Periodontal diseases and adverse pregnancy outcomes. Present and future.

For more than two decades the possible association between periodontal diseases and adverse pregnancy outcomes has been extensively evaluated. Numerous observational, intervention, and mechanistic studies have offered valuable information on this topic. However, several methodologic limitations still remain a significant drawback for this set of investigations, and therefore safe conclusions are not always easy to draw. Unfortunately, despite the strong recommendations from the scientific community, recent studies have not sufficiently addressed these limitations and, therefore, have not significantly altered our perception regarding the association between periodontal disease and adverse pregnancy outcomes. This review briefly describes the established knowledge and gives emphasis to the current literature. In addition, owing to the main theme of this Periodontology 2000 volume, special reference will be made regarding the results from European studies on periodontal disease and adverse pregnancy outcomes. Finally, new strategies and research guidelines are proposed in order to move on to the next level of evidence that will help connect the theoretical knowledge with meaningful clinical interventions that will benefit our pregnant patients and their offspring.

Clinical evaluation of different alveolar ridge preservation techniques after tooth extraction: a randomized clinical trial.

OBJECTIVE: The aim of the present randomized controlled trial (RCT) was to evaluate the efficacy of different alveolar ridge preservation (ARP) techniques on dimensional alterations after tooth extraction, based on clinical measurements. BACKGROUND: Alveolar ridge preservation (ARP) is a common procedure in every day clinical practice, when dental implants are involved in treatment planning. In ARP procedures, a bone grafting material is combined with a socket sealing (SS) material in order to compensate the alveolar ridge dimensional alterations after tooth extraction. Xenograft and allograft are the most frequently used bone grafts in ARP, while free gingival graft (FGG), collagen membrane, and collagen sponge (CS) usually applied as SS materials. The evidence comparing xenograft and allograft directly in ARP procedure is scarce. In addition, FGG is usually combined with xenograft as SS material, while the evidence combing allograft with FGG is absent. Moreover, CS could probably be an alternative choice in ARP as SS material, since it has been used in previous studies but more clinical trials are required to evaluate its effectiveness. MATERIALS AND METHODS: Forty-one patients were randomly assigned in four treatment groups: (A) freeze-dried bone allograft (FDBA) covered with collagen sponge (CS), (B) FDBA covered with free gingival graft (FGG), (C) demineralized bovine bone mineral xenograft (DBBM) covered with FGG, and (D) FGG alone. Clinical measurements were performed immediately after tooth extraction and 4 months later. The related outcomes pertained to both vertical and horizontal assessment of bone loss. RESULTS: Overall, groups A, B, and C presented significantly less vertical and horizontal bone resorption compared to group D. No statistically significant difference was observed between allograft and xenograft, except for the vertical bone resorption at the buccal central site, where xenograft showed marginally statistically significantly reduced bone loss compared to allograft (group C vs group B: adjusted ß coef: 1.07 mm; 95%CI: 0.01, 2.10; p = 0.05). No significant differences were observed in hard tissue dimensions when CS and FGG were applied over FDBA. CONCLUSIONS: No differences between FDBA and DBBM could practically be confirmed. In addition, CS and FGG were equally effective socket sealing materials when combined with FDBA, regarding bone resorption. More RCTs are needed to compare the histological differences between FDBA and DBBM and the effect of CS and FGG on soft tissue dimensional changes. CLINICAL RELEVANCE: Xenograft and allograft were equally efficient in ARP 4 months after tooth extraction in horizontal level. Xenograft maintained the mid-buccal site of the socket marginally better than the allograft, in vertical level. FGG and CS were equally efficient as SS materials regarding the hard tissue dimensional alterations. TRIAL REGISTRATION: Clinical trial registration Number: NCT04934813 (clinicaltrials.gov).

Periodontal disease and adverse pregnancy outcomes.

