Success in periodontology: An evolutive concept

Applications of Machine Learning in Periodontology and Implantology: A Comprehensive Review

Machine learning (ML) has led to significant advances in dentistry, easing the workload of professionals and improving the performance of various medical processes. The fields of periodontology and implantology can profit from these advances for tasks such as determining periodontally compromised teeth, assisting doctors in the implant planning process, determining types of implants, or predicting the occurrence of peri-implantitis. The current paper provides an overview of recent ML techniques applied in periodontology and implantology, aiming to identify popular models for different medical tasks, to assess the impact of the training data on the success of the automatic algorithms and to highlight advantages and disadvantages of various approaches. 48 original research papers, published between 2016 and 2023, were selected and divided into four classes: periodontology, implant planning, implant brands and types, and success of dental implants. These papers were analyzed in terms of aim, technical details, characteristics of training and testing data, results, and medical observations. The purpose of this paper is not to provide an exhaustive survey, but to show representative methods from recent literature that highlight the advantages and disadvantages of various approaches, as well as the potential of applying machine learning in dentistry.

Patient-reported outcome measures and health economics in regenerative periodontal therapy: A systematic review and meta-analysis

Understanding patient responses to periodontal regeneration is crucial. This systematic review and meta-analysis addressed two key questions: (a) the impact of periodontal regeneration on patient-reported outcome measures (PROMs) for intrabony and furcation involvement and (b) the cost-effectiveness of periodontal regeneration for treating periodontal defects. Twenty-four studies were included, with 20 randomized clinical trials (RCTs) reporting patient-reported outcomes and five (three RCTs and two economic model-based studies) reporting cost-effectiveness outcomes. Results favored regeneration therapy over conventional flap surgery for intrabony defects, showing improvements in qualitative (i.e., amount of regenerated attachment apparatus) and quantitative parameters (i.e., probing and radiographic parameters). In terms of PROMs, regenerative treatments involving barrier membranes resulted in longer chair times and higher rates of complications (such as membrane exposure or edema) compared to flap with biologic agents or access flap alone. Despite this, oral health-related quality of life improved after both regenerative and extraction procedures. Economically, regeneration remained favorable compared to extraction and replacement or open flap debridement alone for periodontal defects. Single-flap variants in open flap debridement yielded similar outcomes to regenerative treatment, offering a potentially cost-effective option. Nevertheless, further discussion on the benefits of less-invasive flap designs is needed due to the lack of histological evaluation.

Oral health-related quality of life and patient-reported outcome measures after 10 years of supportive periodontal care

OBJECTIVE

The aim of this retrospective study was to evaluate the oral health-related quality of life (oHRQoL) and patient-reported outcome measures (PROMs) after 10 years of supportive periodontal care (SPC).

MATERIAL AND METHODS

Patients were re-examined 120±12 months after active periodontal therapy. Dental and periodontal status and oHRQoL by completing Oral Health Impact Profile-G49 (OHIP-G49) and PROMs by marking a visual analogue scale (VAS) for self-perceived esthetics (VASe), chewing function (VASc), and hygiene ability (VASh) were assessed. Patient- and tooth-related factors (age, insurance status, number of SPC, compliance, change of therapist, smoking, tooth loss, need for surgery or antibiotic intake, bleeding on probing (BOP), periodontal inflamed surface area) influencing oHRQoL and PROMs were evaluated.

RESULTS

One hundred eight periodontally compromised patients (59 female, mean age 65.4±10.7 years) lost 135 teeth during 10 years of SPC. At re-examination, 1.8% of all sites showed PPD ≥6mm. The mean OHIP-G49 sum score was 17.6±18.5, and VAS resulted in 76.0±22.5 (VASe), 86.3±16.3 (VASc), and 79.8±15.8 (VASh). Linear regression analyses identified a positive correlation with oHRQoL and/or PROMs for private insurance status (OHIP-G49, p=0.015, R2=0.204; VASc, p=0.005, R2=0.084; VASh, p=0.012, R2=0.222) and compliance to SPC (VASe, p=0.032; R2=0.204), as well as a negative correlation for active smoking (VASc, p=0.012, R2=0.084), increased BOP (VASh, p=0.029, R2=0.222) at the start of SPC, and number of lost molars (VASh, p=0.008, R2=0.222).

