Jean Suvan

Association between overweight/obesity and periodontitis in adults. A systematic review

Overweight and obesity have been suggested to be associated with periodontitis as published in studies and narrative summaries. This project presents results of a systematic review investigating the association between overweight or obesity (as defined by the World Health Organization) and periodontitis.

Oxidative Stress, Systemic Inflammation, and Severe Periodontitis

Periodontal infections have been associated with a state of chronic inflammation. To ascertain whether severe periodontitis and its treatment are associated with oxidative stress, we recruited 145 cases (periodontitis) and 56 controls in a case-control study. A further pilot intervention study of 14 cases (periodontal therapy) was performed. Blood samples were taken at baseline (case-control) and 1, 3, 5, 7, and 30 days after treatment (intervention). Diacron-reactive oxygen metabolites (D-ROM), anti-oxidant potential, C-reactive protein (CRP), interleukin-6, and lipid profiles were determined with high-sensitivity assays in serum. Patients with severe periodontitis exhibited higher D-ROM levels (P < 0.001) and lower total anti-oxidant capacity (P < 0.001) compared with healthy control individuals. These findings were independent of age, gender, smoking habits, ethnicity, and standard lipids differences. D-ROM levels were positively correlated with CRP (R = 0.4, P < 0.001) and clinical periodontal parameters (R = 0.20, P < 0.05). Acute increases of D-ROM (P < 0.01) were observed following periodontal therapy. Analysis of these data suggests a positive association between severe periodontitis and oxidative stress.

Principles in prevention of periodontal diseases Consensus report of group 1 of the 11th European Workshop on Periodontology on effective prevention of periodontal and peri-implant diseases

AIMS In spite of the remarkable success of current preventive efforts, periodontitis remains one of the most prevalent diseases of mankind. The objective of this workshop was to review critical scientific evidence and develop recommendations to improve: (i) plaque control at the individual and population level (oral hygiene), (ii) control of risk factors, and (iii) delivery of preventive professional interventions. METHODS Discussions were informed by four systematic reviews covering aspects of professional mechanical plaque control, behavioural change interventions to improve self-performed oral hygiene and to control risk factors, and assessment of the risk profile of the individual patient. Recommendations were developed and graded using a modification of the GRADE system using evidence from the systematic reviews and expert opinion. RESULTS Key messages included: (i) an appropriate periodontal diagnosis is needed before submission of individuals to professional preventive measures and determines the selection of the type of preventive care; (ii) preventive measures are not sufficient for treatment of periodontitis; (iii) repeated and individualized oral hygiene instruction and professional mechanical plaque (and calculus) removal are important components of preventive programs; (iv) behavioural interventions to improve individual oral hygiene need to set specific Goals, incorporate Planning and Self monitoring (GPS approach); (v) brief interventions for risk factor control are key components of primary and secondary periodontal prevention; (vi) the Ask, Advise, Refer (AAR) approach is the minimum standard to be used in dental settings for all subjects consuming tobacco; (vii) validated periodontal risk assessment tools stratify patients in terms of risk of disease progression and tooth loss. CONCLUSIONS Consensus was reached on specific recommendations for the public, individual dental patients and oral health care professionals with regard to best action to improve efficacy of primary and secondary preventive measures. Some have implications for public health officials, payers and educators.

Amoxicillin and metronidazole as an adjunctive treatment in generalized aggressive periodontitis at initial therapy or re‐treatment: a randomized controlled clinical trial