Periodontal diseases are considered not only to affect tooth-supporting tissues but also to have a cause-and-effect relationship with various systemic diseases and conditions, such as adverse pregnancy outcomes. Mechanistic studies provide strong evidence that periodontal pathogens can translocate from infected periodontium to the feto-placental unit and initiate a metastatic infection. However, the extent and mechanisms by which metastatic inflammation and injury contribute to adverse pregnancy outcomes still remain unclear. The presence of oral bacteria in the placenta of women with term gestation further complicates our understanding of the biology behind the role of periodontal pathogens in pregnancy outcomes. Epidemiological studies demonstrate many methodological inconsistencies and flaws that render comparisons difficult and conclusions insecure. Therefore, despite the fact that a number of prospective studies show a positive association between periodontal diseases and various adverse pregnancy outcomes, the evidence behind it is still weak. Future well-designed explanatory studies are necessary to verify this relationship and, if present, determine its magnitude. The majority of high-quality randomized controlled trials reveal that nonsurgical periodontal therapy during the second trimester of gestation does not improve pregnancy outcomes. From a biological standpoint, this can be partially explained by the fact that therapy rendered at the fourth to sixth months of pregnancy is too late to prevent placental colonization by periodontal pathogens and consequently incapable of affecting pathogen-induced injury at the feto-placental unit. Thus, interventions during the preconception period may be more meaningful. With the increase in our understanding on the potential association between periodontal disease and adverse pregnancy outcomes, it is clear that dental practitioners should provide periodontal treatment to pregnant women that is safe for both the mother and the unborn child. Although there is not enough evidence that the anti-infective therapy alters pregnancy outcomes, it improves health-promoting behavior and periodontal condition, which in turn advance general health and risk factor control.

An update of the evidence on the potential impact of periodontal therapy on diabetes outcomes.

AIM: To provide an update of the systematic review by Engebretson and Kocher J Clin Periodontol. 2013 Apr;40 Suppl 14:S153 on the effect of periodontal therapy on glycaemic control of people with diabetes. METHODS: PubMed Literature search restricted to meta-analyses published from 2013 to the present was conducted. The search resulted in seven meta-analyses of RCTs. RESULTS: Reduction in HbA1c at 3-4 months was reported in all reviews for the treatment group ranging from -0.27% (95% CI: -0.46, -0.07, p = .007) to -1.03% (95% CI: 0.36, -1.70, p = 0.003). At 6 months post-treatment, an HbA1c reduction ranging from -0.02 (95% CI: -0.20, -0.16, p = .84) to -1.18% (95% CI: 0.72%, 1.64%, p < 0.001) was reported. CLINICAL RELEVANCE: The magnitude of the reduction in HbA1c, which is found to be associated with non-surgical periodontal treatment in patients with diabetes, seems to have clinically significant effects on systemic health, and thus should have a place in the treatment of diabetic patients. CONCLUSIONS: Periodontal treatment (SRP) results in a statistically significant reduction in HbA1C levels at 3 months, with a lower reduction at 6 months.

Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.

