Calculus removal from multirooted teeth with and without surgical access. (I). Efficacy on external and furcation surfaces in relation to probing depth

Maxillary root amputation: Case report with a 14-year-follow-up and updated mini review

Root resection is performed to create a maintainable furcation area in teeth with advanced periodontitis. However, the long-term feasibility of this treatment remains controversial. We present a case in which distal root resection in a maxillary molar successfully preserved the form and function of the dentition for approximately 14 years.

Furcation-involved molar teeth - part 2: management and prognosis

Furcation-involved molars are a common presentation in general dental practice. Teeth with increasing degrees of furcation involvement are at a higher risk of requiring extraction. This second article reviews management and prognosis of furcation-involved molar teeth. An improved understanding of how to appropriately manage these teeth can result in improved outcomes for patients.

Radiographic Evaluation of Regeneration Strategies for the Treatment of Advanced Mandibular Furcation Defects: A Retrospective Study

Teeth with furcation involvement (FI) present a higher risk of loss and are difficult to maintain. This study evaluated the efficacy of furcation defect regeneration (FDR) as a regeneration strategy. Pre-operative and 6-month postoperative radiographs were collected from patients receiving regeneration therapy for mandibular teeth with degree II and early degree III FI. The linear furcation involvement (LFI), ratio of LFI (RLI), LFI and RLI adjusted bythe alveolar bone crest (ABC), and radiographic intensity were assessed. The effects of demographic characteristics, regeneration treatment strategies, the relationship between furcation and ABC, and adjacent intrabony defect regeneration (AIDR) were evaluated using a generalized linear model and logistic regression. The results demonstrated that 1.5 mm adjusted LFI and 40% adjusted RLI were achieved in both pure furcation defects and combined furcation–angular defects by the combination of bone replacement grafts (BRG) and enamel matrix derivatives (EMD) or collagen membrane (CM); deproteinized bovine bone matrix (DBBM) showed a superior outcome among BRG. In combined furcation–angular defects, EMD appeared more beneficial than CM, and AIDR significantly promoted adjusted LFI and RLI. In conclusion, DBBM with EMD or CM was effective for FDR, and AIDR had a positive effect on FDR in the combined furcation–angular defect.

The added benefit of L-PRF to autogenous bone grafts in the treatment of degree II furcation involvement in mandibular molars

BACKGROUND

Tissue regeneration within the periodontally involved furcation area is one of the most challenging aspects of periodontal surgery. The aim of this study was to evaluate the additional benefit of leukocyte and platelet-rich fibrin (L-PRF) to autogenous bone grafts (ABGs) in the treatment of mandibular molar degree II furcation involvement, comparing the clinical outcomes with those from open flap debridement (OFD)+ABG and OFD alone treatments.

METHODS

Fifty-four patients, exhibiting one buccal or lingual mandibular molar furcation defect, were randomly assigned to three treatment groups: OFD+ABG+L-PRF(n = 18); OFD+ABG (n = 18); and OFD (n = 18). Clinical [probing pocket depth (PPD), horizontal clinical attachment level (HCAL), vertical clinical attachment level (VCAL), gingival recession (GR)] and radiographic [vertical bone level (VBL)] parameters were evaluated at baseline and 6 months after treatment. HCAL change was the primary outcome.

RESULTS

No significant differences within each group were reported for GR changes, but statistically significant improvements in HCAL, VCAL, PPD and VBL were observed in all groups, except for VBL in the OFD group. At 6 months, the mean HCAL gain was 2.29±0.18 mm in the OFD+ABG+L-PRF group, which was significantly greater than that in the OFD+ABG (1.61±0.18 mm) and OFD (0.86±0.18 mm) groups. Both OFD+ABG+L-PRF and OFD+ABG therapies produced a significantly greater clinical and radiographic improvement than OFD.

CONCLUSION

The addition of L-PRF to ABG produces a significantly greater HCAL gain and PPD reduction as compared to OFD+ABG treatment in mandibular degree II furcation involvements. This article is protected by copyright. All rights reserved.

Factors affecting decision making at reassessment of periodontitis. Part 3: interpretation of clinical findings - local factors

This paper is the third in a four-part series outlining treatment planning at periodontal reassessment. The first article focused on the information that should be gathered at the reassessment appointment. The second article discussed systemic factors that can relate to residual periodontal probing depths. This article outlines local factors that need to be assessed when faced with residual periodontal probing depths. Treatment can involve a range of non-surgical and surgical approaches. A variety of general, practical and local site factors can affect the choice of one option over another in choosing the most predictable treatment option.

