Gingival Necrosis Related to Sepsis-Induced Agranulocytosis Due to Pseudomonas aeruginosa Bacteraemia: A Case Report.

Background: There have been no reports of sepsis-induced agranulocytosis causing gingival necrosis in otherwise medically healthy patients to the authors' best knowledge. Even though there are several case reports of gingival necrosis secondary to medication-induced agranulocytosis, they have not systematically described the natural progression of agranulocytosis-related gingival necrosis. Methods: This paper presents a case report of a 29-year-old female Indian patient with generalised gingival necrosis and constitutive signs of intermittent fever, nausea, and vomiting. She also complained of abdominal pains. Blood counts showed agranulocytosis, and the patient was admitted for a workup of the underlying cause. Parenteral broad-spectrum antibiotics were administered, which brought about clinical resolution. Results: Her gingival necrosis was attributed to sepsis-induced agranulocytosis triggered by Pseudomonas aeruginosa bacteraemia, and upon clinical recovery, spontaneous exfoliation left behind exposed bone. Secondary healing over the exposed alveolar bone was noted after a year-long follow-up, albeit with some residual gingival recession. Conclusions: Oral manifestations of gingival necrosis, when present with concomitant constitutive symptoms, could indicate a serious underlying systemic condition that could be potentially life-threatening if left untreated. Dentists should be cognizant of this possibility so that timely intervention is not delayed.

A Mapping Review of the Pathogenesis of Peri-Implantitis: The Biofilm-Mediated Inflammation and Bone Dysregulation (BIND) Hypothesis.

This mapping review highlights the need for a new paradigm in the understanding of peri-implantitis pathogenesis. The biofilm-mediated inflammation and bone dysregulation (BIND) hypothesis is proposed, focusing on the relationship between biofilm, inflammation, and bone biology. The close interactions between immune and bone cells are discussed, with multiple stable states likely existing between clinically observable definitions of peri-implant health and peri-implantitis. The framework presented aims to explain the transition from health to disease as a staged and incremental process, where multiple factors contribute to distinct steps towards a tipping point where disease is manifested clinically. These steps might be reached in different ways in different patients and may constitute highly individualised paths. Notably, factors affecting the underlying biology are identified in the pathogenesis of peri-implantitis, highlighting that disruptions to the host-microbe homeostasis at the implant-mucosa interface may not be the sole factor. An improved understanding of disease pathogenesis will allow for intervention on multiple levels and a personalised treatment approach. Further research areas are identified, such as the use of novel biomarkers to detect changes in macrophage polarisation and activation status, and bone turnover.

The use of artificial intelligence to aid in oral hygiene education: A scoping review.

OBJECTIVES: Artificial intelligence (AI) has the potential to aid in constant, non-invasive monitoring of daily oral hygiene practices, potentially on behalf of a dentist or healthcare provider. This review summarises the evidence around the use of AI in the context of oral hygiene education. DATA & SOURCES: This scoping review was developed according to the Joanna Briggs Institute scoping review protocol guidelines and the PRISMA-ScR guidelines. Publications that involved the use of AI for oral hygiene education in any population and setting were included. A systematic electronic database search (MEDLINE via PubMed, EMBASE, Web of Science, Scopus, Cochrane Library, and IEEE Xplore, arXiv, Proquest, Google Scholar, ClinicalTrials.gov, and PROSPERO) up to, and including 4 February 2023 was carried out. Citation searching from the full-text of included publications was also performed. RESULTS: Of the 3215 publications screened, 20 were selected for qualitative synthesis. These were broadly divided into two categories of AI-assisted feedback: (1) synchronous and (2) asynchronous monitoring. There is a lack of high-quality studies, scarce reflection on possible ethical concerns on AI, and of studies comparing qualitative feedback to quantitative clinical outcomes with a control. Barriers to adoption of AI technologies, patient privacy, and specific areas for improvement were identified. CONCLUSION: Within the limitations of this study, the use of AI to modify oral hygiene behaviour is promising. Further work is required in generating higher quality intra-oral images for dental biofilm detection, and in developing more personalised feedback for users. CLINICAL SIGNIFICANCE: This is the first review to map out the available literature on AI in providing oral hygiene education. It may be useful to dental researchers in appraising AI-assisted technologies in the context of oral health.

