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«EVALUATION OF ORAL NEUTROPHIL LEVELS AS A QUANTITATIVE MEASURE OF PERIODONTAL INFLAMMATORY LOAD IN PATIENTS WITH SPECIAL NEEDS By Anita Moosani BSc, ...»

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In the future, research is required to calibrate the color reaction to allow for a standard colour guide on how the colours reflect extent of disease (e.g. how dark does the sample solution need to be in order to be considered as moderate versus severe periodontitis) in this population. This would enable the PMN assay to move out of the lab setting and allow for a quick and standardized test at the chair-side level. As previously noted, studies similar to the present investigation in other at-risk groups for oral disease (e.g. medically compromised, long hospital admissions), could be helpful to allow for screening and recognition of disease in a non-invasive manner. It would also be interesting to investigate the potential use of the toothbrush to carry PMNs into the sample solution, which is often the only instrument used for diagnosis and treatment while the uncooperative patient is awake, thereby eliminating the extra step in performing the oral swab. This could be useful in cases where the total inflammatory load is important rather than site-specific measures. In line with the current literature in the medical field, it would be interesting to evaluate the potential relationship between oral PMN counts derived from the oral swab and systemic measures of inflammation (e.g. CRP). It is the inflammatory and host responses, and not the clinical signs of periodontitis that are currently used to assess gingival health status, which are associated with systemic conditions (Teng et al., 2002), and could be useful in identification of patients prone to the „inflammatory syndrome‟.

As recognized in this study, diagnosis has direct treatment implications. It would be valuable to investigate measures that may alleviate the high prevalence of disease as diagnosed in the uncooperative special needs population, such as more intensive treatment (i.e. anti-microbial or surgical treatment interventions), and/or frequent treatment (i.e. frequent recalls and maintenance therapy), in order to address the high neutrophil levels collected by the PMN assay. In addition, further research is required to evaluate how long the noted positive treatment effect persists, the ideal treatment or recall interval to allow for maintenance of the improved oral condition in this population, as well as to delineate the effects of intensive treatment on long-term periodontal health in this population.

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1. All of the patients with special needs who were assessed with the oral PMN assay and conventional methods of periodontal measurement demonstrated gingival inflammation, which was influenced by the severity of developmental delay.

2. The measure of gingival inflammation obtained by the PMN assay (oral neutrophil quantification) positively correlated with measures of gingival inflammation as determined by conventional periodontal parameters.

3. The oral swab technique has the potential to provide information regarding the presence of disease, allow for monitoring of disease progression and treatment response, and aid in anticipating future disease.

4. Performing the swab on one arch may be sufficient to indicate total inflammatory load.

5. A single treatment intervention demonstrated a reduction in most periodontal variables, despite prolonged recall intervals.

6. It is feasible to use the PMN assay to assess gingival inflammation in the uncooperative special needs population.

Finally, this study has shown that oral PMN counts derived from swabs correlate significantly with conventional parameters of gingival inflammation and provide a standardized method for clinical assessment, thus overcoming the problem of subjectivity encountered with conventional measures, and finally allows for routine and reliable measurements for diagnosis and management of periodontal diseases in the special needs population.

FIGURES Figure 1: Severity of Developmental Delay in Patients Assessed under GA (n = 49) and at Recall Examination (n = 30) Number of Patients

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Table 2: Intra-Class Correlation Coefficients (ICC) for Inter-Calibration Analyses of Participants 1 to 6 and Gold Standard (GS), at Sessions 1 and 2

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* “Re-scheduled” = did not attend confirmed appointment (i.e. “no show”), or rescheduled in advance of confirmed appointment.

Table 9: Spearman Correlation Coefficients (rs) and p Values Comparing Periodontal Measures and Total Neutrophils for Assessments under GA (n = 49)

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* Significant at the 0.05 level (2-tailed) ** Significant at the 0.01 level (2-tailed) Table 10: Spearman Correlation Coefficients (rs) and p Values Comparing Periodontal Measures and Total Neutrophils Controlling for Number of Teeth for Assessments under GA (n = 49)

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* Significant at the 0.05 level (2-tailed) ** Significant at the 0.01 level (2-tailed) Table 11: Spearman Correlation Coefficients (rs) and p Values Comparing Periodontal Measures and Total Neutrophils Controlling for Number of Teeth for Assessments at Recall (n = 27)

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* Significant at the 0.05 level (2-tailed) ** Significant at the 0.01 level (2-tailed) Table 12: Mean ± Standard Deviations* and Wilcoxon Signed Ranks Test to Compare Mean Periodontal Measures Assessed under GA (n = 49, n = 30) and at Recall (n = 30)

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* Mean and standard deviations are parametric measurements and have been reported in this table rather than median and inter-quartile ranges (non-parametric), for simplicity of visual interpretation.

** Wilcoxon Signed Ranks Test equalizes the ‘n’ in both groups. Therefore, for this test n = 30.

*** n = 27 for neutrophil counts at recall as described in text.

Table 13: Mean and Standard Error of Neutrophil Counts Obtained at Recall, Distinguished by Severity of Developmental Delay, and Controlling for Age and Baseline Levels of Neutrophil Counts under GA

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Table 14: Analysis of Covariance (ANCOVA) Model for Neutrophil Counts Obtained at Recall, Controlling for Baseline Levels of Neutrophil Counts under GA

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Table 16: Spearman Correlation Coefficients (rs) and p Values Comparing Periodontal Measures and Total Neutrophils Controlling for Number of Teeth with VAS for Gingival Inflammation, for Assessments at GA (n = 49) and Recall (n = 30)

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* n = 27 for neutrophil counts at recall as described in text.

