A systematic review on the use of residual probing depth, bleeding on probing and furcation status following initial periodontal therapy to predict further attachment and tooth loss

Influence of residual pockets on periodontal tooth loss: A retrospective analysis

BACKGROUND

Individuals enrolled in supportive periodontal therapy (SPT) can still present with tooth loss due to periodontitis (TLP). There is limited evidence on the influence of residual pockets (RPc) and a defined "threshold" at which a patient's profile is set to be at high risk for TLP in the literature. Therefore, this study aimed to assess the influence of RPc on TLP and determine the prognostic performance of RPc compared to the staging and grading of periodontitis on TLP risk.

METHODS

Clinical data from 168 patients (3869 teeth) treated for periodontitis and receiving SPT for at least 10 years were evaluated in this retrospective study. TLP and the percentage of sites with RPc ≥ 5 mm or ≥6 mm per patient were collected. The prognostic performance of RPc was compared to the staging and grading of the disease on TLP using a multilevel Cox proportional hazard regression model.

RESULTS

Over a median follow-up of 25 years, 13.7% of teeth were lost, 4.6% of which were due to periodontitis. Most patients with TLP had ≥1 site with RPc ≥5 mm (90.8%) or ≥6 mm (77.6%). Multivariate multilevel Cox regression revealed that patients with >15% of sites with RPc ≥5 mm had a hazard ratio of 2.34, and grade C had a hazard ratio of 4.6 for TLP compared to RPc ≤4 mm/grade A. Grading exhibited the best discrimination and model fit.

CONCLUSION

Patients with RPc ≥5 mm at >15% of the sites are at risk for tooth loss. Grading and RPc ≥5 mm displayed very good predictive capability of TLP.

The role of extracellular vesicles in periodontitis: pathogenesis, diagnosis, and therapy

Periodontitis is a prevalent disease and one of the leading causes of tooth loss. Biofilms are initiating factor of periodontitis, which can destroy periodontal tissue by producing virulence factors. The overactivated host immune response is the primary cause of periodontitis. The clinical examination of periodontal tissues and the patient's medical history are the mainstays of periodontitis diagnosis. However, there is a lack of molecular biomarkers that can be used to identify and predict periodontitis activity precisely. Non-surgical and surgical treatments are currently available for periodontitis, although both have drawbacks. In clinical practice, achieving the ideal therapeutic effect remains a challenge. Studies have revealed that bacteria produce extracellular vesicles (EVs) to export virulence proteins to host cells. Meanwhile, periodontal tissue cells and immune cells produce EVs that have pro- or anti-inflammatory effects. Accordingly, EVs play a critical role in the pathogenesis of periodontitis. Recent studies have also presented that the content and composition of EVs in saliva and gingival crevicular fluid (GCF) can serve as possible periodontitis diagnostic indicators. In addition, studies have indicated that stem cell EVs may encourage periodontal regeneration. In this article, we mainly review the role of EVs in the pathogenesis of periodontitis and discuss their diagnostic and therapeutic potential.

The influence of fixed prosthesis placement on the clinical effectiveness of non-surgical periodontal therapy

Background/purpose

Fixed prostheses are essential for restoring teeth with compromised structures. However, the margins of prosthesis potentially create an interface that interferes with proper cleaning. This study evaluated whether the fixed prosthesis placement influenced the clinical effectiveness of non-surgical periodontal therapy (NSPT).

Materials and methods

Clinical records from 202 patients with generalized chronic periodontitis receiving NSPT at the National Taiwan University Hospital in 2012-2014 were included. The change and improvement ratio (IR) of clinical parameters following NSPT in the entire dentition or posterior region, and all or periodontitis-affected teeth/crowns (T/C) and sites were evaluated. The differences among natural teeth (NT), prosthetic crowns (PC), and abutments (AB) were compared by using Kruskal-Wallis tests followed by Dunn's post-hoc test.

Results

Gingival recession (REC) was greater in PC and AB groups than in the NT group before NSPT, while tooth mobility was also lower in the AB group. REC gain was lower in the AB group after NSPT, while mobility reduction was inferior in the PC and AB groups for all or periodontitis-affected T/C and sites. In periodontitis-affected T/C, IRs in probing pocket depth reduction and clinical attachment gain were lower in the PC group, and mobility reduction was lower in the AB group. The tendency in the posterior region is similar but was less pronounced than in the entire dentition.

Conclusion

The effectiveness of NSPT and the improvement of periodontal parameters are reduced when fixed prostheses present. MB reduction is inferior in AB teeth relative to NT.

A new subgingival sling suture technique for periodontally accelerated osteogenic orthodontics

This study aimed to design a modified subgingival sling suture for periodontally accelerated osteogenic orthodontics (PAOO) as well as evaluate postoperative effects including gingival recession (GR), alveolar bone crest resorption, dental plague accumulation on sutures and alveolar bone augmentation. Twelve patients with bone defects in the anterior alveolar region of the mandible were included in this study. Subgingival sling suture, developed from traditional sling suture, was applied in modified PAOO operation. Probing depth, bleeding index, and GR were assessed, and cone-beam computerized tomography and laser microscope for thread surface were evaluated at baseline, postoperative 1 and 3 months to analyze the effects. Alveolar bone thickness on the labial side at the midpoint of the middle third of the root increased from 0.96 ± 0.28 mm to 3.38 ± 0.61 mm (P < .01), and that of the apical third advanced from 1.26 ± 0.33 mm to 3.61 ± 1.02 mm (P < .01), both exhibiting significant increase. No significant alveolar bone crest loss, probing depth increase, GR, and attachment loss was observed. This modified PAOO operation, associated with novel subgingival sling suture, productively augments alveolar bone volume and addresses problems in terms of GR and vertical loss of alveolar bone.

