Inflammatory response in periodontal tissue in children with Down syndrome

Periodontal diseases are inflammatory diseases affecting the supporting tissues of the teeth. Subjects with Down syndrome have a higher prevalence of periodontal disease compared to healthy controls. Periodontal disease in Down syndrome is considered to be multifactorial, although the aetiology is uncertain. The aim of this thesis was to study the inflammatory response in periodontal tissue in terms of cytokines, prostaglandins, matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) in children with Down syndrome as well as in healthy controls. In study I, 18 subjects with Down syndrome and 14 controls were clinically and radiographically examined and matched for age and degree of gingival inflammation expressed as percentage of bleeding on probing (BOP%). In all subjects, gingival crevicular fluid (GCF) was collected from six sites with paper strips, and levels of prostaglandin E2 (PGE2), leukotriene B4 (LTB4), and MMP-9 were analysed using RIA and ELISA kits. BOP% and volume of GCF (μL) were similar in both groups while Down syndrome patients had significantly higher (p<0.05) mean levels of PGE2, LTB4, and MMP-9 in GCF than controls. In study II, PD and BOP% were clinically assessed in subjects with Down syndrome (n=24) and controls (n=29) (both groups, mean age 16.4 yr). The controls were matched for age and BOP% to subjects with Down syndrome. GCF was collected and Bio-Plex cytokine multiplex assays were used to determine levels of interferon-γ (IFN-γ), tumour necrosis factor-α (TNF-α), and interleukin (IL)-1β, IL-4, -6, -10, -12, and -17. GCF volume (μL) was significantly higher in subjects with Down syndrome (p<0.001) than controls. Mean levels of IL-1β, IL-4, IL-6, IL-10, IL-12, IFN-γ, and TNF-α in GCF were significantly (p<0.005) increased in subjects with Down syndrome compared with controls. The correlation between IFN-γ and IL-4 in GCF in subjects with Down syndrome differed significantly from controls (p<0.01). In study III, 21 adolescents with Down syndrome exhibiting gingivitis (DS-G), 12 subjects with Down syndrome exhibiting periodontitis (DS-P), 26 controls with gingivitis (HC-G), and 8 controls with periodontitis (HC-P) were clinically and radiographically examined. All patients were between ages 11 and 20 yr. GCF was collected from each subject and the amounts of MMP-2, -3, -8, -9 and -13 and of TIMP-1, -2 and -3 were determined with R&D multianalyte kits. The amounts of MMP-2, -3, -8, and -9 and of TIMP-2 in GCF were significantly higher (p<0.005) in the DS-G than the HC-G group. The correlation coefficient between MMP-8 and TIMP-2 also differed significantly (p<0.01) between the DS-G and HC-G groups. In contrast, the correlation coefficients between the MMPs and TIMPs did not differ significantly between the DS-P and the HC-P groups. The DS-P group, however, exhibited significantly (p<0.005) lower amounts of TIMP-2 in GCF compared to the HC-P group. In study IV, children with Down syndrome (n=10) and controls (n=10) were clinically and radiographically examined during dental treatment under general anaesthesia. Peripheral blood and GCF were gathered from each patient and levels of MMP-2, -3, -8 and -9, of TIMP-1, -2 and -3 in serum, and of GCF were determined. Peripheral blood leukocytes were isolated, and the relative amounts (%) of the various cells were determined with flow cytometry. Peripheral blood cells were stimulated with lipopolysaccharide (LPS) from Porphyromonas gingivalis (Pg) and MMP and TIMP levels were measured. Levels of MMP-3 and -8 and TIMP-1 in serum were significantly enhanced (p’s<0.05) in subjects with Down syndrome compared to controls. When peripheral blood leukocytes were cultured in the presence or absence of Porphyromonas gingivalis lipopolysaccharide, MMP- 8 levels were significantly (p < 0.05) higher in the Down syndrome group compared to controls. Children with Down syndrome exhibited significant positive correlations of CD8+ T cells with MMP-8 (r=0.630; p=0.050) and MMP-9 (r=0.648; p<0.05) and of CD56+ NK cells with MMP-3 (r=0.828; p<0.005) compared to controls. Conclusions Subjects with Down syndrome had increased levels of the arachidonic acid metabolites PGE2 and LTB4, the cytokines IL-1β, IL-4, IL-6, IL-10, IL-12, IFN-γ and TNF-α, and of MMP-2, -3, -8 and -9 and TIMP-2 in GCF compared to controls. In addition, the balance between pro- and anti-inflammatory cytokines and between MMPs and TIMPs was altered in subjects with Down syndrome but not in controls. Furthermore, in contrast with controls, no significant differences in MMP and TIMP levels in GCF were observed between Down syndrome patients with gingivitis and periodontitis. This finding might indicate that the inflammatory response in Down syndrome is already upregulated during early stages of periodontal disease. We also demonstrate an association between MMPs and lymphocyte subpopulations (CD8+ T-cells and CD56+ NK-cells), which may facilitate the migration of immune cells into the periodontal tissue. This assumption is well compatible with the higher levels of MMPs in GCF found in Down syndrome subjects. These findings, may contribute to the increased periodontal inflammation demonstrated in this current cohort of Down syndrome subjects

