P4 Medicine as a model for precision periodontal care

Chronic periodontitis, dantamoolaroga, indicates chronic systemic inflammation and reduces longevity

A narrative review of chronic periodontitis, a dysfunctional inflammatory disease of the gums finds it is linked to over 60 systemic diseases and has been shown to reduce lifespan. Termed dantamoolaroga in Ayurvedic medicine, the causative vitiated doshas for the 17 types of dantamoolaroga have been described and give leads as to systemic imbalances behind the diseases. By improving periodontal (gum) health, improvements in type 2 diabetes, cardiovascular and other chronic inflammatory markers have been shown. Systemic chronic inflammation is the underlying cause of non-communicable diseases, including periodontitis, cardiovascular diseases, respiratory, diabetes and metabolic diseases, cancer and others, now contributing over 70% of worldwide deaths. It is found that oral health reflects systemic health and provides a window into general health. As personalised medicine is being developed to assess the multiple pathophysiological factors underlying systemic chronic inflammation, it is noted that Ayurveda has a comprehensive approach to diagnosis with the 10 fold assessment (Dashavidha Praiksha) and eight fold examinations (Astasthana Pariksha) being considered the original personalised medicine. There are Ayurvedic clinical correlates and causes of systemic chronic inflammation assisting clinical evaluation and treatment planning. Ayurvedic diagnostic measures for general health and periodontal health need validation in today's terms to strengthen the scientific credentials and enable better clinical use of both systems in an integrative manner. Inclusion of clinical assessment of periodontal health status at consultation, particularly for any chronic disease, is strongly recommended to gain insight into a widespread systemic chronic inflammation marker. The multiple Ayurvedic clinical measures for chronic inflammation provides potential for lines of research that complement the current molecular based approaches.

Computational approaches to investigate the relationship between periodontitis and cardiovascular diseases for precision medicine

Periodontitis is a highly prevalent inflammatory illness that leads to the destruction of tooth supporting tissue structures and has been associated with an increased risk of cardiovascular disease (CVD). Precision medicine, an emerging branch of medical treatment, aims can further improve current traditional treatment by personalizing care based on one's environment, genetic makeup, and lifestyle. Genomic databases have paved the way for precision medicine by elucidating the pathophysiology of complex, heritable diseases. Therefore, the investigation of novel periodontitis-linked genes associated with CVD will enhance our understanding of their linkage and related biochemical pathways for targeted therapies. In this article, we highlight possible mechanisms of actions connecting PD and CVD. Furthermore, we delve deeper into certain heritable inflammatory-associated pathways linking the two. The goal is to gather, compare, and assess high-quality scientific literature alongside genomic datasets that seek to establish a link between periodontitis and CVD. The scope is focused on the most up to date and authentic literature published within the last 10 years, indexed and available from PubMed Central, that analyzes periodontitis-associated genes linked to CVD. Based on the comparative analysis criteria, fifty-one genes associated with both periodontitis and CVD were identified and reported. The prevalence of genes associated with both CVD and periodontitis warrants investigation to assess the validity of a potential linkage between the pathophysiology of both diseases.

Strategies for the prevention of periodontal disease and its impact on general health: Latin America and the Caribbean Consensus 2024

Periodontal diseases are closely related to non-communicable diseases, and their prevention depends on their link with healthy lifestyle programs. The purpose of this consensus was to summarize and propose preventive strategies at the community, individual, and research levels in Latin America and the Caribbean. A critical review and search strategy was carried out in Pubmed, LILACS, and SCIELO on three topics: a) Social determinants, risk factors, and behavioral changes related to PD throughout the lives of individuals; b) Impact of mechanical and chemical control of plaque for the prevention of gingivitis; c) Impact on prevention of systemic diseases. Relative to public health policies, no consensus was reported in the region. In some countries, periodontal educational strategies, mainly for pregnant women and for other chronic diseases have been implemented, but their impact on primary and secondary prevention has hardly been evaluated. In recent years, a positive aspect has been the implementation of some public policies, including clinical practice guidelines and care pathways. Based on the latest consensus, multicenter educational research and technological strategies were found in the region, but their effectiveness needs to be evaluated in clinical studies. A barrier to the implementation of preventive strategies has to do with the human factor. Therefore, the training of periodontists to be experts in communication strategies, technologies that allow the empowerment of patients for taking care of their periodontal health are required . Moreover, it is necessary to train professionals from other areas of health, who are more aware of the importance of oral health as a healthy lifestyle.

