Gisele Maria Campos Fabri

Persistent Periodontal Disease Hampers Anti-Tumor Necrosis Factor Treatment Response in Rheumatoid Arthritis

ObjectiveThis study aimed to evaluate prospectively the influence and the evolution of periodontal disease (PD) in rheumatoid arthritis (RA) patients submitted to anti–tumor necrosis factor (TNF) therapy. MethodsEighteen patients with RA (according to the American College of Rheumatology criteria) were assessed for PD before (BL) and after 6 months (6M) of anti-TNF treatment: 15 infliximab, 2 adalimumab, and 1 etanercept. Periodontal assessment included plaque and gingival bleeding indices, probing pocket depth, cementoenamel junction, and clinical attachment level. Rheumatologic evaluation was performed blinded to the dentist’s assessment: demographic data, clinical manifestations, and disease activity (Disease Activity Score using 28 joints [DAS28], erythrocyte sedimentation rate [ESR], and C-reactive protein [CRP]). ResultsThe median age and disease duration of patients with RA were 50 years (25–71 y) and 94% were female. Periodontal disease was diagnosed in 8 patients (44.4%). Comparing BL to 6M, periodontal parameters in the entire group remained stable (P > 0.05) throughout the study (plaque and gingival bleeding indices, probing pocket depth, cementoenamel junction, and clinical attachment level), whereas an improvement in most analyzed RA parameters was observed in the same period: DAS28 (5.5 vs. 3.9, P = 0.02), ESR (21 vs. 12.5 mm/first hour, P = 0.07), and CRP (7.8 vs. 2.8 mg/dL, P = 0.25). Further analysis revealed that this improvement was restricted to the group of patients without PD (DAS28 [5.5 vs. 3.6, P = 0.04], ESR [23.0 vs. 11.5 mm/first hour, P = 0.008], and CRP [7.4 vs. 2.1, P = 0.01]). In contrast, patients with PD had lack of response, with no significant differences in disease activity parameters between BL and 6M: DAS28 (5.2 vs. 4.4, P = 0.11), ESR (17.0 vs. 21.0, P = 0.56), and CRP (9.0 vs. 8.8, P = 0.55). ConclusionsThis study supports the notion that PD may affect TNF blocker efficacy in patients with RA. The possibility that a sustained gingival inflammatory state may hamper treatment response in this disease has high clinical interest because this is a treatable condition.

Oral Infections and Orofacial Pain in Alzheimer's Disease: A Case-Control Study

BACKGROUND Dental infections are frequent and have recently been implicated as a possible risk factor for Alzheimers disease (AD). Despite a lack of studies investigating orofacial pain in this patient group, dental conditions are known to be a potential cause of pain and to affect quality of life and disease progression. OBJECTIVES To evaluate oral status, mandibular function and orofacial pain in patients with mild AD versus healthy subjects matched for age and gender. METHODS Twenty-nine patients and 30 control subjects were evaluated. The protocol comprised a clinical questionnaire and dental exam, research diagnostic criteria for temporomandibular disorders, the McGill Pain Questionnaire, the decayed, missing, and filled teeth index, and included a full periodontal evaluation. AD signs and symptoms as well as associated factors were evaluated by a trained neurologist. RESULTS A higher prevalence of orofacial pain (20.7%, p < 0.001), articular abnormalities in temporomandibular joints (p < 0.05), and periodontal infections (p = 0.002) was observed in the study group compared to the control group. CONCLUSION Orofacial pain and periodontal infections were more frequent in patients with mild AD than in healthy subjects. Orofacial pain screening and dental and oral exams should be routinely performed in AD patients in order to identify pathological conditions that need treatment thus improving quality of life compromised due to dementia.

Evaluation of patients with Alzheimer's disease before and after dental treatment

Oral infections may play a role in Alzheimers disease (AD). Objective To describe the orofacial pain, dental characteristics and associated factors in patients with Alzheimers Disease that underwent dental treatment. Method 29 patients with mild AD diagnosed by a neurologist were included. They fulfilled the Mini Mental State Exam and Pfeffers questionnaire. A dentist performed a complete evaluation: clinical questionnaire; research diagnostic criteria for temporomandibular disorders; McGill pain questionnaire; oral health impact profile; decayed, missing and filled teeth index; and complete periodontal investigation. The protocol was applied before and after the dental treatment. Periodontal treatments (scaling), extractions and topic nystatin were the most frequent. Results There was a reduction in pain frequency (p=0.014), mandibular functional limitations (p=0.011) and periodontal indexes (p<0.05), and an improvement in quality of life (p=0.009) and functional impairment due to cognitive compromise (p<0.001) after the dental treatment. Orofacial complaints and intensity of pain also diminished. Conclusion The dental treatment contributed to reduce co-morbidities associated with AD and should be routinely included in the assessment of these patients.