BACKGROUND: A variety of systemic diseases and conditions can affect the course of periodontitis or have a negative impact on the periodontal attachment apparatus. Gingival recessions are highly prevalent and often associated with hypersensitivity, the development of caries and non-carious cervical lesions on the exposed root surface and impaired esthetics. Occlusal forces can result in injury of teeth and periodontal attachment apparatus. Several developmental or acquired conditions associated with teeth or prostheses may predispose to diseases of the periodontium. The aim of this working group was to review and update the 1999 classification with regard to these diseases and conditions, and to develop case definitions and diagnostic considerations. METHODS: Discussions were informed by four reviews on 1) periodontal manifestions of systemic diseases and conditions; 2) mucogingival conditions around natural teeth; 3) traumatic occlusal forces and occlusal trauma; and 4) dental prostheses and tooth related factors. This consensus report is based on the results of these reviews and on expert opinion of the participants. RESULTS: Key findings included the following: 1) there are mainly rare systemic conditions (such as Papillon-Lefevre Syndrome, leucocyte adhesion deficiency, and others) with a major effect on the course of periodontitis and more common conditions (such as diabetes mellitus) with variable effects, as well as conditions affecting the periodontal apparatus independently of dental plaque biofilm-induced inflammation (such as neoplastic diseases); 2) diabetes-associated periodontitis should not be regarded as a distinct diagnosis, but diabetes should be recognized as an important modifying factor and included in a clinical diagnosis of periodontitis as a descriptor; 3) likewise, tobacco smoking - now considered a dependence to nicotine and a chronic relapsing medical disorder with major adverse effects on the periodontal supporting tissues - is an important modifier to be included in a clinical diagnosis of periodontitis as a descriptor; 4) the importance of the gingival phenotype, encompassing gingival thickness and width in the context of mucogingival conditions, is recognized and a novel classification for gingival recessions is introduced; 5) there is no evidence that traumatic occlusal forces lead to periodontal attachment loss, non-carious cervical lesions, or gingival recessions; 6) traumatic occlusal forces lead to adaptive mobility in teeth with normal support, whereas they lead to progressive mobility in teeth with reduced support, usually requiring splinting; 7) the term biologic width is replaced by supracrestal tissue attachment consisting of junctional epithelium and supracrestal connective tissue; 8) infringement of restorative margins within the supracrestal connective tissue attachment is associated with inflammation and/or loss of periodontal supporting tissue. However, it is not evident whether the negative effects on the periodontium are caused by dental plaque biofilm, trauma, toxicity of dental materials or a combination of these factors; 9) tooth anatomical factors are related to dental plaque biofilm-induced gingival inflammation and loss of periodontal supporting tissues. CONCLUSION: An updated classification of the periodontal manifestations and conditions affecting the course of periodontitis and the periodontal attachment apparatus, as well as of developmental and acquired conditions, is introduced. Case definitions and diagnostic considerations are also presented.

A randomized controlled clinical trial on the effectiveness of three different mouthrinses (chlorhexidine with or without alcohol and C31G), adjunct to periodontal surgery, in early wound healing.

OBJECTIVES: The use of chlorhexidine (CHX) with or without alcohol has been recommended for a number of clinical applications. On the other hand, there is a plethora of widely subscribed antiseptics, such as agent C31G (alkyl dimethyl glycine/alkyl dimethyl amine oxide), which has not yet been evaluated postsurgically. The effectiveness of three different mouthrinses (CHX with and without alcohol, C31G) in plaque control and early wound healing was compared postoperatively. MATERIALS AND METHODS: In this, randomized, double-blind, controlled clinical trial 42 patients were allocated to three groups assigned to 2 weeks rinsing after non-regenerative periodontal flap surgery with or without osseous surgery with C31G (group A), alcohol-free CHX 0.12% (group B) or alcohol-based CHX 0.12% (group C). At days 7 and 14, plaque and early wound healing indices were recorded. At day 14, total bacterial counts were estimated utilizing real-time quantitative polymerase chain reaction (qPCR). Statistics included linear and generalized linear mixed models. RESULTS: At day 7, healing response was not significantly different among groups. At day 14, group A revealed the highest while group C demonstrated the lowest plaque index values (B vs A, odds ratio-OR = 0.18, p = 0.012; C vs A, OR = 0.01, p < 0.001; C vs B, OR = 0.06, p < 0.001). Group C demonstrated the lowest bacterial counts levels at day 14 (38.470 × 106, 48.190 × 106, and 3.020 × 106 for groups A, B, and C, respectively). At day 14, healing was significantly better in group C compared to B (p = 0.007). Group A showed no significant differences compared to other groups. CONCLUSIONS: (1) The presence of alcohol may increase the effectiveness of CHX in early wound healing, (2) C31G might be an alternative solution prescribed during early postoperative period after non-regenerative periodontal flap surgery. CLINICAL RELEVANCE: The present study found that active agent C31G displayed no significant differences to CHX formulations regarding periodontal wound healing improvement and might be used alternatively after non-regenerative periodontal flap surgery. In addition, an alcohol based 0.12% CHX mouthwash was more effective than an alcohol-free 0.12% CHX and C31G mouthrinse on plaque control in the absence of mechanical oral hygiene.

