Association of periodontal disease treatment with mortality in patients with dementia: a population-based retrospective cohort study (2002-2018).

Dementia is one of the leading causes of death worldwide. In this study, we analyzed the association of periodontal treatment with the risk of death in patients with dementia. The analyzed data were obtained by linking the National Health Insurance Corporation claims data between 2002 and 2018 to the Statistics Korea death registry. In total, 1,131,406 patients with dementia aged ≥ 65 years had undergone dental treatment during the study period. Time-dependent Cox proportional hazards model was performed. The mortality rate was approximately 10% among the patients with dementia. The 17-years cumulative survival rates for patients who received periodontal treatment and their untreated counterparts were 83.5% and 71.5%, respectively. The crude hazard ratio of the periodontal group was approximately twice as high as that of the non-periodontal group (1.99; P < 0.001). Furthermore, in the regression model that was adjusted for socio-demographic variables and systematic chronic diseases, the risk of death in the non-periodontal group was approximately 1.83 times higher than that of the periodontal group (P < 0.00). These findings suggest that preventive periodontal treatment may decrease mortality risk in older people with dementia.

Knowledge and Practice Behaviours of Obstetricians/Gynecologists and Midwives Concerning Periodontal Health and Pregnancy.

PURPOSE: The purpose of the present study was to evaluate the level of knowledge of prenatal health professionals concerning the relationship between periodontal diseases and pregnancy complications, as well as their professional implications in the oral health field. MATERIALS AND METHODS: A questionnaire was distributed to obstetricians/gynecologists, interns specialised in obstetrics/gynecology, midwives, and student midwives at Loire Atlantique and Vendée hospitals (France). The questionnaire included 5 sociodemographic questions and 14 questions regarding the level of knowledge about the relationship between periodontal diseases and pregnancy complications as well as the professionals' level of involvement in oral health care. RESULTS: Twenty-three obstetricians/gynecologists and 55 midwives responded to the questionnaire. Preterm delivery and chorioamnionitis were the most frequently mentioned complications of pregnancy, whereas the risk of pre-eclampsia was rarely mentioned. Half of the professionals said they were aware of the oral manifestations of pregnancy. Gingivitis and an increased risk of caries were the most frequently mentioned items, whereas epulis was the least frequently mentioned item. The level of involvement of prenatal care practitioners in oral health care was limited due to a lack of competence and time. Nevertheless, 64% of the participants discussed the risks of poor oral hygiene with their patients. CONCLUSION: There is good knowledge among French gynecologists/obstetricians and midwives regarding the oral manifestations of pregnancy. However, there is still a lack of knowledge concerning the links between periodontal diseases and pregnancy complications. The involvement and behaviour of pregnancy professionals in the oral health field is inadequate. The present survey highlights the need to improve the initial and continuing education of obstetricians and midwives on this topic.

Pharmacological Therapies for the Management of Inflammatory Bone Resorption in Periodontal Disease: A Review of Preclinical Studies.

Periodontitis, a highly prevalent multicausal chronic inflammatory and destructive disease, develops as a result of complex host-parasite interactions. Dysbiotic bacterial biofilm in contact with the gingival tissues initiates a cascade of inflammatory events, mediated and modulated by the host's immune response, which is characterized by increased expression of several inflammatory mediators such as cytokines and chemokines in the connective tissue. If periodontal disease (PD) is left untreated, it results in the destruction of the supporting tissues around the teeth, including periodontal ligament, cementum, and alveolar bone, which lead to a wide range of disabilities and poor quality of life, thus imposing significant burdens. This process depends on the differentiation and activity of osteoclasts, the cells responsible for reabsorbing the bone tissue. Therefore, the inhibition of differentiation or activity of these cells is a promising strategy for controlling bone resorption. Several pharmacological drugs that target osteoclasts and inflammatory cells with immunomodulatory and anti-inflammatory effects, such as bisphosphonates, anti-RANK-L antibody, strontium ranelate, cathepsin inhibitors, curcumin, flavonoids, specialized proresolving mediators, and probiotics, were already described to manage inflammatory bone resorption during experimental PD progression in preclinical studies. Meantime, a growing number of studies have described the beneficial effects of herbal products in inhibiting bone resorption in experimental PD. Therefore, this review summarizes the role of several pharmacological drugs used for PD prevention and treatment and highlights the targeted action of all those drugs with antiresorptive properties. In addition, our review provides a timely and critical appraisal for the scientific rationale use of the antiresorptive and immunomodulatory medications in preclinical studies, which will help to understand the basis for its clinical application.

