Complications and treatment errors in periodontal therapy in medically compromised patients

Patients who are medically compromised may be at an increased risk of complications and treatment errors following periodontal therapy. A review of the evidence on the topic is presented, in relation to the type of complication reported, of periodontal treatment, and of patients' medical status. Further, a framework for risk assessment and appropriate treatment modifications is introduced, with the aim of facilitating the management of patients with existing comorbidities and reducing the incidence of treatment complications.

Treatment of periodontitis and C-reactive protein: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Systemic inflammation is implicated in the onset and progression of several chronic diseases. Periodontitis is a potential trigger of systemic inflammation.

PURPOSE

To comprehensively appraise all the evidence on the effects of the treatment of periodontitis on systemic inflammation assessed by serum C-reactive protein (CRP) levels.

DATA SOURCES

Six electronic databases were searched up to 10 February 2022 to identify and select articles in English language only.

STUDY SELECTION

Twenty-six randomized controlled clinical trials reporting changes amongst 2579 participants about CRP levels at 6 months or more after treatment.

DATA EXTRACTION

Two reviewers independently extracted data and rated the quality of studies. Meta-analyses were performed using random and fixed effect models.

RISK OF BIAS

Risk of bias (RoB 2.0 tool) and quality of evidence (GRADEpro GDT tool) analyses were completed.

DATA SYNTHESIS

Treatment of periodontitis reduced CRP levels by 0.69 mg/L (95% confidence interval: -0.97 to -0.40) after 6 months, but limited evidence was retrieved from studies with longer follow-ups. Similar findings were observed in participants with other co-morbidities in addition to periodontitis. Greatest reductions were observed in participants with concentrations of CRP >3 mg/L at baseline.

LIMITATIONS

High level of heterogeneity.

CONCLUSIONS

Treatment of periodontitis reduces serum CRP levels (up to 6 months follow-up) to a degree equivalent to that observed after traditional lifestyle or drug interventions. This evidence supports a causal association between periodontitis and systemic inflammation.

Perioperative Care Pathways in Low- and Lower-Middle-Income Countries: Systematic Review and Narrative Synthesis

BACKGROUND

Safe and effective care for surgical patients requires high-quality perioperative care. In high-income countries (HICs), care pathways have been shown to be effective in standardizing clinical practice to optimize patient outcomes. Little is known about their use in low- and middle-income countries (LMICs) where perioperative mortality is substantially higher.

METHODS

Systematic review and narrative synthesis to identify and describe studies in peer-reviewed journals on the implementation or evaluation of perioperative care pathways in LMICs. Searches were conducted in MEDLINE, EMBASE, CINAHL Plus, WHO Global Index, Web of Science, Scopus, Global Health and SciELO alongside citation searching. Descriptive statistics, taxonomy classifications and framework analyses were used to summarize the setting, outcome measures, implementation strategies, and facilitators and barriers to implementation.

RESULTS

Twenty-seven studies were included. The majority of pathways were set in tertiary hospitals in lower-middle-income countries and were focused on elective surgery. Only six studies were assessed as high quality. Most pathways were adapted from international guidance and had been implemented in a single hospital. The most commonly reported barriers to implementation were cost of interventions and lack of available resources.

CONCLUSIONS

Studies from a geographically diverse set of low and lower-middle-income countries demonstrate increasing use of perioperative pathways adapted to resource-poor settings, though there is sparsity of literature from low-income countries, first-level hospitals and emergency surgery. As in HICs, addressing patient and clinician beliefs is a major challenge in improving care. Context-relevant and patient-centered research, including qualitative and implementation studies, would make a valuable contribution to existing knowledge.

Invasive dental treatment and acute vascular events: A systematic review and meta-analysis

BACKGROUND

Acute infection/inflammation increases the risk of acute vascular events (AVEs). Invasive dental treatments (IDTs) trigger short-term acute inflammation.

PURPOSE

The aim of this work is to critically appraise the evidence linking IDTs and AVEs.

DATA SOURCES

Six bibliographical databases were searched up to 31 August 2021. A systematic review following PRISMA guidelines was performed.

STUDY SELECTION

Intervention and observational studies reporting any AVEs following IDT were included.

DATA EXTRACTION

Two reviewers independently extracted data and rated the quality of studies. Data were pooled using fixed-effect, inverse variance weights analysis.

RISK OF BIAS

Risk of bias was assessed by the Newcastle-Ottawa Quality Assessment Scale for observational studies and the Cochrane Handbook-Rob 2.0 for randomized controlled trials.

