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

Treatment of Intrabony Defects with Non-Surgical Subgingival Debridement: A Radiographic Evaluation of Bone Gain Using an Experimental Digital Software "Bone Defect Analysis (BDA)"

Background: The aim of this study was to retrospectively evaluate the 3-year radiographic outcomes of periodontal intrabony defects treated with non-surgical subgingival therapy (NST), assessing radiographic bone gain (RBG) through experimental digital software, named "Bone Defect Analysis (BDA)". Methods: The study included 17 intrabony defects in 14 patients. BDA software (version 1) was used on radiographs to calculate RBG (in %) and variations in defect angle (in °) between baseline (T0) and 3-year follow-up (T1). Soft tissue conditions were registered, reporting bleeding on probing (BOP), probing pocket depth (PPD), and clinical attachment level (CAL). Defects were analyzed according to angles less (group A) or greater (group B) than 30°. Results: Nine and eight defects were, respectively, analyzed in groups A and B. Three years after treatment, an average RBG of 12.28% was found overall, with 13.25% and 10.11% for groups A and B, respectively (p = 0.28). Clinically, a mean CAL of 6.05 mm at T1 (from 10.94 mm at T0) was found, with 6.88 mm and 5.12 mm in groups A and B, respectively (p = 0.07). Conclusions: BDA software demonstrated predictability in the evaluation of bone variations after NST, revealing better clinical findings for intrabony defects with an initial smaller angle.

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.

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.

Clinical and Radiographic Evaluation of Autologous Platelet-Rich Fibrin With or Without Demineralized Bone Matrix in the Treatment of Grade II Furcation Defects

Introduction This study aims to differentiate the employment of demineralized bone matrix (DMBM; Osseograft, Advanced Biotech Products (P) Ltd, Chennai, India) and platelet-rich fibrin (PRF) alone to a composite graft consisting of both materials in the surgical actions toward the anomalies of the human periodontal furcation imperfection. Methods In a split-mouth study, 30 patients with mandibular molars affected by the furcation were allocated without conscious choice to test (PRF + DMBM, n = 30) or control (PRF, n = 30) categories. At the starting point, three months after surgery, and six months later, the following modifiable factors were evaluated: probing pocket depth (PPD), full-mouth plaque scores, full-mouth gingival scores, radiographic defect depth, relative vertical clinical attachment level (RVCAL), and relative horizontal clinical attachment level (RHCAL). Results Results at three and six months demonstrated substantial differences between baseline values for both treatment methods in clinical and X-ray imaging appraisal. Nonetheless, the PRF/DMBM group manifests statistically significantly soaring changes observed in comparison to the PRF group. Overall, the probing depth (PD) in the test site was significantly lower than that in the control site, showing a reduction of 68% (95% CI=41%, 95%, p<0.001). Conclusion Clinical indications significantly improved with PRF and DMBM combined instead of PRF alone. On radiographs, the test group also showed higher bone fill.

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.

Comparison of periodontal status and salivary IL-15 and -18 levels in cigarette-smokers and individuals using electronic nicotine delivery systems

BACKGROUND

It is hypothesized that periodontal status is compromised and whole salivary (WS) interleukin (IL)-15 and IL-18 levels are higher among cigarette-smokers and electronic-nicotine-delivery-systems (ENDS)-users than never-smokers. The aim of the present case-control study was to compare the periodontal status and WS IL-15 and -18 levels among cigarette-smokers, ENDS-users and controls (never-smokers).

METHODS

Participants were divided into 4 groups as follows: Group-1:Current cigarette-smokers; Group-2:ENDS-users; Group-3:Never-smokers with periodontitis; and Group-4: Never-smokers without periodontitis. Demographic data was collected and plaque index (PI), gingival index (GI), probing-depth (PD), clinical attachment-loss (AL), and marginal bone loss (MBL) were measured. Number of missing teeth were recorded and WS IL-15 and IL-18 levels were determined. Group-comparisons were done and P < 0.01 was selected as an indicator of statistical analysis.

RESULTS

Nineteen, 18, 19 and 19 individuals were enrolled in groups 1, 2, 3 and 4, respectively. Scores of PI, clinical AL, PD, and number of missing-teeth were elevated in groups 1(P < 0.001), 2 (P < 0.001) and 3 (P < 0.001) than -4. Scores of PI, clinical AL, PD, MBL and missing teeth were comparable among patients in groups 1, 2 and 3. Levels of IL-15 and IL-18 were elevated in groups 1 (P < 0.001) and 2 (P < 0.001) than groups 3 and 4. The levels of IL-15 and -18 were higher in Group-3 than in Group-4 (P < 0.001).

CONCLUSION

Clinically, cigarette-smokers and never-smokers demonstrate similar periodontal statuses; however, WS immunoinflammatory biomarkers (IL-15 and -18) are elevated in these individuals than non-smokers.

Molecular profiling of intrabony defects' gingival crevicular fluid

AIM

To profile, for the first time, the gingival crevicular fluid (GCF) of intrabony defects against a wide array of inflammatory and regenerative markers.

MATERIALS AND METHODS

Twenty-one patients contributed one intrabony defect and one periodontally healthy site. Clinical and radiographic measures were obtained. GCF samples were analyzed with multiplex bead immunoassays over 27 markers previously identified by our group. Comparisons were performed using Wilcoxon matched-pairs signed-ranks tests, using a Bonferroni corrected α = 0.05/27 = 0.0019.

RESULTS

Intrabony defect sites presented significantly increased GCF volume and disease-associated clinical and radiographic characteristics (p < .05). Intrabony defect sites presented significantly increased IL-1α, IL-1β, IL-6, IFN-γ, and MMP-8 levels compared with periodontally healthy sites (p < .0019). For regeneration markers, significantly higher FGF basic and VEGF levels were observed (p < .0019). Notably, traits of cell senescence were identified for the first time in the GCF.

