Introducing dental hygienists in general practice to research - an in-practice evaluation programme in the United Kingdom.

AIM: To introduce dental hygienists (DHs) in the UK to the principles of research through a practice-based product evaluation programme. METHODS: The programme consisted of an initial training and orientation day with presentations on evidence-based practice, research methods and the structure of research papers. The programme and its aims were explained in detail, and participants were briefed on the methods to be used. Participants then recruited seven to ten patients from their practices (offices), carried out a baseline assessment of: plaque, gingival health, calculus and staining at anterior teeth, and gave the patients a questionnaire asking about their teeth and then provided a 3-month supply of a test toothpaste. About 10 weeks later, a follow-up assessment of the same variables was performed and the questionnaire was repeated. A second training day followed during which the DHs provided feedback of their experiences and received training in literature searching and critical appraisal of literature including interpretation of results. RESULTS: Sixty-five DHs attended the first training day; 31 were able to recruit sufficient patients and attend the second training day. The DHs recruited 168 patients who received baseline and follow-up assessments. All the variables improved overall. Feedback from the DHs was very positive, and patients expressed delight with the care they had received. CONCLUSIONS: Qualitative feedback for participating DHs suggests the programme met its aim and could be used in the future as a mechanism for helping DHs who want to increase their understanding of research methodology.

Periodontal therapy and biomarkers related to cardiovascular risk.

In the last 15-20 years the association between periodontitis and cardiovascular diseases has received greater attention. Clinical evidence also suggests that periodontitis is associated with a systemic host response and with a low-grade inflammatory state, as assessed by raised serum levels of CRP and endothelial dysfunction. This is a perturbation of the normal function of the endothelial cells that are responsible for a normal vascular function (dilatation, constriction). The objective of this review was to systematically appraise the available evidence on the effect of periodontal therapy on systemic biomarkers related to cardiovascular risk. An electronic search was conducted using MEDLINE via PubMed to identify published literature. The electronic search identified 836 references, of which 643 were considered irrelevant for this review. Full texts of 183 possible relevant articles were assessed, with exclusion of 174. Nine studies were included in the review. The overall effect of periodontal therapy was associated with a reduction in CRP of 0.50 mg/ml (95% CI 0.15, 0.85) (P=0.005). In conclusion, this review supports the hypothesis of an association between periodontitis and systemic inflammation. Further research is needed on the possible impact of periodontitis on cardiovascular disease events.

Patient perceptions of healthy weight promotion in dental settings.

INTRODUCTION: Excess weight is a risk factor for systemic and oral diseases. Since dental professionals are already involved in imparting overall health messages when certain conditions impact oral health, it should make sense that they also deliver related health messages such as promoting the maintenance of healthy weight for patients. OBJECTIVES: This study evaluated the perceptions of adult patients attending private dental clinics on healthy weight promotion by dental professionals. METHODS: A cross-sectional multicenter survey was designed and set in four private dental clinics (London/Hampshire) between April and July 2015. All eligible patients (≥ 18 years) completed a questionnaire. Body Mass Index (BMI; kg/m2) was calculated from height and weight measurements. Questionnaire content was centred on patient perceptions of 6 domains with the primary domain as to whether patients would accept healthy weight promotion by dental professionals. RESULTS: 213 adults (aged 20-85 years) participated in this study and 58.2% were females. Although the overwhelming majority endorsed healthy weight promotion by the dental team, the overweight/obese were significantly more sensitive (BMI screening χ2 trend = 6.840, p = 0.009; healthy weight information χ2 trend = 6.231, p = 0.013). Awareness of risk of periodontitis, carcinoma and overall adverse health outcomes associated with overweight or obesity was low. CONCLUSION: The study cohort was well primed for healthy weight advice. Routine healthy weight promotion and BMI screening should be considered in the private dental clinic settings. CLINICAL SIGNIFICANCE: This is an opportunity to collaborate with other health care professionals to support overall health monitoring/advice; a common risk factor strategy as recommended by the WHO. Future research is merited for this new initiative particularly perceptions of: dental teams' on healthy weight management, longitudinal interventions, NHS, children/parents and separate obese groups.

Disease severity associated with presence in subgingival plaque of Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, and Tannerella forsythia, singly or in combination, as detected by nested multiplex PCR.

