Minimally invasive non-surgical approach for the treatment of periodontal intrabony defects: a retrospective analysis

Periodontal granulation tissue - To remove or not to remove, that is the question

Formation of granulation tissue is a fundamental phase in periodontal wound healing with subsequent maturation leading to regeneration or repair. However, persistently inflamed granulation tissue presents in osseous defects as a result of periodontitis and is routinely disrupted and discarded with non-surgical and surgical therapy to facilitate wound healing or improve chances of regeneration. Histological assessment suggests that granulation tissue from periodontitis-affected sites is effectively a chronic inflammatory tissue resulting from impaired wound healing due to persistence of bacterial dysbiotic bioflim. Nevertheless, the immunomodulatory potential and stem cell characteristics in granulation tissue have also raised speculation about the tissue's regenerative potential. This has led to the conception and recent implementation of surgical techniques which preserve granulation tissue with the intention of enhancing innate regenerative potential and improve clinical outcomes. As knowledge of fundamental cellular and molecular functions regulating periodontitis-affected granulation tissue is still scarce, this review aimed to provide a summary of current understanding of granulation tissue in the context of periodontal wound healing. This may provide new insights into clinical practice related to the management of granulation tissue and stimulate further investigation.

Minimally invasive non-surgical periodontal therapy of intrabony defects: A prospective multi-centre cohort study

AIM

To assess the potential benefits of minimally invasive non-surgical therapy (MINST) in teeth with intrabony defects and to explore factors associated with the outcomes.

MATERIALS AND METHODS

A multi-centre trial was conducted in 100 intrabony defects in periodontitis patients in private practice. Steps 1 and 2 periodontal therapy including MINST were provided. Clinical and radiographic data were analysed at baseline and 12 months after treatment, with the primary aim being change in radiographic defect depth at 12 months.

RESULTS

Eighty-four patients completed the 12-month follow up. The mean total radiographic defect depth reduced by 1.42 mm and the defect angle increased by 3° (both p < .05). Statistically significant improvements in probing pocket depth (PPD) and clinical attachment level (CAL) were seen at 12 months compared to baseline (p < .001). Fifty-six defects (66.7%) achieved pocket closure (PPD ≤ 4 mm) and 49 defects (58.3%) achieved the composite outcome (PPD ≤ 4 mm and CAL gain ≥3 mm). Deeper and narrower angled defects were positively correlated with radiographic and clinical improvements, respectively.

CONCLUSIONS

Improvements in clinical and radiographic outcomes were seen after MINST. This study highlights the generalizability and wide applicability of this approach, further supporting its effectiveness in the treatment of intrabony defects.

CLINICAL TRIAL REGISTRATION

NCT03741374. https://clinicaltrials.gov/study/NCT03741374?cond=minimally%20invasive%20non%20surgical%20therapy&locStr=UK&country=United%20Kingdom&distance=50&rank=2.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICALTRIALS

gov identification number: NCT05456555.

Effects of minimally invasive non-surgical therapy on C-reactive protein, lipoprotein-associated phospholipase A2, and clinical outcomes in periodontitis patients: A 1-year randomized, controlled clinical trial

BACKGROUND

Growing evidence suggests the type of periodontal treatment could differentially influence the reduction of key cardiovascular risk mediators in periodontitis patients. This randomized, controlled clinical trial compared the impact of minimally invasive non-surgical therapy (MINST) with quadrant-wise subgingival instrumentation (Q-SI) on C-reactive protein (CRP) together with lipoprotein-associated phospholipase A2 (Lp-PLA2) levels, and clinical periodontal outcomes in patients with periodontitis. Moreover, it was evaluated if baseline CRP levels impacted the efficacy of non-surgical periodontal therapy protocols.

METHODS

Forty-two periodontitis patients were enrolled and randomly treated by means of MINST (n = 21) or Q-SI (n = 21). The outcomes assessed were serum CRP and Lp-PLA2, and periodontal parameters (probing depth [PD], clinical attachment level [CAL], full-mouth bleeding score [FMBS]), at baseline and at follow-ups at 1, 3, and 6 months and at 1 year after treatment.

RESULTS

At 1 year, MINST significantly reduced, among others, mean PD (p = 0.007), mean CAL (p = 0.007), the number of pockets >4 mm (p = 0.011) and ≥6 mm (p = 0.005), and FMBS (p = 0.048) compared to Q-SI. Generalized multivariate analysis evidenced that high baseline CRP (p = 0.039) and FMBS (p = 0.046) levels, together with MINST treatment (p = 0.007) were significant predictors of PD reduction at 1-year follow-up. Moreover, the Jonckheere-Terpstra test showed that patients with high baseline CRP levels gained more benefits from MINST treatment at 1-year follow-up than they did from Q-SI.