Influence on the patient's oral hygiene depending on the treatment performed by either one or different pre-graduate practitioners - a randomized, controlled, clinical short-term trial

Objectives

Plaque control by improved domestic oral hygiene is essential in periodontal treatment. However, changing treatment providers may interfere with building a dentist-patient relationship and in turn affect treatment success. The aim of this randomized, controlled, prospective short-term study was to determine the influence of either one or four different pre-graduate practitioners on patients’ oral hygiene parameters during active periodontal therapy.

Material and Methods

A total of 55 patients with periodontitis were allocated to two groups. Within the group “continuous treatment” (CT, n = 27), each patient was treated by one individual practitioner over the treatment period. For patients of the group “discontinuous treatment” (DT, n = 28), treatment in each session was performed by a different practitioner. Periodontal parameters (BOP, PBI, and PCR) were assessed at two timepoints: T1 (baseline) and T2 (end of active therapy).

Results

With CT, the PBI improved in 93% of the patients, compared to 71% with DT (p = 0.048). T1-T2 intragroup analysis showed a statistically significant improvement of all observed clinical parameters with no differences in ∆PBI, ∆BOP, and ∆PCR. Spearman’s correlation analysis revealed a weak correlation between PCR and BOP of CT only.

Conclusions

In the present study, improvement of all parameters was comparable between the groups. PBI, as a parameter displaying patient’s domestic plaque control compliance, improved in more patients from CT than DT. This is possibly indicating an advantage of continuous treatment by one single practitioner.

Clinical relevance

Treatment by either a single practitioner or by multiple, constantly changing practitioners might influence patients’ compliance to modify their behaviour when medically necessary.

Evaluation of antimicrobial photodynamic therapy with acidic methylene blue for the treatment of experimental periodontitis

OBJECTIVE

To investigate the security and effectiveness of antimicrobial photodynamic therapy (aPDT) with a citric acid-based methylene blue (MB) on the periodontal repair following the treatment of ligature-induced experimental periodontitis (EP) in rats.

MATERIAL AND METHODS

Were used 120 male rats, randomly divided into 4 experimental groups (n = 30): no treatment (NT), SRP alone (SRP), SRP plus aPDT using conventional MB pH 7.0 (aPDT-pH7), SRP plus aPDT using acidic MB pH 1.0 (aPDT-pH1). EP was induced at day 0 by the placement of a ligature around the mandibular left first molars. Ten animals per group/period were euthanized at 14, 22 and 37 days. Histopathological, histometric (percentage of bone in the furcation [PBF]) and immunohistochemical (for tartrate-resistant acid phosphatase [TRAP] and osteocalcin [OCN]) analyses were performed. Data were statistically analyzed.

RESULTS

aPDT-pH1 showed the highest PBF as compared with the other treatments. Collectively, tissues' reaction to both dyes were controlled and healthy for the periodontium. Both aPDT protocols reduced the extent and intensity of the local inflammatory response, reduced the alveolar bone resorption, and promoted a better structural arrangement of the connective tissue as compared with SRP. TRAP expression was downregulated while OCN expression was upregulated by aPDT as compared with SRP alone.

CONCLUSION

Our data implicate that the novel MB pH 1.0 is as safe as the conventional MB for use in aPDT and raises its additional benefit of increasing the amount of alveolar bone in the furcation.

Clinical and microbiological effects of photodynamic therapy applied in non-surgical treatment of periodontitis

Background/Aim. Treatment of periodontitis undergoes several treatment phases. Non-surgical periodontal treatment (NSPT) represents the basic treatment stage, and it is applied to all the patients undergoing periodontal treatment. Adjunctive antimicrobial photodynamic therapy (aPDT) is one of several contemporary and relatively new possibilities with a role to inactivate microorganisms responsible for the occurrence and progression of the disease. The aim of this study was to comparatively analyze the clinical and microbiological effects of the NSPT alone, as well as combined with aPDT. Methods. A split-mouth method design was used in a prospective randomized controlled trial. The following clinical parameters were registered and monitored: plaque index (PI), bleeding on probing, probing depth (PD), and clinical attachment level (CAL). The presence of microorganisms Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, and Treponema denticola was detected by the polymerase chain reaction (PCR) method. Samples were tested before the therapy, as well as three months after the therapy. Therapeutic modalities of NSPT and NSPT with adjunct aPDT were examined. Results. All of the analyzed clinical parameters proved statistically significant improvement after the application of both treatment modalities (p < 0.001). Microbiological analyses showed that the total number of microorganisms was statistically significantly lower after the application of both methods (p < 0.001). Following the treatment, there was a statistically significantly reduced number of microorganisms Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, and Treponema denticola (p < 0.001). NSPT combined with aPDT led to a statistically significant improvement of both clinical parameters and microbiological status compared to NSPT applied on its own. Conclusion. The study showed improvement of all clinical indicators after the application of both treatment modalities. The total number of microorganisms was reduced as well as the number of specific microorganisms. Combining aPDT with NSPT led to a statistically significantly higher reduction in the number of microorganisms compared to NSPT alone.

Unusual Findings in Trials Evaluating Adjuncts to Scaling and Root Planing: Reporting Quality (Part 2)

INTRODUCTION

On the topic of adjuncts to scaling and root planing (SRP), numerous randomized clinical trials (RCTs) were published by a single group of authors and frequently reported unusually large effect sizes. A meta-analysis in part 1 of this project failed to explain the causes for these unusual findings. We assessed the reporting quality and trial registration discrepancies to examine the possibility of replicating the work of this research group as well as the overall rigor of the research methodology.