This study used a nested multiplex PCR method to detect three periodontal pathogens in subgingival plaque collected before treatment and at 2 and 6 months posttreatment from 107 patients with severe, generalized periodontitis. The proportions of the patients who harbored these bacteria before periodontal treatment were as follows: Tannerella forsythia, 81%; Porphyromonas gingivalis, 78%; and Aggregatibacter (formerly Actinobacillus) actinomycetemcomitans, 47%. At 2 months posttreatment there was a significant reduction in the numbers of patients harboring P. gingivalis (46%; P < 0.001) or T. forsythia (63%; P = 0.043) but not A. actinomycetemcomitans (50%) compared to pretreatment data. At 6 months posttreatment, significantly fewer patients harbored P. gingivalis (43%; P < 0.001); A. actinomycetemcomitans, (31%; P = 0.025), or T. forsythia (63%; P = 0.030). Interestingly, at baseline and at 2 months posttherapy, subjects who harbored only a single pathogen had a greater level of periodontal disease than subjects who harbored two, or all three, of these periodontal pathogens. These data suggest that a reduction in the number of species present may be associated with an increase in the severity of periodontal diseases.

Short-term effects of intensive periodontal therapy on serum inflammatory markers and cholesterol.

Severe periodontitis has been associated with increased systemic inflammation. In a three-arm preliminary randomized trial, we investigated the impact of standard (SPT) and intensive periodontal therapy (IPT) on serum inflammatory markers and cholesterol levels. Medical and periodontal parameters, C-reactive protein (CRP), interleukin-6 (IL-6), total cholesterol, and LDL cholesterol were evaluated in 65 systemically healthy subjects suffering from severe generalized periodontitis. Two months after treatment, both SPT and IPT resulted in significant reductions in serum CRP compared with the untreated control (0.5 +/- 0.2 mg/L for SPT, P = 0.030 and 0.8 +/- 0.2 mg/L for IPT, P = 0.001). Similar results were observed for IL-6. Changes in inflammation were independent of age, gender, body mass index, and ethnicity, but a significant interaction between cigarette smoking and treatment regimen was found. The IPT group also showed a decrease in total and LDL cholesterol after 2 months. Analysis of these data indicates that periodontitis causes moderate systemic inflammation in systemically healthy subjects.

Upregulation of gingival tissue miR-200b in obese periodontitis subjects.

Increased local immune and inflammatory responses in obese individuals with periodontitis may explain the aggressive clinical presentation and altered treatment response when compared to that of normal weight subjects. Our goal was to identify any differences in microRNA (miRNA) expression profiles of gingival tissue in periodontitis when obesity is present, which may suggest novel molecular pathways that this miRNA network may affect. Total RNA was extracted from gingival tissue biopsies collected from normal weight and obese individuals with periodontitis; miRNA expression profiling was performed with Affymetrix GeneChip miRNA 3.0 arrays; and results were validated with quantitative reverse transcription polymerase chain reaction (qRT-PCR). In silico identification of previously confirmed miRNA gene targets was conducted through miRTarBase and miRWalk databases, and pathway enrichment analysis identified enriched miRNA gene sets. Expression of selected genes in the same biopsy samples was tested with qRT-PCR. The gingival tissue miRNA profile of obese patients, compared to that of normal weight patients, showed 13 upregulated and 22 downregulated miRNAs, among which miR-200b was validated by qRT-PCR to be significantly increased in obesity. Functional analysis of 51 experimentally validated miR-200b gene targets identified enrichment of genes involved in cell motility, differentiation, DNA binding, response to stimulus, and vasculature development pathways not previously identified in the obesity-specific disease profile. Furthermore, the expression of the miR-200b gene targets ZEB1/2, GATA2, and KDR was confirmed by qRT-PCR as being lower in obese patients with periodontitis versus normal weight patients, suggesting a role of miR-200b in regulation of a set of gene targets and biological pathways relevant to wound healing and angiogenesis. Functional studies to explore the role of miR-200b in the above processes may offer new insights on putative therapeutic targets for this group of patients.

Periodontitis and systemic inflammation: control of the local infection is associated with a reduction in serum inflammatory markers.

Severe periodontitis is associated with elevated inflammatory markers in otherwise healthy populations. However, the nature of this association has not been determined. Our aim was to assess whether the degree of response to periodontal therapy was associated with changes in serological markers of systemic inflammation. Ninety-four systemically healthy subjects with severe generalized periodontitis participated in a prospective six-month blind intervention trial. Periodontal parameters and inflammatory markers [C-reactive Protein (CRP) and Interleukin-6 (IL-6)] were evaluated prior to and 2 and 6 mos after delivery of standard non-surgical periodontal therapy. Six months after treatment, significant reductions in serum IL-6 (p < 0.001, median decrease 0.2 ng/L, 95% CI 0.1-0.4 ng/L) and CRP (p < 0.0001, median decrease 0.5 mg/L, 95% CI 0.4-0.7) were observed. Decreases in inflammatory markers were significant in subjects with above average clinical response to periodontal therapy after correction for possible confounders. Periodontitis may add to the systemic inflammatory burden of affected individuals.

The simplified papilla preservation flap in the regenerative treatment of deep intrabony defects: clinical outcomes and postoperative morbidity.

BACKGROUND: The aims of the present multi-center, randomized, controlled clinical trial were: 1) to compare the efficacy of the simplified papilla preservation flap with and without a barrier membrane in deep intrabony defects; 2) to evaluate the postoperative morbidity and surgical complications; and 3) to preliminarily test the impact of baseline tooth mobility on clinical outcomes. METHODS: This parallel group, randomized, multi-center, controlled clinical trial involved 112 patients in 8 periodontal practices in 4 countries. A deep intrabony defect in each patient was accessed with the simplified papilla preservation flap. In the test defects, a bioabsorbable membrane was positioned. Patients' experiences with the surgical procedure and postoperative period were evaluated with a questionnaire. Clinical outcomes included clinical attachment level (CAL) and probing depth (PD) changes. RESULTS: Complete observations were available for 55 test and 54 control defects. CAL gains at 1 year were 3.5 +/- 2.1 mm in the guided tissue regeneration (GTR) group and 2.6 +/- 1.8 mm in the control group (P = 0.0117). CAL gains > or = 4 mm were observed in 50.9% of GTR sites and 33.3% of control sites. A significant center effect of 2.1 mm was observed (P= 0.01). Initial PD (P= 0.01) and baseline tooth mobility (P= 0.036) were significant covariates. During the procedure, 30.4% of test and 28.6% of controls reported feeling moderate pain, and subjects estimated the hardship of the procedure at 24 +/- 25 visual analog scale (VAS) units in the test group, and at 22 +/- 23 VAS in controls. In terms of the investigated outcomes, differences between test and control groups were not statistically significant. Among the postoperative complications, edema was most prevalent at week 1, and more frequently associated with the test treatment (P= 0.01). In the test group, 53.6% of membranes were exposed at week 3. CONCLUSIONS: The present study further supports the added benefits of guided tissue regeneration with respect to access flap alone in the treatment of deep intrabony defects, as well as the general efficacy of GTR in different clinical settings. Furthermore, our study indicates a possible influence of baseline tooth mobility on clinical outcomes.

Generalizability of the added benefits of guided tissue regeneration in the treatment of deep intrabony defects. Evaluation in a multi-center randomized controlled clinical trial.

