Periodontal infections are hypothesized to increase the risk of adverse systemic outcomes through inflammatory mechanisms. The magnitude of effect, if any, of anti-infective periodontal treatment on ...systemic inflammation is unknown, as are the patient populations most likely to benefit. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to test the hypothesis that anti-infective periodontal treatment reduces systemic c-reactive protein (CRP).
MEDLINE, EMBASE, CENTRAL and CINAHL databases were searched using sensitivity-enhancing search terms. Eligible RCTs enrolled patients with periodontal infection, compared a clearly defined anti-infective periodontal intervention (experimental group) to an "inactive control" (no periodontal intervention) or to an "active control" (lower treatment intensity than the experimental group). Mean differences in final CRP values at the earliest post-treatment time point (typically 1-3 months) between experimental and control groups were analyzed using random-effects regression. Among 2,753 possible studies 20 were selected, which included 2,561 randomized patients(median=57). Baseline CRP values were >3.0 mg/L in 40% of trials. Among studies with a control group receiving no treatment, the mean difference in CRP final values among experimental treatment vs. control groups was -0.37 mg/L 95%CI=-0.64, -0.11, (P=0.005), favoring experimental treatment. Trials for which the experimental group received antibiotics had stronger effects (P for interaction=0.03) and the mean difference in CRP final values among experimental treatment vs. control was -0.75 mg/L 95%CI=-1.17,-0.33. No treatment effect was observed among studies using an active treatment comparator. Treatment effects were stronger for studies that included patients with co-morbidities vs. studies that included "systemically healthy" patients, although the interaction was not significant (P=0.48).
Anti-infective periodontal treatment results in short-term modest reductions in systemic CRP.
Infective endocarditis (IE) often is caused by bacteria that colonize teeth. The authors conducted a study to determine if poor oral hygiene or dental disease are risk factors for developing ...bacteremia after toothbrushing or single-tooth extraction.
One hundred ninety-four participants in a study were in either a toothbrushing group or a single-tooth extraction with placebo group. The authors assessed the participants' oral hygiene, gingivitis and periodontitis statuses. They assayed blood samples obtained before, during and after the toothbrushing or extraction interventions for IE-associated bacteria.
The authors found that oral hygiene and gingival disease indexes were associated significantly with IE-related bacteremia after toothbrushing. Participants with mean plaque and calculus scores of 2 or greater were at a 3.78- and 4.43-fold increased risk of developing bacteremia, respectively. The presence of generalized bleeding after toothbrushing was associated with an almost eightfold increase in risk of developing bacteremia. There was no significant association between any of the measures of periodontal disease and the incidence of bacteremia after toothbrushing. The oral hygiene or disease status of a tooth was not significantly associated with bacteremia after its extraction.
Bacteremia after toothbrushing is associated with poor oral hygiene and gingival bleeding after toothbrushing.
Improvements in oral hygiene may reduce the risk of developing IE.
Periodontal diseases Pihlstrom, Bruce L; Michalowicz, Bryan S; Johnson, Newell W
Lancet,
11/2005, Volume:
366, Issue:
9499
Journal Article, Book Review
Peer reviewed
Open access
The periodontal diseases are highly prevalent and can affect up to 90% of the worldwide population. Gingivitis, the mildest form of periodontal disease, is caused by the bacterial biofilm (dental ...plaque) that accumulates on teeth adjacent to the gingiva (gums). However, gingivitis does not affect the underlying supporting structures of the teeth and is reversible. Periodontitis results in loss of connective tissue and bone support and is a major cause of tooth loss in adults. In addition to pathogenic microorganisms in the biofilm, genetic and environmental factors, especially tobacco use, contribute to the cause of these diseases. Genetic, dermatological, haematological, granulomatous, immunosuppressive, and neoplastic disorders can also have periodontal manifestations. Common forms of periodontal disease have been associated with adverse pregnancy outcomes, cardiovascular disease, stroke, pulmonary disease, and diabetes, but the causal relations have not been established. Prevention and treatment are aimed at controlling the bacterial biofilm and other risk factors, arresting progressive disease, and restoring lost tooth support.
Diabetes and periodontitis Michalowicz, Bryan S.; Pihlstrom, Bruce L.; Hodges, James S.
Journal of clinical periodontology,
September 2024, Volume:
51, Issue:
9
Journal Article
Conduct a systematic review and meta-analysis on nonsurgical treatment of patients with chronic periodontitis by means of scaling and root planing (SRP) with or without adjuncts.
