Failing to meet the goals of periodontal recall programs. What next?

Supportive periodontal care is a crucial aspect of the management of chronic periodontitis and peri-implantitis and is inevitably a long-term commitment for both the clinician and the patient. The principal goals of supportive care are to achieve a high standard of plaque control, minimize bleeding and maintain pockets at less than 6 mm. Gain of attachment around natural teeth during supportive periodontal care has been reported, although gain of attachment and of bone during supportive care may be a more pragmatic and aspirational aim in the longer term. Furthermore, we occasionally see patients for whom, despite excellent home and professional care (surgical or nonsurgical), including the management of risk factors, supportive periodontal care appears to be failing and therefore for such patients the clinician needs to consider further management options. This review considers, in particular, the options of using local or systemically delivered antimicrobials to eradicate periodontal and peri-implant disease progression and discusses the extent to which culture and sensitivity testing before the prescription of systemically delivered antimicrobials may be a cost-effective alternative to prescribing 'blind'.

Gingival recession and root caries in the ageing population: a critical evaluation of treatments.

AIM: To review evidence for the treatments of gingival recession and root caries in older populations. MATERIALS & METHODS: A systematic approach was adopted to identify reviews and articles to allow us to evaluate the treatments for gingival recession and root caries. Searches were performed in PubMed, Medline and Embase, the Cochrane trials register and bibliographies of European and World Workshops. OBSERVATIONS: Gingival recession: We identified no articles that focussed specifically on older populations. Conversely, no evidence suggested that Miller class I and II lesions should be managed differently in older patients when compared to younger cohorts. Six systematic reviews included older patients and suggested that connective tissue grafts are the treatment of choice, alone or in combination with enamel matrix derivative. Root caries can be controlled at the population level by daily brushing with fluoride-containing toothpastes, whilst active decay may be inactivated using professional application of fluoride varnishes/solutions or self-applied high-fluoride toothpaste. Active root caries lesions that cannot be cleaned properly by the patient may be restored by minimally invasive techniques. CONCLUSIONS: Gingival recession and root caries will become more prevalent as patients retain their teeth for longer. Whilst surgical (gingival recession) and non-operative approaches (root caries) currently appear to be favoured, more evidence is needed to identify the most appropriate strategies for older people.

Dental caries and periodontal diseases in the ageing population: call to action to protect and enhance oral health and well-being as an essential component of healthy ageing - Consensus report of group 4 of the joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases.

BACKGROUND: Over the last two decades, progress in prevention and treatment of caries and periodontal diseases has been translated to better oral health and improved tooth retention in the adult population. The ageing population and the increasing expectations of good oral health-related quality of life in older age pose formidable challenges to clinical care and healthcare systems. AIMS: The objective of this workshop was to critically review scientific evidence and develop specific recommendations to: (i) prevent tooth loss and retain oral function through prevention and treatment of caries and periodontal diseases later in life and (ii) increase awareness of the health benefits of oral health as an essential component of healthy ageing. METHODS: Discussions were initiated by three systematic reviews covering aspects of epidemiology of caries and periodontal diseases in elders, the impact of senescence on caries and periodontal diseases and the effectiveness of interventions. Recommendations were developed based on evidence from the systematic reviews and expert opinion. RESULTS: Key messages included: (i) the ageing population, trends in risk factors and improved tooth retention point towards an expected increase in the total burden of disease posed by caries and periodontal diseases in the older population; (ii) specific surveillance is required to monitor changes in oral health in the older population; (iii) senescence impacts oral health including periodontitis and possibly caries susceptibility; (iv) evidence indicates that caries and periodontal diseases can be prevented and treated also in older adults; (v) oral health and functional tooth retention later in life provides benefits both in terms of oral and general quality of life and in terms of preventing physical decline and dependency by fostering a healthy diet; (vi) oral healthcare professionals and individuals should not base decisions impacting tooth retention on chronological age but on level of dependency, life expectancy, frailty, comfort and quality of life; and (vii) health policy should remove barriers to oral health care for vulnerable elders. CONCLUSIONS: Consensus was reached on specific actionable priorities for public health officials, oral healthcare professionals, educators and workforce planners, caregivers and relatives as well as for the public and ageing patients. Some priorities have major implications for policymakers as health systems need to adapt to the challenge by systemwide changes to enable (promote) tooth retention later in life and management of deteriorating oral health in increasingly dependent elders.