BACKGROUND: Several studies have shown that GTR therapy of intrabony defects results in significantly better outcomes than access flap alone. Most of the available data, however, have been produced in highly controlled research environments by a small group of investigators. Generalizability of results to different clinicians and different subject populations has not been evaluated so far. METHODS: This parallel group study involved 143 patients recruited in a practice-based research network of 11 offices in 7 countries. It was designed to evaluate: 1) the applicability of the documented added benefits of GTR in the treatment of intrabony defects to different populations, and 2) the generalizability of the expected results to different clinicians. GTR was compared to access flap alone. Defects, one in each patient, were accessed with a previously described papilla preservation flap in both the test and control group. In addition, GTR sites received application of a bioabsorbable poly-D,L-lactide-co-glycolide membrane. A stringent plaque control regimen was enforced in all patients during the 1-year observation period. Outcomes included gains in clinical attachment (CAL) and reductions in probing depth. RESULTS: Observed gains in CAL were 2.18 +/- 1.46 mm for access flap and 3.04 +/- 1.64 mm for the GTR-treated group. The treatment-associated difference was statistically significant (P = 0.03) after correcting for both center effect and defect anatomy. Among the various centers, a 1.73 mm difference in CAL gain was observed. This is a clinically relevant amount, which underlines the significance of center variability in the outcome of periodontal surgical procedures. A frequency distribution analysis of the obtained CAL gains indicated that GTR treatment of deep intrabony defects decreased, with respect to the access flap control, the probability of obtaining only a modest attachment gain at 1 year. Conversely, CAL gains of 4 mm or more were observed in more than 40% of GTR-treated defects and in less than 20% of the controls (P < 0.0001). CONCLUSIONS: These data indicate that GTR therapy of deep intrabony defects performed by different clinicians on various patient populations resulted in both greater amounts and improved predictability of CAL gains than access flap alone.

Body mass index as a predictive factor of periodontal therapy outcomes.

Body mass index (BMI) and obesity are associated with the prevalence, extent, and severity of periodontitis. This study investigated the predictive role of overweight/obesity on clinical response following non-surgical periodontal therapy in patients with severe periodontitis. Two hundred sixty adults received an intensive course of non-surgical periodontal therapy. Periodontal status at baseline and 2 months was based upon probing pocket depths (PPD), clinical attachment levels (CAL), and whole-mouth gingival bleeding (FMBS) as assessed by two calibrated examiners. Generalized estimating equations (GEE) were used to estimate the impact of BMI and overweight/obesity on periodontal treatment response while controlling for baseline status, age, smoking status (smoker or non-smoker), and full-mouth dental plaque score. BMI (continuous variable) and obesity (vs. normal weight) were associated with worse mean PPD (p < .005), percentage of PPD > 4 mm (p = .01), but not with FMBS (p > .05) or CAL (p > .05) at 2 months, independent of age, smoking status, or dental plaque levels. The magnitude of this association was similar to that of smoking, which was also linked to a worse clinical periodontal outcome (p < .01). BMI and obesity appear to be independent predictors of poor response following non-surgical periodontal therapy.

Oxidative stress, systemic inflammation, and severe periodontitis.

Periodontal infections have been associated with a state of chronic inflammation. To ascertain whether severe periodontitis and its treatment are associated with oxidative stress, we recruited 145 cases (periodontitis) and 56 controls in a case-control study. A further pilot intervention study of 14 cases (periodontal therapy) was performed. Blood samples were taken at baseline (case-control) and 1, 3, 5, 7, and 30 days after treatment (intervention). Diacron-reactive oxygen metabolites (D-ROM), anti-oxidant potential, C-reactive protein (CRP), interleukin-6, and lipid profiles were determined with high-sensitivity assays in serum. Patients with severe periodontitis exhibited higher D-ROM levels (P < 0.001) and lower total anti-oxidant capacity (P < 0.001) compared with healthy control individuals. These findings were independent of age, gender, smoking habits, ethnicity, and standard lipids differences. D-ROM levels were positively correlated with CRP (R = 0.4, P < 0.001) and clinical periodontal parameters (R = 0.20, P < 0.05). Acute increases of D-ROM (P < 0.01) were observed following periodontal therapy. Analysis of these data suggests a positive association between severe periodontitis and oxidative stress.

Supportive periodontal therapy using mechanical instrumentation or 2% minocycline gel: a 12 month randomized, controlled, single masked pilot study.

OBJECTIVE: To compare the short-term performance of subgingival local delivery of 2% minocycline gel and conventional subgingival debridement in supportive periodontal therapy (SPT) patients. METHODS: Forty adult patients having completed active treatment for moderate to advanced chronic periodontitis were included in a randomized, controlled, single masked maintenance care pilot study. Sites with residual pocket probing depths > or =5 mm and bleeding on probing were treated with either minocycline gel (minocycline-group) or scaling and root planing only (debridement-group) at baseline, 3, 6, and 9 months. Clinical and microbiological examinations were performed at baseline, 3, 6, 9, and 12 months. RESULTS: Full-mouth plaque and bleeding scores remained <10% and <20%, respectively, for both groups throughout the study. In both groups there was a persistent reduction in number of teeth and sites with probing pocket depths > or =5 mm (p<0.05) with no significant differences between the groups. The prevalence of Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, Actinobacillus actinomycetemcomitans, Prevotella intermedia, and Prevotella nigrescens, remained at levels < or =10(5) in the majority of patients and sites in both groups. CONCLUSION: This pilot study failed to show a difference between local delivery of 2% minocycline gel as mono-therapy and traditional subgingival debridement in patients on SPT.