BACKGROUND Previously, we showed that systemic metronidazole and amoxicillin significantly improved the outcomes of non-surgical debridement in generalized aggressive periodontitis patients. This study aimed to observe whether re-treatment with adjunctive antimicrobials would give the placebo group benefits comparable with the test group. METHODS Thirty-eight of 41 subjects, from the initial 6-month trial, completed the second phase, re-treatment of sites with remaining pockets 5 mm. Subjects on placebo in phase one, received adjunctive antibiotics for 7 days. Clinical parameters were collected at 2 months posttreatment (8 months from baseline). RESULTS Patients who received antibiotics at initial therapy, showed statistically significant improvement in pocket depth reduction and in the % of sites improving above clinically relevant thresholds, compared with patients who received antibiotics at re-treatment. In deep pockets (7 mm), the mean difference was 0.9 mm (p=0.003) and in moderate pockets (4-6 mm) it was 0.4 mm (p=0.036). For pockets converting from 5 to 4 mm, this was 83% compared with 67% (p=0.041) and pockets converting from 4 to 3 mm was 63% compared with 49% (p=0.297). CONCLUSIONS At 8 months, patients who had antibiotics at initial therapy showed statistically significant benefits compared with those who had antibiotics at re-treatment.

Periodontal Therapy and Systemic Inflammation in Type 2 Diabetes Mellitus: A Meta-Analysis

Aim The aim of this systematic review was to assess the effect of periodontal therapy (PT) on serum levels of inflammatory markers in people with type 2 diabetes mellitus (T2DM). Methods of Study Selection A literature search was carried out using MEDLINE via Pubmed, EMBASE, LILACS and Cochrane Central Register of Controlled Trials (CENTRAL) databases. Randomized-controlled trials (RCTs) and controlled clinical trials (CCTs) evaluating the effect of PT on systemic inflammatory markers were deemed eligible. Case series (CS), reports and pilot trials were excluded. Study quality was assessed using the Cochrane Collaboration’s risk assessment tool. Meta-analysis was carried out using random effect methods. Results The search strategy identified 3,164 potential studies of which 61 were assessed for eligibility and 9 (6 RCTs and 3 CCTs) were included in this systematic review. Three RCTs were classified by the authors as being at low risk of bias and three were “unclear” and classified as uncertain risk of bias. All CCTs were considered to be at a high risk of bias. The meta-analysis showed a statistically significant mean difference (MD) for TNF- α (-1.33 pg/ml, 95% CI: -2.10; -0.56, p<0.001) and CRP (-1.28 mg/l, 95% CI: -2.07; - 0.48, p<0.001) favoring periodontal intervention versus control. Conclusion The results of this meta-analysis support the hypothesis that PT reduces serum levels of TNF- α and CRP in T2DM individuals. The decrease of inflammatory burden has important implications for metabolic control and can, in part, explain the mechanisms linking periodontitis and increased risk for complications in people with T2DM.

The impact of hospitalization on dental plaque accumulation: an observational study.

AIM To investigate the effect of hospitalization on oral health as assessed by dental plaque. MATERIALS AND METHODS Observational study in a critical care unit (CCU). Participants were recruited within 24 h of admission. Dental plaque amount was assessed at baseline, 1 and 2 weeks using the Debris index-soft deposits (Greene & Vermillion 1960). RESULTS Fifty participants were recruited with 36 available for outcome assessment at 1 week and 10 at 2 weeks. The principal reason for losses was early discharge with no evidence of a difference between patients present only at baseline and those present at 1 week. The median value for dental plaque at baseline was 4 (95% CI: 4, 6). The median dental plaque increase from baseline to week 1 was 1.5 (95% CI: -1, 4), and this was statistically significant (p = 0.04). The median increase from week 1 to week 2 was 1.0 (95% CI -8, 6) and not statistically significant (p = 0.68). CONCLUSIONS Oral health as assessed by dental plaque deteriorates following hospitalization in CCU. Such change could lead to impairment of quality of life and well-being as well as to increasing the risk of important healthcare-associated infections such as nosocomial pneumonia.

Effects of a single topical doxycycline administration adjunctive to mechanical debridement in patients with persistent/recurrent periodontitis but acceptable oral hygiene during supportive periodontal therapy.

