Prevalence of HIV-associated Periodontitis and Chronic Periodontitis in a Southeastern US Study Group

OBJECTIVES: This study estimates factors associated with the prevalence of HIV-associated periodontal diseases (HIV-P) and the severity and extent of periodontitis in HIV-infected adults from North Carolina (NC). METHODS: Data are derived from a cross-sectional study of HIV-infected adults (total n = 326, dentate n = 316) treated at the University of North Carolina Hospitals. Outcomes were a diagnosis of HIV-P and measures of probing pocket depth (PPD), recession (REC), and clinical attachment level (CAL). Immunosuppression was measured by peripheral blood CD4+ cells/mm3. RESULTS: In addition to persons with HIV (non-AIDS), this study included 10 percent of the AIDS cases in North Carolina. Median age was 37 years (range = 19-67); 78 percent were male and 60 percent were black. Sixty-two percent of persons had a probing pocket depth > or = 5 mm; 46% had recession > or = 3 mm, and 66 percent had attachment level > or = 5 mm in one or more sites. Cases of HIV-P (n = 15) were rare. Persons taking HIV-antiretroviral medication were one-fifth (OR = 0.20; 95% CI = 0.07, 0.63) as likely to have HIV-P as those not taking those medications, controlling for CD4+ cell counts. CONCLUSIONS: HIV-infected persons in this study group from North Carolina exhibited severe and extensive measures of adult periodontitis. A small proportion experienced a severe form of HIV-P, which was attenuated by antiretroviral therapy.     

Characterizing traditionally defined periodontal disease in HIV+ adults

Abstract – Background: Results have varied from previous studies examining the level and extent of periodontal disease (PD) in HIV‐1 infected (HIV+) adults. These studies used different methodologies to measure and define PD and examined cohorts with divergent characteristics. Inconsistent methodological approaches may have resulted in the underestimation of traditionally‐defined PD in HIV+ individuals. Objectives: To characterize the level, extent and predictors (i.e. immunologic, microbiologic, metabolic and behavioral) of PD in an HIV+ cohort during the era of highly active antiretroviral therapy (HAART). Study Design: Cross‐sectional study. Setting: HIV+ adults receiving outpatient care at three major medical clinics in Cleveland, OH. Subjects were seen from May, 2005 to January, 2008. Measurements: Full‐mouth periodontal examinations included periodontal probing depth (PPD), recession (REC) and clinical attachment level (CAL). Subgingival plaque was assessed for DNA levels of Porphyromonas gingivalis (Pg), Tannerella forsythia, and Treponema denticola by real‐time DNA PCR assays developed for each pathogen. Rather than using categories, we evaluated PD as three continuous variables based on the percent of teeth with ≥1 site per tooth with PPD ≥ 5mm, REC > 0 mm and CAL ≥ 4mm. Results: Participants included 112 HIV+ adults. Each subject had an average 38% (±24%) of their teeth with at least one site of PD ≥ 5 mm, 55% (±31%) of their teeth with at least one site of REC > 0 mm, and 50% (±32%) of their teeth with at least one site of CAL ≥ 4 mm. CD4+ T‐cell count <200 cells/mm³ was significantly associated with higher levels of REC and CAL, but not PPD. Greater levels of Pg DNA were associated with PPD, REC and CAL. By regression analysis, CD4+ T‐cell count <200 cells/mm³ had approximately twice the deleterious effect on CAL as did smoking (standardized β coefficient 0.306 versus 0.64). Annual dental visit compliance remained an independent predictor for lower levels of PD. Conclusions: The level and extent of PD were high in this cohort even though most patients were being treated with HAART. The definition of periodontal disease used and cohort characteristics examined can influence the level of periodontal disease reported in studies of persons with HIV. Traditional periodontal pathogens are associated with PD in this cohort. Those with CD4+ T‐cell counts <200 cells/mm³ are at greater risk for PD. Therefore, earlier HAART initiation may decrease exposure to immunosuppression and reduce PD morbidity. Continuity of dental care remains important for HIV+ patients even when they are being treated with HAART.     