Antibiotic resistance in the microbiota of periodontitis patients: an update of current findings.

Systemic antibiotics are an effective adjunct in the treatment of periodontitis, but their judicious use is necessary as antimicrobial resistance is a growing global concern. This review aims to explore the current understanding and insight related to antibiotic resistance in the subgingival microbiota of periodontitis patients. A search of MEDLINE (PubMed) was carried out from 1 January 2012 to 25 November 2021 for studies related to antibiotic resistance in periodontitis patients. Of the 90 articles identified, 12 studies were selected for inclusion. A significant incidence of antibiotic resistant isolates was reported for Porphyromonas gingivalis, Prevotella intermedia, Prevotella denticola, Prevotella melaninogenica, Fusobacterium nucleatum, Tanerella forsythia, Aggretibacter actinomycetemcomitans, Streptococcus constellatus, Streptococcus intermedius, and Parvimonas micra, but resistance to specific antibiotics did not reach above 10% of isolates in most studies except for amoxicillin resistance in Aggretibacter actinomycetemcomitans. The highest frequency of resistance across all bacterial species was for amoxicillin, clindamycin, and metronidazole. However, resistance patterns were widely variable across geographical locations, and the high heterogeneity between antibiotic-resistant isolates across studies precludes any clinical recommendations from this study. Although antibiotic resistance has yet to reach critical levels in periodontitis patients, an emphasis on antibiotic stewardship interventions such as point-of-care diagnostics and education for key stakeholders is needed to curb a growing problem.

Comparative Efficacy of Different Flapless Ridge Preservation Techniques: A Systematic Review and Meta-Analysis.

Although the efficacy of ridge preservation is well documented, there is a lack of robust evidence regarding the influence of different surgical techniques. Flapless approaches are thought to be better at preserving soft tissue architecture and have been suggested for mild to moderate defects. This review investigates the efficacy of different flapless techniques for ridge preservation in mild to moderate defects with <50% buccal bone loss. PubMed, EMBASE, and Cochrane Library databases were searched to obtain relevant articles published in English from 1974 to December 2019. The primary outcome was horizontal and vertical hard tissue dimensional changes. Soft tissue changes were evaluated as a secondary outcome. The Bio-Col technique, subperiosteal tunnel technique, and hard tissue with autogenous soft tissue graft/collagen matrix technique were identified. Eight studies were included, and quantitative analyses were performed for 4 studies for the primary outcome variables. The meta-analysis revealed significant reductions for horizontal changes (weighted mean difference [WMD] = 2.56 mm, 95% CI [2.18, 2.95]), vertical mid-buccal (WMD = 1.47 mm, 95% CI [1.04, 1.90]), and vertical mid-lingual (WMD = 1.28 mm, 95% CI [0.68, 1.87]) in favor of flapless ridge preservation techniques. Subgroup analysis based on technique suggests minimal hard tissue differences. The efficacy of flapless ridge preservation techniques on soft tissue changes was inconclusive. In conclusion, flapless ridge preservation techniques are effective for mild to moderate defects. The technique or material used to close the extraction socket does not seem to significantly affect hard tissue changes, while the effect on soft tissue changes warrants further investigation.

Macromolecular Crowding as an Intracellular Stimulus for Responsive Nanomaterials.