Influence of Adjacent Teeth Absence or Extraction on the Outcome of Non-Surgical Periodontal Therapy

Background: Extraction of periodontally compromised or strategically non-important teeth is often an integral part of non-surgical periodontal treatment (NSPT). This study evaluated the association between the status of adjacent teeth and the outcome of NSPT on molars. Methods: Charting data of patients with generalized chronic periodontitis receiving NSPT in 2012–2014 were included. The association between initial clinical parameters and significant clinical improvement, including the reductions of probing pocket depth (PPD) and clinical attachment loss (CAL), in molar teeth with severe periodontitis after NSPT was assessed by a generalized linear model and logistic regression. Results: ≥7 mm PPD and <2 mm gingival recession (REC) at the tooth level, and ≥7 mm PPD, ≥7 mm CAL and <2 mm REC at the site level, were associated with significant clinical improvement. Absence or extraction of an adjacent tooth achieved an additional 0.22–0.23 mm and 0.60–0.83 mm clinical improvement. Among the interproximal sites, ≥7 mm PPD, <2 mm REC, ≥7 mm CAL, <Degree II furcation involvement, and absence of an adjacent tooth were associated with significant clinical improvement. Conclusion: Absence or extraction of teeth during NSPT significantly improves the PPD and CAL of the adjacent periodontal sites of molars.

In vitro effect of diode laser against biofilm of Aggregatibacter actinomycetemcomitans

Objective:

The main objective is to investigate the antibacterial effect of diode laser against Aggregatibacter actinomycetemcomitans biofilm.

Materials and Methods:

Biofilms of A. actinomycetemcomitans plus Streptococcus sanguinis grown on bovine root surfaces were treated with an 810-nm diode laser using a noncontact pulsed mode with a pulse interval and pulse length of 20 ms. Four protocols, that is, one episode of 1.5 or 2.5 W for 30 s and three episodes of 1.5 or 2.5 W for 30 s were tested. No treatment and 0.2% chlorhexidine treatment served as negative and positive controls, respectively. Viable bacterial number was determined by colony counting.

Results:

Treatment with chlorhexidine and all laser protocols except that using single episode of 1.5 W reduced the number of A. actinomycetemcomitans in either single-species or dual-species biofilm compared to negative control. A higher percentage of A. actinomycetemcomitans reduction was demonstrated after increasing the power output or repeating the irradiation.

Conclusions:

The laser protocols used in this study could reduce the number of viable bacteria but not eradicate A. actinomycetemcomitans biofilm.

Periodontal regeneration - furcation defects: a systematic review from the AAP Regeneration Workshop

BACKGROUND

The aim of this review is to present the available evidence regarding the effectiveness of different regenerative approaches for the treatment of furcation defects in specific clinical scenarios compared with conventional surgical therapy to provide clinical guidelines for the therapeutic management of furcation defects and to identify priorities for future research that may advance the understanding of periodontal regenerative medicine.

METHODS

A comprehensive search based on predetermined eligibility criteria was conducted to identify human original studies and systematic reviews on the topic of periodontal regeneration of furcation defects. Two reviewers independently screened the title and abstract of the entries yielded from the initial search. Subsequently, both reviewers read the full-text version of potentially eligible studies, made a final article selection, and extracted the data of the selected studies considering specific clinical scenarios. The clinical scenarios contemplated in this review included the following: 1) facial and interproximal Class I defects in maxillary molars; 2) facial and lingual Class I defects in mandibular molars; 3) facial and interproximal Class II furcation defects in maxillary molars; 4) facial and lingual Class II furcation defects in mandibular molars; 5) Class III furcation defects in maxillary molars; 6) Class III furcation defects in mandibular molars; and 7) Class I, II, or III furcation defects in maxillary premolars. Endpoints of interest included different clinical, radiographic, microbiologic, histologic, and patient-reported outcomes.

RESULTS

The initial search yielded a total of 1,500 entries. The final selection consisted of 150 articles, of which six were systematic reviews, 109 were clinical trials, 27 were case series, and eight were case reports. A summary of the main findings of previously published systematic reviews and the available evidence relative to the indication of regenerative approaches for the treatment of furcation defects compared with conventional surgical therapy are presented. Given the marked methodologic heterogeneity and the wide variety of materials and techniques applied in the selected clinical trials, the conduction of a meta-analysis was not viable.

CONCLUSIONS

On the basis of the reviewed evidence, the following conclusions can be drawn. 1) Periodontal regeneration has been demonstrated histologically and clinically for the treatment of maxillary facial or interproximal and mandibular facial or lingual Class II furcation defects. 2) Although periodontal regeneration has been demonstrated histologically for the treatment of mandibular Class III defects, the evidence is limited to one case report. 3) Evidence supporting regenerative therapy in maxillary Class III furcation defects in maxillary molars is limited to clinical case reports. 4) In Class I furcation defects, regenerative therapy may be beneficial in certain clinical scenarios, although most Class I furcation defects may be successfully treated with non-regenerative therapy. 5) Future research efforts should be primarily directed toward the conduction of clinical trials to test novel regenerative approaches that place emphasis primarily on patient-reported outcomes and also on histologic demonstration of periodontal regeneration. Investigators should also focus on understanding the influence that local, systemic, and technical factors may have on the outcomes of regenerative therapy in furcation defects.

Reliability of recordings of subgingival calculus detected using an ultrasonic device

OBJECTIVES

To assess the intra-examiner reliability of recordings of subgingival calculus detected using an ultrasonic device, and to investigate the influence of subject-, tooth- and site-level factors on the reliability of these subgingival calculus recordings.

MATERIALS AND METHODS

On two occasions, within a 1-week interval, 147 adult periodontitis patients received a full-mouth clinical periodontal examination by a single trained examiner. Duplicate subgingival calculus recordings, in six sites per tooth, were obtained using an ultrasonic device for calculus detection and removal.