Do all individuals benefit equally from non-surgical periodontal therapy? Secondary analyses of systematic review data

AIMS

This study aimed to assess the variability and treatment effect heterogeneity in response to non-surgical periodontal therapy (NSPT).

METHODS

Data from randomized controlled trials included in two recent systematic reviews on the effect of NSPT on mean clinical attachment loss (CAL), mean probing pocket depth (PPD), percentage of sites with bleeding on probing (%BOP), PPD ≤3 mm (%PD ≤3 mm), and C-reactive protein levels (CRP) at 3-12-month follow-up among adults with systemic diseases or conditions were used. In these trials, the control arms received no treatment, hygiene advice, or supragingival scaling. The Bayesian meta-regression models were utilized to assess the variability ratios between NSPT and control groups.

RESULTS

Data from 36 trials on mean PPD, 32 trials on mean CAL, eight trials on %PD ≤3 mm, 31 trials on %BOP and 19 trials on CRP were used. Variability in mean CAL and CRP was approximately 10% higher in the NSPT arms than in the control arms, hinting that there may be room for treatment effect heterogeneity. Instead, variability in mean PPD, %BOP, and %PD ≤3 mm was lower in the NSPT arms than in the control arms.

CONCLUSION

Potential treatment effect heterogeneity in response to NSPT was observed for CRP and mean CAL. However, substantial measurement error in CAL and natural variation in CRP may contribute to these findings. Conversely, treatment effect heterogeneity appears less pronounced for mean PPD, %BOP, and %PD ≤3 mm, potentially due to greater treatment effects in patients with more severe periodontitis and reduced measurement error in these parameters.

Effect of non-surgical periodontal therapy on salivary histone deacetylases expression: A prospective clinical study

AIM

To evaluate the effect of non-surgical periodontal therapy (NSPT) on salivary histone deacetylases (HDACs) gene expression in patients with Stage III-IV periodontitis at baseline and at 3 and 6 months post NSPT treatment.

MATERIALS AND METHODS

Twenty patients completed the study. Periodontitis (as well as the corresponding staging and grading) was diagnosed according to the 2017 World Workshop Classification. Clinical measures were recorded and whole unstimulated saliva was collected at baseline and at 3 and 6 months after NSPT. The expression of 11 HDACs was determined using reverse-transcription PCR, and the respective changes over time were evaluated.

RESULTS

Six months after NSPT, significant improvements in all clinical periodontal parameters were observed, concomitant with significant up-regulation of HDAC2, 4, 6, 8, 9 and 11 expressions. Subgroup analyses of non-responders and responders revealed no significant differences in HDACs mRNA expression between groups at any time point.

CONCLUSIONS

This prospective clinical study identified longitudinal changes in salivary HDACs expression in response to NSPT, which provides new insights into the epigenetic mechanisms underlying the pathobiology of periodontitis and creates avenues for the discovery of novel biomarkers.

Realizing the clinical utility of saliva for monitoring oral diseases

In the era of personalized/precision health care, additional effort is being expended to understand the biology and molecular mechanisms of disease processes. How these mechanisms are affected by individual genetics, environmental exposures, and behavioral choices will encompass an expanding role in the future of optimally preventing and treating diseases. Considering saliva as an important biological fluid for analysis to inform oral disease detection/description continues to expand. This review provides an overview of saliva as a diagnostic fluid and the features of various biomarkers that have been reported. We emphasize the use of salivary biomarkers in periodontitis and transport the reader through extant literature, gaps in knowledge, and a structured approach toward validating and determine the utility of biomarkers in periodontitis. A summation of the findings support the likelihood that a panel of biomarkers including both host molecules and specific microorganisms will be required to most effectively identify risk for early transition to disease, ongoing disease activity, progression, and likelihood of response to standard periodontal therapy. The goals would be to develop predictive algorithms that serve as adjunctive diagnostic tools which provide the clinician and patient important information for making informed clinical decisions.