METHODS

This study was preregistered at the Open Science Framework (https://osf.io/4meyd/). The Scopus platform was utilized for the RCT search on SRP adjuncts in intrabony defects in patients with periodontitis as compared with SRP alone. The search analysis was limited from 2010 to 2017, and RCTs on SRP adjuncts published by a single research group were selected for screening and inclusion. RCT registration records were assessed for consistency.

RESULTS

Out of 92 studies that were retrieved from Scopus and PubMed, 32 were included for quality assessment per the CONSORT guidelines (Consolidated Standards of Reporting Trials). Results showed that all RCTs were characterized by a low reporting quality. The majority of CONSORT items scored <50%, including critical items (randomization, registration, and blinding). When registration records were compared with published RCTs, several discrepancies were found. The per-protocol follow-up duration was compared against the study's initiation and termination dates. Only 38% of the RCTs presented a follow-up period within the initiation and termination dates. The remaining RCTs showed inconsistent follow-up in comparison with the initiation and termination dates.

CONCLUSION

RCTs by this group were characterized by poor adherence to reporting quality guidelines. Crucial RCT elements, such as randomization, blinding, and primary outcomes, were not reported properly. RCT registration records revealed systematic inconsistencies when compared with RCT publication. Therefore, the unusually large effects reported by this group should be viewed with extreme caution.

KNOWLEDGE TRANSFER STATEMENT

The included randomized clinical trials were characterized by poor adherence to reporting quality guidelines, missing information about important trial items, and discrepancies between the reports and trial registrations. This quality assessment should guide clinical research and show clinicians that they should be cautious when applying evidence in their clinical practice.

Randomized clinical trials in periodontology: focus on outcomes selection

Randomized clinical trials (RCTs) are human studies carried out to compare different treatments or interventions, and their results are used to support clinical decision-making and improve patient care. Herein, the aim of this study was to review the selection process of study outcomes in periodontology. Primary outcomes should draw the main conclusions of the study, whereas secondary outcomes should only be used to help explain the main findings and generate future research hypothesis. Outcomes are classified as clinically relevant (CROs) or surrogate outcomes. CROs - the first option for primary outcome variables - should convey not only substantial health benefits, but also be deemed important by patients. In periodontology, tooth loss/retention and oral health-related quality of life (OHRQoL) are examples of CROs. While tooth loss has main limitations as a primary outcome, emerging evidence suggest that patient-reported outcome measures (PROMs) can accurately detect OHRQoL following periodontal therapy. When CROs cannot be assessed, validated surrogate outcomes can be used as proxies. Primary outcome variables should reflect a treatment endpoint at the patient level that can be easily used to inform decision-making in daily practice. These outcomes should allow the implementation of a treat-to-target concept in which the intervention can be clearly judged against a prespecified treatment target. Recently, the presence of at most 4 sites with periodontal probing depth ≥5 mm post-treatment was suggested as an effective endpoint for periodontal trials. In perspective, a combination of validated clinical parameters and PROMs will provide a more comprehensive assessment of periodontal treatments.

Treatment of Residual Periodontal Pockets Using a Hyaluronic Acid-Based Gel: A 12 Month Multicenter Randomized Triple-Blinded Clinical Trial

The aim of the present study was to evaluate the adjunctive effect of hyaluronic acid (HA) gel in the treatment of residual periodontal pockets over a 12-month period. Periodontal patients presenting at least one residual periodontal pocket 5-9 mm of depth in the anterior area were recruited from six university-based centers. Each patient was randomly assigned to subgingival instrumentation (SI) with the local adjunctive use of HA for test treatment or adjunctive use of local placebo for control treatment at baseline and after 3 months. Clinical parameters ( )probing depth (PD), bleeding on probing (BoP), plaque index (PI), recession (REC), clinical attachment level (CAL)) and microbiological samples for the investigation of the total bacterial count (TBC) and presence of specific bacterial species (Porphyromonas gingivalis, Treponema denticola, Tannerella forsythia, Fusobacterium nucleatum) were taken at baseline and every 3 months, until study termination. PD was determined as the primary outcome variable. From a total of 144 enrolled, 126 participants (53 males, 73 females) completed the entire protocol. Both treatments resulted in statistically significant clinical and microbiological improvements compared to baseline. Although the local application of HA showed a tendency for better results, there was a lack of statistically significant differences between the groups.

Endpoints of active periodontal therapy

Aim

Position paper on endpoints of active periodontal therapy for designing treatment guidelines. The question was as follows: How are, for an individual patient, commonly applied periodontal probing measures—recorded after active periodontal therapy—related to (a) stability of clinical attachment level, (b) tooth survival, (c) need for re‐treatment or (d) oral health‐related quality of life.

Methods

A literature search was conducted in Ovid MEDLINE(R) and Epub Ahead of Print, In‐Process & Other Non‐Indexed Citations and Daily <1946 to 07 June 2019>.

Results

A total of 94 papers were retrieved. From the literature search, it was found that periodontitis patients with a low proportion of deep residual pockets after active periodontal therapy are more likely to have stability of clinical attachment level over a follow‐up time of ≥1 year. Other supporting literature confirms this finding and additionally reports, at the patient level, that probing pocket depths ≥6 mm and bleeding on probing scores ≥30% are risks for tooth loss. There is lack of evidence that periodontal probing measures after completion of active periodontal treatment are tangible to the patient.

Conclusions

Based on literature and biological plausibility, it is reasonable to state that periodontitis patients with a low proportion of residual periodontal pockets and little inflammation are more likely to have stability of clinical attachment levels and less tooth loss over time. Guidelines for periodontal therapy should take into consideration (a) long‐term tangible patient outcomes, (b) that shallow pockets (≤4 mm) without bleeding on probing in patients with <30% bleeding sites are the best guarantee for the patient for stability of his/her periodontal attachment, (c) patient heterogeneity and patient changes in immune response over time, and (d) that treatment strategies include lifestyle changes of the patient. Long‐term large population‐based and practice‐based studies on the efficacy of periodontal therapies including both clinical and patient‐reported outcomes (PROs) need to be initiated, which include the understanding that periodontitis is a complex disease with variation of inflammatory responses due to environment, (epi)genetics, lifestyle and ageing. Involving people living with periodontitis as co‐researchers in the design of these studies would also help to improve their relevance.