RESULTS

Agreement was observed in 65 % of the 22,584 duplicate subgingival calculus recordings, ranging 45 % to 83 % according to subject. Using hierarchical modeling, disagreements in the subgingival calculus duplicate recordings were more likely in all other sites than the mid-buccal, and in sites harboring supragingival calculus. Disagreements were less likely in sites with PD ≥  4 mm and with furcation involvement  ≥  degree 2. Bleeding on probing or suppuration did not influence the reliability of subgingival calculus. At the subject-level, disagreements were less likely in patients presenting with the highest and lowest extent categories of the covariate subgingival calculus.

CONCLUSIONS AND CLINICAL RELEVANCE

The reliability of subgingival calculus recordings using the ultrasound technology is reasonable. The results of the present study suggest that the reliability of subgingival calculus recordings is not influenced by the presence of inflammation. Moreover, subgingival calculus can be more reliably detected using the ultrasound device at sites with higher need for periodontal therapy, i.e., sites presenting with deep pockets and premolars and molars with furcation involvement.

Low-cost periodontal therapy

Periodontitis is a complex infectious disease that affects low-income individuals disproportionately. Periodontitis is associated with specific bacterial species and herpesviruses, and successful prevention and treatment of the disease is contingent upon effective control of these pathogens. This article presents an efficacious, highly safe, minimally invasive, practical and low-cost periodontal therapy that involves professional and patient-administered mechanical therapy and antimicrobial agents. The major components are scaling for calculus removal, periodontal pocket irrigation with potent antiseptics, and treatment with systemic antibiotics for advanced disease. Povidone-iodine and sodium hypochlorite have all the characteristics for becoming the first-choice antiseptics in the management of periodontal diseases. Both agents show excellent antibacterial and antiviral properties, are readily available throughout the world, have been safely used in periodontal therapy for decades, offer significant benefits for individuals with very limited financial resources, and are well accepted by most dental professionals and patients. Four per cent chlorhexidine applied with a toothbrush to the most posterior part to the tongue dorsum can markedly reduce or eliminate halitosis in most individuals. Systemic antibiotics are used to treat periodontopathic bacteria that are not readily reached by topical therapy, such as pathogens within gingival tissue, within furcation defects, at the base of periodontal pockets, and on the tongue, tonsils and buccal mucosae. Valuable antibiotic therapies are amoxicillin-metronidazole (250 mg of amoxicillin and 250 mg of metronidazole, three times daily for 8 days) for young and middle-aged patients, and ciprofloxacin-metronidazole (500 mg of each, twice daily for 8 days) for elderly patients and for patients in developing countries who frequently harbor enteric rods subgingivally. Scaling to remove dental calculus and the prudent use of inexpensive antimicrobial agents can significantly retard or arrest progressive periodontitis in the great majority of patients.

A double-blind randomized clinical evaluation of enamel matrix derivative proteins for the treatment of proximal class-II furcation involvements

OBJECTIVE

The aim of the present randomized, double-blind study was to evaluate the clinical response of proximal furcations treated with enamel matrix derivative proteins (EMD).

MATERIAL AND METHODS

Fifteen patients, each with a pair of contralateral class-II proximal furcation involvements, presenting probing depths (PDs) >/=5 mm and bleeding on probing (BOP) were selected. The patients were randomly assigned to: control group (n=15) - open flap debridement (OFD)+24% ethylenediaminetetraacetic acid (EDTA) conditioning; test group (n=15) - OFD+24% EDTA conditioning+EMD application. Plaque index (PI), BOP, PD, gingival margin position (GMP), relative vertical and horizontal clinical attachment level (RVCAL and RHCAL), vertical and horizontal bone level (VBL and HBL) and furcation closure were evaluated immediately before and 2, 4 and 6 months after the surgeries.

RESULTS

At 6 months, the RVCAL gains of the control and test group were 0.39 +/- 1.00 and 0.54 +/- 0.95 mm, while the RHCAL gains were 1.21 +/- 2.28 and 1.36 +/- 1.26 mm (p>0.05). The VBL and HBL gains of the control group were 1.04 +/- 1.12 and 1.00 +/- 1.79 mm, and 0.82 +/- 1.82 and 1.17 +/- 1.38 mm for the test group (p>0.05). In addition, a statistical difference was observed in the number of the remaining class-II furcations between the test and control groups (p<0.05) in this period.

CONCLUSION

It may be concluded that the use of EMD in proximal furcations did not promote a superior reduction in PD or a gain in clinical and osseous attachment levels, but resulted in a higher rate of class-II to class-I furcation conversion.

Calculus Removal With Diamond-Coated Ultrasonic Inserts In Vitro

BACKGROUND

Efficient calculus removal is a primary goal in periodontal therapy. Diamond-coated ultrasonic inserts (DIs) offer promise for improved scaling and were evaluated in vitro.