Using prognostic factors from case series and cohort studies to identify individuals with poor long-term outcomes during periodontal maintenance.

BACKGROUND: The accuracy of applying prognostic factors to individual patients is uncertain. AIM/METHOD: The aim was to apply prognostic factors from several outcome studies (case series and cohort) to identify: (1) patients who lost a tooth/teeth during periodontal maintenance; (2) patients who were non-responding to treatment; (3) patients needing re-treatment during periodontal maintenance. In addition, tooth loss was related to initial prognosis and it was determined which of the prognostic factors were also risk factors. Chi squared analysis was carried out for the outcomes of patients with-, and without prognostic factors. Significance level was set at p ≤ 0.05. Sensitivity and specificity was calculated for patients with and without prognostic factors. RESULTS: The prognostic factors only identified a small proportion of patients who lost teeth (34-38%). Combining the prognostic factors resulted in a lower accuracy. A higher proportion of patients with no prognostic factors lost teeth (53.8-96.2%). The chance of identifying a non-responding patient based on family history was 5.9%, for stress 32.4%, and for heavy smoking 8.7%. Significantly more patients (29/40 , χ² = 16.2 p < 0.05) with initial uncertain/poor prognosis and significantly fewer patients (11/40, χ² = 16.2, p < 0.05) with erratic/no compliance needing re-treatment were identified. 21 of 40 patients (52.5%) (p = 0.655) with family history needing retreatment were identified. Combining the prognostic factors identified 5-22% out of a total of 40% of patients needing re-treatment. six out of nine (67%) teeth with an initial hopeless prognosis were lost, 10/109 (9%) teeth with a poor prognosis were lost, 11/346 (3%) teeth with a moderate prognosis were lost and 9/1972 (0.46%) of teeth with a good prognosis were lost. None of the prognostic factors was found also to be a risk factor for developing periodontal diseases. CONCLUSION: Applying prognostic factors to identify individual patients with poor long-term outcomes is associated with low accuracy.

Evidence for the occurrence of gingival recession and non-carious cervical lesions as a consequence of traumatic toothbrushing.

AIM: To identify the best available evidence for the effect of toothbrushing on the initiation and progression of gingival recession and non-carious cervical lesions (NCCLs). METHODS: A protocol was developed for the questions: Does traumatic toothbrushing, compared to normal toothbrushing, lead to an increased prevalence of non-inflammatory gingival recession? [FQ1] and NCCLs? [FQ2]. The search covered four electronic databases. Bibliographies of review articles, relevant texts, World and European Workshops were screened. Hand searches were performed of the Journals of Clinical Periodontology, Periodontology, Periodontal Research and IADR abstracts. RESULTS: A meta-analysis included 159 subjects and showed that subjects who used MTBs (manual toothbrush) had greater gingival recession after 12 months when compared with those using PTBs (powered toothbrush). Thirteen cross-sectional studies identified the most frequent toothbrushing factors associated with gingival recession as being toothbrushing frequency, a horizontal or scrub toothbrushing method, bristle hardness, toothbrushing duration and the frequency of changing a toothbrush. The principal toothbrushing factors associated with NCCLs were toothbrushing method and frequency. CONCLUSION: The data to support or refute the association between toothbrushing and gingival recession and NCCLs remain largely inconclusive.

The impact of structured plaque control for patients with gingival manifestations of oral lichen planus: a randomized controlled study.