DATA SYNTHESIS

In 3 out of 16 clinical studies, a total of 533,175 participants, 124,344 myocardial infarctions, and 327,804 ischaemic strokes were reported. Meta-analysis confirmed that IDT did not increase incidence ratios (IR) for combined vascular events either at 1-4 weeks (IR of 1.02, 95% CIs: 0.92 to 1.13) and at 5-8 weeks (IR of 1.04, 95% CIs: 0.97 to1.10) after treatment.

LIMITATIONS

A high level of heterogeneity (study designs and time point assessments) was found.

CONCLUSION

Patients who received IDT exhibited no substantial increase in vascular risk over 8 weeks post treatment.

Circulating inflammatory cell profiling and periodontitis: A systematic review and meta-analysis

Inflammation is a key driver of common noncommunicable diseases. Among common triggers of inflammation, chronic gingival inflammation (periodontitis) triggers a consistent humoral host inflammatory response, but little is known on its impact on circulating inflammatory cell profiles. We aimed to systematically appraise all the evidence linking periodontitis and its treatment to circulating inflammatory cell profiles. From 6 databases, 157 studies were eligible for qualitative synthesis and 29 studies for meta-analysis. Our meta-analysis showed that participants with periodontitis exhibited a significant mean increase in circulating CD4⁺ , CD4⁺ CD45RO⁺ , IFNγ-expressing CD4⁺ and CD8⁺ T cells, CD19⁺ CD27⁺ and CD5⁺ B cells, CD14⁺ CD16⁺ monocytes, and CD16⁺ neutrophils but decrease in CD8⁺ T and CD14⁺⁺ CD16^- monocytes. Our qualitative synthesis revealed that peripheral blood neutrophils of patients with periodontitis consistently showed elevated production of reactive oxygen species (ROS) when compared with those of healthy controls. Some evidence suggested that the treatment of periodontitis reversed the exaggerated ROS production, but limited and inconclusive data were found on several circulating inflammatory cell profiling. We conclude that periodontitis and its treatment are associated with minor but consistent alterations in circulating inflammatory cell profiles. These changes could represent key mechanisms explaining the association of periodontitis with other comorbidities such as cardiovascular disease, diabetes, and rheumatoid arthritis.

Impact of the treatment of periodontitis on systemic health and quality of life: A systematic review

AIM

To investigate the effect of treatment of periodontitis on systemic health outcomes, pregnancy complications, and associated quality of life.

MATERIALS AND METHODS

Systematic electronic searches were conducted to identify randomized controlled trials with minimum 6-month follow-up and reporting on the outcomes of interest. Qualitative and quantitative analyses were performed as deemed suitable.

RESULTS

Meta-analyses confirmed reductions of high-sensitivity C-reactive protein (hs-CRP) [0.56 mg/L, 95% confidence interval (CI) (-0.88, -0.25), p < .001]; interleukin (IL)-6 [0.48 pg/ml, 95% CI (-0.88, -0.08), p = .020], and plasma glucose [1.33 mmol/l, 95% CI (-2.41, -0.24), p = .016], and increase of flow-mediated dilation (FMD) [0.31%, 95% CI (0.07, 0.55), p = .012] and diastolic blood pressure [0.29 mmHg, 95% CI (0.10, 0.49), p = .003] 6 months after the treatment of periodontitis. A significant effect on preterm deliveries (<37 weeks) was observed [0.77 risk ratio, 95% CI (0.60, 0.98), p = .036]. Limited evidence was reported on quality-of-life (QoL) outcomes in the included studies.

CONCLUSIONS

Treatment of periodontitis results in systemic health improvements including improvement in cardiometabolic risk, reduction in systemic inflammation and the occurrence of preterm deliveries. Further research is however warranted to confirm whether these changes are sustained over time. Further, appropriate QoL outcomes should be included in the study designs of future clinical trials.

Recurrence and progression of periodontitis and methods of management in long-term care: A systematic review and meta-analysis

AIM

To systematically review the literature to evaluate the recurrence of disease of people in long-term supportive periodontal care (SPC), previously treated for periodontitis, and determine the effect of different methods of managing recurrence. The review focused on stage IV periodontitis.

MATERIALS AND METHODS

An electronic search was conducted (until May 2020) for prospective clinical trials. Tooth loss was the primary outcome.