OBJECTIVES To evaluate the efficacy of a slow release doxycycline gel (SRD) adjunctively administered to non-surgical therapy in subjects with recurrent or persistent periodontitis but acceptable oral hygiene during supportive periodontal care. MATERIAL & METHODS In this single blind, parallel group, multicentre study, 202 of 203 recruited periodontal maintenance subjects with recurrent or persistent periodontitis were randomly assigned to subgingival ultrasonic/sonic instrumentation (USI) with (test) or without (control) subsequent administration of SRD in all residual periodontal pockets ≥4 mm. Intergroup differences in probing depth, BOP reductions, treatment time, probing attachment levels were evaluated at 3, 6 and 12 months. The primary outcome was the inter-group difference in absolute change of probing pocket depth (PPD) 3, 6 and 12 months after intervention. RESULTS At baseline, the two groups were comparable. At 3 months, the test group showed a significantly higher decrease in mean probing depth than the control group at 3 months (mean difference = 0.11 mm, 95% CI 0.03-0.19 mm, p = 0.003). Administration of SRD resulted in significantly greater odds of transition of bleeding pockets ≥5 mm to a category of non bleeding sites with PPD ≤4 mm at 3 and 6 months (O.R. = 1.4, 95% CI 1.2-1.8 at 3 months). At 6 months, SRD benefit was observed only in the deeper pockets. 7.5% of subjects (no significant difference between test and control) showed disease progression (attachment loss ≥2 mm) and were exited from the study. No difference in the incidence of adverse events was observed between groups. CONCLUSION The trial results show that topically administered SRD may provide short-term benefit in controlling inflammation and deep pockets in treated periodontal patients participating in a secondary prevention programme and able to maintain a satisfactory level of oral hygiene.

Behaviour change counselling for tobacco use cessation and promotion of healthy lifestyles: a systematic review

AIM To systematically assess the efficacy of oral health behaviour change counselling for tobacco use cessation (TUC) and the promotion of healthy lifestyles. MATERIALS AND METHODS Systematic Reviews, Randomized (RCTs), and Controlled Clinical Trials (CCTs) were identified through an electronic search of four databases complemented by manual search. Identification, screening, eligibility and inclusion of studies were performed independently by two reviewers. Quality assessment of the included publications was performed according to the AMSTAR tool for the assessment of the methodological quality of systematic reviews. RESULTS A total of seven systematic reviews were included. With the exception of inadequate oral hygiene, the following unhealthy lifestyles related with periodontal diseases were investigated: tobacco use, unhealthy diets, harmful use of alcohol, physical inactivity, and stress. Brief interventions for TUC were shown to be effective when applied in the dental practice setting while evidence for dietary counselling and the promotion of other healthy lifestyles was limited or non-existent. CONCLUSIONS While aiming to improve periodontal treatment outcomes and the maintenance of periodontal health current evidence suggests that tobacco use brief interventions conducted in the dental practice setting were effective thus underlining the rational for behavioural support.

Obesity, Inflammation, and Oral Infections Are microRNAs the Missing Link?