Abnormalities in Tooth Formation after Early Bisphosphonate Treatment in Children with Osteogenesis Imperfecta

Treatment with intravenous bisphosphonate (BP) in children and adolescents with osteogenesis imperfecta (OI) started in Sweden in 1991. No human studies on the role of BP therapy in development of disturbances in tooth mineralization or tooth morphology have been published. The study cohort comprised 219 individuals who were divided into four groups: group 1, BP treatment onset before 2 years of age (n = 22); group 2, BP treatment onset between 2 and 6 years of age (n = 20); group 3, BP treatment onset between 6 and 10 years of age (n = 13); and a control group of patients with OI who had not received BP therapy (n = 164). The chi-square test was used in between-group comparisons of the prevalence of tooth agenesis. The prevalence of tooth agenesis was significantly higher in children who began BP treatment before the age of 2 years (group 1; 59%,) compared to the controls (10%; p < 0.001) and to children who had begun BP therapy between ages 2 and 6 years (group 2; 10%; p = 0.009) or between ages 6 and 10 years (group 3; 8%; p = 0.003). Different types of disturbances in the enamel formation were seen in 52 premolars, where 51 were seen in those who began BP treatment before the age of 2 years. To conclude, starting BP treatment before the age of 2 years increases the risk of abnormalities in tooth formation manifesting as morphological aberrations, tooth agenesis, and enamel defects.Peer reviewe

Cone beam computed tomography indications for interdisciplinary therapy planning of impacted canines

Objective: To investigate how cone beam computed tomography (CBCT) affects the therapeutic planning of impacted maxillary canines. Study Design: A total of 132 impacted canines from 89 pediatric patients were collected from 3 specialist clinics in Stockholm, Sweden. An interdisciplinary therapy planning team consisting of 5 dental specialists evaluated each case and chose their preferred treatment alternative, initially without and later with CBCT images, to decide whether CBCT was justified for therapy planning. Predefined variables measurable using only 2-dimensional (2D) assessments were analyzed using stepwise logistic regression analyses. Results: The CBCT was considered indicated in 47% of the cases. Additional information from CBCT led to a treatment decision change in 9.8%. Significant 2D predictors for CBCT justification were horizontal canine angulation compared with vertical angulation (odds ratio [OR] = 10.9), extraction strategy involvement (OR = 6.7), and buccally positioned canines compared with palatal (OR = 5.3), central (OR = 25.0), and distal or uncertain positions (OR = 7.7). Conclusions: The benefit-risk assessment of CBCT for impacted canines may be reinforced by performing and applying justification decisions for CBCT acquisition at the therapeutic thinking level. If preliminary treatment planning motivates further in-depth investigation of either root status or tooth location, a CBCT is indicated.publishedVersio

Salivary biomarkers in the context of gingival inflammation in children with cystic fibrosis

Abstract Background Cystic fibrosis (CF) is a life-threatening chronic inflammatory disease in children due to respiratory complications. Saliva could serve as reservoir of bacterial colonization and potentially reflect systemic inflammation. This study investigated whether salivary triggering receptor expressed on myeloid cells 1 (TREM-1), peptidoglycan recognition protein 1 (PGLYRP1), interleukin (IL)-1? and calprotectin are associated with CF or reflect concomitant gingival inflammation. Methods Ten CF (age:3-12yrs) and ten systemically healthy age-and-gender-matched children (C) were enrolled in the study. Individuals with CF underwent routine laboratory determinations. Probing pocket depth (PPD), gingival index (GI), plaque index (PI) and bleeding on probing (BOP) were recorded on fully erupted teeth and saliva samples collected. Salivary TREM-1, PGLYRP1, IL-1? and calprotectin were analysed by ELISA. Results Children with CF had significantly higher BOP scores (P = 0.001) and calprotectin levels (P = 0.017) compared to the C group. TREM-1, PGLYRP1 and IL-1? could not distinguish between CF and SH but showed positive correlation with GI, PI and BOP in both groups. Calprotectin levels positively correlated with procalcitonin (P = 0.014), thrombocyte counts (P = 0.001), mean platelet volume (P = 0.030) and with PGLYRP1 (P = 0.019) and IL-1? (P = 0.013) in CF children. Receiver operating characteristic curve analysis for calprotectin (CFvsC) showed an area under the curve of 0.79 (95% CI 0.58-0.99, P = 0.034). Conclusions CF children presented with higher gingival inflammation scores and salivary calprotectin levels, that correlated with systemic inflammatory markers. Salivary calprotectin levels were not associated with periodontal parameters. Hence, preliminary data demonstrate that salivary calprotectin might have a chairside diagnostic potential for CF in children. This article is protected by copyright. All rights reservedPeer reviewe

