Orientador: Mauro Pedrine Santamaria / Co-orientador: Andrea Carvalho de Marco / Banca: Renato Corrêa Viana Casarin / Banca: Antônio Olavo Cardoso Jorge / Resumo: O presente estudo clínico controlado randomizado teve como objetivo avaliar a resposta clínica periodontal e os possíveis efeitos adversos da utilização da claritromicina (CLM) associada à terapia mecânica periodontal no tratamento de pacientes com periodontite agressiva generalizada. Para tal, foram selecionados 40 pacientes apresentando periodontite agressiva generalizada que foram distribuídos aleatoriamente, dentro de dois grupos: grupo claritromicina com 20 indivíduos que receberam RAR associado à claritromicina (500 mg - 12/12 horas) durante 3 dias; grupo placebo com 20 indivíduos que receberam RAR associado ao placebo. Foram avaliados profundidade de sondagem (PS), ganho de nível de inserção clínica (NIC) e sangramento à sondagem no baseline, 3 e 6 meses após o procedimento. Quanto aos resultados, ambos os tratamentos obtiveram melhorias clínicas em relação ao baseline, com diferença estatisticamente significativa apenas para redução em PS à favor do grupo claritromicina. Concluímos que o uso da claritromicina associado à terapia mecânia mostra-se superior à terapia padrão ouro para o tratamento de periodontite agressiva generalizada / Abstract: The present randomized, clinical trial aimed to assess the periodontal clinical response and the possible adverse effects of the clarithromycin combined to periodontal mechanical therapy in the treatment of patients with generalized aggressive periodontitis. To this, 40 patients were select and randomly assigned into two groups: Group clatithromycin with 20 subjects received SRP associated with clarithromycin (500 mg - 12/12 hours) for 3 days; group placebo with 20 subjects received SRP associated with placebo. Probing depth (PD), gain in clinical attachment level (CAL) and bleeding probing were evaluated at baseline, 3 and 6 months postoperatively. As results, both treatments had clinical benefits better than baseline, just differing statistically to PD reduction for the clarithromycin group. It may be concluded that the use of clarithromycin associated with mechanical treatment is better than the gold standard for the treatment of generalized aggressive periodontitis / Mestre

Periodontitis is a chronic inflammatory infection caused by the overgrowth of bacteria harbored in tooth-retained plaque. It is estimated to affect 50% of American adults over 30, with an increased incidence of up to 70% for those over 65. The disease is characterized by the destruction of the periodontal tissues, including the periodontal ligament (PDL), root cementum, and alveolar bone. As the PDL provides tooth anchorage by connecting the root cementum to the alveolar bone, damage to this tissue results in a loss of integration with the surrounding bone and cementum, eventually leading to complete tooth detachment. This is the primary reason for tooth extractions and/or loss. Current treatments for periodontitis fail to achieve consistent PDL regeneration and integration of soft and hard tissues, thus alternative approaches are needed to improve long term outcomes. This thesis focuses on the development of a biomimetic, fiber-based, polymer composite scaffold that will enable the regeneration and integration of the hard and soft tissues comprising the periodontium, while also controlling residual infection at the wound site. This work is guided by the hypothesis that a multi-phased scaffold optimized in structure and composition to promote tissue regeneration and integration, as well as control the presence of pathogenic organisms, will augment integrative periodontal healing. The first aim of this thesis investigated scaffold design parameters for ligament regeneration, exploring polymer chemistry, fiber alignment, and antibiotic dose for the support of PDL cell growth and matrix biosynthesis. In addition, the efficacy of antibiotic-containing scaffolds in controlling the growth of periodontal pathogens was evaluated. With the overarching goal of supporting hard tissue integration, aim two optimized scaffold fiber diameter, mineral composition and dose, as well as method of mineral incorporation in order to promote PDL cell viability, growth, differentiation, and mineralized matrix deposition. In the third aim of this thesis a composite scaffold was fabricated, combining the optimized elements from the previous two aims into a multi-phased system that is mimetic of the native periodontal structure. The composite scaffold was then evaluated for tissue healing as well as for integrative potential with native tissue in a tooth-in-bone explant model. Collectively, the results of this thesis demonstrates that a scaffold with optimal structure and composition for PDL growth and integration supports enhanced periodontal healing as assessed through functional evaluation and tissue biosynthesis. In summary, the studies in this thesis led to the development of a novel, anti-infective, multi-phased scaffold which promotes integrative periodontal ligament healing. The broader implications of this work, which includes the elucidation of cell-biomaterial interactions and the implementation of complex scaffold design strategies, can be extended toward the integrative and functional repair of other composite tissue systems.