Changes of volatile sulphur compounds during therapy of a case series of patients with chronic periodontitis and halitosis.

AIM: To assess the effect of different stages of intervention on volatile sulphur compounds (VSCs) of periodontitis patients with halitosis, before and after non-surgical periodontal therapy. MATERIAL & METHODS: This clinical trial included 18 adults with chronic periodontitis and halitosis. After initial examination, patients received oral hygiene (OH) instructions and tongue cleaner. One week later, non-surgical periodontal therapy was completed within 48 h. Measurements were at baseline, 1 week after OH, 1 and 6 weeks post therapy. These included simplified plaque index (sPlI), probing pocket depth (PPD), bleeding on probing (BoP), Winkel Tongue Coating Index (WTCI), organoleptic scores (OLSs) of nose and mouth air and VSCs. RESULTS: sPlI, BoP, WTCI, OLS of the mouth air and VSCs showed significant differences (p < 0.05), even after 1 week of OH. A further significant decrease was determined 1 week after non-surgical therapy for WTCI, OLS (nose and mouth air) and methyl mercaptan concentration. A significant decrease, 6 weeks post therapy, was observed for sPlI, BoP, WTCI, PPD, OLS of the nose and mouth air and VSCs (p < 0.05). CONCLUSIONS: Oral hygiene and tongue cleaning improve the OLSs of the mouth air and reduce VSCs. Periodontal therapy further improves the OLSs and reduces the concentration of VSCs.

Oxytalan-positive peripheral ossifying fibromas express runt-related transcription factor 2, bone morphogenetic protein-2, and cementum attachment protein. An immunohistochemical study.

BACKGROUND: The peripheral ossifying fibroma (POF) represents one of the most common lesions of the periodontal tissues that may originate from the gingival soft tissues, the periosteum, or the periodontal ligament. AIM: To investigate the immunohistochemical expression of runt-related transcription factor 2 (Runx-2), bone morphogenetic protein-2 (BMP-2), and cementum attachment protein (CAP) in oxytalan-positive POF, to establish the use of POF as an in vivo model for the study of the periodontal ligament. MATERIALS AND METHODS: Thirty tumors that presented clinical and histologic features of POF, as well as oxytalan fibers, were included in the study. Immunohistochemical expression of Runx-2, BMP-2, and CAP was evaluated by light microscopy. RESULTS: Runx-2, BMP-2, and CAP were abundantly expressed by POFs; 22 of 30 tumors expressed positive staining for Runx-2, twenty-six tumors for BMP-2, and twenty-five tumors for CAP. The expression of Runx-2 was abundant in POFs where bone was histologically present (P = 0.04) and of BMP-2 in POFs where dystrophic calcifications were present (P = 0.03). CONCLUSION: It is suggested that oxytalan-positive POFs, purportedly originating from the periodontal ligament, express molecules that are specific to bone and cementum (Runx-2, BMP-2), or cementum only (CAP). Thus, the cell populations present in the lesion belong to the mineralized-tissue-forming cell lineages, the cementoblastic or osteoblastic lineage.

Adverse pregnancy outcomes (APOs) and periodontal disease: pathogenic mechanisms.

AIM: To evaluate the evidence on potential biological pathways underlying the possible association between periodontal disease (PD) and adverse pregnancy outcomes (APOs). MATERIAL & METHODS: Human, experimental and in vitro studies were evaluated. RESULTS: Periodontal pathogens/byproducts may reach the placenta and spread to the foetal circulation and amniotic fluid. Their presence in the foeto-placental compartment can stimulate a foetal immune/inflammatory response characterized by the production of IgM antibodies against the pathogens and the secretion of elevated levels of inflammatory mediators, which in turn may cause miscarriage or premature birth. Moreover, infection/inflammation may cause placental structural changes leading to pre-eclampsia and impaired nutrient transport causing low birthweight. Foetal exposure may also result in tissue damage, increasing the risk for perinatal mortality/morbidity. Finally, the elicited systemic inflammatory response may exacerbate local inflammatory responses at the foeto-placental unit and further increase the risk for APOs. CONCLUSIONS: Further investigation is still necessary to fully translate the findings of basic research into clinical studies and practice. Understanding the systemic virulence potential of the individual's oral microbiome and immune response may be a distinctly different issue from categorizing the nature of the challenge using clinical signs of PD. Therefore, a more personalized targeted therapy could be a more predictive answer to the current "one-size-fits-all" interventions.