CONCLUSION

Patients receiving MINST showed a greater reduction in CRP levels than patients with Q-SI after 1 year of follow-up. Moreover, patients with high baseline levels of CRP and Lp-PLA2 gained more benefits from the MINST approach at 1-year follow-up.

A novel periodontal endoscopy-aided non-incisional periodontal regeneration technique in the treatment of intrabony defects: a retrospective cohort study

BACKGROUND

Gingival recession and post-operation discomfort are still a problem for patients receiving the periodontal regeneration surgery for intra-bony defects. To further reduce the trauma and the post-operation gingival recession, a novel periodontal endoscopy-aided non-incisional regeneration technique (NIT) was proposed in the treatment of intra-bony defects.

METHODS

Retrospective analysis of 21 subjects treated with NIT and 21 subjects with periodontal endoscopy-aided scaling and root planing (PSRP) at baseline and 1-year evaluation was conducted. After removing the subgingival calculus and granulation tissue, bone grafting materials were placed into intrabony defects with the assistance of a gingival retractor in the NIT group. Probing depth (PD), gingival recession (GR), clinical attachment level (CAL), as well as the distance between bone crest (BC) level and base of the defect (BD) (intrabony defect depth, IBD) were evaluated at baseline and 1 year after treatment.

RESULTS

At 1-year follow-up, the value of CAL, PD and IBD were statistically significant different compared with baseline in both two groups (p<0.001). CAL gain (p = 0.012) and PD reduction (p = 0.004) was greater in the NIT than PSRP. However, no difference in the IBD reduction was found between the NIT group and PSRP. Better CAL gain and PD reduction was achieved in the 1-year term in the NIT when compared with PSRP.

CONCLUSION

NIT have resulted in significant gains in both clinical and radiographic parameters. NIT might be utilized as an alternative of the surgical treatment for periodontal intrabony defects.

TRIAL REGISTRATION

This clinical trial registration was registered retrospectively (August 3, 2023) and the number is ChiCTR2300074317.

Distribution and influencing factors on residual pockets of the teeth in patients with periodontitis following non-surgical periodontal treatment: a retrospective observational study

BACKGROUND

Periodontitis is a chronic and multi-factorial infectious disease. A notable difference exists in the prognosis of patients with severe periodontitis after non-surgical periodontal treatment. Thus, a retrospective study was conducted to identify common and specific factors that impact the prognosis of patients with periodontitis stage III-IV following non-surgical periodontal treatment at different tooth sites.

METHODS

A total of 977 teeth were included in the study, comprising 266 patients diagnosed with periodontitis stage III-IV. This sample included 330 anterior teeth, 362 maxillary posterior teeth, and 285 mandibular posterior teeth. Following treatment, the teeth were categorized into two groups based on residual pocket depth [probing depth (PD) ≥ 5 mm] at 3 months post-treatment. The prognosis of periodontitis stage III-IV was assessed through multivariate analysis employing logistic regression to determine the association of various risk factors.

RESULTS

The PD values of each site and the deepest PD values of each tooth significantly decreased at 3 months post-treatment. Residual pockets were predominantly found in the mesio/disto-buccal and mesio/disto-lingual regions. Multivariate analysis revealed that gender, PD, sulcus bleeding index (SBI) and plaque index (PLI) at baseline, and crown-root ratio in anterior teeth had a significant influence on periodontitis stage III-IV (P < 0.05). Smoking, PD, PLI and furcation involvement (FI) at baseline, PLI at 3 months post-treatment, grades of periodontitis, and crown-root ratio were prediction factors for maxillary posterior teeth. Factors such as PD, PLI and FI at baseline, PLI at 3 months post-treatment, and crown-root were significant in mandibular posterior teeth.

CONCLUSIONS

The outcome of non-surgical treatment varies depending on the tooth positions for patients with periodontitis stage III-IV. Dentists must accurately identify the affected teeth that have periodontal pockets of more than 5 mm, taking into consideration the positions of the affected teeth, as well as various local and systemic factors. This comprehensive assessment will enable dentists to develop a customized and effective treatment plan.

Minimally invasive non-surgical therapy (MINST) in stage III periodontitis patients: 6-month results of a split-mouth, randomised controlled clinical trial

OBJECTIVES

To determine if minimally invasive non-surgical therapy (MINST) outperforms classical non-surgical periodontal therapy for stage III periodontitis with primarily suprabony (horizontal) type defects.

MATERIALS AND METHODS

In a split-mouth randomised controlled trial, 20 patients' dental quadrants were randomly assigned to MINST or classical non-surgical treatment. The primary outcome variable was the number of sites with probing pocket depth ≥ 5 mm and BOP. Treatment method, tooth type, smoking status, and gender were evaluated using a multivariate multilevel logistic regression model.