CONCLUSIONS

The differentiation of intrabony defects from periodontally healthy control sites can be based on clinical and radiographic measures and on a differentiated GCF profile that is site-specific. Alongside catabolic processes, through significant up-regulation of inflammation and connective tissue remodeling, unique molecular characteristics of intrabony defects may render them a microenvironment amenable to regeneration. Traits of the senescence-associated secretory phenotype may suggest the existence of senescent cells during periodontal inflammation in intrabony defects.

Observation on the Effect of Bone Grafting Alone and Guided Tissue Regeneration Combined with Bone Grafting to Repair Periodontal Intraosseous Defects

Objective

To investigate the curative effect of guided tissue regeneration (GTR) combined with bone grafting and improve the aesthetic appearance of patients' gingiva.

Methods

A total of 86 patients with periodontal intraosseous defects were selected from February 2019 to February 2021. All the patients were divided into a control group and an observation group according to the random number table, with 43 patients in each group. Bone grafting was performed in the control group, while GTR was additionally used in the observation group on the basis of the control group. The surgical data and follow-up data were collected and organized. The alveolar bone mineral density, the change in the height of the bone defect, plaque index (PLI), sulcus hemorrhage index (SBI), PD, gingival recession (GR), clinical attachment loss (CAL), and other relevant data of the two groups in 6 months before and after surgery were compared. Six months after surgery, the cosmetic morphology of the patient's gums in the soft tissues around her teeth was evaluated.

Results

Six months after surgery, the alveolar bone density of patients in two groups increased compared with that before surgery, and the height of the bone defect decreased compared with that before surgery. The alveolar bone density of the observation group was higher than that of the control group, and the height of the bone defect was lower than that of the control group (P < 0.05). Six months after surgery, the PLI, SBI, PD, and CAL of patients in both groups were lower than those before surgery, while the GR was higher than that before surgery. PD and CAL values in the observation group were lower than those in the control group, and GR was higher than that in the control group (P < 0.05). Six months after surgery, there was no significant difference in PLI and SBI scores between the two groups (P < 0.05). Six months after surgery, the gingival cosmetic scores of the two groups of patients were higher than those before surgery. The observation group was higher than the control group (P < 0.05).

Conclusion

GTR combined with bone grafting has a good effect in the repair of periodontal intraosseous defects and can effectively promote the reconstruction and recovery of periodontal intraosseous defects in patients. At the same time, it can significantly improve the aesthetic appearance of patients' gums, with good clinical application value.

The effect of non-surgical and surgical mechanical root debridement on infrabony defects: a retrospective study

The aim of this retrospective study was to assess the outcomes of non-surgical and surgical mechanical root debridement for the treatment of infrabony defects and explore potential prognostic factors. Treated infrabony defects followed for at least 1 year were selected. All data pertaining to the clinical outcomes were recorded. Multi-level regression analysis and Cox Proportional-Hazards Models were used to assess the immediate (3-6 months) clinical outcomes, survival of the treated teeth, and factors influencing these results. 132 patients were included in the analysis. The analysis showed 1.42 ± 1.71 and 2.23 ± 1.64 mm in pocket depth (PD) reduction, 0.13 ± 1.83 and 0.08 ± 1.76 mm in clinical attachment level (CAL) gain, and 1.29 ± 1.56 and 2.15 ± 1.33 mm increase in gingival recession (REC) for the non-surgical and surgical groups, respectively. The 5-year survival rates were 93% for the non-surgically and 90% for the surgically treated teeth. Several factors affected clinical outcomes and tooth survival. Within its limitations, the treatment of infrabony defects with non-surgical and surgical mechanical root debridement was found to result in moderate but significant PD reduction, nevertheless, this may also be attributable to the resultant REC.

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.

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.

Clinical outcomes following periodontal surgery and root surface decontamination by erythritol-based air polishing. A randomized, controlled, clinical pilot study

Aim

To evaluate the outcomes following surgical periodontal treatment and root surface decontamination by means of air polishing using an erythritol powder or conventional mechanical root debridement.

Material and methods

Thirty systemically healthy patients (44.38 ± 8.2 years old, 11 smokers, 19 women) diagnosed with periodontitis stages III–IV were included. Each patient, with one single-rooted tooth, with one probing pocket depth (PD) ≥ 6 mm associated with horizontal bone loss, was treated by means of simplified papilla preservation flap (SPPF) and randomized to either test treatment (careful removal of the calculus with the tip of a blade, air polishing of the root surfaces with erythritol) or to the control group (scaling and root planing with hand curettes, ultrasonic instruments). PD, clinical attachment (CAL), bone sounding (BS), and radiographic bone level (BL) were evaluated at baseline and 12 months postsurgically.

Results

Twenty-seven patients completed the 12-month follow-up (test: n = 14, control: n = 13). In both groups, statistically significant improvements were obtained (p < 0.05, mean CAL gain/PD reduction: test, 2.50 ± 1.60 mm/3.00 ± 0.96 mm; control, 2.85 ± 1.21 mm/3.38 ± 1.12 mm). No statistically significant differences were observed between the groups for any of the investigated parameters (p < 0.05).

Conclusion

Within their limits, the present results indicate that the use of air polishing with an erythritol powder during periodontal surgery may represent a valuable minimally invasive adjunct following calculus removal by means of hand and ultrasonic instruments or a valuable alternative to these, for root surfaces without calculus.

Clinical relevance

The use of air polishing with an erythritol powder during periodontal surgery appears to represent a valuable minimally invasive adjunct following calculus removal by means of hand and ultrasonic instruments or a valuable alternative to these, for root surfaces without calculus.