METHODS

Extracted human teeth with moderate to severe calculus had areas of calculus ( approximately 5 x 5 mm) delineated with small burs. Each calculus area was treated under 2.5x magnification to the point of visible root cleanliness with sharp Gracey curets (hand instruments [HIs]), plain ultrasonic inserts (PIs), or ultrasonic inserts with fine-grit diamond coating; the latter two were used in a magnetostrictive ultrasonic instrument at a medium power setting. Each curet or insert was used for four teeth and then replaced by a new instrument. The time needed to clean each tooth/surface was recorded. The total area treated and the area of the residual calculus were calculated using an imaging analysis program.

RESULTS

The mean time required for clinical calculus removal was 29.7 seconds for DIs, 91.9 seconds for PIs, and 49.8 seconds for HIs (all P <0.0001 from each other). Overall, the mean percentage of residual calculus was 6.3% for DIs, 5.4% for PIs, and 3.1% for HIs (significant differences between HIs and the other treatments).

CONCLUSIONS

In vitro calculus removal was faster with DIs, followed by HIs and PIs. More residual calculus was found with the DIs; however, the 1% to 3% difference (93.7% clean versus 94.6% clean versus 96.9% clean with DIs, PIs, and HIs, respectively) does not seem to be clinically significant.

Adjunctive Antimicrobial Therapy of Periodontitis: Long-Term Effects on Disease Progression and Oral Colonization

BACKGROUND

This study assessed the long-term effects of adjunctive antimicrobial therapy on periodontal disease progression and oral colonization.

METHODS

Patients with previously untreated chronic periodontitis and subgingival Actinobacillus actinomycetemcomitans and/or Porphyromonas gingivalis were randomly assigned to subgingival scaling without (control group) or with systemic amoxicillin plus metronidazole and CHX irrigation (test group). Relative attachment levels were determined and subgingival and mucosal plaque samples were taken at baseline, at 10 days (plaque only) and at 3, 6, 9, 12, 18, and 24 months following initial therapy. During maintenance therapy, patients received supragingival debridement only.

RESULTS

After 24 months, the 18 test group patients showed at sites with initial probing depths (PD) > or =7 mm a significantly (P <0.05) higher frequency of 2 mm or more attachment gain (37.3% +/- 4.6%) and lower frequency of attachment loss (7.2% +/- 3.1%) compared to the 17 controls (8.2% +/- 3.9% and 19.1% +/- 13.1%, respectively). Compared to controls, the intraoral prevalence of A. actinomycetemcomitans (up to 18 months) and P. gingivalis (up to 3 months) decreased and that of Eikenella corrodens (at 10 days) increased in test patients (P <0.05). In both treatment groups, the detection frequency of Tannerella forsythensis decreased transiently, while an overall increase was recorded for Treponema ssp.

CONCLUSIONS

Over the 24-month period, a single course of the administered adjunctive antimicrobial therapy led to a relative risk reduction of 62% for attachment loss at deep sites. However, with the exception of A. actinomycetemcomitans, it failed to induce long-term changes in the prevalence profiles of oral colonization.

Comparison of the effects of various periodontal rotary instruments on surface characteristics of root surface

The efficacy of scaling and root planing using various periodontal rotary instruments was examined. Eighty extracted human teeth with a history of periodontal disease were divided into four groups of 20 and subjected to one of the following procedures: Use of 1) a Root Burnisher, 2) a Perio Planing Bur (both rotating instruments for contra angle handpieces), 3) a Tooth Planing Bur (rotating instrument for use with an air turbine), or 4) a Gracey Scaler. In each case, the time required for cleaning was measured. Twenty healthy extracted human teeth were used as untreated controls. After treatment, the surface roughness of 10 specimens out of each group were measured using a profilometer and observed by scanning electron microscopy (SEM). Half of the samples were then incubated in dishes with a suspension of fibroblasts. After counting the number of attached cells, the attachment of fibroblasts was observed by SEM. The root surfaces treated with the rotary instruments appeared smooth and there were no significant differences between groups. From the SEM observations, smooth root surfaces with different surface textures were evident and a tight attachment of fibroblasts was observed. The results of this study suggest that use of rotary instruments is superior for periodontal scaling and root planing.

Impaired healing response of periodontal furcation defects following flap debridement surgery in smokers. A controlled clinical trial

OBJECTIVES

The purpose of the present parallel-design, controlled clinical trial was to evaluate the treatment outcome of periodontal furcation defects following flap debridement surgery (FDS) procedure in cigarette smokers compared to non-smokers.

MATERIALS AND METHODS

After initial therapy, 31 systemically healthy subjects with moderate to advanced periodontitis, who presented at least one Class I or II molar furcation defect, were selected. Nineteen patients (mean age: 40.3 years, 15 males) were smokers (>or=10 cigarettes/day) and 12 patients (mean age: 44.8 years, 3 males) were non-smokers. Full-mouth plaque score (FMPS) and full-mouth bleeding score (FMBS), probing pocket depth (PPD), vertical clinical attachment level (v-CAL), and horizontal clinical attachment level (h-CAL) were assessed immediately before and 6 months following surgery.

