Periodontitis and Cardiovascular Diseases. Consensus Report.

Background: In Europe cardiovascular disease (CVD) is responsible for 3.9 million deaths (45% of deaths), being ischaemic heart disease, stroke, hypertension (leading to heart failure) the major cause of these CVD related deaths. Periodontitis is also a chronic non-communicable disease (NCD) with a high prevalence, being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease. Material and Methods: There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In 2012 a joint workshop was held between the European Federation of Periodontology (EFP) and the American Academy of Periodontology to review the literature relating periodontitis and systemic diseases, including CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations. Results and Conclusions: The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation (WHF), which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes. This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices.

Oral Vaccination with Hepatitis E Virus Capsid Protein and Immunobiotic Bacterium-Like Particles Induce Intestinal and Systemic Immunity in Mice.

The hepatitis E virus (HEV) genotype 3 (GT3) is an emergent pathogen in industrialized countries. It is transmitted zoonotically and may lead to chronic hepatitis in immunocompromised individuals. We evaluated if the major antigen of HEV, the capsid protein, can be used in combination with immunobiotic bacterium-like particles (IBLP) for oral vaccination in a mouse model. We have cloned and expressed the RGS-His5-tagged HEV GT3 capsid protein (ORF2) in E. coli and purified it by NiNTA. IBLP were obtained from two immunobiotic Lactobacillus rhamnosus strains acid- and heat-treated. ORF2 and the IBLP were orally administered to Balb/c mice. After three oral immunizations (14-day intervals), blood, intestinal fluid, Peyer´s patches, and spleen samples were drawn. IgA- and IgG-specific antibodies were determined by ELISA. Mononuclear cell populations from Peyer's patches and spleen were analyzed by flow cytometry, and the cytokine profiles were determined by ELISA to study cellular immunity. Orally administered recombinant ORF2 and IBLP from two L. rhamnosus strains (CRL1505 and IBL027) induced both antigen-specific humoral and cellular immune responses in mice. IBLP027 was more effective in inducing specific secretory IgA in the gut. IFN-γ, TNF-α, and IL-4 were produced by Peyer's plaques lymphocytes stimulated with ORF2 ex vivo suggesting a mixed Th1/Th2-type adaptive immune response in immunized mice. Oral vaccines are not invasive, do not need to be administered by specialized personal, and elicit both systemic and local immune responses at the port of entry. Here, we present an experimental oral vaccine for HEV GT3, which could be further developed for human and/or veterinary use.

The directional and non-directional associations of periodontitis with chronic kidney disease: A systematic review and meta-analysis of observational studies.

This systematic review aimed to assess the current evidence on the directional and non-directional associations of periodontitis with chronic kidney disease (CKD). Electronic search for observational studies on the association of periodontitis with CKD was performed in MEDLINE, EMBASE, PubMed, Open GREY and Cochrane library up to June 5, 2017. Two reviewers conducted study selection, data collection and assessment of methodological quality using the original and modified Newcastle-Ottawa Scale. Cohort, case-control and cross-sectional studies were included, which clearly defined periodontitis and CKD or reported acceptable clinical parameters of these 2 diseases in adults. Meta-analysis was employed to estimate the pooled odds ratio on the non-directional association and the incidence rate ratio (IRR) for the directional association. Among 2530 potential eligible articles, 47 were finally included. Most of them investigated a non-directional association of periodontitis with CKD, including 7 case-control studies and 38 cross-sectional studies; 24 studies had statistical analysis on the non-directional association and 75% of them reported significant results, which were supported further by the meta-analysis (random: odds ratio = 2.12, P < .001; χ2  = 25.74, I2  = 88.3%). None of the studies focused on the directional association of CKD (as the exposure) with periodontitis (as the outcome), whereas 2 retrospective cohort studies explored a directional association of periodontitis (as the exposure) with CKD (as the outcome) (random: IRR=2.10, P > .05; fixed: IRR=1.76, P < .05; χ2  = 4.65, I2  = 78.3%). Overall, the high heterogeneity of studies limits the significance of these results. There is substantial evidence on the non-directional association of periodontitis with CKD, while there are limited studies on the directional association. Well-designed prospective studies with longer follow-ups in representative communities are needed to clarify the directional association and enhance the quality of the evidence on this topic.

