BSP Implementation of Prevention and Treatment of Peri-implant Diseases - The EFP S3 Level Clinical Practice Guideline.

OBJECTIVES: to adapt the supranational European Federation of Periodontology (EFP) Prevention and Treatment of Peri-implant Diseases - The EFP S3 Level Clinical Practice Guideline for UK healthcare environment, taking into account a broad range of views from stakeholders and patients. SOURCES: This UK version, based on the supranational EFP guideline [1] published in the Journal of Clinical Periodontology, was developed using S3-level methodology, combining assessment of formal evidence from 13 systematic reviews with a moderated consensus process of a representative group of stakeholders, and accounts for health equality, environmental factors and clinical effectiveness. It encompasses 55 clinical recommendations for the Prevention and Treatment of Peri-implant Diseases, based on the classification for periodontal and peri-implant diseases and conditions [2]. METHODOLOGY: The UK version was developed from the source guideline using a formal process called the GRADE ADOLOPMENT framework. This framework allows for adoption (unmodified acceptance), adaptation (acceptance with modifications) and the de novo development of clinical recommendations. Using this framework, following the S3-process, the underlying evidence was updated and a representative guideline group of 111 delegates from 26 stakeholder organisations was assembled into four working groups. Following the formal S3-process, all clinical recommendations were formally assessed for their applicability to the UK and adoloped accordingly. RESULTS AND CONCLUSION: Using the ADOLOPMENT protocol, a UK version of the EFP S3-level clinical practice guideline for the Prevention and Treatment of Peri-implant Diseases was developed. This guideline delivers evidence- and consensus-based clinical recommendations of direct relevance to the UK healthcare community including the public. CLINICAL SIGNIFICANCE: The S3-level-guidelines combine evaluation of formal evidence, grading of recommendations and synthesis with clinical expertise of a broad range of stakeholders. The international S3-level-guideline was implemented for direct clinical applicability in the UK healthcare system, facilitating a consistent, interdisciplinary, evidence-based approach with public involvement for the prevention and treatment of peri-implant diseases.

Peri-implant diseases and systemic inflammation: A preliminary analysis from a cross-sectional survey of patients with hypertension.

BACKGROUND: The aim of this study was to investigate the association between peri-implant diseases and systemic inflammation assessed by serum C-reactive protein (CRP) levels in a sample of patients with hypertension. METHODS: A total of 151 participants with hypertension were included in a cross-sectional study. The population was divided into six groups according to their peri-implant and periodontal status (healthy controls, mucositis, peri-implantitis, periodontitis, periodontitis and mucositis, periodontitis, and peri-implantitis). Linear, logistic regression, and correlation analyses were performed. RESULTS: CRP levels were statistically significantly higher in participants with periodontitis alone (median 3.2 mg/L, interquartile range [IQR] 1.8, p = 0.012), combined with mucositis (3.10 mg/L, IQR 2.35, p < 0.001) or peri-implantitis (2.7 mg/L, IQR 2.53, p = 0.002) when compared to the healthy controls (1 mg/L, IQR 1.2). This association was independent of age, sex, smoking status, and adiposity differences. Participants with periodontitis with and without peri-implant diseases had the greatest odds of exhibiting CRP > 3 mg/L (odds ratio = 7.3, 95% confidence interval 1.6-33.9). CONCLUSIONS: Peri-implant diseases are associated with systemic inflammation, but the nature of the association should be further investigated.

Systematic review and meta-analysis of randomized controlled trials evaluating the efficacy of non-surgical periodontal treatment in patients with concurrent systemic conditions.

