Periodontal diseases: is it possible to prevent them? A populational and individual approach

Abstract Periodontal diseases are infectious inflammatory chronic diseases of a multifactorial nature. They are primarily caused by dysbiotic ecological changes in dental biofilm, which may be influenced by risk factors. The prevention of periodontal diseases may involve different strategies focused on reducing distal, intermediate, and proximal risk factors at both the population and individual levels. Effective prevention depends on interdisciplinary and common risk factor approaches. Also, patient-centered preventive models are more effective than professional-centered models in the management of periodontal diseases. Regular and periodic control of dental biofilm is an essential measure for the different levels of prevention of periodontal diseases. The effectiveness of periodontal disease prevention largely depends on positive modifications of behavior, knowledge, health literacy, patient empowerment, motivation, and compliance.

Clinical and microbiological evaluation of non-surgical periodontal therapy in obese and non-obese individuals with periodontitis: a 9-month prospective longitudinal study

Abstract Objective Obesity is a chronic disease that negatively affects an individual's general and oral health. The present study aimed to compare the clinical and microbiological effects of non-surgical periodontal therapy with the full mouth disinfection (FMD) protocol on obese and non-obese individuals at 9 months post-therapy. Methodology This clinical study was first submitted and approved by the Ethics Committee. Fifty-five obese patients and 39 non-obese patients with periodontitis were evaluated. The full-mouth periodontal clinical parameters, clinical attachment level (CAL), probing depth (PD), gingival index (GI), and plaque index (PI), were monitored at baseline, 3, 6, and 9 months after periodontal treatment with full mouth disinfection (FMD) protocol. The mean count of Tannerella forsythia , Porphyromonas gingivalis , Treponema Denticola , and Aggregatibacter actinomycetemcomitans was determined by quantitative polymerase chain reaction on subgingival biofilm samples. Demographic data were assessed by Chi-square test. For clinical and microbiological parameters, two-factor repeated-measures ANOVA was used. Results In both groups, periodontal therapy using the one-stage full-mouth disinfection protocol significantly improved CAL, PD, GI, and PI (p<0.05). Obese and non-obese patients equally responded to non-surgical periodontal therapy (p>0.05). Microbial count found no major differences (p>0.05) between obese and non-obese individuals who had undergone non-surgical periodontal therapy. Conclusions Obesity did not affect the clinical and microbiological outcomes of non-surgical periodontal therapy.

Clinical trials sponsored by industry and other private organizations

Abstract The present manuscript discussed some relevant aspects related to private sponsored clinical trials in dentistry. For decades, the academy has been the major responsible for research in Brazil. Distant from the trade sector, academic research has not always provided clear benefits to society. A key aspect of making benefits clearer is the process of scientific knowledge transference to decision-makers, which is, in fact, the ground of evidence-based dentistry. Although private sponsoring of clinical research seems to be part of the research progress of the business rates, investment in Brazil is lower than those observed in other countries. It is particularly important to understand that instead of creating its own rules, dentistry imported the high-quality standards originally designed for pharmaceutical studies. Therefore, it is critical to understand the original rules and how dental items are classified by regulatory agencies. In fact, knowledge about international and local regulation is a basic assumption in industry-sponsored research. Despite globalization, the identification of industry-sponsored studies through open access databases is still very hard and time-demanding. A common concern when conducting industry-sponsored trials is study biases. Fortunately, many relevant organizations, academic and industry groups, have been working seriously against that. Finally, for less experienced researchers, many aspects related to industry-sponsored studies - such as confidentiality, authorship, budget - are deeply discussed until a final version of the trial agreement can be written and signed, protecting all sides. In short, the scenario should be improved, but it already represents a nice opportunity for dental research.

Periodontitis and periodontopathogens in individuals hospitalized in the intensive care unit: a case-control study

Abstract The aim of the present study was to compare periodontal conditions between intensive care unit (ICU) in-patients and non-ICU patients through clinical and microbiological periodontal parameters. This case-control study included 88 individuals hospitalized in ICU and 176 non-hospitalized controls. All individuals underwent a complete periodontal examination and microbiological sampling. The total bacterial load and counts of Porphyromonas gingivalis, Treponema denticola and Aggregatibacter actinomycetemcomitans were evaluated using qPCR. Data were analyzed through the Chi-square, Fisher exact, and t-Student tests, and the Spearman correlation, as appropriate. The prevalence of periodontitis was 39.7% among controls and 59.0% among ICU in-patients (OR=2.18; p=0.002). ICU in-patients had a significantly higher occurrence of cardiovascular disease (p=0.002; OR=2.20) and history of periodontal disease (p=0.031; OR=1.92) than controls. Bacterial counts of A. actinomycetemcomitans, T. denticola and P. gingivalis were significantly higher in ICU in-patients with periodontitis than in controls. The correlation between periodontal parameters and microbiological findings among cases and controls showed a significant and positive correlation between: total bacteria load and % of sites with probing depth (PD) ≥ 4 mm (cases: r=0.22 and controls: r=0.13) and P. gingivalis and % sites with bleeding on probing (BOP) (cases: r=0.22 and controls: r=0.23). Thus, ICU in-patients presented a higher prevalence of periodontitis and worse periodontal condition (higher mean plaque index, BOP, clinical attachment level ≥3 mm, and sites with PD 4 to 6 mm).

