Nonsurgical and surgical treatment of periodontitis: how many options for one disease?
TL;DR: Treatment of periodontitis aims at preventing further disease progression with the intentions to reduce the risk of tooth loss, minimize symptoms and perception of the disease, possibly restore lost periodontal tissue and provide information on maintaining a healthy periodontium.
Abstract: Treatment of periodontitis aims at preventing further disease progression with the intentions to reduce the risk of tooth loss, minimize symptoms and perception of the disease, possibly restore lost periodontal tissue and provide information on maintaining a healthy periodontium. Therapeutic intervention includes introduction of techniques to change behavior, such as: individually tailored oral-hygiene instructions; a smoking-cessation program; dietary adjustment; subgingival instrumentation to remove plaque and calculus; local and systemic pharmacotherapy; and various types of surgery. No single treatment option has shown superiority, and virtually all types of mechanical periodontal treatment benefit from adjunctive antimicrobial chemotherapy. Periodontal treatment, because of the chronic nature of periodontitis, is a lifelong commitment to intricate oral-hygiene techniques, which, when properly implemented, will minimize the risk of disease initiation and progression.
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TL;DR: Research during the past 25 years has significantly changed the concepts of periodontitis pathobiology and has produced more-effective and less-costly therapeutic options.
Abstract: This volume of Periodontology 2000 represents the 25th anniversary of the Journal, and uses the occasion to assess important advancements in periodontology over the past quarter-century as well as the hurdles that remain. Periodontitis is defined by pathologic loss of the periodontal ligament and alveolar bone. The disease involves complex dynamic interactions among active herpesviruses, specific bacterial pathogens and destructive immune responses. Periodontal diagnostics is currently based on clinical rather than etiologic criteria, and provides limited therapeutic guidance. Periodontal causative treatment consists of scaling, antiseptic rinses and occasionally systemic antibiotics, and surgical intervention has been de-emphasized, except perhaps for the most advanced types of periodontitis. Plastic surgical therapy includes soft-tissue grafting to cover exposed root surfaces and bone grafting to provide support for implants. Dental implants are used to replace severely diseased or missing teeth, but implant overuse is of concern. The utility of laser treatment for periodontitis remains unresolved. Host modulation and risk-factor modification therapies may benefit select patient groups. Patient self-care is a critical part of periodontal health care, and twice-weekly oral rinsing with 0.10-0.25% sodium hypochlorite constitutes a valuable adjunct to conventional anti-plaque and anti-gingivitis treatments. A link between periodontal herpesviruses and systemic diseases is a strong biological plausibility. In summary, research during the past 25 years has significantly changed our concepts of periodontitis pathobiology and has produced more-effective and less-costly therapeutic options.
460 citations
Cites background from "Nonsurgical and surgical treatment ..."
...They conclude that current treatments yield essentially similar outcome and that systemic antibiotics can help arrest aggressive/disease-active periodontitis (75)....
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...In this volume of Periodontology 2000, Graziani and colleagues (75) review various surgical and nonsurgical periodontal treatments and offer a wealth of valuable insights....
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TL;DR: It is demonstrated that the deep CNN algorithm was useful for assessing the diagnosis and predictability of PCT and with further optimization of the PCT dataset and improvements in the algorithm, a computer-aided detection system can be expected to become an effective and efficient method of diagnosing and predicting PCT.
Abstract: Purpose The aim of the current study was to develop a computer-assisted detection system based on a deep convolutional neural network (CNN) algorithm and to evaluate the potential usefulness and accuracy of this system for the diagnosis and prediction of periodontally compromised teeth (PCT). Methods Combining pretrained deep CNN architecture and a self-trained network, periapical radiographic images were used to determine the optimal CNN algorithm and weights. The diagnostic and predictive accuracy, sensitivity, specificity, positive predictive value, negative predictive value, receiver operating characteristic (ROC) curve, area under the ROC curve, confusion matrix, and 95% confidence intervals (CIs) were calculated using our deep CNN algorithm, based on a Keras framework in Python. Results The periapical radiographic dataset was split into training (n=1,044), validation (n=348), and test (n=348) datasets. With the deep learning algorithm, the diagnostic accuracy for PCT was 81.0% for premolars and 76.7% for molars. Using 64 premolars and 64 molars that were clinically diagnosed as severe PCT, the accuracy of predicting extraction was 82.8% (95% CI, 70.1%-91.2%) for premolars and 73.4% (95% CI, 59.9%-84.0%) for molars. Conclusions We demonstrated that the deep CNN algorithm was useful for assessing the diagnosis and predictability of PCT. Therefore, with further optimization of the PCT dataset and improvements in the algorithm, a computer-aided detection system can be expected to become an effective and efficient method of diagnosing and predicting PCT.