Outcomes of apexification in immature traumatised necrotic teeth and risk factors for premature tooth loss : a 20-year longitudinal study

Background/Aim: To evaluate the long-term survival of immature traumatized incisors with pulp necrosis and apical periodontitis after endodontic treatment with two apexification techniques (calcium hydroxide apexification and MTA-apical plug) and to identify major factors affecting the survival of these teeth. Materials and Methods: Records of 2400 children and adolescents were screened for presence of traumatic dental injuries to immature incisors where endodontic treatment with the two apexification techniques was performed during January 2003 and December 2022, compared to a control group of mature teeth treated with conventional endodontic techniques. The studied variables were age; sex; apexification technique, presence of luxation and hard tissue injuries; preoperative root development stage (RDS), preoperative and postoperative periapical index (PAI), the time-point for tooth loss, and overall survival time in years. Kaplan–Meier estimates were used to graphically present the survival functions and Cox proportional hazard model to calculate hazard ratios (HR, 95% CI). Results: The median survival time was 10 years for calcium hydroxide apexification, 16.1 for MTA-apexification, for luxation injuries other than intrusions and avulsions 15.5 years, for intrusions 12.5 years and for avulsions 6.8 years. The variables with significant negative impact on tooth survival were calcium hydroxide apexification, avulsion and postoperative PAI 3–5. No significant relationships were found for the variables MTA apexification, concussion; subluxation; lateral luxation; extrusion, intrusion, hard tissue injuries, preoperative RDS and PAI scores and postoperative PAI 1–2. After adjustment, the risk for premature tooth loss was 13.5 times higher in calcium hydroxide apexification, approximately 2 to 4 times higher in PAI 3–5, and 5.6 times higher in avulsions. Conclusions: Calcium hydroxide apexification, avulsion, and postoperative PAI 3–5 were identified as prognostic variables with significant negative impact on the risk for premature tooth loss

Endodontic pulp revitalization in traumatized necrotic immature permanent incisors : Early failures and long-term outcomes—A longitudinal cohort study

Aim: This prospective cohort study evaluates clinical and radiographical outcomes of endodontic pulp revitalization (PR) of traumatized necrotic incisors. Methodology: Pulp revitalization was performed in 75 traumatized necrotic immature incisors from 71 patients. The radiographic outcome measures were continued root formation (width and length), root resorption, apex closure, periapical index, and root development stage. The clinical outcome measures were percussion pain, palpation pain, pathological tooth mobility, swelling, sinus tract, ankylosis, crown discolouration, response to pulp sensitivity test, and subjective pain. Treatment outcomes were categorized as a success based on the absence of clinical symptoms and when radiographic evidence was present for apical healing and continued root development. The performed statistical tests were repeated measures anova, pairwise comparisons of interactions (t-test), McNemar's test, and linear regression model. Results: In 45 of 75 teeth (60%), PR was successful with the resolution of clinical and radiographic signs and continued root development. PR failed due to the absence of bleeding (n = 19) and persistent infection (n = 11). PR showed statistically significant increases in root length (11%), and dentinal wall thickness (30%), root maturation (pre-operative 3.38 [CI 1.88; 4.88]; post-operative 4.04, [CI 2.56; 5.52]) apical closure (71.4%), healing of pre-operative apical periodontitis (100%), and healing of pre-operative inflammatory root resorptions (100%). Three predictive variables for continued root maturation were identified – root development stage at entry (p =.0001, β 0.649), [CI 0.431; 0.867], trauma to the soft tissues (p =.026, β −0.012), [CI −0.0225; −0.015], and pre-operative dentinal wall thickness (p =.009, β −0.001); [CI −0.001; 0.0001]. Conclusions: Our findings indicate that PR provides satisfactory clinical and radiographical outcomes in traumatized necrotic incisors. The failed cases were related to lack of bleeding and persistent infections, indicating that new techniques are needed to improve the predictability of PR

Image quality assessment of low-dose protocols in cone beam computed tomography of the anterior maxilla

