Pocket closure after repeated subgingival instrumentation: a stress test to the EFP guideline for stage III-IV periodontitis

Effectiveness of nonsurgical re-instrumentation: Tooth-related factors

BACKGROUND

To investigate tooth-related factors that influence pocket closure (PC) and the reduction of pocket probing depths (PPD) after nonsurgical re-instrumentation (NSRI) as part of step 3 therapy.

METHODS

A total of 480 patients (10,807 teeth) presenting with residual pockets 6.33 ± 3.79 months after steps 1 and 2 of periodontal therapy were included and retrospectively analyzed before and 5.93 ± 4.31 months after NSRI. Reduction of PPD and PC rates following NSRI were associated with tooth-related factors, namely tooth type, arch, number of roots, furcation involvement (FI), pulp vitality, mobility, type of restoration, presence of plaque, and bleeding on probing (BOP), using mixed-effects regression models.

RESULTS

NSRI reduced periodontal pockets persisting after initial cause-related therapy by (mean ± SD) 1.32 ± 1.79 mm in PPD, and PC rate was 40%. Moderate pockets (4-5 mm) responded better to NSRI than deep pockets (≥ 6 mm) in terms of PC (51% vs. 16%). Both PPD reduction and PC rates of deep residual pockets were significantly influenced by tooth type, arch, number of roots, and presence of BOP.

CONCLUSION

Tooth type, arch, number of roots, and presence of BOP at re-evaluation (before NSRI) had a significant and clinically relevant influence on NSRI as part of step 3 therapy. Considering these factors, particularly for deep residual pockets, may allow more tailored re-intervention.

PLAIN LANGUAGE SUMMARY

The present study aimed to investigate the influence of tooth-related factors on the outcome of repeated nonsurgical therapy of periodontitis. Therefore, 480 patients (10,807 teeth) presenting with clinical symptoms of persistent periodontitis after initial therapy were administered repeated nonsurgical therapy and retrospectively analyzed. Therapy outcomes were associated with tooth-related factors, namely tooth type, tooth location (maxilla/mandible), number of roots, involvement of the root furcation area in multi-rooted teeth, pulp vitality, mobility, restoration, presence of plaque and bleeding upon periodontal probing, using mixed-effects models. The results revealed that repeated nonsurgical therapy was effective in reducing inflammation and clinical signs of disease, with moderate residual periodontal defects responding better than deep defects. Healing of deep defects after repeated nonsurgical therapy; however, was significantly influenced by the factors: tooth type, location, number of roots, and bleeding on probing. Considering these factors, particularly in deep residual defects which are commonly suggested to be treated surgically, may allow less invasiveness and thus a more tailored re-intervention.

Non-surgical retreatment versus papillary preservation flap surgery for residual pockets: A randomized controlled trial with clinical and patient-reported outcomes

AIM

To compare the efficacy of non-surgical re-instrumentation (NSR) and papillary preservation flap (PPF) surgery at single-rooted teeth with residual pockets.

MATERIALS AND METHODS

Patients with at least a residual pocket depth (PD ≥ 5 mm) after Steps I and II were enrolled and randomly assigned to receive NSR or PPF surgery. The primary outcome was PD reduction, and secondary outcomes were clinical attachment level (CAL) change and patient-reported outcome measures (PROMs). Outcome variables were measured at baseline, 3 and 6 months. The examiner was blinded. Statistical analysis, one site for each patient, included descriptive statistics and analysis of covariance.

RESULTS

Forty-six participants were enrolled, and one patient dropped out in the PPF group. After 6 months, both treatments resulted in significant PD reduction (1.3 ± 1.2 mm, p = .009 NSR; 2.0 ± 0.7 mm, p < .001 PPF) and CAL gain (1.0 ± 2.4 mm, p = .031 NSR; 1.4 ± 0.8 mm, p < .001 PPF). PD reduction between groups was not statistically significant (diff: 0.6 mm; 95% confidence interval [CI] [-0.3 to 1.5]; p = .167). Pocket closure was 61% NSR versus 86% PPF (p = .091). Smoking was associated with less PD reduction of almost 1 mm in both treatments. Treatment time was longer for PPF surgery, but PROMs and post-operative pain were similar between groups.

CONCLUSIONS

Both NSR and PPF reduced PD without significant difference between treatments at 6 months. PPF surgery may offer faster PD reduction, but smoking habits reduce treatment efficacy.