CONCLUSION

It is realistic to obtain satisfactory oHRQoL and PROM values in most of the patients after 10 years of SPC. The identified factors may help to predict patient satisfaction in the long-term course of therapy.

CLINICAL RELEVANCE

Systematic therapy of periodontally compromised patients provides values for oHRQoL and PROMs in a favorable range 10 years after therapy. This should encourage dentists to implement SPC in their daily routine.

CLINICAL TRIAL NUMBER

NCT03048045.

Immediate vs. Delayed Placement of Immediately Provisionalized Self-Tapping Implants: A Non-Randomized Controlled Clinical Trial with 1 Year of Follow-Up

This study aimed to examine the clinical and esthetic outcomes of immediately provisionalized self-tapping implants placed in extraction sockets or healed edentulous ridges one year after treatment. Sixty patients in need of a single implant-supported restoration were treated with self-tapping implants (Straumann BLX) and immediate provisionalization. The implant stability quotient (ISQ) and insertion torque were recorded intraoperatively. After one year in function, the implant and prosthesis survival rate, pink esthetic score (PES), white esthetic score (WES), and marginal bone levels (MBL) were assessed. Sixty patients received 60 self-tapping implants. A total of 37 implants were placed in extraction sockets and 23 in edentulous ridges, and then all implants were immediately provisionalized. All implants achieved a high implant stability with a mean insertion torque and ISQ value of 58.1 ± 14.1 Ncm and 73.6 ± 8.1 Ncm, respectively. No significant differences were found between healed vs. post-extractive sockets (p = 0.716 and p = 0.875), or between flap vs. flapless approaches (p = 0.862 and p = 0.228) with regards to the insertion torque and ISQ value. Nonetheless, higher insertion torque values and ISQs were recorded for mandibular implants (maxilla vs. mandible, insertion torque: 55.30 + 11.25 Ncm vs. 62.41 + 17.01 Ncm, p = 0.057; ISQ: 72.05 + 8.27 vs. 76.08 + 7.37, p = 0.058). One implant did not osseointegrate, resulting in an implant survival rate of 98.3%. All implants achieved PES and WES scores higher than 12 at the 1-year follow-up. The clinical use of newly designed self-tapping implants with immediate temporization was safe and predictable. The implants achieved a good primary stability, high implant survival rate, and favorable radiographic and esthetic outcomes, regardless of the immediate or delayed placement protocols.

Soft tissue phenotype modification predicts gingival margin long-term (10-year) stability: Longitudinal analysis of six randomized clinical trials

Aim

To assess the prognostic value of soft tissue phenotype modification following root coverage procedures for predicting the long‐term (10‐year) behaviour of the gingival margin.

Materials and Methods

Participants from six randomized clinical trials on root coverage procedures at the University of Michigan were re‐invited for a longitudinal evaluation. Clinical measurements were obtained by two calibrated examiners. A data‐driven approach to model selection with Akaike information criterion (AIC) was carried out via multilevel regression analyses and partial regression plotting for changes in the level of the gingival margin over time and interactions with the early (6‐month) results of soft tissue phenotypic modification.

Results

One‐hundred and fifty‐seven treated sites in 83 patients were re‐assessed at the long‐term recall. AIC‐driven model selection and regression analyses demonstrated that 6‐month keratinized tissue width (KTW) and gingival thickness (GT) influenced the trajectory of the gingival margin similarly in a concave manner; however, GT was the driving determinant that predicted significantly less relapse in the treatments, with stability of the treated gingival margin obtained beyond values of 1.46 mm.

Conclusions

Among a compliant patient cohort, irrespective of the rendered therapy, the presence of at least 1.5 mm KTW and 1.46 mm GT was correlated with the long‐term stability of the gingival margin.

Success of supportive periodontal therapy in periodontitis patients - A retrospective analysis

Objective

The aim of this retrospective analysis was to evaluate, in adult patients treated for periodontitis, the periodontal stability during supportive periodontal therapy (SPT).

Methods

Data were collected and analyzed retrospectively for periodontitis patients aged ≥36 years who underwent active periodontal therapy (APT) and were following an SPT programme. The stability of the APT success, defined as a probing pocket depth (PPD) of ≤5 mm, was the main outcome parameter. Analyses were performed in which PPD, tooth loss (TL), bleeding on probing (BOP), periodontal epithelium surface area (PESA), and the effects of age, gender, smoking status, and the number of years in SPT were evaluated. The annual TL and BOP of <10% in addition to a PPD of ≤5 mm were considered to be secondary outcome variables.