Adjunctive local treatments for patients with residual pockets during supportive periodontal care: A systematic review and network meta-analysis

AIM

This systematic review and network meta-analysis aimed to evaluate the efficacy of adjunctive locally delivered antimicrobials, compared to subgingival instrumentation alone or plus a placebo, on changes in probing pocket depth (PPD) and clinical attachment level (CAL), in patients with residual pockets during supportive periodontal care.

MATERIALS AND METHODS

Literature search was performed with electronic databases and by hand until 31 May 2020. Primary outcome was the changes in PPD. The treatment effects between groups were estimated with weighted mean differences (WMD) with 95% confidence intervals (CI) and prediction intervals (PI) by using random-effects network meta-analysis.

RESULTS

Twenty-two studies were included. Significantly greater PPD reduction was achieved in chlorhexidine chip group (WMD: 0.65 mm, 95% CI: 0.21-1.10) and tetracycline fibre group (WMD: 0.64 mm, 95% CI: 0.20-1.08) over 6-month follow-up. Other adjunctive antimicrobial agents achieved non-significant improvements compared to scaling and root planing alone. All differences between adjunctive therapies were statistically non-significant. Similar findings were observed for CAL gain.

CONCLUSION

Adjunctive local antimicrobial agents achieved small additional PPD reduction and CAL gain in residual pockets for a follow-up of up to 6 months. Tetracycline fibre and chlorhexidine chip achieved better results than other antimicrobials.

Definitions used for a healthy periodontium-A systematic review

OBJECTIVE

To investigate the explicitness and variability of the definition of periodontal health in the current scientific literature.

MATERIAL AND METHODS

The authors conducted a systematic literature review using PubMed and CENTRAL (2013-01/2019-05) according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the guidelines of the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) statement.

RESULTS

A total of 51 papers met the predefined inclusion criteria. Of these, 13 papers did not report any explicit definitions of periodontal health. Out of the 38 remaining articles, half of them used a reference to support their definition and half of them not. The studies published in periodontics-related journals or those that scored a low risk of bias for the methodical quality presented more explicit and valid definitions. Probing pocket depth was the most frequently used individual parameter for defining periodontal health. However, there were substantial variations in the methods of measurement and cut-off values.

CONCLUSIONS

Given the diversity of periodontal health definitions, a cross-study comparison is difficult. The results of this review may be useful in making others aware of the significance of standardizing the definition of a healthy periodontium.

Use of digital periodontal data to compare periodontal treatment outcomes in a practice-based research network (PBRN): a proof of concept

Background

Scientific studies in dentistry are mainly conducted at universities. However, most patients are treated in dental practices, which differ in many ways from treatment at the university. Through the establishment of practice-based research networks, however, it is also possible to examine studies in a real-world setting in dental practices. For this reason the aim of this non-interventional, observational study was to develop and evaluate a digital procedure to access, extract and analyse recorded clinical data in practices to assess periodontal treatment outcomes.

Methods

Participating periodontists were former or active postgraduate students of a master’s course in periodontics in Freiburg who routinely used a digital periodontal diagnostic program. All available stored periodontal patient charts were extracted, anonymized and digitally sent to the study centre.

Results

In this study, data were collected from 6301 patients from 9 different practices. Information such as probing depth (PD), bleeding on probing (BOP), mobility, furcation and gingival attachment for 153,163 teeth at first visit were successfully transferred to the study centre. During the average observational period of 9.77 years, only 2.8% of all teeth were lost. The number of visits was significantly negatively correlated with BOP (p < 0.0001), and the number of BOP-positive sites was significantly correlated with deeper PDs (p < 0.001).

Conclusion

The presented procedure was able to gather a large amount of practice-based periodontal data, and thus this study may support practice-based research networks. The data indicate that systematic and supportive periodontal therapy is successful on a practice-based level.

Trial registration The study was internationally registered on 4 January 2017 in the German Clinical Trials Register (DRKS 00011448). https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011448

Clinical outcomes after intentional replantation of permanent teeth: A systematic review

This study aimed to systematically assess the outcomes of intentional replantation (IR) of teeth and to determine the survival rate, success rate, and prognostic factors related to the treatment. A search was conducted for all relevant English language articles published from January 2000 to October 2017. The search terms included "intentional replantation" and "teeth" according to the inclusion criteria. The Methodological Index for Non-randomized Studies (MINORS) was used to assess the methodological quality of included studies. Twelve studies were identified as relevant for the systematic review. In total, 896 patients with 905 teeth were examined for intentional teeth replantation. The success rate was greater than 90% in four studies (33.33%) and between 70% and 80% in five studies. At short-term follow-up (<6 months), the survival rate was approximately 90% in four studies. At longer-term follow-up (>36 months), the survival rates of teeth were slightly reduced in four studies, and tended to be stable after 48 months. In conclusion, the long-term success and survival rate of IR are likely dependent upon short extraoral time, reduced pocket depth, type of tooth, type of root-end filling material, and the prevention of atraumatic tooth root damage.