Association of T CD4 lymphocyte levels and subgingival microbiota of chronic periodontitis in HIV-infected Brazilians under HAART

OBJECTIVE: The aim of this study was to determine the subgingival microbiota of HIV-infected patients with chronic periodontitis and different T CD4 lymphocyte levels under HAART. STUDY DESIGN: 64 HIV+ patients (mean age 34.5 +/- 7.3; 75% males) were distributed into Group I: chronic periodontitis (> or = 3 sites with probing pocket depth (PPD) and/or clinical attachment level (CAL) > or = 5 mm); and Group II: periodontal health (no sites with PPD > 3 mm and/or CAL > 4 mm). All subjects received conventional periodontal therapy. Periodontal clinical parameters were evaluated at 6 sites/tooth in all teeth at baseline and 4 months after therapy. The levels of T CD4 were obtained from the patient's medical record. Subgingival plaque samples were taken from the 6 sites with the largest pocket depth in each subject of Group I, and 6 randomly selected sites in subjects of Group II. The presence of 22 subgingival species was determined using the checkerboard DNA-DNA hybridization method. Significant microbiological differences within and among groups were sought using Wilcoxon signed-rank and Mann-Whitney tests, respectively. Relationships between T CD4 levels and microbiological parameters were determined using Kruskal-Wallis test. RESULTS: Sixty-one percent of the HIV-infected patients represented AIDS cases, although 69% of them were periodontally healthy. The T CD4 lymphocyte mean level was 333 cells/mm3 and viral load was 12,815 +/- 24,607 copies/mm3. Yet, the prevalence of chronic periodontitis was relatively low (36%). Several periodontal pathogens, in particular T. forsythensis (P < .05), were more prevalent in HIV-positive patients with periodontitis than in HIV-positive subjects with periodontal health. Most of the species decreased in frequency after therapy, particularly P. gingivalis (P < .05). E. faecalis and F. nucleatum were significantly more prevalent in the subgingival microbiota of patients with chronic periodontitis and lower levels of T CD4 (P < .05), while beneficial species tended to be more frequently detected in individuals with T CD4 counts over 500 cells/mm3. CONCLUSION: The subgingival microbiota of HIV-infected patients with chronic periodontitis include a high prevalence of classical periodontal pathogens observed in non-infected individuals. Furthermore, the severe immunosuppression seems to favor the colonization by these species, as well as by species not commonly found in the subgingival microbiota.     

Association of T CD4 lymphocyte levels and chronic periodontitis in HIV-infected brazilian patients undergoing highly active anti-retroviral therapy: clinical results

BACKGROUND: Controversial data regarding the association between immunosuppression and prevalence/ severity of periodontal diseases in HIV infection have been reported. Thus, the aim of this study was to test the hypothesis that lower T CD4 lymphocyte levels are not related to a higher prevalence of chronic periodontitis in HIV-infected Brazilians undergoing highly active anti-retroviral therapy (HAART). METHODS: Sixty-four HIV-infected patients under HAART were classified as having chronic periodontitis; i.e., > or = three sites with probing depth (PD) and/or clinical attachment level (CAL) > or = 5 mm or periodontal healthy (no sites with PD > 3 mm and/or CAL > 4 mm). All subjects received conventional periodontal therapy. Bleeding on probing, plaque accumulation, PD, and CAL were registered at six sites/tooth at baseline and 4 months after therapy. Epidemiological features and levels of T CD4 lymphocytes were obtained from medical records. Significance of differences in periodontal clinical parameters within and between groups were determined using Wilcoxon signed-rank and Mann-Whitney or independent sample t tests. Associations between T CD4 levels and clinical parameters were determined using the chi square test. RESULTS: Sixty-one percent of the HIV-infected patients represented AIDS cases, although 69% of them were periodontally healthy. The overall T CD4 lymphocyte mean levels was 333 +/- 254 cells/mm3 and viral load was 12,815 +/- 24,607 copies/mm3. Yet the prevalence of chronic periodontitis was relatively low (36%). In addition, patients with periodontitis presented a moderate disease (mean PD = 2.2 +/- 0.10; mean CAL = 2.6 +/- 0.13) and responded successfully to periodontal therapy. These subjects showed higher levels of T CD4 cells, but lower counts of neutrophils than periodontally healthy patients. Among periodontally healthy and chronic periodontitis patients, 41.7% and 22.9%, respectively, had low levels of T CD4 lymphocytes. No significant differences between periodontal status and epidemiological and immunological parameters were observed. CONCLUSION: Based on these results, the hypothesis that lower T CD4 lymphocyte levels are not associated with higher prevalence of chronic periodontitis in HIV-infected Brazilians under HAART cannot be rejected.     