AIM: To evaluate the impact of a structured plaque control intervention on clinical and patient-centred outcomes for patients with gingival manifestations of oral lichen planus. MATERIALS AND METHODS: Eighty-two patients were recruited into a 20-week randomized controlled trial. The intervention was structured plaque control comprising powered tooth brushing and inter-dental cleaning advice. Control subjects continued with their normal dental plaque control regimen. The primary outcome measure was the oral health impact profile (OHIP) with secondary outcomes of pain, plaque index, mucosal disease score and cost-effectiveness. RESULTS: Overall, the intervention patients showed statistically significant improvements in OHIP sum ordinal and OHIP dichotomous scores compared with control. There were improvements in the functional limitation, psychological discomfort and physical disability domains at 4- and 20-weeks and in the psychological disability domain at 20-weeks. The intervention was successful in reducing plaque compared to control (p < 0.001) and improvements were observed using the mucosal disease indices at the 4- and 20-week follow-ups (p < 0.001). CONCLUSION: A structured plaque control intervention was effective in improving the oral health-related quality of life and clinically observed gingival lesions. This study provides evidence to include intensive plaque control within patients' initial and on-going management.

Cost-effectiveness of personalized plaque control for managing the gingival manifestations of oral lichen planus: a randomized controlled study.

AIM: To undertake cost-effectiveness and cost-benefit analyses of an intervention to improve oral health in patients presenting with the gingival manifestations of oral lichen planus (OLP). MATERIALS & METHODS: Eighty-two patients were recruited to a 20-week randomized controlled trial. The intervention was personalized plaque control comprising powered tooth brushing and inter-dental cleaning advice. The primary outcome measure was the oral health impact profile (OHIP) with secondary outcomes of pain, plaque index, mucosal disease score and cost-effectiveness. Private cost data and stated willingness-to-pay (WTP) values for treatment were obtained from intervention patients at 20 weeks. RESULTS: Overall, 81% of intervention patients showed improvement in both plaque index and mucosal disease score at 20 weeks compared to 30% of controls that continued with their usual plaque control regimen. All intervention group patients stated a positive WTP value. The mean net value of the treatment was £172 compared to the incremental cost of the treatment estimated at £122.75. The cost-effectiveness analysis resulted in an incremental cost-effectiveness ratio of £13 per OHIP point. CONCLUSIONS: The tailored plaque control programme was more effective than control in treating the gingival manifestations of oral lichen planus. The programme is cost effective for modest values placed on a point on the OHIP scale and patients generally valued the treatment in excess of the cost.

Effects of smoking cessation on the outcomes of non-surgical periodontal therapy: a systematic review and individual patient data meta-analysis.

AIM: To conduct an individual patient data (IPD) meta-analysis to assess the effect of smoking cessation (SC) on clinical outcomes following the non-surgical periodontal treatment in patients with chronic periodontitis. METHODS: MEDLINE, EMBASE and CENTRAL were searched up to, and including, August 2012. Prospective cohort studies of at least 6 months' duration were included if the participants met the following criteria: (1) smokers who had expressed an interest in quitting the habit; and (2) a diagnosis of periodontitis. Search was conducted by two independent reviewers. IPD meta-analyses were undertaken using multiple linear or Poisson regression to evaluate the impact of SC on five different dependent variables. RESULTS: Of 2455 potentially eligible articles, two studies were included. The two studies found that SC seems to promote additional beneficial effects in reducing probing depths (PD) and improving attachment level following non-surgical periodontal treatment. The IPD approach allowed data combination but it might not have usefully added strength to the data in this review. CONCLUSION: SC seems to be an important component of periodontal therapy, and smokers should be encouraged to quit as part of their overall periodontal management; however, only a limited base of evidence was available for analysis.

IQuaD dental trial; improving the quality of dentistry: a multicentre randomised controlled trial comparing oral hygiene advice and periodontal instrumentation for the prevention and management of periodontal disease in dentate adults attending dental primary care.