A panel of experts ...convened by the American Dental Association Council on Scientific Affairs conducted a search of PubMed (MEDLINE) and Embase for randomized controlled trials of SRP with or without the use of adjuncts with clinical attachment level (CAL) outcomes in trials at least 6 months in duration and published in English through July 2014. The authors assessed individual study bias by using the Cochrane Risk of Bias Tool and conducted meta-analyses to obtain the summary effect estimates and their precision and to assess heterogeneity. The authors used funnel plots and Egger tests to assess publication bias when there were more than 10 studies. The authors used a modified version of the US Preventive Services Task Force methods to assess the overall level of certainty in the evidence.
The panel included 72 articles on the effectiveness of SRP with or without the following: systemic antimicrobials, a systemic host modulator (subantimicrobial-dose doxycycline), locally delivered antimicrobials (chlorhexidine chips, doxycycline hyclate gel, and minocycline microspheres), and a variety of nonsurgical lasers (photodynamic therapy with a diode laser, a diode laser, neodymium:yttrium-aluminum-garnet lasers, and erbium lasers).
With a moderate level of certainty, the panel found approximately a 0.5-millimeter average improvement in CAL with SRP. Combinations of SRP with assorted adjuncts resulted in a range of average CAL improvements between 0.2 and 0.6 mm over SRP alone. The panel judged the following 4 adjunctive therapies as beneficial with a moderate level of certainty: systemic subantimicrobial-dose doxycycline, systemic antimicrobials, chlorhexidine chips, and photodynamic therapy with a diode laser. There was a low level of certainty in the benefits of the other included adjunctive therapies. The panel provides clinical recommendations in the associated clinical practice guideline.
Aim
The recent ADA‐commissioned Clinical Practice Guideline on the nonsurgical treatment of chronic periodontitis has provided the most exhaustive library of clinical trials on scaling and root ...planing (SRP) with or without adjuncts. This network meta‐analysis (NMA) compared the adjuncts against each other.
Materials and Methods
A star‐shaped NMA was performed based on 36 indirect comparisons of clinical attachment‐level (CAL) gains among nine adjuncts in 74 studies from the Clinical Practice Guideline.
Results
All pairwise differences were accompanied by wide confidence intervals, and none of the adjuncts were statistically significantly superior to another. Local doxycycline hyclate and photodynamic therapy with a diode laser had the highest probabilities for ranking first and second, respectively. Publication bias was evident, with fewer than expected studies with small effects. The lack of these studies inflated the treatment effects by an estimated by 20%.
Conclusions
Adjuncts improve CAL gain by about a third of a mm over 6–12 months compared with SRP alone, but no significant differences were found among the adjuncts. The patient‐perceived benefit of this gain is unclear because CAL is a physical measure made by the clinician and not a patient‐oriented outcome. Publication bias inflated the observed treatment effects.
A panel of experts convened by the American Dental Association Council on Scientific Affairs presents an evidence-based clinical practice guideline on nonsurgical treatment of patients with chronic ...periodontitis by means of scaling and root planing (SRP) with or without adjuncts.
The authors developed this clinical practice guideline according to the American Dental Association's evidence-based guideline development methodology. This guideline is founded on a systematic review of the evidence that included 72 research articles providing clinical attachment level data on trials of at least 6 months' duration and published in English through July 2014. The strength of each recommendation (strong, in favor, weak, expert opinion for, expert opinion against, and against) is based on an assessment of the level of certainty in the evidence for the treatment's benefit in combination with an assessment of the balance between the magnitude of the benefit and the potential for adverse effects.
For patients with chronic periodontitis, SRP showed a moderate benefit, and the benefits were judged to outweigh potential adverse effects. The authors voted in favor of SRP as the initial nonsurgical treatment for chronic periodontitis. Although systemic subantimicrobial-dose doxycycline and systemic antimicrobials showed similar magnitudes of benefits as adjunctive therapies to SRP, they were recommended at different strengths (in favor for systemic subantimicrobial-dose doxycycline and weak for systemic antimicrobials) because of the higher potential for adverse effects with higher doses of antimicrobials. The strengths of 2 other recommendations are weak: chlorhexidine chips and photodynamic therapy with a diode laser. Recommendations for the other local antimicrobials (doxycycline hyclate gel and minocycline microspheres) were expert opinion for. Recommendations for the nonsurgical use of other lasers as SRP adjuncts were limited to expert opinion against because there was uncertainty regarding their clinical benefits and benefit-to-adverse effects balance. Note that expert opinion for does not imply endorsement but instead signifies that evidence is lacking and the level of certainty in the evidence is low.
Periodontitis is a common oral disease associated with coronary artery disease (CAD), cerebrovascular disease (CBVD) and type 2 diabetes (T2D). We studied if periodontitis treatment improves clinical ...outcomes and reduces medical care costs in patients with CAD, CBVD or T2D.
