewhere. Physicians suspect there is a connection between periodontitis pathogens and the sort of cardiovascular damage that can cause heart attacks or strokes. In order to stop the source of inflammation, dentists remove dental calculus and deposits from the surface of teeth, but this is often not enough; particularly aggressive bacteria can only be eliminated with antibiotics.

Of the estimated 700 species of bacteria found in the mouth cavity, there are only eleven that are known to cause periodontal disease in particular; of these, some are deemed to be severely pathogenic. If these biomarkers are present in the gingival sulcus – the small gap around the base of the tooth – then the patient is at high risk of a severe form of periodontitis. But the only way to find out is by conducting a bacteria test. The problem is that current methods for identifying pathogens are time-consuming and must be carried out in an external contract laboratory. Conventional bacterial analysis using microbial culture carries the risk of bacteria being killed as soon as they come into contact with oxygen.
A new mobile diagnostic platform is designed to speed up identification of the eleven most relevant periodontitis pathogens considerably. Scientists at the Fraunhofer Institute for Cell Therapy and Immunology IZI in Leipzig have collaborated with two companies, BECIT GmbH and ERT-Optik, to develop a lab-on-a-chip module called ParoChip. In future this will allow dentists and medical labs to prepare samples quickly and then analyze the bacteria. All the steps in the process – the duplication of DNA sequences and their detection – take place directly on the platform, which consists of a disk-shaped microfluidic card that is around six centimeters in diameter. “Until now, analysis took around four to six hours. With ParoChip it takes less than 30 minutes. This means it’s possible to analyze a large number of samples in a short amount of time,” says Dr. Dirk Kuhlmeier, a scientist at the IZI.

The analysis is conducted in a contactless and fully automated manner. Samples are taken using sterile, toothpick-shaped paper points, after which the bacteria are removed from the point and their isolated DNA injected into reaction chambers containing dried reagents. There are eleven such chambers on each card, each featuring the reagent for one of the eleven periodontal pathogens. The total number of bacteria is determined in an additional chamber, via polymerase chain reaction (PCR). This method allows millions of copies of even tiny numbers of pathogen DNA sequences to be made. In order to generate the extremely quick changes in temperature that are required for PCR, the disk-shaped plastic chip is attached to a metal heating block with three temperature zones and mechanically turned so it passes over these zones. This causes a fluorescent signal to be generated that is measured by a connected optical measuring device featuring a fluorescence probe, a photo detector and a laser diode. The key benefit is that the signal makes it possible not only to quantify each type of bacterium and thus determine the severity of the inflammation, but also to establish the total number of all the bacteria combined. This enables doctors to fine-tune an antibiotic treatment accordingly.

“As the connected optical measuring system allows us to quantify bacteria, ParoChip is also suited to the identification of other bacterial causes of infection, such as food-borne pathogens or those that lead to sepsis ,” says Kuhlmeier, who goes on to emphasize further advantages of the compact diagnostic platform: “Using ParoChip does away with many of the manual steps that are a necessary part of current bacteria tests. The synthetic disks can be produced cheaply and disposed of after use in the same way as disposable gloves.” Already available as a prototype, ParoChip is initially intended for use in clinical laboratories; however it could also be used by dentists to carry out inhouse analysis of patient samples in their own practice

        

[Author]

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