Resumo O objetivo deste estudo foi comparar as condição periodontais entre pacientes internados em Unidade de terapia intensiva (UTI) e indivíduos não hospitalizados através de parâmetros periodontais clínicos e microbiológicos. Este estudo caso-controle incluiu 88 indivíduos hospitalizados em UTI e 176 controles não hospitalizados. Todos os indivíduos foram submetidos a um exame periodontal completo e amostragem microbiológica. A carga bacteriana total e as contagens de Porphyromonas gingivalis, Treponema denticola e Aggregatibacter actinomycetemcomitans foram avaliadas utilizando qPCR. Os dados foram analisados, conforme apropriado, por meio dos testes de Qui-quadrado, Fisher exato, t-Student, Mann-Whitney e correlação de Spearman. A prevalência de periodontite foi de 39,7% entre os controles e de 59,0% entre pacientes internados em UTI (OR=2,18, IC 95%: 1,29-3,68; p=0,002). Pacientes admitidos na UTI apresentram significativamente uma maior ocorrência de doença cardiovascular (p=0,002, OR=2,20) e história de doença periodontal (p=0,031; OR=1,92) do que os controles. As contagens bacterianas de A. actinomycetemcomitans, T. denticola e P. gingivalis foram significativamente maiores nos pacientes em UTI com periodontite do que nos controles. A correlação entre os parâmetros clínicos periodontais e os achados microbiológicos entre casos e controles mostrou correlação significativa e positiva entre: carga bacteriana total e % de sítios com profundidade de sondagem (PS) ≥4 mm (casos: r=0,22 e controles: r=0,13) e P. gingivalis e % de sítios com sangramento à sondagem (SS) (casos: r=0,22 e controles: r=0,23). Pacientes internados na UTI apresentaram maior prevalência de periodontite e pior condição periodontal (maior média de índice de placa, SS, de sítios com nível de inserção clínica ≥ 3mm e PS de 4 a 6 mm) do que os controles.

Terapia periodontal de suporte em paciente com periodontite agressiva generalizada: acompanhamento clínico e radiográfico de 13 anos / Periodontal maintenance therapy in patient with generalized aggessive periodontitis: clinical and radiographic following by 13 years

A terapia periodontal de suporte (TPS) tem como objetivo principal a manutenção dos resultados obtidos durante o tratamento periodontal ativo, sendo a forma mais previsível de controlar a doença periodontal. Essa extensão do tratamento periodontal, pode ocorrer em intervalos de tempo que variam de acordo com a severidade da doença, condição sistêmica do indivíduo, idade, fatores de risco, entre outros. A TPS contribui para a redução da perda dentária e recorrência da doença periodontal, além de possibilitar o diagnóstico de outras doenças bucais. Durante essa etapa, é possível traçar o perfil do paciente, identificar suas dificuldades e estabelecer condutas educativas, preventivas e terapêuticas necessárias para o controle do biofilme e da doença periodontal. Assim, o periodontista deve conscientizar o paciente sobre a importância da TPS, sendo que, a adesão ao tratamento é fundamental para a manutenção da saúde dos tecidos periodontais a longo prazo. O presente relato de caso clínico, demonstra o sucesso da TPS em paciente jovem acometida por periodontite agressiva generalizada. Após a realização da terapia periodontal não cirúrgica, a paciente foi inserida em um programa de manutenção periodontal, há 13 anos atrás, no qual participa ativamente até o presente momento. (AU)

The main objective of the periodontal maintenance therapy (PMT) is to maintain the results achieved during the active periodontal therapy, being the most predictable way of controlling the periodontal disease. This extension of the periodontal treatment may occur at different times, varying according to the aggressiveness of the disease, general health condition of the subject, age and risk factors, among others. The PMT contributes to the reduction of dental loss and prevents the reoccurrence of the periodontal disease, while also allowing the diagnose of other diseases of the mouth. During this phase it is possible to trace the patient's profile, identifying the difficulties and stablishing educational, preventive and therapeutic practices to control oral biofilm and periodontal disease. Thus, the periodontist must raise the patient's awareness to the importance of the PMT, as the patient compliance to the treatment is essential for the long term preservation of the periodontal tissue health. The clinical case here described demonstrates the success of the PMT performed on a young female patient afflicted with generalized aggressive periodontitis. After having performed the non-surgical periodontal therapy, the patient entered a periodontal maintenance program 13 years ago, in which she has been actively participating until the present time.(AU)

Salivary arginase activity after mechanical-chemical therapy / Atividade de arginase salivar após tratamento mecânico-químico

Introduction: Salivary components can be used as biomarkers for diagnosing and monitoring oral diseases. There is evidence that one potential biomarker, arginase, is associated with the inflammatory processes of periodontal disease, and its enzymatic activity is reduced according to the improvement in the clinical parameters after treatment. Objective: The present study aimed to evaluate the salivary arginase activity in gingivitis and periodontitis patients treated with full-mouth mechanical procedures combined with the adjunctive use of essential oils or chlorhexidine mouthwash, respectively. Material and method: Twenty-six gingivitis and 16 periodontitis patients received complete periodontal examinations at the baseline and 3 months after therapy, in which the periodontal probing depth, clinical attachment loss, plaque index, and gingival index measurements were taken. At these same appointments, the salivary total protein level and salivary arginase activity were also established via spectrophotometry. Result: There were improvements in all of the clinical parameters (p < 0.05) evaluated from the baseline to 3 months in both groups. In addition, the salivary arginase activity and total protein levels were reduced after the gingivitis treatment. Conclusion: Similar to the clinical results, both therapeutic protocols positively affected the salivary arginase activity; however, further studies are necessary to clarify its potential as a salivary biomarker for periodontal monitoring.