Antimicrobial photodynamic therapy (aPDT) with curcumin and LED, as an enhancement to scaling and root planing in the treatment of residual pockets in diabetic patients: A randomized and controlled split-mouth clinical trial

INTRODUCTION

Residual pockets represent a risk factor for periodontal disease progression. Diabetes Mellitus (DM) may impair prognosis after cause-related therapy, mainly due to the chronic hyperglycemia that negatively influences tissue repair. This study evaluated the clinical efficacy of antimicrobial photodynamic therapy (aPDT) with curcumin (CUR) solution (100 mg/L) and LED irradiation (465-485 nm), as an adjunctive therapy to scaling and root planing (SRP), in the treatment of residual pockets in type 2 diabetic patients.

METHODS

Individuals with type 2 DM and chronic periodontitis presenting at least one residual pocket per quadrant were selected (n = 25). In each patient, all residual pockets with probing depth (PD) ≥5 mm and bleeding on probing (BOP) were allocated to receive, according to quadrant: 1) SRP (SRP group); 2) SRP and irrigation with CUR solution (100 mg/L) (CUR group); 3) SRP and LED irradiation (InGaN, 465-485 nm, 0.78 cm², 78 mW, 100 mW/cm², 60 s) (LED group); 4) SRP, irrigation with CUR solution (100 mg/L), one minute of pre-irradiation, and LED irradiation (InGaN, 465-485 nm, 60 s) (aPDT group). Clinical parameters of PD, gingival recession (GR), clinical attachment level (CAL), BOP and visible plaque index (PI) were evaluated at baseline, three and six months post-therapies. Differences between the examination periods in each group were analyzed by Friedman's test for non-parametric data, while parametric data were submitted to analysis of variance (One-way ANOVA), followed by Tukey's test. Intergroup comparisons were performed by Kruskal-Wallis test.

RESULTS

In an intergroup comparison, the mean values for PD, GR, CAL, BOP and PI were not different at baseline, three and six months (p > 0.05). The intragroup comparison evidenced reduction in PD and BOP in all treatment groups at three and six months (p < 0.05). Significant CAL gain was notable only for the aPDT and LED groups at three months in comparison to baseline data (p < 0.05).

CONCLUSION

Treatment of residual pockets in patients with type 2 DM through association of SRP with aPDT (CUR solution 100 mg/L and LED irradiation) or LED irradiation may yield short-term (three months) clinical benefits regarding CAL gain.

Periodontal complications with age

The present literature review on periodontal complications in aging focuses on the diagnosis, etiology and development of periodontal complications as a complete entity. In addition, the review also focuses on some of the common systemic diseases that either may further add to periodontal complications or, as result of anti-inflammatory treatment, limit the expression of periodontal disease. There is no evidence to suggest that clinical methods to provide periodontal therapies have been developed especially for older individuals. There is evidence that aging can be associated with periodontally healthy conditions through life and with a high level of tooth retention and function. Periodontal complications that are difficult to manage are usually associated with concurrent medical diseases and complications, or with socio-economic factors that limit the ability to provide dental care for the aging population. Currently, some systemic medical conditions are managed with anti-inflammatory medications with positive effects, while slowing the progression and expression of chronic periodontitis. The lack of data from clinical studies on how to manage periodontal complications in aging is obvious.

Antibiotics/antimicrobials: systemic and local administration in the therapy of mild to moderately advanced periodontitis

This review gives an update of the current scientific evidence on the efficacy of the adjunctive use of systemic and local antibiotics/antimicrobials in the treatment of periodontitis. In particular, it addresses whether their use can improve the results of nonsurgical mechanical therapy in mild-to-moderate forms of the disease. Large numbers of randomized clinical trials and systematic reviews with meta-analyses have clearly established that adjunctive systemic antibiotics, combined with mechanical debridement, offer clinical improvements additional to those obtained with scaling and root planing alone. These effects are more pronounced in aggressive periodontitis and in initially deep pockets, whereas more limited additional improvements, of 0.3 mm for additional pocket reduction and 0.2 mm for additional clinical attachment gain, have been documented for moderately deep sites (4-6 mm) in patients with chronic periodontitis. The marginal clinical benefit in patients with moderate disease has to be balanced against possible side effects. Notably, it has to be realized that an increasing number of warnings have been articulated against the unrestricted use of antibiotics in treating periodontal diseases because of the emerging global public health issue of bacterial resistance. The effects of the adjunctive local administration of antimicrobials have also been very well documented in several systematic reviews. Overall, in persistent or recurrent localized deep sites, the application of antimicrobials by sustained-delivery devices may offer a benefit of an additional 0.4 mm in pocket depth reduction and 0.3 mm in clinical attachment level gain. In conclusion, the slight additional benefits of adjunctive antimicrobials, which were shown for moderate forms of periodontitis, have to be balanced against their side effects and therefore their prescription should be limited as much as possible.

Predictors of long-term outcomes in patients undergoing periodontal maintenance

AIM

This retrospective study aimed to characterize the baseline status of patients following periodontal maintenance, analysing the association between the long-term outcome of these patients, smoking, bruxism, and the main clinical and radiographic variables.

MATERIAL AND METHODS

A sample of 174 patients with moderate to severe periodontitis was refined into homogeneous subsamples according to smoking and bruxism and the rate of tooth loss due to periodontal disease (TLPD): 0, 1-2, and >2 teeth. The association and the distribution (χ² test) of the variables within the subsamples were analysed.

RESULTS

Smoking and bruxism were significantly associated with higher TLPD rates. Vertical and circumferential bone defects (p < .0001), and abfractions (p < .0001) were associated with bruxism and particularly with bruxism and TLPD >2. Furcation defects (p = .0002), fewer radio-opaque subgingival calculus (χ² p < .0001), a lower mean Gingival index (χ² p = .027), and increased mean recessions >1.5 mm (χ² p = .0026) were associated with smoking and higher TLPD rates. The mean baseline mobility, abfractions, and recessions characterized two basic types of TLPD.