The Effect of Gaseous Ozone Therapy in Conjunction with Periodontal Treatment on Glycated Hemoglobin Level in Subjects with Type 2 Diabetes Mellitus: An Unmasked Randomized Controlled Trial.

BACKGROUND: It is established that inflammation is involved in the pathogenesis of Type 2 Diabetes Mellitus (T2DM) by promoting insulin resistance and impaired beta cell function in the pancreas. Among the hypothesized independent risk factors implicated in the pathogenetic basis of disease, periodontal infection has been proposed to promote an amplification of the magnitude of the advanced glycation end product (AGE)-mediated upregulation of cytokine synthesis and secretion. These findings suggest an interrelationship between periodontal disease and type 2 diabetes, describing poor metabolic control in subjects with periodontitis as compared to nondiabetic subjects and more severe periodontitis in subjects with T2DM as compared to a healthy population, with a significant positive correlation between periodontal inflammatory parameters and glycated hemoglobin level. Results from clinical trials show that periodontal treatment is able to improve glycemic control in subjects with diabetes. Many therapeutic strategies have been developed to improve periodontal conditions in conjunction with conventional treatment, among which ozone (O3) is of specific concern. The principal aim of this trial was to compare the clinical effectiveness of an intensive periodontal intervention consisting of conventional periodontal treatment in conjunction with ozone gas therapy in reducing glycated hemoglobin level in type 2 diabetic patients and standard periodontal treatment. METHODS: This study was a 12-month unmasked randomized trial and included 100 patients aged 40-74 years older, with type 2 diabetes mellitus diagnosed. All the patients received conventional periodontal treatment, or periodontal treatment in conjunction with ozone gas therapy in a randomly assigned order (1:1). The primary outcome was a clinical measure of glycated hemoglobin level at 3, 6, 9 and 12 months from randomization. Secondary outcomes were changes in periodontal inflammatory parameters. RESULTS: At 12 months, the periodontal treatment in conjunction with ozone gas therapy did not show significant differences than standard therapy in decreasing glycated hemoglobin (HbA1C) level and the lack of significant differences in balance is evident. CONCLUSIONS: Although the change was not significant, periodontal treatment in conjunction with the gaseous ozone therapy tended to reduce the levels of glycated hemoglobin. The study shows a benefit with ozone therapy as compared to traditional periodontal treatment.

A Pilot Study Examining Vitamin C Levels in Periodontal Patients.

BACKGROUND: Periodontal disease is the leading cause of tooth loss worldwide. Current periodontal treatment is limited by its dependency on patients learning and maintaining good dental habits, and repeated visits to oral health physicians. Vitamin C's role in collagen synthesis and immune function makes it important in wound healing and possibly periodontal healing. Therefore, if some patients are deficient, this may worsen patient outcomes. METHODS: Patients were invited to participate following assessment and treatment at the Westmead Centre of Oral Health Periodontic Clinic, regardless of current disease stage or treatment. Adults were eligible if they gave informed consent and had current periodontal disease. Study involvement consisted of periodontal assessment and care followed by an interview and measurement of serum vitamin C and C-reactive protein (CRP). RESULTS: A total of 6 out of 20 patients had vitamin C levels less than the institutional normal range, of whom 2 had levels <11.4 µmol/L and one <28 µmol/L. Low vitamin C was associated with higher periodontal disease stage (p = 0.03). Elevated CRP was found in 2/3 of people with low vitamin C and CRP was negatively correlated with vitamin C (p < 0.01). Vitamin C did not correlate with patient-reported fruit or vegetable consumption, but high processed meat intake was associated with lower vitamin C. CONCLUSION: Although a small study, this rate of vitamin C deficiency in the periodontal clinic is clinically important and correlations with disease severity and CRP suggests biological importance. This warrants further studies to assess vitamin C and whether supplementation improves periodontal outcomes, particularly in deficient subjects.

Evaluation of halitosis in adult patients after treatment with photodynamic therapy associated with periodontal treatment: Protocol for a randomized, controlled, single-blinded trial with 3-month follow up.