Incomplete adherence to an adjunctive systemic antibiotic regimen decreases clinical outcomes in generalized aggressive periodontitis patients: a pilot retrospective study

AIM: The objective of this study was to explore the effect of incomplete adherence to the prescribed antibiotic regimen, amoxicillin and metronidazole, in the non-surgical treatment of generalized aggressive periodontitis (GAP). METHODS: This retrospective study included 18 GAP subjects who received a conventional course of full-mouth non-surgical periodontal treatment using machine-driven and hand instruments and an adjunctive course of systemic antibiotics (500 mg amoxicillin and 500 mg metronidazole three times a day for 7 days). Clinical parameters were collected at baseline and at 2 months post-treatment. Self-reported adherence to the prescribed medication regimen was recorded at 2 months. RESULTS: All clinical parameters, except for the mean clinical attachment level (CAL) in sites with initial probing pocket depth (PPD) < or = 3 mm, improved at 2 months in all subjects. PPD reduction was 3.7 mm [95% confidence interval (CI) 3.2, 4.3 mm] in deep pockets (> or = 7 mm) and 2.2 mm (95% CI 1.9, 2.4 mm) in moderate pockets (4-6 mm), while CAL gain was 2.2 mm (95% CI 1.7, 2.6 mm) and 1.2 mm (95% CI 0.8, 1.5 mm), respectively. However, only 11 subjects (61.1%) reported full adherence to the medication. In deep pockets (> or = 7 mm), the difference between an adherent and non-adherent/partially adherent subject was 0.9 mm (95% CI 0.1, 1.7 mm, ancova, p=0.027) in PPD reduction and 0.8 mm (95% CI -0.2, 1.9, p=0.129) in CAL gain at 2 months. In moderate pockets (4-6 mm) this difference was smaller in magnitude: 0.4 mm (95% CI 0.1, 0.9 mm, p=0.036) in PPD reduction and 0.2 mm (95% CI -0.3, 0.9 mm, p=0.332) in CAL gain. CONCLUSIONS: Within the limits of this design, these data suggest that incomplete adherence to a 7-day adjunctive course of systemic metronidazole and amoxicillin is associated with decreased clinical outcomes in subjects with generalized aggressive periodontitis.     

Occurrence of oral lesions in relation to clinical and immunological status among HIV-infected adult Tanzanians

OBJECTIVE: To determine the association, if any, between the presence of oral lesions and clinical and immunological status of untreated HIV-infected adults in Tanzania. DESIGN: A cross-sectional study. SETTING: AIDS Clinical Trial Clinic (ATCC) at Muhimbili Medical Centre in Dar-es-Salaam, Tanzania. SUBJECTS: 192 HIV-infected individuals not receiving treatment; 156 individuals confirmed to be HIV-seronegative acted as a control group. METHODS: Examination of oral structures, determination of HIV serostatus, clinical status, and peripheral CD4+ T cell and total lymphocyte counts. MAIN OUTCOME MEASURE: Presence of oral lesions. RESULTS: Intra-oral lesions were seen among 7.7% of the HIV-seronegative, 10.4% of the HIV-seropositive and 36.8% of the AIDS groups, respectively. Enlarged parotid glands were seen in 20% of the AIDS patients, 11.9% of the HIV-seropositives, and 5.1% of the HIV seronegatives. Enlargement of submandibular salivary glands was seen in 29.6% of the AIDS patients, 31.3% of the HIV-seropositives compared with 14.7% among the HIV-seronegatives. Multiple regression analysis was used to calculate adjusted odds ratio (OR) for presence of oral lesions. OR for an intra-oral lesion was 1.6 (95% CI = 0.5; 5.0) among the HIV-seropositives and 8.2 (95% CI = 3.5; 19.7) among the AIDS patients using the HIV-seronegatives as reference. OR for an intra-oral lesion was 0.9 (95% CI = 0.3; 2.9) in HIV-infected patients with peripheral CD4+ T cell count of between 200-500 cells mm-3 and 2.7 (95% CI = 0.9; 7.7) in patients with less than 200 cells mm-3. OR for an intra-oral lesion was 0.4 (95% CI = 0.2; 0.9) for patients with peripheral total lymphocyte counts of between 1000-2000 cells mm-3 and 0.9 (95 CI = 0.4; 2.0) for patients with less than 1000 cells mm-3. CONCLUSION: The association of oral lesions with the clinical stage of HIV infection and to a lesser extent peripheral CD4+ T cell count does suggest that these lesions could be used as additional markers of immunosuppression and AIDS.     

The influence of stress and anxiety on the response of non-surgical periodontal treatment

AIM: The aim of this study was to evaluate the influence of stress and anxiety on the response to non-surgical periodontal treatment (NPT) in patients with chronic periodontitis. METHOD: Sixty-six patients (mean age 46.1 +/- 8 years) were assigned to three groups: control group, probing pocket depth (PPD) or=4 and 6 mm, n=20. Stress, state anxiety (SA) and trait anxiety (TA) and plaque index (PI), gingival index, PPD and clinical attachment level (CAL) were recorded at baseline and 3 months after NPT. RESULTS: TA scores were different among groups at baseline and after NPT. TA was related to periodontitis at baseline and after NPT. PI was associated with the SA at baseline. The reduction of frequency of CAL >6 mm was correlated with TA after adjusting for confounders. Stressed subjects did not show reduction of frequency of PPD >6 mm (T1), CAL 4-6 mm and CAL >6 mm (T2). CONCLUSIONS: The data suggest an influence of trait of anxiety and stress on the response to NPT.     