RESULTS

Twenty-four publications were retrieved to address recurrence of disease in long-term SPC. Eight studies were included in the meta-analyses for tooth loss, and three studies for disease progression/recurrence (clinical attachment level [CAL] loss ≥2 mm). For patients in SPC of 5-20 years, prevalence of losing more than one tooth was 9.6% (95% confidence interval [CI] 5%-14%), while experiencing more than one site of CAL loss ≥2 mm was 24.8% (95% CI 11%-38%). Six studies informed on the effect of different methods of managing recurrence, with no clear evidence of superiority between methods. No data was found specifically for stage IV periodontitis.

CONCLUSIONS

A small proportion of patients with stage III/IV periodontitis will experience tooth loss in long-term SPC (tendency for greater prevalence with time). Regular SPC appears to be important for reduction of tooth loss. No superior method to manage disease recurrence was found.

Genetic relationships among American donkey populations: insights into the process of colonization

This study presents the first insights into the genetic diversity and structure of the American donkey metapopulation. The primary objectives were to detect the main structural features underlying variability among American donkey populations, identify boundaries between differentiated gene pools, and draw the main colonization pathways since the introduction of donkeys into America in the 15th century. A panel of 14 microsatellite markers was applied for genotyping 350 American donkeys from 13 countries. The genetic structure of this metapopulation was analysed using descriptive statistics and Bayesian model-based methods. These populations were then compared to a database containing information on 476 individuals from 11 European breeds to identify the most likely ancestral donor populations. Results showed the presence of two distinct genetic pools, with confluence of the two in Colombia. The southern pool showed a unique genetic signature subsequent to an older founder event, but lacked any significant influence of modern gene flow from Europe. The northern pool, conversely, may have retained more ancestral polymorphisms and/or have experienced modern gene flow from Spanish breeds. The Andalusian and, to a lesser extent, the Catalan breeds have left a more pronounced footprint in some of the American donkey populations analysed.

Genome-wide analysis of Italian sheep diversity reveals a strong geographic pattern and cryptic relationships between breeds

Italy counts several sheep breeds, arisen over centuries as a consequence of ancient and recent genetic and demographic events. To finely reconstruct genetic structure and relationships between Italian sheep, 496 subjects from 19 breeds were typed at 50K single nucleotide polymorphism loci. A subset of foreign breeds from the Sheep HapMap dataset was also included in the analyses. Genetic distances (as visualized either in a network or in a multidimensional scaling analysis of identical by state distances) closely reflected geographic proximity between breeds, with a clear north-south gradient, likely because of high levels of past gene flow and admixture all along the peninsula. Sardinian breeds diverged more from other breeds, a probable consequence of the combined effect of ancient sporadic introgression of feral mouflon and long-lasting genetic isolation from continental sheep populations. The study allowed the detection of previously undocumented episodes of recent introgression (Delle Langhe into the endangered Altamurana breed) as well as signatures of known, or claimed, historical introgression (Merino into Sopravissana and Gentile di Puglia; Bergamasca into Fabrianese, Appenninica and, to a lesser extent, Leccese). Arguments that would question, from a genomic point of view, the current breed classification of Bergamasca and Biellese into two separate breeds are presented. Finally, a role for traditional transhumance practices in shaping the genetic makeup of Alpine sheep breeds is proposed. The study represents the first exhaustive analysis of Italian sheep diversity in an European context, and it bridges the gap in the previous HapMap panel between Western Mediterranean and Swiss breeds.

The mathematical modeling of the lactation curve for dairy traits of the donkey (Equus asinus)

In recent years, an increase in the number of donkeys farmed in Italy as a consequence of the growing demand for donkey milk for direct consumption has been observed. Some research has been carried out on jenny milk composition and on its nutritional properties, whereas milk production features are scarcely described for this species. In this work, the lactation curve shape of donkeys for milk yield and composition was investigated. A total of 453 test-day records for milk yield, fat and protein percentage, and somatic cell count of 62 lactations measured on 46 multiparous jennies of the Ragusano breed were considered. Effects of herd, age, and foaling season were assessed by using a mixed model analysis. Average and individual lactation curves were fitted using the Wood incomplete gamma function, the Cappio-Borlino modified gamma, and a third-order Legendre orthogonal polynomial model. Donkeys foaling between 6- and 10-yr-old had the highest test-day milk yield (about 1.85 kg/d). Donkeys foaling in winter and autumn had a higher daily milk yield compared with those foaling in summer and spring. Less defined results were obtained for composition traits. The general pattern of the donkey lactation curve is similar to the standard shape reported for the main dairy ruminant species, with a peak yield occurring at about 5 wk from parturition. Younger jennies tended to have lower production peaks and higher lactation persistency. Similarly to what is reported for dairy cattle, a large variability in individual patterns has been observed. No differences in goodness of fit have been observed between the models in the case of average lactation curves, whereas orthogonal polynomials were more efficient in fitting individual patterns.