RATIONALE: Halitosis is an unpleasant odor that emanates from the mouth. Studies show halitosis returns in a week, after treatment with PDT. Probably, bacteria living in the periodontal sulcus could recolonize the dorsum of the tongue. Until nowadays, there are no study in adult population that associates halitosis and periodontal treatment with follow-up evaluation. The aim of this randomized, controlled, single-blinded clinical trial is to treat oral halitosis in healthy adults with photodynamic therapy (PDT), associated with periodontal treatment and follow them up for 3 months. PATIENT CONCERNS:: the concerns assessments will be done over the study using anamnesis interviews and specific questionnaire. DIAGNOSES:: halitosis will be evaluated by OralChroma. INTERVENTIONS: The participants (n = 40) with halitosis will be randomized into 2 groups: G1-treatment with PDT (n = 20) or G2-cleaning of the tongue with a tongue scraper (n = 20). OUTCOMES: Halitosis will be evaluated by measuring volatile sulfur compounds using gas chromatography. After the treatments, a second evaluation will be performed, along with a microbiological analysis (RT-PCR) for the identification of the bacteria T. denticola. The assessment of halitosis and the microbiological analysis will be repeated. After that, patients will receive periodontal treatment. The participants will return after 1 week and 3 months for an additional evaluation. Quality of life will be measured by Oral Health Impact Profile questionnaire (OHIP-14). LESSONS: This protocol will determine the effectiveness of phototherapy regarding the reduction of halitosis in adults. clinicaltrials.gov NCT03996915. ETHICS AND DISSEMINATION: This protocol received approval from the Human Research Ethics Committee of Universidade Nove de Julho (certificate number: 3.257.104). The data will be published in a peer-reviewed periodical.

Two-way relationship between diabetes and periodontal disease: a reality or a paradigm?

Diabetes mellitus (DM) and periodontal disease (PD) are both chronic diseases. From one side, DM have an adverse effect on PD, and on the other side PD may influence DM. Systemic therapy of DM with glycaemic control, affects the progress of PD. Reversely treatment of PD combined with the administration of systemic antibiotics seems to have a double effect on diabetic patients reducing the periodontal infection and improving the glycaemic control. Inflammation, altered host responses, altered tissue homeostasis are common characteristic of both DM and PD. The potential common pathophysiologic pathways of direct or reverse relationship of DM and PD are still unknown and further in vitro and in vivo studies are needed to explore this relationship.

The Relationship between Vitamin D and Periodontal Pathology.

Osteoporosis and periodontal diseases are common problems among the elderly population. Vitamin D is a secosteroid hormone that is either synthesized by human skin cells under the effect of UV radiation or consumed through diet. Deficiency in vitamin D leads to reduced bone mineral density, osteoporosis, the progression of periodontal diseases and causes resorption to occur in the jawbone. Sufficient intake of vitamin D can decrease the risk of gingivitis and chronic periodontitis, as it has been shown to have immunomodulatory, anti-inflammatory, antiproliferative effects and initiates cell apoptosis. In addition, vitamin D is also important for bone metabolism, alveolar bone resorption and preventing tooth loss. It increases antibacterial defense of gingival epithelial cells and decrease gingival inflammation, improves postoperative wound healing after periodontal surgery and is an important supplement used as prophylaxis in periodontology. This publication aims to update the recent advances, stress the clinical importance, and evaluate vitamin D in the prevention of periodontal diseases to reach a successful outcome of conservative and surgical treatment. An analysis of the literature shows that vitamin D plays a significant role in maintaining healthy periodontal and jaw bone tissues, alleviating inflammation processes, stimulating post-operative healing of periodontal tissues and the recovery of clinical parameters. However, further research is needed to clarify the required vitamin D concentration in plasma before starting periodontal treatment to achieve the best outcome.

Retrieval of a periodontally compromised tooth by allogeneic grafting of mesenchymal stem cells from dental pulp: A case report.

Objective To report a case of successful allogeneic grafting of mesenchymal dental pulp stem cells (DPSCs) as preliminary findings in a patient with periodontal disease enrolled into clinical trial ISRCTN12831118. Methods Mesenchymal stem cells from the dental pulp of a deciduous tooth from a 7-year-old donor were separated from the pulp chamber and processed via enzymatic digestion and centrifugation. DPSCs were passaged and cultured on a 35 × 13 mm culture dish in minimum essential medium-alpha, without supplementation. After reaching 80% confluency, 5 x 106 allogeneic DPSCs in 250 µl phosphate buffered saline were seeded onto a dry scaffold of lyophilized collagen-polyvinylpyrrolidone sponge placed in the left lower premolar area of a 61-year-old patient with periodontal disease. Surgical access to the lower premolar area was achieved using the flap technique. Results At 3 and 6 months following allogeneic graft, the patient showed no sign of rejection and exhibited decreases in tooth mobility, periodontal pocket depth and bone defect area. Bone mineral density had increased at the graft site. Conclusions Regenerative periodontal therapy using DPSCs of allogeneic origin may be a promising treatment for periodontal disease-induced bone defects.