RESULTS

After 6 months, the percentage of sites with PD ≥ 5 mm and BOP that healed (MINST = 75.5%; control group = 74.1%; p = 0.98), and the median number of persisting sites (MINST: 6.5, control group: 7.0; p = 0.925) were similar in both groups. In the test and control groups, respectively, median probing pocket depths (2.0 mm vs. 2.1 mm) and clinical attachment level (1.7 mm vs. 2.0 mm) changed significantly (p < 0.05) but similarly. Significantly less gingival recession occurred in the MINST group's deep molar pockets compared to the control group (p = 0.037). Men (OR = 0.52, p = 0.014) and non-molars (OR = 3.84, p 0.001) had altered odds for healing of sites with PD ≥ 5 mm and BOP.

CONCLUSIONS

MINST reduces gingival recession associated with molar teeth, although it performs similarly to traditional non-surgical therapy in treating stage III periodontitis with predominately horizontal-type defects.

CLINICAL RELEVANCE

MINST performs similarly to non-surgical periodontal therapy in stage III periodontitis with predominantly suprabony defects.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT04036513) on June 29, 2019.

Minimal invasiveness in nonsurgical periodontal therapy

Periodontal treatment is quickly moving towards a philosophy consisting of a less invasive approach. In this context, minimally invasive nonsurgical therapy (MINST) is a promising option. This paper reviews the concepts behind minimal invasiveness in nonsurgical periodontology and reports the state-of the art evidence for this topic. Instruments used and protocols suggested for these applications are introduced and discussed. The original papers reviewed show probing pocket depth (PPD) reductions and clinical attachment level (CAL) gains ranging from 2 to 4 mm between baseline and 6 months to 5 years posttreatment for intrabony defects and from 1.5 to 3 mm between baseline and 2-6 months of follow-up for full-mouth results. These clinical outcomes are accompanied by statistically significant reductions in radiographic bone defect depth and increases in intrabony defect angles posttreatment. Wound healing mechanisms following MINST are presented, and clinical applications and directions for future research are suggested.

Minimally Invasive Non-Surgical Technique in the Treatment of Intrabony Defects-A Narrative Review

Intrabony defects occur frequently in periodontitis and represent sites that, if left untreated, are at increased risk for disease progression. Although resective or repair procedures have been used to treat intrabony defects, aiming at their elimination, the treatment of choice is surgical periodontal regeneration. The development of periodontal regeneration in the last 30 years has followed two distinctive, though totally different, paths. The interest of researchers has so far focused on regenerative materials and products on one side, and on novel surgical approaches on the other side. In the area of materials and products, three different regenerative concepts have been explored namely, barrier membranes, bone grafts, and wound healing modifiers/biologics, plus many combinations of the aforementioned. In the area of surgical approaches, clinical innovation in flap design and handling, as well as minimally invasive approaches, has radically changed regenerative surgery. Recently, a minimally invasive non-surgical technique (MINST) for the treatment of intrabony defects was proposed. Initial clinical trials indicated comparable results to the surgical minimally invasive techniques in both clinical and radiographic outcomes. These results support the efficacy of this treatment approach. The aim of this review is to present the evidence on the application of minimally invasive non-surgical techniques and their efficacy in the treatment of intrabony defects.

Clinical efficacy of hand and power-driven instruments for subgingival instrumentation during periodontal surgical therapy: a systematic review

OBJECTIVE

This systematic review aims to assess the available literature on the clinical efficacy of hand versus power-driven instruments for subgingival instrumentation during surgical periodontal therapy (ST).

MATERIALS AND METHODS

A search of the literature was carried out on MEDLINE via Ovid, Embase, Web of Science, the Cochrane Database, LILACS, and Scopus. RCTs comparing the use of powered instruments (test) to hand scalers (control) for subgingival instrumentation in terms of changes in probing pocket depth (PPD) after surgical periodontal treatment were included and screened in duplicate. Descriptive synthesis of the data and risk of bias assessment were undertaken.

RESULTS

Four RCTs met the inclusion criteria and were included in this systematic review. ST in all studies was performed by means of open flap debridement. Gracey curettes were the most commonly used hand instruments, while sonic and ultrasonic devices were used in the test group. Sites with initial PPD ≥ 6 mm had pocket reduction ranging from 2.93 to 4.89 mm in the control group and from 2.77 to 3.86 mm in the test group. All studies found no significant difference between the different types of instruments/devices in terms of PPD reduction.

CONCLUSIONS

Despite the limited number of studies, both manual and power-driven instruments appear to be effective in reducing PPD after surgical treatment of periodontitis.

CLINICAL RELEVANCE

Based on the findings of this systematic review, the clinician may make a decision whether to use manual or powered instruments during ST on a case-by-case basis and considering other factors, such as the risk of creating high concentrations of aerosols.

