Periodontitis and Cardiovascular Diseases. Consensus Report

Background

In Europe cardiovascular disease (CVD) is responsible for 3.9 million deaths (45% of deaths), being ischaemic heart disease, stroke, hypertension (leading to heart failure) the major cause of these CVD related deaths. Periodontitis is also a chronic non-communicable disease (NCD) with a high prevalence, being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease.

Material and Methods

There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In 2012 a joint workshop was held between the European Federation of Periodontology (EFP) and the American Academy of Periodontology to review the literature relating periodontitis and systemic diseases, including CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations.

Results and Conclusions

The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation (WHF), which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes. This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices.

Central systolic blood pressure increases with aortic stiffness

OBJECTIVES

Central systolic blood pressure (CSBP) is the pressure in the root of aorta, which directly influences organs such as brain, heart and kidneys and is related to organ damage. Its value increases with the aortic stiffness. The aim of this study was to analyze the relationships of CSBP to aortic stiffness parameters.

METHODS

Central blood pressure (BP) and related parameters were measured by Arteriograph, working based on oscillometric principle, using pulse wave analysis (PWA) approach. We examined 123 patients (69 females, 54 males) with a primary hypertension.

RESULTS

Using a linear correlation analysis, we found that CSBP was correlated to aortic pulse wave velocity (PWV), aortic and brachial pulse pressure (PP), aortic augmentation index, return time of reflected pressure wave (RT) and aortic and brachial augmentation indexes. Multivariate analysis defines the aortic pulse pressure (PPao) as the most powerful parameter influencing CSBP. By an individual analysis of BP in each patient separately, we defined two different types of central hemodynamics; those with a higher CSBP than brachial SBP occur in stiffer aorta.

CONCLUSION

The CSBP increases with aortic PP, the most powerful stiffness parameter of aorta. Higher CSBP than brachial SBP usually accompanies a stiffer aorta (Tab. 5, Ref. 19).

Automated classification of celiac disease during upper endoscopy: Status quo and quo vadis

A large amount of digital image material is routinely captured during esophagogastroduodenoscopies but, for the most part, is not used for confirming the diagnosis process of celiac disease which is primarily based on histological examination of biopsies. Recently, considerable effort has been undertaken to make use of image material by developing semi- or fully-automated systems to improve the diagnostic workup. Recently, focus was especially laid on developing state-of-the-art deep learning architectures, exploiting the endoscopist's expert knowledge and on making systems fully automated and thereby completely observer independent. In this work, we summarize recent trends in the field of computer-aided celiac disease diagnosis based on upper endoscopy and discuss about recent progress, remaining challenges, limitations currently prohibiting a deployment in clinical practice and future efforts to tackle them.

Clinical value of FDG Hybrid-PET in staging and restaging of malignant lymphoma – compared with conventional diagnostic methods

Aim of the present retrospective study was to validate the clinical value of F-18-FDG PET imaging in lymphoma patients with a dual head camera modified for coincidence detection. Staging before and after oncological treatment was compared with a conservative diagnostic approach. Methods: 48 patients (28 non-Hodgkin lymphoma, 20 Hodgkin’s disease) received FDG-Hybrid-PET scans. Pretherapeutic staging was realized in 28 patients, 9 of them had control studies after they had completed therapy. Totally 29 persons were examined for posttherapeutic restaging. Computed tomography imaging and lymph node sonography was performed in all cases. Results were validated by clinical follow-up, in three cases a récidivé was proven by biopsy. Results: CT and ultrasound detected 77 lesions in 28 patients compared with 100 visualized by PET, but this difference in pretherapeutic staging did not reach significance at p >0.05 by Fisher’s t-test. Hybrid-PET obtained a sensitivity of 93%, a specifity of 79%, a positive of 82% and a negative predictive value of 92% for detection of residual disease. The values for CT + US were 87%, 64%, 72% and 88% respectively. Conclusion: FDG Hybrid-PET is as or even more accurate than standard morphologic diagnostic methods for prestaging in malignant lymphoma. Additionally, there is a substancial benefit for therapy monitoring of residual disease using coincidence detection PET with a ¾-inch crystal gamma camera.