Results

In total, 993 patients were included, in 36% of whom a PPD ≤5 mm was found at the evaluation of APT. If the outcome was defined as a BOP of <10% in addition to a PPD of ≤5 mm, this was present in only 16% of the patients. During SPT, a small overall increase in clinical parameters for the total population and an annual average TL of 0.15 per patient was observed. Patients of male gender and smokers negatively affected the success of SPT.

Conclusion

The periodontal clinical status remained ‘fairly’ stable during SPT in chronic periodontitis patients aged ≥36 years. Smoking negatively affects the outcome of APT and periodontal stability during SPT.

Efficacy of microsurgery and comparison to macrosurgery for gingival recession treatment: a systematic review with meta-analysis

OBJECTIVES

Microsurgical principles, techniques, and armamentarium have made significant contributions to the periodontal plastic surgery. The present meta-analysis aimed to investigate the overall efficacy of microsurgery on root coverage, and its clinical outcomes when compared to traditional macrosurgery.

MATERIAL AND METHODS

Electronic searches on PubMed, Embase, and CINAHL were used to retrieve prospective clinical trials. Primary outcomes were the mean root coverage (mRC) and probability of achieving complete root coverage (cRC), with secondary outcomes as other periodontal parameters and patient-reported outcome measures (PROMs).

RESULTS

Nineteen studies were included in the quantitative analysis. Microsurgery was estimated to achieve 83.3% mRC and 69.3% cRC. From a subgroup of 9 comparative studies, it was estimated microsurgery increased mRC by 6.6% (p<0.001) and cRC by 27.9% (p<0.01) compared to macrosurgical control treatments. Operating microscope (OM) yielded a significantly 6.7% higher mRC than the control group (p=0.002), while using loupes showed 6.16% increase in mRC with a borderline significance (p=0.09). OM and loupes-only had a 31.05% (p=0.001) and 25.54% (p=0.001) increases in achieving cRC compared to control, respectively. As for PROMs, microsurgery reduced postoperative pain (p<0.001) and enhanced esthetics (p= 0.05).

CONCLUSIONS

Microsurgery significantly improved mean root coverage, probability of achieving complete root coverage, esthetics, and post-surgical recovery. Microsurgery enhances not only subclinical healing but also clinical outcomes, possibly owing to its minimally invasive approach and surgical precision.

CLINICAL RELEVANCE

Periodontal plastic microsurgery is minimally invasive, inducing less surgical trauma and ultimately resulting in improved clinical outcomes, patient's satisfaction, and quality of life.

Diagnosis of Stage III Periodontitis and Ambiguities of the "Gray Zones" in Between Stage III and Stage IV

INTRODUCTION

How to best classify the Stage III and IV periodontitis cases that share common features of the most severe clinical attachment loss and the most severe radiographic bone loss?

CASE PRESENTATION

Two patients presented features of generalized periodontitis, with severe probing depth and clinical attachment loss that would meet inclusion in both Stage III and IV. The cases retained all teeth but were further complicated by teeth drifting and secondary occlusal trauma. Appropriate disease classification required clinical judgement and led to the final classification of Stage III, Grade C for both cases.

CONCLUSION

Patient-based clinical judgement, aiming for long-term preservation of natural dentition, drives the final assignment of staging when the case falls in the "gray zone" that focuses on major differences in Stage III and IV periodontitis.

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.

On the value of the 2017 classification of phenotype and gingival recessions

The 2017 World Workshop completely restructured knowledge in periodontology with a series of official consensus statements jointly agreed upon by the American Academy of Periodontology and the European Federation of Periodontology. Among them, the 2017 classification of phenotype and gingival recession successfully incorporated the most relevant previous classifications into a treatment-oriented diagnostic matrix. Despite the significant advantages related with the implementation of this new classification of gingival recessions, recent articles still report data based on previous outdated systems. Therefore, the present commentary aimed to dive into the key advantages of the 2017 classification of phenotype and gingival recession, and to stress why it should be fully integrated into research and practice settings.