Treatment of gingival recessions in heavy smokers using two surgical techniques: a controlled clinical trial

Smokers have small root coverage which is associated with bad vascularity of periodontal tissues. This study evaluated a technique that can increase the blood supply to the periodontal tissues compared with a traditional technique. Twenty heavy smokers (10 males and 10 females) with two bilateral Miller class I gingival recessions received coronally positioned flaps in one side (Control group)and extended flap technique in the other side (Test group). Clinical measurements (probing pocket depth, clinical attachment level, bleeding on probing, gingival recession height, gingival recession width, amount of keratinized tissue, and width and height of the papillae adjacent to the recession) were determined at baseline, 3 and 6 months postoperatively. Salivary cotinina samples were taken as an indicator of the nicotine exposure level. No statistically significant differences (p>0.05) were detected for the clinical measurements or smoke exposure. Both techniques promoted low root coverage (Control group: 43.18% and Test group: 44.52%). In conclusion, no difference was found in root coverage between the techniques. Root coverage is possible and uneventful even, if rather low, in heavy smoker patients with low plaque and bleeding indices.

Cementum, apical morphology and hypercementosis: a probable adaptive response of the periodontal support tissues and potential orthodontic implications

Information about orthodontic movement of teeth with hypercementosis is scarce. As cementum deposition continues to occur, cementum is expected to change the shape of the root and apex over time, but this has not yet been demonstrated. Nor has it ever been established whether it increases or decreases the prevalence of root resorption during orthodontic treatment. The unique biological function of the interconnected network of cementocytes may play a role in orthodontic movement and its associated root resorptions, but no research has ever been conducted on the topic. Unlike cementum thickness and hypercementosis, root and apex shape has not yet been related to patient age. A study of the precise difference between increased cementum thickness and hypercementosis is warranted. Hypercementosis refers to excessive cementum formation above and beyond the extent necessary to fulfill its normal functions, resulting in abnormal thickening with macroscopic changes in the tooth root, which may require the delivery of forces that are different from conventional mechanics in their intensity, direction and distribution. What are the unique features and specificities involved in moving teeth that present with hypercementosis? Bodily movements would be expected to occur, since inclination might prove difficult to achieve, but would the root resorption index be higher or lower?

Study of the number of occlusal contacts in maximum intercuspation before orthodontic treatment in subjects with Angle Class I and Class II Division 1 malocclusion

OBJECTIVE: Define and compare numbers and types of occlusal contacts in maximum intercuspation. METHODS: The study consisted of clinical and photographic analysis of occlusal contacts in maximum intercuspation. Twenty-six Caucasian Brazilian subjects were selected before orthodontic treatment, 20 males and 6 females, with ages ranging between 12 and 18 years. The subjects were diagnosed and grouped as follows: 13 with Angle Class I malocclusion and 13 with Angle Class II Division 1 malocclusion. After analysis, the occlusal contacts were classified according to the established criteria as: tripodism, bipodism, monopodism (respectively, three, two or one contact point with the slope of the fossa); cuspid to a marginal ridge; cuspid to two marginal ridges; cuspid tip to opposite inclined plane; surface to surface; and edge to edge. RESULTS: The mean number of occlusal contacts per subject in Class I malocclusion was 43.38 and for Class II Division 1 malocclusion it was 44.38, this difference was not statistically significant (p>0.05). CONCLUSIONS: There is a variety of factors that influence the number of occlusal contacts between a Class I and a Class II, Division 1 malocclusion. There is no standardization of occlusal contact type according to the studied malocclusions. A proper selection of occlusal contact types such as cuspid to fossa or cuspid to marginal ridge and its location in the teeth should be individually defined according to the demands of each case. The existence of an adequate occlusal contact leads to a correct distribution of forces, promoting periodontal health.

Short-term effects of systemic antibiotics during periodontal healing

OBJECTIVES: To investigate the short-term effects of nonsurgical therapy (scaling and root planing, SRP) on the subgingival microbiota in chronic (CP) and aggressive (AP) periodontal disease. METHOD AND MATERIALS: Ninety-seven CP and AP subjects underwent full-mouth SRP on 2 consecutive days. AP patients were randomly assigned to either receive systemic metronidazole plus amoxicillin (AP+AB) or were treated mechanically alone (AP). Pathogens were identified with 16S rRNA oligodeoxynucleotide probes and dot-blot hybridization before and at days 2, 3, 4, 7, 10, and 21 of healing. CP subjects were treated by scaling and root planing along with placebo tablets. RESULTS: Initially, AP cell counts were 69.9- (Porphyromonas gingivalis), 10.2- (Aggregatibacter actinomycetemcomitans), 5.7- (Tannerella forsythia), and 3.3-fold (Prevotella intermedia) enhanced compared to CP cell counts. Following SRP, immediate elimination occurred in single individuals of all three treatment groups at day 2. After SRP plus antibiotic therapy (AP+AB), the prevalence scores dropped beyond the levels of AP and CP, beginning at day 7, and remained low until day 21 (P =or< .05). Clinical healing statistically benefited from SRP with no differences among the three treatment groups. CONCLUSION: Nonsurgical therapy resulted in both a suppression and early elimination of single taxa immediately after completion of active treatment. Systemic antibiotics significantly accelerate the suppression of the periodontal microflora, but have limited effect on the elimination of target isolates during healing.