CONCLUSIONS

Smoking, bruxism, and routine clinical and radiological parameters can be used to characterize the baseline status of patients with worse outcomes.

Photodynamic therapy decrease immune-inflammatory mediators levels during periodontal maintenance

Antimicrobial photodynamic therapy (aPDT) was introduced as a promising adjuvant therapy on the periodontal treatment. The aim of this study was to evaluate the effect of aPDT on inflammatory mediator levels in residual periodontal pockets of patients with severe chronic periodontitis under periodontal maintenance, during 12 months follow-up. A randomized controlled trial study was conducted in 28 patients with severe chronic periodontitis. After non-surgical periodontal treatment, patients with at least four teeth with residual pocket probing depth (PPD) ≥4 mm were randomly assigned to either aPDT or control group. The aPDT (low power laser: 660 nm, 40 mW, 90 J/cm², methylene blue 0.01 %) was performed at baseline and 3, 6, and 9 months. Clinical parameters were collected before and 3 and 12 months after the intervention, and gingival crevicular fluid was collected in the same times, including 1 week after the intervention. Immunological evaluation was carried out using the Luminex assay which quantified the expression of ten cytokines: interleukin (IL)-1α, IL-1β, IL-8, IL-1ra, fibroblast growth factor (FGF), vascular endothelial growth factor (VEGF), interferon (IFN)-γ, tumor necrosis factor (TNF)-α, IL-4, and IL-10. All clinical variables showed significant improvement for both groups, but there was no statistical difference between groups with no clinical benefits. IL-1α, IL-1β, IL-8, and VEGF showed significant differences (p < 0.05) between groups, whereas IL-1ra mediators, IFN-γ, and IL-10 demonstrated a statistical difference (p < 0.01) over time in the same group. At any time, FGF, IL-4, and TNF-α showed no statistical difference between groups (p > 0.05). aPDT therapy can improve the benefits on inflammation control during the periodontal maintenance.

Effect of root planing on the reduction of probing depth and the gain of clinical attachment depending on the mode of interproximal bone resorption

Purpose

The purpose of the present study was to evaluate the effect of root planing on the reduction of probing pocket depth and the gain of clinical attachment depending on the pattern of bone resorption (vertical versus horizontal bone loss) in the interproximal aspect of premolar teeth that showed an initial probing pocket depth of 4-6 mm.

Methods

In this study, we analyzed 68 teeth (15 from the maxilla and 53 from the mandible) from 32 patients with chronic periodontitis (17 men and 15 women; mean age, 53.6 years). The probing pocket depth and clinical attachment level at all six sites around each tooth were recorded before treatment to establish a baseline value, and then three months and six months after root planing.

Results

The reduction in interdental pocket depth was 1.1 mm in teeth that experienced horizontal bone loss and 0.7 mm in teeth that experienced vertical bone loss. Interdental attachment was increased by 1.0 mm in teeth with horizontal bone loss and by 0.7 mm in teeth with vertical bone loss. The reduction of probing pocket depth and the gain of clinical attachment occurred regardless of defect patterns three and six months after root planing.

Conclusions

The reduction of pocket depth and gain in the clinical attachment level were significantly larger in horizontally patterned interproximal bone defects than in vertical bone defects.

Variables affecting tooth survival and changes in probing depth: a long-term follow-up of periodontitis patients

AIM

To retrospectively assess tooth-survival rate and its association with patient and oral variables in periodontal office patients, followed up to 18 years.

MATERIAL AND METHODS

Patients in a private periodontal office whose files included initial examination (T0 ), reevaluation (TRe ) and ≥ 10 years after T0 (TF ) chartings, and received periodontal therapy and supportive periodontal therapy (SPT) after TRe were included. General health, plaque scores (PI), probing depth (PPD), bleeding on probing (BOP) at six points/tooth, tooth extractions, and SPT visits were extracted from patient files at T0 , TRe , and TF . Descriptive statistics and Cox regression analysis were performed.

RESULTS

Fifty patients (mean 26 ± 4 teeth/patient, 1301 teeth) fulfilled inclusion criteria. About 20 and 129 teeth respectively were extracted before/after TRe , 96 of them for periodontal causes. PPD>7 mm at TRe (HR = 17.7, 95%CI 8.6, 36.6), age above 60 years (HR = 3.3, 95%CI 1.5, 7.2), multi-rooted teeth (HR = 1.9, 95%CI 1.2, 3.1) and SPT<3 times/year (HR = 1.8, 95%CI 1.1, 2.9), were the best prognostic factors for tooth loss during follow-up. (p < 0.05, Cox regression analysis). A continuous, statistically significant reduction was observed in mean PPD among teeth that survived follow-up [4.3 ± 1.8 mm, 3.5 ± 1.4 mm, 3.2 ± 1.3 mm, at T0 , TRe , TF , respectively. (p < 0.001, Repeated-measures test)].

CONCLUSION

Regular SPT was associated with low tooth-loss rates and continuous reductions in probing depth. PPD after initial therapy, age above 60, multi-rooted teeth and infrequent SPT were strong negative prognostic factors for long-term tooth survival among periodontal patients.

In vitro evaluation of a novel biofilm remover

OBJECTIVE

To evaluate a novel device for its efficacy in removing experimental biofilm from root surfaces and its potential for concomitantly removing/roughening the surface substance.

METHODS AND MATERIALS

A novel acrylic rotary device (biofilm remover, BR) was tested in vitro in three experiments: surface loss, surface roughness [positive controls: Perioset (PS) and Proxoshape (PR)] and biofilm removal [positive controls: ultrasonic (US) and PS]. Surface loss/surface roughness was evaluated for dentin samples instrumented for three 20 s periods. The calcium removed during instrumentation was analysed after each interval and cumulatively, using atomic absorption spectrophotometry (AAS). Surface roughness was measured using profilometric analysis. Biofilm removal was evaluated on dentin specimens coated with a 64.5 h 6-species in vitro formed biofilm, after one 20 s treatment. Surface loss was analysed using anova with Scheffé post hoc test, and surface roughness/biofilm removal was analysed using Mann-Whitney test (all P ≤ 0.05).

