Periodontitis and rheumatoid arthritis examined
A multidisciplinary team of scientists from the University of Groningen, the Netherlands, analyzed the literature to determine if a causal relationship is the most likely explanation for a topic under increasing scrutiny — the association between periodontitis and rheumatoid arthritis. They published a commentary about their findings in the September 2015 issue of the Journal of Periodontology.
Considering the absence of longitudinal cohort studies testing causality, the scientists applied Bradford Hill criteria to examine existing literature. They explored the relationship by delving into strength and consistency of the association, biologic plausibility, temporality, specificity in the causes, the dose response relationship, experimental evidence, coherence and analogy.
Results showed that the association between periodontitis and RA is relatively consistent, but the strength of the association is uncertain. Two hypothetical models were proposed as rational and theoretical bases for causation, with periodontitis preceding RA. Of five different periodontal pathogens examined, only DNA of Pg (Porphyromonas gingivalis) was detected more frequently in the synovial fluid of patients with RA than in the synovial fluid of non-RA controls. There were indications that periodontitis precedes RA. However, there was no evidence to show that (Pg) plays a direct role in this temporal relationship. A dose response pattern in the association between severity of periodontitis and RA development was found.
Experimental evidence in humans on the effect of periodontal treatment on RA disease activity is limited. In animal models citrullination (protein citrullination is suspected of triggering the immune system and driving the events leading to RA), by Pg plays a distinct role in the development and aggravation of arthritis. “The correlation of RA disease activity with the severity of periodontitis in humans can probably be attributed to mutual exacerbation of inflammatory responses of both diseases,” authors surmised after exploring studies to assess the coherence criteria of a cause-and-effect interpretation.
Among conclusions researchers said, “Although the role of periodontal pathogens in RA remains speculative, a causative role for periodontitis as a chronic inflammatory disease caused by infectious agents in RA seems biologically plausible. Considering the great variety in disease manifestation of both periodontitis and RA, a causal relationship, if one exists, may only be present between certain forms of periodontitis and RA.”
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Periodontal maintenance and adjunctive laser therapy
More good prospective, randomized, controlled clinical trials of various laser therapy techniques and instrumentation are needed, according to authors publishing in the October 2015 Journal of Periodontology. The scientists call out widespread use and promotion of laser therapy in clinical practice today and describe a concurrent “relative lack of evidence” supporting claimed clinical results.
They made the assertion after examining the findings related to a randomized clinical trial they conducted of 22 patients receiving regular periodontal maintenance therapy (PMT) at the University of Nebraska in Lincoln. The literature shows that long-term success of periodontal therapy is dependent on the continuing periodontal maintenance phase of therapy. Clinicians have long recognized the need for improvement in patient-friendly technology to more effectively treat inflamed periodontal pockets during PMT.
Finding almost all of the clinical studies assessing laser therapy to have evaluated the active phase of periodontal treatment, the researchers deemed studies evaluating the use of the diode laser as adjunctive therapy to scaling and root planing (SRP) during PMT of inflamed periodontal pockets lacking.
To compare the effectiveness of using SRP and laser (SRP + L) and SRP alone after treatment of inflamed periodontal pockets in PMT patients, scientists analyzed changes within and between each of two therapy groups — SRP + L and SRP — between baseline (before therapy) and three months after therapy in 22 patients. They randomized the type of therapy by flipping a coin. SRP + L were test sites (56) and SRP alone (58) were control sites. Nearly all patients had test and control sites.
Scientists assessed changes in clinical attachment levels, probing depth, bleeding on probing and an inflammatory marker consistently shown to be elevated in periodontitis sites. They collected clinical data at six sites per tooth with identified disease and one healthy site from each patient before therapy and again three months after therapy.
Intragroup analyses showed that sites treated with SRP + L or SRP alone had a statistically significant reduction of probing depth, gain in clinical attachment level and reduction of bleeding on probing three months after treatment. However, intergroup analyses showed no statistically significant difference in the mean change of the clinical parameters between the SRP + L and SRP-alone groups.