Autogenous bone graft in conjunction with enamel matrix derivative in the treatment of deep periodontal intra-osseous defects: a report of 13 consecutively treated patients

AIM: The purpose of the present study was to investigate the effectiveness of a regenerative procedure based on supra-crestal soft tissue preservation in association with combined autogenous bone (AB) graft/enamel matrix derivative (EMD) application in the treatment of deep periodontal intra-osseous defects. METHODS: Thirteen consecutively treated patients, seven females and six males, aged 30-65 years, three smokers, were included. A total of 15 deep, one- to two-wall intra-osseous defects were selected. Immediately before surgery and 6 months after surgery, pocket probing depth (PPD), clinical attachment level (CAL), and gingival recession (REC) were recorded. RESULTS: PPD amounted to 9.4+/-1.8 mm before surgery, and decreased to 4.7+/-1.2 mm post-surgery (p<0.0000). CAL varied from 10.5+/-2.0 mm pre-surgery to 6.2+/-1.7 mm post-surgery (p<0.0000), with CAL gain averaging 4.3+/-1.4 mm. Fourteen (93.3%) defects presented CAL gain >/=3 mm. REC change was 0.4+/-0.7 mm. CONCLUSIONS: Results from the present study indicated that a regenerative procedure based on supra-crestal soft tissue preservation and combined AB/EMD treatment leads to a clinically and statistically significant improvement of soft tissue conditions of deep periodontal intra-osseous defects.     

Supracrestal soft tissue preservation with enamel matrix proteins in treatment of deep intrabony defects

BACKGROUND/AIMS: The purpose of the present study was to investigate the effectiveness of a regenerative procedure based on supracrestal soft tissue preservation in association with enamel matrix proteins (EMP) in the treatment of deep intrabony defects. METHODS: The subjects included 35 consecutively treated patients, 23 females and 12 males, aged 28-61 years, 11 of whom were smokers. Patients presented with at least one intrabony defect with probing pocket depth > or = 6 mm and a radiographic depth of the defect > or = 4 mm at the initial visit. Immediately before surgery and 9-12 months after surgery, Local Plaque Score (LPS), Local Bleeding Score (LBS), probing pocket depth (PPD), clinical attachment level (CAL), gingival recession (REC), and radiographic depth of the defect (DEPTH) were recorded. RESULTS: Thirty-one (88.6%) defects were LPS-negative presurgery, while 29 (82.9%) defects presented with no plaque postsurgery. The prevalence of LBS-positive defects shifted from 94.3% presurgery to 8.4% postsurgery (p < 0.0000). PPD was 8.9 mm before surgery, and decreased to 3.5 mm postsurgery (p < 0.0000). CAL varied from 10.1 mm presurgery to 5.4 mm postsurgery (p < 0.0000), with an average improvement (gain) of 4.7 +/- 1.7 mm. Twenty-six (74.3%) defects presented a gain of least 4 mm. Regression analysis showed a positive correlation between CAL gain as a dependent variable, and presurgery PPD and amount of supracrestal soft tissues as predictors. DEPTH improvement (gain) was 3.9 +/- 1.8 mm, which represented 65% of defect fill. Twenty (57.1%) defects presented a DEPTH gain of at least 4 mm. DEPTH gain was significantly correlated to presurgery PPD (p < 0.000). No significant differences were found between smokers and non-smokers in terms of CAL and DEPTH gain. CONCLUSIONS: Results from the present study indicated that the regenerative procedure based on supracrestal soft tissue preservation and EMP application leads to clinically and statistically significant improvement of hard and soft tissue conditions of deep intrabony defects.     

