Publications by authors named "Yvonne Jockel-Schneider"

30 Publications

  • Page 1 of 1

Sex-specific genetic factors affect the risk of early-onset periodontitis in Europeans.

J Clin Periodontol 2021 Aug 18. Epub 2021 Aug 18.

Department of Periodontology, Oral Medicine and Oral Surgery, Charité - University Medicine Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute for Dental and Craniofacial Sciences, Berlin, Germany.

Aims: Various studies have reported that young European women are more likely to develop early-onset periodontitis compared to men. A potential explanation for the observed variations in sex and age of disease onset is the natural genetic variation within the autosomal genomes. We hypothesized that genotype-by-sex (G × S) interactions contribute to the increased prevalence and severity.

Materials And Methods: Using the case-only design, we tested for differences in genetic effects between men and women in 896 North-West European early-onset cases, using imputed genotypes from the OmniExpress genotyping array. Population-representative 6823 controls were used to verify that the interacting variables G and S were uncorrelated in the general population.

Results: In total, 20 loci indicated G × S associations (P < 0.0005), 3 of which were previously suggested as risk genes for periodontitis (ABLIM2, CDH13, and NELL1). We also found independent G × S interactions of the related gene paralogs MACROD1/FLRT1 (chr11) and MACROD2/FLRT3 (chr20). G × S-associated SNPs at CPEB4, CDH13, MACROD1, and MECOM were genome-wide-associated with heel bone mineral density (CPEB4, MECOM), waist-to-hip ratio (CPEB4, MACROD1), and blood pressure (CPEB4, CDH13).

Conclusions: Our results indicate that natural genetic variation affects the different heritability of periodontitis among sexes and suggest genes that contribute to inter-sex phenotypic variation in early-onset periodontitis.
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http://dx.doi.org/10.1111/jcpe.13538DOI Listing
August 2021

The utilization of dental emergency services during COVID-19 pandemic in a German university center: Do we lose vulnerable patients?

Quintessence Int 2021 Sep;52(9):828-836

Objectives: The COVID-19 pandemic poses a major challenge to health care worldwide. As a part of the virus containment strategy, health care services were limited to the treatment of essential emergencies. The aim was to evaluate the influence of COVID-19 pandemic on patients' utilization of dental emergency services, focusing on patients vulnerable to severe courses of COVID-19.

Method And Materials: Files of 1,299 patients of the Dental School of the University Hospital Wuerzburg between 3 February and 7 June 2020 were retrospectively analyzed. The observation period was divided into pre-lockdown (Pre-L), during lockdown (Dur-L), and post-lockdown (Post-L). Patients' demographics, diagnosis, and medical history including COVID-19 anamnesis were recorded.

Results: The number of dental emergency patients decreased by approximately 50% (Pre-L, n = 576; Dur-L, n = 309). Proportions of risk patients among them did not change. Stationary admissions increased by approximately 4% (Pre-L, 12.3% to Dur-L, 16.2%). The most frequent diagnosis was uncontrollable pain (45.6%), originating in 25.2% of endodontic and periodontal diseases. Abscesses (23.0%), dental trauma (16.5%), facial trauma (9.4%), and uncontrollable bleeding (5.5%) followed consecutively.

Conclusion: Patients with an increased risk for severe courses of COVID-19 infection did not refrain from consulting dental emergency care. Dental emergencies should be treated early to avoid stationary admissions to preserve hospital bed capacities.
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http://dx.doi.org/10.3290/j.qi.b1702163DOI Listing
September 2021

Nitrate-rich diet alters the composition of the oral microbiota in periodontal recall patients.

J Periodontol 2021 Mar 20. Epub 2021 Mar 20.

Department of Periodontology and Operative Dentistry, University Hospital of Münster, Münster, Germany.

Background: This follow-up study evaluated microbiome changes in periodontal recall patients after consuming a nitrate-rich diet that led to a marked decrease of gingival inflammation.

Methods: Subgingival microbial samples of 37 patients suffering from gingival inflammation with reduced periodontium were taken before professional mechanical plaque removal (baseline) and subsequently after 2 weeks of regularly consuming a lettuce juice beverage (day 14) containing a daily dosage of 200 mg of nitrate (test group, n = 18) or being void of nitrate (placebo group, n = 19). Three hundred base pairs paired-end sequencing of the V3-V4 hypervariable region of the 16S rDNA was performed.

Results: At baseline, there were no significant differences about the bacterial diversity parameters between the groups (Mann-Whitney U test). After intervention in the test group, Rothia and Neisseria, including species reducing nitrate, increased significantly (negative binomial regression model). Alpha diversity decreased significantly from 115.69 ± 24.30 to 96.42 ± 24.82 aRSVs/sample (P = 0.04, Wilcoxon signed-rank test), accompanied by a significant change in beta diversity (P < 0.001, PERMANOVA). In the control group, however, no genus changed significantly, and alpha-, as well as beta-diversity did not change significantly.

Conclusions: The decrease of gingival inflammation in periodontal recall patients induced by a nitrate-rich diet is accompanied by significant compositional changes within the subgingival microbiome.
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http://dx.doi.org/10.1002/JPER.20-0778DOI Listing
March 2021

Impact of 0.1% octenidine mouthwash on plaque re-growth in healthy adults: a multi-center phase 3 randomized clinical trial.

Clin Oral Investig 2021 Jul 22;25(7):4681-4689. Epub 2021 Jan 22.

Department of Periodontology, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.

Objectives: To investigate plaque inhibition of 0.1% octenidine mouthwash (OCT) vs. placebo over 5 days in the absence of mechanical plaque control.

Materials And Methods: For this randomized, placebo-controlled, double-blind, parallel group, multi-center phase 3 study, 201 healthy adults were recruited. After baseline recording of plaque index (PI) and gingival index (GI), collection of salivary samples, and dental prophylaxis, subjects were randomly assigned to OCT or placebo mouthwash in a 3:1 ratio. Rinsing was performed twice daily for 30 s. Colony forming units in saliva were determined before and after the first rinse. At day 5, PI, GI, and tooth discoloration index (DI) were assessed. Non-parametric van Elteren tests were applied with a significance level of p < 0.05.