Effect of smoking on the results of a chlorhexidine digluconate treatment extended up to 3 months after scaling and root planing-a pilot study

The aim of the study was to evaluate the impact of smoking on a prolongated chlorhexidine digluconate regimen after scaling and root planing. Forty-two smokers (test group) and 85 nonsmoking patients (control group) with generalized chronic periodontitis were examined for clinical attachment level (CAL), probing depth (PD), bleeding on probing (BoP), and Plaque Index (Pl) at baseline and after 1 and 3 months. During scaling and root planing, a 0.2% chlorhexidine digluconate solution and a 1% chlorhexidine digluconate gel were used. The subjects used a 0.2% chlorhexidine digluconate solution twice daily for 3 months. The Mann-Whitney U and Wilcoxon tests were used for statistical analysis. There were significant improvements of all studied variables after 1 and 3 months in both groups. After 3 months, the mean improvement in the test group was 1.62 mm for CAL, 2.85 mm for PD, and 48% for BoP; in the control group, the values were 2.18 mm for CAL, 2.81 mm for PD, and 47% for BoP. Only the maximum changes of CAL between 1 and 3 months (test group, 0.32 mm vs 0.69 mm in the control group) and PD (test group, 0.47 mm vs 0.76 mm in the control group) were significantly different between the groups (P < .05 and P = .05, respectively). The present data appear to suggest that the use of chlorhexidine digluconate twice daily during a period of 3 months following nonsurgical periodontal therapy may result in significant clinical improvements in smokers and nonsmokers.

In vitro evaluation of surface roughness, adhesion of periodontal ligament fibroblasts, and Streptococcus gordonii following root instrumentation with Gracey curettes and subsequent polishing with diamond-coated curettes

OBJECTIVES: The objective of the study was to evaluate the efficacy of an additional usage of a diamond-coated curette on surface roughness, adhesion of periodontal ligament (PDL) fibroblasts, and of Streptococcus gordonii in vitro. MATERIALS AND METHODS: Test specimens were prepared from extracted teeth and exposed to instrumentation with conventional Gracey curettes with or without additional use of diamond-coated curettes. Surface roughness (Ra and Rz) was measured before and following treatment. In addition, the adhesion of PDL fibroblasts for 72 h and adhesion of S. gordonii ATCC 10558 for 2 h have been determined. RESULTS: Instrumentation with conventional Gracey curettes reduced surface roughness (median Ra before: 0.36 μm/after: 0.25 μm; p < 0.001; median Rz before: 2.34 μm/after: 1.61 μm; p < 0.001). The subsequent instrumentation with the diamond-coated curettes resulted in a median Ra of 0.31 μm/Rz of 2.06 μm (no significance in comparison to controls). The number of attached PDL fibroblasts did not change following scaling with Gracey curettes. The additional instrumentation with the diamond-coated curettes resulted in a two-fold increase in the number of attached PDL fibroblasts but not in the numbers of adhered bacteria. CONCLUSIONS: Treatment of root surfaces with conventional Gracey curettes followed by subsequent polishing with diamond-coated curettes may result in a root surface which provides favorable conditions for the attachment of PDL fibroblasts without enhancing microbial adhesion. CLINICAL RELEVANCE: The improved attachment of PDL fibroblasts and the limited microbial adhesion on root surfaces treated with scaling with conventional Gracey curettes followed by subsequent polishing with diamond-coated curettes may favor periodontal wound healing.