Pain perception during debridement of hypersensitive teeth elicited by two ultrasonic scalers

OBJECTIVES

The ultrasonic NO PAIN technology (Electro Medical Systems, Nyon, CH) promises minimal pain during debridement due to linear oscillating action combined with a sinusoidal power output and feedback control. The aim of the present study was to measure pain perception on a visual analogue scale (VAS) during supportive periodontal therapy including debridement of hypersensitive teeth. Two ultrasonic scalers were used, one with and one without NO PAIN technology.

MATERIAL AND METHODS

In a randomized-controlled clinical study with split-mouth design, 100 hypersensitive teeth matched for air blast hypersensitivity were either treated with the ultrasonic device Piezon Master 700 or the Mini Piezon (both EMS, Nyon, CH). Pain perception during debridement was assessed by a VAS (range 0-10).

RESULTS

The average VAS for the test device Piezon Master 700 with NO PAIN technology was 3.16 ± 2.10, and for the control device Mini Piezon without NO PAIN technology 3.40 ± 2.59 (p = 0.490). Placing an arbitrary threshold at the VAS score of 3 for significant pain experience, 60 % of the subjects experienced no significant pain with either instrument.

CONCLUSION

No statistically significant difference in perceived pain between the instruments used was found.

CLINICAL RELEVANCE

Both ultrasonic devices showed very small pain intensities during debridement of highly hypersensitive teeth and can therefore be recommended for supportive periodontal therapy.

Upregulation of osteoprotegerin expression correlates with bone invasion and predicts poor clinical outcome in oral cancer

OBJECTIVES

We aimed to determine the prognostic significance of receptor activator of nuclear factor kappa-B ligand (RANKL), RANK and osteoprotegerin (OPG) in patients with oral squamous cell carcinoma (OSCC).

MATERIALS AND METHODS

The protein expression of RANKL, RANK and OPG was assessed by immunohistochemistry on pretreatment biopsies of 93 patients with locally advanced OSCC who received preoperative chemoradiotherapy (CRT). The primary endpoint was cancer-specific survival. Secondary endpoints were correlation of biomarkers with bone invasion and pathological tumor response. Kaplan-Meier curves and Cox regression models were used for survival analyses.

RESULTS

A significantly higher OPG expression was demonstrated in patients with malignant bone invasion and non-responders to CRT as compared to patients without bone invasion and responders (p=0.032 and p=0.033, respectively). Multivariate analysis revealed that higher OPG expression was independently associated with shorter cancer-specific survival (p=0.04). The expression status of RANKL and RANK was not significantly related to clinicopathological characteristics and had no impact on survival of OSCC patients.

CONCLUSION

Upregulation of OPG expression is associated with bone invasion, poor pathological tumor regression to neoadjuvant CRT, and worse long-term cancer-specific survival in patients with locally advanced OSCC. Our results indicate that OPG may be a novel prognostic biomarker in oral cancer.

Two models for linear comparative calibration

We consider the comparative calibration problem in the case when linear relationship is assumed between two considered measuring devices with possibly different units and precisions. The first method for obtaining the approximate confidence region for unknown parameters of the calibration line applies the maximum likelihood estimators of the unknown parameters. The second method is based on estimation of the calibration line via replicated errors-in-variables model. Essential point in this approach is approximation of the small sample distribution of the Wald-type test statistic. This enables to construct the interval estimators for the multiple-use calibration case.

Decision-making for and impact of early immunomodulatory treatment: the Austrian Clinically Isolated Syndrome Study (ACISS)

BACKGROUND AND PURPOSE

When to start disease-modifying treatment (DMT) in patients with a clinically isolated syndrome (CIS) requires individual weighing of benefits versus possible burden of side effects and costs. How this occurs in a routine setting is barely known. The aim of the study was to investigate the decision-making process regarding immediate or later DMT and the ensuing impact on CIS patients in Austria.

METHODS

Demographic and (para) clinical characteristics of 296 CIS patients were recorded in 29 multiple sclerosis (MS) centres, and the patients' overall condition was rated on a visual analogue scale (VAS). Clinical follow-up and VAS ratings were repeated at 6-month intervals over 2 years. The decision for initiation of DMT was at the physician's and patient's discretion.