Oral manifestations of eleven individuals with Noonan syndrome. A case series.

AIMS: Noonan syndrome (NS) is a clinically and genetically heterogeneous condition characterized by distinctive facial features, short stature, and congenital heart defects. The oral manifestations have not been sufficiently described. In an attempt to enrich our understanding regarding the oral manifestations, the aim of the current study was to present the clinical, radiographic, and microbiological findings of eleven subjects with NS syndrome. METHODS AND RESULTS: A complete intraoral clinical evaluation, a radiographic analysis using panoramic and cephalometric x-rays, and a supra- and sub-gingival microbiological profiling of 20 periodontal and cariogenic microbiota using the checkerboard DNA-DNA hybridization technique were performed in a series of 11 NS individuals. Compared to previous reports very few dental findings were present. Gingivitis and carious lesions were present in all subjects and could be related to poor oral hygiene. High-arched palate and malocclusions such as crossbite, open-bite, and deep-bite were very common findings but without a specific pattern. Two findings that have not been reported before included the different shapes of the condyles and the irregular shape of the sella turcica. CONCLUSION: Due to the elevated prevalence of gingivitis, caries, and malocclusion, a multidisciplinary approach including dental follow-ups should be the standard care in NS patients.

A randomized, controlled trial on the effect of non-surgical periodontal therapy in patients with type 2 diabetes. Part I: effect on periodontal status and glycaemic control.

AIM: the purpose of the present study was to assess the effect of non-surgical periodontal therapy on glycaemic control of type 2 diabetes patients with moderate-to-severe periodontitis. MATERIALS AND METHODS: this was a randomized, controlled clinical trial of patients with type 2 diabetes. A total of 60 patients with moderate-to-severe periodontal disease were assigned to either a periodontal treatment arm, consisting of scaling and root planing (intervention group [IG]), or a delayed treatment arm that received periodontal care after 6 months (control group [CG]). Periodontal parameters and glycosylated haemoglobin (A1C) were evaluated at 1, 3 and 6 months. RESULTS: all periodontal parameters improved significantly in the IG. A1C levels decreased statistically significantly more in the IG versus the CG (0.72%versus 0.13%; p<0.01) independently of other confounders. CONCLUSIONS: this study provides evidence that periodontal treatment contributes to improved glycaemic control in type 2 diabetes mellitus patients. Larger controlled trials are needed to confirm if this finding is generalizable to other populations of patients with type 2 diabetes.

Oral surgery during Byzantine times.

The Byzantine World covers the eleven-century period between 323-1453 AD and was characterized by a comprehensive system of medicine based on the fundamental principles of Ancient Greek medicine. Several clinical entities, such as epulis, parulis, constrictions of the tongue (short frenum), sublingual ranula, jaws fractures and disclocations, oral fistulae were well-known and treated during the Byzantine period with primarily surgical, but also non-surgical, interventions. Tooth extractions and operations on the uvula were also popular. The variety of these operations, for which special dental instruments were used, demonstrates the high level of surgical knowledge among physicians in Byzantine times.

Association of Vitamin D With Periodontal Disease: A Narrative Review.