The role of cigarette smoking in periodontal disease and treatment outcomes of dental implant therapy

Tobacco smoking has been implicated in periodontal pathology through various mechanisms, including perturbations of the inflammatory and host responses to putative periodontal pathogens, alterations in the subgingival microbial communities, and a compromised healing potential of the tissues leading to imbalance of tissue homeostasis. This review provides the evidence for the relationship between cigarette smoking and periodontal disease in an attempt to explain possible mechanisms of how tobacco smoking may exert its negative effects on the periodontal tissues via systemic and localized pathways. Early and more recent studies explore cigarette smoking-induced changes in periodontal clinical indices; in subgingival microbial flora by employing traditional detection methods for selected microorganisms, in addition to modern techniques such as deep sequencing and bioinformatics analyses that are able to fully characterize the microbial communities; and in inflammatory and immune responses critically appraising study limitations and differences in study protocol designs. Periodontal treatment outcomes and implant therapy outcomes are reviewed in an attempt to shed light on possible mechanisms for the inferior treatment outcome noted in smokers. The potential harmful effects of passive smoking are also reviewed, providing evidence for the advantages of smoking cessation. Quitting cigarette smoking should be recommended by the dentist, and effort should be made to inform smokers about the negative effects of smoking on the periodontal status and implant therapy outcomes.

Clinical Benefits of Minimally Invasive Non-Surgical Periodontal Therapy as an Alternative of Conventional Non-Surgical Periodontal Therapy-A Pilot Study

Minimally invasive procedures were introduced in periodontics, which could enhance clinical outcomes and reduce post-operative discomfort. However, minimally invasive non-surgical periodontal therapy (MINST) as an alternative modality of conventional non-surgical root surface debridement has not been clearly evaluated by randomized controlled clinical trial. The present study aimed to investigate clinical outcomes and patients’ comfort feedback of MINST compared to conventional non-surgical periodontal therapy (CNST). Patients with moderate to severe periodontitis were included. Nine out of ten patients were recruited and completed the post-treatment re-evaluation in this study. Randomized split-mouth design, CNST and MINST on each side, was performed. Clinical parameters, including periodontal probing depth (PD), gingival recession (REC), clinical attachment level (CAL), and gingival bleeding on probing (BOP), were recorded on baseline, 1 month and 3 months post-treatment. Non-parametric statistics were used for analysis. PD, REC, CAL, and BOP were improved after treatment in both CNST and MINST groups. Comfort feedback and gingival recession showed better outcomes in the MINST group than in the CNST group. No statistical significance of parameters was found between CNST and MINST. Within the limitations, minimally invasive non-surgical periodontal therapy could be an alternative modality of conventional non-surgical periodontal therapy. Further studies are required to establish clinical protocol and evidence of MINST.

Post-Operative Bleeding Complications in a Periodontitis Patient Testing Positive for COVID-19

Recent scientific evidence states that a subset of COVID-19 patients may have a risk of increased bleeding tendency. This case report presents a healthy 38-year-old woman with generalized stage III, grade C periodontitis with an abnormal post-operative blood clot formation who tested positive for COVID-19 after a standard periodontal surgery. Previously, two periodontal surgeries proceeded without any complications and were considered standard. On day one after the third periodontal surgery the patient had no complaints. On day two the patient reported excess bleeding in the oral cavity from the operated area simultaneously with fever and loss of taste. On day three the patient was seen in our clinic; general malaise symptoms and bleeding tendency had started to decline and the patient received a COVID-19 PCR test. At day four the test resulted positive, and she reported no further complaints of intraoral bleeding. Six months later the taste of the patient was still distorted. For this patient with free medical anamnesis, we suggest that the patient had increased plasma levels of tissue plasminogen activator during the crucial postoperative period due to an acute COVID-19 infection. This led to increased plasmin levels with a hyper-fibrinolytic state as a consequence.

Enamel matrix derivative as an adjunct to minimally invasive non-surgical treatment of intrabony defects: A randomized clinical trial

AIM

To compare the efficacy of minimally invasive non-surgical technique (MINST) with or without enamel matrix derivative (EMD) in the treatment of intrabony defects ≤7 mm.

MATERIALS AND METHODS

Thirty-six patients were randomly assigned to the two groups. The control group received MINST, while the experimental MINST+EMD. Clinical measurements were recorded at baseline and at 6 and 12 months, and radiographic measurements were made at baseline and 12 months.

RESULTS

All subjects completed the study, 18 in each group. Significant improvements were observed in both groups at 12 months (p < .001) with no differences in mean PD reduction (4.0 ± 1.4 vs. 4.2 ± 1.7 mm), CAL gain (3.5 ± 1.4 vs. 3.4 ± 1.6 mm), and defect resolution (1.9 ± 1.1 vs. 1.8 ± 0.9 mm) for the MINST and the MINST+EMD groups, respectively (p > .05). A trend for greater pocket closure (PD ≤4 mm and no BoP) was achieved with the application of EMD (77.8% vs. 55.6% sites), particularly for sites with baseline PD ≤8 mm (92.3% vs. 69.2% sites), accompanied by an increased number of successful composite outcome results (61.1% vs. 44.4% sites).