RESULTS

Overall, statistically significant v-CAL gain was observed in smokers (1.0 +/- 1.3 mm) and non-smokers (1.3+/-1.1 mm), the difference between groups being statistically significant (p=0.0003). In proximal furcation defects, v-CAL gain amounted to 2.3+/-0.7 mm in non-smokers as compared to 1.0+/-1.1 mm in smokers (p=0.0013). At 6 months postsurgery, non-smokers presented a greater h-CAL gain (1.3+/-1.1 mm) than smokers (0.6+/-1.0 mm), with a statistically significant difference between groups (p=0.0089). This trend was confirmed in both facial/lingual (1.4+/-1.0 versus 0.8+/-0.8 mm) and proximal furcation defects (1.2+/-1.3 versus 0.5+/-1.2 mm). The proportion of Class II furcations showing improvement to postsurgery Class I was 27.6% in smokers and 38.5% in non-smokers. After 6 months, 3.4% of presurgery Class I furcation defects in smokers showed complete closure, as compared to 27.8% in non-smokers.

CONCLUSIONS

The results of the present study indicated that (1) FDS produced clinically and statistically significant PPD reduction, v-CAL gain, and h-CAL gain in Class I/II molar furcation defects, and (2) cigarette smokers exhibited a less favorable healing outcome following surgery in terms of both v-CAL and h-CAL gain.

Antimicrobial effects of mechanical debridement

Self-performed plaque removal using manual or powered toothbrushes and interdental cleaning devices is improved in subjects that have received oral hygiene instructions. Personal oral hygiene coupled with regular professional supragingival debridement may further improve the level of plaque control but still fails to achieve a completely plaque-free dentition. Both patient-performed and professional supragingival plaque removal has an effect on subgingival microbiota that is limited to the marginal 3 mm of the periodontal pocket. At sites with 4 mm or more of probing depth, only subgingival scaling leads to a significant reduction of the bacterial load. The subgingival microflora can be further reduced by pocket elimination surgery. Due to the sequence of bacterial recolonization that occurs following mechanical debridement, the level of periodontal pathogens such as B. forsythus, P. gingivalis and T. denticola may be reduced for several months. Mechanical debridement also influences the patient's immune system response, resulting in antibody titers and avidity against periodontal pathogens. As a basis for the restoration and maintenance of periodontal health, repeated subgingival debridement, as performed in supportive periodontal therapy, can reduce the number and proportions of periodontopathogenic bacteria in subgingival plaque. However, intensive subgingival scaling and root planing should be avoided in sites that probe less than 3 mm, as this is likely to traumatize the periodontium and cause attachment loss.

Clinical comparison of microporous biocompatible composite of PMMA, PHEMA and calcium hydroxide grafts and expanded polytetrafluoroethylene barrier membranes in human mandibular molar Class II furcations. A case series

BACKGROUND

Class II furcations present difficult treatment problems. Several treatment approaches to obtain furcation fill have been used with varying success.

METHODS

The response of mandibular Class II furcations to treatment with either a microporous biocompatible composite of PMMA (poly-methyl-methacrylate), PHEMA (poly-hydroxyl-ethyl methacrylate) and calcium hydroxide graft synthetic bone (HTR) replacement graft material; ePTFE barrier membrane; or a combination of the two was evaluated in trios of mandibular molars with Class II furcations in 8 patients with moderate to advanced periodontitis. Following initial preparation, full-thickness flaps were raised in the areas being treated, the bone and furcation defects debrided of granulomatous tissue, and the involved root surfaces mechanically prepared and chemically conditioned. By random allocation, HTR, ePTFE, or a combination of both was placed into and/or fitted over the furcations, packed and/or secured in place, and the host flap replaced or coronally positioned with sutures. Postsurgical deplaquing was performed every 10 days leading up to ePTFE removal at approximately 6 weeks. Continuing periodontal maintenance therapy was provided until surgical reentry at 6 months for documentation and any further necessary treatment.

RESULTS

Direct clinical measurements demonstrated essentially similar clinical results with all 3 treatments for bone and soft tissue changes. There were no statistically or clinically significant differences except for better horizontal amount and percent defect fill with HTR alone. Four of 8 furcations became Class I clinically with HTR alone, 5 of 8 became Class I with ePTFE alone, and 5 of 8 with combination treatment. The only complete furcation closure occurred with HTR.

CONCLUSION

The findings of this study suggest essentially equal clinical results with HTR bone replacement graft material alone, ePTFE barrier alone, and a combination of the two in mandibular molar Class II furcations. However, a real difference may not have been detected based on the small number of subjects in the study.

Failure of resin ionomers in the retention of multi-rooted teeth with Class III furcation involvement: a rebuttal case report

BACKGROUND

Severe periodontal furcation invasion has long been a treatment dilemma for the clinician. Many techniques have been advocated in the treatment of multi-rooted posterior teeth ranging from conventional scaling and root planing (SRP), apically positioned flaps, root amputations, root resections, tunnel procedures, guided tissue regeneration, and restorations. The keys to success depend on the clinician's ability to access the furcation to remove local factors and create an environment that enhances the patient's own hygiene efforts. Long-term success in treating teeth with furcation invasion depends upon tooth retention and arresting the destructive processes within the furcation area.

METHODS

A Class III furcation invasion in a mandibular molar was treated by surgical access for SRP along with obliterating the furcation utilizing a resin ionomer restoration.

