Evidence-based periodontal treatment. Highlights from the 1996 World Workshop in Periodontics

Effect of alveolar ridge preservation on peri-implant mucositis and peri-implantitis prevalence: A multicenter, cross-sectional study

OBJECTIVES

Alveolar ridge preservation (ARP) is a procedure with the aim to reduce bone resorption that occurs after tooth extraction, facilitating the following implant placement. The aim of this cross-sectional study was to evaluate the prevalence of mucositis and peri-implantitis around implants inserted in sites treated with ARP and to investigate possible risk factors.

MATERIALS AND METHODS

Patients who received at least one dental implant inserted in a grafted socket were considered eligible for this study. Patients were recalled for a follow-up visit; medical history, clinical and demographic data were collected. Univariate logistic regression analyses have been performed for both implant-level and patient-level variables. Indeed, moderation analysis was used to investigate the indirect relationship between age and marginal bone level.

RESULTS

Fifty-one patients who received 61 implants were enrolled in this cross-sectional study. Thirty-three implants were classified as "healthy" (54.1%), 23 implants showed signs of peri-implant mucositis (37.7%), and 5 implants were diagnosed with peri-implantitis (8.2%). Data analyzed at the patient level showed that 49% of the patients were healthy, 45.1% of the patients had mucositis and 5.9% of the patients were affected by peri-implantitis. Mandibular sites and type III grafted sockets showed a significant association with peri-implantitis; in addition, a history of periodontitis and an increase in age showed higher risks of developing mucositis or peri-implantitis.

CONCLUSIONS

Implants inserted in grafted sockets showed favorable rates of healthy implants in the long term.

CLINICAL RELEVANCE

The ridge preservation procedures do not seem to increase the risk of developing mucositis or peri-implantitis.

The Comparison of the Anti-inflammatory Efficacy of Phytochemical Extracts in Punica granatum and Lawsonia inermis Among Patients Diagnosed With Chronic Periodontitis

Introduction The oral cavity is the gateway to the human body. Periodontitis is a common inflammatory condition affecting the oral cavity and a known etiological cause of tissue destruction, discomfort, and halitosis. Pomegranate (Punica granatum) and henna (Lawsonia inermis) are herbs known to mankind from time immemorial whose extracts are proven to fight inflammation. The current study was done to evaluate the phytochemical anti-inflammatory efficacy of Punica and Lawsonia in patients with chronic periodontitis and test the potency of herbal mouthwashes in fighting the inflammatory condition affecting the oral cavity using distilled water as a control group. Materials and methods A double-blinded randomized control trial was conducted on 60 patients who were recruited and divided into three groups, in which 20 patients were prescribed with pomegranate (Punica: n=20) mouthwash and 20 patients with henna (Lawsonia: n=20) mouthwash along with distilled water (n=20). All patients were randomly allocated using the coin toss method and advised to use the prescribed mouthwash for a period of two weeks. Unstimulated saliva was collected before using the mouthwash, and salivary enzymes such as aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LDH) and their levels were assessed spectrometrically using the infrared spectrophotoscopy (IFSC) method. Each patient was assigned a mouthwash and recalled after two weeks. Unstimulated saliva was again collected, and salivary activity levels of enzymes AST, ALT, and LDH were analyzed after using mouthwash in a similar method as done before. Later on, the salivary levels of enzymes AST, ALT, and LDH were compared before and after the usage of mouthwashes. Statistical significance was seen in the salivary enzymatic activity of AST, ALT, and LDH before and after using Punica and Lawsonia mouthwashes due to their potent phytochemical action in fighting inflammation. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) 22 (IBM SPSS Statistics, Armonk, NY). The Shapiro-Wilk test was used to determine the normality and significance; intragroup comparison was done using the Wilcoxon signed-rank test and Mann-Whitney U test. Intergroup comparison was done using the Kruskal-Wallis test. Results Punica patients had much lower levels of salivary AST and ALT (p<0.001) and a decrease in LDH (p=0.002) after the usage of mouthwash for a period of two weeks. Also, patients using Lawsonia as herbal mouthwash had reduction in the values of AST (p=0.001) and LDH (p=0.003) and prominent reduction in ALT (p<0.001) after a period of two weeks. But in the case of patients using distilled water, there was an increase in the salivary enzymatic activity of AST and ALT, which was statistically significant (p<0.001), and LDH (p=0.006) depicting the disease progression even after using mouthwash for the given time period of two weeks. Conclusion This study demonstrated that both Punica and Lawsonia were effective in reducing the inflammation in patients diagnosed with chronic periodontitis. However, when intergroup comparison was done, the anti-inflammatory efficacy was superior in Punica with significant reduction in the parameters such as of AST, ALT, and LDH when compared to Lawsonia owing to its potent phytochemical constituency in cutting down the inflammation. Hence, Punica can be used as an implicated effective anti-inflammatory herbal mouthwash.

Effects of an Ozonated Water Irrigator on the Plaque Index and Bleeding Index of Pregnant Women

Pregnancy causes physiological changes in the woman’s body, which can also affect oral health. Therefore, pregnant women may manifest gingival inflammation that is favored by their hormonal increase. This clinical trial (ClinicalTrials.gov Identifier: NCT04140643) evaluated the variation in the plaque index (PI) or bleeding index (BOP) in pregnant women after daily use of an ozonated water irrigator and proper home oral hygiene, compared to a control group who only performed home oral hygiene. The inclusion criteria were the gestation period from the 14th week to the 30th week, a diagnosis of gingivitis, and a minimum number of teeth equal to 20. The PI and BOP index were evaluated at T0, fifteen days after T0 (T1), and two months after T1 (T2). The PI values systematically decreased over time (F (1.19) = 41.82) in both groups, with a systematic difference in PI values between the two groups (F (1.19) = 6.28, p = 0.021). A statistically significant difference was assessed in the BOP index at T2 between the two groups, with the control group suffering a higher BOP index. The results show that the patients in the study group showed a decrease in the BOP index over the three time points, in contrast to the control group, due to the beneficial properties of ozonated water.

