Giuseppe Pizzo

Dentistry and internal medicine: from the focal infection theory to the periodontal medicine concept

During past decades the relationship between dentistry and internal medicine and especially the concept of the so-called focal infection theory have long been a matter of debate. The pathogenesis of focal diseases has been classically attributed to dental pulp pathologies and periapical infections. Nonetheless, in recent years, their role is being dismissed while increasing interest is being devoted to the possible associations between periodontal infection and systemic diseases. In fact, periodontal pathogens and their products, as well as inflammatory mediators produced in periodontal tissues, might enter the bloodstream, causing systemic effects and/or contributing to systemic diseases. On the basis of this mechanism, chronic periodontitis has been suggested as a risk factor for cardiovascular diseases associated with atherosclerosis, bacterial endocarditis, diabetes mellitus, respiratory disease, preterm delivery, rheumatoid arthritis, and, recently, osteoporosis, pancreatic cancer, metabolic syndrome, renal diseases and neurodegenerative diseases such as Alzheimers disease. Various hypotheses, including common susceptibility, systemic inflammation, direct bacterial infection and cross-reactivity, or molecular mimicry, between bacterial antigens and self-antigens, have been postulated to explain these relationships. In this scenario, the association of periodontal disease with systemic diseases has set the stage for introducing the concept of periodontal medicine. This narrative review summarizes the evolution of focal infection theory up to the current pathophysiology of periodontal disease, and presents an update on the relationships between chronic periodontitis and systemic diseases.

In vitro activities of antimicrobial agents against Candida species

OBJECTIVE Antimicrobial mouthrinses may represent a valid alternative to topical antifungal agents. However, the action of antimicrobials could be affected by the different ingredients incorporated into mouthrinse products. The purpose of the present study was to investigate the in vitro antifungal and fungicidal activities of antimicrobials alone. STUDY DESIGN A broth macrodilution method was used to determine the minimum inhibitory concentration of 4 antimicrobial agents against Candida species. Minimum fungicidal concentration was also determined. RESULTS All antimicrobials showed antifungal activity against all tested organisms, but cetylpyridinium chloride received significantly lower minimum inhibitory concentrations (P < .005). Cetylpyridinium chloride also showed a greater fungicidal activity than chlorhexidine digluconate and hexetidine (P< .005), whereas sanguinarine chloride appeared to be less fungicidal against most of the isolates tested. CONCLUSIONS These findings suggest that cetylpyridinium chloride may be used as a topical antifungal agent. Clinical trials are now required to assess its value in the management of oral candidosis.

Genotyping and antifungal susceptibility of human subgingival Candida albicans isolates

Subgingival colonization by Candida albicans has been described in human immunodeficiency virus (HIV)-infected individuals, but subgingival isolates have scarcely been characterized, particularly with respect to genotype and antifungal susceptibility. A series of 29 subgingival strains of C. albicans isolated from nine HIV-infected individuals was typed by electrophoretic karyotyping and tested for susceptibility to fluconazole, itraconazole, the new investigational triazole posaconazole and amphotericin B. DNA typing showed genetic heterogeneity within subgingival isolates, as almost every individual harbored his/her own specific isolate. Genetic identity was usually demonstrated within oral and subgingival isolates simultaneously collected from the same individual, but a number of DNA types were found to be unique to subgingival strains. These findings suggest that colonization is not just the result of Candida spreading from oral surfaces, and that subgingivally adapted strains could be involved. All isolates were susceptible to all the triazole drugs tested and amphotericin B. Additional studies on subgingival Candida colonization and further characterization of subgingival isolates are now required to clarify the role of Candida as opportunistic periodontal pathogen.

Effect of desquamative gingivitis on periodontal status: a pilot study.

OBJECTIVE Desquamative gingivitis (DG) represents the gingival manifestation associated with several mucocutaneous disorders and systemic conditions. Little is known of whether or not DG could influence the onset or progression of plaque-related periodontitis. In this study, the potential impact of DG on plaque-related attachment loss and pocket formation has been evaluated. METHODS A cross-sectional evaluation of 12 patients with DG [eight oral lichen planus (OLP), four mucous membrane pemphigoid (MMP)], never treated for DG lesions or plaque-related periodontitis, was carried out. Probing depth (PD), clinical attachment loss (CAL), full-mouth plaque (FMPS), and bleeding (FMBS) scores were evaluated at six sites per tooth. Clinical parameters of sites with DG lesions were compared with that of DG unaffected sites. RESULTS Median PD and CAL, as well as FMPS and FMBS, were not significantly different (P > 0.05 Mann-Whitney test) for both OLP and MMP patients. However, a negative association between DG lesions and PD < 4 mm (OLP: OR = 0.26; MMP: OR = 0.47), and a positive association with PD 4-6 mm (OLP: OR = 3.76; MMP: OR = 2.68) and with PD > 6 mm (only for OLP: OR = 3.83) were found to be significant. CONCLUSIONS The potential interference between DG lesions and periodontitis needs further prospective investigation; nonetheless, a higher level of attention might be prudent.