234 citations
Cites background from "Nonsurgical and surgical treatment ..."
...Various non-surgical and surgical methods have been devised and improved for the treatment of periodontally compromised teeth (PCT) and supporting structures, and numerous studies have also been conducted on regenerative periodontal tissues [9,10]....
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TL;DR: The adjunctive use of systemic antimicrobials in periodontal therapy results in statistically significant benefits in clinical outcomes, with more frequent adverse events in test groups using systemic antimmicrobials.
Abstract: Aim: To answer the following PICOS questions: in patients with periodontitis, which is the efficacy of adjunctive systemic antimicrobials, in comparison with subgingival debridement plus a placebo, in terms of probing pocket depth (PPD) reduction, in randomized clinical trials with at least 6 months of follow-up?. Material and Methods: A systematic search was conducted: 34 articles (28 studies) were included. Data on clinical outcome variables changes were pooled and analysed using weighted mean differences (WMDs), 95% confidence intervals (CI) and prediction intervals (PIs), in case of significant heterogeneity. Results: For PPD, statistically significant benefits (p <.001) were observed in short-term studies (WMD = 0.448, 95% CI [0.324; 0.573], PI [−0.10 to 0.99]) and long-term studies (WMD = 0.485, 95% CI [0.322; 0.648], PI [−0.11 to 1.08]). Additionally, statistically significant benefits were also found for clinical attachment level, bleeding on probing, pocket closure and frequency of residual pockets. The best outcomes were observed for the combination of amoxicillin plus metronidazole, followed by metronidazole alone and azithromycin. Adverse events were more frequently reported in groups using systemic antimicrobials. Conclusions: The adjunctive use of systemic antimicrobials in periodontal therapy results in statistically significant benefits in clinical outcomes, with more frequent adverse events in test groups using systemic antimicrobials.
137 citations
TL;DR: Recent progresses of periodontal regeneration using tissue-engineering and regenerative medicine approaches are discussed, with special attention given to the development of advanced bio-inspired scaffolding biomaterials and temporospatial control of multi-drug delivery for the regeneration of cementum-periodontal ligament-alveolar bone complex.
127 citations
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TL;DR: Intensive periodontal treatment resulted in acute, short-term systemic inflammation and endothelial dysfunction, however, 6 months after therapy, the benefits in oral health were associated with improvement in endothelial function.
Abstract: Background: Systemic inflammation may impair vascular function, and epidemiologic data suggest a possible link between periodontitis and cardiovascular disease.
Methods: We randomly assigned 120 patients with severe periodontitis to community-based periodontal care (59 patients) or intensive periodontal treatment (61). Endothelial function, as assessed by measurement of the diameter of the brachial artery during flow (flow-mediated dilatation), and inflammatory biomarkers and markers of coagulation and endothelial activation were evaluated before treatment and 1, 7, 30, 60, and 180 days after treatment.
Results: Twenty-four hours after treatment, flow-mediated dilatation was significantly lower in the intensive-treatment group than in the control-treatment group (absolute difference, 1.4%; 95% confidence interval [CI], 0.5 to 2.3; P=0.002), and levels of C-reactive protein, interleukin-6, and the endothelial-activation markers soluble E-selectin and von Willebrand factor were significantly higher (P<0.05 for all comparisons). However, flow-mediated dilatation was greater and the plasma levels of soluble E-selectin were lower in the intensive-treatment group than in the control-treatment group 60 days after therapy (absolute difference in flow-mediated dilatation, 0.9%; 95% CI, 0.1 to 1.7; P=0.02) and 180 days after therapy (difference, 2.0%; 95% CI, 1.2 to 2.8; P<0.001). The degree of improvement was associated with improvement in measures of periodontal disease (r=0.29 by Spearman rank correlation, P=0.003). There were no serious adverse effects in either of the two groups, and no cardiovascular events occurred.