OBJECTIVE: To conduct a systematic review of the published scientific evidence to evaluate the efficacy of nonsurgical periodontal therapy (NSPT) in treating periodontitis in patients with concurrent systemic conditions (diabetes, CVD, erectile dysfunction, chronic kidney disease, rheumatoid arthritis, polycystic ovarian syndrome, obesity, pregnancy). We hypothesised that NSPT results in better periodontal outcomes when compared to untreated controls after follow-up. MATERIALS AND METHODS: A systematic search (PUBMED/EMBASE) was conducted from 1995 to 2023 to identify randomised controlled trials (RCTs) with a minimum follow-up of 3 months. The primary outcome was the difference in mean probing depth (PD), and the secondary outcomes were mean clinical attachment loss (CAL), percentage of sites with PD ≤ 3 mm (%PD ≤ 3 mm) and percentage of sites with bleeding on probing (%BOP) between the treated and untreated control group in patients with comorbidities. RESULTS: The electronic search resulted in 2,403 hits. After removing duplicates, 1,565 titles and abstracts were screened according to the eligibility criteria, resulting in 126 articles for full-text screening. Following this, 44 studies were analysed. Restricting to studies with low bias or some concerns, NSPT group demonstrated a 0.55 mm lower mean PD (95%CI: -0.69; -0.41) after 3 months compared to the control group. CONCLUSION: Compared to the untreated controls, NSPT notably reduced mean PD, mean CAL, and %BOP while increasing %PD ≤ 3 mm in patients with concurrent systemic conditions. These findings suggest that NSPT is also an effective procedure in managing periodontitis in patients with concurrent systemic conditions. TRIAL REGISTRATION: This systematic review was registered under the protocol registration number CRD42021241517/PROSPERO.

Association between peri-implantitis and systemic inflammation: a systematic review.

Background: Peri-implantitis is an infectious/inflammatory disease with similar clinical and radiographic features to periodontitis. Overwhelming evidence confirmed that periodontitis causes elevations in systemic inflammatory mediators; this is unclear for peri-implantitis. Hence, this study aimed to appraise all available evidence linking peri-implantitis with systemic inflammation. Methods: A systematic review was completed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eight electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Web of Science, Dentistry & Oral Sciences Source, Scopus, LILACS, and China Online), ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP), and gray literature were searched up to February 9, 2023. Human studies of randomized controlled trials, non-randomized intervention studies, cohort studies, case-control, and cross-sectional studies were eligible for inclusion. Quantitative analyses were performed using random effects models. Results: A total of 27 full-text articles were retrieved, and 11 clinical studies were included in the final analyses. All evidence gathered demonstrated a consistent association between peri-implantitis and systemic inflammation. Patients with peri-implantitis exhibited higher levels of serum C-reactive protein (CRP) (standard mean difference (SMD): 4.68, 98.7% CI: 2.12 to 7.25), interleukin-6 (IL-6) (weighted mean difference (WMD): 6.27 pg/mL, 0% CI: 5.01 to 7.54), and white blood cell counts (WMD: 1.16 * 103/µL, 0% CI: 0.61 to 1.70) when compared to participants without peri-implantitis. Conclusion: Peri-implantitis is associated with higher systemic inflammation as assessed by serum CRP, IL-6, and white blood cell counts. Further research is needed to clarify the nature of this association. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=246837, identifier CRD42021246837.

Removal and dispersal of biofluid films by powered medical devices: Modeling infectious agent spreading in dentistry.

Medical procedures can disperse infectious agents and spread disease. Particularly, dental procedures may pose a high risk of disease transmission as they use high-powered instruments operating within the oral cavity that may contain infectious microbiota or viruses. Here we assess the ability of powered dental devices in removing the biofluid films and identified mechanical, hydrodynamic, and aerodynamic forces as the main underlying mechanisms of removal and dispersal processes. Our results indicate that potentially infectious agents can be removed and dispersed immediately after dental instrument engagement with the adherent biofluid film, while the degree of their dispersal is rapidly depleted owing to the removal of the source and dilution by the coolant water. We found that droplets created by high-speed drill interactions typically travel ballistically, while aerosol-laden air tends to flow as a current over surfaces. Our mechanistic investigation offers plausible routes for reducing the spread of infection during invasive medical procedures.