Results: Treatment with OCT inhibited plaque formation more than treatment with placebo (PI: 0.36 vs. 1.29; p < 0.0001). OCT reduced GI (0.04 vs. placebo 0.00; p = 0.003) and salivary bacterial counts (2.73 vs. placebo 0.24 lgCFU/ml; p < 0.0001). Tooth discoloration was slightly higher under OCT (DI: 0.25 vs. placebo 0.00; p = 0.0011). Mild tongue staining and dysgeusia occurred.

Conclusions: OCT 0.1% mouthwash inhibits plaque formation over 5 days. It therefore can be recommended when regular oral hygiene is temporarily compromised.

Clinical Relevance: When individual plaque control is compromised, rinsing with octenidine mouthwash is recommended to maintain healthy oral conditions while side effects are limited.
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http://dx.doi.org/10.1007/s00784-021-03781-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310509PMC
July 2021

Consumption of Lactobacillus reuteri-containing lozenges improves periodontal health in navy sailors at sea: A randomized controlled trial.

J Periodontol 2020 10 26;91(10):1328-1338. Epub 2020 Feb 26.

Department of Periodontology, University Hospital Würzburg, Würzburg, Germany.

Background: The objective of this trial was to evaluate whether the regular consumption of probiotics may improve the known deterioration of periodontal health in navy sailors during deployments at sea.

Methods: 72 healthy sailors of a naval ship on a practicing mission at sea were recruited and randomly provided with a blinded supply of lozenges to be consumed twice daily for the following 42 days containing either the probiotic strains Lactobacillus reuteri (DSM 17938 and L. reuteri (ATTC PTA 5289) (test n = 36) or no probiotics (placebo n = 36). At baseline, at day 14 and day 42 bleeding on probing (primary outcome), gingival index, plaque control record, probing attachment level, and probing pocket depth were assessed at the Ramfjord teeth.

Results: At baseline there were no significant differences between the groups. At day 14 and day 42 test group scores of all assessed parameters were significantly improved (P < 0.001) compared to baseline and to the placebo group which by contrast showed a significant (P < 0.001) deterioration of all parameters at the end of the study.

Conclusions: The consumption of probiotic L. reuteri-lozenges is an efficacious measure to improve and maintain periodontal health in situations with waning efficacy of personal oral hygiene.
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http://dx.doi.org/10.1002/JPER.19-0393DOI Listing
October 2020

Status of periodontal health in German patients suffering from chronic kidney disease-Data from the GCKD study.

J Clin Periodontol 2020 01 6;47(1):19-29. Epub 2019 Nov 6.

Division of Periodontology, University Hospital of Würzburg, Würzburg, Germany.

Aim: To assess the prevalence and severity of periodontitis in patients with moderate chronic kidney disease (CKD) and comparing the results with the self-reported periodontitis awareness of the study subjects.

Material And Methods: The periodontal status of 270 patients with moderate CKD randomly selected from a cohort of 5,217 subjects participating in the prospective observational German Chronic Kidney Disease (GCKD) project was analysed by recording bleeding on probing (BOP), probing pocket depth (PPD) and clinical attachment level (CAL). Furthermore, the awareness of the study subjects of their periodontal conditions was evaluated by a self-reported questionnaire.

Results: 24.4% of the CKD study patients showed no or only mild signs of periodontal disease, 47.6% displayed moderate and 27% severe periodontitis. Questionnaire data revealed that 62.3% of the study subjects with severe periodontitis were not aware of the presence of the disease, 44.4% denied having received any systematic periodontal therapy so far, although 50% of them indicated to visit their dentist regularly for professional tooth cleanings.

Conclusion: While the clinical study data confirm an increased prevalence of periodontitis in CKD patients, their self-reported awareness of periodontitis was low.
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http://dx.doi.org/10.1111/jcpe.13208DOI Listing
January 2020

A combined epigenome- and transcriptome-wide association study of the oral masticatory mucosa assigns CYP1B1 a central role for epithelial health in smokers.

Clin Epigenetics 2019 07 22;11(1):105. Epub 2019 Jul 22.

Department of Periodontology and Synoptic Dentistry, Institute for Dental and Craniofacial Sciences, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Aßmannshauser Str. 4-6, 14197, Berlin, Germany.

Background: The oral mucosa has an important role in maintaining barrier integrity at the gateway to the gastrointestinal and respiratory tracts. Smoking is a strong environmental risk factor for the common oral inflammatory disease periodontitis and oral cancer. Cigarette smoke affects gene methylation and expression in various tissues. This is the first epigenome-wide association study (EWAS) that aimed to identify biologically active methylation marks of the oral masticatory mucosa that are associated with smoking.

Results: Ex vivo biopsies of 18 current smokers and 21 never smokers were analysed with the Infinium Methylation EPICBeadChip and combined with whole transcriptome RNA sequencing (RNA-Seq; 16 mio reads per sample) of the same samples. We analysed the associations of CpG methylation values with cigarette smoking and smoke pack year (SPY) levels in an analysis of covariance (ANCOVA). Nine CpGs were significantly associated with smoking status, with three CpGs mapping to the genetic region of CYP1B1 (cytochrome P450 family 1 subfamily B member 1; best p = 5.5 × 10) and two mapping to AHRR (aryl-hydrocarbon receptor repressor; best p = 5.9 × 10). In the SPY analysis, 61 CpG sites at 52 loci showed significant associations of the quantity of smoking with changes in methylation values. Here, the most significant association located to the gene CYP1B1, with p = 4.0 × 10. RNA-Seq data showed significantly increased expression of CYP1B1 in smokers compared to non-smokers (p = 2.2 × 10), together with 13 significantly upregulated transcripts. Six transcripts were significantly downregulated. No differential expression was observed for AHRR. In vitro studies with gingival fibroblasts showed that cigarette smoke extract directly upregulated the expression of CYP1B1.

Conclusion: This study validated the established role of CYP1B1 and AHRR in xenobiotic metabolism of tobacco smoke and highlights the importance of epigenetic regulation for these genes. For the first time, we give evidence of this role for the oral masticatory mucosa.
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http://dx.doi.org/10.1186/s13148-019-0697-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6647091PMC
July 2019

No differences in microbiome changes between anti-adhesive and antibacterial ingredients in toothpastes during periodontal therapy.

J Periodontal Res 2019 Aug 9;54(4):435-443. Epub 2019 Mar 9.