Clinical effects of root instrumentation using conventional steel or non-tooth substance removing plastic curettes during supportive periodontal therapy (SPT).

Although root instrumentation has been accepted as the most important cause-related treatment of periodontal diseases, repeated scaling and root planing may over time result in substantive loss of tooth substance and increased sensitivity of the teeth. In an effort to minimize these side effects of therapy, non-root substance removing curettes have been developed. However, the clinical effects of such plastic curettes with regard to the control of the periodontal infection has not yet been established. The aims of this study were, therefore, to compare the effects of root instrumentation using plastic curettes (Universal Perio Soft Scaler, Hawe-Neos Dental, Bioggio, TI, Switzerland) versus conventional steel curettes on the periodontal conditions during supportive periodontal therapy. 40 subjects participated in this parallel, randomized, double blind, prospective longitudinal clinical study following active peridontal therapy. 20 subjects served as a control group and were treated with conventional steel curettes during a supportive periodontal care visit (SPT). The other 20 subjects, the experimental group, were treated using plastic curettes during a similar SPT visit. Clinical parameters, such as bleeding on probing (BOP) and probing pocket depth (PPD), were assessed at baseline and 3-6 months later at the next regular SPT visit. In addition, the BOP percentage was determined 10 days following baseline. The results showed that there were no statistically significant differences between the 2 treatment modalities regarding BOP and PPD at any observation time. Both treatments were effective in reducing the BOP percentage which ranged from 17-42% at baseline by about 40% after 10 days (mean BOP baseline: 26%, mean BOP after 10 days: 16%). This clinical study suggests that non-root substance removing curettes may be valuable instruments for periodontally treated patients during maintenance care, thus minimizing trauma on the hard structures of the teeth.

Initial extractions and tooth loss during supportive care in a periodontal population seeking comprehensive care.

BACKGROUND/AIMS: This retrospective survey was aimed at determining the prevalence of tooth extractions and the dental pathologies associated with them during both the active and maintenance phase of periodontal therapy in a periodontal population seeking comprehensive dental care. METHODS: A total of 273 randomly selected subjects from the oral prophylaxis clinic of the University of Berne were included. All subjects had received comprehensive care consisting of periodontal and restorative treatment and participated in a supervised maintenance program for an average of 67+/-46 months (range 5 to 278 months). The population consisted of 39.6% current smokers and 27.8% previous smokers. 6.2% of the patients had gingivitis, 20.5% mild periodontitis, 48.4% moderate and 24.9% severe periodontitis. The average frequency of the recall visits was 4.4+/-1.5 appointments/year (range 1.7-12 appointments/year). RESULTS: Results indicated that 574 out of a total of 6503 teeth were extracted; 311 teeth were extracted during active therapy and 263 during the supportive periodontal care (SPC) phase of therapy. 46% of patients received tooth extractions as part of their active treatment and 41% during their participation in the secondary prevention program. In the subgroup whose treatment plan included extractions the average number was 2.5+/-1.6 teeth per patient. Likewise, the patients who received extractions during recall lost an average of 2.35+/-1.9 teeth per subject with an incidence of 0.4+/-0.37 teeth per patient per year. These data reinforce the concept that a minority of the population is responsible for the majority of tooth extractions, both during active therapy and SPC. Periodontal disease was the only pathology observed at 57% of the extracted teeth; while caries, endodontic pathology and technical problems in the absence of periodontitis were observed in 29% of cases. CONCLUSIONS: These observations indicate that the rendered treatment was effective in the long-term maintenance of the dentition of these subjects and suggest that advanced periodontal disease represented the major cause of tooth loss in this population.

Comparison of the clinical effects and gingival abrasion aspects of manual and electric toothbrushes.