Severe Periodontitis and Biomarkers of Bacterial Burden. Results From a Case-Control and Intervention Clinical Trial.

Background and aims: Periodontitis is an inflammatory-infectious disease. Identifying markers of systemic exposure of periodontitis might be of interest to study its interaction with other conditions. Soluble triggering receptor expressed on myeloid cells 1 (sTREM-1) is upregulated during bacterial infections. Our aim was therefore to investigate whether periodontitis and its treatment are associated with bacterial endotoxin and sTREM-1. Methods: Fifty patients with severe periodontitis and 50 age-matched controls were included in a case-control study (all never smokers). A secondary analysis of a previously published intervention study was performed, in which included 69 patients with severe periodontitis were randomized to receive either intensive (IPT) or control periodontal therapy (CPT) and monitored over 6 months. Serum levels of bacterial endotoxin and sTREM-1 were determined at one time point (case-control study) and at baseline, 1 day, 1 and 6 months after periodontal treatment (intervention study). Results: Severe periodontitis was associated with elevated circulating endotoxin levels when cases (22.9 ± 2.2 EU/ml) were compared to controls (3.6 ± 0.5 EU/ml, p < 0.001) and with sTREM-1 levels (1302.6 ± 47.8 vs. 870.6 ± 62.0 pg/ml, p < 0.001). A positive correlation was observed between sTREM-1 and endotoxin levels (r = 0.4, p < 0.001). At 6 months after treatment, IPT significantly decreased serum levels of sTREM-1 compared to CPT (adjusted mean difference of 500.2 pg/ml, 95% CI: 18.9-981.4; p = 0.042). No substantial differences were noted in endotoxin levels at any time point after treatment between groups. Conclusions: Severe periodontitis is linked to increased circulating endotoxin and sTREM-1 levels and following IPT a reduction in sTREM-1 levels is observed.

The effect of a behavioural management tool in adults with mild to moderate periodontitis. A single-blind, randomized controlled trial.

OBJECTIVE: To compare a behavioural management program (test) to a standard communication approach (control) to reduce plaque, improve clinical outcomes and patient's compliance with oral self-care. BACKGROUND: Since psychological factors affect oral health-related behaviours, approaches directed at changing behaviours and improving compliance might improve the effect of oral health education. MATERIALS AND METHODS: This was a randomized, single-blind, parallel-design trial involving 71 patients with mild to moderate periodontitis. During a run-in period, all participants began using a power toothbrush. Two sessions of non-surgical periodontal therapy were performed post-baseline, along with one of the two oral healthcare communication approaches. Plaque and bleeding scores, probing pocket depth (PPD) and clinical attachment level (CAL) were recorded at the screening visit, baseline visit and at 8 and 14 weeks post-baseline. Patients were asked to fill in oral self-care diaries. Experience questionnaires were administered to both clinicians and patients to assess subjective experience of the clinician-patient interactions during the visits. RESULTS: In both groups, a significant reduction in plaque and bleeding scores was observed from baseline to 8 weeks after baseline, which then remained stable at week 14, but no differences between the groups were noted. An improvement in CAL and PPD was recorded at week 8 post-baseline in the test compared to the control group. No inter-group differences in the clinician's and subject's experience questionnaires were observed. CONCLUSION: Both approaches significantly promoted periodontal health. However, changing lifestyle requires repeated communication/engagement over time and a behavioural management program based upon two visits did not provide additional benefit compared to a standard approach.

Effect of Treatment of Periodontitis on Incretin Axis in Obese and Nonobese Individuals: A Cohort Study.