Trabajo de Investigación Requisito para optar al Título de Cirujano Dentista / Las periodontitis son un conjunto de patologías inflamatorias crónicas que se desencadenan en respuesta a la disbiosis polimicrobiana generada por bacterias periodonto-patógenas residentes en la bio-película sub-gingival. En este contexto, la formación de un denso infiltrado inmuno-inflamatorio en los tejidos periodontales, compuesto por una amplia variedad de leucocitos, citoquinas, quimioquinas proinflamatorias y factores ósteo-destructivos, resulta en la destrucción de los tejidos de soporte de los dientes. El receptor de quimioquinas homeostático CCR7 y sus ligandos desempeñan un rol clave en la migración de linfocitos y células dendríticas hacia los órganos linfoides secundarios, regulando el proceso de presentación antigénica. En otras enfermedades inflamatorias crónicas, se ha demostrado que la expresión ectópica de CCR7 altera la ubicación de los infiltrados de células inmunitarias, promoviendo la migración, activación y diferenciación de células naïve en la periferia, induciendo la formación de agregados linfoides ectópicos. Sin embargo, el rol de CCR7 en etiopatogenia de la periodontitis no ha sido aun completamente dilucidado. El objetivo de este estudio fue establecer la frecuencia de linfocitos T CD4+CCR7+ infiltrantes en tejidos periodontales de pacientes afectados de periodontitis crónica y sujetos sanos. A partir de biopsias gingivales obtenidas de pacientes afectados de periodontitis y sujetos sanos, se obtuvieron células totales en suspensión mediante digestión enzimática. La expresión de los marcadores CD4, CD25α, CD45RA, CD45RO, RORC2, Foxp3, T-bet y CCR7 fue analizada mediante citometría de flujo. Además, los marcadores CD4 y CCR7 fueron inmunolocalizados en los tejidos periodontales mediante inmuno-fluorescencia. Se detectó un mayor porcentaje de linfocitos T CD4+CD25α-CD45RA+CCR7+ (naïve), CD4+CD25α-CD45RO+CCR7 (memoria) y CD4+CD25+RORC2+CCR7 (Th17) en pacientes afectados de periodontitis en comparación con los sujetos sanos. En conclusión, existe un aumento en la frecuencia de linfocitos T naïve, de memoria y Th17 CCR7+ en los tejidos periodontales de sujetos afectados de periodontitis, lo que sugiere el posible rol quimiotáctico de CCR7 en la formación del infiltrado inflamatorio y de agrupaciones linfoides ectópicas durante la periodontitis. / Adscrito a Proyecto de FONDECYT regular 1140904.