Oral manifestations in 70 German HIV-infected women

OBJECTIVE: To describe the prevalence of oral lesions in HIV-infected women, and to determine the association of oral lesions with the level of immunosuppression and the route of transmission. PATIENTS: In a retrospective, cross-sectional study, a cohort of 70 HIV-infected women (median age: 32.5 y; median CD4⁺-cell count 262 per μl) comprising 18% of all HIV-infected individuals (n = 389) was selected in an outpatient clinic. Oral lesions strongly associated with HIV-infection were evaluated. RESULTS: The overall prevalence of oral lesions was 27/70 (39%). Among HIV-infected women with CD4⁺-cell counts <200 per μl, the prevalence was 65% (19/29); and with counts >200 per μl, the prevalence was 27% (11/41). The prevalence of candidiasis and hairy leukoplakia was similar among those infected heterosexually or by intravenous drug use. CONCLUSIONS: As reported in men, these findings demonstrate that oral lesions are common in HIV-infected women. Candidiasis is more likely to occur at low CD4⁺-cell counts, whereas no difference was seen regarding the level of immunosuppression and hairy leukoplakia. Interestingly, the route of transmission does not play a role regarding the presence of oral lesions among HIV-infected women.     

Clinical comparison of the effectiveness of novel sonic instruments and curettes for periodontal debridement after 2 months

AIM: The aim of this study was to evaluate in vivo the effectiveness of scaling and root planing of new oscillating instruments (Periosonic) using a sonic handpiece compared to hand curettes with a split mouth design after 2 months. METHODS: 11 patients with adult periodontitis participated in this study. Plaque index (PII) (O'Leary), bleeding on probing (BOP), probing pocket depth (PPD), recession (REC) and clinical attachment level (CAL) were recorded at baseline and 2 months after treatment. After oral hygiene instruction, 2 randomly assigned quadrants per patient were scaled and root planed with curettes (control side) and the remaining 2 quadrants with the Periosonic instruments 1 and 2 (test side). The student t-test for paired data was used to test the significance of difference between test and control sides. RESULTS: There was no statistical difference (p>0.05) between the 2 sides for the improvement of the clinical parameters excepted for the group with initial PPD of 4-6 mm (test: 1.3+/-0.4 mm PPD reduction, control: 1.6+/-0.4 mm). For PPD > or =7 mm, the test side had better clinical improvement in attachment levels (2.2+/-0.9 mm), less recession (-0.4+/-0.5 mm) with lower PPD reduction (2.4+/-0.6 mm) than the control side (AL: 1.6+/-1.8 mm; REC: -1.3+/-0.7 mm, PPD reduction: 3.0+/-1.4 mm). CONCLUSION: This clinical study demonstrated that Periosonic(R) instruments are clinically at least as effective as curettes in PPD reduction when initial PPD is < or =6 mm and show better clinical attachment level improvement with less recession for initial PPD of > or =7 mm.     

The use of enamel matrix derivative alone versus in combination with bone grafts to treat patients with periodontal intrabony defects: A meta-analysis

BackgroundThe authors performed a meta-analysis to compare the clinical outcomes of enamel matrix derivative (EMD) used in combination with various bone grafts with EMD alone in patients with intrabony defects.Types of Studies ReviewedThe authors retrieved relevant studies through Sept. 30, 2011, from MEDLINE, PubMed, Embase and Cochrane Central Register of Controlled Trials. The main clinical outcomes were probing pocket depth (PPD) reduction, clinical attachment level (CAL) gain, gingival recession (REC) increase and defect fill gain. The authors performed two separate meta-analyses, according to the length of follow-up. They also conducted subgroup analyses regarding the study designs and surgical procedures used.ResultsThe authors included 11 studies in their meta-analysis. At six to eight months' follow-up, pooled estimates showed that there was no significant difference regarding PPD reduction (P = .62) and CAL gain (P = .23) among the treatment groups, but there was a significant difference regarding defect fill gain and REC increase. At 12 months' follow-up, pooled estimates revealed no significant differences regarding PPD reduction (P = .29), CAL gain (P = .15) and REC increase (P = .30) between the groups, but the authors still detected a significant difference for defect fill gain.Clinical ImplicationsIn trials with a short-term follow-up, the combination therapies yielded better clinical outcomes regarding defect fill gain and REC increase compared with EMD alone, whereas most clinical outcomes were not significantly different between the two groups in the long run. The additional benefits from using combination therapies to promote periodontal tissue regeneration need to be confirmed.     