AIMS: The clinical effects and gingival abrasion aspects of 2 electrical tooth-brushes (Braun Oral-B Plak Control Ultra and the novel development Braun Oral-B Plak Control 3D) were to be compared with conventional manual tooth-brushing. MATERIAL AND METHODS: In a cross-over study, 26 dental student volunteers participated and were assigned to 1 of 3 groups. Following instruction in the use of the electric as well as manual toothbrushes, the volunteers were timed for 2 min each day to apply one electric or the manual toothbrush, respectively, during 3 experimental phases of 2 weeks. No other methods of tooth cleaning were to be performed except the one specified for the respective test period. When brushing manually, the Bass toothbrushing technique was applied. Between each test period, a recovery period of 1 week was allowed during which no oral hygiene was performed at all. At the start and the end of each of the experimental periods, the extension of plaque deposits from the gingival margin in coronal direction was assessed using the Turesky et al. modification of the Quigley and Hein plaque index. Presence or absence of gingival inflammation was evaluated by bleeding and probing (BOP). The extent and severity of gingival abrasions were assessed by use of a modified method of Breitenmoser et al. and adapted by Danser et al. RESULTS: The plaque-reducing effect was similar in all groups with the same cleaning regime. For that reason, the result of the different experimental phases with the respective cleaning modalities were collapsed. Cleaning with the Braun Oral-B Plak Control Ultra electric toothbrush resulted consistently in the lowest plaque scores when compared to both the Braun Oral-B Plak Control 3D and the manual toothbrush. Although the differences in plaque reduction were statistically significant between cleaning with Braun Oral-B Plak Control Ultra and 3D, they were small and of questionable clinical relevance. No significant differences in plaque reductions were found between manual brushing and any of the 2 electric brushes. Gingival abrasions were least pronounced following brushing with the Braun Oral-B Plak Control 3D electric toothbrush. However, no significant differences in gingival abrasion were encountered following brushing with the Braun Oral-B Plak Control Ultra electric in comparison with the manual toothbrush. CONCLUSIONS: The results of the present study have shown that in a group of dental students trained in manual brushing technique, where efficacy was similar with the 3 toothbrushes tested, there is no evidence of greater gingival abrasion with either Braun Oral-B Plak Control Ultra or 3D when compared with a manual brush.

Phase 1 evaluation of a local delivery device releasing silver ions in periodontal pockets: safety, pharmacokinetics and bioavailability.

A new local delivery device (LDD) capable of releasing silver in periodontal pockets has been developed and tested pre-clinically. Silver has potent antimicrobial effects on Gram-negative periodontal pathogens with a mean in vitro minimum bactericidal concentration (MBC) < or =0.5 microg/ml. This phase 1 study assessed the safety, pharmacokinetics and bioavailability of silver ions delivered intracrevicularly with a resorbable LDD (PocketGuard) in a group of 9 volunteers affected with periodontitis. In each subject, a PLGA/PEG LDD loaded with 12% silver nitrate (w/w) was inserted in each of 4 selected pockets > or =5 mm. Serum, gingival fluid and subgingival plaque samples were evaluated before and at various time points after LDD placement for 21 days. At each time point, the concentration of silver in gingival crevicular fluid (GCF) was quantified with an Inductively Coupled Plasma-Mass Spectrometer. Subgingival plaque samples were processed for evaluation of total anaerobic and aerobic counts (CFU/ml). The maximum mean silver concentration in GCF was 1,493 +/- 709 microg/ml (range 589-2,245). It decayed exponentially with a half-life of 7.1 +/- 6.1 days (2.7-20.4). Average silver concentrations in excess of 10 microg/ml were detected in each patient for 14 days after LDD placement with the average concentration for all patients in excess of 25 microg/mL at day 21. Total anaerobic counts decreased an average of 1.7 +/- 1.9 x 10(6) CFU/ml (p= 0.0078) from baseline to day 7, indicating that the silver was biologically active. A mild increase in cervical root discoloration was observed at day 21:0.25 +/- 0.31 stain index units. Discoloration that did not resolve spontaneously could be removed at the end of the study with polishing. No systemic effects were observed. It is concluded that local silver concentrations above the MBC in serum were maintained for at least 21 days. A specific microbiologic effect was also observed.