Department of Periodontology and Conservative Dentistry, Muenster University Hospital, Muenster, Germany.

Aim: This subgroup analysis of a 12-week randomized, double-blind, and two-center trial aimed to evaluate whether two different toothpaste formulations can differentially modulate the dental microbiome.

Material And Methods: Forty one mild to moderate periodontitis patients used as an adjunct to periodontal treatment either a toothpaste with anti-adhesive zinc-substituted carbonated hydroxyapatite (HA) or with antimicrobial and anti-adhesive amine fluoride/stannous fluoride (AmF/SnF ) during a 12-week period. Plaque samples from buccal/lingual, interproximal, and subgingival sites were taken at baseline, 4 weeks after oral hygiene phase, and 8 weeks after periodontal therapy. Samples were analyzed with paired-end Illumina Miseq 16S rDNA sequencing. The differences and changes on community level (alpha and beta diversity) and on the level of single agglomerated ribosomal sequence variants (aRSV) were calculated with analysis of covariance (ANCOVA) and likelihood ratio test (LRT).

Results: Interproximal and subgingival sites harbored predominately Fusobacterium and Prevotella species associated with periodontitis, whereas buccal/lingual sites harbored mainly Streptococcus and Veillonella species associated with periodontal health. Alpha and beta diversity did not change noticeably differently between both toothpaste groups (P > 0.05, ANCOVA). Furthermore, none of the aRSVs showed a noticeably different change between the tested toothpastes during periodontal therapy (P > 0.05, LRT).

Conclusion: The use of a toothpaste containing anti-adhesive HA did not induce statistically noticeably different changes on microbial composition compared to an antimicrobial and anti-adhesive AmF/SnF formulation.
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http://dx.doi.org/10.1111/jre.12645DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6767489PMC
August 2019

Meta-analysis of genome-wide association studies of aggressive and chronic periodontitis identifies two novel risk loci.

Eur J Hum Genet 2019 01 14;27(1):102-113. Epub 2018 Sep 14.

Department of Periodontology and Synoptic Dentistry, Institute of Health, Institute for Dental and Craniofacial Sciences, Charité-University Medicine Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.

Periodontitis is one of the most common inflammatory diseases, with a prevalence of 11% worldwide for the severe forms and an estimated heritability of 50%. It is classified into the widespread moderate form chronic periodontitis (CP) and the rare early-onset and severe phenotype aggressive periodontitis (AgP). These different disease manifestations are thought to share risk alleles and predisposing environmental factors. To obtain novel insights into the shared genetic etiology and the underlying molecular mechanisms of both forms, we performed a two step-wise meta-analysis approach using genome-wide association studies of both phenotypes. Genotypes from imputed genome-wide association studies (GWAS) of AgP and CP comprising 5,095 cases and 9,908 controls of North-West European genetic background were included. Two loci were associated with periodontitis at a genome-wide significance level. They located within the pseudogene MTND1P5 on chromosome 8 (rs16870060-G, P = 3.69 × 10, OR = 1.36, 95% CI = [1.23-1.51]) and intronic of the long intergenic non-coding RNA LOC107984137 on chromosome 16, downstream of the gene SHISA9 (rs729876-T, P = 9.77 × 10, OR = 1.24, 95% CI = [1.15-1.34]). This study identified novel risk loci of periodontitis, adding to the genetic basis of AgP and CP.
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http://dx.doi.org/10.1038/s41431-018-0265-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6303247PMC
January 2019

Genome-wide association meta-analysis of coronary artery disease and periodontitis reveals a novel shared risk locus.

Sci Rep 2018 09 12;8(1):13678. Epub 2018 Sep 12.

Charité - University Medicine Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute for Dental and Craniofacial Sciences, Department of Periodontology and Synoptic Dentistry, Berlin, Germany.

Evidence for a shared genetic basis of association between coronary artery disease (CAD) and periodontitis (PD) exists. To explore the joint genetic basis, we performed a GWAS meta-analysis. In the discovery stage, we used a German aggressive periodontitis sample (AgP-Ger; 680 cases vs 3,973 controls) and the CARDIoGRAMplusC4D CAD meta-analysis dataset (60,801 cases vs 123,504 controls). Two SNPs at the known CAD risk loci ADAMTS7 (rs11634042) and VAMP8 (rs1561198) passed the pre-assigned selection criteria (P < 0.05; P < 5 × 10; concordant effect direction) and were replicated in an independent GWAS meta-analysis dataset of PD (4,415 cases vs 5,935 controls). SNP rs1561198 showed significant association (PD[Replication]: P = 0.008 OR = 1.09, 95% CI = [1.02-1.16]; PD [Discovery + Replication]: P = 0.0002, OR = 1.11, 95% CI = [1.05-1.17]). For the associated haplotype block, allele specific cis-effects on VAMP8 expression were reported. Our data adds to the shared genetic basis of CAD and PD and indicate that the observed association of the two disease conditions cannot be solely explained by shared environmental risk factors. We conclude that the molecular pathway shared by CAD and PD involves VAMP8 function, which has a role in membrane vesicular trafficking, and is manipulated by pathogens to corrupt host immune defense.
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http://dx.doi.org/10.1038/s41598-018-31980-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6135769PMC
September 2018

Wild-type isolates of Porphyromonas gingivalis derived from periodontitis patients display major variability in platelet activation.

J Clin Periodontol 2018 06 10;45(6):693-700. Epub 2018 May 10.

Divison of Periodontology, University Hospital Würzburg, Würzburg, Germany.

In vitro studies revealed that Porphyromonas gingivalis (Pg), a pathogen intimately associated with the onset and progression of periodontitis, is able to activate platelets, thus linking periodontal inflammation with the endangerment of vascular health. As wild-type Pg strains are characterized by major genetic heterogeneity, the commonness of platelet-activating Pg strains in periodontitis patients is unknown as of yet. Therefore, this study evaluated the platelet activation capacity of wild-type Pg isolates sampled from patients with aggressive periodontitis.

Methods: Extent and velocity of platelet aggregation were determined by light transmission aggregometry. Platelet surface expression of P-selectin was measured by flow cytometry, activation of p38 MAP kinase, and protein kinase C by Western blot using phospho-specific antibodies.