CONCLUSIONS

MINST demonstrates significant improvements 12 months after treatment of intrabony defects ≤7 mm. The additional application of EMD does not further improve the mean clinical or radiographic outcomes. This study is registered in ClinicalTrials.gov (NCT03622255).

Changes in clinical parameters following adjunctive local sodium hypochlorite gel in minimally invasive nonsurgical therapy (MINST) of periodontal pockets: a 6-month randomized controlled clinical trial

BACKGROUND

The mechanical disruption and removal of the subgingival biofilm represent the most important step in the treatment of periodontitis. However, in deep periodontal pockets, mechanical removal of the subgingival biofilm is difficult and frequently incomplete. Preliminary findings indicate that the use of amino acid buffered sodium hypochlorite (NaOCl) gel may chemically destroy the bacterial biofilm and facilitate its mechanical removal.

OBJECTIVES

To clinically evaluate the efficacy of minimally invasive nonsurgical therapy (MINST) of periodontal pockets with or without local application of an amino acid buffered sodium hypochlorite (NaOCl) gel.

MATERIALS AND METHODS

Forty untreated patients diagnosed with severe/advanced periodontitis (i.e. stage III/IV) with a slow/moderate rate of progression (i.e. grade A/B) were randomly allocated in two treatment groups. In the test group, the periodontal pockets were treated by means of MINST and NaOCl gel application, while in the control group, treatment consisted of MINST alone. Full-mouth plaque scores (FMPS), full-mouth bleeding scores (FMBS), probing depths (PD), clinical attachment levels (CAL) and gingival recessions (GR) were assessed at baseline and at 6 months following therapy. The primary outcome variable was PD reduction at sites with PD ≥ 5 mm at baseline.

RESULTS

At 6 months, statistically significant differences between the two groups were found (p = 0.001) in terms of PD and CAL change. No statistically significant differences were found in terms of GR (p = 0.81). The number of sites with PD ≥ 5 mm and BOP (+) decreased statistically significantly (p = 0.001), i.e. from 85.3 to 2.2% in the test group and from 81.6 to 7.3% in the control group, respectively. Statistically significant differences between test and control groups were recorded at 6 months (p = 0.001). MINST + NaOCl compared to MINST alone decreased statistically significantly (p = 0.001) the probability of residual PDs ≥ 5 mm with BOP- (14.5% vs 18.3%) and BOP+ (2.2% vs. 7.2%).

CONCLUSIONS

Within their limits, the present results indicate that (a) the use of MINST may represent a clinically valuable approach for nonsurgical therapy and (b) the application of NaOCl gel in conjunction with MINST may additionally improve the clinical outcomes compared to the use of MINST alone.

CLINICAL RELEVANCE

In patients with untreated periodontitis, treatment of deep pockets by means of MINST in conjunction with a NaOCl gel may represent a valuable approach to additionally improve the clinical outcomes obtained with MINST alone.

ACCESS FLAPS MAY RESULT IN GREATER POCKET REDUCTION THAN SUBGINGIVAL DEBRIDEMENT FOR DEEP POCKETS BUT MAY NOT BE BENEFICIAL FOR SHALLOW TO MODERATELY DEEP POCKETS

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Sanz-Sánchez I, Montero E, Citterio F, Romano F, Molina A, Aimetti M. Efficacy of access flap procedures compared to subgingival debridement in the treatment of periodontitis. A systematic review and meta-analysis. J Clin Periodontol. 2020 Jul;47 Suppl 22:282-302. doi:10.1111/jcpe.13259. PMID: 31,970,821.

SOURCE OF FUNDING

This systematic review was self-funded.

TYPE OF STUDY/DESIGN

Systematic review with meta-analysis.

Minimally Invasive Periodontology: A Treatment Philosophy and Suggested Approach

Severe periodontitis is a highly prevalent dental disease. With the advent of implant dentistry, teeth are often extracted and replaced. Periodontal surgery, where indicated, could also result in increased trauma to the patient. This literature review discusses different treatment modalities for periodontitis and proposes a treatment approach emphasizing maximum preservation of teeth while minimizing morbidity to the patient. Scientific articles were retrieved from the MEDLINE/PubMed database up to January 2021 to identify appropriate articles that addressed the objectives of this review. This was supplemented with hand searching using reference lists from relevant articles. As tooth prognostication does not have a high predictive value, a more conservative approach in extracting teeth should be abided by. This may involve repeated rounds of nonsurgical periodontal therapy, and adjuncts such as locally delivered statin gels and subantimicrobial-dose doxycycline appear to be effective. Periodontal surgery should not be carried out at an early phase in therapy as improvements in nonsurgical therapy may be observed up to 12 months from initial treatment. Periodontal surgery, where indicated, should also be minimally invasive, with periodontal regeneration being shown to be effective over 20 years of follow-up. Biomarkers provide an opportunity for early detection of disease activity and personalised treatment. Quality of life is proposed as an alternative end point to the traditional biomedical paradigm focused on the disease state and clinical outcomes. In summary, minimally invasive therapy aims to preserve health and function of the natural dentition, thus improving the quality of life for patients with periodontitis.

