Faculty Bibliography

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a growing health problem worldwide. People with T2DM are at risk of experiencing periodontitis and likely require treatment. Using data from the national multicenter Diabetes and Periodontal Therapy Trial (DPTT), the authors assessed patient-based characteristics associated with the clinical response to nonsurgical therapy. METHODS: The DPTT investigators randomly assigned adults with T2DM (hemoglobin A1c [HbA1c] >/= 7 percent and < 9 percent) and moderate to advanced periodontitis to receive immediate or delayed therapy (scaling and root planing, oral hygiene instruction, chlorhexidine rinse). The investigators assessed probing depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), and medical conditions at baseline, three months and six months. Six-month changes in mean PD, CAL and BOP defined the treatment response. Complete data were available for 473 of 514 DPTT participants. The authors used multiple regression models to evaluate participant-level factors associated with the response. RESULTS: More severe baseline PD, CAL and BOP were associated with greater improvements in these same measurements (P < .0001). Hispanic participants experienced greater improvements in PD and CAL than did non-Hispanic participants (P < .0001). Obese participants (those with a body mass index > 30 kilograms per square meter) experienced greater reductions in PD and BOP than did participants who were not obese (P < .001). Age, sex, HbA1c values, diabetes duration, and smoking were not associated with change in any outcome (P > .1). CONCLUSIONS: In patients with T2DM, baseline disease severity was associated with the clinical response to nonsurgical periodontal therapy. Body mass index and Hispanic ethnicity-but not glycemic control, diabetes duration or smoking-also may be useful in predicting clinical changes in this population. PRACTICAL IMPLICATIONS: These findings could help clinicians identify patients with T2DM who may or may not respond well to initial periodontal treatment.

Treatment of multiple recession defects with the adjunct use of a connective tissue graft (CTG) represents a challenge when diagnosed in several teeth of the mouth. The amount of CTG harvested from the palate may not be adequate to address this condition. In such scenarios, alternative sources such as acellular dermal matrix (ADM) are preferred due to the unlimited availability. A case report is presented, dealing with the treatment of multiple gingival recessions affecting the majority of dentition using ADM, with a 6-month follow-up.

Data sourcesMedline, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL). This was supplemented by handsearching of the Journal of Clinical Periodontology, Journal of Periodontology, Journal of Dental Research, Journal of Dentistry, Journal of Periodontal Research, International Journal of Periodontics and Restorative Dentistry, Periodontology 2000, Odontology, Clinical Oral Investigations, Annals of Periodontology, Journal of American Dental Association, British Dental Journal, Community Dentistry and Oral Epidemiology, Diabetes, Diabetes Care, Diabetes & Metabolic Syndrome, Diabetes & Metabolism and Annals of Internal Medicine. There were no language restrictions.Study selectionRandomised controlled trials (RCTs) on diabetic patients with periodontal disease that reported glycated haemoglobin (HbA1c) and/or fasting plasma glucose (FPG) modification after treatment, with a minimum of three months follow-up were included. Study quality was assessed independently by two reviewers.Data extraction and synthesisData extraction was carried out independently by two reviewers. Meta-analysis was carried out to evaluate the effect of non-surgical periodontal treatment on HbA1c and FPG levels. The effect of the adjunctive use of antimicrobials was also assessedResultsFifteen studies were included, five were considered to be at low risk of bias, three at high risk and the remainder at unclear risk. Seven studies (678 patients) contributed to the meta-analysis for HbA1c. At the three-four months follow-up, the weighted mean difference was -0.38% (95% CI -0.23 to -0.53; P < 0.001) and at six months it was -0.31% (95% CI 0.11 to -0.74; P = 0.15), favouring the treatment groups [three studies contributing to meta-analysis]. There was statistically significant heterogeneity for both comparisons. For FPG, five studies presented data for three-four months and two for six months. At the three-four months follow-up, the weighted mean difference was -9.01 mg/dL (95% CI -2.24 to -15.78; P = 0.009) and at six months it was -13.62 mg/dL (95% CI 0.45 to -27.69; P = 0.06).ConclusionsDespite the limitations of the present study, it can be concluded that periodontal treatment might be effective in improving metabolic control in terms of reduction of HbA1c and FPG concentrations in patients with diabetes. However, the significance of this improvement is questionable and should be further investigated.