Results: Pg isolates displayed high variability regarding extent and velocity of platelet activation, as well as the involved activating pathways. Corresponding results were observed for platelet P-selectin expression, activation of p38 MAP kinase, or protein kinase C. Inhibitors of platelet immune receptor FcγRIIA and protease-activated receptors revealed several, diverging pathways of activation. Some isolates induced platelet aggregation even in the presence of potent therapeutical platelet inhibitors.

Conclusions: Chronic bacteremia involving specific, platelet-activating Pg strains may constitute a substantial hazard for the integrity of cardiovascular health.
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http://dx.doi.org/10.1111/jcpe.12895DOI Listing
June 2018

Impact of different concentrations of an octenidine dihydrochloride mouthwash on salivary bacterial counts: a randomized, placebo-controlled cross-over trial.

Clin Oral Investig 2018 Nov 2;22(8):2917-2925. Epub 2018 Mar 2.

Department of Periodontology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.

Objectives: This bi-centric, placebo-controlled, randomized, evaluator-blinded, incomplete cross-over clinical phase II trial was initialized to identify the most appropriate concentration of octenidine dihydrochloride (OCT) in mouth rinses.

Materials And Methods: Rinses of 0.10, 0.15, and 0.20% OCT were compared to a saline placebo rinse regarding the reduction of salivary bacterial counts (SBCs) in 90 gingivitis patients over 4 days. Changes in plaque (PI) and gingival index (GI), taste perception, and safety issues were evaluated.

Results: At baseline, the first OCT (0.10, 0.15, 0.20%) rinse resulted in a decrease of SBC (reduction by 3.63-5.44 log colony forming units [CFU]) compared to placebo (p < 0.001). Differences between OCT concentrations were not verified. After 4 days, the last OCT rinse again resulted in a significant SBC decrease (3.69-4.22 log CFU) compared to placebo (p < 0.001). Overall, SBC reduction between baseline and day 4 was significantly higher in OCT 0.15 and 0.20% groups compared to OCT 0.10% and placebo. Mean GI/PIs were significantly lower in OCT groups than in the placebo group (p < 0.001). Differences in GI/PI between OCT groups were not verified. Adverse effects increased with increasing OCT concentrations.

Conclusions: Considering antibacterial efficacy, frequency of adverse events, and user acceptance, 0.10% OCT was identified as the preferred concentration to be used in future clinical trials.

Clinical Relevance: Due to its low toxicity and pronounced antibacterial properties, octenidine dihydrochloride (OCT) is a promising candidate for the use in antiseptic mouth rinses. OCT concentrations of 0.10% are recommended for future clinical trials evaluating the plaque-reducing properties of OCT mouth rinses. ( www.clinicaltrials.gov , NCT022138552).
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http://dx.doi.org/10.1007/s00784-018-2379-0DOI Listing
November 2018

Impact of anti-infective periodontal therapy on parameters of vascular health.

J Clin Periodontol 2018 03 12;45(3):354-363. Epub 2018 Jan 12.

Department of Periodontology, University Hospital Würzburg, Würzburg, Germany.

Aim: This study assessed the impact of anti-infective periodontal therapy on the status of vascular health.

Materials And Methods: Periodontal and vascular health of 55 patients with severe untreated chronic periodontitis was evaluated before and 12 months after anti-infective periodontal therapy. Observed parameters were bleeding on probing (BoP), pocket probing depth (PPD), periodontal inflamed surface area index (PISA), pulse wave velocity (PWV), augmentation index (AIx), central pulse pressure (PPao) and peripheral systolic pressure (RRsys).

Results: ΔPISA (baseline-12 months) correlated with ΔPWV (τ 0.21; p < .03), ΔAIx (τ 0.29; p < .002) and ΔPPao (τ 0.23; p < .02). ΔBoP% (baseline-12 months) correlated with ΔPWV (τ 0.18; p < .05) and ΔAIx (τ 0.25; p < .01), while mean ΔPPD (baseline-12 months) correlated with ΔPWV (τ 0.24; p < .01) and ΔAIx (τ 0.21; p < .03). Grouping patients evenly into three groups based on tertiles of BoP resolution after 12 months revealed a significant decrease in the observed PWV median value by -0.6 m/s (p < .04) in the best response tertile (ΔBoP ≥ 88%). In the worst response tertile (ΔBoP ≤ 66%), by contrast, significant increase in PPao (+10.5 mmHg; p < .02) and AIx (+5.5; p < .02) was observed.

Conclusion: Efficacious resolution of periodontal inflammation may beneficially impact on vascular health.
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http://dx.doi.org/10.1111/jcpe.12849DOI Listing
March 2018

A haplotype block downstream of plasminogen is associated with chronic and aggressive periodontitis.

J Clin Periodontol 2017 Oct 11;44(10):962-970. Epub 2017 Sep 11.

Department of Periodontology, Institute of Dental, Oral and Maxillary Medicine, Charité - University Medicine Berlin, Berlin, Germany.

Aim: The intronic variant rs4252120 in the plasminogen gene (PLG) is known to be associated with aggressive periodontitis (AgP) and atherosclerosis. Here, we examined the chromosomal region spanning PLG for associations with both chronic periodontitis (CP) and AgP.

Materials And Methods: The association of PLG candidate rs4252120 was tested in a German case-control sample of 1,419 CP cases using the genotyping assay hCV11225947 and 4,562 controls, genotyped with HumanOmni BeadChips. The German and Dutch sample of AgP cases (N = 851) and controls (N = 6,836) were genotyped with HumanOmni BeadChips. The North American CP sample (N = 2,681 cases, 1,823 controls) was previously genotyped on the Genome-Wide Human SNP Array 6.0. Genotypes were imputed (software Impute v2), and association tests were performed using an additive genetic model adjusting for sex and smoking.

Results: Rs4252120 was not associated with CP. However, a haplotype block downstream of PLG and not in linkage disequilibrium with rs4252120 (r = .08) was associated with both AgP (rs1247559; p = .002, odds ratio [OR] = 1.33) and CP (p = .02, OR = 1.15). That locus was also significantly associated with PLG expression in osteoblasts (p = 6.9 × 10 ).