FundaÃÃo Cearense de Apoio ao Desenvolvimento Cientifico e TecnolÃgico / CoordenaÃÃo de AperfeÃoamento de Pessoal de NÃvel Superior / The bisphosphonate tiludronic acid (TIL) presents anti-resorptive and anti-inflammatory properties and it has not been evaluated in the association periodontitis-diabetes mellitus (DM) to date. The purpose of this study was to evaluate the effects of local administration of TIL on experimental periodontitis (EP) in rats with streptozotocin (STZ)-induced DM. On day 1, thirty two rats received STZ injection. The animals were divided into groups (n=8): DM/C (Control), DM/EP, DM/EP/TIL1 and DM/EP/TIL3. In groups EP, a ligature was placed around the cervical area of mandibular first molars at day 8. In groups DM/EP/TIL1 and DM/EP/TIL3, TIL solutions of 1 and 3 mg/kg body weight, respectively, were injected into the buccal gingival margin of mandibular first molars every other day. Animals were euthanized at day 18. Histomorphometric analyses were performed. Data were statistically analyzed (p<0.05). Group DM/EP/TIL3 presented reduced alveolar bone loss and attachment loss when compared with group DM/EP (p<0.05). Within the limits of this study, it can be concluded that i) the local administration of TIL solutions presented a protective effect on tissue destruction in EP in diabetic rats and ii) the dosage of TIL may influence its effects. / O bisfosfonato Ãcido tiludrÃnico (TIL) apresenta propriedades antirreabsortivas e anti-inflamatÃrias e ainda nÃo foi estudado na associaÃÃo periodontite-diabetes mellitus (DM). O objetivo deste estudo foi avaliar os efeitos da administraÃÃo local do TIL na periodontite experimental (PE) em ratos com DM induzido por streptozotocina (STZ). No 1 dia, trinta e dois ratos receberam injeÃÃo de STZ. Os animais foram divididos nos grupos (n = 8): DM/C (Controle), DM/PE, DM/PE/TIL1 e DM/PE/TIL3. Nos grupos PE, uma ligadura foi colocada na Ãrea cervical dos primeiros molares inferiores no 8 dia. Nos grupos DM/PE/TIL1 e DM/PE/TIL3, soluÃÃes de TIL (1 e 3 mg/kg de peso corporal, respectivamente) foram injetadas na margem gengival vestibular dos primeiros molares inferiores em dias alternados. Os animais foram submetidos à eutanÃsia no 18 dia. AnÃlises histomorfomÃtricas foram realizadas. Os dados foram estatisticamente analisados (p<0,05). O grupo DM/PE/TIL3 apresentou perda Ãssea alveolar e perda de inserÃÃo reduzidas quando comparado com o grupo DM/PE (p<0,05). Dentro dos limites deste estudo, pode-se concluir que i) a administraÃÃo local de soluÃÃes de TIL apresentou um efeito protetor na destruiÃÃo tecidual na PE em ratos diabÃticos e ii) a dosagem de TIL pode influenciar seus efeitos.

In periodontitis, there is a disruption in the homeostasis of the oral microbiome by peridontopathogenic bacteria. However, while bacteria is essential for periodontitis to occur, the severity, pattern and progression of the disease is not solely determined by the microbial burden, and in fact has a lot to do with the overwhelming host inflammatory response. The response can vary even in two individuals with similar periodontopathogenic profiles. The host response leads to extracellular matrix (ECM) destruction, loss of attachment, alveolar bone resorption and eventually, edentulism. The host's reaction is orchestrated by proinflammatory cytokines and chemokines and matrix metalloproteinases (MMPs). MMPs are proteolytic enzymes capable of degrading collagen fibers from the extracellular matrix and are the main responsible for tissue damage and gingival recession in periodontitis. As a response to the limitations of the traditional therapies, new agents have been used in preclinical and clinical studies, namely host-modulatory agents, including anti-proteinase agents, anti-inflammatory agents and anti-resorptive agents. Focusing on changing the inflammatory process, as opposed to the microbial insult, can slow down the disease progression, improve clinical outcomes and even prevent tooth loss in severely compromised patients. This work examines the role of pro-inflammatory markers homocysteine in chronic inflammation and periodontitis. Homocysteine (Hcy) is a non-protein amino acid derived from the metabolism of the essential amino acid methionine via methyl group metabolism. Controlling Homocysteine as a potential inductor of MMPs, and hence of tissue destruction, can lead to new adjuvant therapies to improve clinical outcomes and prevent activation of the disease