Diagnostic delay in oral squamous cell carcinoma： the role of cognitive and psychological variables

This retrospective study investigated, in two cohorts of subjects living in Southern Italy and awaiting treatment for oral squamous cell carcinoma (OSCC), the variables related to diagnostic delay ascribable to the patient, with particular reference to the cognitive and psychological ones. A total of 156 patients with OSCC (mean age: 62 years, M/F: 2.39∶1) were recruited at the Universities of Palermo and Naples. Risk factors related to patient delay included: sociodemographic, health-related, cognitive and psychological variables. The analysis was conducted by considering two different delay ranges: dichotomous (≤1 month vs. >1 month) and polytomous (<1 month, 1–3 months, >3 months) delay. Data were investigated by univariate and multivariate analyses and a P value ≤0.05 was considered statistically significant. For both delay measurements, the most relevant variables were: ‘Personal experience of cancer’ (dichotomous delay: P=0.05, odds ratio (OR)=0.33, 95% confidence interval (CI)=0.11–0.99; polytomous delay: P=0.006, Chi-square=10.224) and ‘Unawareness’ (dichotomous delay: P<0.01, OR=4.96, 95% CI=2.16–11.37; polytomous delay: P=0.087, Chi-square=4.77). Also ‘Denial’ (P<0.01, OR=6.84, 95% CI=2.31–20.24) and ‘Knowledge of cancer’ (P=0.079, Chi-square=8.359) were found to be statistically significant both for dichotomous and for polytomous categorization of delay, respectively. The findings of this study indicated that, in the investigated cohorts, the knowledge about cancer issues is strongly linked to the patient delay. Educational interventions on the Mediterranean population are necessary in order to increase the patient awareness and to emphasize his/her key role in early diagnosis of OSCC.

Risk factors of oral candidosis: A twofold approach of study by fuzzy logic and traditional statistic

OBJECTIVE To assess a panel of risk factors associated to oral candidosis (OC) onset and its chronic maintenance by means of fuzzy logic (FL) approach and statistical traditional methodology (STM); to investigate their casual relationship within a multifactorial framework. DESIGN Case-control study. SETTING One hospital-based clinic. PATIENTS Eighty-nine patients with OC infection microbiologically diagnosed and 98 healthy subjects were consecutively recruited. OUTCOME MEASUREMENTS Anamnestic and clinical evaluations for OC, microbiological assessment (i.e. culture, CFU/mL counting and identification) were performed. The commonest predisposing factors for OC onset and its chronic status were analysed by FL and STM. RESULTS By means of a twofold analysis (FL and STM) significant associations between OC onset and its chronic maintenance were found with respect to denture wearing and hyposalivation/xerostomia, as local risk factors, and to age and female gender, as socio-demographical variables. Tobacco smoking was found not to be a risk factor. CONCLUSIONS The twofold (FL and STM) statistical approach for the identification of OC risk factors has been found useful and accurate in individuating a more selected target population for OC onset and chronic maintenance. The target patient appears to be an elderly person with multiple disease inducing, directly or by medications, hyposalivation/xerostomia. This data could provide to general and dental practitioners a decision-making model finalised to their preventative strategies for the geriatric population.

Effect of antimicrobial mouthrinses on the in vitro adhesion of Candida albicans to human buccal epithelial cells

Abstract Adhesion to epithelial cells is a critical step in successful oral colonization and infection by Candida albicans. Therefore, three mouthrinse products, containing chlorhexidine 0.2% (CHX), cetylpyridinium chloride 0.05% (CPC) or triclosan 0.045% (TRN), were compared for their effects on the in vitro adhesion of C. albicans to human buccal epithelial cells (BEC). Candidal adhesion appeared to be significantly reduced by oral rinsing with the CHX-containing mouthrinse (P<0.0001). In vivo exposure of BEC to the CPC mouthrinse also inhibited adhesion of C. albicans (P<0.0001). Both CHX and CPC products suppressed adhesion to the same extent (P>0.01). On the other hand, the TRN mouthrinse did not significantly affect epithelial adhesion of C. albicans (P>0.01). These findings suggest that mouthrinses containing CHX or CPC could be of value in the control of candidal colonization and infection. Clinical trials are warranted on the effectiveness of these products in reducing oral Candida carriage.