Conclusions: Intensive periodontal treatment resulted in acute, short-term systemic inflammation and endothelial dysfunction. However, 6 months after therapy, the benefits in oral health were associated with improvement in endothelial function.
1,185 citations
"Nonsurgical and surgical treatment ..." refers background in this paper
...Most research data pertain to treatment with amoxicillin plus metronidazole, ciprofloxacin plus metronidazole, metronidazole alone or azithromycin (299, 300), with azithromycin being generally less effective but more convenient in terms of compliance and adverse effects....
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...Subgingival instrumentation during the first hours/days post-treatment results in a sharp increase in systemic inflammatory markers, such as C-reactive protein, fibrinogen and serum-amyloid A (61, 99); enhancement of coagulative tendency (62); and reduction of endothelial function (300)....
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TL;DR: Current data suggest that pathogens are necessary but not sufficient for disease activity to occur, and the local environment of the periodontal pocket may be important in the regulation of expression of virulence factors by pathogenic species.
Abstract: The interpretation of diagnostic tests for the detection of subgingival bacterial species is dependent on knowledge of the microbial etiology of destructive periodontal diseases. Specific etiologic agents of these diseases have been sought for over 100 years; however, the complexity of the microbiota, an incomplete understanding of the biology of periodontal diseases, and technical problems have handicapped this search. Nonetheless, a number of possible pathogens have been suggested on the basis of their association with disease, animal pathogenicity, and virulence factors. The immunological response of the host to a species and the relation of successful therapy to the elimination of the species have also been used to support or refute suspected periodontal pathogens. Current data suggest that pathogens are necessary but not sufficient for disease activity to occur. Factors which influence activity include susceptibility of the individual host and the presence of interacting bacterial species which facilitate or impede disease progression. Recent studies have attempted to distinguish virulent and avirulent clonal types of suspected pathogenic species and seek transmission of genetic elements needed for pathogenic species to cause disease. Finally, the local environment of the periodontal pocket may be important in the regulation of expression of virulence factors by pathogenic species. Thus, in order that disease result from a pathogen, 1) it must be a virulent clonal type; 2) it must possess the chromosomal and extra-chromosomal genetic factors to initiate disease; 3) the host must be susceptible to this pathogen; 4) the pathogen must be in numbers sufficient to exceed the threshold for that host; 5) it must be located at the right place; 6) other bacterial species must foster, or at least not inhibit, the process; and 7) the local environment must be one which is conducive to the expression of the species' virulence properties.
1,118 citations
TL;DR: Patients in a private periodontal practice were reexamined an average of 22 years after their active treatment and the patterns of tooth loss were observed and tooth retention seemed more closely related to the case type than the surgery performed.
Abstract: 1. Six hundred patients in a private periodontal practice were reexamined an average of 22 years after their active treatment and the patterns of tooth loss were observed. 2. During the post-treatment period, 300 patients had lost no teeth from periodontal disease, 199 had lost one to three teeth, 76 had lost 4 to 9 teeth and 25 had lost 10 to 23 teeth. 3. Of 2,139 teeth that originally had been considered of questionable prognosis, 666 were lost. Of these, 394 were lost by one sixth of the patients and only 272 by the other five-sixths. 4. Of 1,464 teeth which originally had furcation involvements, 460 were lost, 240 of them by one-sixth of the patients who deteriorated most. 5. The mortality of teeth which were treated with periodontal surgery was compared with that of teeth which did not have surgery. Tooth retention seemed more closely related to the case type than the surgery performed. 6. In general, periodontal disease is bilaterally symmetrical and there is a predictable order of likelihood of tooth loss according to position in the arch.
894 citations
"Nonsurgical and surgical treatment ..." refers background in this paper
...Single-rooted teeth and posterior teeth with intact furcations usually respond better than multirooted teeth with compromised furcations to nonsurgical treatment and are more easily maintained than teeth with furcation involvement (12, 96, 124, 188, 202, 224)....