PURPOSE: To present a review of available literature on the association of vitamin D and periodontal disease. MATERIALS AND METHODS: A thorough search of articles was carried out on the databases PUBMED and MEDLINE regarding vitamin D and periodontal disease. The selected literature included cross-sectional, case-control and prospective and retrospective cohort studies. The main aspects of the association evaluated were a) the association of 25(OH)D and 1,25(OH)2D3 with periodontal disease severity, periodontal disease progression and tooth loss, b) the effect of vitamin D supplementation on periodontal health and c) the association of vitamin D receptor polymorphisms with periodontal disease. A brief overview of the biological mechanisms linking periodontal disease with vitamin D was also included. RESULTS AND CONCLUSIONS: There is conflicting evidence regarding the effects of 25(OH)D on periodontal disease severity, progression and tooth loss, with some studies reporting beneficial effects of higher 25(OH)D serum concentrations on periodontal health and tooth retention, whereas others could not find such an association. Limited evidence also supports a positive association between 1,25(OH)2D3 and periodontal health as well as a trend towards better periodontal health with vitamin D supplementation. Finally, various vitamin D polymorphisms were associated with chronic and aggressive periodontitis, with different outcomes reported for the various ethnic populations assessed.

Association between periodontal disease and vulnerable plaque morphology in patients undergoing carotid endarterectomy.

BACKGROUND: Periodontal disease (PD) is a chronic inflammatory oral condition with potentially important systemic sequelae. We sought to determine whether the presence of PD in patients with severe carotid disease was associated with morphological features consistent with carotid plaque instability. METHODS: A total of 52 dentate patients hospitalized for carotid endarterectomy (CEA) had standardized assessments of their periodontal status, including measurements of probing pocket depth (PPD), clinical attachment level (CAL) and bleeding on probing (BoP). Carotid plaque morphology was assessed by ultrasound using the gray scale median (GSM) score and by immunohistochemistry using anti-CD68 and anti-alpha-actin antibodies, markers for macrophages and smooth muscle cells (SMCs) respectively. RESULTS: In total 30/52 patients (58%) had PD. Significant associations were noted between low GSM on ultrasound and each mm in PPD (p = 0.001), each mm in CAL (p = 0.002) and with a 10% increase in BoP (p = 0.009). Using the standardized PERIO definition the association remained robust (aOR = 10.4 [95% CI:2.3-46.3], p = .002). Significant associations were also observed with high macrophage accumulation and each individual PD measure (p < 0.01 for PPD, CAL and BoP) and with the PERIO definition (aOR = 15 [95% CI:1.8-127.8], p = .01). Similarly, low SMC density was also significantly associated with individual measures of PD (p < 0.05 for PPD, CAL and BoP), but not with the PERIO definition (aOR 3.4 [95% CI:0.9-12.8], p = .07). CONCLUSIONS: The presence of PD was significantly associated with both ultrasound and immunohistochemistry features of carotid plaque instability in patients undergoing CEA.

Outcomes of dental implants in osteoporotic patients. A literature review.

PURPOSE: This article reviews available data on the outcome of dental implants in osteoporotic patients. MATERIALS AND METHODS: A search was performed in PubMed and completed in July 2007. The keywords "dental AND implants AND osteoporosis," "dental AND implants AND age," "dental AND implants AND gender," and "dental AND implants AND bone AND quality," with no limitations for language or year of publication, resulted in 82, 598, 94, and 541 articles, respectively. After abstract scanning (in case of doubt the article was read), 39 nonreview articles studying dental implant outcomes in osteoporotic/osteopenic subjects remained for our review. The bibliographies of the 39 articles were also inspected, but no additional studies were identified. RESULTS: Thirteen of 16 animal studies found lower osseointegration rates in osteoporotic/osteopenic bone than in normal bone. Six in nine clinical reports mention success. Eight of 12 studies in humans support the applicability of dental implants in osteoporotic patients. CONCLUSIONS: There are no data to contraindicate the use of dental implants in osteoporotic patients; however, a proper adjustment of the surgical technique and a longer healing period may be considered in order to achieve osseointegration. Data on the use of biphosphonates in osteoporotic patients and implant outcomes are very limited, and no conclusions can be drawn. In addition, large prospective studies investigating the long-term success of dental implants in osteoporotic individuals are required.

Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.