Gingival capillary changes and oral motor weakness in juvenile dermatomyositis

OBJECTIVE We assessed the orofacial involvement in JDM, and evaluated the possible association of gingival and mandibular mobility alterations with demographic data, periodontal indices, clinical features, muscle enzyme levels, JDM scores and treatment. METHODS Twenty-six JDM patients were studied and compared with 22 healthy controls. Orofacial evaluation included clinical features, dental and periodontal assessment, mandibular function and salivary flow. RESULTS The mean current age was similar in patients with JDM and controls (P > 0.05). A unique gingival alteration characterized by erythema, capillary dilation and bush-loop formation was observed only in JDM patients (61 vs 0%, P = 0.0001). The frequencies of altered mandibular mobility and reduced mouth opening were significantly higher in patients with JDM vs controls (50 vs 14%, P = 0.013; 31 vs 0%, P = 0.005). Comparison of the patients with and without gingival alteration showed that the former had lower values of median of cementoenamel junction (-0.26 vs -0.06 mm, P = 0.013) and higher gingival bleeding index (27.7 vs 14%, P = 0.046). This pattern of gingival alteration was not associated with periodontal disease [plaque index (P =0.332) and dental attachment loss (P = 0.482)]. The medians for skin DAS and current dose of MTX were higher in JDM with gingival alteration (2.5 vs 0.5, P = 0.029; 28.7 vs 15, P = 0.012). A significant association of lower median manual muscle testing with a reduced ability to open the mouth was observed in patients with JDM than those without this alteration (79 vs 80, P = 0.002). CONCLUSIONS The unique gingival pattern associated with cutaneous disease activity, distinct from periodontal disease, suggests that gingiva is a possible target tissue for JDM. In addition, muscle weakness may be a relevant factor for mandibular mobility.

Oral Infections and Cytokine Levels in Patients with Alzheimer's Disease and Mild Cognitive Impairment Compared with Controls.

BACKGROUND Oral infections are prevalent in the adult population. Their impact includes the implication as a risk factor for Alzheimers disease (AD), altering its progression. One of the potential mechanisms involves immune mediators such as circulating cytokines. OBJECTIVE The goal of the present study was to investigate the prevalence of oral infections and blood levels of IL-1β, TNF-α, and IL-6 in patients with AD, mild cognitive impairment (MCI), and controls. METHODS Sixty-five elderly were evaluated (25 AD, 19 MCI, and 21 controls) by the following methods: Mini Mental State Exam, Questionnaire of Functional Activities, periodontal and oral evaluation, and blood concentrations of IL-1β, TNF-α and IL-6. RESULTS Patients with AD had high serum IL-6 levels (p = 0.029), and patients with periodontitis had high serum TNF-α levels (p = 0.005). There was an association between IL-6 and TNF-α in patients with AD/MCI and periodontitis (p = 0.023). CONCLUSION The increased levels of TNF-α and IL-6 in this study suggests their implication in the overlapping mechanisms between oral infections and AD. Longitudinal studies are necessary for further investigation.

Periodontitis Response to Anti-TNF Therapy in Ankylosing Spondylitis.

BackgroundRecently, it has been demonstrated that patients with ankylosing spondylitis (AS) and rheumatoid arthritis (RA) have a higher risk of periodontitis; however, the effect of anti-TNF therapy in periodontal status of patients with AS and particularly in dental attachment is not known. ObjectiveTo evaluate longitudinally the local periodontal effect of TNF-antagonist in AS and compare to patients with RA. MethodsFifteen patients with AS and 15 RA control patients were prospectively evaluated at baseline and after 6 months (6 M) of anti-TNF therapy. Periodontal assessment included: probing pocket depth (PPD), clinical attachment level (CAL), gingival bleeding index, and plaque index. Rheumatologic clinical and laboratory evaluations were the following: Bath AS Disease Activity Index, Bath AS Metrology Index, Bath AS Functional Index, C-reactive protein and erythrocyte sedimentation rate for AS and Disease Activity Score 28 joints, and C-reactive protein and erythrocyte sedimentation rate for patients with RA. ResultsAt baseline, periodontal parameters were alike in AS and RA (P > 0.05). After 6 M of anti-TNF therapy, clinical and laboratory parameters of rheumatic diseases decreased significantly in the patients with AS and RA (P < 0.05). A significant improvement in periodontal attachment measurements were observed in the patients with AS (PPD, 2.18 vs 1.94 mm; P = 0.02; CAL, 2.29 vs.2.02 mm; P = 0.03), but not in RA (PPD, 1.92 vs 2.06 mm; P = 0.06; CAL, 2.14 vs 2.28 mm; P = 0.27). Oral hygiene and gingival inflammation remained unchanged from baseline to 6-M evaluation in AS and RA (P > 0.05). ConclusionPatients with AS under anti-TNF improved periodontal attachment. The mechanism for this effect needs further studies.