RESULTS

Significantly less substance loss [μg (± 1 SD)] was observed with the novel device at all time points, both interval and cumulative (1.0 (± 0.5) versus 9.3 (± 3.2) PS and 9.9 (± 1.9) PR at 60 s). Surface roughness [μm (95% CI)] was significantly lower for BR than for PS and PR [0.00 (-0.01, 0.08) 0.20 (0.16, 0.27) and 0.21 (0.19, 0.24) at 60 s]. Significantly less biofilm bacteria remained after treatment with both BR 4.5 (-0.1, 16.2) and US 1.9 (-0.2, 14.3), compared to PS 52 (27.9, 82.1).

CONCLUSIONS

The novel biofilm remover was less damaging to dentin surfaces, while removing biofilm at least as effectively as devices used in this study.

Effects of photodynamic therapy on clinical and gingival crevicular fluid inflammatory biomarkers in chronic periodontitis: a split-mouth randomized clinical trial

BACKGROUND

There are limited clinical experiments addressing the effects of photodynamic therapy (PDT) as an adjunct to conventional scaling and root planing (SRP) on clinical and biologic features of periodontitis. This trial compares the clinical parameters and cytokine profiles in gingival crevicular fluid of patients with moderate-to-severe chronic periodontitis (CP) who have been treated using SRP alone or SRP + PDT.

METHODS

Twenty-two patients with two contralateral teeth affected with moderate-to-severe CP were selected. After SRP, the participants' teeth were randomized to receive either no further treatment or a single application of PDT using a 638-nm laser and toluidine blue. Although the change in probing depth was the primary outcome, bleeding on probing, clinical attachment level, gingival recession, interleukin-1β, tumor necrosis factor (TNF)-α, and matrix metalloproteinase 8 and 9 were also evaluated at baseline and 3 months postintervention. An oral rinse assay was also performed to determine the total levels of oral polymorphonuclear cells (PMNs) before and 3 months after the treatments.

RESULTS

Within each group, significant improvements (P <0.001) were found for all variables in 3-month follow-up compared with baseline. Only TNF-α was significantly improved in the PDT + SRP versus SRP group. Total levels of PMNs were reduced for all patients compared with baseline levels (P <0.001).

CONCLUSION

In patients with CP, a single application of PDT (using a 638-nm laser and toluidine blue) did not provide any additional benefit to SRP in terms of clinical parameters or inflammatory markers 3 months following the intervention.

Hierarchical decisions on teeth vs. implants in the periodontitis-susceptible patient: the modern dilemma

It is estimated that advanced periodontitis typically affects about 10% of most adult populations studied. These individuals can be considered highly susceptible to periodontitis and often present difficulties for clinicians in therapeutic decision making, especially when dental implants are involved. Poor plaque control and smoking are well established risk factors for periodontitis, as well as for peri-implant disease. Long-term follow-up studies have clearly demonstrated that treatment of periodontal disease, even if advanced, can be successful in arresting disease progression and preventing (or at least significantly delaying) tooth loss. With the increasing development of implant dentistry, traditional well documented and evidence-based therapies to treat periodontal diseases may sometimes not be used to their full potential. Instead, there appears to be an increasing tendency to extract periodontally compromised teeth and replace them with implants, as if implants can solve the problem. However, peri-implant diseases are prevalent, affecting between 28% and 56% of people with implants, and (at the implant level) 12-43% of implants. A history of periodontal disease, smoking and poor oral hygiene are all risk factors for developing peri-implantitis. Unlike periodontitis, there are currently no predictable means for treating peri-implantitis, although resective surgery seems to be the most effective technique. Consequently, if implant treatment is considered in patients who are susceptible to periodontitis, it should be preceded by appropriate and adequate periodontal treatment or re-treatment to control the condition, and should be followed by a stringent supportive maintenance program to prevent the development of peri-implant disease. The decision whether implant treatment should be performed should be based on an assessment of the patient's risk profile at the subject level, as well as at the site level.

Er:YAG laser in the treatment of periodontal sites with recurring chronic inflammation: a 12-month randomized, controlled clinical trial

AIM

The objective of this randomized, controlled clinical trial was to compare the clinical and microbiological effects of pocket debridement using erbium-doped: yttrium, aluminium and garnet (Er:YAG) laser with conventional debridement in maintenance patients.

MATERIAL & METHODS

Fifteen patients, all smokers, having at least four teeth with residual probing depth (PD) ≥ 5 mm were recruited. Two pockets in two jaw quadrants were randomly assigned to subgingival debridement using an Er:YAG laser (test) or ultrasonic scaler/curette (control) at 3-month intervals. Relative attachment level (RAL), PD, bleeding on probing and dental plaque were recorded at baseline and at 6 and 12 months. Microbiological subgingival samples were taken at the same time points and analysed using a checkerboard DNA-DNA hybridization technique.

RESULTS

A significant decrease in PD took place in both treatments from baseline to 12 months (p < 0.01). In the control, the mean initial PD decreased from 5.4 to 4.0 mm at 12 months. For the test, a similar decrease occurred. No significant between-treatment differences were shown at any time point. The mean RAL showed no overall significant inter- or intra-treatment differences (p > 0.05). No significant between-treatment differences were observed in subgingival microbiological composition or total pathogens.