New surgery approaches preserving entire papilla to treat isolated interdental intrabony defects: A narrative review

OBJECTIVES

To review novel techniques of preserving the entire papilla to minimize the trauma of fragile papilla in periodontal regeneration surgeries.

MATERIAL AND METHODS

Electronic databases (Pubmed) and relevant journals were searched until September 4, 2020. Randomized controlled trials, cross-sectional and cohort studies in English were included. Three novel approaches of preserving the entire papilla were applied to bone regeneration for intrabony defects, which were entire papilla preservations (EPP), nonincised papillae surgical approach (NIPSA) and modified vestibular incision subperiosteal tunnel access (M-VISTA).

RESULTS

Randomized control trials of the novel preserving entire papilla techniques were rarely reported. There were only case series or cohort studies. Several papilla preservation techniques (PPT) or minimally invasiveness surgical techniques (MIST) have existed for a long time. However, these techniques still have dissection at the papilla. There were no related RCTs comparing the three novel approaches of keeping the entire papilla with PPT and MIST. All three techniques showed totally primary wound closure. Compared with PPT/MIST, EPP and NIPSA seemed to have better clinical outcomes in reducing probing depth (PD) and clinical attachment level (CAL) gain.

CONCLUSIONS

EPP and NIPSA seemed to have advanced results of PD reduction and CAL gain than PPT and MIST. This is needed to be confirmed by further research.

Interproximal attachment gain: The challenge of periodontal regeneration

The new classification of periodontal diseases recognizes the key role of the interdental clinical attachment for defining the periodontal status and the extent of disease severity. Regenerating interdental clinical attachment not only improves the prognosis of the tooth, but it also lessens the severity of the disease condition. This manuscript provides a state-of-the-art review on surgical reconstructive approaches for treating papillary deficiency associated with soft and hard tissue interproximal defects. Combination therapy of papilla preservation, connective tissue grafting, and coronally advanced flaps may result in regeneration of the intrabony defect coupled with root coverage. Future research highlighted here may have the potential, especially in combination approaches, to repair challenging interproximal soft and hard tissue deficiencies.

Comparison of Er,Cr:YSGG laser to minimally invasive surgical technique in the treatment of intrabony defects: Six-month results of a multicenter, randomized, controlled study

BACKGROUND

The purpose of this publication is to report on the six-month clinical results and patient-reported outcomes (PROs) comparing the surgical use of the erbium, chromium-doped: yttrium, scandium, gallium, and garnet (Er,Cr:YSGG) laser (ERL) and minimally invasive surgical technique (MIST) for the treatment of intrabony defects in subjects with generalized periodontitis stage III, grade B.

METHODS

Fifty-three adults (29 females and 24 males; aged 19 to 73 years) with 79 intrabony defects were randomized following scaling and root planing (SRP) to receive ERL monotherapy (n = 27) or MIST (n = 26). Recession, probing depth (PD), clinical attachment level (CAL), treatment time, and PROs were assessed and compared for each treatment group. Clinical measurements were recorded at baseline, 4 to 6 weeks following SRP, and 6 months following surgical therapy.

RESULTS

The following primary and secondary outcome variables were non-inferior with the following margins: CAL with a non-inferiority margin of 0.6 mm (p = 0.05), PD with a non-inferiority margin of 0.5 mm (p = 0.05). Recession with a non-inferiority margin of 0.4 mm (p = 0.05). Faster procedure times were found for ERL (16.39 ± 6.21 minutes) versus MIST (20.17 ± 5.62 minutes), p = 0.0002. In the first 2 to 3 days of post-therapeutic diary outcomes, subjects reported less bruising, facial swelling, and use of ice pack for the ERL group.

CONCLUSIONS

This is the first multicenter, randomized, masked, and controlled study demonstrating the ERL is not inferior to MIST in terms of clinical outcomes but is superior in PROs for the surgical treatment of intrabony defects.

Effect of Flap Design for Enamel Matrix Derivative Application in Intraosseous Defects

Objective:

To systematically review the literature addressing the focused question: What is the effectiveness of different surgical and nonsurgical procedures combined with enamel matrix derivative (EMD) on clinical, radiographic, and patient-centered outcomes in intraosseous defects?