OBJECTIVES: The aim of this study was to compare microradiography (MR) and microcomputed tomography (muCT) analysis of bone samples following maxillary sinus augmentation at different time periods and determine the relationships between measured area and volume fractions. MATERIALS AND METHODS: Lateral window sinus grafts were performed on 10 patients using a mineralized human bone allograft (MHBA). At implant placement, 5-13 months after surgery, 10 bone core biopsies were harvested. Prior to histologic sectioning, bone samples were evaluated with muCT. The morphometric parameters computed by MR and muCT were compared using Pearson's correlation and Bland and Altman analysis and included hard tissue fraction (HV/TV:%), soft tissue fraction (SV/TV:%), vital bone fraction (BV/TV:%) and residual graft fraction (GV/TV:%). RESULTS: Strong positive correlation between MR and muCT was found for HV/TV and SV/TV and BV/TV [r = 0.84, 0.84 and 0.69, respectively] but weak for GV/TV [r = 0.10]. CONCLUSION: muCT technology shows promising potential as an indicator of bone morphology changes; however, caution should be used in interpreting morphometric parameters, as the different methods reveal important biases.

OBJECTIVES: The aim of the study was to introduce a novel three-dimensional (3D) method to quantify the relative amount of different tissue components in bone substitute-treated defects by means of integration of confocal laser imaging into micro-computed tomography (muCT) analysis. MATERIALS AND METHODS: One standardized semisaddle intraosseous defect was prepared in the mandibles of six minipigs and scanned by an optical scanner to capture the surface of the fresh defect in a 3D manner. Subsequently, all the defects were filled with a biphasic calcium phosphate material. The animals were divided into two groups of three animals each, which were allowed to heal for 3 and 8 weeks, respectively. muCT analysis followed the two healing periods and was performed on all defect locations. The data from optical scanning and muCT were used for three-dimensional evaluation of bone formation, nonmineralized tissue ratio, and graft degradation. The integration of confocal laser scanning into muCT analysis through a superimposition imaging procedure was conducted using the software Amira (Mercury Computer Systems, Chelmsford, MA, USA). RESULTS: The feasibility of combining the confocal imaging into muCT data with regard to obtaining accurate 3D quantification was demonstrated. The amount of tissue components was identified and quantified in all the investigated samples. Quantitative analysis demonstrated that a significant increase in the amount of bone filling the defect was observed in vivo (p < 0.02) while a significant decrease in the amount of nonmineralized tissue occurred (p < 0.04). No difference in the amount of residual grafting material was detected between 3 and 8 weeks in vivo (p > 0.38). CONCLUSIONS: The combination of confocal imaging and micro-computed tomography techniques allows for analysis of different tissue types over time in vivo. This method has revealed to be a feasible alternative to current bone regeneration quantification methods. CLINICAL RELEVANCE: Assessment of bone formation in a large animal model is a key step in assessing the performance of new bone substitute materials. Reliable and accurate methods are needed for the analysis of the regenerative potential of new materials.

BACKGROUND:Diabetes and periodontitis are complex chronic diseases with an established bidirectional relationship. There is long-established evidence that hyperglycaemia in diabetes is associated with adverse periodontal outcomes. However, given the ubiquity of periodontal diseases and the emerging global diabetes epidemic, the complications of which contribute to significant morbidity and premature mortality, it is timely to review the role of periodontitis in diabetes. AIMS/OBJECTIVE:To report the epidemiological evidence from cross-sectional, prospective and intervention studies for the impact of periodontal disease on diabetes incidence, control and complications and to identify potential underpinning mechanisms. EPIDEMIOLOGY/BACKGROUND:Over the last 20 years, consistent and robust evidence has emerged that severe periodontitis adversely affects glycaemic control in diabetes and glycaemia in non-diabetes subjects. In diabetes patients, there is a direct and dose-dependent relationship between periodontitis severity and diabetes complications. Emerging evidence supports an increased risk for diabetes onset in patients with severe periodontitis. Biological mechanisms: Type 2 diabetes is preceded by systemic inflammation, leading to reduced pancreatic b-cell function, apoptosis and insulin resistance.Increasing evidence supports elevated systemic inflammation (acute-phase and oxidative stress biomarkers) resulting from the entry of periodontal organisms and their virulence factors into the circulation, providing biological plausibility for the effects of periodontitis on diabetes. AGE (Advanced Glycation Endproducts)-RAGE (Receptor for AGEs) interactions and oxidative-stress-mediated pathways provide plausible mechanistic links in the diabetes to periodontitis direction. INTERVENTIONS/METHODS:Randomized controlled trials (RCTs) consistently demonstrate that mechanical periodontal therapy associates with approximately a 0.4% reduction in HbA1C at 3 months, a clinical impact equivalent to adding a second drug to a pharmacological regime for diabetes. RCTs are needed with larger numbers of subjects and longer term follow-up, and if results are substantiated, adjunctive periodontal therapies subsequently need to be evaluated. There is no current evidence to support adjunctive use of antimicrobials for periodontal management of diabetes patients. GUIDELINES/CONCLUSIONS:Given the current evidence, it is timely to provide guidelines for periodontal care in diabetes patients for medical and dental professionals and recommendations for patients/the public.