CONTEXT: Periodontitis confers an increased risk of developing type 2 diabetes and, in patients with obesity, it might interfere with the incretin axis. The effect of periodontal treatment on glucoregulatory hormones remains unknown. OBJECTIVE: To evaluate the effect of periodontal treatment on incretin axis in obese and lean nondiabetic individuals. SETTING: King's College Dental Hospital and Institute, London, UK. PARTICIPANTS AND METHODS: The metabolic profile of obese and normal-body-mass-index individuals affected by periodontitis was studied at baseline, 2, and 6 months after intensive periodontal treatment, by measuring plasma insulin, glucagon, glucagon-like peptide-1(GLP-1), and glucose-dependent insulinotropic polypeptide (GIP) and markers of systemic inflammation and oxidative stress. MAIN OUTCOME MEASURE(S): Circulating levels of incretins and inflammatory markers. RESULTS: At baseline, periodontal parameters were worse for obese than nonobese; this was accompanied by higher levels of circulating high-sensitivity C-reactive protein (hs-CRP), insulin, and GLP-1. The response to periodontal treatment was less favorable in the obese group, without significant variations of hs-CRP or malondialdehyde. Glucoregulatory hormones changed differently after treatment: while insulin and glucagon did not vary at 2 and 6 months, GLP-1 and GIP significantly increased at 6 months in both groups. In particular, GLP-1 increased more rapidly in obese participants, while the increase of GIP followed similar trends across visits in both groups. CONCLUSIONS: Nonsurgical treatment of periodontitis is associated with increased GLP-1 and GIP levels in nonobese and obese patients; changes in GLP-1 were more rapid in obese participants. This might have positive implications for the metabolic risk of these individuals.

Association of oral health-related quality of life measures with aggressive and chronic periodontitis.

BACKGROUND AND OBJECTIVE: Evidence suggests that periodontitis has a negative effect on the quality of life of an individual, with increased impacts by greater disease severity. The aim of this study was to assess the association between quality of life and the presence of different severity and forms of periodontitis (aggressive and chronic), compared to a disease-free control group. MATERIALS AND METHODS: Four hundred and seventy one study participants were classified according to periodontal diagnosis using the 1999 Consensus Classification into chronic periodontitis (CP), aggressive periodontitis (AgP) and periodontally healthy. Oral health-related quality of life was assessed using the OHIP-14 questionnaire. Outcomes consisted of the prevalence of oral impacts reported occasionally, fairly often or very often (OFOVO) as well as fairly often or very often (FOVO), OHIP-14 total and domain scores. Logistic and linear regression analyses were carried out to test associations between periodontal diagnosis and quality of life outcomes, adjusted for smoking, age, ethnicity and body mass index. RESULTS: Over 90% of periodontitis patients reported at least one oral impact experienced occasionally, fairly often or very often (OFOVO) compared with 53.8% of periodontally healthy controls (P < .001). After adjustment for covariates, significant differences were found between the periodontitis groups and healthy controls for OHIP-14 outcome scores (P < .001) and across all of the OHIP-14 domains (P < .005). These differences were clinically meaningful as they were higher than the measurement errors. No significant differences were identified between AgP and CP in adjusted analysis when comparing OHIP-14 scores. CONCLUSION: Patients with periodontitis have worse quality of life than periodontally healthy individuals, with differences being clinically meaningful. AgP patients reported worse OHRQoL overall compared to CP patients, but these moderate and meaningful differences were explained through the adjustment process.

Subgingival instrumentation for treatment of periodontitis. A systematic review.

OBJECTIVES: To evaluate the efficacy of subgingival instrumentation (PICOS-1), sonic/ultrasonic/hand instruments (PICOS-2) and different subgingival instrumentation delivery protocols (PICOS-3) to treat periodontitis. METHODS: Systematic electronic search (CENTRAL/MEDLINE/EMBASE/SCOPUS/LILACS) to March 2019 was conducted to identify randomized controlled trials (RCT) reporting on subgingival instrumentation. Duplicate screening and data extraction were performed to formulate evidence tables and meta-analysis as appropriate. RESULTS: As only one RCT addressed the efficacy of subgingival instrumentation compared with supragingival cleaning alone (PICOS-1), baseline and final measures from 9 studies were considered. The weighted pocket depth (PD) reduction was 1.4 mm (95%CI: 1.0 1.7) at 6/8 months, and the proportion of pocket closure was estimated at 74% (95%CI: 64-85). Six RCTs compared hand and sonic/ultrasonic instruments for subgingival instrumentation (PICOS-2). No significant differences were observed between groups by follow-up time point or category of initial PD. Thirteen RCTs evaluated quadrant-wise versus full-mouth approaches (PICOS-3). No significant differences were observed between groups irrespective of time-points or initial PD. Five studies reported patient-reported outcomes, reporting no differences between groups. CONCLUSIONS: Nonsurgical periodontal therapy by mechanical subgingival instrumentation is an efficacious means to achieve infection control in periodontitis patients irrespective of the type of instrument or mode of delivery. Prospero ID: CRD42019124887.