Methods:

Electronic (Medline, Scopus, and Cochrane databases) and hand literature searches were performed for studies including at least 1 treatment arm where EMD had been applied according to 1 of the following procedures: modified Widman flap; papilla preservation variants (PPVs), including papilla preservation technique, modified papilla preservation technique, and simplified papilla preservation technique; minimally invasive variants, including minimally invasive surgical approach and minimally invasive surgical technique; single-flap variants (SFVs), including single-flap approach and modified minimally invasive surgical technique; or nonsurgical application (flapless approach). Data from 42 selected articles were used to perform a network meta-analysis, and a hierarchy of surgical and nonsurgical applications of EMD was built separately for EMD and EMD + graft based on 6- to 12-mo clinical and radiographic outcomes.

Results:

Among surgical approaches, EMD was associated with best regenerative outcomes when applied through SFVs, with a mean clinical attachment level gain of 3.93 mm and a reduction in the intrabony component of the defect of 3.35 mm. For EMD + graft, limited differences in regenerative outcomes were observed among surgical procedures. PPVs were associated with the highest residual probing depth for EMD (4.08 mm) and EMD + graft (4.32 mm).

Conclusions:

In the treatment of periodontal intraosseous defects, 1) SFVs appear to optimize the regenerative outcomes of EMD; 2) substantial regenerative outcomes can be obtained with SFVs and conservative double flaps (i.e., PPVs and minimally invasive variants) when EMD is combined with a graft; and 3) residual probing depth was higher following PPVs for EMD and EMD + graft.

Knowledge Transfer Statement:

The results of the present systematic review and meta-analysis can be used by clinicians to identify the most effective surgical or nonsurgical procedure to treat an intraosseous defect with EMD or EMD + graft. The main findings indicate that when EMD application is indicated, surgical access based on a single flap seems the most appropriate to optimize clinical outcomes. The application of EMD + graft can be effectively combined with single flaps and conservative double flaps.

Minimally invasive non-surgical vs. surgical approach for periodontal intrabony defects: a randomised controlled trial

Background

Periodontal intrabony defects are usually treated surgically with the aim of increasing attachment and bone levels and reducing risk of progression. However, recent studies have suggested that a minimally invasive non-surgical therapy (MINST) leads to considerable clinical and radiographic defect depth reductions in intrabony defects. The aim of this study is to compare the efficacy of a modified MINST approach with a surgical approach (modified minimally invasive surgical therapy, M-MIST) for the treatment of intrabony defects.

Methods

This is a parallel-group, single-centre, examiner-blind non-inferiority randomised controlled trial with a sample size of 66 patients. Inclusion criteria are age 25–70, diagnosis of periodontitis stage III or IV (grades A to C), presence of ≥ 1 ‘intrabony defect’ with probing pocket depth (PPD) > 5 mm and intrabony defect depth ≥ 3 mm. Smokers and patients who received previous periodontal treatment to the study site within the last 12 months will be excluded. Patients will be randomly assigned to either the modified MINST or the M-MIST protocol and will be assessed up to 15 months following initial therapy. The primary outcome of the study is radiographic intrabony defect depth change at 15 months follow-up. Secondary outcomes are PPD and clinical attachment level change, inflammatory markers and growth factors in gingival crevicular fluid, bacterial detection, gingival inflammation and healing (as measured by geometric thermal camera imaging in a subset of 10 test and 10 control patients) and patient-reported outcomes.

Discussion

This study will produce evidence about the clinical efficacy and potential applicability of a modified MINST protocol for the treatment of periodontal intrabony defects, as a less invasive alternative to the use of surgical procedures.

Trial registration

ClinicalTrials.gov, NCT03797807. Registered on 9 January 2019.

Significant Enrichment and Diversity of the Staphylococcal Arginine Catabolic Mobile Element ACME in Staphylococcus epidermidis Isolates From Subgingival Peri-implantitis Sites and Periodontal Pockets

Staphylococcus aureus and Staphylococcus epidermidis are frequent commensals of the nares and skin and are considered transient oral residents. Reports on their prevalence in the oral cavity, periodontal pockets and subgingivally around infected oral implants are conflicting, largely due to methodological limitations. The prevalence of these species in the oral cavities, periodontal pockets and subgingival sites of orally healthy individuals with/without implants and in patients with periodontal disease or infected implants (peri-implantitis) was investigated using selective chromogenic agar and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Staphylococcus epidermidis was predominant in all participant groups investigated. Its prevalence was significantly higher (P = 0.0189) in periodontal pockets (30%) than subgingival sites of healthy individuals (7.8%), and in subgingival peri-implantitis sites (51.7%) versus subgingival sites around non-infected implants (16.1%) (P = 0.0057). In contrast, S. aureus was recovered from subgingival sites of 0-12.9% of the participant groups, but not from periodontal pockets. The arginine catabolic mobile element (ACME), thought to enhance colonization and survival of S. aureus, was detected in 100/179 S. epidermidis and 0/83 S. aureus isolates screened using multiplex PCR and DNA microarray profiling. Five distinct ACME types, including the recently described types IV and V (I; 14, II; 60, III; 10, IV; 15, V; 1) were identified. ACME-positive S. epidermidis were significantly (P = 0.0369) more prevalent in subgingival peri-implantitis sites (37.9%) than subgingival sites around non-infected implants (12.9%) and also in periodontal pockets (25%) compared to subgingival sites of healthy individuals (4.7%) (P = 0.0167). To investigate the genetic diversity of ACME, 35 isolates, representative of patient groups, sample sites and ACME types underwent whole genome sequencing from which multilocus sequence types (STs) were identified. Sequencing data permitted ACME types II and IV to be subdivided into subtypes IIa-c and IVa-b, respectively, based on distinct flanking direct repeat sequences. Distinct ACME types were commonly associated with specific STs, rather than health/disease states or recovery sites, suggesting that ACME types/subtypes originated amongst specific S. epidermidis lineages. Ninety of the ACME-positive isolates encoded the ACME-arc operon, which likely contributes to oral S. epidermidis survival in the nutrient poor, semi-anaerobic, acidic and inflammatory conditions present in periodontal disease and peri-implantitis.