A phase IIa randomized controlled pilot study evaluating the safety and clinical outcomes following the use of rhGDF-5/β-TCP in regenerative periodontal therapy

To present the safety profile, the early healing phase and the clinical outcomes at 24 weeks following treatment of human intrabony defects with open flap debridement (OFD) alone or with OFD and rhGDF-5 adsorbed onto a particulate β-tricalcium phosphate (β-TCP) carrier. Twenty chronic periodontitis patients, each with at least one tooth exhibiting a probing depth ≥6 mm and an associated intrabony defect ≥4 mm entered the study. Ten subjects (one defect/patient) were randomized to receive OFD alone (control) and ten subjects OFD combined with rhGDF-5/β-TCP. Blood samples were collected at screening, and at weeks 2 and 24 to evaluate routine hematology and clinical chemistry, rhGDF-5 plasma levels, and antirhGDF-5 antibody formation. Plaque and gingival indices, bleeding on probing, probing depth, clinical attachment level, and radiographs were recorded pre- and 24 weeks postsurgery. Comparable safety profiles were found in the two treatment groups. Neither antirhGDF-5 antibody formation nor relevant rhGDF-5 plasma levels were detected in any patient. At 6 months, treatment with OFD + rhGDF-5/β-TCP resulted in higher but statistically not significant PD reduction (3.7 ± 1.2 vs. 3.1 ± 1.8 mm; p = 0.26) and CAL gain (3.2 ± 1.7 vs. 1.7 ± 2.2 mm; p = 0.14) compared to OFD alone. In the tested concentration, the use of rhGDF-5/β-TCP appeared to be safe and the material possesses a sound biological rationale. Thus, further adequately powered, randomized controlled clinical trials are warranted to confirm the clinical relevance of this new approach in regenerative periodontal therapy. rhGDF-5/β-TCP may represent a promising new techology in regenerative periodontal therapy.

Microbial colonization patterns predict the outcomes of surgical treatment of intrabony defects

AIM: To explore the impact of bacterial load and microbial colonization patterns on the clinical outcomes of periodontal surgery at deep intrabony defects. MATERIALS AND METHODS: One hundred and twenty-two patients with advanced chronic periodontitis and at least one intrabony defect of >3 mm were recruited in 10 centres. Before recruitment, the infection control phase of periodontal therapy was completed. After surgical access and debridement, the regenerative material was applied in the test subjects, and omitted in the controls. At baseline and 1 year following the interventions, clinical attachment levels (CAL), pocket probing depths (PPD), recession (REC), full-mouth plaque scores and full-mouth bleeding scores were assessed. Microbial colonization of the defect-associated pocket was assessed using a DNA-DNA checkerboard analysis. RESULTS: Total bacterial load and counts of red complex bacteria were negatively associated with CAL gains 1 year following treatment. The probability of achieving above median CAL gains (>3 mm) was significantly decreased by higher total bacterial counts, higher red complex and T. forsythensis counts immediately before surgery. CONCLUSIONS: Presence of high bacterial load and specific periodontal pathogen complexes in deep periodontal pockets associated with intrabony defects had a significant negative impact on the 1 year outcome of surgical/regenerative treatment.

Guided tissue regeneration/deproteinized bovine bone mineral or papilla preservation flaps alone for treatment of intrabony defects. II: radiographic predictors and outcomes

OBJECTIVES: This study reports the secondary analysis of a randomized-controlled clinical trial designed to assess the efficacy of deproteinized bovine mineral and a collagen membrane in the treatment of intrabony defects. The specific aims of this report are (1) to analyse the radiographic bone changes 1 year after therapy and (2) to assess the association between radiographic defect angle and treatment outcomes. MATERIALS AND METHODS: Baseline and 12-month radiographs were collected from 120 patients with advanced chronic periodontitis from 10 centres in seven countries as part of a multi-centre clinical trial. All patients had at least one intrabony defect > or =3 mm in depth. The treatment consisted of simplified or modified papilla preservation flaps to access the defect. After debridement of the area, a deproteinized bovine mineral and a collagen membrane were applied in the test subjects, and omitted in the controls. Main outcome measures were radiographic bone fill and defect resolution 1 year after surgery. RESULTS: One hundred and twenty pairs of radiographs were obtained, of which 110 pairs were measurable (57 tests and 53 controls). One year after treatment, radiographic resolution of the intrabony component was significantly higher in the test group (3.2+/-1.7 mm) when compared with the controls (1.7+/-1.9 mm). Multivariate analysis indicated that the treatment and the baseline radiographic depth of the intrabony defect significantly influenced the radiographic bone fill of the intrabony defect 1 year following treatment. The percentage of resolution of the defect was influenced by the treatment provided and the baseline plaque score. The baseline radiographic defect angle did not show a significant impact on the clinical and radiographic outcomes. CONCLUSIONS: Regenerative periodontal surgery with a deproteinized bovine bone mineral and a collagen membrane offered additional benefits in terms of radiographic resolution of the intrabony defect and predictability of outcomes with respect to papilla preservation flaps alone.