RESULTS

Initially, the patient was asymptomatic. Within 3 months of treatment, the patient presented with suppuration that was refractory to local efforts. Radiographs taken only 5 months postsurgery demonstrated advanced bone loss apical to the restoration. The tooth ultimately was extracted because mobility increased and the tooth became symptomatic.

CONCLUSIONS

The clinician must consider the multi-factorial etiology of periodontal breakdown within a furcation. For this patient, the technique of sealing off the exposed furcation with restorative material appeared to have resulted in progressive bone loss and accelerate tooth loss. This single case report is presented as a rebuttal to recently published articles, which have demonstrated excellent results when treating furcations with ionomer restorations.

A comparison of the success of root resected molars and molar position implants in function in a private practice: results of up to 15-plus years

BACKGROUND

When faced with a furcated molar, today's clinician must decide between a number of treatment options, including root resection, tooth removal, and implant placement. This paper assesses the results in one private clinical practice of root resection and subsequent restoration or molar implant placement and subsequent restoration. Clinical considerations in treatment selection are discussed.

METHODS

A retrospective analysis of treated patients was carried out by examining active and inactive patient charts. When patients had discontinued therapy, every effort was made to determine the reason for leaving the private practice, so as to assess the impact of previously undocumented treatment failure on the statistics in question.

RESULTS

A total 701 root resected molars and 1,472 molar implants were evaluated after > or = 15 and 13 years in function, respectively. Resection of the distal root of a mandibular molar demonstrated the lowest success rate (75%). All other success rates for various root resected molars in function ranged from 95.2% to 100%. Lone standing implants in second molar positions demonstrated the lowest success rate (85%). All other implant use in molar positions demonstrated a success rate ranging from 97.0% to 98.6%. Root resected molars and molar implants demonstrated the highest degree of failure when they were lone standing terminal abutments. Seven out of 23 (30.4%) root resected molar failures, and 17 of 45 (37.8%) of the molar implant failures were associated with untreated parafunction. Cumulative success rates were 96.8% for root resected molars and 97.0% for molar implants. Success and failure are discussed by tooth and/or implant position, and resected root, where applicable. Possible ramifications of these findings upon treatment planning are also reviewed.

CONCLUSIONS

Both molar root resection and appropriate restoration and molar implant placement and restoration demonstrated a high degree of success in function. However, this success rate is markedly affected when either the root resected molar or molar implant is a lone standing terminal abutment. Care must be taken to choose the appropriate treatment modality for a given patient scenario.

Clinical comparison of bioactive glass bone replacement graft material and expanded polytetrafluoroethylene barrier membrane in treating human mandibular molar class II furcations

BACKGROUND

Class II furcations present difficult treatment problems and historically several treatment approaches to obtain furcation fill have been used.

METHODS

The response of mandibular Class II facial furcations to treatment with either bioactive glass (PG) bone replacement graft material or expanded polytetrafluoroethylene (ePTFE) barrier membrane was evaluated in 27 pairs of mandibular molars in 27 patients with moderate to advanced periodontitis. Following initial preparation, full thickness flaps were raised in the area being treated, the bone and furcation defects debrided of granulomatous tissue, and the involved root surfaces mechanically prepared and chemically conditioned. By random allocation, PG or ePTFE was placed into or fitted over the furcations, packed or secured in place, and the host flap replaced or coronally positioned with sutures. Postsurgical deplaquing was performed every 10 days leading up to ePTFE removal at about 6 weeks. Continuing periodontal maintenance therapy was provided until surgical reentry at 6 months for documentation and any further necessary treatment.

RESULTS

Direct clinical measurements demonstrated essentially similar clinical results with both treatments for bone and soft tissue changes. There were no statistically or clinically significant differences (e.g., mean horizontal furcation fill 1.4 mm PG, 1.3 mm ePTFE; mean percent horizontal furcation fill 31.6% PG, 31.1% ePTFE, both P>0.85). Seventeen of the PG treated and 18 of the ePTFE furcations became Class I clinically and 1 furcation completely closed clinically with each treatment. Intrapatient comparisons showed similar horizontal furcation responses with both treatments.

CONCLUSION

The findings of this study suggest essentially equal clinical results with PG bone replacement graft material and e-PTFE barriers in mandibular molar Class II furcations. PG use was associated with simpler application and required no additional material removal procedures.

Periodontal treatment decisions for molars: an analysis of influencing factors and long-term outcome

BACKGROUND

The purpose of this retrospective study was 1) to analyze factors influencing the treatment decision for periodontitis-affected molars and 2) to evaluate the long-term outcome of the decision. The treatment alternatives included in the analysis were maintenance of the tooth with only non-surgically/surgically performed scaling/root planing with or without furcation plasty, root separation/resection, and tooth extraction.

METHODS

Data collected from a total of 1,313 first and second molars in 222 patients (mean age 45 years; range 14 to 73 years), referred for periodontal treatment, were analyzed with respect to treatment decisions for furcation-involved teeth. The patients had been examined with respect to oral hygiene status, gingival conditions, probing depth, furcation involvement, and radiographic bone height before and after active periodontal treatment. Frequencies, mean values and standard deviations were calculated for the various variables assessed. Multiple regression models were formulated in order to analyze the influence of various variables on treatment decisions. One-hundred and sixty (72%) of the patients agreed to participate in a follow-up examination to determine the clinical and radiographic status of the molars 8 to 12 years after the active phase of treatment for evaluation of the long-term outcome of the treatment decision.