Objetivos: Durante años, el diagnóstico de la enfermedad periodontal se ha basado en parámetros clínicos, estos parámetros clínicos convencionales miden la consecuencia de la enfermedad y la cantidad de tejido que ha sido dañado, sin embargo, no brindan información específica acerca de la actividad, progresión de la enfermedad y su respuesta al tratamiento. La respuesta del huésped a la enfermedad periodontal incluye la liberación de diferentes enzimas, algunas de ellas relacionadas con injuria y daño tisular como la enzima Alanina aminotransferasa (ALT).El propósito de este estudio fue comparar los niveles de la enzima ALT en saliva estimulada entre pacientes sanos y con enfermedad periodontal como también antes y después del tratamiento periodontal con la finalidad de conocer si la enzima ALT es un biomarcador útil para la enfermedad Periodontal. Diseño del estudio: El grupo de estudio estuvo conformado por 40 sujetos, 20 con Gingivitis y 20 con Periodontitis. El grupo control estuvo conformado por 20 sujetos sanos. Se recolectó saliva estimulada con la técnica de Parafina en ambos grupos mediante la utilización de tubos estériles y se determinó la absorbancia de ALT a través del Espectrofotómetro .Asímismo el diagnóstico de la enfermedad Periodontal en los grupos de estudio fue determinada en base a parámetros clínicos tales como el Índice de Higiene oral de O leary, índice de sangramiento gingival, profundidad al sondaje y nivel de Adherencia clínica. Resultados: Los resultados demostraron diferencia estadísticamente significativa en los niveles de ALT en el grupo de estudio específicamente para el grupo Periodontitis (p<0,001) .Igualmente, los niveles de la enzima ALT disminuyeron de manera significativa después de la terapia periodontal (p<0,001). Conclusiones: En base a estos resultados se puede concluir que los niveles de la enzima ALT en saliva estimulada puede ser considerado un marcador útil para la enfermedad periodontal y en la evaluación de la terapia periodontal. Palabras claves: Diagnóstico, Periodontitis, Gingivitis, saliva / Objectives: For years, periodontal disease diagnosis was based on clinical parameters, these conventional clinical parameters measure the result of the disease and the amount of tissue that has been damaged, however, provide no information about the activity, progression of disease and response to treatment. The host response to periodontal disease include the release of different enzymes, some of which relate to injury and tissue damage as the enzyme Alanine aminotransferase (ALT). The purpose of this study was to compare the levels of the enzyme ALT in stimulated saliva from healthy patients with periodontal disease as well as before and after periodontal treatment in order to find a biomarker for periodontal disease. Design: The study group consisted of 40 subjects, 20 with gingivitis and 20 periodontitis. The control group consisted of 20 healthy subjects. Stimulated saliva was collected with Paraffin technique of both groups in sterile tubes and ALT concentration determined through the spectrophotometer before and after periodontal therapy, the latter in the study group. Likewise Periodontal disease was determined based on clinical parameters such as the Oral Hygiene Index O leary, gingival bleeding index, probing depth and clinical adherence level. Results: The results showed statistically significant differences in ALT levels in the study group specifically for Periodontitis group (p <0.001). Similarly, the enzyme ALT levels decreased after periodontal therapy (p <0.001). Conclusions: Based on these results it can be concluded that the enzyme ALT levels in stimulated saliva can be considered a biomarker for periodontal disease and the evaluation of periodontal therapy. Key words: Diagnosis, Gingivitis, Periodontitis, Saliva. / Tesis