Treatment of replacement resorption by intentional replantation, resection of the ankylosed sites, and Emdogain--results of a 6-year survey

The present clinical study investigated the outcome of intentional replantation using resection of the ankylosed sites of the root, extraoral endodontic treatment using titanium posts and Emdogain for periodontal healing following trauma-related ankylosis. During an evaluation period of 6 years, 16 ankylosed teeth affected by replacement resorption were treated as described. Evaluation parameters before treatment and during the follow-up period included Periotest scores, percussion sound and periapical radiographs. All findings were compared to those of the adjacent teeth. In a second accident, one tooth was lost after 7 months and was excluded as a dropout. Ankylosis did not recur in seven replanted teeth, which were observed for an average of 52.3 months (range: 24-68 months). Ankylosis recurred in eight teeth after an average period of 12 months (range: 4-26 months). An infraocclusion, normal or only slightly reduced Periotest scores and normal percussion sound were preoperatively found in six of seven successfully replanted teeth, which corresponded to a relatively small area of ankylosis. The majority of the teeth showing recurrent ankylosis preoperatively presented with normal position, negative Periotest scores and a high percussion sound which corresponded to an extended area of ankylosis. Statistically significant relationship between preoperative findings and the treatment outcome (P = 0.031) have become apparent. The results indicate that the treatment of minor areas of ankylosis by intentional replantation, resection of the ankylosed sites and Emdogain appeared to prevent or delay the recurrence of ankylosis in 7 of 15 teeth.

Pulp and periodontal healing of laterally luxated permanent teeth: results after 4 years

AIM: To evaluate the pulp and periodontal healing of laterally luxated permanent teeth. MATERIAL AND METHODS: Patients presenting with lateral luxation of permanent teeth during 2001-2002 were enrolled in this clinical study. Laterally luxated teeth were repositioned and splinted with a TTS/composite resin splint for 4 weeks. Immediate (prophylactic) root-canal treatment was performed in severely luxated teeth with radiographically closed apices. All patients received tetracycline for 10 days. Re-examinations were performed after 1, 2, 3, 6, 12 and 48 months. RESULTS: All 47 laterally luxated permanent teeth that could be followed over the entire study period survived. In 10 teeth (21.3%), a prophylactic root-canal treatment was performed within 2 weeks following injury. The remaining 37 teeth showed the following characteristics at the 4-year re-examination: 19 teeth (51.4%) had pulp survival (no clinical or radiographic signs or symptoms), nine teeth (24.3%) presented with pulp canal calcification, and pulp necrosis was seen in another nine teeth (24.3%), within the first year after trauma. None of the teeth with a radiographically open apex at the time of lateral luxation showed complications. External root resorption was only seen in one tooth. CONCLUSIONS: Laterally luxated permanent teeth with incomplete root formation have a good prognosis, with all teeth surviving in this study. The most frequent complication was pulp necrosis that was only seen in teeth with closed apices.

One-year outcomes of repeated adjunctive photodynamic therapy during periodontal maintenance: a proof-of-principle randomized-controlled clinical trial

BACKGROUND: Single photodynamic therapy (PDT) has been effective in initial periodontal therapy, but only improved bleeding on probing (BoP) in maintenance patients after a single use. Repeated PDT has not been addressed. OBJECTIVES: To study the possible added benefits of repeated adjunctive PDT to conventional treatment of residual pockets in patients enrolled in periodontal maintenance. MATERIAL AND METHODS: Ten maintenance patients with 70 residual pockets [probing pocket depth (PPD)>or=5 mm] were randomly assigned for treatment five times in 2 weeks (Days 0, 1, 2, 7, 14) with PDT (test) or non-activated laser (control) following debridement. The primary outcome variable was PPD, and the secondary variables were clinical attachment level (CAL) and BoP. These were assessed at 3, 6 and 12 months following the interventions. RESULTS: Greater PPD reductions were observed in the test (-0.67 +/- 0.34; p=0.01) compared with the control patients (-0.04 +/- 0.33; NS) after 6 months. Significant CAL gain (+0.52 +/- 0.31; p=0.01) was noted for the test, but not in the control (-0.27 +/- 0.52; NS) patients after 6 months. BoP percentages decreased significantly in test (97-64%, 67%, 77%), but not control patients after 3, 6 and 12 months. CONCLUSIONS: Repeated (five times) PDT adjunctive to debridement yielded improved clinical outcomes in residual pockets in maintenance patients. The effects were best documented after 6 months.