The oral microbiome - an update for oral healthcare professionals.

For millions of years, our resident microbes have coevolved and coexisted with us in a mostly harmonious symbiotic relationship. We are not distinct entities from our microbiome, but together we form a 'superorganism' or holobiont, with the microbiome playing a significant role in our physiology and health. The mouth houses the second most diverse microbial community in the body, harbouring over 700 species of bacteria that colonise the hard surfaces of teeth and the soft tissues of the oral mucosa. Through recent advances in technology, we have started to unravel the complexities of the oral microbiome and gained new insights into its role during both health and disease. Perturbations of the oral microbiome through modern-day lifestyles can have detrimental consequences for our general and oral health. In dysbiosis, the finely-tuned equilibrium of the oral ecosystem is disrupted, allowing disease-promoting bacteria to manifest and cause conditions such as caries, gingivitis and periodontitis. For practitioners and patients alike, promoting a balanced microbiome is therefore important to effectively maintain or restore oral health. This article aims to give an update on our current knowledge of the oral microbiome in health and disease and to discuss implications for modern-day oral healthcare.

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.

Global oral health inequalities: task group--periodontal disease.

Periodontal diseases constitute one of the major global oral health burdens, and periodontitis remains a major cause of tooth loss in adults worldwide. The World Health Organization recently reported that severe periodontitis exists in 5-20% of adult populations, and most children and adolescents exhibit signs of gingivitis. Likely reasons to account for these prevalent diseases include genetic, epigenetic, and environmental risk factors, as well as individual and socio-economic determinants. Currently, there are fundamental gaps in knowledge of such fundamental issues as the mechanisms of initiation and progression of periodontal diseases, which are undefined; inability to identify high-risk forms of gingivitis that progress to periodontitis; lack of evidence on how to prevent the diseases effectively; inability to detect disease activity and predict treatment efficacy; and limited information on the effects of integration of periodontal health as a part of the health care program designed to promote general health and prevent chronic diseases. In the present report, 12 basic, translational, and applied research areas have been proposed to address the issue of global periodontal health inequality. We believe that the oral health burden caused by periodontal diseases could be relieved significantly in the near future through an effective global collaboration.

The influence of surface microroughness and hydrophilicity of titanium on the up-regulation of TGFß/BMP signalling in osteoblasts.

The topography of titanium implants has been identified as an important factor affecting the osseointegration of surgically placed dental implants. Further modification to produce a hydrophilic microrough titanium implant surface has been shown to increase osseointegration compared with microrough topology alone. This study aimed to determine possible molecular mechanisms to explain this clinical observation by examining differences in the whole genome mRNA expression profile of primary human osteoblasts in response to sand-blasted acid-etched (SLA) and hydrophilic SLA (modSLA) titanium surfaces. A decrease in osteoblast proliferation associated with the titanium surfaces (modSLA > SLA > control) correlated with an increase in expression of the osteogenic differentiation markers BSPII and osteocalcin. Pathway analysis demonstrated that a number of genes associated with the TGFß­BMP signalling cascade (BMP2, BMP6, SP1, CREBBP, RBL2, TBS3, ACVR1 and ZFYVE16) were significantly differentially up-regulated with culture on the modSLA surface. BMP2 was shown to have the largest fold change increase in expression which was subsequently confirmed at the protein level by ELISA. Several other genes associated with the functionally important mechanisms relevant to bone healing, such as Wnt signalling (CTNNA1, FBX4, FZD6), angiogenesis (KDR), osteoclastogenesis (HSF2, MCL1) and proteolysis (HEXB, TPP1), were also differentially regulated. These results suggest that chemical (hydrophilic) modification of the SLA surface may result in more successful osseointegration through BMP signalling.

Association between periodontitis and common variants in the promoter of the interleukin-6 gene.