Stimuli-responsive materials are exploited in biological, materials, and sensing applications. We introduce a new endogenous stimulus, biomacromolecule crowding, which we achieve by leveraging changes in thermoresponsive properties of polymers upon high concentrations of crowding agents. We prepare poly(2-oxazoline) amphiphiles that exhibit lower critical solution temperatures (LCST) in serum above physiological temperature. These amphiphiles stabilize oil-in-water nanoemulsions at temperatures below the LCST but are ineffective surfactants above the LCST, resulting in emulsion fusion. We find that the transformations observed upon heating nanoemulsions above their surfactant's LCST can instead be induced at physiological temperatures through the addition of polymers and protein, rendering thermoresponsive materials "crowding responsive." We demonstrate that the cytosol is a stimulus for nanoemulsions, with droplet fusion occurring upon injection into cells of living zebrafish embryos. This report sets the stage for classes of thermoresponsive materials to respond to macromolecule concentration rather than temperature changes.

The efficacy of probiotics in the management of intra-oral halitosis: a systematic review.

OBJECTIVES: To evaluate the efficacy of probiotics in reducing halitosis of dental origin. METHODS: MEDLINE, EMBASE, and CENTRAL were searched up to and including June 2020. Randomised placebo-controlled, double-blinded clinical trials in systemically healthy adult patients who were given any form of probiotics to manage halitosis of dental origin were included. Primary outcome measures were organoleptic scores and volatile sulphur concentration levels. Secondary outcome measures were microbiologic parameters and quality of life (QOL). RESULTS: Of the 301 potentially relevant articles, eight articles were selected for the review. The risk of bias assessment showed that two studies were of low risk of bias, four studies had some concerns, and two studies had a high risk of bias. The beneficial effect of probiotics could neither be confirmed in periodontally treated patients administered with up to 8 weeks of probiotics, nor in periodontitis patients who received both non-surgical periodontal therapy and adjunctive probiotics up to 90 days. Microbiological findings 1 month after probiotics administration and QOL measures showed no significant differences compared to control. Considerable heterogeneity was observed among probiotic administration protocols. CONCLUSIONS: The available evidence suggests no convincing benefit for the use of probiotics in the management of halitosis. Standardised protocols on recruitment of halitosis subjects and organoleptic measurements are required for future studies on probiotics as an intervention. CLINICAL RELEVANCE: The lack of well-conducted studies with a low risk of bias precludes any clinical recommendation. Further research is needed to verify the efficacy of probiotics in the management of intra-oral halitosis.

Healing complications and their detrimental effects on bone gain in vertical-guided bone regeneration: A systematic review and meta-analysis.

PURPOSE: Guided bone regeneration (GBR) utilizes a barrier membrane to allow osteogenic cells to populate a space by excluding epithelial and connective tissue cells. The purpose of this systematic review was to investigate the ratio of means (RoM) of vertical bone gained (Outcome) in vertical GBR procedures with healing complications (Intervention) and in vertical GBR procedures without healing complications (Comparison) in patients with vertically resorbed edentulous ridges that require dental implant placement (Population). A further aim was to investigate the incidence of complications after vertical GBR, and the influence of the timing of implant placement and regenerative devices on complications. MATERIALS AND METHODS: MEDLINE (through PubMed), EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched in duplicate up to, and including, November 2020 for randomized and controlled clinical trials and prospective and retrospective case series. Outcomes included patient-level and site-level RoM of vertical bone gain between healing complications and uneventful healing, and incidences of complications that occurred after vertical GBR. Random-effects and fixed-effects meta-analyses were performed where appropriate. This study was registered on PROSPERO (CRD42021226432). RESULTS: A total of 31 publications were selected for the qualitative and quantitative analyses. The RoM of vertical bone gained was 0.65 [95% CI = 0.47, 0.91] and 0.62 [95% CI = 0.45, 0.85] when membrane exposure without suppuration and abscess formation without membrane exposure occurred respectively, in comparison to uneventful healing. The overall incidence proportion of healing complications occurring at the augmented site at a site- and patient-level was 11.0% [95% CI = 7.0, 15.6] and 10.8% [95% CI = 6.6, 15.7]. At a patient-level, there were no significant differences between a simultaneous or staged approach, or with the regenerative device used. The site-level incidence proportion of membrane exposure without suppuration, membrane exposure with suppuration, and with abscess formation without membrane exposure was 8.7% [95% CI = 4.2, 14.2], 0.7% [95% CI = 0.0, 2.9], and 0.5% [95% CI = 0.0, 1.7], respectively. The site-level weighted mean incidence proportion of neurologic complications occurring at the donor site was 0.8% [95% CI = 0.0, 5.3]. CONCLUSIONS: There is a significant reduction in bone gain when healing complications occur. However, healing complications are relatively uncommon surgical complications after vertical GBR.

