the global strategy and teamwork for periodontal health and overall health - filippo graziani

Filippo GrazianiDDS, MClinDent, PhD

University of PisaSchool of Dentistry

Periodontology

University Hospital of PisaUnit of Dentistry and Oral Surgery

Section of Periodontology

Control of periodontal infection: effects on overall health and well-being

Periodontitis & Systemic Involvements Periodontitis & Psychosocial Involvements Treatment effects on General Health Treatment effects on Psyco-Social Well-Being Conclusions

Overview

Overview


6° Most Prevalent Condition 10.8% (95% CI: 10.1%-11.6%) 743 milion worldwide

Prevalence

Bacteria Inflammation = ClinicalSequelae

+

Periodontitis

Edentulism

Social Factors (Aesthetic, Speaking)

Function (Malnutrition,

Gastric disease)

Cognitive Alterations

Costs

Periomedicine Rationale

Graziani & Tonetti Management of cardiovascular risk in

patients with periodontal diseasesIn “Current Advances in Cardiovascular

Risk” 2012

Periomedicine Rationale

Bacteriemia

Forner, Larsen, Kilian, HolmstrupIncidence of bacteremia after

chewing, tooth brushing and scaling in individuals with periodontal inflammation

Journal of Clinical Periodontology 2006

PeriodontitisGingivitisHealthy Controls

20%0%0%

10%0%0%

75%20%10%

Chewing Brushing Scaling

Bacteriemia

Reyes, Herrera, Kozarov, Roldan, Progulske-Fox Periodontal bacterial invasion and infection: contribution to atherosclerotic pathology.


Jain, Batista Jr, Serhan, Stahl, Van DykeRole for periodontitis in the progression of

lipid deposition in an animal model Infection and Immunity 2003

Systemic Inflammation

Bacteria + Inflammation

C-Reactive Protein

Ridker & SilvertownInflammation, C-Reactive Protein and

AtherothrombosisJournal of Periodontology 2008

Perio & CRP

Paraskevas, Huizinga, Loos A systematic review and meta-analyses on

C-reactive protein in relation to periodontitisJournal of Clinical Periodontology 2008

Vascular-Endothelial Function

Tsioufis , Kasiakogias, Thomopoulos Stefanadis Periodontitis and blood pressure:

The concept of dental hypertension. Atherosclerosis. 2011

NHANES : 12000 subjects

Mean sistolic BP > in Perio+ subjects (mild-severe).

Linear correlation among SBP and perio severity

Holtfreter, Empen, Glaser, Lorbeer, Volzke et al.Periodontitis Is Associated with Endothelial

Dysfunction in a General Population: A Cross-Sectional Study.

PLoS ONE 201

Vascular-Endothelial Function

The Endothelium

TA tunica adventitia TM tunica media EC endothelial cells LU arteriole lumen TI tunica intima

5 m

SURFACE: 400 m2 WEIGHT: 1.5 Kg cell n°: 1.200.000.000 Orlandi, Suvan, Petrie, Donos, Masi, Hingorani,

Deanfield, D'Aiuto Association between periodontal disease and its treatment,flow-

mediated dilatation and carotid intima-media thickness. Atherosclerosis. 2014

c-IMT measurements (5452 subjects)

Perio cases showed a greater c-IMT (0.08 mm)

(per every 0.1mm of c-IMT difference the RR ofmyocardial infarction increases of 1.15 times and

for stroke increases of 1.18 times)

Shimazi, Saito, Kiyohara, Kato, Kubo, KogaRelationship between electrocardiographic

abnormalities and periodontal disease: the Hisayama Study.

Journal of Periodontology 2004

Average PD, CAL are associated with ECG abnormalities (O.R. 1.6)

Franek, Klamczynska, Ganowicz, et al. Association of chronic periodontitis with left

ventricular mass and central blood pressure in treated patients withessential hypertension.

American Journal of Hypertension 2009

Severe Perio to the cardiologist?