The flapless approach with and without enamel matrix derivatives for the treatment of intrabony defects: A randomized controlled clinical trial

AIM

To compare the clinical and radiographic outcomes of flapless procedure alone or in combination with enamel matrix derivatives (EMD) in the treatment of deep intrabony defects.

MATERIALS AND METHODS

Forty-six patients re-evaluated after non-surgical therapy were randomly assigned to the test (flapless with EMD) or control group (flapless alone). Clinical measurements were recorded pre-surgery and at 6 and 12 months after surgery, and radiographic measurements were taken pre-surgery and after 12 months.

RESULTS

Forty-six patients completed the study. Improvements were observed in both groups at 12 months for mean clinical attachment level (CAL) gain, with significant differences between test (3.9 ± 1.1 mm) and control groups (3.0 ± 1.2) (p = .017). Probing pocket depth (PPD) reduction (4.0 ± 0.7 vs. 3.3 ± 1.4 mm) was also near to statistical significance (p = .051). Also, more sites achieved successful composite outcome measure (final PPD ≤ 4 mm and CAL gain ≥3 mm) for the regenerative treatment in the flapless + EMD group (82.6% vs. 52.2%; p = .028). In terms of radiographic outcomes, EMD yielded a greater defect bone fill than flapless treatment alone (3.0 ± 1.0 mm vs. 1.8 ± 1.5 mm; p < .001).

CONCLUSIONS

The additional application of EMD during the flapless procedure for intrabony defects slightly improved clinical and radiographic outcomes.

CLINICALTRIALS

gov identification number: NCT05456555.

Orally Derived Stem Cell-Based Therapy in Periodontal Regeneration: A Systematic Review and Meta-Analysis of Randomized Clinical Studies

The present systematic review was performed to assess the application of orally derived stem cells in periodontal regenerative therapy, and because of this, the following PICO question was proposed: "In patients with periodontitis, can the adjunctive use of orally derived stem cells provide additional clinical and radiographic benefits for periodontal regeneration?". Randomized clinical studies were electronically and manually searched up until December 2023. Quantitative analyses were performed with the aim of evaluating the mean differences (MDs) between the treatment and control groups in terms of clinical attachment level (CAL) gain, probing pocket depth (PPD) reduction, gingival recession (GR), and radiographic bone gain (RBG) using random effect models. A total of seven studies were selected for the systematic review. Meta-analyses excluding studies with a high risk of bias highlighted a non-statistically significant result for the use of stem cells when compared to the control groups in terms of CAL gain [MD = 1.05; 95% CI (-0.88, 2.97) p = 0.29] and PPD reduction [MD = 1.32; 95% CI (-0.25, 2.88) p = 0.10]. The same also applied to GR [MD = -0.08; 95% CI (-0.79, 0.63) p = 0.83] and RBG [MD = 0.50; 95% CI (-0.88, 1.88) p = 0.48]. Based on the high heterogeneity, there is not enough evidence to consider the adjunctive application of orally derived mesenchymal stem cells as a preferential approach for periodontal regenerative treatment, as compared to standard procedures.

From Basic Science to Clinical Practice: A Review of Current Periodontal/Mucogingival Regenerative Biomaterials

Periodontitis is a dysbiosis-driven inflammatory disease affecting the tooth-supporting tissues, characterized by their progressive resorption, which can ultimately lead to tooth loss. A step-wise therapeutic approach is employed for periodontitis. After an initial behavioral and non-surgical phase, intra-bony or furcation defects may be amenable to regenerative procedures. This review discusses the regenerative technologies employed for periodontal regeneration, highlighting the current limitations and future research areas. The search, performed on the MEDLINE database, has identified the available biomaterials, including biologicals (autologous platelet concentrates, hydrogels), bone grafts (pure or putty), and membranes. Biologicals and bone grafts have been critically analyzed in terms of composition, mechanism of action, and clinical applications. Although a certain degree of periodontal regeneration is predictable in intra-bony and class II furcation defects, complete defect closure is hardly achieved. Moreover, treating class III furcation defects remains challenging. The key properties required for functional regeneration are discussed, and none of the commercially available biomaterials possess all the ideal characteristics. Therefore, research is needed to promote the advancement of more effective and targeted regenerative therapies for periodontitis. Lastly, improving the design and reporting of clinical studies is suggested by strictly adhering to the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement.