A Reappraisal of the Accuracy of the Tactile Method for the Detection of the Subgingival Cementoenamel Junction: An In Vivo Study.

OBJECTIVES: This article reappraises the accuracy and factors associated with the detection of the cementoenamel junction (CEJ) using the tactile method. MATERIALS AND METHODS: A total of 111 tooth sites of 7 patients scheduled for flap surgery were selected for the study. The CEJ was detected in a blind manner using the conventional tactile method with a standard periodontal probe by a single, trained examiner. A custom-made stent was prepared to standardize the measurements and the distance from a fixed reference point on the stent to the CEJ was measured before (apparent CEJ) and after (real CEJ) opening a gingival flap. To evaluate the effect of local anesthesia (LA) on the measurement error, assessment with and without LA given prior to the measurement was also evaluated. The bone crest-CEJ distance at each site was also recorded in all sites. STATISTICAL ANALYSIS: The measurement error of apparent versus real distance, if any, was compared using Cohen's weighted kappa coefficient (WKC) (± 1 mm). RESULTS: A weak WKC (WKC = 0.539) was found between the apparent and real CEJ distance. Higher WKCs were noted at posterior and proximal sites than the anterior and buccal/lingual sites, respectively (0.840 and 0.545 vs. 0.475 and 0.488). A higher confluence of the agreements was noted when CEJ distance was measured in anesthetized sites (WKC = 0.703). Sites without bone loss showed more coronal deviation of CEJ detection, as opposed to apical deviation seen at sites with bone loss. CONCLUSION: The conventional CEJ detection using the tactile method was relatively imprecise depending on the anatomical location of the tooth and the bone loss at the site of measurement. However, the detection accuracy improved when the sites were anesthetized. In clinical terms, our data, reported here for the first time imply that, in the absence of visual cues, posterior tooth site measurements of periodontal attachment loss were more reliable in comparison to the other sites. The bone crest level also impacted the measurement deviation to some extent, implying that, possible overestimate of clinical attachment loss may occur at sites without bone loss.

Simple flowcharts for periodontal diagnosis based on the 2018 new periodontal classification increased accuracy and clinician confidence in making a periodontal diagnosis: a randomized crossover trial.

OBJECTIVE: To evaluate the effectiveness of the simple flowcharts for practical periodontal diagnosis based on the 2018 new periodontal classification. MATERIALS AND METHODS: In this randomized two-period crossover trial, 152 participants assigned a periodontal diagnosis for 25 case scenarios using the flowcharts (test group) and using the consensus reports (control group). Self-confidence questionnaires were completed at the end of each period. Questionnaires about the perception of the flowcharts were completed at the end of the study. The accuracy of the diagnosis, the time used, and participants' confidence in assigning a diagnosis between using the flowcharts and using the consensus reports were compared. RESULTS: The mixed model analysis indicated that using the flowcharts was associated with a significant increase in the accuracy of the periodontal diagnosis, compared with using the consensus reports (P = 0.008). After the subgroup analysis, a significant increase in the accuracy of the full diagnosis and the accuracy of periodontal health, gingivitis, and periodontitis identification was seen in only the dental students. The time used for making the diagnosis using flowcharts and using consensus reports was similar. The self-confidence scores significantly increased when using flowcharts for diagnosis. CONCLUSIONS: The simple flowcharts are user-friendly tools that can aid clinicians in accurately assigning a periodontal diagnosis and improve clinicians' confidence in assigning a periodontal diagnosis using the new periodontal classification. CLINICAL RELEVANCE: The flowcharts can be used for periodontal screening and assigning periodontal diagnosis using the new classification in routine practice.

Periodontitis is associated with cardiovascular diseases: A 13-year study.

AIM: To prospectively evaluate the association between periodontitis and the incidence of cardiovascular diseases (CVDs) in Thai adults. MATERIALS AND METHODS: Medical data from the questionnaires and physical examinations of 1850 participants aged 47-73 years from EGAT study were gathered. Random half-mouth periodontal examination of each participant was performed by calibrated periodontists, and periodontal status was defined. The incidence of new CVD events, including coronary heart disease (CHD) and stroke, was verified by cardiologists. The Cox proportional hazard regression model was used to estimate hazard ratios (HRs). RESULTS: The prevalence of no/mild, moderate and severe periodontitis in the study participants was 11.7%, 52.7% and 35.6%, respectively. During the 13-year follow-up, CVD events occurred in 110 (5.9%) participants, with 82 (4.4%) from CHD and 28 (1.5%) from stroke. After adjusting for cardiovascular risk factors, a significant association between severe periodontitis and the incidence of CHD was found compared with the no/mild periodontitis group with an HR of 4.53 (95% confidence intervals: 1.08-19.02). However, no significant association was seen when considering total CVD events and stroke outcome. CONCLUSIONS: This study demonstrates that severe periodontitis is associated with an increased incidence of CHD, independent of established cardiovascular risk factors.

The severity and extent of periodontitis is associated with cardio-ankle vascular index, a novel arterial stiffness parameter.