Differences in the inflammatory marker levels between SRP + L and SRP alone were not statistically significant, but similar, when healthy sites were compared to inflamed pockets in the same patients.
Scientists concluded that SRP + L did not enhance clinical outcomes compared to SRP alone in the treatment of inflamed sites with ≥5 millimeters probing depth in periodontal maintenance patients.
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"You Don’t Know What You Don’t Know"
Dr. R. Bruce Cochrane, DDS, MS presents You Don’t Know What You Don’t Know: A Paradigm Shift in Conservative Periodontal Treatment on Nov. 14 at 4:00-4:45 PM. Prescription tray delivery augments surgical and non-surgical periodontal treatment, helping address biofilm infections for immediate and long-term improvements in periodontal health. This course includes decision making, knowing when surgery is necessary and how to maintain surgical gains. To learn more click here.
Single versus double flap approach
A study designed to compare the clinical outcomes of the single flap approach (SFA) versus the double flap approach (DFA) in accessing periodontal defects was published in the June 2015 issue of The Journal of Clinical Periodontology. Scientists put clinical, radiographic and patient centered outcomes of the two approaches side by side when combined with a well-established regenerative strategy.
Except for the soft tissue management (SFA or DFA), scientists performed identical regenerative procedures on 29 patients (15 patients in the SFA group, 14 in the DFA group), in the single-center, parallel-arm double-blind, randomized-controlled trial. All subjects were diagnosed with chronic or aggressive periodontitis, had at least one intraosseous periodontal defect with probing depth ≥6 millimeters and underwent full mouth scaling and root planing.
The scientists’ study methods included recording clinical parameters at six sites before surgery and at six months post-surgery. Patients were prescribed Ibuprofen 600 mg to be used at their discretion as needed. Sutures were removed at two weeks post-surgery. Digital photographs were taken and wound healing was evaluated using the Early Healing Index (EHI). Radiographs were evaluated before surgery and six months after surgery. Patients assessed self-perceived pain on a visual analogue scale (VAS) immediately after surgery, at 8 a.m., 1 p.m. and 8 p.m. on each postoperative day up to the 3rd day and at 8 p.m. on the 4th, 5th, 6th, 7th and 14th postoperative day. Patients recorded their analgesic consumption.
A total of 28 patients completed the full study. Results showed that 12 sites in the SFA group and six sites in the DFA group showed complete flap closure at two weeks post-surgery. The frequency of sites showing optimal wound healing was eight in the SFA group and three in the DFA group.
No significant differences in six-month changes in probing parameters and radiographic defects were found between groups.
However, patient in the SFA group reported significantly lower values on the VAS scale for pain when compared to the DFA group on day one (8 a.m., 1 p.m., 8 p.m., day 2 (1 p.m., 8 p.m.) and day six. Also, patients in the DFA group reported that they consumed significantly more analgesics the day after surgery than patients in the SFA group did.
Authors concluded that when combined with the established periodontal regenerative treatment described in their study, the SFA approach may result in similar clinical outcomes, better quality for early wound healing and lower pain and consumption of analgesics during the first postoperative days compared to the DFA.
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AAP focuses 1999 Classification update
Three specific areas of concern about the current Classification of Periodontal Diseases and Conditions slated for change with the 2017 update were discussed in a report published in the July 2015 issue of the Journal of Periodontology. They are: attachment levels in diagnosis of periodontitis, chronic versus aggressive periodontitis and localized versus generalized periodontitis.
The education community, the American Board of Periodontology and the practicing community expressed that the current classification presents challenges for education of dental students and implementation in clinical practice.
A classification for peri-implant diseases and risk assessment for periodontal disease progression and prognostic subtypes or profiles within aggressive versus chronic periodontitis are slated for development, according to the AAP Task Force report.