Adjunctive probiotics after periodontal debridement versus placebo: a systematic review and meta-analysis.

OBJECTIVE: To comprehensively investigate the efficacy of adjunctive probiotics compared to placebo, using conventional and novel treatment outcomes. MATERIALS AND METHODS: Three databases (MEDLINE, EMBASE, and CENTRAL) were searched. Outcomes included percent change in the total number of deep sites before and after therapy, change in mean probing pocket depth (mm), percentage patients requiring additional therapy, risk for disease progression, and microbiological and immunological results. Meta-analysis was conducted to evaluate treatment effects wherever appropriate. RESULTS: Ten studies were selected from 818 records. Meta-analysis showed that adjunctive probiotics had no additional benefit for percentage change of the total number of deeper sites (≥5 mm, ≥6 mm, ≥7 mm) before and after therapy. No significant difference was observed for mean probing pocket depth reduction at 3 and 6 months. Statistically significant beneficial odds ratios for need for additional therapy (OR = 0.19, 95% CI [0.07-0.56]) and risk of disease progression (OR = 0.32, 95% CI [0.14-0.73]) were observed with probiotic administration. Immunological rather than microbiological outcomes correlated more consistently with clinical findings. No adverse events were reported. CONCLUSIONS: Adjunctive probiotics are safe in systemically healthy individuals and could offer additional patient-level benefits compared to placebo, hence its use can sometimes be justified.

Minimally Invasive Periodontology: A Treatment Philosophy and Suggested Approach.

Severe periodontitis is a highly prevalent dental disease. With the advent of implant dentistry, teeth are often extracted and replaced. Periodontal surgery, where indicated, could also result in increased trauma to the patient. This literature review discusses different treatment modalities for periodontitis and proposes a treatment approach emphasizing maximum preservation of teeth while minimizing morbidity to the patient. Scientific articles were retrieved from the MEDLINE/PubMed database up to January 2021 to identify appropriate articles that addressed the objectives of this review. This was supplemented with hand searching using reference lists from relevant articles. As tooth prognostication does not have a high predictive value, a more conservative approach in extracting teeth should be abided by. This may involve repeated rounds of nonsurgical periodontal therapy, and adjuncts such as locally delivered statin gels and subantimicrobial-dose doxycycline appear to be effective. Periodontal surgery should not be carried out at an early phase in therapy as improvements in nonsurgical therapy may be observed up to 12 months from initial treatment. Periodontal surgery, where indicated, should also be minimally invasive, with periodontal regeneration being shown to be effective over 20 years of follow-up. Biomarkers provide an opportunity for early detection of disease activity and personalised treatment. Quality of life is proposed as an alternative end point to the traditional biomedical paradigm focused on the disease state and clinical outcomes. In summary, minimally invasive therapy aims to preserve health and function of the natural dentition, thus improving the quality of life for patients with periodontitis.

Economic evaluations in the treatment and evaluation of patients with periodontal disease: A critical review.