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TL;DR: Whether available data support an independent association between ASVD and PD and whether PD treatment might modify ASVD risks or outcomes is assessed and mechanistic details of both PD and ASVD relevant to this topic are presented.
Abstract: A link between oral health and cardiovascular disease has been proposed for more than a century. Recently, concern about possible links between periodontal disease (PD) and atherosclerotic vascular disease (ASVD) has intensified and is driving an active field of investigation into possible association and causality. The 2 disorders share several common risk factors, including cigarette smoking, age, and diabetes mellitus. Patients and providers are increasingly presented with claims that PD treatment strategies offer ASVD protection; these claims are often endorsed by professional and industrial stakeholders. The focus of this review is to assess whether available data support an independent association between ASVD and PD and whether PD treatment might modify ASVD risks or outcomes. It also presents mechanistic details of both PD and ASVD relevant to this topic. The correlation of PD with ASVD outcomes and surrogate markers is discussed, as well as the correlation of response to PD therapy with ASVD event rates. Methodological issues that complicate studies of this association are outlined, with an emphasis on the terms and metrics that would be applicable in future studies. Observational studies to date support an association between PD and ASVD independent of known confounders. They do not, however, support a causative relationship. Although periodontal interventions result in a reduction in systemic inflammation and endothelial dysfunction in short-term studies, there is no evidence that they prevent ASVD or modify its outcomes.
862 citations
"Nonsurgical and surgical treatment ..." refers background in this paper
...Studies indicate that periodontitis: (i) represents a relative risk for aggravating existing diabetes (26) because of a deterioration of glucose metabolism (67); (ii) increases the risk for cardiovascular disease (128, 132) because it augments probability for developing atherosclerosis (179), probably mediated by systemic inflammatory mediators (182, 214); and (iii) is a potential risk for adverse pregnancy outcome (41)....
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TL;DR: Many of the systemic risk factors for periodontal disease, such as smoking, diabetes and obesity, and osteoporosis in postmenopausal women, are relatively common and can be expected to affect most patients with periodontals seen in clinics and dental practices.
Abstract: Risk factors play an important role in an individual's response to periodontal infection. Identification of these risk factors helps to target patients for prevention and treatment, with modification of risk factors critical to the control of periodontal disease. Shifts in our understanding of periodontal disease prevalence, and advances in scientific methodology and statistical analysis in the last few decades, have allowed identification of several major systemic risk factors for periodontal disease. The first change in our thinking was the understanding that periodontal disease is not universal, but that severe forms are found only in a portion of the adult population who show abnormal susceptibility. Analysis of risk factors and the ability to statistically adjust and stratify populations to eliminate the effects of confounding factors have allowed identification of independent risk factors. These independent but modifiable, risk factors for periodontal disease include lifestyle factors, such as smoking and alcohol consumption. They also include diseases and unhealthy conditions such as diabetes mellitus, obesity, metabolic syndrome, osteoporosis, and low dietary calcium and vitamin D. These risk factors are modifiable and their management is a major component of the contemporary care of many periodontal patients. Genetic factors also play a role in periodontal disease and allow one to target individuals for prevention and early detection. The role of genetic factors in aggressive periodontitis is clear. However, although genetic factors (i.e., specific genes) are strongly suspected to have an association with chronic adult periodontitis, there is as yet no clear evidence for this in the general population. It is important to pursue efforts to identify genetic factors associated with chronic periodontitis because such factors have potential in identifying patients who have a high susceptibility for development of this disease. Many of the systemic risk factors for periodontal disease, such as smoking, diabetes and obesity, and osteoporosis in postmenopausal women, are relatively common and can be expected to affect most patients with periodontal disease seen in clinics and dental practices. Hence, risk factor identification and management has become a key component of care for periodontal patients.
853 citations
"Nonsurgical and surgical treatment ..." refers background in this paper
...Not only do smokers have a higher risk of periodontitis (94), they also show compromised healing following surgical and nonsurgical therapy compared with nonsmokers and former smokers (4, 298)....
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