Periodontal regeneration in aggressive periodontitis patients: A systematic review of the literature

A Modern Approach to Treat Molar/Incisor Pattern Periodontitis-Review

Molar-incisor pattern periodontitis (MIPP) is a severe form of periodontal disease characterized by rapid attachment loss and bone destruction affecting the molars and incisors. Formerly referred to as aggressive periodontitis, the terminology for this condition was revised after the 2017 workshop on the classification of periodontal and peri-implant diseases and conditions. Despite the modification in nomenclature, the treatment strategies for MIPP remain a critical area of investigation. The core principles of MIPP treatment involve controlling local and systemic risk factors, managing inflammation, and arresting disease progression. Traditional non-surgical periodontal therapy, including scaling and root planing, is commonly employed as an initial step together with the prescription of antibiotics. Surgical intervention may be necessary to address the severe attachment loss. Surgical techniques like resective and regenerative procedures can aid in achieving periodontal health and improving esthetic outcomes. This review article aims to provide an overview of the current understanding and advancements in the treatment modalities of MIPP. Through an extensive analysis of the existing literature, we discuss various modern therapeutic approaches that have been explored for managing this challenging periodontal condition.

Testosterone Enanthate: An In Vitro Study of the Effects Triggered in MG-63 Cells

The aim of this study was to investigate the effects of the androgenic hormone testosterone enanthate (TE) on human MG-63 cells. MG-63 were cultured for 24 h in the presence of TE at increasing concentrations to assess its lethal dose. Therefore, the suitable concentration for a prolonged use of TE in vitro was assessed by viability assay over 9 days. Finally, MG-63 were exposed to TE for 14 days and assayed for differentiation by qPCR and Alizarin Red S staining. TE in the amount of 100 µM resulted as the maximum dose tolerated by MG-63 cells after 24 h. However, a prolonged exposure in culture TE in the amount of 100 µM showed a cytostatic effect on cell proliferation. On the contrary, TE 10 µM was tolerated by the cells and did not boost cell proliferation, but did enhance new bone formation, as revealed by COL1A1, ALPL, BGLAP, and IBSP gene expression after 3, 7, and 14 days, and calcium deposition by Alizarin Red S staining after 14 days. Based on the current study, 10 µM is the critical dose of TE that should be used in vitro to support bone differentiation of MG-63 cells.

Dual-Function Semaphorin 4D Released by Platelets: Suppression of Osteoblastogenesis and Promotion of Osteoclastogenesis

Effects of the antiosteoblastogenesis factor Semaphorin 4D (Sema4D), expressed by thrombin-activated platelets (TPs), on osteoblastogenesis, as well as osteoclastogenesis, were investigated in vitro. Intact platelets released both Sema4D and IGF-1. However, in response to stimulation with thrombin, platelets upregulated the release of Sema4D, but not IGF-1. Anti-Sema4D-neutralizing monoclonal antibody (mAb) upregulated TP-mediated osteoblastogenesis in MC3T3-E1 osteoblast precursors. MC3T3-E1 cells exposed to TPs induced phosphorylation of Akt and ERK further upregulated by the addition of anti-sema4D-mAb, suggesting the suppressive effects of TP-expressing Sema4D on osteoblastogenesis. On the other hand, TPs promoted RANKL-mediated osteoclastogenesis in the primary culture of bone-marrow-derived mononuclear cells (BMMCs). Among the known three receptors of Sema4D, including Plexin B1, Plexin B2 and CD72, little Plexin B2 was detected, and no Plexin B1 was detected, but a high level of CD72 mRNA was detected in RANKL-stimulated BMMCs by qPCR. Both anti-Sema4D-mAb and anti-CD72-mAb suppressed RANKL-induced osteoclast formation and bone resorptive activity, suggesting that Sema4D released by TPs promotes osteoclastogenesis via ligation to a CD72 receptor. This study demonstrated that Sema4D released by TPs suppresses osteogenic activity and promotes osteoclastogenesis, suggesting the novel property of platelets in bone-remodeling processes.