Conclusions: Our findings support a role of genetic variants in PLG in the aetiology of periodontitis.
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http://dx.doi.org/10.1111/jcpe.12749DOI Listing
October 2017

A genome-wide association study identifies nucleotide variants at SIGLEC5 and DEFA1A3 as risk loci for periodontitis.

Hum Mol Genet 2017 07;26(13):2577-2588

Clinic of Internal Medicine, University Clinic Schleswig-Holstein, Kiel, Germany.

Periodontitis is one of the most common inflammatory diseases, with a prevalence of 11% worldwide for the severe forms and an estimated heritability of 50%. The disease is characterized by destruction of the alveolar bone due to an aberrant host inflammatory response to a dysbiotic oral microbiome. Previous genome-wide association studies (GWAS) have reported several suggestive susceptibility loci. Here, we conducted a GWAS using a German and Dutch case-control sample of aggressive periodontitis (AgP, 896 cases, 7,104 controls), a rare but highly severe and early-onset form of periodontitis, validated the associations in a German sample of severe forms of the more moderate phenotype chronic periodontitis (CP) (993 cases, 1,419 controls). Positive findings were replicated in a Turkish sample of AgP (223 cases, 564 controls). A locus at SIGLEC5 (sialic acid binding Ig-like lectin 5) and a chromosomal region downstream of the DEFA1A3 locus (defensin alpha 1-3) showed association with both disease phenotypes and were associated with periodontitis at a genome-wide significance level in the pooled samples, with P = 1.09E-08 (rs4284742,-G; OR = 1.34, 95% CI = 1.21-1.48) and P = 5.48E-10 (rs2738058,-T; OR = 1.28, 95% CI = 1.18-1.38), respectively. SIGLEC5 is expressed in various myeloid immune cells and classified as an inhibitory receptor with the potential to mediate tyrosine phosphatases SHP-1/-2 dependent signaling. Alpha defensins are antimicrobial peptides with expression in neutrophils and mucosal surfaces and a role in phagocyte-mediated host defense. This study identifies the first shared genetic risk loci of AgP and CP with genome-wide significance and highlights the role of innate and adaptive immunity in the etiology of periodontitis.
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http://dx.doi.org/10.1093/hmg/ddx151DOI Listing
July 2017

Impact of the Daily Use of a Microcrystal Hydroxyapatite Dentifrice on De Novo Plaque Formation and Clinical/Microbiological Parameters of Periodontal Health. A Randomized Trial.

PLoS One 2016 28;11(7):e0160142. Epub 2016 Jul 28.

Department of Periodontology, University Hospital Muenster, Muenster, Germany.

Aim: This 12-week prospective, randomized, double-blind, two-center trial evaluated the impact of a microcrystalline zinc hydroxyapatite (mHA) dentifrice on plaque formation rate (PFR) in chronic periodontitis patients. We hypothesized that mHA precipitates cause delayed plaque development when compared to a fluoridated control (AmF/SnF2), and therefore would improve periodontal health.

Material & Methods: At baseline and after 4 and 12 weeks, PFR and other clinical and microbiological parameters were recorded. Seventy periodontitis patients received a mHA or AmF/SnF2 dentifrice as daily oral care without hygiene instructions. Four weeks after baseline, participants received full mouth debridement and continued using the dentifrices for another 8 weeks.

Results: Primary outcome PFR did not change statistically significantly from baseline to weeks 4 and 12, neither in mHA (n = 33; 51.7±17.2% vs. 48.5±16.65% vs. 48.4±19.9%) nor in AmF/SnF2-group (n = 34; 52.3±17.5% vs. 52.5±21.3% vs. 46.1±21.8%). Secondary clinical parameters such as plaque control record, gingival index, bleeding on probing, and pocket probing depth improved, but between-group differences were not statistically significant. Microbiological analyses showed similar slight decreases in colony-forming units in both groups.

Conclusion: In patients with mild-to-moderate periodontitis, periodontal therapy and use of a mHA-or AmF/SnF2 dentifrice without instructions induced comparable improvements in periodontal health but did not significantly reduce the PFR.

Trial Registration: ClincalTrials.gov NCT02697539.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0160142PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4965058PMC
August 2017

Regular consumption of Lactobacillus reuteri-containing lozenges reduces pregnancy gingivitis: an RCT.

J Clin Periodontol 2016 11 12;43(11):948-954. Epub 2016 Aug 12.

Department of Obstetrics and Gynaecology, University Hospital Wuerzburg, Wuerzburg, Germany.

Aim: This randomized controlled trial assessed the impact of Lactobacillus reuteri on pregnancy gingivitis in healthy women.

Materials And Methods: Forty-five healthy women (24 test/21 placebo) with pregnancy gingivitis in the third trimester of pregnancy were enrolled. At baseline Gingival Index (GI) and Plaque Index (PlI) were assessed at the Ramfjord teeth and venous blood taken for TNF-α analysis. Subsequently participants were randomly provided with lozenges to be consumed 2 × daily until birth (approx. 7 weeks) containing ≥10 CFU L. reuteri ATCC PTA 5289 and ≥10 CFU L. reuteri DSM 17938 (test) or being devoid of L. reuteri (placebo). Within 2 days after birth recording of GI, PlI and blood sampling were repeated.

Results: At baseline, mean GI and mean PlI did not differ significantly between both groups. In the test group mean TNF-α serum level was significantly (p < 0.02) lower than in the placebo group. At reevaluation, mean GI and mean PlI of the test group were both significantly (p < 0.0001) lower than in the placebo group. Mean TNF-α serum level did no longer differ significantly between the groups.

Conclusions: The consumption of L. reuteri lozenges may be a useful adjunct in the control of pregnancy gingivitis.
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http://dx.doi.org/10.1111/jcpe.12606DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6299356PMC
November 2016

Stimulation of the nitrate-nitrite-NO-metabolism by repeated lettuce juice consumption decreases gingival inflammation in periodontal recall patients: a randomized, double-blinded, placebo-controlled clinical trial.

J Clin Periodontol 2016 07 10;43(7):603-8. Epub 2016 May 10.

Department of Periodontology, University Hospital of Wuerzburg, Wuerzburg, Germany.

Aim: This prospective, parallel group, two-armed, double-blind, placebo-controlled randomized trial evaluated the impact of dietary nitrate consumption on gingival inflammation in periodontal recall patients.