Periodontal diseases and adverse pregnancy outcomes: Is there a role for vitamin D?

Studies have shown a relationship between maternal periodontal diseases (PDs) and premature delivery. PDs are commonly encountered oral diseases which cause progressive damage to the periodontal ligament and alveolar bones, leading to loss of teeth and oral disabilities. PDs also adversely affect general health by worsening of cardiovascular and metabolic diseases. Moreover, maternal PDs are thought to be related to increasing the frequency of preterm-birth with low birth weight (PBLBW) in new-borns. Prematurity and immaturity are the leading causes of prenatal and infant mortality and is a major public health problem around the world. Inflamed periodontal tissues generate significantly high levels of proinflammatory cytokines that may have systemic effects on the host mother and the fetus. In addition, the bacteria that cause PDs produce endotoxins which can harm the fetus. Furthermore, studies have shown that microorganisms causing PDs can get access to the bloodstream, invading uterine tissues, to induce PBLBW. Another likely mechanism that connects PDs with adverse pregnancy outcome is maternal vitamin D status. A role of inadequate vitamin D status in the genesis of PDs has been reported. Administration of vitamin D supplementation during pregnancy could reduce the risk of maternal infections and adverse pregnancy outcomes. As maternal PDs are significant risk factors for adverse pregnancy outcome, preventive antenatal care for pregnant women in collaboration with the obstetric and dental professions are required.

The effect of professional tooth cleaning or non-surgical periodontal therapy on oral halitosis in patients with periodontal diseases. A systematic review.

OBJECTIVE: The aim of this systematic review was to give the best available evidence on the impact of professional tooth cleaning (PTC) and scaling and root planing (SRP) on oral halitosis in patients with periodontal diseases. MATERIAL AND METHODS: Three databases were screened for relevant studies. Only randomized controlled trials (RCTs) or controlled clinical trials (CCT) were included. The primary outcome in all included studies was volatile sulphur compounds (VSC) measured by Halimeter or OralChroma and organoleptic scores as secondary outcome. Only studies investigating healthy adults except for periodontitis or gingivitis were included. The considered intervention strategies were professional tooth cleaning and non-surgical periodontal treatment. For both strategies, additional oral hygiene instructions (OHI) were possible. Two independent reviewers performed the study selection and quality assessment. SEARCH RESULTS: After abstract and title screening and subsequent full-text reading of potential papers, a placebo-controlled RCT could not be found. However, eight studies or particular arms used PTC or SRP as sole interventions and were included in this review. All trials or study arms included showed a positive effect on VSC levels or organoleptic scores after intervention. CONCLUSIONS: Based on best available evidence, PTC and SRP in combination with oral hygiene instructions reduced VSC values in patients with oral halitosis and/or periodontal diseases, independent of tongue cleaning and the use of mouth rinses.

Impact of Cranberry Juice Enriched with Omega-3 Fatty Acids Adjunct with Nonsurgical Periodontal Treatment on Metabolic Control and Periodontal Status in Type 2 Patients with Diabetes with Periodontal Disease.

OBJECTIVES: Cranberries, high in polyphenols, have been associated with a favorable glycemic response in patients with type 2 diabetes and also are beneficial for oral health. Because type 2 diabetes mellitus and periodontal disease have a physiological relationship, this study aimed to evaluate the hypothesis that cranberry juice enriched with omega-3 will improve glycemic and lipid profiles and periodontal status in patients with diabetes with periodontal disease. MATERIALS AND METHODS: In this randomized clinical trial, 41 patients with diabetes (age 35-67 years) with periodontal disease were recruited and randomly assigned to 4 groups: control (C; n = 12), receiving omega-3 (I1; n = 10, 1 g/ twice daily), cranberry juice (I2; n = 9, 200 ml, twice daily), and cranberry juice enriched with omega-3 (I3; n = 10, 200 ml, containing 1 g omega-3) twice daily for 8 weeks. Nonsurgical periodontal therapy was provided for all patients during the study. Fasting blood glucose and glycated hemoglobin, lipid profile, probing depth, anthropometric indices, and 3-day 24-hour dietary recalls were measured pre- and postintervention. RESULTS: Glycated hemoglobin was decreased significantly in I1 and I3 groups. Serum high-density lipoprotein cholesterol (HDL-C) levels increased significantly in the I3 group compared to baseline and compared to I1 and I2 groups. Probing depth was significantly reduced in all groups postintervention. CONCLUSION: Consumption of cranberry juice enriched with omega-3 can be beneficial as adjuvant therapy with nonsurgical periodontal therapy in decreasing glycated hemoglobin, increasing HDL-C, and improving periodontal status in patients with diabetes with periodontal disease.

Efeitos terapêuticos do uso de produtos derivados da romã (punica granatum) como coadjuvante no tratamento das doenças periodontais: uma revisão de literatura / Therapeutic effects of the use of pomegranate products (Punica granatum) as adjuvant in the treatment of periodontal diseases: a review of the literature

A romã (Punica granatum) possui uma vasta história médica conhecida por sua ação antibacteriana, antioxidante e anti-inflamatória. A presente revisão teve como objetivo verificar os potenciais efeitos terapêuticos do uso de produtos derivados da P. granatum como coadjuvante no tratamento das doenças periodontais. Descritores em inglês e português dos termos: "romã", "doença periodontal", "gengivite", "periodontite" e "punica granatum", foram utilizados para consulta nas bases de dados Pubmed, Lilacs e Scielo. Para avaliação dos efeitos anti-inflamatórios, antimicrobianos e clínicos da romã foram incluídos trabalhos clínicos e pré-clínicos, sem restrições de data. Os diferentes estudos selecionados avaliaram P. granatum em diferentes formulações, incluindo bochechos, géis, infusão, dentifrícios, e chips biodegradáveis. Os resultados demostraram que os componentes fitoquímicos de P. granatum, como polifenóis flavonoides, punicalaginas, ácido punícico e antocinas apresentam propriedades relevantes pró-saúde periodontal, que incluem efeitos anti-inflamatórios, antioxidantes, hemostáticos e imunoregulatórios. Estudos in vivo utilizando diferentes formulações da romã em participantes acometidos por gengivite ou periodontite apresentaram reduções nos índices de placa, sangramento gengival e profundidade de sondagem em graus variados. Conclui-se que P. granatum pode ser uma promissora alternativa à terapia antimicrobiana padrão, para auxílio do controle mecânico de placa, com melhora dos sinais clínicos das doenças periodontais. Contudo, mais estudos clínicos ainda são necessários. (AU)

The pomegranade (Punica granatum) has a vast medical history know by its antibacterial, antioxidant and antiinflammatory action. The presente review aimed at verifying the potential therapeutic effects of products derived from P. granatum as adjuvant in the treatment of periodontal diseases. English and Portugueses descriptors of the terms "pomegranate", "periodontal disease", "gingivitis", "periodontitis" and "Punica granatum" were used for search in Pubmed, Lilacs and Scielo databases. To assess the anti-inflammatory, antimicrobial and clinical effects of pomegranate, clinical and preclinical were included, with no date restrictions. The different studies evaluated P. granatum in different formulations, including mouthwash, gels, infusion, dentifrices, and biodegradable chips. Results showed that the phytochemical components of P. granatum, such as polyphenois flavonoids, punicalagins, punicic acid and antocines, demonstrated relevant periodontal prohealth properties, including anti-inflammatory, antioxidant, hemostatic and immunoregulatory effects. In vivo studies, using different pomegranade formulations in individuals affected by gingivitis or periodontitis, showed reductions in plaque index, gingival bleeding and probing depth in different levels. It was concluded that P. granatum could be a promising alternative to the standard antimicrobial therapy in order to aid the mechanical control of plaque, with improvement of clinical signs of periodontal diseases. However, more clinical studies are still necessary. (AU)

Association between periodontal disease and non-communicable diseases: A 12-year longitudinal health-examinee cohort study in South Korea.

The National Health Insurance Service-Health Examinee Cohort during 2002 to 2013 was used to investigate the associations between periodontal disease (PD) and the following non-communicable diseases (NCDs): hypertension, diabetes mellitus, osteoporosis, cerebral infarction, angina pectoris, myocardial infarction, and obesity.Univariate and multivariate logistic regression analyses adjusting for potential confounders during the follow-up period-including age, sex, household income, insurance status, residence area, health status, and comorbidities-were used to estimated odds ratios (ORs) with 95% confidence intervals (CIs) in order to assess the associations between PD and NCDs.We enrolled 200,026 patients with PD and 154,824 subjects with a healthy oral status. Statistically, significant associations were found between PD and the investigated NCDs except for cerebral and myocardial infarction after adjusting for sociodemographic and comorbidity factors (P < .05). In particular, obesity (OR = 1.30, 95% CI = 1.04-1.63, P = .022), osteoporosis (OR = 1.22, 95% CI = 1.18-1.27, P < .001), and angina pectoris (OR = 1.22, 95% CI = 1.17-1.27, P < .001) were significantly and positively associated with PD.This longitudinal cohort study has provided evidence that patients with PD are at increased risk of NCDs. Further studies are required to confirm the reliability of this association and elucidate the role of the inflammatory pathway in periodontitis pathogenesis as a triggering and mediating mechanism.