Pharmacological Approaches and Regeneration of Bone Defects with Dental Pulp Stem Cells

Bone defects in the craniomaxillofacial skeleton vary from small periodontal defects to extensive bone loss, which are difficult to restore and can lead to extensive damage of the surrounding structures, deformities, and limited functions. Plenty of surgical regenerative procedures have been developed to reconstruct or prevent alveolar defects, based on guided bone regeneration involving the use of autogenous bone grafts or bone substituents. However, these techniques have limitations in the restoration of morphological and functional reconstruction, thus stopping disease progression but not regenerating lost tissue. Most promising candidates for regenerative therapy of maxillofacial bone defects represent postnatal stem cells, because of their replication potential in the undifferentiated state and their ability to differentiate as well. There is an increased need for using various orofacial sources of stem cells with comparable properties to mesenchymal stem cells because they are more easily available with minimally invasive procedures. In addition to the source of MSCs, another aspect affects the regeneration outcomes. Thermal, mechanical, and chemical stimuli after surgical procedures have the ability to generate pain, usually managed with pharmacological agents, mostly nonsteroidal anti-inflammatory drugs (NSAIDs). Some studies revealed that NSAIDs have no significant cytotoxic effect on bone marrow stem cells from mice, while other studies showed regulation of osteogenic and chondrogenic marker genes in MSC cells by NSAIDs and paracetamol, but no effect was observed in connection with diclofenac use. Therefore, there is a need to focus on such pharmacotherapy, capable of affecting the characteristics and properties of implanted MSCs.

MALAT1 regulates osteogenic differentiation of human periodontal ligament stem cells through mediating miR-155-5p/ETS1 axis

BACKGROUND

Osteogenic differentiation of human periodontal ligament stem cells is essential to periodontal regeneration treatment for periodontitis. This study investigated the mechanism of lncRNAs-related osteogenic differentiation.

METHODS

Human periodontal ligament stem cells were extracted from human periodontal ligament and identified via flow cytometry. After being induced into osteogenic differentiation for three weeks using osteoblast inducing conditional media, human periodontal ligament stem cells were transfected with siRNA-MALAT1, or miR-155-5p inhibitor. Human periodontal ligament stem cells osteogenesis was observed by alkaline phosphatase staining, followed by alizarin red staining for evaluating mineralized nodes formation. Runt-related gene 2, collagen-1 and osteocalcin expressions were assessed by western blot and qRT-PCR.

RESULTS

MALAT1 expression was assumed a negative correlation with miR-155-5p expression which was dropping over time in differentiating human periodontal ligament stem cells. MALAT1 could bind with miR-155-5p, and E26 transformation specific-1 (ETS1) was the targeted gene of miR-155-5p. Silenced MALAT1 suppressed ALP activity and mineralized nodes formation and inhibited the expressions of runt-related gene 2, collagen-1 and osteocalcin in differentiating human periodontal ligament stem cells, while miR-155-5p inhibitor reversed the effect of si-MALAT1 on differentiation of human periodontal ligament stem cells.

CONCLUSION

MALAT1 modulated differentiation of human periodontal ligament stem cells via regulating miR-155-5p.

Clinical, radiographic, and patient-centered outcomes after use of enamel matrix proteins for the treatment of intrabony defects in patients with aggressive periodontitis: A 12-month multicenter clinical trial

BACKGROUND

The aim of this study was to evaluate the clinical, radiographic and patient-centered results of enamel matrix derivative (EMD) therapy in intrabony defects in aggressive periodontitis (AgP) patients and compare them with those in chronic periodontitis (CP) patients.

METHODS

Sixty intrabony defects in AgP and CP patients associated with ≥ 6 mm residual probing pocket depth (PPD) were included and randomly assigned to one of three groups: AgP+CS (conservative surgery) (n = 20); AgP+CS/EMD (n = 20); CP+CS/EMD (n  =  20). Clinical parameters were measured at baseline and after 6 and 12 months. Defect resolution (DR) and bone filling (BF) were used for radiographic analysis. The quality of life was recorded at baseline and 6 months using OHIP-14 and VAS scale in the early post-therapy period.

RESULTS

PPD and relative clinical attachment level (rCAL) improved for all groups during follow-up (P ≤ 0.05), and AgP+CS/EMD presented a higher rCAL gain (2.4 ± 1.0 mm) when compared to AgP control patients (1.6 ± 1.6 mm, P ≤ 0.05) after 12 months. No difference was observed between AgP+CS/EMD and CP+CS/EMD groups (P > 0.05). No radiographic differences were observed among groups at any time point (P > 0.05). All the groups reported a positive impact on OHIP-14 total score, without differences among them.