We recently reported an association between interleukin-6 (IL6) polymorphisms (SNPs) and haplotypes and aggressive periodontitis (AgP). The aim of this study was to investigate this association in a larger cohort of subjects, affected by either aggressive or chronic periodontitis. Five IL6 SNPs were analyzed in 765 subjects (167 generalized aggressive periodontitis, 57 localized aggressive, 310 chronic periodontitis and 231 periodontally healthy). Among Caucasians (n=454) there were moderate associations for -1363T allele (p=0.011) and for -174GG and -1363GG genotypes with diagnosis of periodontitis (respectively, p=0.044, OR=1.6, 95% CI=1.0-2.4, and p=0.017, OR=1.8, 95% CI=1.1-2.8, adjusted for age, gender and smoking). Haplotypes containing the -174G>C, -1363G>T and -1480C>G polymorphisms were associated with diagnosis of periodontitis (p=0.02). Subgroup analysis by disease phenotype showed associations for the localized AgP (LAgP) group and -1480C>G and -6106A>T SNPs (p=0.007 and 0.010, respectively). Among Caucasians the genotypes IL6 -1480 CC and -6106 TT increased the adjusted OR for LAgP (OR=3.09 and 2.27, respectively). This study supports the hypothesis that IL6 polymorphisms and haplotypes are moderately associated with periodontitis, possibly acting through influencing tissue levels of IL6. This association is stronger for LAgP than for other periodontal disease phenotypes.

Association of the composite IL-1 genotype with peri-implantitis: a systematic review.

OBJECTIVE: Cytokine gene polymorphisms may modulate the host response to the bacterial challenge and influence susceptibility to peri-implantitis. OBJECTIVE: To systematically review the evidence of an association between the interleukin-1 (IL-1) composite genotype, i.e. presence of the allele 2 in the gene clusters IL-1A (-889) and in IL-1B (+3953), and peri-implantitis. MATERIAL AND METHODS: An electronic search in the National Library of Medicine-computerized bibliographic database MEDLINE and a manual search were performed. The search was conducted for longitudinal clinical trials comparing progression of peri-implantitis in IL-1 genotype positive (carrying allele 2) with IL-1 genotype negative (not carrying allele 2) subjects. Selection of publications, extraction of data and validity assessment were made independently by two reviewers. RESULTS: The search provided 44 titles of which two longitudinal publications were included. CONCLUSION: Based on the findings from this study, there is not enough evidence to support or refute an association between the IL-1 genotype status and peri-implantitis. Systematic genetic testing for the assessment of the risk of peri-implantitis cannot be recommended as a standard of care at this time.

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.

Regenerative periodontal therapy in intrabony defects: state of the art.

Many scientific data show that periodontal regeneration is an effective and predictable procedure for the treatment of isolated and multiple intrabony defects. Meta-analyses from systematic reviews show a clinical advantage in terms of clinical attachment level gain when demineralized freeze dried bone allograft, barrier membranes and amelogenins are applied in comparison with open flap debridement alone. On the other hand, a consistent amount of variability of the outcomes is evident among different studies and within the experimental population of the same study. This variability is explained, at least in part, by the different patient and defect characteristics and by a different degree of skill of the surgeon. Patient-related factors are smoking habit, compliance with home oral hygiene and residual inflammation after cause-related therapy. Defect-associated factors include defect depth and Rx angle, number of residual bony walls, pocket depth, and the degree of hypermobility. Surgical skill and experience to manipulate the delicate papilla preservation techniques is required along with the knowledge of indication and limits of the different regenerative materials. A strategy to optimise the surgical design of the flap, the use of the regenerative materials according to their characteristics, and the application of passive sutures is presented in this review, along with the foundation of the scientific background.

Comparison of gingival blood flow during healing of simplified papilla preservation and modified Widman flap surgery: a clinical trial using laser Doppler flowmetry.