Heart Function

http://ajh.oxfordjournals.org.libproxy.ucl.ac.uk/content/current

Lockhart et al.Periodontal disease and atherosclerotic vascular disease: does the evidence support an independent association? A scientific statement from the Am. Heart Association

Circulation 2012

Periodontal disease (PD)is associated with atherosclerotic vascular

disease independent of known confounders

Atherosclerosis

Perio & Lipid Metabolism

Nibali, D’Aiuto, Griffiths, Patel, Suvan, Tonetti Severe periodontitis is associated with

systemic inflammation and a dysmetabolic status: a case–control study.


High Density Lipoproteins are considered as “heart protectors” ( the higher the

level the lower atheroscelrosis)

Severe Perio (HEP) shows significantly lower values of HDL than healthy controls

(1.14 mmol/L, p<0.001)

%AL ≥5 mm category experienced an 0.08% greater 5-year increase in HBA1C

Demmer, Desvarieux, Holtfreter, Jacobs Jr, Wallaschofski, Nauck, Volzke, KocherPeriodontal status and A1C change:

longitudinal results from the study of health in Pomerania Diabetes Care 2010

-0.05

0

0.05

0.1

0.15

0.2

0.25

CRP≥ 1mg/lCRP< 1mg/l

5 ye

ar a

bsol

ute

HBA1

c ch

ange

(%)

Q1 Q2 Q3 Q4 Edentulous %AL≥ 5mm

Metabolic Function

http://ajh.oxfordjournals.org.libproxy.ucl.ac.uk/content/current

Dietrich , Joshipura, Dawson-Hughes, Bischoff-Ferrari. Association between serum

concentrations of 25-hydroxyvitamin D3 and periodontal disease in the US population. American Journal of Clinical Nutrition 2004

Inverse association between serum 25(OH)D3 concentrations and periodontitis in subjects > 50 y.

When compared with highest Vit. D quintile, these subjects lost 27% (95% CI: 12%, 42%) and 23% (95% CI: 8%, 38%) more attachment.

Kuzmanova, Jansen, Schoenmaker, Nazmi, Teeuw, Bizzarro, Loos , van der Velden Vitamin C in plasma and leucocytes in

periodontitis. Journal of Clinical Periodontology 2012

Xu & Lu Prospective association of periodontitis with

cardiovascular and all-cause mortality: NHANES III follow-up study

Atherosclerosis 2011

Mortality

Borgnakke, Ylostalo, Taylor, Genco Effect of periodontal disease on diabetes:

systematic review of epidemiologic evidence Journal of Clinical Periodontology 2013

Diabetics with severe periodontitis die 3.5

more for cardio-renal death

Take Home Message

Periodontal patients compared to controls:

Higher level of systemic inflammation Pressure and vascular lower efficiency Cardiac alterations Metabolism deficiency Possible higher risk of death

Manifesto

Overview


Stress

Allostatic Load

Higher Susceptibility to

Periodontitis

Boyapati & WangThe role of stress in periodontal disease

and wound healing.Periodontology 2000. 2007

Poor Behaviours

smoking, + alcohol,

comfort eating, risk taking,

sleep deprivation

Low Plaque Control

Hypothalamus

↑ Corticotropin realising hormon

(CRH)

Pituitary Gland

↑ Adrenocorti-cotropic hormon

Suprarenal Cortex

↑ Cortisol Release

Autonomous Nervous system

Suprarenal Medullae

↑ Epinephrin & Norepinephrine

↑ Glucose level, GF Alteration, ↑ Citokines

levels , Immunodepression

Stress & Clinical Perio

Genco, Ho, Grossi, Dunford, TedescoRelationship to Stress, Distress and inadequate

copying behaviour to Periodontal DiseaseJournal of Periodontology 1999

1426 Periodontal Patients

4 questionnaires Life Events Scale Measures of Chronic Stress Measures of Distress Coping Styles and Strategies

Adjusted for counfounds: smoking, age, gender, general health

Stress (as financial strain) associated with higher levels of CAL and bone loss (OR 1.7 & 1.68)

Subjects with good copying behaviour = subjects with no stress despite financial strain