Introdução: Componentes salivares podem ser usados como biomarcadores para diagnóstico e monitoramento de doenças orais. Há evidências de que um potencial biomarcador, arginase, está associado com os processos inflamatórios da doença periodontal, e após o tratamento sua atividade enzimática é reduzida em concordância com a melhora nos parâmetros clínicos. Objetivo: O presente estudo objetivou avaliar a atividade da arginase salivar em pacientes com gengivite e periodontite tratados com procedimentos mecânicos em estágio único combinados ao uso coadjuvante de enxaguatórios com óleos essenciais ou clorexidina, respectivamente. Material e método: Vinte e seis pacientes com gengivite e 16 pacientes com periodontite receberam exame periodontal completo antes e 3 meses após a terapia, em que mensurações de profundidade de sondagem, perda de inserção clínica, índice de placa e índice gengival foram realizadas. Nestas mesmas consultas os níveis de proteína total e a atividade de arginase salivar foram estabelecidos via espectrofotometria. Resultado: Todos os parâmetros clínicos melhoraram, em ambos os grupos, do exame inicial para o de 3 meses (p < 0,05). Adicionalmente, após tratamento para gengivite houve redução da atividade de arginase salivar e do nível de proteína total. Conclusão: Semelhante aos resultados clínicos, ambos os protocolos terapêuticos afetaram positivamente a atividade da arginase salivar; entretanto, estudos futuros são necessários para clarificar seu potencial como biomarcador salivar para o monitoramento periodontal.

Periodontal condition and immunological aspects of individuals hospitalized in the intensive care unit

Abstract There are few studies on the clinical and immunological periodontal status of intensive care unit (ICU) in-patients. The aim of the present study was to evaluate the periodontal condition among ICU in-patients through clinical and immunological periodontal parameters. From the sample of 373 hospitalized ICU patients, 182 were submitted' to a thorough clinical periodontal and immunological evaluation. Data on bleeding on probing (BOP), probing depth (PD), and clinical attachment level (CAL) were collected and gingival sulcular fluid samples were quantified through ELISA on IL-1, IL-6, and MMP-2 for immunological evaluation. Data was statistically analyzed by Chi-square, Fisher's exact, Mann-Whitney tests, and Sperman's correlation and multivariate logistic regression analysis. A high dental plaque index and a high prevalence of periodontitis (48.3%), mostly in moderate and localized chronic form, were observed. Individuals with periodontitis presented higher levels of IL-1 and MMP-2, while individuals with cardiovascular disease (CVD) and individuals with two or more systemic diseases (MSD) presented higher levels of IL-1; diabetes mellitus (DM) and MSD individuals presented higher levels of IL-6. A positive association was found between the severity of periodontitis and CVD (OR 2.2; CI = 1.11-4.42). This study reported a 48.3% of the prevalence of periodontitis in ICU patients and a positive association between the severity of periodontitis and CVD. Additionally, higher levels of IL-1 and MMP-2 were found in individuals with periodontitis, higher levels of IL-6 were found in individuals with DM, and higher levels of IL-1 were found in individuals with CVD.

Resumo Existem poucos estudos sobre o estado clínico periodontal e imunológico de pacientes em unidade de terapia intensiva (UTI). O objetivo do presente estudo foi avaliar a condição periodontal entre os pacientes internados na UTI através de parâmetros clínicos periodontais e imunológicos. De uma amostra inicial de 373 pacientes internados em UTI, 183 foram submetidos a exame periodontal completo e análise imunológica. Os dados sobre o sangramento na sondagem (BOP), profundidade de sondagem (PD) e nível clínico de inserção (CAL) foram coletados e as amostras de fluido sulcular gengival foram quantificadas para avaliação imunológica através de ELISA para IL-1, IL-6 e MMP-2. Os dados foram analisados estatisticamente pelos testes de Qui-quadrado, exato de Fischer, Mann-Whitney, correlação de Sperman e análise de regressão logística multivariada. Foi observado um alto índice de placa dental e uma alta prevalência de periodontite (48,3%), principalmente na forma crônica moderada e localizada. Os indivíduos com periodontite apresentaram níveis mais altos de IL-1 e MMP-2, enquanto indivíduos com doença cardiovascular (CVD) e com mais de duas doenças sistêmicas (MSD) apresentaram níveis mais altos de IL-1 e os com diabetes mellitus (DM) e MSD apresentaram níveis mais elevados de IL-6. Foi encontrada associação positiva entre a gravidade da periodontite e CVD (OR 2.2; IC = 1,11-4,42). Este estudo reportou uma prevalência de periodontite em 48.3% dos pacientes em UTI e uma associação positiva entre ocorrência de periodontite e CVD. Além disso, níveis mais elevados de IL-1 e MMP-2 foram encontrados em indivíduos com periodontite, de IL-6 em indivíduos com DM e de IL-1 em indivíduos com CVD.

Influência dos braquetes convencionais ou autoligados nos parâmetros periodontais ­ revisão / Influence of conventional or self-ligated brackets on periodontal parameters - literature review

O aspecto retentivo dos braquetes promove alterações na microbiota bucal podendo causar danos, às vezes irreversíveis, ao periodonto de sustentação. Há uma controvérsia quanto à associação do desenho dos braquetes com o aumento quantitativo e as alterações qualitativas no microbioma periodontal. Braquetes autoligados supostamente acumulariam menor quantidade de biofilme que os braquetes convencionais devido à ausência das ligaduras elásticas. Mas, existem outras variáveis que intercedem na retenção do biofilme. Assim, o presente estudo teve como objetivo revisar a literatura sobre as alterações microbiológicas que se associam ao uso de braquetes convencionais ou autoligados. A literatura analisada mostrou que para entender o perfil microbiológico e suas alterações deve-se além de comparar o desenho dos braquetes, considerar o tipo de material, a retentividade dos sítios onde os braquetes estão instalados e o padrão de higiene bucal. Ainda não está claro se as alterações microbiológicas observadas se restringem ao período de tratamento ortodôntico ativo ou se elas permanecem mesmo após a remoção dos braquetes. É possivel concluir que a presença de braquetes ortodônticos aumenta a quantidade de biofilme e induz alterações da microbiota, que podem, em alguns casos, serem apenas transitórias. Porém ainda não está claro quais são as reais diferenças entre braquetes convecionais e autoligados no que se refere à colonização microbiana. (AU)