BACKGROUND: A variety of systemic diseases and conditions can affect the course of periodontitis or have a negative impact on the periodontal attachment apparatus. Gingival recessions are highly prevalent and often associated with hypersensitivity, the development of caries and non-carious cervical lesions on the exposed root surface and impaired esthetics. Occlusal forces can result in injury of teeth and periodontal attachment apparatus. Several developmental or acquired conditions associated with teeth or prostheses may predispose to diseases of the periodontium. The aim of this working group was to review and update the 1999 classification with regard to these diseases and conditions, and to develop case definitions and diagnostic considerations. METHODS: Discussions were informed by four reviews on 1) periodontal manifestions of systemic diseases and conditions; 2) mucogingival conditions around natural teeth; 3) traumatic occlusal forces and occlusal trauma; and 4) dental prostheses and tooth related factors. This consensus report is based on the results of these reviews and on expert opinion of the participants. RESULTS: Key findings included the following: 1) there are mainly rare systemic conditions (such as Papillon-Lefevre Syndrome, leucocyte adhesion deficiency, and others) with a major effect on the course of periodontitis and more common conditions (such as diabetes mellitus) with variable effects, as well as conditions affecting the periodontal apparatus independently of dental plaque biofilm-induced inflammation (such as neoplastic diseases); 2) diabetes-associated periodontitis should not be regarded as a distinct diagnosis, but diabetes should be recognized as an important modifying factor and included in a clinical diagnosis of periodontitis as a descriptor; 3) likewise, tobacco smoking - now considered a dependence to nicotine and a chronic relapsing medical disorder with major adverse effects on the periodontal supporting tissues - is an important modifier to be included in a clinical diagnosis of periodontitis as a descriptor; 4) the importance of the gingival phenotype, encompassing gingival thickness and width in the context of mucogingival conditions, is recognized and a novel classification for gingival recessions is introduced; 5) there is no evidence that traumatic occlusal forces lead to periodontal attachment loss, non-carious cervical lesions, or gingival recessions; 6) traumatic occlusal forces lead to adaptive mobility in teeth with normal support, whereas they lead to progressive mobility in teeth with reduced support, usually requiring splinting; 7) the term biologic width is replaced by supracrestal tissue attachment consisting of junctional epithelium and supracrestal connective tissue; 8) infringement of restorative margins within the supracrestal connective tissue attachment is associated with inflammation and/or loss of periodontal supporting tissue. However, it is not evident whether the negative effects on the periodontium are caused by dental plaque biofilm, trauma, toxicity of dental materials or a combination of these factors; 9) tooth anatomical factors are related to dental plaque biofilm-induced gingival inflammation and loss of periodontal supporting tissues. CONCLUSION: An updated classification of the periodontal manifestations and conditions affecting the course of periodontitis and the periodontal attachment apparatus, as well as of developmental and acquired conditions, is introduced. Case definitions and diagnostic considerations are also presented.

The effects of periodontal therapy on vascular endothelial function: a pilot trial.

BACKGROUND: Chronic periodontal infection is associated with an increased risk of coronary heart disease. Although the mechanism responsible for the relationship between periodontal disease and cardiovascular events is not fully understood, it is hypothesized that the chronic inflammatory burden of periodontal disease may lead to impaired functioning of the vascular endothelium. METHODS: Twenty-two otherwise healthy adults with moderate to severe periodontitis who underwent complete mouth disinfection were evaluated to determine if periodontal therapy would result in improved endothelial function and a decrease in serum inflammatory markers. Subjects had measurements of periodontal disease severity, flow-mediated (endothelium-dependent), and nitroglycerin-mediated (endothelium-independent) dilation of the brachial artery, serum C-reactive protein (CRP) and interleukin 6 (IL-6), and serum total and high-density lipoprotein cholesterol levels on 2 baseline visits separated by 1 month and, again, 1 month after treatment. RESULTS: There were no significant changes in clinical periodontal measures, flow-mediated dilation, nitroglycerin-mediated dilation, CRP, IL-6, total cholesterol, or high-density lipoprotein cholesterol between the repeated baseline measurements. Periodontal treatment, however, resulted in significant improvements in periodontal pocketing, flow-mediated dilation, and serum IL-6, as well as a trend toward reduction in serum CRP; there were no significant changes in nitroglycerin-mediated dilation or in cholesterol levels. CONCLUSIONS: These results represent proof of concept that improvement in endothelial function, as measured by flow-mediated dilation of the brachial artery, may be possible through near-elimination of chronic oral infection and suggest that the conduct of a larger controlled trial is justified.