AIM: This prospective randomized-controlled clinical trial compared the gingival blood flow responses following simplified papilla preservation (test) versus modified Widman flap (control). MATERIALS AND METHODS: Twenty contra-lateral upper sites with pocket depth > or = 5 mm after initial treatment in 10 chronic periodontitis patients were randomly assigned to either test or control treatment, using a split-mouth design. Laser Doppler flowmetry recordings were performed pre-operatively, following anaesthesia, immediately post-operatively and on days 1, 2, 3, 4, 7, 15, 30 and 60, at nine selected sites per flap. RESULTS: Significant ischaemia was observed at all sites following anaesthesia and immediately post-operatively. At the mucosal flap basis, a peak hyperaemic response was observed on day 1, which tended to resolve by day 4 at the test sites, but persisted until day 7 at the control sites. The buccal and palatal papillae blood perfusion presented the maximum increase on day 7 in both groups and returned to baseline by day 15. Both surgical modalities yielded significant pocket depth reduction, recession increase and clinical attachment gain. CONCLUSIONS: Periodontal access flaps represent an ischaemia-reperfusion flap model. The simplified papilla preservation flap may be associated with faster recovery of the gingival blood flow post-operatively compared with the modified Widman flap.

Gingival blood flow changes following periodontal access flap surgery using laser Doppler flowmetry.

AIM: To investigate the pattern of gingival blood flow changes following periodontal access flap surgery by laser Doppler flowmetry (LDF). MATERIAL AND METHODS: Fourteen patients with chronic periodontitis presenting upper anterior sites with pocket depth >or=5 mm after initial treatment were included in the study. Periodontal access flap surgery was performed on the experimental areas and LDF recordings were taken at baseline, following anaesthesia, immediately postoperatively and on days 1, 2, 3, 4, 7, 15, 30 and 60 of healing, at nine predetermined sites per flap. RESULTS: Significant ischaemia was observed at all flap sites following anaesthesia and immediately postoperatively. At the alveolar mucosal sites, a peak increase of the gingival blood flow was observed on postoperative day 1 (p<0.001), which persisted until day 7 (p=0.012) and resolved by day 15. The mucosal sites close to the flap periphery presented higher blood perfusion compared with the sites located centrally in the flap. The microcirculatory perfusion of the buccal and palatal papillae was maximum on postoperative day 7 (p=0.013 and <0.001, respectively) and returned to baseline by day 15. CONCLUSION: Topographically distinct areas of the periodontal access flap consistently present different patterns of microvascular blood flow alterations during the wound-healing period.

Gene polymorphisms and the prevalence of key periodontal pathogens.

Growing evidence suggests that individual genetic susceptibility may influence the host's response to infections. The aim of this project was to study whether gene polymorphisms of inflammatory markers are associated with the presence of viable periodontopathogenic bacteria. We extracted genomic DNA from 45 young adults diagnosed with generalized aggressive periodontitis to study Fc receptors, formyl peptide receptor, Interleukin-6, tumor necrosis factor-alpha, and vitamin D receptor polymorphisms. The presence and viable numbers of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Tannerella forsythensis were determined by culture, and their identities confirmed by PCR. Multiple logistic regressions revealed that both Fcgamma receptor and IL-6 -174 polymorphisms were associated with increased odds of detecting A. actinomycetemcomitans, P. gingivalis, and T. forsythensis after adjustment for age, ethnicity, smoking, and periodontitis extent. These findings support the hypothesis that complex interactions between the microbiota and host genome may be at the basis of susceptibility to aggressive periodontitis.

The association of the composite IL-1 genotype with periodontitis progression and/or treatment outcomes: a systematic review.