Doença periodontal em doenças reumáticas pediátricas

Gingivitis and periodontitis are immunoinflammatory periodontal diseases characterized by chronic localized infections usually associated with insidious inflammation This narrative review discusses periodontal diseases and mechanisms influencing the immune response and autoimmunity in pediatric rheumatic diseases (PRD), particularly juvenile idiopathic arthritis (JIA), childhood-onset systemic lupus erythematosus (C-SLE) and juvenile dermatomyositis (JDM). Gingivitis was more frequently observed in these diseases compared to health controls, whereas periodontitis was a rare finding. In JIA patients, gingivitis and periodontitis were related to mechanical factors, chronic arthritis with functional disability, dysregulation of the immunoinflammatory response, diet and drugs, mainly corticosteroids and cyclosporine. In C-SLE, gingivitis was associated with longer disease period, high doses of corticosteroids, B-cell hyperactivation and immunoglobulin G elevation. There are scarce data on periodontal diseases in JDM population, and a unique gingival pattern, characterized by gingival erythema, capillary dilation and bush-loop formation, was observed in active patients. In conclusion, gingivitis was the most common periodontal disease in PRD. The observed association with disease activity reinforces the need for future studies to determine if resolution of this complication will influence disease course or severity.

Delivering Resveratrol on the Buccal Mucosa Using Mucoadhesive Tablets: A Potential Treatment Strategy for Inflammatory Oral Lesions

BACKGROUND Resveratrol is a polyphenol that has gained momentum in therapeutics in the last few years. OBJECTIVE In this study, we hypothesised that resveratrol could act prophylactically and/or treat inflammatory lesions of the oral cavity after being delivered by two different formulations of buccal mucoadhesive tablets (F1 and F2, which differed in terms of viscosity agents used). METHODS This hypothesis was assessed through permeation studies, to verify diffusion of the drug through the buccal mucosa using a porcine model to predict human in vivo behaviour. RESULTS F2 (tablet with less viscosity agent) presented better permeation than F1, but the amount of drug that crossed the mucosa was still low compared to the amount retained within it (35.90 µg found in the receptor medium and 15.63 mg quantified within the mucosa). CONCLUSION This accounted for a local effect rather than a systemic one, which is desirable for local processes, such as oral mucositis, lichen planus, erythema multiforme, nicotinic stomatitis, recurrent aphthous stomatitis, among others. In this sense, resveratrol-loaded mucoadhesive tablets appear to be a prominent alternative to prevent and/or cure inflammatory lesions of the oral cavity.

Oral warning signs of elastic pseudoxanthoma: case report.

The pseudoxanthoma elasticum is a multisystemic heritable disease that primarily affects the connective tissue. It has been characterized by fragmentation and calcification of elastic fibers that can lead to complications of skin and cardiovascular system and changes in retina. Involvement of the oral mucosa has been described like white patches striated especially in the mucosa of both upper and lower lips. These oral signs are potentially useful to diagnose the disease, since it is an often undiagnosed disease due to the variability in phenotypic expressions. This study reports a case of pseudoxanthoma elasticum affecting a woman who developed lesions in the oral mucosa during the disease progression. Intraoral clinical assessment revealed the presence of changes mainly in lower labial mucosa and also slightly changes in the mouth floor and the upper labial mucosa. Therefore, the acknowledgment of oral pseudoxanthoma elasticum lesions helps dental practitioners to establish an early and appropriate diagnosis of this disease. This is very important because pseudoxanthoma elasticum is a multisystem disease with morbidity and mortality, and its early diagnosis and also the establishment of a follow-up protocol for these patients could prevent systemic and oral complications.

Periodontitis and Metabolic Control: A Preliminary Study

El objetivo fue evaluar la condicion periodontal y el control metabolico de pacientes con diabetes mellitus tipo 2. En los pacientes con diabetes mellitus tipo 2 se evaluaron previo y posterior (30 dias) al tratamiento de la periodontitis los siguientes examenes: glucemia, hemoglobina glicosilada, indice de placa bacteriana, indice de sangrado gingival e indice de profundidad de la bolsa periodontal. El tratamiento periodontal consistio en: curetage, alisado radicular y control de placa, asociado a la terapia sistemica antibiotica con amoxicilina. Se evaluaron 17 pacientes (12 mujeres y 5 hombres, con una edad media de 55,94 anos). Las principales complicaciones fueron: sangrado gingival (n= 13), dolor gingival (n= 8), movilidad dental (n= 3), edema gingival (n= 2) y halitosis (n= 2). El tiempo medio de estas complicaciones vario entre 2 meses y 20 anos. Ninguno de ellos reconocio haber recibido orientacion sobre higiene oral o evaluacion dental. Hubo una reduccion (30 dias despues del tratamiento periodontal) en los siguientes indices: placa, de 41,79±24% a 12,26±13%) (p0,0005); sangrado gingival, de 51,58±25%) a 15,77±15% (p0,0005), profundidad de la bolsa periodontal, de 0,98±0,91 mm a 1,76±0,63 mm) (p0,0005). En 15 pacientes se observo una reduccion en la hemoglobina glucosilada (10,85±3,03% a 8,72±1,68%) (p0,0005). Observamos que los pacientes de esta muestra tenian enfermedad periodontal cronica y severa; que hubo una reduccion en los niveles de hemoglobina glucosilada, pero no de la glucemia, 30 dias despues del tratamiento periodontal. Estudios longitudinales son necesarias, sin embargo los pacientes con diabetes mellitus requieren control de las infecciones cronicas, como la enfermedad periodontal.