Low-grade inflammation in chronic infectious diseases: paradigm of periodontal infections.

Increasing evidence implicates periodontitis, a chronic inflammatory disease of the tooth-supporting structures, as a potential risk factor for increased morbidity or mortality for several systemic conditions including cardiovascular disease (atherosclerosis, heart attack, and stroke), pregnancy complications (spontaneous preterm birth [SPB]), and diabetes mellitus. Cross-sectional, case-control, and cohort studies indicate that periodontitis may confer two- and up to sevenfold increase in the risk for cardiovascular disease and premature birth, respectively. Given the recently acquired knowledge that systemic inflammation may contribute in the pathogenesis of atherosclerosis and may predispose to premature birth, research in the field of periodontics has focused on the potential of this chronic low-grade inflammatory condition to contribute to the generation of a systemic inflammatory phenotype. Consistent with this hypothesis clinical studies demonstrate that periodontitis patients have elevated markers of systemic inflammation, such as C-reactive protein (CRP), interleukin 6 (IL-6), haptoglobin, and fibrinogen. These are higher in periodontal patients with acute myocardial infarction (AMI) than in patients with AMI alone, supporting the notion that periodontal disease is an independent contributor to systemic inflammation. In the case of adverse pregnancy outcomes, studies on fetal cord blood from SBP babies indicate a strong in utero IgM antibody response specific to several oral periodontal pathogens, which induces an inflammatory response at the fetal-placental unit, leading to prematurity. The importance of periodontal infections to systemic health is further strengthened by pilot intervention trials indicating that periodontal therapy may improve surrogate cardiovascular outcomes, such as endothelial function, and may reduce four- to fivefold the incidence of premature birth. Nevertheless, further research is needed to fully discern the underlying mechanisms by which local chronic infections can have an impact on systemic health, and in this endeavor periodontal disease may serve as an ideal disease model.

The Association Between Periodontal Inflammation and Labor Triggers (Elevated Cytokine Levels) in Preterm Birth: A Cross-Sectional Study.

BACKGROUND: Periodontitis is considered to be a risk factor for preterm birth. Mechanisms have been proposed for this pathologic relation, but the exact pathologic pattern remains unclear. Therefore, the objective of the present study is to evaluate levels of four major labor triggers, prostaglandin E2 (PGE2), interleukin (IL)-1ß, IL-6, and tumor necrosis factor (TNF)-α, in gingival crevicular fluid (GCF) and serum samples between women with preterm birth (PTB) and full-term birth (FTB) and correlate them with periodontal parameters. METHODS: PGE2, IL-1ß, IL-6, and TNF-α levels were estimated using enzyme-linked immunosorbent assays in GCF and serum samples collected 24 to 48 hours after labor from 120 women (60 FTB, 60 PTB). RESULTS: Women with PTB exhibited significantly more periodontitis, worse periodontal parameters, and increased GCF levels of IL-6 and PGE2 compared with the FTB group; there were no significant differences in serum levels of measured markers. GCF levels of IL-1ß, IL-6, and PGE2 and serum levels of TNF-α and PGE2 were significantly higher in women with periodontitis compared with periodontally healthy women. Serum levels of PGE2 were positively correlated with probing depth (PD) and clinical attachment level (CAL) as well as with GCF levels of TNF-α in women with PTB. CONCLUSIONS: Women with PTB demonstrated worse periodontal parameters and significantly increased GCF levels of IL-6 and PGE2 compared with those with FTB. Based on significant correlations among serum PGE2 and PD, CAL, and GCF TNF-α in PTB, periodontitis may cause an overall increase of labor triggers and hence contribute to preterm labor onset.