Comparative evaluation of the use of magnification loupes in supragingival scaling procedures

AIM

The main aim of the present investigation was to evaluate clinical and patient-centered outcomes of supragingival scaling performed with or without the use of 2.5× magnification loupes and illumination.

METHODS

A total of 30 patients, divided into three groups, were treated with 2.5× loupes and 2.5× loupes and illumination, and without any magnification device. Full-mouth plaque score percentage (FMPS%) and full-mouth bleeding score percentage (FMBS%) were registered before and after the treatment. Moreover, perceived pain and quality of the treatment were recorded using a visual analog scale. Appropriate statistical analysis was adopted to analyze between-group differences for the investigated parameters.

RESULTS

All of the patients completed the study protocol. All the groups were homogeneous at baseline. Supragingival scaling caused a significant reduction of FMPS% and FMBS% in all groups without differences among them. Moreover, no differences could be found for patient-centered outcomes. The duration of the treatment was significantly higher in the group in which loupes and illumination was used than in the control group.

CONCLUSIONS

The use of magnification loupes (with or without illumination) did not significantly improve clinical and patient-centered outcomes of supragingival scaling procedures.

Ultrasonic Surgical Aspirator to Treat Deep Infrabony Defects: A New Flapless Minimally Invasive Approach

The primary outcome of the present study was to assess the percentage of pocket closure, and the secondary aim was to evaluate the clinical performance in terms of clinical attachment level (CAL) gain, probing pocket depth (PPD) reduction, and gingival recession (REC) after the use of cavitron ultrasonic surgical aspirator (CUSA) in deep infrabony defects. Fourteen deep infrabony defects in 11 patients who were previously treated with active periodontal therapy followed by one year of supportive periodontal therapy (at least three sessions) were additionally treated by the aid of CUSA. Eighty-six percent of the initial defects (12 out of 14) resulted in a PD < 5 mm, showing complete resolution six months after CUSA treatment, without any adverse event and with negligible pain (VAS from 0 to 3). CUSA showed potential as a method to promote pocket healing, reduce PPD, and increase clinical attachment (P < 0.001) in deep infrabony defects. This trial is registered with ClinicalTrials.gov NCT03567161.

A novel flapless approach versus minimally invasive surgery in periodontal regeneration with enamel matrix derivative proteins: a 24-month randomized controlled clinical trial

OBJECTIVES

This investigation was designed to compare the effectiveness of enamel matrix derivative (EMD) proteins in combination with flapless or flap procedure in periodontal regeneration of deep intrabony defects.

MATERIALS AND METHODS

Thirty chronic periodontitis patients who had at least one residual periodontal defect with an intrabony component of ≥3 mm were consecutively enrolled. Defects were randomly assigned to test or control treatments which both consisted of the use of EMD to reach periodontal regeneration. Test sites (n = 15) were treated according to a novel flapless approach, whereas control sites (n = 15) by means of minimally invasive surgery (MIST). Clinical and radiographic parameters were recorded at baseline, 12 and 24 months post-operatively.

RESULTS

Both therapeutic modalities yielded similar probing depth (PD) reduction and clinical attachment level (CAL) gain at 24 months. In flapless-treated sites, a mean PD reduction of 3.6 ± 1.0 mm and a CAL gain of 3.2 ± 1.1 mm were observed. In the MIST group, they were 3.7 ± 0.6 and 3.6 ± 0.9 mm. The operative chair time was twice as long in the MIST compared to the flapless group, whereas comparable patient-oriented outcomes were observed.

CONCLUSION

The flapless procedure may be successfully applied in the regenerative treatment of deep intrabony defects reaching clinical outcomes comparable with those of minimally invasive surgical approaches and may present important advantages in terms of reduction of operative chair time.

CLINICAL RELEVANCE

The use of EMD as an adjunct to non-surgical periodontal treatment may be considered a suitable option to treat defects mainly in the anterior sextants.