Analysis of genetic diversity and the determination of relationships among western Mediterranean horse breeds using microsatellite markers

The distribution of genetic diversity and the genetic relationships among western Mediterranean horse breeds were investigated using microsatellite markers. The examined sample included seven Spanish and three Italian local horse breeds and populations, plus a Spanish Thoroughbred outgroup. The total number of animals examined was 682 (on average 62 animals per breed; range 20-122). The microsatellite marker set analysed provided 128 alleles (10.7 alleles per locus). Within-breed genetic diversity was always high (>0.70), with breeds contributing about 8% of the total genetic variability. The mean molecular coancestry of the entire population examined was 0.205, Losino being the breed that contributed most. In addition to Nei's standard and Reynolds' genetic distances, pair-wise kinship distance and molecular coancestry were estimated. Remarkably similar breed rankings were obtained with all methods. Clustering analysis provided an accurate representation of the current genetic relationships among the breeds. Determining coancestry is useful for analysing genetic diversity distribution between and within breeds and provides a good framework for jointly analysing molecular markers and pedigree information. An integrated analysis was undertaken to obtain information on the population dynamics in western Mediterranean native horse populations, and to better determine conservation priorities.

Characterization of single nucleotide polymorphisms in sheep and their variation as evidence of selection

The discovery of SNPs was performed using animals from eight European sheep breeds. Eleven SNPs were further characterized using about 1,700 sheep belonging to 57 breeds. A method for the identification of loci that were likely subject to selection was applied; three of the 11 SNPs lying outside the 95% confidence region of the conditional joint distribution of F(ST) and mean heterozygosity were identified as outliers.

Assessment of population structure by single nucleotide polymorphisms (SNPs) in goat breeds

Single nucleotide polymorphisms (SNPs) may be used in biodiversity studies and commercial tasks like traceability, paternity testing and selection for suitable genotypes. Twenty-seven SNPs were characterized and genotyped on 250 individuals belonging to eight Italian goat breeds. Multilocus genotype data were used to infer population structure and assign individuals to populations. To estimate the number of groups (K) to test in population structure analysis we used likelihood values and variance of the bootstrap samples, deriving optimal K from a drop in the likelihood and a rise in the variance plots against K.

Characterization of the CSN1AG allele of the bovine alpha s1-casein locus by the insertion of a relict of a long interspersed element

The bovine CSN1AG allele is associated with a lower proportion of alpha s1-casein in milk and is characterized by an insertion in the last noncoding exon (19th). According to DNA sequence analysis, the location, length, and origin of the insertion characterizing the bovine CSN1AG allele have been identified. This insertion interrupts the 19th exon between nucleotides 58 and 59, is 371 bp long, and has a high level of homology with relicts of long interspersed elements of retropositional origin. Northern blot analysis shows that the inserted element is transcribed and that the number of transcripts of the CSN1AG allele is less than one-half of the number of transcripts of the CSN1AB allele. The lower amount of alpha s1-casein in milk obtained from cows carrying the CSN1AG allele can be explained by a reduced mRNA stability. Furthermore, a method has been developed using polymerase chain reaction for identification of the carriers of the CSN1AG allele.

Effect of sustained-release somatotropin on performance and grazing behavior of ewes housed at different stocking rates

This study evaluated the effects of recombinant bovine somatotropin (bST; one injection of 320 mg per ewe) on milk production and composition and on the grazing behavior of multiparous ewes in the third to fourth lactation. Forty Comisana lactating ewes were divided into four groups: 1) untreated, grazing on natural pasture (botanical composition: 35% of Graminaceae, 49% of Fabaceae, 6% of Cruciferae, 10% of other families) at a low stocking rate (16 m2/d); 2) untreated, grazing at a high stocking rate (8 m2/d); 3) treated with bST, grazing at a low stocking rate; and 4) treated with bST, grazing at a high stocking rate. The diets of the ewes were supplemented with vetch and oat hay (500 g/d) and with concentrate (500 g/d). Treatment increased milk production (923.8 vs. 669.5 g/d) but had little effect on fat and protein contents. Administration of bST significantly increased herbage intake; the effect on intake was more marked at the high stocking rate. Under these grazing conditions, the treated ewes reduced selective intake behavior and, thus, achieved good feed intake despite the low biomass availability.