Dental plaque, gingival inflammation and tooth -discolouration with different commercial -formulations of 0.2% chlorhexidine rinse: a double-blind randomised controlled clinical trial.

PURPOSE: To investigate the efficacy of various formulations of chlorhexidine 0.2% (CHX) in terms of plaque and gingival bleeding control compared to each other and to saline rinse (CTRL) over a 35-day rinsing period. MATERIALS AND METHODS: Seventy subjects were randomly allocated to one of 4 groups rinsing twice daily for 35 days. The different groups used CHX 0.2% rinse with alcohol (CHX1) and without alcohol (CHX2), with an antidiscolouration system (CHX3) or saline rinse (CTRL). Clinical examinations to evaluate full-mouth plaque scores (FMPS) and periodontal parameters were performed at baseline, 7, 21 and 35 days. Tooth discolouration (TD) was measured at each time point using digital photographs and spectrophotometric analysis. RESULTS: At 35 days, CTRL showed the highest levels of plaque. The mean changes in FMPS from baseline were 69.8% ± 6.8 for CHX1, 57.5% ± 9.8 for CHX2, 43.7% ± 9.8 for CHX3 and 25.8% ± 7.7 for CTRL. Statistically significant differences were demonstrated between CHX1 and CHX3 (p = 0.02), CHX2 vs CHX3 (p ≤ 0.05) and CHX1/CHX2 vs CHX3 (p < 0.05). In contrast, CHX3 appeared more effective in reducing inflammatory indexes. TD increased over time in 60% to 70% of participants, although lighter staining was found in the CHX3 group. Greater FMPS reduction was observed in participants with staining vs without staining (26.0% ± 12.3, p = 0.04). CONCLUSION: Conventional CHX appeared more effective in terms of plaque reduction. Interestingly, the newest formulation showed a higher control of gingival inflammation. Staining was associated with lower plaque levels.

Association between periodontal disease and its treatment, flow-mediated dilatation and carotid intima-media thickness: a systematic review and meta-analysis.

OBJECTIVE: This meta-analysis sought to investigate the association between carotid intima-media thickness (c-IMT), flow-mediated dilation (FMD) and periodontitis (PD) and to assess the effect of periodontal treatment on c-IMT and FMD. METHODS: Electronic database searching, hand searching of bibliographic references of included papers, related reviews, and journals in relation to oral, cardiovascular and ultrasound imaging field was carried out. Random effects meta-analyses were performed to investigate the association of co-existence of increased c-IMT, impaired FMD and PD with potential changes in these variables following periodontal intervention. RESULTS: 2009 citations and 101 full text articles were screened, with 35 meeting the review inclusion criteria of which 22 suitable for quantitative analysis. Meta-analysis demonstrated that the diagnosis of PD was associated with a mean increase in c-IMT of 0.08 mm (95% C.I. = 0.07-0.09) and a mean difference in FMD of 5.1% compared to controls (95% C.I. = 2.08-8.11%). A meta-analysis of the effects of periodontal treatment on FMD showed a mean improvement of 6.64% between test and control (95% C.I. = 2.83-10.44%). CONCLUSIONS: This review demonstrated an association between increased c-IMT, impaired FMD and PD. Data from intervention studies suggested a beneficial effect of periodontal treatment on FMD indicating an improvement in endothelial function. The findings support investigation of periodontitis treatment on cardiovascular outcomes.