The retentive bracket design promotes changes in the oral microbiome and it can cause damage, sometimes irreversible, to periodontal supportive tissues. The association between bracket design with qualitative changes and quantitative bacterial increase in periodontal microbiome is controversial. Self-ligating brackets would supposedly accumulate less biofilm then conventional brackets due to the absence of elastic ligature. However, other variables could influence biofilm retention. Thus, the present study aimed at reviewing the literature on microbiological changes associated with the use of conventional or self - ligating brackets. The analyzed literature showed that the understandingregarding microbiological profile and related changesrequires evaluation of material type, retentive nature of sites where the brackets are installed, oral hygiene pattern in adittion to bracket design. It is not clear if observed microbiological changes are restricted to the period of active orthodontic treatment or if they remain even after bracketsremoval. It is possible to conclude that the presence of orthodontic brackets increases the amount of biofilm and promotes changes in microbiome, which may in some cases be only transitory. However, it is still not clear what are the real differences between conventional and selfligating brackets regarding microbial colonization. (AU)

Effects of chlorhexidine preprocedural rinse on bacteremia in periodontal patients: a randomized clinical trial

Abstract Objective: Single dose of systemic antibiotics and short-term use of mouthwashes reduce bacteremia. However, the effects of a single dose of preprocedural rinse are still controversial. This study evaluated, in periodontally diseased patients, the effects of a pre-procedural mouth rinse on induced bacteremia. Material and Methods: Systemically healthy individuals with gingivitis (n=27) or periodontitis (n = 27) were randomly allocated through a sealed envelope system to: 0.12% chlorhexidine pre-procedural rinse (13 gingivitis and 13 periodontitis patients) or no rinse before dental scaling (14 gingivitis and 15 periodontitis patients). Periodontal probing depth, clinical attachment level, plaque, and gingival indices were measured and subgingival samples were collected. Blood samples were collected before dental scaling, 2 and 6 minutes after scaling. Total bacterial load and levels of P. gingivalis were determined in oral and blood samples by real-time polymerase chain reaction, while aerobic and anaerobic counts were determined by culture in blood samples. The primary outcome was the antimicrobial effect of the pre-procedural rinse. Data was compared by Mann-Whitney and Signal tests (p<0.05). Results: In all sampling times, polymerase chain reaction revealed higher blood bacterial levels than culture (p<0.0001), while gingivitis patients presented lower bacterial levels in blood than periodontitis patients (p<0.0001). Individuals who experienced bacteremia showed worse mean clinical attachment level (3.4 mm vs. 1.1 mm) and more subgingival bacteria (p<0.005). The pre-procedural rinse did not reduce induced bacteremia. Conclusions: Bacteremia was influenced by periodontal parameters. In periodontally diseased patients, pre-procedural rinsing showed a discrete effect on bacteremia control.

Effect of 1% sodium alendronate in the non-surgical treatment of periodontal intraosseous defects: a 6-month clinical trial

Abstract Background and objectives Few studies have evaluated the effect of the topical application of sodium alendronate (ALN) on the treatment of intrabuccal bone defects, especially those caused by periodontitis. This 6-month randomized placebo controlled clinical trial aimed at evaluating the effect of non-surgical periodontal treatment associated with the use of 1% ALN, through clinical evaluations and cone-beam computed tomography (CBCT). Material and Methods Twenty individuals with chronic periodontitis underwent periodontal examination at the baseline as well as 3 and 6 months after periodontal treatment, registering clinical attachment level (CAL), periodontal probing depth (PPD), and bleeding on probing (BOP) as the clinical outcomes. After manual scaling and root planing, 40 bilateral sites with interproximal vertical bone defects were randomly treated with either 1% ALN gel or a placebo. Bone defects were evaluated through CBCT at the baseline and 6 months post-treatment. The clinical and CBCT parameters were compared using the Wilcoxon and Friedman tests (p<0.05). Results Although ALN produced a greater CAL gain when compared to the placebo at 6 months post-treatment (p=0.021), both treatments produced similar effects on the PPD, BOP, and bone height. Significant differences in bone fill were observed only in patients of the ALN group (4.5 to 3.8 mm; p=0.003) at 6 months post-treatment. Conclusions Topical application of 1% ALN might be a beneficial adjuvant to non-surgical periodontal therapy.

Periodontitis and type 2 diabetes among women with previous gestational diabetes: epidemiological and immunological aspects in a follow-up of three years

Abstract Periodontitis can contribute to the development of insulin resistance. Gestational diabetes is a risk factor for type 2 diabetes. Therefore, periodontitis, when associated with gestational diabetes, could increase the risk for the development of type 2 diabetes after pregnancy. Objective The aim of this study was to verify the incidence on the development of type 2 diabetes in women with previous gestational diabetes with and without periodontitis after a three-year time interval. Material and Methods Initial sample of this follow-up study consisted of 90 women diagnosed with gestational diabetes who underwent periodontal examination. After three years, 49 women were subjected to new periodontal examination and biological, behavioral, and social data of interest were collected. Additionally, the quantification of the C-reactive protein in blood samples was performed. Fasting glucose and glycated hemoglobin levels were requested. Saliva samples were collected for quantification of interleukin 6 and 10, tumor necrosis factor α, matrix metalloproteinase 2 and 9. Results The incidence of type 2 diabetes mellitus was 18.4% and of periodontitis was 10.2%. There was no significant difference in the incidence of type 2 diabetes mellitus among women with and without periodontitis. It was observed impact of C-reactive protein in the development of type 2 diabetes mellitus. However, it was not observed impact of periodontitis on the development of type 2 diabetes mellitus among women with previous gestational diabetes. Conclusions It was not observed impact of periodontitis on the development of type 2 diabetes among women with previous gestational diabetes. The impact of C-reactive protein in the development of type 2 diabetes mellitus highlights the importance of an inflammatory process in the diabetes pathogenesis.