BACKGROUND: Genetically transmitted traits such as cytokine gene polymorphisms may accentuate the host inflammatory response to the bacterial challenge and influence susceptibility to periodontitis. OBJECTIVE: To systematically review the evidence of an association between the interleukin-1 (IL-1) composite genotype, i.e. presence of the allele 2 in the gene clusters IL-1A-889 and in IL-1B +3953, and periodontitis progression and/or treatment outcomes. MATERIAL AND METHODS: Based on the focused question, a search was conducted for longitudinal clinical trials comparing progression of periodontitis and/or treatment outcomes in IL-1 genotype-positive (carrying allele 2) and IL-1 genotype-negative (not carrying allele 2) subjects. A search in the National Library of Medicine computerized bibliographic database MEDLINE and a manual search were performed. Selection of publications, extraction of data and validity assessment were made independently by two reviewers. RESULTS: The search provided 122 titles of which 11 longitudinal publications were included. The heterogeneity of the data prevented the performance of a meta-analysis. While findings from some publications rejected a possible role of IL-1 composite genotype on progression of periodontitis after various therapies, other reported a prognostic value for disease progression of the positive IL-1 genotype status. When assessed on a multivariate risk assessment model, several publications concluded that the assessment of the IL-1 composite genotype in conjunction with other covariates (e.g. smoking and presence of specific bacteria) may provide additional information on disease progression. The small sample size of the available publications, however, requires caution in the interpretation of the results. CONCLUSION: Based on these findings, (i) there is insufficient evidence to establish if a positive IL-1 genotype status contributes to progression of periodontitis and/or treatment outcomes. Therefore, (ii) results obtained with commercially available tests should be interpreted with caution.

NADPH oxidase (CYBA) and FcgammaR polymorphisms as risk factors for aggressive periodontitis: a case-control association study.

INTRODUCTION: Neutrophils (PMN) in aggressive periodontitis (AgP) patients have been reported to be hyperactive especially with regards to superoxide production. Polymorphisms in genes influencing PMN function have been proposed as candidate risk factors for AgP. The aim of this study was to test the association of specific gene polymorphisms affecting PMN functions with AgP. MATERIALS AND METHODS: Two hundred and twenty-four patients with confirmed diagnosis of AgP and 231 subjects with healthy periodontium took part in the study. A blood sample was collected from subjects and genotypes for p22phox (CYBA) NADPH oxidase, FP, Fcalpha and Fcgamma receptors were analysed in a blind fashion. RESULTS: The C242T p22phox NADPH oxidase T allele was significantly associated with AgP in a multiple logistic regression model adjusting for confounders, and this was observed for all subjects [p = 0.002, odds ratio (OR) = 1.87, 95% confidence interval (CI) = 1.27-2.83] and Caucasians (p = 0.009, OR=2.07, 95% CI = 1.20-3.59). Concomitant presence of C242T p22phox NADPH oxidase T allele and FcgammaRIIIb NA1 homozygosity was associated with the generalized AgP phenotype in Caucasians (p = 0.001, OR = 30.35, 95% CI = 3.81-241.97). CONCLUSIONS: C242T p22phox NADPH oxidase and FcgammaR polymorphisms may predispose to AgP through a modulation of neutrophil superoxide production.

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.

Periodontal therapy: a novel acute inflammatory model.

OBJECTIVE AND DESIGN: We designed a clinical trial at the Eastman Dental Hospital with the objective of developing a novel in vivo inflammatory model. SUBJECTS: We recruited 55 subjects suffering from severe periodontitis. TREATMENT: Participants received intensive periodontal therapy. METHODS: Blood samples were collected at baseline and 1 and 7 and 30 days after treatment and processed for a series of biomarkers (TNF-alpha, IL-6, CRP and Fibrinogen) by high-sensitivity assays and differential blood counts (standard laboratory procedures). RESULTS: TNF-alpha levels were significantly raised only after 1 day of therapy (P<0.01) whereas IL-6 (P<0.01), CRP (P<0.001) and Fibrinogen (P<0.001) concentrations peaked 24 hrs after and returned to baseline values within one month following therapy. Mild neutrophilia, monocytosis and lymphopenia were also observed. CONCLUSIONS: Intensive periodontal therapy induces a one week moderate inflammatory response and therefore it is proposed as a novel therapeutic and reliable non drug-induced in vivo model of acute inflammation.

Functional gene polymorphisms in aggressive and chronic periodontitis.

There is strong evidence that genetic as well as environmental factors affect the development of periodontitis, and some suggestion that aggressive and chronic forms of the disease share the same genetic predisposition. This study addresses the hypothesis that there are both shared and unique genetic associations in these forms of periodontitis. A sample of 51 patients with aggressive disease, 57 patients with chronic disease, and 100 healthy controls was recruited for this study. Ten functional polymorphisms in 7 candidate genes were genotyped. The results show statistically significant (p