BACKGROUND: Periodontal disease is the most common oral disease affecting adults, and although it is largely preventable it remains the major cause of poor oral health worldwide. Accumulation of microbial dental plaque is the primary aetiological factor for both periodontal disease and caries. Effective self-care (tooth brushing and interdental aids) for plaque control and removal of risk factors such as calculus, which can only be removed by periodontal instrumentation (PI), are considered necessary to prevent and treat periodontal disease thereby maintaining periodontal health. Despite evidence of an association between sustained, good oral hygiene and a low incidence of periodontal disease and caries in adults there is a lack of strong and reliable evidence to inform clinicians of the relative effectiveness (if any) of different types of Oral Hygiene Advice (OHA). The evidence to inform clinicians of the effectiveness and optimal frequency of PI is also mixed. There is therefore an urgent need to assess the relative effectiveness of OHA and PI in a robust, sufficiently powered randomised controlled trial (RCT) in primary dental care. METHODS/DESIGN: This is a 5 year multi-centre, randomised, open trial with blinded outcome evaluation based in dental primary care in Scotland and the North East of England. Practitioners will recruit 1860 adult patients, with periodontal health, gingivitis or moderate periodontitis (Basic Periodontal Examination Score 0-3). Dental practices will be cluster randomised to provide routine OHA or Personalised OHA. To test the effects of PI each individual patient participant will be randomised to one of three groups: no PI, 6 monthly PI (current practice), or 12 monthly PI.Baseline measures and outcome data (during a three year follow-up) will be assessed through clinical examination, patient questionnaires and NHS databases.The primary outcome measures at 3 year follow up are gingival inflammation/bleeding on probing at the gingival margin; oral hygiene self-efficacy and net benefits. DISCUSSION: IQuaD will provide evidence for the most clinically-effective and cost-effective approach to managing periodontal disease in dentate adults in Primary Care. This will support general dental practitioners and patients in treatment decision making. TRIAL REGISTRATION: Protocol ID: ISRCTN56465715.

How to measure the cost-effectiveness of periodontal treatments.

There is a need to measure efficiency of periodontal treatments. Efficiency questions can be addressed through a variety of economic evaluation techniques: cost minimization, cost-effectiveness, cost utility and cost-benefit analysis. Each of these techniques is outlined in this article, including a detailed discussion of different preference-based outcome (utility) measures. Despite the need, few analyses have been undertaken in periodontology. There are several issues in undertaking cost-effectiveness analyses specific to periodontology and these are examined in detail: outcome measures including patient-based vs. clinical measures of outcome; discounting or taking into account time preference for outcomes and costs; problems of costing, including the perspective taken in an analysis; interpreting the evidence, in particular using incremental cost-effectiveness ratios; and global variation in periodontal care delivery, including healthcare systems and the use of hygienists. The need for cost-effectiveness analysis in periodontology is explored further, and the need to involve a health economist in such an evaluation is underlined.

The cost-effectiveness of supportive periodontal care: a global perspective.

AIM: To evaluate the cost-effectiveness of supportive periodontal care (SPC) provided in generalist and periodontal specialist practices under publicly subsidized or private dental care. MATERIAL AND METHODS: SPC cost data and the costs of replacing teeth were synthesized with estimates of the effectiveness of SPC in preventing attachment and tooth loss and adjusted for differences in clinician's time. Incremental cost-effectiveness ratios were calculated for both outcomes assuming a time horizon of 30 years. RESULTS: SPC in specialist periodontal practice provides improved outcomes but at higher costs than SPC provided by publicly subsidized or private systems. SPC in specialist periodontal practice is usually more cost-effective than in private dental practice. For private dental practices in Spain, United Kingdom and Australia, specialist SPC is cost-effective at modest values of attachment loss averted. Variation in the threshold arises primarily from clinician's time. CONCLUSION: SPC in specialist periodontal practice represents good value for money for patients (publicly subsidized or private) in the United Kingdom and Australia and in Spain if they place relatively modest values on avoiding attachment loss. For patients in Ireland, Germany, Japan and the United State, a higher valuation on avoiding attachment loss is needed to justify SPC in private or specialist practices.