Objectives. To evaluate overall image quality and visibility of anatomic structures on low-dose cone beam computed tomography (CBCT) scans and the effect of a noise reduction filter for assessment of the anterior maxilla. Methods. We obtained 48 CBCT volumes on 8 skull-phantoms using 6 protocols: 2 clinical default protocols [standard definition (SD) and high definition (HD)] and 4 low-dose protocols, 2 with a noise reduction filter [ultra-low-dose with high definition (ULDHD) and ultra-low-dose (ULD)] and 2 without [low-dose with high definition (LDHD) and low-dose (LD)]. Overall image quality and visibility of 8 anatomic structures were assessed by 5 observers and statistically analyzed using the Wilcoxon signed rank test. Intra- and interobserver agreement was measured using Cohen's weighted kappa. Results. HD provided higher overall image quality than diagnostically required; LD scored lower than diagnostically acceptable. ULDHD, ULD, and LDHD were acceptable. For anatomic structures, ULDHD and ULD were acceptable. LDHD and LD showed significantly inferior visibility for 1 and 4 structures, respectively. Mean values of intra- and interobserver agreement were 0.395 to 0.547 and 0.350 to 0.370, respectively. Conclusions. ULDHD, ULD, and LDHD may be recommended for assessment of impacted maxillary canines. The noise reduction filter affects image quality positively only at low exposure

Detection of Approximal Caries in 5-year-old Swedish Children

The aim was to assess how accurately some commonly used risk factors/risk markers (predictors) for caries development could identify children with and without approximal caries as judged from bitewing radiography. Two hundred and sixtyseven consecutive 5-year-old children from two Swedish cities participated. Three experienced dentists examined the children. The predictors were the overall dmfs (de-cayed, missing and filled surfaces) value (canines and molars), the number of occlusal dmfs, the frequency of intake of between-meal sugary products, visible plaque on free smooth surfaces of second primary molars, toothbrushing habits and (before bitewing examination) an overall judgement by the examining dentist. The mean dmfs value without bitewing examination was 0.40 (SD = 1.22). Twelve percent of the children had at least one dentin lesion and 33% at least one enamel lesion that were detected from bitewing examination only. The gain from adding bitewing examination to clinical examination amounted to a mean of 1.2 approximal enamel and/or dentin lesions. The ability to correctly identify children with approximal caries from the predictors was limited; sensitivity ranged from 0.27 to 0.75 and specificity ranged from 0.41 to 0.93. The single best predictor was the dentist's overall judgement with an average precision of 73%; average sensitivity for the presence of enamel and dentin lesions was 0.48 and for the presence of dentin lesions 0.66. The rest of the predictors added little to the predictive power. It is concluded that 33% of the 5-year-olds, representing a low caries prevalence population, benefited from bitewing examination. The ability to identify these children from the predictors was, however, limited. Copyright (c) 2005 S. Karger AG, Basel

Microbiological assessment of success and failure in pulp revitalization : a randomized clinical trial using calcium hydroxide and chlorhexidine gluconate in traumatized immature necrotic teeth

Aim: To compare differences in the disinfection efficacy of calcium hydroxide (CH) and chlorhexidine gluconate (CHD) dressings in pulp revitalization (PR) of traumatized immature necrotic teeth; to investigate the microflora in successful/failed PR and whether bacterial persistence influences the outcomes of PR. Methods: Microbiological assessment of the average bacterial load (CFU/sample) and bacterial diversity (taxa/sample) was performed on 41 teeth at three timepoints (S2-before, S3-after debridement and S5- after root canal dressing). Results: The primary microflora was more diverse in successful cases than in failed. Decreases in CFU/sample and taxa/sample occurred S2 - S3, though new increases occurred at S5 in the CHD subgroup (successful and failed) and CFU/sample in the CH subgroup (failed). At S5, the successful cases showed more bacterial decreases. No specific species was associated with the outcomes with no statistical differences between the disinfection efficacy. Conclusions: There were no statistical differences in CH and CHD efficacy. At S5, microflora persisted in both successful and failed outcomes, but the abundance and diversity increased significantly only in the failed cases. The successful outcomes presented higher diversity and higher decreases of the primary microflora at S5 than the failed outcomes. The abundance and diversity increased significantly at S5 only in failed cases

Specialist paediatric dentistry in Sweden 2008 - a 25-year perspective

Background. Paediatric dentistry in Sweden has been surveyed four times over the past 25 years. During this period postgraduate training, dental health, and the organization of child dental care have changed considerably. Aim. To investigate services provided by specialists in paediatric dentistry in Sweden in 2008, and to compare with data from previous surveys. Design. The same questionnaire was sent to all 30 specialist paediatric dental clinics in Sweden that had been used in previous surveys. Comparisons were made with data from 1983, 1989, 1996 and 2003. Results. Despite an unchanged number of specialists (N = 81 in 2008), the number of referrals had increased by 16% since 2003 and by almost 50% since 1983. There was greater variation in reasons for referrals. The main reason was still dental anxiety/behaviour management problems in combination with dental treatment needs (27%), followed by medical conditions/disability (18%), and high caries activity (15%). The use of different techniques for conscious sedation as well as general anaesthesia had also increased. Conclusions. The referrals to paediatric dentistry continue to increase, leading to a heavy work load for the same number of specialists. Thus, the need for more paediatric dentists remains