RESULTS

In 29% of patients, DMT was started within 3 months and this decision was independently associated with a T2-lesion number >or=9 on MRI and a worse VAS rating by the physician. DMT initiation in the subsequent 6 months was additionally associated with the presence of oligoclonal bands and rarely occurred thereafter. Adapted to the clinical course, later treatment was associated with the highest rate of conversion to clinically definite MS and greatest disability after 2 years whilst never treated patients fared best. Patient VAS ratings significantly improved during follow-up independently of treatment decisions.

CONCLUSION

The management of Austrian CIS patients relies strongly on MRI findings and the physicians' interpretation of the patients' overall situation which, after 2 years, depends primarily on the course of the disease.

Functional quality of molar crown occlusal surfaces in the different design modes of Cerec 2

The goal of the present study was to objectify whether the design modes of "Correlation", "Function", and "Extrapolation" of the Cerec 2 system are suitable for generating a functionally perfect occlusal surface of a first mandibular molar crown. For this purpose, an occlusal surface was waxed up according to the biomechanical concept of MH Polz, and this served as the reference occlusal surface. Four different Cerec 2 comparison crowns (produced in the laboratory, Extrapolation mode, Correlation mode, Function mode) were produced and the positions of the cusps were measured. It was shown that the Correlation mode delivers the most accurate results, and the manually produced occlusal surface also showed good results. The occlusal surfaces of the crowns produced according to the Extrapolation and Function mode were clearly inferior.

The effect of three different periodontal pre-treatment procedures on the success of telescopic removable partial dentures

In this prospective study, 120 teeth consisting of maxillary and mandibular canines and premolars were divided into three groups each containing 40 teeth. The teeth were assigned randomly in quadrants to three different periodontal treatment protocols. The first group was treated with professional prophylaxis only. The second group received additional deep scaling. With the third group, additional surgical periodontal flap surgery and scaling was performed. Both papillary bleeding index (PBI) and probing depth (PD) were evaluated before, during and after treatment. During the subsequent prosthetic treatment phase all teeth were then used as telescope abutments supporting a removable prosthesis. The documentation of the attachment level (AL) was then used as a clinical parameter. One year after the incorporation of telescopic removable partial dentures (RPDs), PD, PBI and AL were again evaluated. The resulting periodontal parameters were compared between the different groups using the general linear model (GLM) repeated measures and the Kruskal-Wallis test for non-parametric variables. Differences within the three treatment groups were determined using the t-test, e.g. the Wilcoxon test for dependent variables (P < 0.05). A significant decrease in inflammatory indices (PBI) was found for all types of periodontal treatment (P < 0.03 for all groups). Additionally, the reduction in PD was significant for all of the three groups (P < 0.001 for all groups). The greatest reduction in PD was observed in the group in which a surgical approach was used. Evaluation of the attachment level after the incorporation of the telescopic RPDs showed that tooth position did not influence the periodontal prognosis and that the use of telescopic RPDs exerted no ascertainable negative influence on the periodontium of the abutment teeth.

Severe heart failure from light chain cardiomyopathy (cardiac amyloidosis)

Primary (AL)amyloidosis is characterized by clonal production of immunoglobulin with subsequent deposition in several organs. We describe the clinical features of a 66-year old female who was referred to our department for congestive heart failure. One year before, she was examined and found to have diastolic dysfunction of the left ventricle. We could evaluate the diagnosis of primary amyloid cardiomyopathy by echocardiography, Doppler echocardiography and laboratory findings and confirmed the diagnosis by biopsy of the rectum mucosa. Clinical outcome was poor, because therapy is poor.

Myofibrillar (desmin-related) myopathy: clinico-pathological spectrum in 3 cases and review of the literature

Myofibrillar or desmin-related myopathies encompass neuromuscular disorders with abnormal deposits of desmin and myofibrillar alterations. We report 3 unrelated patients presenting with proximal and distal myopathy, and, as a unique congenital syndrome, diffusely distributed myopathy, osteoporosis and myopia. Muscle biopsies shared cytoplasmic inclusions, rimmed vacuoles, and ragged-red-like fibers. Sarcoplasmic inclusions, either plaque-like or amorphous, strongly immunoreacted on dystrophin and variably for desmin, alphaB crystallin and ubiquitin. Cyclin-dependent kinases CDK1, CDK2 and CDK5 were overexpressed in affected fibers. Ultrastructurally, focal myofibrillar disruption was accompanied by tubulo-filamentous inclusions in one case and abundant glycogen and enlarged mitochondria displaying respiratory chain dysfunction at biochemistry in another case. Molecular analysis of the alphaB crystallin gene coding sequence and exons 4, 5 and 6 of the desmin gene did not reveal any mutation. The morphologic denominator of hyaline structures and areas of myofibrillar destruction occurs in heterogeneous conditions and may overlap with features of inclusion body myopathy and mitochondrial myopathy.