Predictions from the World Health Organization indicate that over the next 5 years close to 3 billion adults will be overweight or obese (with a 3:1 ratio) across the globe (WHO, 2011). Indeed, over the past 50 years, the occurrence of obesity has risen at a worrisome rate worldwide. Obesity prevalence figures are well beyond 30% of the adult population in rich countries (Flegal et al., 2010), with estimates expected to be similar in lowand middle-income countries in the future if no action is taken. The obesity pandemic has become a significant health threat, comparable with global warming or swine flu. It has resulted in considerable higher morbidity and mortality rates and increasing costs for healthcare systems. The main causes of human obesity are increased energy intake and decreased energy expenditure that result in greater accumulation of adipose tissue (Cummings and Schwartz, 2003). In addition to lipid storage, however, adipocytes exert a number of endocrine functions, resulting in a state of low-grade inflammation and insulin resistance, both harmful to health. Indeed, obesity is a major risk factor for several chronic diseases, including Type 2 diabetes, cardiovascular diseases, and cancer (Hotamisligil, 2006). Recent evidence suggests that obesity could increase individuals’ susceptibility to numerous infections by altering the host immune responses to them (Falagas and Kompoti, 2006). Periodontitis, driven by bacterial pathogens, is one of the most common oral infections worldwide. The host response to periodontal pathogens represents a crucial determinant of periodontitis susceptibility. Several pro-inflammatory molecules and processes implicated in periodontitis pathogenesis, including cytokines (e.g., Interleukin-IL-6), chemokines, and T-cell function, could be influenced by obesity (Falagas and Kompoti, 2006). Several possible pathways involving the host response and bacterial challenge have been proposed. An altered (delayed and sustained) inflammatory state, such as that found both in animal experimental conditions (Amar et al., 2007) and in obese individuals, could predispose individuals to increased periodontal tissue destruction (Boesing et al., 2009). These findings are also corroborated by several lines of clinical evidence suggesting that obesity is a risk factor for periodontitis (Suvan et al., 2011). Indeed, obese individuals present with an increased prevalence of periodontitis, with raised gingival inflammatory responses and possibly altered periodontal microbial compositions (Boesing et al., 2009). Alternatively, the insulin resistance state found in obese individuals, coupled with the increased production and the accumulation of advanced glycation endproducts at the gingival level, such as that reported in people with diabetes, could result in greater periodontal tissue destruction (Genco et al., 2005). However, the molecular mechanisms that influence the individual susceptibility to obesity and other co-morbidities, including oral infections such as periodontitis, remain to be elucidated. In the past decade, the area of RNA molecular biology has been transformed and radically re-interpreted. The most significant advance has been the discovery of small (20-30 nucleotides in length) molecules of RNA that do not translate into proteins (non-coding). These microRNAs (miRNA) can regulate several genes. Studying this complex machinery has allowed for the prediction and, in some cases, control of the specific pathways of microRNA-gene interactions (Carthew and Sontheimer, 2009). The effects of miRNAs are generally inhibitory and have been referred to as the function of RNA silencing. More than ten thousand miRNAs have been identified, and may regulate over one-third of protein-coding genes. Each miRNA can target hundreds of genes, which can be predicted on the basis of the complementary nature of specific nucleotide regions on the miRNA. Several algorithms have been proposed to predict the putative binding loci in human coding genes, resulting in 40,000 or more potential sites (Carthew and Sontheimer, 2009). The loss of a specific miRNA (miR-14) in Drosophila has been associated with increased body fat and represented the discovery of its first metabolic function. Deregulation of miRNAs has since been reported in human obesity involving several biological processes, including adipocyte differentiation, metabolic integration, and insulin resistance (McGregor and Choi, DOI: 10.1177/0022034511427164

Changes in dental plaque following hospitalisation in a critical care unit: an observational study

IntroductionPrevious research has suggested that deterioration in oral health can occur following hospitalisation. The impact of such deterioration could increase the risk of oral disease, reduce quality of life and increase the potential for healthcare-associated infections (HCAI) such as healthcare-associated pneumonia (HAP). However, the strength of the evidence is limited by, amongst other factors, the few observational studies published that assess oral health longitudinally. In view of the microbiological component of oral diseases and HCAIs, the objective of this study was to investigate the microbiological changes in dental plaque following hospitalisation in a Critical Care Unit (CCU): (1) total number of cultivable bacteria and (2) presence and changes in specific HAP pathogens.MethodsWe conducted a prospective, longitudinal observational study in the CCU of University College Hospital, London. Study participants were recruited within 24 hours of admission. Dental plaque samples were collected from up to six sites per patient. The primary outcome was microbiological change from baseline to seven days with additional analysis for participants still present at day 14.Results50 patients were recruited with 36 available for review at one week, with early discharge accounting for much of the loss to follow-up. The median total viable count of the plaque microbiota at baseline was 4.40 × 105 cfu/ml and increased at week one to 3.44 × 106 cfu/ml. The total viable microbe counts increased by a median of 2.26 × 106 cfu/ml from baseline to week one (95% CI: 3.19 × 106, 1.24 × 107) and this was statistically significant (P < 0.01). Specific HAP bacteria were detected in 26% of participants sampled, although accounted for a relatively low proportion of the total viable bacteria.ConclusionTotal bacterial count of dental plaque increases during hospitalisation in CCU. This finding, together with the colonisation of dental plaque by HAP bacteria strengthens the evidence for a deterioration in oral health in CCU and a risk factor for negative health and quality of life outcomes.