AIM: To evaluate the types and quality of reporting of economic evaluations carried out in the clinical management of periodontal disease over 32 years from 1987 to 2019. MATERIAL AND METHODS: A systematic search of articles from 1987 to 2019 was conducted using PubMed, Web of Science, The Cochrane Central Register of Controlled Trials, Health Technology Assessment Database and Embase. The quality of the economic evaluations was assessed based on the Consolidated Health Economic Evaluation Reporting Standard checklist. Due to considerable between-study heterogeneity, a meta-analysis was not performed. RESULTS: Twenty one publications were included. 11 studies used cost-effectiveness analysis, five used cost-minimization analysis, four used cost-utility analysis and two used cost-benefit analysis. Comparators, choice of health outcomes, estimating resources and costs were fully reported in all studies. Many studies had inadequate reporting in terms of estimating resources and costs, choice of health outcomes, characterizing heterogeneity and study perspective. CONCLUSIONS: There has been an increase in health economics studies in the field of clinical periodontology over the past decade. Several studies did not report study perspective, and the health outcomes chosen were not relevant for some studies. Future studies should follow an economic evaluation checklist for high-quality reporting and consistency.

Metagenomic sequencing provides new insights into the subgingival bacteriome and aetiopathology of periodontitis.

"Open-ended" molecular techniques such as 16S rRNA sequencing have revealed that the oral bacteriome of subgingival plaque is more diverse than originally thought. 16S rRNA analysis has demonstrated that constituents of the overall bacterial community are qualitatively similar in health and disease, differing mainly in their relative proportions with respect to each other. Species in low abundance can also act as critical species, leading to the concept of global community dysbiosis which relates to shifts in community structure, rather than shifts in membership. Correlation analysis suggests that coordinated interactions in the community are essential for incipient dysbiosis and disease pathogenesis. The subgingival bacteriome also provides biomarkers that are useful for disease detection and management. Combined with clinical and biological parameters, these may assist clinicians in developing and implementing effective treatment strategies to restore microbial homeostasis and monitor disease. Identification of higher risk groups or poor responders to treatment using unique subgingival bacteriome signatures may also lead to early intervention.

A Risk-Based Approach to the COVID-19 Pandemic: The Experience in National Dental Centre Singapore.

The emergence of a highly infectious coronavirus strain, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to a major global public health emergency. The increasing number of infected cases and fatalities worldwide forced several countries into lockdown in a bid to control virus transmission. The practice of dentistry is considered high-risk due to the generation of aerosols associated with most dental procedures, and healthcare professionals must take appropriate precautions whilst working in this challenging environment. This review aims to provide an overview on transmission routes and shares a risk-based approach to coronavirus disease 2019 (COVID-19) in a specialty tertiary center. Risk assessment and mitigation focussed on staff and patient safety, adopting a wide safety margin, and responding dynamically to the level of risk at the workplace. As the severity of the pandemic depends on many still-unknown factors and shows little sign of abating, the routine practice of dentistry will continue to be disrupted in the near future. We describe a color-coded framework to maximize safety and to minimize disease spread. Areas covered include healthcare team management, personal protective equipment, clinical work, and dental education. Guidelines in each category change with the corresponding severity of the situation, and we believe it will be useful for the safer practice of dentistry in this current climate and can be modified for future similar disease outbreaks.

An Overview of Different Interdental Cleaning Aids and Their Effectiveness.

Optimisation of plaque control is essential for the success of non-surgical and surgical periodontal therapy. This cannot be achieved with brushing alone; hence, there is a need for adjunctive interdental cleaning aids. The aim of this paper is to provide an overview of different interdental cleaning aids and review the literature for consensus on their effectiveness. A literature search of articles in English, up to December 2018, was conducted in Pubmed. High-quality flossing is difficult to achieve, and ineffective routine use of floss may not confer significant benefits over brushing alone. Interdental brushes are more effective than brushing as a monotherapy. They are at least as good if not superior to floss in reducing plaque and gingivitis. Although they are effective for patients regardless of their periodontal status (healthy or active), they are especially indicated in periodontal patients where widened embrasures are common. Added benefits include ease of use, patient acceptance, and recontouring of interdental tissues. Rubberpiks do not demonstrate inferiority to conventional interdental brushes. Wooden interdental aids appear to offer no significant advantage over brushing with respect to plaque removal; they may, however, reduce gingival bleeding. Oral irrigators are a promising tool for reducing gingival inflammation, despite minimal changes to plaque levels. For cleaning around dental implants, oral irrigators and interdental brushes are preferred over floss.