OBJECTIVES: To evaluate the association between the severity and extent of periodontitis and arterial stiffness using the cardio-ankle vascular index (CAVI). MATERIALS AND METHODS: A cross-sectional study of 2888 Electricity Generation Authority of Thailand (EGAT) employees aged 44-78 years was conducted. The severity of periodontitis was evaluated based on mean clinical attachment level (CAL). The percentage of sites with CAL ≥ 5 mm was used to divide the extent of periodontitis into healthy (0%), localized (> 0-< 30%), and generalized (≥ 30%). The CAVI value, a novel blood pressure-independent arterial stiffness parameter, was analyzed as both continuous and categorical data (low: < 9 or high: ≥ 9). Regression analysis was used to estimate the level of association. RESULTS: The participants demonstrated a mean CAL, % sites with CAL ≥ 5 mm, and a CAVI value of 3.2 ± 1.2 mm, 16.0 ± 20.8%, and 8.24 ± 1.12, respectively. Higher mean CAVI was observed with greater mean CAL and % sites with CAL ≥ 5 mm. The mean CAVI of the healthy, localized, and generalized periodontitis groups were 8.01 ± 1.11, 8.22 ± 1.12, and 8.51 ± 1.04, respectively (p < 0.01). Linear and logistic regression analysis demonstrated a significant relationship between CAVI and all periodontal variables with ß = 0.004-0.17 and OR = 1.01-1.58, respectively. CONCLUSIONS: There is a significant dose-dependent association between the severity and extent of periodontitis and arterial stiffness measured by CAVI in Thai adults. CLINICAL RELEVANCE: Preventing arterial stiffness, an early sign of cardiovascular events, by controlling the emerging risk factors, such as periodontitis, might have a high impact on health promotion.

Flowcharts for Easy Periodontal Diagnosis Based on the 2018 New Periodontal Classification.

FOCUSED CLINICAL QUESTION: How can a clinician simply and quickly perform a periodontal screening and make a proper periodontal diagnosis using the 2018 proposed new periodontal classification? SUMMARY: The 2018 periodontal classification has been released, however, it is challenging for clinicians especially for the dental students to apply the published information in practice. A diagnostic flowchart was created for three of the most common periodontal conditions: health, gingivitis, and periodontitis. Additionally, flowcharts were proposed for the diagnosis of periodontitis severity and risk of progression by staging and grading. Probing depth was the first clinical parameter to categorize the type of diseases. Subsequently, bleeding on probing, radiographic bone loss/clinical attachment loss, and history of periodontal treatment were further added for making a proper diagnosis. Three clinical cases were given to demonstrate the use of the simplified proposed flowcharts. CONCLUSIONS: The proposed diagnostic flowcharts are the user-friendly tool to assist clinicians to perform an initial screening and diagnosis based on the 2018 newly proposed periodontal disease classification.

Memory T cell subsets in healthy gingiva and periodontitis tissues.

BACKGROUND: In the gingival sulcus, effective and balanced innate and adaptive immune responses against subgingival plaque microbiome are crucial to maintain immune homeostasis. In this study, we investigated the memory T cell subsets in healthy gingiva and periodontitis tissues. METHODS: Anatomical localization of T cells (CD3+ , CD4+ , and CD8+ ) in healthy gingiva and periodontitis tissues were examined immunohistochemically. Subsets of memory T cells from isolated gingival cells were analyzed by flow cytometry using a cocktail of monoclonal antibodies (anti-CD69, anti-CD103, anti-CD45RA, anti-CCR7, anti-CD28, and anti-CD95). Intracellular cytokine staining of interleukin (IL)-17 and interferon (IFN)-γ expression on memory T cells in periodontitis tissues was also investigated. RESULTS: We found that healthy gingiva contains two memory T cell populations; a CD69- recirculating population and a CD69+ gingiva-resident memory T cell population. CD4+ T cells with transitional memory (TTM ) phenotype (CD45RA- CCR7- CD28+ CD95+ ) constitute the major subset within these two populations. A significant increase in the proportion of CD4+ CD69+ CD103- memory T cells was observed in periodontitis tissues compared with healthy gingiva. CD4+ memory T cells from periodontitis tissues produced either IL-17 or IFN-γ whereas CD8+ memory T cells produced only IFN-γ. CONCLUSIONS: Our findings suggest that recirculating and gingiva-resident memory T cells could represent an important part of the immune surveillance network in the connective tissue, maintaining periodontal homeostasis. Imbalance of subgingival bacterial communities could damage gingival barrier allowing bacterial antigens to get access to the deeper connective tissue where they activate memory T cells leading to deleterious inflammation; a hallmark of periodontitis.

Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, and Treponema denticola / Prevotella intermedia Co-Infection Are Associated with Severe Periodontitis in a Thai Population.

Periodontitis is a polymicrobial infection of tooth-supporting tissues. This cross-sectional study aimed to examine the associations between five target species and severe periodontitis in a Thai population. Using the CDC/AAP case definition, individuals diagnosed with no/mild and severe periodontitis were included. Quantitative analyses of Aggregatibacter actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), Tannerella forsythia (Tf), Treponema denticola (Td), and Prevotella intermedia (Pi) in subgingival plaque were performed using real-time polymerase chain reaction. The association between target species and severe periodontitis was examined using logistic regression analysis. The study subjects comprised 479 individuals with no/mild periodontitis and 883 with severe periodontitis. Bacterial prevalence and quantity were higher in subjects with severe periodontitis than in those with no/mild disease. In the fully adjusted model, all species except Tf showed a dose-dependent relationship with periodontitis. The mere presence of Pg, even in low amount, was significantly associated with severe periodontitis, while the amount of Aa, Td, and Pi had to reach the critical thresholds to be significantly associated with disease. Compared to individuals with low levels of both Td and Pi, high colonization by either Td or Pi alone significantly increased the odds of having severe periodontitis by 2.5 (95%CI 1.7-3.5) folds. The odds ratio was further increased to 14.8 (95%CI 9.2-23.8) in individuals who were highly colonized by both species. Moreover, the presence of Pg and high colonization by Aa were independently associated with severe periodontitis with odds ratios of 5.6 (95%CI 3.4-9.1) and 2.2 (95%CI 1.5-3.3), respectively. Our findings suggest that the presence of Pg and high colonization by Aa, Td, and Pi play an important role in severe periodontitis in this study population. We also demonstrate for the first time that individuals co-infected with Td and Pi were more likely to have periodontitis than were those infected with a single pathogen.