Salivary Cortisol Levels

Genco, Ho, Kopman, Grossi, Dunford, TedescoModels to Evaluate the Role of Stress in

Periodontal Disease Annals of Periodontology 1998

Severe Periodontitis, a high level of financial strain, and

high emotion-focused coping

Little or no periodontal disease, low financial strain, and low levels of emotion-

focused coping

11.04 ± 4.4 nmol/L 8.6 ± 4.1 nmol/L

Financial Strain

Ng, Leung A community study on the relationship

between stress, coping, affective dispositions and periodontal attachment loss

Community Dent Oral Epidemiol. 2006Healthy Low Moderate High Severe

0

0.5

1

1.5

2

2.5

3

3.5

JobFinancial

1000 subjects Cross-sectional

Study

Quality of Life

Quality of life is concerned with the degree to

which a person enjoys the important possibilities of life as well-being is maintained

OHRQoL

Oral Health Related Quality of Life (OHRQoL)

Assessing impact of Disease/Treatment on patient’s daily lifethrough Questionnaires/interviews:

Oral Health Impact Profile (OHIP)-14, -20, -49, -UK General Oral Health Assessment Index (GOAI) Oral Impacts on Daily Performances (OIDP)

Shanbhag, Dahiya, Croucher The impact of periodontal therapy on oral

health-related quality of life in adults: a systematic review.

J Clin Periodontol 2012;39: 725–735.

OHRQoL

ORAL HEALTH RELATED

QUALITY OF LIFE

FUNCTIONS Mastication Speech

PSYCHOLOGY Appearance Self esteem

SOCIAL Intimacy Communication

PAIN/DISCOMFORT Acute Chronic

QoL & Perio

Needleman, McGrath, Floyd & Biddle Impact of oral health on the life quality of

periodontal patients Journal of Clinical Periodontology 2004

The impact of oral health of life is significant

90% of the subjects (185/205) feels that oral health had a significant impact on their lives

Symptoms are related (gengival bleeding, halythosis, ecc.)

Take Home Message

Stress, Financial Burden, Depression, Anxiety are strongly associated to Periodontitis

Quality of Life is tremendously affected by periodontal disease

There is a tendency of direct association between severity of the disease and Psychological aspects

Severe disease affects even more the QoL

Overview


To Arrest Disease Progression

To Nullify Symptoms and Perception

To Restore (Regenerate) Lost Tissues

To Maintain & Support = keep teeth

longer

Patient-Centered Treatment Goals

Treatment Philosopy

Paradigm Shift: from Certainty to Probability

Periodontal Disease cannot be removed but controlled

Periodontal Treatment: altering factors which may increase the risk of disease progression

Risk of Progression

Lang &Tonetti Periodontal Risk Assestment (PRA) for

patients in Supportive Periodontal Therapy Oral Health & Preventive Dentistry 2003

Trombelli, Farina, Ferrari, Pasetti, Calura Comparison between two

methods for periodontal risk assessment Minerva Stomatologica 2009

somma: 0-2punteggio di rischio 1


RISCHIOBASSO

RISCHIOMEDIO-BASSO

RISCHIO MEDIO

RISCHIOMEDIO-ALTO

RISCHIO ALTO




Treatment Scheme

Adjuntive Pharmaceutics

Diagnosis

Health/Gingivitis Periodontitis

Re-Examination

Causative Treatment

Need for Surgery? Success

Supportive TX

Perio/Implant Surgery

Re-Examination

Primary Prevention

NOYESYES

NO

PHASE 1

PHASE 2

PHASE 3

Discepoli, Nisi, Gennai, Karapetsa, Cei, GrazianiPatient perception of periodontal disease

in a cohort of 240 patientsJournal of Clinical Periodontology 2015

Periodontal disease is not silent (15% had no symptoms) Main symptom is bleeding (49.2%), followed by halythosys

(41.7%) and mobility (38.4%) Many symptoms are not recognized as “symptoms” Self perception of bleeding and mobility were associated to

severe periodontitis (OR=3.5). Pooled together symptoms show specificity of 91.2/81.2 for severe/mild

Symptoms

Periodontal Treatment

Periodontal treatment successfully decreases gingival inflammation, obtains pocket reduction/closure

and improvement of clinical attachment level

Van der Weijden & Timmerman A systematic review on the clinical efficacy

of subgingival debridement in the treatment of chronic periodontitis.