Orientador: Ana Cláudia Okamoto / Banca: Suzely Adas Saliba Moimaz / Banca: Aylton Valsecki Júnior / Resumo: A utilização da saliva na avaliação de condições fisiológicas e patológicas em seres humanos tem muitas vantagens como coleta simples, fácil, não invasiva e de baixo custo de armazenamento. Tem sido muito empregada no diagnóstico da doença periodontal, bem como de sua evolução e monitoramento. Durante a gestação, algumas mulheres podem desenvolver a diabete gestacional, sendo este um fator modulador da doença periodontal. A colonização e implantação do complexo vermelho de Socransky e de P. intermedia estão intimamente associados a diversas modalidades de doença periodontal podendo variar da gengivite até a doença periodontal crônica. Objetivou-se avaliar a pressão arterial e glicemia capilar em gestantes com e sem doença periodontal, relacionar alterações de pressão arterial e glicemia com as condições periodontais, bem como verificar a presença de bactérias do complexo vermelho de Socransky e de P. intermedia em gestantes com e sem doença periodontal, por meio da PCR. Participaram deste estudo caso-controle 86 gestantes com idade gestacional entre o 4º e o 7º mês, submetidas ao atendimento pré-natal em UBS. Foi avaliada a condição periodontal utilizando-se o índice IPC, proposto pela Organização Mundial da Saúde (OMS) para levantamentos epidemiológicos de saúde bucal; para o exame de verificação dos níveis glicêmicos no sangue foi utilizado um monitor de glicemia (Accu-Chek Advantage II, Roche, USA), para a aferição da pressão arterial utilizou-se esfigmomanômetroe para a coleta de saliva foram utilizados cones de papel absorventes esterilizados (No. 30, Endopoints Ind. Com. Ltda, RJ.).A extração de DNA foi realizada pelo o kit Easy-DNA (Invitrogen, SP) e a presença das bactérias foi detectada por PCR com primers e sondas específicas para cada microrganismo. O teste Exato de Fisher foi utilizado para verificar... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Saliva has been an important resource for the evaluation of physiological and pathological conditions in humans. Its utilization has several advantages, including simple and easy collection, besides being non invasive and having a low storage cost. Saliva utilization as a diagnosis mean for periodontal disease, as well as its evolution and management, has become more studied. During pregnancy, some women can develop gestational diabetes, which is a modulating factor of periodontal disease. The colonization and implantation of the Socransky red complex and Prevotella intermedia are intimately associated to several modalities of periodontal disease, varying from gingivitis to chronic periodontal disease. This study aimed to evaluate the arterial pressure and capillary glycemia of pregnant women with and without periodontal disease, and to relate arterial pressure and glycemia alterations with periodontal conditions, as well as to verify the presence of bacteria from the Socransky red complex and P. intermedia in pregnant women with and without periodontal disease, by PCR. This case-control study included 86 pregnant women with gestational age between the 4th and the 7th months, submitted to pre-natal attendance in Health Basic Units (HBU). Periodontal condition was assessed through the CPI (Community Periodontal Index), proposed by the World Health Organization (WHO) for epidemiologic analysis of oral health; for the verification of blood glycemic levels it was used a glycemia monitor (Accu-Chek Advantage II, Roche, USA); a sphygmomanometer was used to check the arterial pressure; and, for the saliva gathering, sterilized absorbent paper cones were used (No. 30, Endopoints Ind. Com. Ltda., RJ., Brazil). DNA extraction was accomplished through the Easy-DNA Kit test (Invitrogen, SP, Brazil) and the presence of bacteria was detected by PCR with primers and specific probes... (Complete abstract click electronic access below) / Mestre

Objectives: The aim of this pilot study was to compare the changes in oral and gut microbiota, endotoxemia, and systemic and local inflammatory markers following oral interventions in subjects with and without cirrhosis. Methods: Study subjects displaying gingivitis or mild/moderate periodontitis were placed into two groups: with cirrhosis (n= 24) and without cirrhosis (n=21). Each subject received nonsurgical periodontal therapy. Serum, stool and saliva samples were collected prior to and 30 days post-therapy and analyzed for stool/saliva microbiome, MELD score, endotoxin and IL-6 levels. Results: There was no difference in age, gender and the periodontal disease status between groups. At day 30 post therapy, there was a significant reduction in MELD score, endotoxin levels, IL-6 levels and oral and stool microbiome dysbiosis in cirrhotic patients. Conclusion: Endotoxemia and systemic inflammation can be reduced following periodontal therapy, which is likely due to improvement in oral-origin microbiota in both saliva and stool in cirrhotic patients.