Material And Methods: Forty-four (23 test/21 placebo) periodontal recall patients with chronic gingivitis were enrolled. At baseline, gingival index (GI), plaque control record (PCR) and salivary nitrate level (SNL) were recorded, followed by sub- and supragingival debridement. Subsequently, participants were randomly provided with 100 ml bottles of a lettuce juice beverage to be consumed 3× daily over 14 days, containing either a standardized amount of nitrate resulting in an intake of approximately 200 mg nitrate per day (test) or being devoid of nitrate (placebo).

Results: At baseline, mean GI, PCR and SNL did not differ significantly between the groups. At day 14, mean GI of the test group was significantly reduced compared to baseline and significantly lower (p = 0.002) than in the placebo group (GI 0.3 versus 0.5). Also, mean SNL in the test group was significantly higher than in the placebo group (54.0 μg/ml versus 27.8 μg/ml; p < 0.035). Mean PCR did not change significantly in both groups.

Conclusions: Dietary nitrate consumption may be a useful adjunct in the control of chronic gingivitis.
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http://dx.doi.org/10.1111/jcpe.12542DOI Listing
July 2016

Prevalence of periodontitis in individuals with human leukocyte antigens (HLA) A9, B15, A2, and B5.

Clin Oral Investig 2016 May 26;20(4):703-10. Epub 2015 Aug 26.

Department of Operative Dentistry and Periodontology, Martin Luther University Halle-Wittenberg, Große Steinstraße 19, 06108, Halle (Saale), Germany.

Objective: Human leukocyte antigens (HLA) have been associated with periodontitis. Previous studies revealed HLA-A9 and HLA-B15 as potential susceptibility factors, while HLA-A2 and HLA-B5 might have protective effects. The aim of the study was to verify these associations in a group of HLA-typed blood donors with previously unknown periodontal status.

Materials And Methods: In four German centers, 140 blood donors with known HLA class I status were enrolled and allocated to the following five groups: HLA-A9 (N = 24), HLA-B15 (N = 20), HLA-A2 (N = 30), HLA-B5 (N = 26), and controls (N = 40). Periodontal examination included the measurement of probing depths (PDs), clinical attachment level (CAL), bleeding on probing (BOP), and community periodontal index of treatment needs (CPITN).

Results: Carriers with HLA-A9 and HLA-B15 had higher values of mean PD (P < 0.0001), CAL (P < 0.0001), and BOP (P < 0.002) as well as sites with PD and CAL with ≥4 and ≥6 mm (P < 0.0003), respectively, than controls. Multiple regression analyses revealed HLA-A9, HLA-B15, and smoking as risk indicators for moderate to severe (CPITN 3-4; odds ratio (OR): 66.7, 15.3, and 5.1) and severe (CPITN 4; OR: 6.6, 7.4, and 3.8) periodontitis. HLA-A2 and HLA-B5 did not show any relevant associations.

Conclusion: The present data support a role of HLA-A9 and HLA-B15 as susceptibility factors for periodontitis, whereas HLA-A2 and HLA-B5 could not be confirmed as resistance factors.

Clinical Relevance: Both HLA antigens A9 and B15 are potential candidates for periodontal risk assessment.
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http://dx.doi.org/10.1007/s00784-015-1570-9DOI Listing
May 2016

Genetic evidence for PLASMINOGEN as a shared genetic risk factor of coronary artery disease and periodontitis.

Circ Cardiovasc Genet 2015 Feb 2;8(1):159-67. Epub 2014 Dec 2.

Background: Genetic studies demonstrated the presence of risk alleles in the genes ANRIL and CAMTA1/VAMP3 that are shared between coronary artery disease (CAD) and periodontitis. We aimed to identify further shared genetic risk factors to better understand conjoint disease mechanisms.

Methods And Results: In-depth genotyping of 46 published CAD risk loci of genome-wide significance in the worldwide largest case-control sample of the severe early-onset phenotype aggressive periodontitis (AgP) with the Illumina Immunochip (600 German AgP cases, 1448 controls) and the Affymetrix 500K array set (283 German AgP cases and 972 controls) highlighted ANRIL as the major risk gene and revealed further associations with AgP for the gene PLASMINOGEN (PLG; rs4252120: P=5.9×10(-5); odds ratio, 1.27; 95% confidence interval, 1.3-1.4 [adjusted for smoking and sex]; 818 cases; 5309 controls). Subsequent combined analyses of several genome-wide data sets of CAD and AgP suggested TGFBRAP1 to be associated with AgP (rs2679895: P=0.0016; odds ratio, 1.27 [95% confidence interval, 1.1-1.5]; 703 cases; 2.143 controls) and CAD (P=0.0003; odds ratio, 0.84 [95% confidence interval, 0.8-0.9]; n=4117 cases; 5824 controls). The study further provides evidence that in addition to PLG, the currently known shared susceptibility loci of CAD and periodontitis, ANRIL and CAMTA1/VAMP3, are subjected to transforming growth factor-β regulation.

Conclusions: PLG is the third replicated shared genetic risk factor of atherosclerosis and periodontitis. All known shared risk genes of CAD and periodontitis are members of transforming growth factor-β signaling.
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http://dx.doi.org/10.1161/CIRCGENETICS.114.000554DOI Listing
February 2015

A large candidate-gene association study suggests genetic variants at IRF5 and PRDM1 to be associated with aggressive periodontitis.

J Clin Periodontol 2014 Dec 15;41(12):1122-31. Epub 2014 Nov 15.

Institute for Clinical Molecular Biology, Christian-Albrechts-University, Kiel, Germany.

Aim: Epidemiological and clinical studies indicated a relationship of periodontitis with rheumatoid arthritis (RA). We aimed to identify shared genetic susceptibility loci of RA and periodontitis.

Materials And Methods: Forty-seven risk genes of genome-wide significance of RA and SLE were genotyped in a German case-control sample of aggressive periodontitis (AgP), using Immunochip genotyping arrays (Illumina, 600 cases, 1440 controls) and Affymetrix 500 K Genotyping Arrays (280 cases and 983 controls). Significant associations were replicated in 168 Dutch AgP cases and 679 controls and adjusted for the confounders smoking and sex.