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A Delicate Balancing Act
Patients come to the dental office with clear health care needs, but their concerns about costs, time away from work, fears or anxieties and hopes for smile makeovers can complicate treatment. A delicate balancing act is required to satisfy patients. Dr. Patricia Lugo-Blanco is particularly good at this.
The 71-year-old patient in this award winning case study first presented to Dr. Lugo-Blanco’s office with pocket probing scores up to 9mm, bone loss, generalized heavy bleeding and a request to improve her smile.
The periodontal treatment started immediately with oral hygiene instructions, followed by prescription Perio Trays from Perio Protect LLC. Patients use the trays for just minutes each day to deliver hydrogen peroxide gel deep into periodontal pockets.
“Perio Protect has become a priority in our office simply because patients can’t brush and floss away periodontal disease. With the Perio Tray, medication is maintained below the gums to fight the infections causing the disease. And,” Dr. Lugo-Blanco emphasized, “we really want to address the cause, not just the symptoms, to improve patient health.”
After three weeks of tray usage, bleeding had subsided significantly. Scaling and laser therapy were completed. Within months, pocket depths measured within normal limits. Dr. Lugo-Blanco then prescribed removable partial dentures, which improved the patient’s occlusion and appearance. Importantly for the patient, her natural teeth were significantly whiter, a nice side effect of the hydrogen peroxide gel.
Dr. Lugo-Blanco was not compensated for this editorial. The Perio Tray by Perio Protect was cleared by the FDA to place doctor-selected medication into periodontal pockets. Successful Perio Protect treatment depends on patient compliance and patient conditions. Your results may vary. Doctors use Perio Protect in conjunction with scaling and when necessary with surgery. For a full report of this case study see www.TheOrkosAward.com/studies. Additional information on prescription tray delivery is available at www.PerioProtect.com.
AAP Annual Meeting convenes next month
The 101st Annual Meeting of the American Academy of Periodontology will be held Nov. 14-17, 2015, at the Gaylord Palms Resort & Convention Center in Orlando, Florida. Offering over 25 hours of continuing education credits, the 2015 Annual Meeting provides more than 40 different courses relevant to periodontal care, including advances in treatment techniques, emerging technologies, scientific advancements, practice development and management, clinical applications and more.
To register for the 2015 Annual Meeting or for more information, please visit www.perio.org/meetings, call 1-800-282-4867 ext. 3213, or email firstname.lastname@example.org.
Early treatment can help prevent tooth loss
Convey this crucial point to patients with a succinct ADA brochure, Periodontal Disease: Keep Your Gums Healthy. It lets patients know that they can have perio disease with no clear symptoms and that disease can lead to tooth loss.
This patient education resource from the ADA includes prevention tips, warning signs and treatment explanations. The brochure further promotes understanding with photos of healthy gums versus periodontitis, plus new probing illustrations.
The 6-panel brochure is sold in packs of 50. Brochure contents can be viewed on this page. To order, call 1-800-947-4746 or go to adacatalog.org. A personalized version is also available. Readers who use the code 15408E before Oct. 30 can save 15 percent on all ADA Catalog products.
“Getting to the Bottom of It”
Periodontal patients need effective treatment options between office visits. Learn how prescription tray delivery of medication helps. Attend Duane Keller’s course Getting to the Bottom of It with Prescription Tray Delivery on Jan. 29 to review the research on medications, the benefits and limitations of prescription trays, and step-by-step case studies. Walk out of the course ready to help your patients. Free certification included! To register click here.
What is Specialty Scan?
This is one in a series of quarterly newsletters updating dentists on selected specialties in dentistry. Information presented is aggregated and summarized from previously published materials, each item attributed to its publication of origin. This issue of JADA Specialty Scan focuses on Periodontics, the fourth in the series on this topic for 2015. Other Specialty Scan issues are devoted to endodontics, oral pathology, oral and maxillofacial radiology, orthodontics, pediatric dentistry and prosthodontics. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. We welcome feedback on this and all Specialty Scan issues.
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