Frequency of periodontal pathogens and Helicobacter pylori in the mouths and stomachs of obese individuals submitted to bariatric surgery: a cross-sectional study

ABSTRACT Objectives This cross-sectional study compared the frequency of oral periodontopathogens and H. pylori in the mouths and stomachs of obese individuals with or without periodontitis submitted to bariatric surgery. Material and Methods One hundred and fifty-four men and women aged 18-65 were conveniently distributed into four groups. Two groups were composed of individuals who underwent bariatric surgery with (BP) (n=40) and without (BNP) (n=39) periodontitis and two obese control groups with (CP) (n=35) and without (CNP) (n=40) periodontitis. The oral pathogens Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Parvimonas micra, Treponema denticola, Tannerella forsythia, Campylobacter rectus, and Helicobacter pylori were detected by a polymerase chain reaction technique using saliva, tongue and stomach biopsy samples. Results Statistical analysis demonstrated that periodontopathogens were highly frequent in the mouth (up to 91.4%). In the bariatric surgically treated group, orally, P. gingivalis, T. denticola and T. forsythia were more frequent in periodontitis, while C. rectus was more frequent in non-periodontitis subjects. Stomach biopsies also revealed the high frequency of five oral species in both candidates for bariatric surgery (91.6%) and the bariatric (83.3%) groups. H. pylori was frequently detected in the mouth (50.0%) and stomach (83.3%). In the stomach, oral species and H. pylori appeared in lower frequency in the bariatric group. Conclusions Obese individuals showed high frequencies of periodontopathogens and H. pylori in their mouths and stomachs. Bariatric surgery showed an inverse microbial effect on oral and stomach environments by revealing higher oral and lower stomach bacterial frequencies.

Salivary and microbiological parameters of chronic periodontitis subjects with and without type 2 diabetes mellitus: a case-control study / Parâmetros salivares e microbiológicos em indivíduos com periodontite crônica com ou sem diabetes melito tipo 2: estudo caso-controle

Background: Several studies have investigated the differences in salivary parameters and microbial composition between diabetic and non-diabetic patients, however, specific differences are still not clear mainly due to the effects of confounder. Aim: The aim of this case-control study was to evaluate the salivary and microbial parameters of chronic periodontitis subjects with and without type 2 diabetes mellitus. Material and method: This case-control study included 60 chronic periodontitis subjects, 30 diabetics (case group) and 30 non-diabetics (control group), paired according to periodontitis severity, gender and age. Stimulated whole saliva was collected from all volunteers to measure the salivary pH and the salivary flow rate. Bacterial samples were collected with paper points from periodontal sites showing the deepest periodontal pocket depth associated with the highest clinical attachment loss. The frequency of A. actinomycetemcomitans, P. intermedia, P. gingivalis, T. forsythia and C. rectus was evaluated by PCR. Data was statistically analyzed by Student's t, Mann-Whitney and Chi-square (p<0.05). Result: Diabetic subjects showed higher salivary glucose levels and lower stimulated flow rates in comparison to non-diabetic controls. P. gingivalis and T. forsythia were the most frequent pathogens (p<0.05). Bacterial frequency did not differ between case and control groups. Conclusion: Diabetes status influenced salivary glucose levels and flow rate. Within the same severity of chronic periodontitis, diabetic subjects did not show higher frequency of periodontal pathogens in comparison to their paired controls. .

Introdução : Diversos estudos têm investigado as diferenças dos parâmetros salivares e microbianos entre pacientes diabéticos e não diabéticos, contudo, diferenças específicas ainda não estão claras, principalmente devido aos efeitos de variáveis de confusão. Objetivo: O objetivo deste estudo caso-controle foi avaliar os parâmetros salivares e microbianos de indivíduos com doença periodontal crônica com ou sem diagnóstico de diabetes melito tipo 2. Material e método: Este estudo caso-controle incluiu 60 indivíduos com periodontite crônica, 30 diabéticos (casos) e 30 não diabéticos (controles), pareados pela severidade da doença periodontal, gênero e idade. Saliva total estimulada foi coletada de todos os voluntários para mensuração do pH salivar e fluxo salivar. Amostras bacterianas foram coletadas com pontas de papel absorvente dos sítios periodontais com maior profundidade de sondagem e perda de inserção clínica. A frequência de A. actinomycetemcomitans, P. intermedia, P. gingivalis, T. forsythia e C. rectus foi avaliada por PCR. Os dados foram analisados estatisticamente pelo teste t de Student, Mann -Whitney e Qui-quadrado (p < 0,05). Resultado: Diabéticos apresentaram maior nível de glicose salivar e menor fluxo salivar em comparação aos não diabéticos. P. gingivalis e T. forsythia foram os patógenos mais frequentes (p < 0,05). Frequência bacteriana não diferiu entre os casos e controles. Conclusão: A condição diabetes influenciou o fluxo e os níveis de glicose salivar. Dentro da mesma severidade da periodontite crônica, indivíduos diabéticos não mostraram maior frequência de patógenos periodontais em comparação aos seus controles. .