Results: Variants at IRF5 and PRDM1 showed association with AgP. Upon covariate adjustment for smoking and sex, the most strongly associated variant at IRF5 was the rare variant rs62481981 (ppooled  = 0.0012, odds ratio [OR] = 3.1, 95% confidence interval [95% CI] = 1.6-6.1; 801 cases, 1476 controls).Within PRDM1 it was rs6923419 (ppooled  = 0.004, OR = 0.7, 95% CI = 0.6-0.9; 833 cases, 1440 controls). The associations lost significance after correction for multiple testing in the replication. Both genes are implicated in beta-interferon signalling and are also genome-wide associated with SLE and inflammatory bowel disease.

Conclusion: The study gives no definite evidence for a pathogenic genetic link of periodontitis and RA but suggests IRF5 and PRDM1 as shared susceptibility factors.
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http://dx.doi.org/10.1111/jcpe.12314DOI Listing
December 2014

Genome-wide exploration identifies sex-specific genetic effects of alleles upstream NPY to increase the risk of severe periodontitis in men.

J Clin Periodontol 2014 Dec 11;41(12):1115-21. Epub 2014 Nov 11.

Institute of Medical Informatics and Statistics, Christian-Albrechts-University Kiel, Kiel, Germany.

Aim: Periodontitis (PD) is influenced by genetic as well as lifestyle and socio-economic factors. Epidemiological studies show that men are at greater risk of severe forms of PD, suggesting interplay between sex and genetic factors. We aimed to systematically analyse patients with aggressive periodontitis (AgP) for gene-sex interactions.

Materials And Methods: Three hundred and twenty-nine German AgP cases and 983 controls were genotyped with Affymetrix 500K Arrays and were analysed by logistic regression analysis. The most significant gene-sex interaction was replicated in an independent sample of 382 German/Austrian AgP cases and 489 controls.

Results: Ten single-nucleotide polymorphisms (SNPs) in strong linkage disequilibrium (r(2)  > 0.85) upstream the gene neuropeptide Y (NPY) suggested gene-sex interaction (p < 5 × 10(-5) ). SNP rs198712 showed the strongest association in interaction with sex (p = 5.4 × 10(-6) ) with odds ratios in males and females of 1.63 and 0.69 respectively. In the replication, interaction of sex with rs198712 was verified with p = 0.022 (pooled p = 4.03 × 10(-6) ) and similar genetic effects. Analysis of chromatin elements from ENCODE data revealed tissue-specific transcription at the associated non-coding region.

Conclusion: This study is the first to observe a sexually dimorphic role of alleles at NPY in humans and support previous genome-wide findings of a role of NPY in severe PD.
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http://dx.doi.org/10.1111/jcpe.12317DOI Listing
December 2014

Arterial stiffness and pulse wave reflection are increased in patients suffering from severe periodontitis.

PLoS One 2014 1;9(8):e103449. Epub 2014 Aug 1.

Clinic of Internal Medicine II, University Hospital Schleswig-Holstein, Luebeck, Germany.

Aim: This single blind cross-sectional study compared the vascular health of subjects suffering from severe chronic periodontitis, severe aggressive periodontitis and periodontal healthy controls by evaluating pulse wave velocity (PWV), augmentation index (AIx) and pulse pressure amplification (PPA).

Material And Methods: In a total of 158 subjects, 92 suffering from severe periodontitis and 66 matched periodontal healthy controls, PWV, AIx, central and peripheral blood pressure were recorded using an oscillometric device (Arteriograph).

Results: Subjects suffering from severe chronic or aggressive periodontitis exhibited significantly higher PWV (p = 0.00004), higher AIx (p = 0.0049) and lower PPA (p = 0.028) than matched periodontal healthy controls.

Conclusions: The results of this study confirm the association between periodontal inflammation and increased cardiovascular risk shown by impaired vascular health in case of severe periodontitis. As impaired vascular health is a common finding in patients suffering from severe periodontal disease a concomitant routine cardiovascular evaluation may be advised.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0103449PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4119014PMC
April 2015

SLC23A1 polymorphism rs6596473 in the vitamin C transporter SVCT1 is associated with aggressive periodontitis.

J Clin Periodontol 2014 Jun;41(6):531-40

Department of Periodontology and Oral Biochemistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, VU University Amsterdam, Amsterdam, The Netherlands.

Aim: Identification of variants within genes SLC23A1 and SLC23A2 coding for vitamin C transporter proteins associated with aggressive (AgP) and chronic periodontitis (CP).

Material And Methods: Employment of three independent case-control samples of AgP (I. 283 cases, 979 controls; II. 417 cases, 1912 controls; III. 164 cases, 357 controls) and one sample of CP (1359 cases, 1296 controls).

Results: Stage 1: Among the tested single-nucleotide polymorphisms (SNPs), the rare allele (RA) of rs6596473 in SLC23A1 showed nominal significant association with AgP (p = 0.026, odds ratio [OR] 1.26, and a highly similar minor allele frequency between different control panels. Stage 2: rs6596473 showed no significant association with AgP in the replication with the German and Dutch case-control samples. After pooling the German AgP populations (674 cases, 2891 controls) to significantly increase the statistical power (SP = 0.81), rs6596473 RA showed significant association with AgP prior to and upon adjustment with the covariates smoking and gender with padj  = 0.005, OR = 1.35. Stage 3: RA of rs6596473 showed no significant association with severe CP.

Conclusion: SNP rs6596473 of SLC23A1 is suggested to be associated with AgP. These results add to previous reports that vitamin C plays a role in the pathogenesis of periodontitis.
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http://dx.doi.org/10.1111/jcpe.12253DOI Listing
June 2014

Early wound healing and patient morbidity after single-incision vs. trap-door graft harvesting from the palate--a clinical study.

Clin Oral Investig 2014 Dec 23;18(9):2213-9. Epub 2014 Feb 23.

Department of Periodontology, Julius-Maximilians-University Würzburg, Pleicherwall 2, 97070, Würzburg, Germany,

Objectives: The aim of this study is to compare wound healing and patient pain perception of single-incision (single-incision, modified single-incision) and trap-door surgical techniques to harvest subepithelial connective tissue grafts from the palate.