Probiotics and Oral Health

Probiotics are living microorganisms (e.g., bacteria) that are either the same as or similar to organisms found naturally in the human body and may be beneficial to health. Current researches have shown that the balance between beneficial and pathogenic bacteria is essential in order to maintain the oral health. Therefore, oral cavity has recently been suggested as a relevant target for probiotic applications. Dental caries can be seen as a microbial imbalance where the oral microbiota shift towards community dominance which produces acidogenic and acid-tolerant gram positive bacteria. Similarly, the accumulation of bacteria within the biofilm, facilitated by poor oral hygiene, predisposes to allogenic shifts in the microbial community, leading to the onset of periodontal inflammation. Probiotic bacteria belonging to the genus of Lactobacillus, Bifidobacterium and Streptococcus have been proven effective for preventing caries by reducing the number of cariogenic bacteria in saliva after a short period of consuming the probiotic. In contrast, the effect of probiotics on improving gingivitis and periodontitis has been less investigated. The currently available studies on the effect of probiotics on periodontal pathogens and clinical periodontal parameters showed differing results depending on the strains used and the endpoints analyzed. Many of the clinical studies are pilot in nature and with low quality, therefore, properly conducted clinical trials, using probiotic strains with in vitro proven periodontal probiotic effects, are needed. The putative beneficial effects of probiotics on oral malodour have also been evaluated, but further evidence is needed to fully explore the potential of probiotics for preventing malodour.

Effect of hormone replacement therapy (HRT) on periodontal status of postmenopausal women

Summary Background The risks/benefits balance of hormone replacement therapy (HRT) is controversial. The aim of this study was to assess the periodontal status of a postmenopausal women group receiving HRT and to determine the effects of HRT on clinical measures of periodontal disease. Material/Methods Ninety-one postmenopausal women, 52 taking HRT (HRT+) and 39 not taking HRT (HRT−), completed the study. Clinical parameters measured included visible supragingival plaque, probing pocket depth (PD) and clinical attachment level (CAL). Gingival status was recorded as gingival bleeding on probing (BOP). Previous oral contraceptive use and current and past smoking status were also assessed. Results Data indicated that PD and CAL were not significantly different between HRT+ patients and HRT− patients (P=0.8067 and P=0.1627, respectively). The HRT+ group exhibited significantly lower visible plaque levels compared to the control group (P<0.0001). The percentage of gingival sites with positive BOP was significantly lower in the HRT+ group compared to the HRT− group (34.85% vs. 65.15%; P=0.0007). Plaque accumulation was also tested in ANCOVA as a possible explanatory variable for the differences observed in gingival bleeding. The ANCOVA showed no significant differences in gingival bleeding between HRT+ and HRT− women (P=0.4677). No significant differences in past smoking status and oral contraceptive use were detected between HRT+ and HRT− women (P=0.9999 and P=0.0845, respectively). Conclusions These findings indicated that long-term HRT was not associated with relevant effects on periodontal status and clinical measures of periodontal disease, thus suggesting that HRT may not confer protection against periodontitis in postmenopausal women.

Topical Fluoride for Preventing Dental Caries in Children and Adolescents

The use of topically applied fluoride has been widely researched as a means to reduce the risk of dental caries in conjunction with other treatment modalities (mechanical oral hygiene, dietary control, antimicrobial intervention, pit and fissure sealants). There is overwhelming evidence that reports not only the significance and importance of the use of fluoride as a caries-preventive agent, but also how safe fluoride application is when used appropriately, particularly in higher risk individuals and populations. This paper reviews the caries-protective benefits of topical fluoride application in children and adolescents, with an emphasis on the clinical efficacy and safety of the vehicles by which fluoride is topically delivered. Fluoride toothpaste represents today the most cost-effective fluoride-delivery system in the oral cavity and its use should be the centerpiece in all caries-preventive strategies. On the other hand, mouthrinses, gels and varnishes currently represent adjuncts to toothpaste use and should be targeted towards individuals and groups at high risk of caries.