Artificial intelligence and personalized diagnostics in periodontology: A narrative review

Periodontal diseases pose a significant global health burden, requiring early detection and personalized treatment approaches. Traditional diagnostic approaches in periodontology often rely on a "one size fits all" approach, which may overlook the unique variations in disease progression and response to treatment among individuals. This narrative review explores the role of artificial intelligence (AI) and personalized diagnostics in periodontology, emphasizing the potential for tailored diagnostic strategies to enhance precision medicine in periodontal care. The review begins by elucidating the limitations of conventional diagnostic techniques. Subsequently, it delves into the application of AI models in analyzing diverse data sets, such as clinical records, imaging, and molecular information, and its role in periodontal training. Furthermore, the review also discusses the role of research community and policymakers in integrating personalized diagnostics in periodontal care. Challenges and ethical considerations associated with adopting AI-based personalized diagnostic tools are also explored, emphasizing the need for transparent algorithms, data safety and privacy, ongoing multidisciplinary collaboration, and patient involvement. In conclusion, this narrative review underscores the transformative potential of AI in advancing periodontal diagnostics toward a personalized paradigm, and their integration into clinical practice holds the promise of ushering in a new era of precision medicine for periodontal care.

Advances and Opportunities of Mobile Health in the Postpandemic Era: Smartphonization of Wearable Devices and Wearable Deviceization of Smartphones

Mobile health (mHealth) with continuous real-time monitoring is leading the era of digital medical convergence. Wearable devices and smartphones optimized as personalized health management platforms enable disease prediction, prevention, diagnosis, and even treatment. Ubiquitous and accessible medical services offered through mHealth strengthen universal health coverage to facilitate service use without discrimination. This viewpoint investigates the latest trends in mHealth technology, which are comprehensive in terms of form factors and detection targets according to body attachment location and type. Insights and breakthroughs from the perspective of mHealth sensing through a new form factor and sensor-integrated display overcome the problems of existing mHealth by proposing a solution of smartphonization of wearable devices and the wearable deviceization of smartphones. This approach maximizes the infinite potential of stagnant mHealth technology and will present a new milestone leading to the popularization of mHealth. In the postpandemic era, innovative mHealth solutions through the smartphonization of wearable devices and the wearable deviceization of smartphones could become the standard for a new paradigm in the field of digital medicine.

Microbial biomarkers as a predictor of periodontal treatment response: A systematic review

To evaluate the prognostic accuracy of microbial biomarkers and their associations with the response to active periodontal treatment (APT) and supportive periodontal therapy (SPT). Microbial dysbiosis plays a crucial role in the disease processes of periodontitis. Biomarkers based on microbial composition may offer additional prognostic value, supplementing the limitations of current clinical parameters. While these microbial biomarkers have been clinically evaluated, there is a lack of consensus regarding their prognostic accuracy. A structured search strategy was applied to MEDLINE (PubMed), Cochrane Library, and Embase on 1/11/2022 to identify relevant publications. Prospective clinical studies involving either APT or SPT, with at least 3-month follow-up were included. There were no restrictions on the type of microbial compositional analysis. 1918 unique records were retrieved, and 13 studies (comprising 943 adult patients) were included. Heterogeneity of the studies precluded a meta-analysis, and none of the included studies had performed the sequence analysis of the periodontal microbiome. Seven and six studies reported on response to APT and SPT, respectively. The prognostic accuracy of the microbial biomarkers for APT and SPT was examined in only two and four studies, respectively. Microbial biomarkers had limited predictive accuracy for APT and inconsistent associations for different species across studies. For SPT, elevated abundance of periodontal pathogens at the start of SPT was predictive of subsequent periodontal progression. Similarly, persistent high pathogen loads were consistently associated with progressive periodontitis, defined as an increased pocket probing depth or clinical attachment loss. While there was insufficient evidence to support the clinical use of microbial biomarkers as prognostic tools for active periodontal treatment outcomes, biomarkers that quantify periodontal pathogen loads may offer prognostic value for predicting progressive periodontitis in the subsequent supportive periodontal therapy phase. Additional research will be required to translate information regarding subgingival biofilm composition and phenotype into clinically relevant prognostic tools.