CONCLUSION

The results failed to support that an Er:YAG laser may be superior to conventional debridement in the treatment of smokers with recurring chronic inflammation. This appears to be the first time that repeated Er-YAG laser instrumentation has been compared with mechanical instrumentation of periodontal sites with recurring chronic inflammation over a clinically relevant time period.

Porous titanium granules in the treatment of mandibular Class II furcation defects: a consecutive case series

BACKGROUND

The osteoconductive potential of titanium is interesting from the perspective of periodontal surgery and reconstitution of osseous defects. The aim of the present consecutive case series is to evaluate a surgical strategy based on the use of porous titanium granules (PTG) in the treatment of Class II buccal furcation defects in mandibular molars in humans.

METHODS

Surgical intervention with PTG used as a bone graft substitute was performed in 10 patients with 10 mandibular Class II buccal furcation defects. Clinical parameters (probing depth (PD), clinical attachment level (CAL), gingival recession (GR), gingival index (GI), bleeding on probing (BOP), and horizontal and vertical bone sounding) and radiographic measurements of vertical furcation height were compared among baseline (presurgery), 6, and 12 months (post-surgery). The significance level (α) was set at 0.05.

RESULTS

With respect to vertical and horizontal bone sounding measurements, CAL, and GR, no significant improvements between baseline and the 12-month examination were seen. Both PD and radiographic vertical furcation height were significantly reduced between baseline and 12 months. When comparing the baseline to 12-month data, a significantly lower GI score was seen but the BOP score was unchanged. None of the treated teeth showed radiographic signs of root resorption.

CONCLUSION

This study suggests that PTG is safe to use in close proximity to root surfaces, but no significant improvements in clinical endpoints of defect resolution were observed.

Tenascin-C and matrix metalloproteinase-9 levels in crevicular fluid of teeth and implants

BACKGROUND

The role of and interaction between bacterial infection and biomechanical impact in the development of peri-implant inflammatory processes is not clear.

OBJECTIVE

To determine the amount and concentration of tenascin-C (TNC) in gingival crevicular fluid (GCF) around teeth and in peri-implant sulcus fluid from healthy implants and implants with peri-implantitis, and to correlate it with matrix metalloproteinase-9 (MMP-9) levels.

MATERIALS AND METHODS

Seven control individuals and 18 patients with 41 implants with/without peri-implantitis were included. GCF was collected with filter strips and volumes were measured with a Periotron device. The amount of serum albumin per sample was quantified by densitometric analysis of Coomassie-stained sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Relative activity of MMP-9 was determined from the densitometry of zymograms. Amounts and concentrations of TNC were evaluated by ELISA.

RESULTS

Relative MMP-9 activity was increased in peri-implantitis. A tendency was observed to measure higher TNC concentrations at teeth than at implants. The amount of TNC in GCF collected from healthy implant sites and the peri-implantitis sites was significantly different. Based on immunoblotting, TNC in GCF seemed degraded. In contrast to TNC, MMP-9 was significantly related to the PD and the volume of GCF.

CONCLUSION

TNC is known to be induced in inflammation. The increase found in peri-implantitis was less than expected. In the context of peri-implantitis, TNC might be a marker of bone remodelling rather than inflammation and infection. A possible proteolytic degradation of TNC during peri-implantitis needs to be studied.

Strategic considerations in treatment planning: deciding when to treat, extract, or replace a questionable tooth

Prosthodontists face the difficult task of judging the influence and significance of multiple risk factors of periodontal, endodontic, or prosthetic origin that can affect the prognosis of an abutment tooth. The purpose of this review is to summarize the critical factors involved in deciding whether a questionable tooth should be treated and maintained, or extracted and possibly replaced by dental implants. A MEDLINE (PubMed) search of the English, peer-reviewed literature published from 1966 to August 2009 was conducted using different keyword combinations including treatment planning, in addition to decision making, periodontics, endodontics, dental implants, or prosthodontics. Further, bibliographies of all relevant papers and previous review articles were hand searched. Tooth maintenance and the acceptance of risks are suitable when: the tooth is not extensively diseased; the tooth has a high strategic value, particularly in patients with implant contraindications; the tooth is located in an intact arch; and the preservation of gingival structures is paramount. When complete-mouth restorations are planned, the strategic use of dental implants and smaller units (short-span fixed dental prostheses), either tooth- or implant-supported, as well as natural tooth abutments with good prognoses for long-span FDPs, is recommended to minimize the risk of failure of the entire restoration.

Short-term benefits of the adjunctive use of metronidazole plus amoxicillin in the microbial profile and in the clinical parameters of subjects with generalized aggressive periodontitis

AIM

The aim of this study was to evaluate the clinical and microbiological effects of scaling and root planing (SRP) alone or combined with metronidazole (MTZ) and amoxicillin (AMX) in the treatment of subjects with generalized aggressive periodontitis (GAgP).

MATERIALS AND METHODS

A double-blind, placebo-controlled, randomized clinical trial was conducted in 30 subjects receiving SRP alone or combined with MTZ (400 mg 3 x per day) and AMX (500 mg 3 x per day) for 14 days. Clinical and microbiological examinations were performed at baseline and 3 months post-SRP. Nine subgingival plaque samples per subject were analysed using checkerboard DNA-DNA hybridization.

RESULTS

Subjects receiving MTZ and AMX showed the greatest improvements in the mean full-mouth probing depth and clinical attachment level and at initially intermediate and deep sites. The most beneficial changes in the microbial profile were also observed in the MTZ+AMX group, which showed the lowest proportions of the red complex as well as a significant decrease in the proportions of the orange complex after treatment. The antibiotic therapy also reduced the levels of Aggregatibacter actinomycetemcomitans at initially deep sites.

CONCLUSION

Subjects with GAgP significantly benefit from the adjunctive use of MTZ and AMX. The short-term advantages are observed in the clinical and microbiological parameters.