Gingival recessions and the change of inclination of mandibular incisors during orthodontic treatment

SUMMARY A recent systematic review demonstrated that, overall, orthodontic treatment might result in a small worsening of periodontal status. The aim of this retrospective study was to test the hypothesis that a change of mandibular incisor inclination promotes development of labial gingival recessions. One hundred and seventy-nine subjects who met the following inclusion criteria were selected: age 11-14 years at start of orthodontic treatment (TS), bonded retainer placed immediately after treatment (T₀), dental casts and lateral cephalograms available pre-treatment (TS), post-treatment (T₀), 2 years post-treatment (T₂), and 5 years post-treatment (T₅). Depending on the change of lower incisor inclination during treatment (ΔInc_Incl), the sample was divided into three groups: Retro (N = 34; ΔInc_Incl ≤ -1 degree), Stable (N = 22; ΔInc_Incl > -1 degree and ≤1 degree), and Pro (N = 123; ΔInc_Incl > 1 degree). Clinical crown heights of mandibular incisors and the presence of gingival recessions in this region were assessed on plaster models. Fisher's exact tests, one-way analysis of variance, and regression models were used for analysis of inter-group differences. The mean increase of clinical crown heights (T₀ to T₅) of mandibular incisors ranged from 0.6 to 0.91 mm in the Retro, Stable, and Pro groups, respectively; the difference was not significant (P = 0.534). At T₅, gingival recessions were present in 8.8, 4.5, and 16.3 per cent patients from the Retro, Stable, and Pro groups, respectively. The difference was not significant (P = 0.265). The change of lower incisors inclination during treatment did not affect development of labial gingival recessions in this patient group.

Clinical outcomes following subgingival application of a novel erythritol powder by means of air polishing in supportive periodontal therapy: a randomized, controlled clinical study

OBJECTIVES The aim of this prospective, randomized, controlled clinical study was to compare the clinical outcomes of the subgingival treatment with erythritol powder by means of an air-polishing (EPAP) device and of scaling and root planing (SRP) during supportive periodontal therapy (SPT). METHOD AND MATERIALS 40 patients enrolled in SPT were randomly assigned to two groups of equal size. Sites had to show signs of inflammation (bleeding on probing [BOP]-positive) and a probing pocket depth (PPD) of ≥ 4 mm, however, without presence of detectable subgingival calculus. During SPT, these sites were treated with EPAP or SRP, respectively. Full mouth and site-specific plaque indices, BOP, PPD, and clinical attachment level (CAL) were recorded at baseline (BL) and at 3 months, whereas the percentage of study sites positive for BOP (BOP+) was considered as primary outcome variable. Additionally, patient comfort using a visual analog scale (VAS) and the time needed to treat per site was evaluated. RESULTS At 3 months, mean BOP level measured 45.1% at test sites and 50.6% at control sites, respectively, without a statistically significant difference between the groups (P > .05). PPD and CAL slightly improved for both groups with comparable mean values at 3 months. Evaluation of patient tolerance showed statistically significantly better values among patients receiving the test treatment (mean VAS [0-10], 1.51) compared to SRP (mean VAS [0-10], 3.66; P = .0012). The treatment of test sites was set to 5 seconds per site. The treatment of control sites, on the other hand, lasted 85 seconds on average. CONCLUSION The new erythritol powder applied with an air-polishing device can be considered a promising modality for repeated instrumentation of residual pockets during SPT. CLINICAL RELEVANCE With regard to clinical outcomes during SPT, similar results can be expected irrespective of the two treatment approaches of hand instrumentation or subgingival application of erythritol powder with an air-polishing device in sites where only biofilm removal is required.

Absorbable collagen membranes for periodontal regeneration: a systematic review

Guided tissue regeneration (GTR) with bioabsorbable collagen membranes (CM) is commonly used for the treatment of periodontal defects. The objective of this systematic review of randomized clinical trials was to assess the clinical efficacy of GTR procedures with CM, with or without bone substitutes, in periodontal infrabony defects compared with that of open flap debridement (OFD) alone. Primary outcomes were tooth loss and gain in clinical attachment level (CAL). Screening of records, data extraction, and risk-of-bias assessments were performed by two reviewers. Weighted mean differences were estimated by random effects meta-analysis. We included 21 reports on 17 trials. Risk of bias was generally high. No data were available for the primary outcome tooth loss. The summary treatment effect for change in CAL for GTR with CM compared with OFD was 1.58 mm (95% CI, 1.27 to 1.88). Despite large between-trial heterogeneity (I2 = 75%, p < .001), all trials favored GTR over OFD. No differences in treatment effects were detected between trials of GTR with CM alone and trials of GTR with CM in combination with bone substitutes (p for interaction, .31). GTR with CM, with or without substitutes, may result in improved clinical outcomes compared with those achieved with OFD alone. Our findings support GTR with CM for the treatment of infrabony periodontal defects.