Low prevalence of subgingival viruses in periodontitis patients.

BACKGROUND: Viruses such as Human Cytomegalovirus (HCMV) and Epstein-Barr virus (EBV) have been proposed to be periodontal pathogens. The aim of this study was to analyse the presence of herpesvirus DNA in subgingival plaque samples of patients with different forms of periodontitis and in healthy periodontia. MATERIALS AND METHODS: A total of 140 ethnically mixed (prevalently Caucasian) subjects took part in the study. Sixteen were affected by localized aggressive periodontitis (LAgP), 64 by generalized aggressive periodontitis (GAgP), 20 by chronic periodontitis (CP) and 40 were periodontally healthy. Polymerase chain reaction (PCR) analyses were performed to detect HCMV and EBV. Sera were tested for anti-HCMV and EBV IgG antibodies. PCRs for herpes simplex (HSV) and varicella zoster virus (VZV) were performed in subgingival samples from a subset of 20 AgP subjects. RESULTS: HCMV DNA was not detected in any plaque samples. EBV DNA was detected in four LAgP (25%), two GAgP (3%) subjects and four healthy individuals (10%). HSV DNA and VZV DNA were not detected in the subset of studied individuals. CONCLUSIONS: This study challenges the previously reported high prevalence of herpesvirus DNA in subgingival samples from periodontitis patients and so questions whether they act as pathogens in such patients.

Healing, post-operative morbidity and patient perception of outcomes following regenerative therapy of deep intrabony defects.

AIM: This prospective multicenter randomized controlled clinical trial was designed to compare the clinical outcomes of papilla preservation flap surgery with or without the application of enamel matrix derivatives (EMD). This article reports on early healing events, post-operative morbidity and patient perceptions of the surgical outcomes. MATERIAL AND METHODS: One hundred and seventy-two patients with advanced chronic periodontitis and at least one intrabony defect of > or =3 mm were recruited in 12 centres in seven countries (European Research Group on Periodontology (ERGOPERIO)). Papilla preservation flaps were used to obtain access and primary closure. After debridement, and root conditioning, EMD was applied in the test subjects, and omitted in the controls. Healing was monitored 1, 2, 3, 4, 6 and 12 weeks after surgery. During the first 12 weeks of healing, supracrestal soft-tissue density was evaluated with a computer-assisted densitometric image analysis system (CADIA) using underexposed radiographs taken on a subset of 34 patients. Patient perceptions were evaluated with a questionnaire immediately after the procedure, at suture removal 1 week later and at 1 year. RESULTS: Subjects reported little intraoperative or post-operative pain or discomfort for both test and controls. Twenty-four percent of controls and 30% of tests (p=0.64) reported a degree of interference with daily activities for an average of 3 and 3.5 days, respectively. Post-surgical edema was noted in 25% of tests and 28% of controls. Wound dehiscence in the interdental portion of the flap was uncommon (14% of tests and 12% of controls at week 1) and of limited size. Root sensitivity was the most frequent post-operative adverse event: it affected 45% of test and 35% of controls (p=0.55). Up to 6 weeks post-operatively, soft-tissue densities were significantly higher in subjects treated with EMD with respect to controls. One year after completion of the surgery, patients reported high levels of satisfaction with the outcomes. The most frequently reported benefits included the ability to preserve a tooth/dentition and to maintain/improve chewing ability. The cost and need for frequent follow-ups were cited as significant drawbacks. CONCLUSIONS: This study portrayed the early healing events, pain, discomfort and adverse events of papilla preservation flap surgery and the 1-year patient perceptions of the benefits and disadvantages of periodontal surgery in intrabony defects. Earlier gains in soft-tissue density were observed following application of EMD. In terms of patient-centered outcomes, however, both procedures performed in a similar manner.