The efficacy of air polishing devices in supportive periodontal therapy: A systematic review and meta-analysis.

OBJECTIVE: This systematic review analyzes existing literature on the clinical efficacy of air polishing devices (APDs), discussing the evidence-based data available for justifying their use as an alternative to conventional periodontal debridement in supportive periodontal therapy. The main objective of the review was to assess whether APD was as equally efficient or superior in obtaining successful treatment outcomes when compared with conventional methods. DATA SOURCES: Following PRISMA guidelines, a systematic literature search of articles in English, up to December 2016, was conducted using PubMed, Cochrane, and Medline. Relevant articles were selected based on specific criteria. Seven studies were selected for the final assessment. One more study was added after a manual search of the literature. Due to considerable heterogeneity in study designs and outcome variables measured, only clinical parameters (probing depth, bleeding on probing, and clinical attachment level) were selected for meta-analysis. CONCLUSION: The studies selected for this systematic review provide some evidence that APDs as monotherapy could be an alternative to conventional debridement of single- and multi-rooted teeth with no furcation involvement, during supportive periodontal therapy. Comparing clinical and microbiologic outcomes, APDs seem to be as effective as conventional treatments. The primary advantage for the use of APDs in supportive periodontal therapy seems to be their ability to efficiently remove biofilm, without causing damage to the periodontal soft tissues or tooth and root structure. There may also be an advantage regarding patient comfort and time consumed.

Methodological Comparisons of Heart Rate Variability Analysis in Patients With Type 2 Diabetes and Angiotensin Converting Enzyme Polymorphism.

Angiotensin converting enzyme (ACE) polymorphism has been shown to be important in hypertension progression and also in diabetes complications, especially associated with heart disease. Heart rate variability (HRV) is an established measure for classification of autonomic function regulating heart rate, based on the interbeat interval time series derived from a raw ECG recording. Results of this paper show that the length (number of interbeat intervals) and preprocessing of the tachogram affect the HRV analysis outcome. The comparison was based on tachogram lengths of 250, 300, 350, and 400 RR-intervals and five preprocessing approaches. An automated adaptive preprocessing method for the heart rate biosignal and tachogram length of 400 interbeat intervals provided the best classification. HRV results differed for the Type 2 Diabetes Mellitus (T2DM) group between the I/I genotype and the I/D and D/D genotypes, whereas for controls there was no significant difference in HRV between genotypes. Selecting an appropriate length of recording and automated preprocessing has confirmed that there is an effect of ACE polymorphism including the I/I genotype and that I/I should not be combined with I/D genotype in determining the extent of autonomic modulation of the heart rate.

Relationship between heart rate variability and angiotensinogen gene polymorphism in diabetic and control individuals.

Heart Rate Variability (HRV) is extensively used to investigate general Autonomic Nervous System (ANS) function and is affected by many factors including age, gender, pathology such as diabetes and genetic polymorphisms. One of these genetic polymorphisms is the Angiotensin Converting Enzyme (ACE) polymorphism corresponding to insertion (I) or deletion (D) of a 287-base pair sequence of DNA in intron 16 of the ACE gene (rs4340). Some studies have addressed the relationship between HRV and D/D, I/D and I/I ACE polymorphism while others combined I/D and I/I ACE groups. In this study HRV is determined for diabetic and control individuals with different ACE polymorphism considering either separate or combined I/D and I/I genotypes. Linear time domain parameters, entropy, low frequency and total power of HRV were found to be significantly different between diabetic and control individuals with combined I/I and I/D ACE polymorphism, while only entropy was different for diabetic and control subjects with D/D ACE genotype. Separate analysis of I/I and I/D genotypes was preferred for a thorough investigation of HRV and ACE polymorphism, as the combined analysis masked some differences in HRV parameters such as Poincaré plot between ACE polymorphisms and diabetes status. Furthermore, a separate analysis demonstrated that most of the significant differences for HRV were between the diabetic group with I/I genotype and I/D and D/D groups.