Developing a core outcome set for periodontal trials.

BACKGROUND: There is no agreement which outcomes should be measured when investigating interventions for periodontal diseases. It is difficult to compare or combine studies with different outcomes; resulting in research wastage and uncertainty for patients and healthcare professionals. OBJECTIVE: Develop a core outcome set (COS) relevant to key stakeholders for use in effectiveness trials investigating prevention and management of periodontal diseases. METHODS: Mixed method study involving literature review; online Delphi Study; and face-to-face consensus meeting. PARTICIPANTS: Key stakeholders: patients, dentists, hygienist/therapists, periodontists, researchers. RESULTS: The literature review identified 37 unique outcomes. Delphi round 1: 20 patients and 51 dental professional and researchers prioritised 25 and suggested an additional 11 outcomes. Delphi round 2: from the resulting 36 outcomes, 13 patients and 39 dental professionals and researchers prioritised 22 outcomes. A face-to-face consensus meeting was hosted in Dundee, Scotland by an independent chair. Eight patients and six dental professional and researchers participated. The final COS contains: Probing depths, Quality of life, Quantified levels of gingivitis, Quantified levels of plaque, Tooth loss. CONCLUSIONS: Implementation of this COS will ensure the results of future effectiveness trials for periodontal diseases are more relevant to patients and dental professionals, reducing research wastage. This could reduce uncertainty for patients and dental professionals by ensuring the evidence used to inform their choices is meaningful to them. It could also strengthen the quality and certainty of the evidence about the relative effectiveness of interventions. REGISTRATION: COMET Database: http://www.comet-initiative.org/studies/details/265?result=true.

Examining the impact of oral hygiene advice and/or scale and polish on periodontal disease: the IQuaD cluster factorial randomised controlled trial.

Objective To compare the clinical effectiveness and cost benefit of different frequencies of scale and polish (S&P) treatments in combination with different types of oral hygiene advice (OHA).Design Multi-centre, multi-level cluster randomised factorial open trial with blinded outcome evaluation. UK dental practices were cluster randomised to deliver OHA as usual or personalised. In a separate randomisation, patients were allocated to receive S&P 6-monthly, 12-monthly or never.Setting UK primary dental care.Participants Practices providing NHS care and adults who had received regular dental check-ups.Main outcome measures The percent of sites with bleeding on probing, patient confidence in self-care, incremental net benefits (INB) over three years.Results Sixty-three practices and 1,877 adult patients were randomised and 1,327 analysed (clinical outcome). There was no statistically significant or clinically important difference in gingival bleeding between the three S&P groups (for example, six-monthly versus none: difference 0.87% sites, 95% CI: 1.6 to 3.3, p = 0.48) or between personalised or usual OHA groups (difference -2.5% sites, -95%CI: -8.3 to 3.3, p = 0.39), or oral hygiene self-efficacy (cognitive impact) between either group (for example, six-monthly versus none: difference -0.028, 95% CI -0.119 to 0.063, p = 0.543). The general population place a high value on, and are willing to pay for, S&P services. However, from a dental health perspective, none of the interventions were cost-effective.Conclusion Results suggest S&P treatments and delivering brief personalised OHA provide no clinical benefit and are therefore an inefficient approach to improving dental health (38% of sites were bleeding whatever intervention was received). However, the general population value both interventions.

Response of subgingival bacteria to smoking cessation.