We used clinic records and claims data from a health care system to identify patients with periodontitis and CAD, CBVD or T2D, and to assess periodontal treatments, hospitalizations, medical costs (total, inpatient, outpatient, pharmacy), glycated hemoglobin, cardiovascular events, and death following concurrent disease diagnoses. We compared clinical outcomes according to receipt of periodontal treatment and/or maintenance care in the follow-up period, and care costs according to treatment status within one year following concurrent disease diagnoses, while adjusting for covariates. The data were analyzed in 2019-21.
We identified 9,503 individuals, 4,057 of whom were in the CAD cohort; 3,247 in the CBVD cohort; and 4,879 in the T2D cohort. Patients who were selected and elected to receive treatment and maintenance care were less likely to be hospitalized than untreated individuals (CAD: OR = 0.71 (95% CI: 0.55, 0.92); CBVD: OR = 0.73 (0.56, 0.94); T2D: OR = 0.80 (0.64, 0.99)). Selection to treatment and/or maintenance care was not significantly associated with cardiovascular events, mortality, or glycated hemoglobin change. Total care costs did not differ significantly between treated and untreated groups over 4 years. Treated patients experienced lower inpatient costs but higher pharmacy costs.
Patients with periodontitis and CAD, CBVD or T2D who were selected and elected to undergo periodontal treatment or maintenance care had lower rates of hospitalizations, but did not differ significantly from untreated individuals in terms of clinical outcomes or total medical care costs.
Background
A wide selection of Interdental Oral Hygiene (IOH) aids is available to consumers. Recommendations for selection are, however, limited by the lack of direct comparisons in available ...studies. We aimed to assess the comparative efficacy of IOH aids using Bayesian Network Meta‐Analysis (BNMA).
Methods
Two independent reviewers performed a systematic literature review of randomized clinical trials assessing IOH aids, based on a focused question. Gingival inflammation (Gingival Index (GI), Bleeding‐on‐probing (BOP)) was the primary outcome and plaque and probing depth were secondary outcomes A random‐effects arm‐based BNMA model was run for each outcome; posterior medians and 95% credible‐intervals (CIs) summarized marginal distributions of parameters.
Results
A two‐phase selection process identified 22 trials assessing 10 IOH aids as brushing adjuncts. Interdental brushes (IB) yielded the largest reduction in GI (0.23 95% CI: 0.09, 0.37) as toothbrushing adjuncts, followed by water‐jet (WJ) (0.19 95% CI: 0.14, 0.24). Rankings based on posterior probabilities revealed that IB and WJ had the highest probability of being “best” (64.7% and 27.4%, respectively) for GI reduction, whereas the probability for toothpick and floss being the “best” IOH aids was near zero. Notably, except for toothpicks, all IOH aids were better at reducing GI as compared with control.
Conclusions
BNMA enabled us to quantitatively evaluate IOH aids and provide a global ranking of their efficacy. Interdental brushes and water‐jets ranked high for reducing gingival bleeding, whereas toothpicks and floss ranked last. The patient‐perceived benefit of IOH aids is not clear because gingival inflammation measures are physical indicators of periodontal health.
Aims
Infection may be a rheumatoid arthritis (RA) risk factor. We examined whether signs of periodontal infection were associated with RA development in the First National Health and Nutrition ...Examination Survey and its epidemiological follow‐up study.
Material and Methods
In 1971–1974, 9702 men and women aged 25–74 were enrolled and surveyed longitudinally (1982, 1986, 1987, 1992). Periodontal infection was defined by baseline tooth loss or clinical evidence of periodontal disease. Baseline (n = 138) and incident (n = 433) RA cases were defined via self‐report physician diagnosis, joint pain/swelling, ICD‐9 codes (714.0–714.9), death certificates and/or RA hospitalization.
Results
Adjusted odds ratios (ORs) (95% CI) for prevalent RA in gingivitis and periodontitis (versus healthy) were 1.09 (0.57, 2.10) and 1.85 (0.95, 3.63); incident RA ORs were 1.32 (0.85, 2.06) and 1.00 (0.68, 1.48). The ORs for prevalent RA among participants missing 5–8, 9–14, 15–31 or 32 teeth (versus 0–4 teeth) were 1.74 (1.03, 2.95), 1.82 (0.81, 4.10), 1.45 (0.62, 3.41) and 1.30 (0.48, 3.53); ORs for incident RA were 1.12 (0.77, 1.64), 1.67 (1.12, 2.48), 1.40 (0.85, 2.33) and 1.22 (0.75, 2.00). Dose‐responsiveness was enhanced among never smokers. The rate of death or loss‐to‐follow‐up after 1982 was two‐ to fourfold higher among participants with periodontitis or missing ≥9 teeth (versus healthy participants).
Conclusions
Although participants with periodontal disease or ≥5 missing teeth experienced higher odds of prevalent/incident RA, most ORs were non‐statistically significant and lacked dose‐responsiveness. Differential RA ascertainment bias complicated the interpretation of these data.
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