Enamel matrix proteins in the regenerative therapy of deep intrabony defects

AIM: This prospective multicentre randomized controlled clinical trial was designed to compare the clinical outcomes of papilla preservation flap surgery with or without the application of enamel matrix proteins (EMD). MATERIAL AND METHODS: 172 patients with advanced chronic periodontitis were recruited in 12 centers in 7 countries. All patients had at least one intrabony defect of > or =3mm. Heavy smokers (> or =20 cigarettes/day) were excluded. The surgical procedures included access for root instrumentation using either the simplified or the modified papilla preservation flap in order to obtain optimal tissue adaptation and primary closure. After debridement, roots were conditioned for 2 min with a gel containing 24% EDTA. EMD was applied in the test subjects, and omitted in the controls. Postsurgically, a strict plaque control protocol was followed. At baseline and 1 year following the interventions, clinical attachment levels (CAL), pocket probing depths (PPD), recession (REC), full-mouth plaque scores and full-mouth bleeding scores were assessed. A total of 166 patients were available for the 1-year follow-up. RESULTS: At baseline, 86 test and 86 control patients presented with similar subject and defect characteristics. On average, the test defects gained 3.1+/-1.5 mm of CAL, while the control defects yielded a significantly lower CAL gain of 2.5+/-1.5 mm. Pocket reduction was also significantly higher in the test group (3.9+/-1.7 mm) when compared to the controls (3.3+/-1.7 mm). A multivariate analysis indicated that the treatment, the clinical centers, cigarette smoking, baseline PPD, and defect corticalisation significantly influenced CAL gains. A frequency distribution analysis of the studied outcomes indicated that EMD increased the predictability of clinically significant results (CAL gains > or =4 mm) and decreased the probability of obtaining negligible or no gains in CAL (CAL gains <2 mm). CONCLUSIONS: The results of this trial indicated that regenerative periodontal surgery with EMD offers an additional benefit in terms of CAL gains, PPD reductions and predictability of outcomes with respect to papilla preservation flaps alone.     

Treatment of intraosseous defects with bioabsorbable barriers alone or in combination with decalcified freeze-dried bone allograft: a randomized clinical trial

BACKGROUND: This study clinically compares the outcomes obtained from the use of a bioabsorbable barrier device in combination with demineralized freeze-dried bone allograft (DFDBA) to the results obtained from the barrier device used alone in the treatment of human intraosseous defects. METHODS: The study consisted of 30 patients with one intraosseous periodontal defect each. The trial included defects with loss of attachment of > or = 6 mm, with a radiographically detectable defect of at least 4 mm and with at least 2 remaining osseous walls. After the hygienic phase, at baseline, probing depth (PD), clinical attachment level (CAL), and recession (REC) were measured. During open flap debridement, the defects were randomly assigned to receive either a polylactic acid (PLA) barrier in combination with DFDBA (test) or a PLA barrier alone (control). Additionally, baseline osseous intrasurgical measurements of the periodontal defect were obtained to evaluate the amount of bone regeneration. PD, CAL, and REC were remeasured at 6 and 12 months postsurgery and osseous measurements repeated at 12 months during a re-entry procedure. RESULTS: Two-sample t-test comparisons of mean PD, CAL, and REC measurements (mm) between test (PLA+DFDBA) and control (PLA alone) groups at baseline, PLA+DFDBA: PD = 7.3, CAL = 8.1, REC = -0.7; PLA-alone: PD = 7.9, CAL = 8.4, REC = -0.5, were not statistically different (P>0.05). The following mean changes (delta) at 6 months for the test and the control groups were: decreased PD = 3.6 and 4.0 mm; gain CAL = 2.7 and 3.1 mm; and increased REC = -0.8 and -0.8 mm, respectively. At 12 months the changes for the test and control groups were: decreased PD = 3.3 and 4.1 mm; gain CAL = 2.3 and 3.2 mm; and increased REC = -0.8 and -1.0 mm, respectively. Two-sample t-test comparisons between PD, CAL, and REC changes yielded no significant differences between treatments (P > 0.05), except for the change in CAL at 12 months in favor of the control group, P = 0.008. Comparisons of osseous measurements resulted in no significant differences between groups at baseline and at 12 months (P > 0.05). The intrabony defect filled on the average 3.72 mm for the test and 4.85 mm for the control group. The experimental defects showed a 4.73 mm defect depth reduction, while the control defects reduced 5.35 mm. Re-entry measurements of osseous crest resorption were 1.1 mm for the test and 0.61 mm for the control. CONCLUSIONS: In the intraosseous defects treated in this study, the addition of DFDBA to the GTR procedure did not significantly enhance the clinical results obtained with the GTR procedure alone.     