CONCLUSIONS

EMD therapy of intrabony defects promotes additional benefits in AgP patients, presenting a similar regeneration rate compared to CP patients, and has proven to be a viable therapy for the treatment of individuals with AgP.

Efficacy of regenerative therapy in aggressive periodontitis: a systematic review and meta-analysis of randomised controlled clinical trials

OBJECTIVES

To analyse evidence regarding the efficacy of periodontal regenerative procedures in intrabony defects in patients treated for aggressive periodontitis (AgP).

MATERIAL AND METHODS

A systematic search of the literature for randomised controlled clinical trials including patients treated for aggressive periodontitis that compared a group treated with regenerative therapy with another group treated with surgical debridement alone was conducted by two independent reviewers.

RESULTS

Six studies were included in the meta-analysis of clinical and/or radiographic parameters at 6 and 12 months. Probing pocket depth was smaller at 6 months in patients treated with regenerative therapies compared with those treated with regular debridement (1.00 mm, p < 0.001, 95% CI (0.67, 1.34)). At 12 months this difference was more marked (0.41 mm, p = 0.12, 95% CI (- 0.10, 0.91)). The distance between the cemento-enamel junction and the alveolar crest at both 6 (1.36 mm, p < 0.001, 95% CI (1.03, 1.68)) and 12 months (0.90 mm, p = 0.01, 95% CI (0.24, 1.56)) was smaller in the group treated with regeneration.

CONCLUSIONS

The use of biomaterials for regenerative therapy in AgP may be more effective than surgical debridement. Better outcomes were observed in terms of probing pocket depth and distance between the cemento-enamel junction and the alveolar crest at 6 months. Regeneration should be considered as a therapy to prevent tooth loss, although more studies with larger sample size and longer follow-up are needed.

CLINICAL RELEVANCE

Periodontal regeneration is effective in the treatment of intrabony defects in patients with AgP, as it leads to better outcomes in clinical and radiographic parameters.

Treatment of intrabony defects with modified perforated membranes in aggressive periodontitis: a 4-year follow-up of a randomized controlled trial

OBJECTIVE

(1) To assess long-term outcomes 4 years following guided tissue regeneration (GTR) of intrabony defects in patients diagnosed with aggressive periodontitis (AgP) and (2) to identify predictors of clinical attachment level (CAL) gain and bone/graft density gain.

MATERIALS AND METHODS

In 15 patients, two deep intrabony defects were randomly treated with xenogenic graft plus modified perforated membranes (MPM, tests) or xenogenic graft plus standard collagen membranes (CM, controls). After 4 years, clinical and radiographic outcomes were evaluated and compared with outcomes at baseline and after 1 year.

RESULTS

After 4 years, 14 test sites and 13 control sites were available for analysis. One tooth was lost as a result of root fracture. There were significant improvements in all evaluated parameters after 1 and 4 years in relation to baseline, but no differences were observed between tests and controls. However, some non-significant changes were found between 1 and 4 years. Regression analyses showed that recurrence of periodontitis was a significant predictor for CAL gain (p = 0.001) and bone/graft density gain (p = 0.024) from 1 to 4 years.

CONCLUSIONS

GTR of intrabony defects in AgP with either standard or modified CM yielded similarly successful and maintainable clinical benefits for compromised teeth 4 years following the surgery. The use of MPM showed no additional benefit.

CLINICAL RELEVANCE

This study demonstrates that most of the positive outcomes of GTR in AgP may be preserved over 4 years. Periodontitis recurrence might influence long-term outcomes.

Periodontal Regeneration with Enamel Matrix Derivative in the Management of Generalized Aggressive Periodontitis: A Case Report with 11-Year Follow-up and Literature Review

Objectives:

Aggressive periodontitis (AgP) represents an uncommon but rapidly advanced inflammatory process, which involves the destruction of periodontal tissues. This study aimed to report a case of generalized AgP (GAgP), where the treatment approach consists of the utilization of the full-mouth disinfection protocol (FMDP) in conjunction with flap curettage and regenerative appliance of enamel matrix derivatives (EMDs). The associated literature was also reviewed.