** Significant at the 0.01 level (2-tailed) APPENDICES APPENDIX 1: Frankl Behaviour Rating Scale for Assessment of Cooperation in the Dental Clinic

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APPENDIX 4: Definitions of Periodontal Measures of Gingival Inflammation Used in this Study Selection of Teeth According to Ramfjord Technique (Ramfjord, 1959)  Maxillary: right first molar, left central incisor, left first premolar.

 Mandibular: left first molar, right central incisor, right first premolar.

o If Ramfjord tooth not present, choose the adjacent and most similar tooth (e.g. substitute missing incisor for adjacent incisor).

Probing Depth (Newman, Takei, & Carranza, 2002)  Measurement of the distance from the free gingival margin to the base of the periodontal pocket.

 Measured at 6 points of tooth (buccal – mesial, midline, distal; then lingual – mesial, midline, distal).

Modified Gingival Index (Lobene, Weatherford, Ross, Lamm, & Menaker, 1986) 0 No inflammation noted.

1 Slight change in texture or colour of a portion of, but not the entire marginal or papillary gingiva.

2 Slight change in texture or colour of the entire marginal gingiva and papilla.

3 Edema, redness, and/or hypertrophy of the marginal gingiva and papilla.

4 Significant edema, redness, and/or hypertrophy of the marginal gingiva and papilla.

Spontaneous bleeding or ulceration may also be noted.

Plaque Index (Ramfjord, 1959) 0 No visible plaque.

1 Plaque on some of the interproximal and gingival surfaces of the tooth.

2 Plaque on all interproximal and gingival surfaces, and covering less than one half of the entire tooth crown.

3 Plaque on all interproximal and gingival surfaces, and covering more than one half of the entire tooth crown.

Calculus Index (Ramfjord, 1959) 0 No visible calculus.

1 Supragingival calculus below the free gingival margin, but less than 1 mm of extension.

2 Subgingival calculus only, or moderate amounts of supra and subgingival calculus.

3 Significant supra and subgingival calculus accumulation noted.

APPENDIX 4: Definitions of Periodontal Measures of Gingival Inflammation Used in this Study, Continued… Gingival Bleeding Index (Ainamo & Bay, 1975) + Bleeding noted from probed site within 10 seconds.

- No bleeding noted.

 Measured at 6 points of tooth (buccal – mesial, midline, distal; then lingual – mesial, midline, distal).

 Number of sites with bleeding divided by total number of sites probed x 100.

Mobility (Miller, 1950) 0 Physiologic or normal mobility.

I Tooth movement that is greater than normal.

II Tooth movement of 1 mm from normal, in any direction.

III Tooth movement of more than 1 mm in any direction. Depression and/or rotation in the dental alveolus may be noted.

Bleeding on Brushing (Defined By This Study) 0 No sulcular bleeding, no bleeding onto toothbrush head.

1 Slight sulcular bleeding noted ( 50% of sites), and slight change in color of toothbrush bristles may be noted.

2 Sulcular bleeding noted (≥ 50% of sites), and blood covers all toothbrush bristles.

3 Tendency toward spontaneous bleeding.

Visual Analog Scale for Gingival Inflammation (Defined By This Study) The intersection of an ‘X’ mark indicated by the examiner on a 100 mm line, with endpoints of ‘Absent’ and ‘Severe’ inflammation.

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Ainamo, J., Bay, I. (1975). Problems and proposals for recording gingivitis and plaque. Int Dent J, 25(4), 229-35.

Akpek, G., Knight, R.D., Wright, D.G. (2003). Use of oral mucosal neutrophil counts to detect the onset and resolution of profound neutropenia following high-dose myelosuppressive chemotherapy. Am J Hematol, 72(1), 13–19.

American Academy of Pediatric Dentistry Council on Clinical Affairs. (2011/12). Guideline on management of dental patients with special health care needs. Pediatr Dent, 33(6), 16.

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Apsey, D.J., Kaciroti, N., Loesche, W.J. (2006). The diagnosis of periodontal disease in private practice. J Periodontol, 77(9), 1572-81.

Armitage, G.C. (1996). Periodontal diseases: Diagnosis. Ann Periodontol, 1(1), 37-215.

Armitage, G.C. (1999). Development of a classification system for periodontal diseases and conditions. Ann Periodontol, 4(1), 1-6.

Armitage, G.C. (2004). Periodontal diagnoses and classification of periodontal diseases.

Periodontol 2000, 34, 9-21.

Attstrom, R. (1970). Presence of leukocytes in crevices of healthy and chronically inflamed gingivae. J Periodontal Res, 5(1), 42-7.

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Use of high-level evidence from research syntheses to identify diseases and disorders associated with periodontal disease. J Can Dent Assoc, 78(2), 103-5.

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Bassiouni, A., Naidoo, Y., Wormald, P.J. (2012). When FESS fails: The inflammatory load hypothesis in refractory chronic rhinosinusitis. Laryngoscope, 122(2), 460-6.

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