Avaliação clínica da raspagem dental em associação ao uso de azitromicina ou clorexidina no tratamento periodontal por meio de ensaio clínico controlado randomizado / Clinical evaluation of scaling and root planing associated with azithromycin or chlorhexidine: a randomized controlled clinical trial

O objetivo deste estudo foi avaliar, por meio de ensaio clínico controlado randomizado, a efetividade da técnica one stage full mouth disinfection (FMD) e sua associação com clorexidina ou azitromicina em relação à raspagem e alisamento radicular por quadrante (RAR) associada à clorexidina e azitromicina sob uma perspectiva clínica (avaliação da profundidade de sondagem e nível clínico de inserção). Neste ensaio clínico controlado randomizado foram avaliados 77 indivíduos divididos em 6 grupos: FMD-CX (raspagem e alisamento radicular de todos os dentes em 24 h associada à clorexidina n= 15), FMD (raspagem e alisamento radicular de todos os dentes em 24 h– n=10), FMD-AZ (raspagem e alisamento radicular de todos os dentes em 24 h + azitromicina – n=15), RAR-AZ (raspagem e alisamento radicular por quadrante em intervalos semanais + azitromicina – n=11), RAR-CX (raspagem e alisamento radicular por quadrante, em intervalos semanais + clorexidina – n=13), RAR (raspagem e alisamento radicular, por quadrantes, em intervalos semanais – n=13). Os parâmetros clínicos foram analisados estatisticamente pelo teste de análise de variância (ANOVA) baseado em um planejamento para medidas repetidas e teste de comparações múltiplas de médias. O grupo FMD-CX mostrou maior redução da profundidade de sondagem e ganho do nível clínico de inserção que os demais. Os grupos que utilizaram azitromicina não mostraram melhores resultados clínicos. Pode-se concluir que a utilização da clorexidina nos grupos FMD-CX e RAR-CX mostrou melhores resultados clínicos. Por outro lado, a utilização da azitromicina não apresentou melhorias nesses parâmetros.

The aim of this study was to evaluate, through randomized controlled clinical trial, the effectiveness of the technique one stage full mouth disinfection (FMD) and its association with chlorhexidine or azithromycin compared to scaling and root planing per quadrant (RAR) associated with chlorhexidine and azithromycin under a clinical perspective (assessment of probing depth and clinical attachment level). In this randomized controlled trial were evaluated 77 patients divided into 6 groups: FMD-CX (scaling and root planing of all teeth in 24 h associated with chlorhexidine n = 15), FMD (scaling and root planing of all teeth in 24 h - n = 10), FMD-AZ (scaling and root planing of all teeth in 24 h + azithromycin - n = 15), RAR-AZ (scaling and root planing per quadrant at weekly intervals azithromycin + - n = 11), RAR-CX (scaling and root planing per quadrant, at weekly intervals chlorhexidine + - n = 13), RAR (scaling and root planing, per quadrant, at weekly intervals - n = 13). The clinical parameters were statistically analyzed by analysis of variance (ANOVA) based on a planning for repeated measures and multiple comparisons of means test. The FMD-CX group showed greater reduction in probing depth and gain in clinical attachment level than the others. Groups using azithromycin did not show improved clinical outcomes. It can be conclude that the use of chlorhexidine groups FMD-CX and CX-RAR showed the best clinical results. On the other hand, the use of azithromycin in these parameters showed no improvement.

Bacteriemia em pacientes periodontais: revisão de literatura / Bacteremia in periodontal patients: a literature review

Bacteriemia é a presença de microrganismos - bactérias, vírus e fungos - viáveis no sangue circulante. O objetivo do presente estudo foi revisar a literatura sobre bacteriemia enfocando principalmente seu impacto sistêmico e os estudos em odontologia/periodontia. Para isso foram acessadas as bases Pubmed e Scielo, sendo aceitos artigos publicados em português ou inglês, entre os anos 2002 a 2014. Os trabalhos demonstraram que os episódios de bacteriemia resolvem-se espontaneamente na maioria das ocorrências, mas que podem haver complicações graves embora pouco frequentes. Embora o efeito cumulativo dos episódios de bacteriemia ainda não tenha sido esclarecido, a bacteriemia sofre influência da condição periodontal. Em pacientes periodontalmente doentes, até atividades cotidianas podem desencadear o evento. Antibióticos profiláticos devem ser prescritos para pacientes de risco. Os estudos em periodontia ainda são relativamente escassos e inconsistentes. Inúmeras questões ainda precisam ser investigadas...

Bacteremia is the presence of viable microorganisms – bacteria, virus and fungi – in the blood. The aim of the present study was to review literature about bacteremia focusing on its systemic impact and studies in dentistry/ periodontics. Pubmed and Scielo databases were consulted. Manuscripts published in Portuguese and English between 2002 a 2014 were accepted. Data showed that bacteremia is frequently associated with spontaneous resolution although in same cases there could be severe comorbidity. Cumulative effect due to episodes of bacteremia has not been already investigated. Periodontal diseases influence bacteremia. In periodontally diseased patients, even daily activities can induce bacteremia. Prophylactic antibiotics should be prescribed for at-risk patients. Studies in periodontics are still scarce. Several questions should be investigated...