Bruno 63 yrs Hypertension treated with β-blockers Former Smokers Chief complaint: Halythosis

Non-Surgical Treatment

Re-examination

Non-Surgical Treatment

Salvadori Bruno Periodontal Charting

Sondaggio 3 3 3 3 2 3 2 1 2 3 1 3 2 1 2 1 1 1 2 1 2 3 1 3 2 1 2 3 1 3 2 1 3 3 2 3 3 1 3 3 2 2 3 3 3 3 2 3RecessioneSanguinamentoIndice PlaccaForcazione

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Sondaggio 3 2 3 3 3 4 3 3 3 3 2 3 3 1 2 3 1 3 2 1 2 1 1 3 2 1 2 1 1 1 2 1 3 2 1 2 3 1 3 3 2 3 3 2 3 3 3 3RecessioneSanguinamentoIndice PlaccaForcazione

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Mobilità

F.M.B.S.#### ####F.M.P.S.

33 37363241

ARCATA DENTARIA INFERIORE

3144 353448 47 46 45 4243

V

P

38

Sondaggio 3 1 6 6 3 3 3 2 3 4 1 3 3 1 5 4 2 5 5 2 5 5 1 6 5 2 4 5 2 4 4 2 4 5 2 6 5 2 6 5 5 5 6 3 5 6 5 5RecessioneSanguinamento 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1Indice PlaccaForcazione

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Sondaggio 5 5 5 5 3 5 6 3 5 5 2 4 3 2 3 4 3 4 3 3 3 1 1 1 1 1 2 1 1 1 3 1 2 3 1 2 3 3 3 3 3 4 5 4 3 4 4 4RecessioneSanguinamentoIndice PlaccaForcazione

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Mobilità

3544 31 33 3734 38363241

ARCATA DENTARIA INFERIORE

43

V

P

48 47 46 45 42

Tooth Mortality

Graziani, Gennai, Cei, Cairo, Baggiani, Miccoli, Gabriele , Tonetti

Clinical performance of access flap surgery in the treatment of the

intrabony defect.

J Clin Periodontol. 2012

Graziani, Gennai, Cei, Ducci, Discepoli, Carmignani, Tonetti

Does enamel matrix derivative application provide additional clinical benefits in

residual periodontal pockets associated with suprabony defects?


Graziani, Gennai, Karapetsa, Rosini, Gabriele, Tonetti

Clinical performance of access flap surgery in the treatment of class II

furcation defects.


Salvadori Bruno Tooth Mortality

O,11 Teeth lost/patient*year maintenance (Tonetti et al. 2000)

Molars with furcation are lost more frequently. The higher the degreee of furcation the more can be lost in long term (Nibali et al. 2016)

However a significant portion of teeth are not lost after treatment in the very long term (Hirschfield & Wasserman 1978)

Inflammation

Graziani, Cei, Gabriele, TonettiEffects of non surgical peridontal

therapy on kidneyJournal of Clinical Periodontology 2010

Baseline 1day 1 week 1 month 3 months

Timepoints

0

10

20

30

VES

14

34

54

74

84

94


Timepoints

0,00

1,00

2,00

3,00

4,00

PCR

37

11

3

71

76


Timepoints

0,00

0,10

0,20

0,30

0,40

0,50

0,60

D-Dim

er

7

28

5775

3

34

32

47

67

68


Timepoints

0,0

50,0

100,0

150,0

200,0

250,0

300,0

sier

o-am

iloid

e a

23

56

3

37

76

Graziani, Gennai, Gabriele, Nisi, D'Aiuto. Acute-phase response following full-mouth versus

quadrant non-surgicalperiodontal treatment: A randomized clinical trial.