Apolipoprotein E epsilon 4 is associated with rapid progression of multiple sclerosis

OBJECTIVE

The apolipoprotein E (APOE) polymorphism is known to impact on various neurologic disorders and has differential effects on the immune system and on CNS repair. Previous findings concerning a possible modulation of the clinical course of MS have been inconsistent, however.

METHODS

In a cross-sectional study, the authors investigated 374 patients with clinically definite MS and a disease duration of at least 3 years and related their clinical and demographic findings to the allelic polymorphism of the APOE gene. The genotype distribution of patients with MS was compared with a cohort of 389 asymptomatic, randomly selected elderly volunteers.

RESULTS

The authors found no significant differences in the distribution of genotypes between patients with MS and controls. However, patients with MS with the epsilon4 allele (n = 85) had a significantly higher progression index of disability (0.46 +/- 0.4 versus 0.33 +/- 0.26; p < 0.004) and a worse ranked MS severity score (5.1 +/- 1.9 versus 5.7 +/- 1.7; p = 0.05) than their non-epsilon4 counterparts, despite significantly more frequent long-term immunotherapy in epsilon4 carriers (74% versus 58%; p < 0.007). The annual relapse rate in epsilon4 carriers (0.87 +/- 0.56) was significantly higher than in patients with MS without an epsilon4 allele (0.71 +/- 0.47; p = 0.03).

CONCLUSIONS

These results suggest no effect of the APOE genotype on susceptibility to MS, but indicate an association of the APOE epsilon4 allele with a more severe course of the disease.

Residual dentin thickness after 1.2-mm shoulder preparation for Cerec crowns

Since the introduction of crown software for Cerec, it has been possible to produce full-ceramic crown restorations. Despite the excellent material quality of industrially made ceramic blocks and the good clinical long-term success of these ceramics in inlay- and onlay preparations, extended preparation with high loss of dental tissue is incident to crown restorations, which may endanger the vitality of the respective tooth. The aim of this experimental study was to determine the residual dentin thickness after preparation of an extended circular shoulder in the molar and premolar region. On extracted human molars and premolars, 1.2-mm-wide circular shoulders with rounded inner edges were prepared, and the thickness of the residual dentin wall was measured under a microscope. Using this preparation method, it was found that only the group of maxillary molars showed an average residual dentin thickness of more than 0.7 mm.

[Clinical value of FDG PET using coincident gamma cameras in staging and restaging of malignant lymphoma--compared with convenitonal diagnostic methods]

AIM of the present retrospective study was to validate the clinical value of F-18-FDG PET imaging in lymphoma patients with a dual head camera modified for coincidence detection. Staging before and after oncological treatment was compared with a conservative diagnostic approach.

METHODS

48 patients (28 non-Hodgkin lymphoma, 20 Hodgkin's disease) received FDG-Hybrid-PET scans. Pretherapeutic staging was realized in 28 patients, 9 of them had control studies after they had completed therapy. Totally 29 persons were examined for post-therapeutic restaging. Computed tomography imaging and lymph node sonography was performed in all cases. Results were validated by clinical follow-up, in three cases a recidive was proven by biopsy.

RESULTS

CT and ultrasound detected 77 lesions in 28 patients compared with 100 visualized by PET, but this difference in pretherapeutic staging did not reach significance at p > 0.05 by Fisher's t-test. Hybrid-PET obtained a sensitivity of 93%, a specificity of 79%, a positive of 82% and a negative predictive value of 92% for detection of residual disease. The values for CT + US were 87%, 64%, 72% and 88% respectively.