Materials and Methods:

A 19-year-old female patient was diagnosed with GAgP. The treatment was initiated with FMDP and administration of antibiotics. Afterward, open flap debridement was performed, and EMD was selected as the regenerative material for the reconstruction of the periodontal defects. Over an 11-year period and during all the phases of the treatment, the outcomes were regularly evaluated with clinical measurements and radiographic controls.

Results:

The 11-year results demonstrated no recurrence of disease, and the patient's periodontal health exhibited evident improvement. Overall, the pocket depths presented satisfactory reduction while the clinical attachment loss (CAL) was improved. Both our limited experience and available literature data revealed that the use of EMD in AgP treatment contributes to bone fill of the intrabony defects as well as regeneration of the destructed periodontal apparatus.

Conclusions:

Although the outcomes of this treatment approach have not been widely evaluated, it seems that the use of EMD may be an effective means of periodontal regeneration in patients with GAgP. Additional prospective studies with adequate number of GAgP patients are essential to thoroughly assess the effectiveness of this approach.

Treatment of intrabony defects with modified perforated membranes in aggressive periodontitis: subtraction radiography outcomes, prognostic variables, and patient morbidity

Objectives

The main objectives of this study were (1) to evaluate bone/graft density alterations by digital subtraction radiography; (2) to determine factors associated with favorable clinical and radiographic outcomes, and (3) to report on patient morbidity after guided tissue regeneration (GTR) in aggressive periodontitis (AgP) patients.

Materials and methods

Adapting a split-mouth design, 30 comparative intrabony defects in 15 patients were randomly treated with xenogenic graft plus modified perforated membranes (MPM, tests) or xenogenic graft plus standard collagen membranes (CM, controls). The time period of observation was 12 months.

Results

There were significant improvements in clinical and radiographic parameters within each group, without intergroup differences. However, higher PPD reduction for three-wall defects was noted in MPM sites (5.22 versus 3.62 mm; p = 0.033). Moreover, a significant gain in bone/graft density of 4.9% from 6 to 12 months post-operatively was observed in test sites. Multivariate analysis demonstrated that morphology of intrabony defects was a predictor of CAL gain (p = 0.06), while independent prognostic variables effecting changes in bone/graft density were radiographic defect depth (p = 0.025) and radiographic angle (p = 0.033). The majority of patients reported some discomfort, pain, and edema with mild intensity without any significant differences between treatment modalities.

Conclusions

This study demonstrated enhanced bone/graft density gain after GTR with MPM, which may indicate greater area of new bone formation. Independent variables effecting treatment outcomes were intrabony defect morphology, radiographic defect depth, and radiographic angle.

Clinical relevance

This study supports the regenerative treatment of intrabony defects in AgP patients and identifies some variables with prognostic value.

Treatment of intrabony defects with modified perforated membranes in aggressive periodontitis: a 12-month randomized controlled trial

OBJECTIVE

The aim of this study was to compare the clinical and radiographic efficacy of guided tissue regeneration with a modified perforated collagen membrane (MPM) or standard collagen membrane (CM) in the treatment of intrabony defects in patients with aggressive periodontitis (AgP).

MATERIALS AND METHODS

Fifteen AgP patients were included in the study. Two single intrabony defects of at least 3 mm depth with ≥ 6 mm probing pocket depth (PPD) from each patient were randomly assigned to either xenogenic graft plus MPM (test group) or xenogenic graft plus CM (control group). PPD, clinical attachment level (CAL), and gingival recession (GR) were recorded at baseline and at 12 months. The radiographic assessments included the measurements of defect depth (DD), change in alveolar crest position (ACP), linear defect fill (LDF), and percentage defect fill (%DF).

RESULTS

After treatment, PPD, CAL, DD, and ACP values improved significantly in both groups, without statistical differences between them. However, with respect to LDF and %DF, the 12-month radiographic analysis at MPM-treated sites showed a significant improvement compared to the 6-month outcomes, that was not observed at control sites (additional LDF of 0.4 ± 0.5 mm, p = 0.010 and %DF of 6.4 ± 7.6%, p = 0.025).

CONCLUSIONS

Both strategies proved effective in the treatment of intrabony defects in patients with AgP. Nonetheless, enhanced LDF and %DF 12 months postoperatively at MPM-treated sites may stem from cellular and molecular migration from the periosteum and overlying gingival connective tissue through barrier's pores.

CLINICAL RELEVANCE

Modification of CM may have positive ramifications on periodontal regeneration.