Periodontal diseases as a source of halitosis: a review of the evidence and treatment approaches for dentists and dental hygienists.

Bad breath (halitosis) is an important social complaint. In most cases (≥90%), the cause of halitosis can be found within the oral cavity. Under this circumstance, the term oral malodor applies. It affects both healthy and periodontally diseased individuals. Oral malodor is mainly caused by a microbial degradation of both sulfur-containing and nonsulfur-containing amino acids into volatile, bad-smelling gases. Anaerobic gram-negative bacteria, the same species that have been linked to periodontal diseases, are especially involved in this process, explaining why clinicians often associate oral malodor with periodontitis. Some volatile organic compounds render patients more susceptible to periodontitis and this supports the malodor-periodontitis link. This review investigates the interaction between oral malodor and periodontal diseases. Pro and con arguments regarding the mechanisms of halitosis and clinical implications will be presented. In general, however, the impact of tongue coatings has been found to be the dominant factor, besides gingivitis and periodontitis. The last part of this review discusses the treatment of bad breath, with different options.

Oral Infections and Pregnancy: Knowledge of Gynecologists/Obstetricians, Midwives and Dentists.

PURPOSE: To establish an inventory of knowledge, attitudes and daily pratice of dental and medical practitioners in France regarding oral health care and its relationship to pregnancy, particularly to preterm delivery and low birth-weight infants. MATERIALS AND METHODS: A questionnaire was distributed to health-care professionals (n= 460), consisting of 100 prenatal care practitioners (obstetricians, midwives) and 360 dentists, about their knowledge of oral alterations during pregnancy, the possible association between periodontal disorders and preterm/low birth weight, and their conduct toward their patients. RESULTS: Bleeding gums and pregnancy gingivitis were the oral manifestations most often cited by all the practitioners. In contrast, prenatal care practitioners were unaware of epulis and a greater percentage of them than dentists believed caries risk to increase during pregnancy. The most adverse pregnancy outcomes cited were risk of premature delivery and chorioamniotis. Only dentists had received initial training on pregnancy complications. Finally, all health professionals point out the lack of continuing education on this topic. CONCLUSION: The present results underline the need for a better initial professional education and continuing education regarding pregnancy and oral health conditions and emphasise the need to update the guidelines in health care practices for pregnant women for a more effective prevention of risk-related adverse pregnancy outcomes, such as pre-term birth or pre-eclampsia.

Fatal thalamic abscess secondary to dental infection.

We present the case of poor neurological recovery and subsequent death secondary to a thalamic abscess in a 53-year-old man. This patient initially presented with sudden dysarthria and left hemiparesis while driving. Neuroimaging showed a multilobular abscess involving the right thalamus with oedema extending to the basal ganglionic region and brainstem. The source of the abscess was initially unknown and it required draining multiple times while the different causes were being explored. The patient's neurological state along with intubation made for a difficult and inconclusive oral examination. It was only after neuroimaging included tooth-bearing areas that it became evident that this patient had extensive periodontal disease with multiple areas of periapical radiolucencies. The patient underwent complete dental clearance alongside repeated drainage of the abscess. Despite initial postoperative improvement, the patient never recovered from the neurological damage and died 3 weeks later.

Evolution of Comprehensive Care, Part 3. Periodontal Treatment Continues to Evolve.

Perio treatment has evolved beyond simple scaling with hand instruments. Ultrasonics and diode lasers have improved both the efficiency of treatment as well as treatment prognosis to arresting the disease process and gaining clinical attachment and decreasing pocket depth. Add to this the benefits of adjunct medicaments both at time of treatment via site placement and during routine home care by the patient, and we are able to tip treatment outcome in a more favorable direction. Periodontology has been closely linked to systemic health both as a causative agent to health issues and as a secondary site for some medical conditions. Dentistry has truly--and finally--become a part of total healthcare.