Justification for the 2017 periodontitis classification in the light of the Checklist for Modifying Disease Definitions: A narrative review

Once a while, disease classifications have needed revision because new knowledge has accumulated, and new technologies and better treatments have emerged. Changes made to disease classifications should be trustworthy and openly justified. The periodontitis definition and classification system was changed in 2017 by the 'World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions'. The workshop, comprising clinicians and researchers, resulted in the production of a 23-article special issue that introduced the new definitions and classifications of periodontitis. In this narrative review, we critically review how the changes made to the periodontitis definition and classification were justified in the light of the Checklist for Modifying Disease Definitions. Under each of the eight items of the checklist, we have discussed how the item was or could have been considered in the light of the checklist and its guidance. In our view, the new definition and classification of periodontitis was presented in an understandable way, even though the changes from the previous definition were not made visible. However, the issues of (1) estimated changes in prevalence or incidence, (2) triggers for the change, (3) prognostic ability, (4) repeatability or reproducibility, (5) incremental benefits, (6) incremental harms or (7) net benefits and harms related to the introduction of new classification were not considered in the way suggested in the checklist. Thereby, a balanced assessment of potential benefits and harms associated with the new periodontitis classification system was not presented, and to a large extent it remains unknown if the use of the new classification system will provide more net benefits to patients and to the community than previous systems. It is our view that patients and societies deserve transparent and balanced assessments of the potential benefits and harms associated with the periodontitis classification. Importantly, these should reflect the values and preferences also of the patients and the wider community and consider the impact on resource usage.

A leap of faith: building the trust in human biobanks

Background: Human biobanks are an essential resource for contemporary medical research, crucial in treating and preventing human diseases and improving health. Public trust in human biobanks is a vital social prerequisite for their continued operation and related research. Methods: Drawing on the "leap of faith" theory proposed by Georg Simmel and Guido Möllering, this paper first examines the relationship between public trust and human biobanks and the process through which such trust is established. Subsequently, based on the results of this analysis, targeted policy recommendations are put forward to consolidate or enhance public trust in human biobanks. Results: Public trust in human biobanks stems from certain "good reasons," through which uncertainty and vulnerability are "suspended" by faith, leading to a leap toward the "land of expectations." In this progress, the critical factors in building and enhancing public trust in human biobanks are the public's propensity to trust, the inherent trustworthiness of human biobanks, and the security and interactivity of the trust environment. Conclusion: Public trust in human biobanks cannot be determined by any universal formula, as it is influenced by many factors, including intangible elements such as faith that defy empirical understanding. Nonetheless, public trust in human biobanks can be enhanced through measures such as fostering the public's propensity to trust, enhancing the inherent trustworthiness of human biobanks, establishing structural safeguards for the trust environment through ethical norms, systems, and supervision, and promoting public participation.

Assessing Adherence to Provider's Recommendations in Caries Risk Assessment and Management: A Retrospective Data Review

AIM

To evaluate the distribution of caries risk category of patients at a dental institution and determine adherence to providers' recommendations.

MATERIALS AND METHODS

A cross-sectional retrospective review of 1,235 patients records that included data collection on demographics, the sum of the number of decayed, missing due to caries, and filled teeth in the permanent teeth (DMFT), presence of frequent snacking, stimulated salivary flow rate, stimulated saliva pH, saliva buffering capacity, biofilm activity, caries risk category, anti-caries prescription accept/decline, and change in the caries risk category. Statistical analysis was carried out through Pearson's Chi-squared test and linear model ANOVA with a significance level of 0.05.

RESULTS

Pearson's Chi-squared test showed a statistically significant difference in frequency by risk category (p < 0.001) indicating that patients were skewed toward high and extreme caries risk. Linear model ANOVA showed that higher risk categories were associated with lower salivary flow rates (p = 0.010) and higher biofilm activity (p < 0.001). About, 1 out of 3 patients were reported to have frequent snacking (N = 391, 32%). Frequent snacking patients were more likely to present with higher caries risk assessment (p < 0.001), younger age (p < 0.001), and female (p < 0.001). Despite recommendations from the dental student provider, only 27% accepted the anti-cavity prescriptions while 61% declined the recommendation.

CONCLUSION

Distribution of caries risk category is not evenly distributed, but rather skewed toward high and extreme caries risk levels. Despite the identified risks, there is low adherence to the recommendations provided by healthcare providers. The results underscore the necessity for targeted interventions and initiatives aimed at fostering behavioral changes to enhance oral health outcomes.

CLINICAL SIGNIFICANCE

There is a high need for targeted interventions and initiatives that promote behavioral changes to enhance oral health outcomes.