RESULTS

Twenty-eight percent of the molars were extracted and 4% were root separated/resected. Factors found to significantly influence the decision of tooth extraction were tooth mobility, tooth position, lack of occlusal antagonism, degree of furcation involvement, and remaining bone support. Of the factors analyzed with respect to root separation/resection, molar position and degree of furcation involvement showed the strongest influence on the treatment decision. The 8- to 12-year follow-up examination revealed that 96% of the molars subjected to non-resective therapy were still in function. The corresponding figure for root separated/resected molars was 89%. Loss of radiographic bone support during the 10-year follow-up period was 0.1 to 0.6 mm for the various molars with the highest value for maxillary second molars.

CONCLUSIONS

A conservative approach to the treatment of molars with even deep furcation invasions may show a high long-term success rate, provided maintenance care is offered.

Comparison of four methods of assessing root surface debridement

BACKGROUND

While there is great interest in measuring the efficacy of root surface debridement, there is little consensus on how this might be best achieved. The aim of this study was therefore to compare four different methods of assessing root surface debridement in their ability to discriminate between ultrasonically instrumented root surfaces and non-instrumented control surfaces.

METHODS

Single-session subgingival root debridement was performed by an experienced operator on 30 teeth prior to their extraction. Following extraction, efficacy of root surface debridement was measured by percentage of remaining calculus, instrument efficiency, modified instrument efficiency, and percentage apical plaque border. In addition, the effect of probing depth landmark (apical plaque border versus connective tissue attachment) on outcomes was assessed.

RESULTS

The results indicated that percentage apical plaque border demonstrated highly statistically significant differences between instrumented and control surfaces (P= 0.02). No other assessment method was able to discriminate between instrumented and non-instrumented surfaces, and this may be a function of the low amount of root surface calculus in the experimental sample. In addition, choice of probing depth landmark had a notable effect on the outcomes for instrument efficiency and modified instrument efficiency. Ninety-five percent limits of agreement of interexaminer reproducibility were found to be much higher than intra-examiner measurement for all four methods of assessment.

CONCLUSIONS

Percentage apical plaque border appeared to be potentially more useful than other methods for assessing the efficacy of debridement of periodontally involved root surfaces, particularly for measuring instrument penetrability.

Comparative in vitro effectiveness of closed root debridement with fine instruments on specific areas of mandibular first molar furcations. II. Furcation area

The purpose of this study was to demonstrate the extent of deposits removed from within the furcation area of mandibular first molars following the use of curets with a modified blade and slim ultrasonic inserts in an in vitro model simulating a closed root debridement approach to furcation treatment. The furcation areas of 100 artificial mandibular first molars were uniformly coated with black model paint. The molars were fixed into a custom acrylic model, maintained in a firm position with modified occlusal splints, and the roots covered with a heavy rubber dam. The model was set in a mannequin and mounted on a dental chair recreating a clinical situation. Fifty molars (25 right, 25 left) were instrumented with the experimental curets and an equivalent number of molars with the ultrasonic inserts. An experienced dental hygienist completed all the instrumentation, spending 4 minutes on each molar. The molars were sectioned buccolingually from the crown apically to separate the roots, and areas in the internal surface of mesial and distal roots were analyzed to determine the percentage of deposits remaining using a computerized imaging routine system. A 2-factor analysis of variance was conducted to test for differences between both types of instruments. The curets produced furcation root surfaces with significantly less percentage of residual deposits than the ultrasonic inserts (P < 0.01). This study indicates the potential value of small bladed curets in debriding involved furcations during initial therapy and supportive periodontal therapy. The current findings should be corroborated in a clinical study.

Comparative in vitro effectiveness of closed root debridement with fine instruments on specific areas of mandibular first molar furcations. I. Root trunk and furcation entrance

The purpose of this study was to compare curets with a small blade to slim ultrasonic inserts on their efficacy in removing artificial deposits from the root trunk and furcation entrance areas of mandibular molars using an in vitro model simulating a clinically closed root debridement approach. The study was conducted on 100 artificial mandibular first molars (50 right side and 50 left side) with anatomical roots. Root trunks, furcation entrances, and furcation areas of each molar were colored by a coat of black model paint. The teeth were fixed in a custom acrylic model and maintained in a firm position by modified acrylic occlusal splints. The root areas were covered with a heavy rubber dam imitating gingival tissue. The model was attached to a mannequin and mounted on a dental chair. Fifty molars (25 right, 25 left) were instrumented with the experimental curets and an equivalent number of molars with the ultrasonic inserts. The instrumentation was carried out by one experienced operator, spending 4 minutes on each molar. The instrumented areas were individually analyzed to determine the percentage of deposits remaining, using a computerized imaging routine system. One-way analysis of variance was conducted to test for differences between both types of instruments. Results revealed that the curets were significantly more efficient (P < 0.01) than the ultrasonic inserts in removing paint from both root trunks and furcation entrances. These findings should be corroborated in a clinical study to determine the potential value of the instruments tested during initial therapy or supportive care of involved mandibular furcations.