The combined use of enamel matrix proteins and a tetracycline-coated expanded polytetrafluoroethylene barrier membrane in the treatment of intra-osseous defects

OBJECTIVES: The purpose of this split-mouth study was to evaluate the clinical response of enamel matrix proteins (EMPs, Emdogain Gel in intra-osseous defects with or without a combined application of a tetracycline-coated expanded polytetrafluoroethylene barrier membrane (e-PTFE, Gore-Tex). METHODS: Twelve pairs of intra-osseous periodontal defects in 11 patients received the application of EMPs on the exposed root surface (EMP). One of the two defects received randomly, as an adjunct to EMP treatment, a tetracycline-coated e-PTFE membrane (MEMP). At baseline, 6- and 12-month probing pocket depth (PPD), clinical attachment level (CAL) and probing bone level (PBL) were measured. RESULTS: After 12 months, the EMP defects showed a significant mean PPD reduction of 2.86+/-0.75 mm, a mean gain in CAL of 1.28+/-2.04 mm, a mean PBL gain of 1.63+/-1.21 mm and a mean increase of recession (REC) of 1.56+/-2.30 mm. The MEMP defects showed a significant mean PPD reduction of 3.02+/-1.55 mm, a mean gain in CAL of 1.65+/-1.29 mm, a mean PBL gain of 1.58+/-1.92 mm and a mean increase of REC of 1.38+/-1.63 mm. Except for significantly more post-operative discomfort at the MEMP sites, no significant differences were found between EMP and MEMP defects. CONCLUSION: Within the limits of this study, it is concluded that in the treatment of intra-osseous defects with EMP, the adjunctive use of a tetracycline-coated e-PTFE membrane failed to show more gain of CAL and PBL.     

Association between passive and active smoking evaluated by salivary cotinine and periodontitis

AIM: This study attempted to determine the relationship between passive and active smoking on the basis of salivary cotinine levels and periodontitis severity. METHODS: Japanese workers (n=273) were surveyed via an oral examination, a self-administered questionnaire and collection of whole saliva. Probing pocket depth (PPD) and clinical attachment level (CAL) served as periodontal parameters. Periodontitis was defined as the presence of two or more teeth with PPD > or =3.5 mm and CAL > or =3.5 mm. Salivary cotinine was determined using ELISA. Statistical methods included Wilcoxon's rank-sum test and multiple logistic regression analysis. RESULTS: Based on the results of receiver-operating characteristic plots for cotinine-level classification derived from self-reported smoking status, non-, passive and active smokers were defined as those subjects exhibiting cotinine levels of 0, 1-7 and > or =8 ng/ml, respectively. Numbers of teeth displaying CAL > or =3.5 mm in passive and active smokers were significantly higher than those in non-smokers. Multiple logistic regression analysis revealed significantly higher periodontitis odds ratios in passive and active smokers relative to non-smokers following adjustment for other lifestyle factors; odds ratios were 2.87 [95% confidence interval (CI); 1.05-7.82] and 4.91 (95% CI; 1.80-13.35), respectively. CONCLUSION: These findings suggest that passive smoking classified in terms of salivary cotinine level may be an independent periodontitis risk indicator.     

The relationship of stress and anxiety with chronic periodontitis

AIM: This case-control study investigates the relationship of stress and anxiety with periodontal clinical characteristics. METHOD: Seventy-nine selected patients (mean age 46.8+/-8 years) were assigned to three groups in accordance with their levels of probing pocket depth (PPD): control group (PPD< or =3 mm, n=22), test group 1 (at least four sites with PPD > or =4 mm and < or =6 mm, n=27) and test group 2 (at least four sites with PPD >6 mm, n=30). An inclusion criterion of the study required that patients presented a plaque index (PI) with a value equal to or larger than 2 in at least 50% of dental surfaces. All subjects were submitted to stress and anxiety evaluations. Stress was measured by the Stress Symptom Inventory (SSI) and the Social Readjustment Rating Scale (SRRS), while the State-Trait Anxiety Inventory (STAI) was used to assess anxiety. Clinical measures such as PI, gingival index (GI), PPD and clinical attachment level (CAL) were collected. Patient's medical history and socioeconomic data were also recorded. RESULTS: The mean clinical measures (PI, GI, PPD and CAL) obtained for the three groups, were: control group, 1.56+/-0.32, 0.68+/-0.49, 1.72+/-0.54 and 2.04+/-0.64 mm; group 1, 1.56+/-0.39, 1.13+/-0.58, 2.67+/-0.67 and 3.10+/-0.76 mm, group 2, 1.65+/-0.37, 1.54+/-0.46, 4.14+/-1.23 and 5.01+/-1.60 mm. The three groups did not differ with respect to percentage of clinical stress, scores of the SRRS, trait and state anxiety. Frequency of moderate CAL (4-6 mm) and moderate PPD (4-6 mm) were found to be significantly associated with higher trait anxiety scores after adjusting for socioeconomic data and cigarette consumption (p<0.05). CONCLUSIONS: Based on the obtained results, individuals with high levels of trait anxiety appeared to be more prone to periodontal disease.     