Bioprinting extracellular vesicles as a "cell-free" regenerative medicine approach

Regenerative medicine involves the restoration of tissue or organ function via the regeneration of these structures. As promising regenerative medicine approaches, either extracellular vesicles (EVs) or bioprinting are emerging stars to regenerate various tissues and organs (i.e., bone and cardiac tissues). Emerging as highly attractive cell-free, off-the-shelf nanotherapeutic agents for tissue regeneration, EVs are bilayered lipid membrane particles that are secreted by all living cells and play a critical role as cell-to-cell communicators through an exchange of EV cargos of protein, genetic materials, and other biological components. 3D bioprinting, combining 3D printing and biology, is a state-of-the-art additive manufacturing technology that uses computer-aided processes to enable simultaneous patterning of 3D cells and tissue constructs in bioinks. Although developing an effective system for targeted EVs delivery remains challenging, 3D bioprinting may offer a promising means to improve EVs delivery efficiency with controlled loading and release. The potential application of 3D bioprinted EVs to regenerate tissues has attracted attention over the past few years. As such, it is timely to explore the potential and associated challenges of utilizing 3D bioprinted EVs as a novel "cell-free" alternative regenerative medicine approach. In this review, we describe the biogenesis and composition of EVs, and the challenge of isolating and characterizing small EVs - sEVs (< 200 nm). Common 3D bioprinting techniques are outlined and the issue of bioink printability is explored. After applying the following search strategy in PubMed: "bioprinted exosomes" or "3D bioprinted extracellular vesicles", eight studies utilizing bioprinted EVs were found that have been included in this scoping review. Current studies utilizing bioprinted sEVs for various in vitro and in vivo tissue regeneration applications, including angiogenesis, osteogenesis, immunomodulation, chondrogenesis and myogenesis, are discussed. Finally, we explore the current challenges and provide an outlook on possible refinements for bioprinted sEVs applications.

Personalized Oral and Dental Care

Recent advances in genomics, data analytics technologies, and biotechnology have been unprecedented, ushering in a new era of healthcare in which interventions are increasingly tailored to individual patients [...].

Integrating P4 Medicine in Teledentistry and M-Health in Oral, Dental, and Periodontal Care

Given that dental practice is currently based on the "average" patient, providing therapeutic and rehabilitative interventions rather than preventive measures [...].

Next-Generation Examination, Diagnosis, and Personalized Medicine in Periodontal Disease

Periodontal disease, a major cause of tooth loss, is an infectious disease caused by bacteria with the additional aspect of being a noncommunicable disease closely related to lifestyle. Tissue destruction based on chronic inflammation is influenced by host and environmental factors. The treatment of periodontal disease varies according to the condition of each individual patient. Although guidelines provide standardized treatment, optimization is difficult because of the wide range of treatment options and variations in the ideas and skills of the treating practitioner. The new medical concepts of “precision medicine” and “personalized medicine” can provide more predictive treatment than conventional methods by stratifying patients in detail and prescribing treatment methods accordingly. This requires a new diagnostic system that integrates information on individual patient backgrounds (biomarkers, genetics, environment, and lifestyle) with conventional medical examination information. Currently, various biomarkers and other new examination indices are being investigated, and studies on periodontal disease-related genes and the complexity of oral bacteria are underway. This review discusses the possibilities and future challenges of precision periodontics and describes the new generation of laboratory methods and advanced periodontal disease treatment approaches as the basis for this new field.

The Relevance of DNA Methylation and Histone Modification in Periodontitis: A Scoping Review

Background: Periodontitis is a chronic inflammatory disease involving an interplay between bacteria, inflammation, host response genes, and environmental factors. The manifestation of epigenetic factors during periodontitis pathogenesis and periodontal inflammation is still not well understood, with limited reviews on histone modification with periodontitis management. This scoping review aims to evaluate current evidence of global and specific DNA methylation and histone modification in periodontitis and discuss the gaps and implications for future research and clinical practice. Methods: A scoping literature search of three electronic databases was performed in SCOPUS, MEDLINE (PubMed) and EMBASE. As epigenetics in periodontitis is an emerging research field, a scoping review was conducted to identify the extent of studies available and describe the overall context and applicability of these results. Results: Overall, 30 studies were evaluated, and the findings confirmed that epigenetic changes in periodontitis comprise specific modifications to DNA methylation patterns and histone proteins modification, which can either dampen or promote the inflammatory response to bacterial challenge. Conclusions: The plasticity of epigenetic modifications has implications for the future development of targeted epi-drugs and diagnostic tools in periodontitis. Such advances could be invaluable for the early detection and monitoring of susceptible individuals.