Dental calculus: recent insights into occurrence, formation, prevention, removal and oral health effects of supragingival and subgingival deposits

Dental calculus, both supra- and subgingival occurs in the majority of adults worldwide. Dental calculus is calcified dental plaque, composed primarily of calcium phosphate mineral salts deposited between and within remnants of formerly viable microorganisms. A viable dental plaque covers mineralized calculus deposits. Levels of calculus and location of formation are population specific and are affected by oral hygiene habits, access to professional care, diet, age, ethnic origin, time since last dental cleaning, systemic disease and the use of prescription medications. In populations that practice regular oral hygiene and with access to regular professional care, supragingival dental calculus formation is restricted to tooth surfaces adjacent to the salivary ducts. Levels of supragingival calculus in these populations is minor and the calculus has little if any impact on oral-health. Subgingival calculus formation in these populations occurs coincident with periodontal disease (although the calculus itself appears to have little impact on attachment loss), the latter being correlated with dental plaque. In populations that do not practice regular hygiene and that do not have access to professional care, supragingival calculus occurs throughout the dentition and the extent of calculus formation can be extreme. In these populations, supragingival calculus is associated with the promotion of gingival recession. Subgingival calculus, in "low hygiene" populations, is extensive and is directly correlated with enhanced periodontal attachment loss. Despite extensive research, a complete understanding of the etiologic significance of subgingival calculus to periodontal disease remains elusive, due to inability to clearly differentiate effects of calculus versus "plaque on calculus". As a result, we are not entirely sure whether subgingival calculus is the cause or result of periodontal inflammation. Research suggests that subgingival calculus, at a minimum, may expand the radius of plaque induced periodontal injury. Removal of subgingival plaque and calculus remains the cornerstone of periodontal therapy. Calculus formation is the result of petrification of dental plaque biofilm, with mineral ions provided by bathing saliva or crevicular fluids. Supragingival calculus formation can be controlled by chemical mineralization inhibitors, applied in toothpastes or mouthrinses. These agents act to delay plaque calcification, keeping deposits in an amorphous non-hardened state to facilitate removal with regular hygiene. Clinical efficacy for these agents is typically assessed as the reduction in tartar area coverage on the teeth between dental cleaning. Research shows that topically applied mineralization inhibitors can also influence adhesion and hardness of calculus deposits on the tooth surface, facilitating removal. Future research in calculus may include the development of improved supragingival tartar control formulations, the development of treatments for the prevention of subgingival calculus formation, the development of improved methods for root detoxification and debridement and the development and application of sensitive diagnostic methods to assess subgingival debridement efficacy.

Management of furcation-involved teeth. A retrospective analysis

In the present study, data from more than 550 periodontally diseased patients with more than 1100 furcation invasions were retrospectively analysed. There were apparent differences in the distribution of different furcation degrees in patient populations treated by 2 differently experienced operators. However, treatment modality patterns were rather similar. Scaling during periodontal flap surgery was the most often performed treatment procedure in degree I (97-98%) and II (75-83%) involvements. About 44% of degree III involved teeth were extracted. In order to determine the influence of degree of furcation involvement, tooth type and operator variability on treatment modality, logistic regression analysis was applied. Degree of furcation involvement was an important indicator variable in all models. Scaling as a sole measure was mainly performed in relation to degree I of furcation involvement. With every increase in degree, the odds of scaling decreased by factor 12.7. The odds of root resection was upper 1st molars 46 x higher than in wisdom teeth or lower 2nd molars with the same degree of involvement, but only 3.3 x higher than in lower 1st molars. Tunnel preparation as well as regenerative procedures were mainly confirmed to lower molars. Operator variability was only introduced as a covariate in the extraction model. hence, despite of different operator skill and severity of periodontal disease in treated populations, decision for one or the other treatment modality seems to depend essentially on degree of furcation involvement as well as tooth type.

Calculus removal from multirooted teeth with and without surgical access. II. Comparison between external and furcation surfaces and effect of furcation entrance width

The purpose of this study was to evaluate the effect of furcation entrance width on the efficacy of calculus removal from furcation areas as well as to compare this efficacy between external and furcation surfaces after closed root planing, open root planing and use of a rotary diamond for the furcation area. 30 first and second lower molars scheduled for extraction with a calculus index > or = 2 and a degree II or III furcation involvement were divided into 3 groups: 10 molars were scaled and root planed using a closed approach: 10 molars were scaled and root planed using an open approach; 10 molars were scaled and root planed with an open approach and rotary diamond was used for removal of deposits in the furcation area. After extraction, the width of the furcation entrance was measured buccally and lingually 2 mm apical from the bifurcation and furcations were categorized as wide (width > 2.4 mm) or narrow (width < 2.4 mm). The teeth were assessed in a stereomicroscope and the % of residual calculus on external and furcation surfaces was calculated. The width of the furcation entrance influenced the efficacy in root planning in the open group (p = 0.0015). The use of rotary diamond was the most effective method for removing calculus both for narrow and wide furcations. The effectiveness of open root planning in the mesial root was related to the width of the furcation entrance where the % of residual calculus was significantly higher for narrow furcations (p = 0.008).(ABSTRACT TRUNCATED AT 250 WORDS)