Full-mouth treatment concepts for chronic periodontitis: a systematic review

Objectives: To systematically review the effectiveness of full-mouth treatment concepts for chronic periodontitis.
Material and Methods: A search was conducted for randomized, controlled clinical trials including full-mouth scaling with (FMD) or without (FMS) the use of antiseptics and quadrant scaling (control). Data sources included COHG, CENTRAL, MEDLINE and EMBASE. Reviewers independently conducted data abstraction and quality assessment. The primary outcome was tooth loss; secondary outcomes were the reductions of PPD and BOP and a gain of CAL.
Results: Of 216 identified abstracts, seven trials were included. Meta-analysis revealed a weighted mean difference (WMD) for the reduction of PPD between FMD and control of 0.53 mm [95% confidence interval (CI) (0.28, 0.77), p <0.0001] in moderately deep pockets of single-rooted teeth. The WMD for gain in CAL was 0.33 mm [95% CI (0.04, 0.63), p =0.03] in moderately deep pockets of single- and multi-rooted teeth. Comparing FMD and FMS, the WMD for the reduction of CAL amounted to 0.74 mm [95% CI (0.17, 1.31), p =0.01] in deep pockets of multi-rooted teeth in favour of FMS. For BOP a WMD –18.0% [95% CI (−34.30, −1.70), p =0.03] was calculated in deep pockets of single-rooted teeth in favour of FMD.
Conclusions: In adults with chronic periodontitis only minor differences in treatment effects were observed between the treatment strategies.     

Socket preservation using bovine bone mineral and collagen membrane: a randomized controlled clinical trial with histologic analysis

After tooth extraction, varying amounts of bone resorption occur because of qualitative and quantitative changes at the edentulous site of the alveolar process. The aims of this randomized controlled clinical trial were (1) to compare the postextraction changes in residual ridge dimensions during spontaneous healing with those during socket preservation, (2) to analyze the histologic and histomorphometric aspects of the grafted sockets, and (3) to compare probing procket depth (PPD) and clinical attachment level (CAL) changes at teeth adjacent to extraction sites. Forty-eight teeth were extracted from 41 patients referred for extraction of 1 or more maxillary or mandibular premolars or molars. The edentulous sites were randomly assigned to the control (EXT, extraction alone) or experimental groups (SP, extraction and socket preservation). In the SP group, the sockets were filled with bovine bone mineral and covered with porcine collagen membrane. At baseline and after 4 months, PPD, gingival recession (REC), and CAL were measured at teeth adjacent to the edentulous sites. The changes in ridge dimensions from baseline to 4 months were assessed on dental casts. At 4 months, bone was harvested from the grafted areas in the SP group and the edentulous areas in the EXT group. PPD, REC, and CAL were comparable between groups. However, from baseline to 4 months, the SP group showed significantly less reduction in ridge width (1.04 ± 1.08 mm vs 4.48 ± 0.65 mm, P < .001) and height (0.46 ± 0.46 mm vs 1.54 ± 0.33 mm, P < .001). Histologically, the grafted sockets exhibited various stages of bone maturation and formation without inflammatory responses. No significant difference in the mineralized and nonmineralized fractions was noted between the groups. Socket preservation using bovine bone mineral and porcine collagen membrane considerably limits the amount of horizontal and vertical bone resorption when compared with extraction alone.     

Comparison of periodontal disease status of adults in two untreated indigenous populations of Guatemala,Central America

OBJECTIVE: To compare the periodontal disease levels of two distinct indigenous populations of Guatemala, Central America, to determine whether differences exist. MATERIAL AND METHODS: Cross-sectional studies were performed in adults from the communities of San Juan La Laguna, SJLL (n = 125) and Tzununa (n = 54). In both cases, full-mouth pocket probing depths (PPDs) and clinical attachment levels (CALs) were measured by a single examiner, and the same examiner was employed in both studies. Recession at each site was derived from PPD and CAL measures. RESULTS: Tooth number did not differ significantly between SJLL and Tzununa (28.0 and 27.2, respectively). With respect to periodontal disease status, the percentage of sites with PPD >or= 5, 6 and 7 mm did not differ significantly, although mean PPD was significantly greater in the Tzununa sample (P = 0.01). Mean CAL and percentage of sites with CAL >or= 4, 5, 6 and 7 mm was significantly greater in SJLL than in Tzununa (P < 0.005) and the difference increased with age. Mean recession was also significantly greater in SJLL than Tzununa (P < 0.005), as was the percentage of sites with recession >or= 3 mm (P = 0.02), 4 mm (P = 0.002) and 5 mm (P = 0.008). CONCLUSION: The disease levels differed between these two indigenous Guatemalan communities. Whether this has a primarily environmental or genetic basis remains to be elucidated. :