It has been demonstrated that smoking cessation alters the subgingival microbial profile; however, the response of individual bacteria within this ecosystem has not been well studied. The aim of this investigation, therefore, was to longitudinally examine the effect of smoking cessation on the prevalence and levels of selected subgingival bacteria using molecular approaches for bacterial identification and enumeration. Subgingival plaque was collected from 22 smokers at the baseline and 12 months following periodontal nonsurgical management and smoking cessation counseling. The prevalence and abundance of selected organisms were examined using nested PCR and multiplexed bead-based flow cytometry. Eleven subjects successfully quit smoking over 12 months (quitters), while 11 continued to smoke throughout (smokers). Smoking cessation led to a decrease in the prevalence of Porphyromonas endodontalis and Dialister pneumosintes at 12 months and in the levels of Parvimonas micra, Filifactor alocis, and Treponema denticola. Smoking cessation also led to an increase in the levels of Veillonella parvula. Following nonsurgical periodontal therapy and smoking cessation, the subgingival microbiome is recolonized by a greater number of health-associated species and there are a significantly lower prevalence and abundance of putative periodontal pathogens. The results indicate a critical role for smoking cessation counseling in periodontal therapy for smokers in order to effectively alter the subgingival microbiome.

Compromised periodontal status in an urban Sri Lankan population with type 2 diabetes.

AIM: To determine the prevalence of periodontitis in an urban population of Sri Lankans with type 2 diabetes (T2DM) and to compare the data with those from a population of adults without diabetes. METHODS: Demographic data and a diabetes profile were recorded for a population of urban Sri Lankan adults with T2DM including duration of diabetes, blood pressure; percentage glycosylated haemoglobin, fasting blood glucose level, total cholesterol; triglycerides, low- and high-density lipoproteins. The clinical examination comprised an oral soft tissue examination, full-mouth probing depths (PD), gingival recession (GR), clinical attachment levels and bleeding on probing (BoP). RESULTS: Two hundred and eighty-five individuals with T2DM and 72 controls were examined. 33.3% of T2DM patients were diagnosed with chronic periodontitis compared with 21.7% of controls (p=0.077). Subjects with T2DM had significantly more sites with PD>or=4 and >or=5 mm (p<0.01), and higher mean GR and BoP scores (p<0.01). CONCLUSION: This urban Sri Lankan population of subjects with T2DM demonstrated a compromised periodontal status compared with non-diabetic controls.

Smoking, chronic periodontitis and smoking cessation support: reviewing the role of dental professionals.

Smoking is one of the main modifiable risk factors for chronic periodontitis. Smokers tend to have poorer periodontal health and a poor response to periodontal treatment, showing approximately half as much improvement following surgical or non-surgical therapy. In light of the current health target ("Better help for smokers to quit"), the purpose of this article is to review the role of dental professionals in providing smoking cessation support, and to review the literature associated with the aetiology of chronic periodontitis, specifically on the impact that smoking cessation has on periodontal health and treatment outcomes. The current New Zealand Smoking Cessation Guidelines state that "all people who smoke, regardless of whether they express a desire to want to stop or not, should be advised to stop smoking." Although there are only limited data from long-term clinical studies to demonstrate the benefit of smoking cessation for periodontal treatment outcomes, the evidence does indicate that smoking cessation improves periodontal health. Smoking cessation support provided by dental professionals could therefore be pivotal in improving periodontal health and the outcome of periodontal treatment.

Peri-implant diseases.

UNLABELLED: Peri-implant diseases are inflammatory conditions that affect the soft and hard supporting tissues around implant fixtures. Peri-implant mucositis usually responds to oral hygiene instructions, scaling and prophylaxis, but peri-implantitis, which involves bone resorption, has less predictable treatment outcomes following non-surgical management. Adjunctive treatment for decontaminating sites may include the use of antimicrobials and resistant cases may sometimes be managed with a surgical approach. CLINICAL RELEVANCE: As dental implant-retained prostheses become more popular the prevalence of peri-implant complications will also increase. Dental practitioners and care professionals should appreciate their potential roles in the management of these conditions.

Provision of treatment for periodontitis in Norway in 2013 - a national profile.