Níveis comparativos pré- e pós-tratamento de CSV, carga bacteriana total subgengival e sangramento gengival / Pre-and post-treatment comparative levels of VSC, subgingival total bacterial load and gingival bleeding

O objetivo deste ensaio clínico randomizado de 3 meses de duração foi avaliar os efeitos da combinação de procedimentos mecânicos e químicos sobre os níveis de sangramento gengival, Compostos Sulfurados Voláteis (CSV) e carga total bacteriana de pacientes com gengivite. Sessenta voluntários sistemicamente saudáveis com gengivite foram divididos em dois grupos: raspagem profissional associada ao uso diário de óleos essenciais (20ml/2x/dia) ou solução placebo (20ml/2x/dia). Todos os participantes receberam instruções de higiene bucal. Índice de sangramento gengival, carga bacteriana total subgengival (PCR em tempo real) e concentrações de CSV (dosador portátil Halimeter) foram mensurados antes e 90 dias após o tratamento gengival. Os dados foram comparados estatisticamente pelos teste t-Student e teste t-pareado (p < 0,05). Resultados: Finalizaram o estudo 27 indivíduos no grupo teste e 25 no grupo placebo. A carga bacteriana total e o IG reduziram mais evidentemente no grupo teste do que no grupo placebo. No grupo teste os valores médios de CSV reduziram de 94,62ppb (inicial) para 62,19ppb (3 meses) enquanto no grupo placebo eles se mantiveram estáveis entre as mensurações inicial (93,46ppb) e de 3 meses (95,00ppb). Conclusões: o tratamento gengival seguido de 90 dias de uso de solução de óleos essenciais acarretou melhora dos parâmetros monitorados, IG, carga total bacteriana e CSV.

The aim of this 3-month randomized clinical study was to evaluate the effects of the combination of mechanical and chemical procedures over the levels of gingival bleeding, VSC and total bacterial load in patients with gingivitis. Sixty systemically healthy individuals with gingivitis were randomized in two groups: professional debridement along with the daily use of essential oils (20ml/2x/day) or of a placebo solution (20ml/2x/day). All participants received oral hygiene instructions. Gingival Index, total bacterial load (real time PCR) and VSC concentration (portable Halimeter) were measured at baseline and at 90 days after gingival treatment. Data were statistically compared by Student-t test and paired-t test (p < 0.05). Results: Twenty-seven individuals finished the study in the test group and 25 in the placebo group. Total bacterial load and GI were greatest reduced in the test group than in the placebo group. Mean VSC values in the test group were reduced from 94,62ppb (at baseline) to 62,19ppb (3 months) while in the placebo group measures continued stable between baseline (93,46ppb) and (95,00ppb) 3-month examinations. Conclusions: Gingival treatment followed by the use of essential oils for 90 days lead to an improvement in the monitored parameters, GI, total bacterial load and VSC.

Clinical and microbiological evaluation of one-stage full-mouth disinfection: a short-term study / Avaliação clínica e microbiológica do protocolo one-stage full-mouth disinfection: estudo de curto prazo

Introduction: Patients seem to adhere better to short-term periodontal treatment schemes. Besides, time-reduced treatments are more cost-effective. However, the degree of benefits related to this type of treatment still requires additional investigations. Aim: The present short-term study evaluated clinical and microbiological outcomes, from baseline to 3-months, of chronic periodontitis subjects treated by the one-stage full-mouth disinfection protocol. Material and Method: Sixteen chronic periodontitis subjects (mean-age 49.87 ± 8.22) who met inclusion/exclusion criteria were included. A calibrated examiner measured whole-mouth plaque and gingival indices, periodontal pocket depth and clinical attachment level at baseline and at 3-months. Subgingival samples were also collected from the 5 most diseased periodontal sites to determine total bacterial load and levels of P. gingivalis and S. oralis by real time qPCR. Periodontal treatment consisted of full-mouth manual debridement plus wide intraoral use of chlorhexidine in gel and solution. Additionally, after debridement, individuals rinsed 0.12% chlorhexidine at home twice a day for the following 2 months. Data monitored were compared by paired Student-t test (p<0.05). Result: Statistical analysis revealed that, in general, one-stage full-mouth disinfection treatment provided significant clinical and microbiological improvements at 3-months. Total bacterial load showed one of the most pronounced reductions from baseline to 3-months (p=0.0001). Also, subgingival levels P. gingivalis and S. oralis reduced overtime. Conclusion: After a short period of monitoring, chronic periodontitis subjects showed clinical and microbial improvements following one-stage full-mouth disinfection treatment.

Introdução: Os pacientes parecem aderir melhor ao tratamento periodontal de curto prazo. Além disso, tratamentos de tempo curto possuem melhor custo-benefício. No entanto, os benefícios associados a este tipo de tratamento ainda requerem investigações adicionais. Objetivo: O presente estudo avaliou longitudinalmente indivíduos com periodontite crônica clínica e microbiologicamente tratados pelo protocolo one-stage full-mouth disinfection. Material e Método: Dezesseis indivíduos (49,87 ± 8,22), que se enquadraram nos critérios de inclusão/exclusão foram incluídos. Um examinador calibrado, avaliou índice de placa e gengival, profundidade de bolsa e nível clínico de inserção pré e pós terapia. Amostras subgengivais coletadas dos cinco sítios periodontais mais doentes estabeleceram a carga bacteriana total e níveis de P. gingivalis e S. oralis por qPCR. One-stage full-mouth disinfection foi realizado com instrumentos manuais associado a gel de clorexidina e solução. Após, os indivíduos utilizaram clorexidina 0,12% para bochecho, duas vezes ao dia, durante os dois meses. Dados foram comparados pelo teste pareado t de Student (p<0,05). Resultado: A análise estatística revelou que o tratamento proporcionou melhorias clínicas e microbianas significativas em três meses. A carga bacteriana total evidenciou reduções mais pronunciadas do pré para o pós-tratamento (p=0,0001). Similarmente, P. gingivalis e S. oralis mostraram redução no pós-tratamento. Conclusão: Após 3 meses de monitoramento, indivíduos com periodontite crônica apresentaram melhora clínica e microbiana com o protocolo one stage full-mouth disinfection.