Trabajo de Investigación Requisito para optar al Título de Cirujano Dentista / La periodontitis es una enfermedad inmuno-inflamatoria que destruye los tejidos de soporte dentario, su etiología es la presencia de bacterias generadoras de respuestas inmuno-inflamatorias en el hospedero. El tratamiento convencional es el destartraje supragingival en conjunto con el pulido y alisado radicular, el cual, dependiendo de las condiciones del paciente, puede ser asociado a un antibiótico sistémico, uno de los antibióticos más utilizados es la azitromicina, debido a su efecto sobre anaerobios Gram negativos, que posee vida media prolongada, posee una dosificación cómoda y mínimas reacciones adversas. Por otro lado, Lactobacillus rhamnosus es una bacteria Gram positivo, que al ser ocupada como probiotico, ha mostrado eficacia en el tratamiento de las caries, y capacidad inhibitoria de algunos periodontopatógenos. El objetivo de este trabajo fue comparar la eficacia del uso de un probiótico, en base a l. rhamnosus, con azitromicina y controlado con un placebo, asociados a terapia periodontal convencional. Para esto se cuantificó la microbiota total cultivable, se determinó, comparó y cuantificó la presencia de Porphyromonas gingivalis (Pg), Tannerella forsythia (Tf), y Aggregatibacter actinomycetemcomitans (Aa), se midieron los parámetros clínicos (nivel de inserción clinica, profundidad de sondaje, índice de placa e índice de sangrado) durante 9 meses de seguimiento, en el tratamiento de un grupo de adultos chilenos con periodontitis crónica. Materiales y métodos: Se realizó un ensayo clínico aleatorizado, de diseño paralelo, enmascarado y controlado mediante placebo. Los pacientes seleccionados fueron seleccionados y randomizados en 3 grupos (probiotico, antibiótico y placebo). Se realizaron mediciones de los parámetros en el tiempo basal, y control a los 9 meses. Se evaluaron parámetros microbiológicos y clínicos (profundidad de sondaje, índice de placa, índice de sangrado y nivel de inserción clínica). La microbiota total cultivable y el recuento de Pg fueron analizados mediante técnicas microbiológicas clásicas. La prevalencia de Pg, Tf y Aa fue determinada mediante identificación molecular por PCR. Se consideró significancia estadística para valor p < 0,05 y un intervalo de confianza de un 95%. / Adscrito a proyecto de investigación FONDECYT No11305705

Tesis Magister en Ciencias Odontológicas con Mención en Periodontologia / Las enfermedades orales, periodontitis crónica y caries dental, además de ser las principales causas de pérdida dentaria, son un grave problema de salud pública. Sin embargo, la simultaneidad de ambas enfermedades y/o asociación, ha sido escasamente estudiada. El propósito del presente estudio secundario, fue determinar la simultaneidad en prevalencia y severidad de periodontitis y caries dental e identificar los factores asociados a dicha simultaneidad dentro de la población chilena adulta entre 35-44 años utilizando la base de datos del Primer Estudio Nacional de Salud Bucal en Adultos 2007-8. Se determinó que la periodontitis se asocia positivamente con un aumento en la prevalencia y severidad de caries no tratada (vs los individuos sin periodontitis). Sin embargo, no se detectó una asociación positiva entre la severidad de periodontitis y la prevalencia y severidad de caries no tratada. El género masculino y el tabaquismo se asociaron positivamente con la ocurrencia simultanea de ambas patologías.