Material And Methods: Thirty-six patients were selected for root coverage procedures with subepithelial connective tissue grafts and randomly assigned to two single-incision groups or a trap-door group (n = 12/group). One week after surgery, a modified early-wound healing index (EHI), patient pain and painkiller intake were recorded. Follow-up was performed until complete epithelialization was achieved.

Results: Single-incision techniques showed significantly improved early healing over trap-door approaches. Specifically, the mean EHI was 2.50 ± 1.14 for single-incision techniques, as compared to 3.33 ± 1.30 for trap door. The incidence of secondary healing was significantly lower in the single-incision groups. Concomitantly, the cumulative dosage and duration of painkiller intake were significantly reduced, as compared to the trap-door group.

Conclusion: Within the limits of this trial, single-incision techniques can lead to improved early healing and reduced patient pain after subepithelial connective tissue graft harvesting than trap-door techniques.

Clinical Relevance: Avoiding trap-door incisions for harvesting of connective tissue grafts may reduce patient morbidity.
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http://dx.doi.org/10.1007/s00784-014-1204-7DOI Listing
December 2014

On the relationship between gingival biotypes and supracrestal gingival height, crown form and papilla height.

Clin Oral Implants Res 2014 Aug 30;25(8):894-8. Epub 2013 May 30.

Department of Periodontology, Julius-Maximilians-University, Würzburg, Germany.

Objectives: To determine the association between gingival biotypes and supracrestal gingival height (primary aim) and its relation to crown shape and papilla height (secondary aim).

Materials And Methods: Eighty adult subjects were evaluated in this study. Based on the transparency of a periodontal probe through the buccal gingival margin, 38 subjects comprised the thin biotype group and 42 subjects comprised the thick biotype group, respectively. Three different parameters were clinically assessed: supracrestal gingival height (SGH) by bone sounding, crown width/crown length ratio and papilla height.

Results: No statistical difference (P > 0.05) was detected neither for the correlation between different biotypes (thick/thin) and SGH nor for the association of biotypes and crown width/crown length ratio. Papilla height was only significantly increased (P ≤ 0.05) in the area of teeth no. 21/22 for the thin periodontal biotype. Intra-examiner deviation was found to be very low for all clinical parameters (percentile agreement > 95%).

Conclusions: Within the limits of this study, we found that in young Caucasians (i) soft tissue dimensions seem to be similar between biotypes (ii) and the traditional hypothesis that a thick gingiva merges with broad-short crown shape and flat papillae and a thin gingiva with a narrow-long crown shape and high scalloping, may be questionable.
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http://dx.doi.org/10.1111/clr.12196DOI Listing
August 2014

Validation of reported genetic risk factors for periodontitis in a large-scale replication study.

J Clin Periodontol 2013 Jun 16;40(6):563-72. Epub 2013 Apr 16.

Institute for Clinical Molecular Biology, Christian-Albrechts-University, Kiel, Germany.

Aim: Many studies investigated the role of genetic variants in periodontitis, but few were established as risk factors. We aimed to validate the associations of recent candidate genes in aggressive periodontitis (AgP).

Material And Methods: We analysed 23 genes in 600 German AgP patients and 1441 controls on the Illumina custom genotyping array Immunochip. We tested a suggestive association in a Dutch and German/Austrian AgP case-control sample, and a German chronic periodontitis (CP) case-control sample using Sequenom iPlex assays. We additionally tested the common known risk variant rs1333048 of the gene ANRIL for its association in a Turkish and Italian population.

Results: None of the analysed genes gave statistical evidence for association. Upon covariate adjustment for smoking and gender, in the pooled German-Austrian AgP sample, IL10 SNP rs6667202 was associated with p = 0.016, OR = 0.77 (95% CI = 0.6-0.95), and in the Dutch AgP sample, adjacent IL10 SNP rs61815643 was associated with p = 0.0009, OR = 2.31 (95% CI = 1.4-3.8). At rs61815643, binding of the transcription factor PPARG was predicted. ANRIL rs1333048 was associated in the Turkish sample (pallelic = 0.026, OR = 1.67 [95% CI = 1.11-2.60]).

Conclusions: Previous candidate genes carry no susceptibility factors for AgP. Association of IL-10 rs61815643 with AgP is suggested. ANRIL is associated with periodontitis across different populations.
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http://dx.doi.org/10.1111/jcpe.12092DOI Listing
June 2013

Porcine dermal matrix for covering of recession type defects: a case series.

Quintessence Int 2013 Mar;44(3):243-6

Department of Periodontology, Julius-Maximilians- University Würzburg, Germany.

Objective: To study the clinical applicability of porcine dermal matrix for treatment of recession type defects.

Method And Materials: Twenty-eight gingival recessions in six patients were selected for root coverage procedures using a modified tunneling technique and porcine dermal matrix. As primary outcome, depth and width of gingival recession were assessed at baseline and at 6 and 12 months postoperatively. As a secondary outcome, the width of keratinized tissue was studied.

Results: At 6 and 12 months postoperatively, mean root coverage was 65.52% and 56.82%, respectively. Complete root coverage was achieved in 42.86% of the treated defects.

Conclusion: Porcine dermal matrix may potentially be used as a replacement material for autologous tissue. However, complete root coverage was only achieved in less than half of the studied defects.
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http://dx.doi.org/10.3290/j.qi.a29053DOI Listing
March 2013

Treatment of a crown-root fracture with concomitant root fracture.

Quintessence Int 2011 Mar;42(3):239-42

Department of Operative Dentistry and Periodontology, Albert-Ludwigs-University of Freiburg, Freiburg, Germany.

The aim of this case report was to present a treatment strategy for severely injured teeth in children and adolescents by using periodontal surgery and adhesive techniques. A 16-year-old boy presented after a severe bicycle accident. A radiograph revealed a root fracture with connective tissue healing and displacement. Clinically, a crown-root fracture as well as an uncomplicated crown fracture of the same fragment was obvious. The root canal was prepared and filled with gutta-percha to the fracture line. A full periodontal flap was performed, and the crown-root fragment was adhesively fixed. The flap was tightly apposed, and the missing mesial edge of the tooth was restored with composite resin. A control radiograph showed a neatly fixed coronal fragment and sufficient root canal filling. The amount of work required proved to be acceptable for both patient and clinician--even if an implantation might have to be considered when the patient is full-grown--because of the longevity of the procedure.
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March 2011
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