Avaliação da eficácia clínica e microbiana de dois protocolos terapêuticos periodontais / Clinical and microbial efficacy of two periodontal therapeutic protocols

O objetivo principal deste ensaio clínico randomizado foi o de avaliar a efetividade clínica e microbiana da terapia de raspagem dental realizada por quadrante em relação a raspagem dental em estágio único. Para responder este objetivo foram incluídos 20 indivíduos com periodontite crônica avançada distribuídos aleatoriamente em 2 grupos a saber: Grupo 1 (10 indivíduos-Raspagem Quadrante), Grupo 2 (10 indivíduos-Raspagem Estágio Único). Mensurações longitudinais foram realizadas durante todo o ensaio confrontando parâmetros clínicos de profundidade de sondagem e nível de inserção clínica para avaliação das terapias. Análise microbiana quantitativa (qPCR) da espécie A. actinomycetemcomitans e P. gingivalis em função do evento “raspagem dental” foi realizada em toda a população do estudo nas etapas pré raspagem [T0] e pós raspagem [T1]. As amostras intrassulculares para a análise do qPCR foram coletadas dos cinco dentes com maior evidência de atividade de doença periodontal ou seja, com as maiores profundidades de sondagem associadas a perda de inserção clínica. Os dados obtidos foram analisados por teste t pareado (p<0.05). Os resultados mostraram que em ambos os grupos houve uma melhora clínica tanto do parâmetro profundidade de sondagem quanto do nível de inserção clinica, já para a frequência dos patógenos testados verificou-se que similarmente ocorreu redução microbiana nos dois grupos investigados. Após análise dos dados conclui-se que ambos protocolos terapêuticos aqui investigados foram eficazes tanto clínica quanto microbiologicamente

The aim of this randomized clinical trial was to evaluate the effectiveness of clinical and microbial effects of scaling and root planing using quadrant debridement or full-mouth debridement. A total of 20 patients diagnosed severe chronic periodontitis were enrolled in this survey: Ten subjects were allocated in quadrant debridement group and 10 subjects in full-mouth debridement group. Longitudinal clinical measurements such as periodontal pocket depth as well as clinical attachment loss were investigated at baseline and at 90 days in both therapies. Also, microbial analysis were performed by qPCR to detect the presence of A. actinomycetemcomitans and P. gingivalis. We collected subgingival samples of 5 severe site from each patient. All clinical and microbial data were analyzed by t student test (p<0.05) and the results showed that both periodontal treatment exhibited good results. Then, we concluded that both treatments provide clinical and microbial benefits for all included patients

Validation of the anti-bacteremic efficacy of an essential oil rinse in a Brazilian population: a cross-over study

This cross-over study was conducted to assess the germ-killing efficacy of an essential oil mouthrinse (EOM) by determining the blood levels of microorganisms associated with induced bacteremia and investigating the prevalence of this event in Brazilians with mild-to-moderate gingivitis. Thirty four (31.19%) subjects positive for bacteremia induced by chewing a ration of apple were enrolled out of 109 screened subjects (50 males and 59 females). A difference of at least 10 colony forming units between the pre- and post-insult blood samples was defined as a positive result. For the following two weeks patients underwent a toothbrush plus fluoride dentifrice normalization period, and were then scheduled for the Phase I protocol as follows. At baseline I, subjects were instructed to chew a new apple ration, had new blood samples taken before and after this oral stimulus, and were randomly assigned to an experimental essential oil (n = 17) or placebo (P) mouthrinse (n = 17) treatment for 2 weeks. These procedures were repeated at the end of Phase I and then followed by a two-week wash-out period (tooth brushing with fluoride dentifrice). Bacteremia was again induced at baseline and at the end of Phase II, when subjects were crossed-over to the other EOM or placebo groups. Bacterial count differences between baseline and 2-week post-treatment (EOM versus P) in the blood samples collected were assessed by analysis of covariance. Mean aerobic counts decreased by 45.8%, whereas mean anaerobic counts decreased by 63.3% after EOM treatment. After the P treatment, aerobic bacteria increased by 28.4% and anaerobic bacteria decreased by 18.5%. This study validated this novel methodology and showed that the germ-killing action of EOM significantly reduced bacteremia.

Mechanisms of action of systemic antibiotics used in periodontal treatment and mechanisms of bacterial resistance to these drugs

Antibiotics are important adjuncts in the treatment of infectious diseases, including periodontitis. The most severe criticisms to the indiscriminate use of these drugs are their side effects and, especially, the development of bacterial resistance. The knowledge of the biological mechanisms involved with the antibiotic usage would help the medical and dental communities to overcome these two problems. Therefore, the aim of this manuscript was to review the mechanisms of action of the antibiotics most commonly used in the periodontal treatment (i.e. penicillin, tetracycline, macrolide and metronidazole) and the main mechanisms of bacterial resistance to these drugs. Antimicrobial resistance can be classified into three groups: intrinsic, mutational and acquired. Penicillin, tetracycline and erythromycin are broad-spectrum drugs, effective against gram-positive and gram-negative microorganisms. Bacterial resistance to penicillin may occur due to diminished permeability of the bacterial cell to the antibiotic; alteration of the penicillin-binding proteins, or production of β-lactamases. However, a very small proportion of the subgingival microbiota is resistant to penicillins. Bacteria become resistant to tetracyclines or macrolides by limiting their access to the cell, by altering the ribosome in order to prevent effective binding of the drug, or by producing tetracycline/macrolide-inactivating enzymes. Periodontal pathogens may become resistant to these drugs. Finally, metronidazole can be considered a prodrug in the sense that it requires metabolic activation by strict anaerobe microorganisms. Acquired resistance to this drug has rarely been reported. Due to these low rates of resistance and to its high activity against the gram-negative anaerobic bacterial species, metronidazole is a promising drug for treating periodontal infections.