BACKGROUND: Epidemiological studies have reported high levels of periodontal diseases worldwide. Over the last 40 years, Norway has introduced several measures including major financial support to reduce periodontal diseases. The aims of this study were to establish the present level of periodontal treatment, the treatment profiles for the nation, and to assess if long-term clinical data support the findings. MATERIALS AND METHODS: The database of the Norwegian Health Economic Administration for 2013 was analysed to establish the prevalence of treated periodontitis in a cross-sectional register-based study. Treatment profiles including patients' ages, gender, geographic distributions, treatment types, prosthetic tooth replacements and the treatment distributions between the dental health professionals were assessed. RESULTS: 4.4% of the 20 years and older age group was treated for periodontitis. More females (55%) than males (45%) were treated with predominance in the 60-69 year age group. Private general dental practitioners performed 43.8% of the total periodontal treatment, while dental hygienists performed 22.5%. Periodontists performed 32.8% of the non-surgical and 74.6% of the surgical treatment. Tooth replacements for teeth lost due to periodontal diseases were provided for 0.57% of the population. Clinical studies from Norway showed marked improvements in the periodontal parameters examined over the last 40 years. CONCLUSION: The frequency of periodontal treatments in Norway was low, but sufficient to maintain major tooth retention for the population. Long-term external clinical data supported these findings. The treatments were well distributed between private general dental practitioners, hygienists and periodontists.

The impact of powered and manual toothbrushing on incipient gingival recession.

AIM: To compare clinical effects of manual and powered toothbrushes on sites of localized gingival recession over 12 months. To evaluate patterns and the extent of toothbrush bristle wear. METHODS: A longitudinal, single-blind, randomized, parallel group clinical trial compared the effects of one manual and one powered toothbrush on incipient lesions of localized gingival recession. Toothbrush wear was evaluated concurrently by wear index and wear rating. RESULTS: Sixty patients were recruited and randomized to two groups with 52 (26 per group) attending the final visit at month 12. There were no differences between groups for full-mouth plaque index, pocket depth or bleeding on probing at baseline and month 12. There were no differences at target sites for clinical attachment level, pocket depth, bleeding on probing, plaque index, width of keratinized gingiva or maximal height of recession. There were no differences between the wear of the brushes as measured by wear index or wear rating. CONCLUSION: There was no progression of gingival recession in subjects using either toothbrush over 12 months. There was no difference in the overall wear of the powered and manual toothbrushes over successive 3-month periods.

Exploring a temporal relationship between biofilm microbiota and inflammatory mediators during resolution of naturally occurring gingivitis.

BACKGROUND: This study uses multiple, contemporary methodologies to expand our knowledge of the temporal relationship between host-microbial interactions and clinical signs of gingivitis. METHODS: Subgingival plaque and crevicular fluid samples were collected from 31 systemically healthy adults with naturally occurring plaque-induced gingivitis. Professional prophylaxis was administered and participants were followed over 7 weeks. Microbial characterization was performed using a bead-based hybridization assay and cytokine analysis using bead-based flow cytometry. RESULTS: The provision of sequential interventions, oral hygiene instruction, and subsequent professional prophylaxis brought about significant reduction of plaque and resolution of gingivitis at all post baseline time points (P < 0.0001). Candidate cytokines that increased significantly (95% level) were interleukin (IL)-1ß, matrix metalloproteinases (MMP)-1, MMP-3, MMP-8, MMP-9, from baseline to week 2; regulated on activation, normal T cell expressed and secreted (RANTES) at week 4 and week 8; macrophage inflammatory protein (MIP)-1α and MIP-1ß at week 8. Resolution of inflammation was accompanied by a shift in the microbiological flora toward those species associated with health. CONCLUSIONS: This study provides further evidence of the dynamic relationships that exist between the overt clinical signs, the microbial biofilm, and the host response in gingivitis and upon resolution following clinical interventions. Understanding the interactions between the host immune system and subgingival microbial communities during the resolution of established gingivitis continues to evolve as additional knowledge is achieved through using new analytical technologies. The present study confirms a critical effect of oral hygiene measures on restoration of microbial eubiosis in subgingival communities, confirming the important role for home care and professional intervention in maintaining oral health.