B a sel ine D a y 1 D a y7 D a y 900

1

2

3

4

5

6

7

CRPM

g/L

RELATIVE INCREASE AT DAY 1

0%

50%

100%

150%

200%

250%

300%

350%

400%

FM-SRPQ-SRP

* p<0.01 between groups at day 1** p<0.05 between groups at day 1

*

**

Short-term Inflammation

Graziani, Gennai, Gabriele, Nisi, D'Aiuto. Acute-phase response following full-mouth versus

quadrant non-surgicalperiodontal treatment: A randomized clinical trial.


Treatment time is related to the inflammatory

response


Visioni Linguali – Luglio 2014

Salvadori Bruno

Visioni Linguali – Luglio 2014

Salvadori Bruno

Luca 46 yrs Systemically Healthy No complaint Referred

RE-EXAMINATION

Diagnosis

Health Gengivitis Periodontitis

Re-Examination

Causative Treatment Causative TreatmentPrimary Prevention

PHASE 1

Periodontitis Control and Re-examination

F. Graziani

Re-examination: from Patient to Site. Managing residual pockets and furcations.

Graziani et al.Systemic inflammation following non-surgical

and surgical periodontal therapyJournal of Clinical Periodontology 2010

Non surgical Periodontal Treatment is strongly

associated to inflammatory response


Soraia 56 yrs Professional Singer, Hyperglicemia, Overweight Chief complaint: Bleeding on Brushing, receeding gums #PPD>3mm 67, PPD>5mm 15, FMPS : 88%, FMBS: 79%

Medium-term Inflammation

FMPS: 88% to 12% FMBS: 79% to 9% #PPD>4mm 67 to 0 No Furc +


Soraia 56 yrs Professional Singer, Hyperglicemia, Overweight Chief complaint: Bleeding on Brushing, receeding gums #PPD>3mm 67, PPD>5mm 15, FMPS : 88%, FMBS: 79%


Graziani et al.Systemic inflammation following non-surgical

and surgical periodontal therapyJournal of Clinical Periodontology 2010


Overall inflammation tend to decrease along the control of the periodontal infection (i.e. active treatment)

Teeuw, Slot, Susanto, Gerdes, Abbas, D’Aiuto, Kastelein, Loos Treatment of periodontitis

improves the atherosclerotic profile: a systematic review and meta-analysis.


Inflammation

Hs-CRP is significantly reduced by Perio Tx

Especially in subjects with co-morbidities, normal weigtht or non-smoking

Endothelial Function

Orlandi, Suvan, Petrie, Donos, Masi, Hingorani, Deanfield, D'Aiuto Association between

periodontal disease and its treatment,flow-mediated dilatation and carotid intima-media

thickness. Atherosclerosis. 2014

Engebretson & Kocher Evidence that periodontal treatment improves

diabetesoutcomes: a systematic review and meta-analysis.


Yun Singh Koromantzos Jones Katagari Sun

-0.4

-0.2

0

0.2

0.4

0.6

0.8 Tx ParoNo Tx Paro

HbA1c reduction 3 months after perio tx

• 719 subjects•Mean weighted difference: 0,36%

(95% CI -0.54 to -0.19%)• Heterogeneity: I² = 9%

Glucose Metabolism

Lipids Metabolism

Teeuw, Slot, Susanto, Gerdes, Abbas, D’Aiuto, Kastelein, Loos Treatment of periodontitis

improves the atherosclerotic profile: a systematic review and meta-analysis.


Triglycerides 0.24 mmol/l (CI: 0.26; 0.22, p < 0.00001)

Total cholesterol 0.15 mmol/l (CI: 0.29; 0.01, p = 0.03)

HDL-C 0.05 mmol/l (CI: 0.03; 0.06, p < 0.00001)

Nutraceutic

Dodington, Fritz, Sullivan, Ward Higher Intakes of Fruits and Vegetables, β-Carotene,

Vitamin C, α-Tocopherol, EPA, and DHA Are Positively Associated with Periodontal Healing after Nonsurgical

Periodontal Therapy in Nonsmokers but Not in Smokers.The Journal of Nutrition 2004

Higher dietary intakes of fruits and vegetables, b-carotene, vitamin C, a-tocopherol, EPA, and DHA are associated with greater reductions in PD after SRP in

nonsmokers with periodontal disease.