CONCLUSION

FDG Hybrid-PET is as or even more accurate than standard morphologic diagnostic methods for prestaging in malignant lymphoma. Additionally, there is a substantial benefit for therapy monitoring of residual disease using coincidence detection PET with a 3/4-inch crystal gamma camera.

[Primary lymphoma of the thyroid with contralateral recurrence--case report]

Primary lymphomas located in the thyroid gland are rare clinical findings. The therapy and the subsequent monitoring of the disease continue to be a subject of debate. We present the case of a 63-year-old female patient in whom a hemi-thyroidectomy was performed because of a growing goiter. Histological examination of the excised tissue revealed a large-cell B-lymphocytic lymphoma which extended to neighboring lymph nodes. The patient received chemotherapy which led to remission of disease for two years. The disease re-occurred in the remaining thyroid lobe. Subsequently, the patient was treated with involved-field radiation therapy which lead to long term remission. We conclude that total thyroidectomy should be considered in the treatment of lymphomas located in the thyroid gland.

Numerical Simulations of Stochastic Circulatory Models

Properties of two of the stochastic circulatory models theoretically introduced by Smith et al., 1997, Bull. Math. Biol. 59, 1-22 were investigated. The models assumed the gamma distribution of the cycle time under either the geometric or Poisson elimination scheme. The reason for selecting these models was the fact that the probability density functions of the residence time of these models are formally similar to those of the Bateman and gamma-like function models, i.e., the two common deterministic models. Using published data, the analytical forms of the probability density functions of the residence time and the distributions of the simulated values of the residence time were determined on the basis of the deterministic models and the stochastic circulatory models, respectively. The Kolmogorov-Smirnov test revealed that even for 1000 xenobiotic particles, i.e., a relatively small number if the particles imply drug molecules, the probability density functions of the residence time based on the deterministic models closely matched the distributions of the simulated values of the residence time obtained on the basis of the stochastic circulatory models, provided that parameters of the latter models fulfilled selected conditions.

Prevalence of varicose veins of the lower limbs in the women working at a department store

The prevalence of varicose veins of the lower limbs and their risk factors were investigated in the group of 696 women working at a large department store. It was found that 421 of them suffered from varicose veins with the following prevalence of individual clinical types: trunk varices--14.4%, reticular varices--15.4%, and hyphenwebs--30.7%. In our study women with VV of all types compared to women without VV were older (p less than 0.05), more often obese (p less than 0.05), had the positive family history for VV (p less than 0.01), higher systolic and diastolic blood pressure and lower levels of physical activity (not significantly). Women with at least one pregnancy had significantly higher prevalence of VV (p less than 0.001) and women standing at their work had a higher prevalence of trunk varices than those who were sitting at the work (p less than 0.05).

[The startle response and epilepsy]

Startle responses (SR) are described as epileptic and non-epileptic attacks and their mechanisms are poorly understood. Long-loop reflexes and a satisfactory response to L-tryptophan treatment have only seldom been published in this condition. This prompted us to report a case with epilepsy and startle-induced tonic spasms, the latter refractory to all conventional medication except for L-tryptophan. Special emphasis is placed on the electrophysiological findings. Similar observations of non-habituation of SR in post-anoxic brain damage and in the case of startle epilepsy possibly suggest a deficit of cortical inhibition, probably in the supplementary motor area, rather than brain stem dysfunction in both instances.

[Demonstration of aortocoronary venous bypasses using digital subtraction angiography]

In 43 patients with a total of 86 aortocoronary bypass grafts digital subtraction angiography was employed in the early post-operative period. Contrast injection into the aortic root allowed in all instances a definitive answer whether the aortocoronary bypass was free or obstructed. The method makes it possible also to assess distal anastomoses and their connected coronary vascular bed.

[Procedure for shunt imaging in dialysis patients with special reference to digital subtraction angiography]

All angiographic procedures established for imaging of hemodialysis fistulas, such as direct venous angiography, intravenous subtraction angiography and arteriography by direct puncture of the brachial artery or by Seldinger's transfemoral technique, can also be effected with digital image processing. Depending on the angiographic technique, the use of digital subtraction angiography has several advantages: lower doses and concentrations of the contrast agent, lower risk of complications (thrombosis of the fistula, vasospasm) and freedom from pain. In addition, there is a marked reduction of examination time and film cost.