Nutraceutic

Reduction of Bleeding and Plaque in un treated patients (p<0.0001)

Possible adjunctive effects in deep pockets after treatment

Graziani, Discepoli, Gennai, Karapetsa, Rosema, Van der Velden The effect of twice daily kiwifruit

consumption on periodontal and systemic conditions before and after treatment.

Journal of Clinical Periodontology Submitted

Overview


Re-examination

Valerio 43 yrs Personal Trainer, Systemicaly Healthy Chief complaint: Bleeding on Brushing #PPD>3mm 120, PPD>5mm 47, FMPS : 84%, FMBS: 61%

Treatment effect on Quality of Life

Increase of OHRQoL after periodontal treatment is shown.

No differences among various type of non surgical tx.

No adjunctive effects are noted after surgery if the subjects had received already non surgical tx.

Shanbhag, Dahiya, Croucher The impact of periodontal therapy on oral

health-related quality of life in adults: a systematic review.

J Clin Periodontol 2012;39: 725–735.

403 subjects 58,3 % females 19,3% Former smokers, 33,5% smokers, 47,3% never-smokers Questionnaire of 88 items, divided in 7 areas before and after treatment

Perio-Perception Study

OHIP-14 PSQI(Sleep)

MACQ(Memory)

IIEF-5(Erection) Fagerstrom Perio-

SimptomsPerio-

Perception


Baseline Post-treatment

OHIP-14 31,30±14,07 12,49±11,87*

PSQI 3,6±3,06 3,62±1,51

MACQ 7,18±3,03 3,62±1,51*

IIEF-5 22,58±1,08 22,27±1,21

Fagerstrom 8,08±1,63 7,33±1,75*

Periosintomatology 7,90±3,49 5,91±2,94*

Perioperception 11,25±3,12 3,84±4,06*

*P<0.05 compared to baseline


Slight Moderate Severe0

1

2

3

4

5

6

1.41

4.04

5.32

1.79

3.4 3.52


P<0.05

Slight Moderate Severe6.6

6.8

7

7.2

7.4

7.6

7.8

8

8.2

8.4

8.6

7.9

8.45

8.06

7.63

8.33

7.22


P<0.05Pittsburgh Sleep Index Fagerstrom


Do you think that periodontal disease could increase your stress?

Do you think that periodontitis is damaging your sleep quality?

Slight Moderate Severe0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

77.50%

87.50% 85.70%

22.20%17.80%

27.20%

Slight Moderate Severe0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

55.30%

68.20%

62.00%

24.40%

30.80%

20.30%

All p<0.05

Quality of Treatment

QUality Index of PEriodontal Treatment (QUIPET)

304 subjects in 14 European centres

Clinical Data & Quality Evaluation

OHIP-14, VAS & Quality Evaluation

Professional Performance

(TECHNICALITY)

Resources Usage(EFFICIENCY)

Patient Satisfaction

Risk Managment

(SAFETY)

World Health Organisation. The principles of quality assurance

Copenhagen: WHO, 1983.

QUIPET

No correlation was noted among therapists and patients in terms of correlation of quality appreciation ( p=0.983).

Quality perception is higher among patients Quality perception is influenced by many intangible factors

Conclusions

Periodontal disease has an impact that extends beyond the border of the oral cavity

Periodontal Treatment produces not exclusively oral benefits also improvements of general health and quality of life perception

Limitations: NO hard clinical endpoints (Incidence of CVD disease or depression)

We treat Patients (not teeth, gums or millimetres). The social opportunity of an holistic approach to our patient is humongous

GRAZIE

the global strategy and teamwork for periodontal health and overall health - filippo graziani

Healthcare