Periodontal Treatment in Patients with Learning Disabilities Part 2: Professional Mechanical Intervention

The first part of this two part series discussed the potential barriers and risk factors that may lead to an increased incidence and severity of periodontal disease amongst patients with learning disabilities. Additionally, preventive strategies and tools that can be used by general dental practitioners, oral health promotion teams as well as specialists within the field to control and prevent disease progression were explored. To prevent periodontal disease progression and attain optimal periodontal health, a combination of prevention and professional mechanical instrumentation is usually required. The second part of the series concentrates on the role of the dental professional in implementing professional mechanical instrumentation to attempt to reduce the burden of disease further in this patient group. Clinical relevance: Although research continues into which professional techniques for instrumentation are the most successful amongst patients with periodontal disease, very little data specifically explore the needs of patients with learning disabilities, despite their high unmet needs. This paper aims to report on any available data present to produce suggestions for care.

Quality assessment of systematic reviews on periodontal regeneration in humans

BACKGROUND

Systematic reviews represent the highest form of evidence in the current hierarchy of evidence-based dentistry. Critical analysis of published systematic reviews may help to analyze their strengths and weaknesses and to identify areas that need future improvement. The aim of this overview is to determine and compare the quality of systematic reviews published in the field of periodontal regeneration using established checklists, such as the Assessment of Multiple Systematic Reviews (AMSTAR) guidelines.

METHODS

A systematic search was conducted to retrieve reviews on periodontal regeneration in humans. A total of 14 systematic reviews were selected using a set of inclusion and exclusion criteria. Two independent reviewers appraised the quality of the selected reviews using AMSTAR guidelines. Each article was given an AMSTAR total score, based on the number of AMSTAR criteria that were fulfilled. The quality of included reviews was further assessed using a checklist proposed in 2003.

RESULTS

Only one of the selected systematic reviews satisfied all the AMSTAR guidelines, whereas two reviews satisfied just two of the 11 items. This study shows that published systematic reviews on periodontal regeneration exhibit significant structural and methodologic variability. Quality assessment using the additional checklist further confirmed the variability in the way systematic reviews were conducted and/or reported.

CONCLUSION

Consideration of guidelines for quality assessment, such as AMSTAR, when designing and conducting systematic reviews may increase the validity and clinical applicability of future reviews.

The association of a polydioxanone tent without a guided tissue regeneration membrane to a coronal sliding flap for root coverage

BACKGROUND

This study verifies clinical results of using a polydioxanone (PDS) tent without a guided tissue regeneration (GTR) membrane for root coverage.

METHODS

Forty-nine gingival recessions (in 16 patients) were treated with a PDS tent inserted under the coronally positioned gingival flap. The recession level (RL), probing depth (PD), and keratinized mucosa width (KMW) were registered. Statistical analysis was performed with the Wilcoxon test.

RESULTS

In 48 cases, there was a significant reduction in the RL (2.55 +/- 1.11 mm on day 0 and 0.34 +/- 0.65 mm on day 120; P = 0.0001). PD showed the same values at the beginning and end of treatment in 47 cases (0.99 +/- 0.71 mm on days 0 and 120; z = 0.000). There was a significant increase of KMW in 46 cases (2.38 +/- 0.76 mm on day 0 and 3.18 +/- 0.90 mm on day 120; P = 0.0001).

CONCLUSIONS

The association of the PDS tent without the GTR membrane to a coronal sliding flap for root coverage of Miller Class I and II gingival recessions allows root coverage, gain of attachment level, and an increase of keratinized mucosa. For root coverage, it is not necessary to use the GTR membrane associated to the PDS tent, thereby reducing surgical costs. Future studies should be conducted to assess the sole performance of the PDS as an alternative method to a connective tissue graft and coronal sliding flap, thus decreasing risks and post-surgery discomfort.

Evidence-based periodontal therapy: An overview

Dentists need to make clinical decisions based on limited scientific evidence. In clinical practice, a clinician must weigh a myriad of evidences every day. The goal of evidence-based dentistry is to help practitioners provide their patients with optimal care. This is achieved by integrating sound research evidence with personal clinical expertise and patient values to determine the best course of treatment. Periodontology has a rich background of research and scholarship. Therefore, efficient use of this wealth of research data needs to be a part of periodontal practice. Evidence-based periodontology aims to facilitate such an approach and it offers a bridge from science to clinical practice. The clinician must integrate the evidence with patient preference, scientific knowledge, and personal experience. Most important, it allows us to care for our patients. Therefore, evidence-based periodontology is a tool to support decision-making and integrating the best evidence available with clinical practice.

Repair of Experimental Alveolar Bone Defects by Tissue-Engineered Bone

Alveolar bone resorption caused by periodontal diseases remains a difficult clinical problem to treat. Our purpose here was to develop protocols for repairing experimental horizontal alveolar bone defects. The procedure entailed isolating bone marrow stromal cells (BMSC). They were expanded and induced in vitro into osteogenic cells in a defined medium. Induced BMSCs were mixed with calcium alginate to form a gel form of cell-scaffold construct for developing engineered bone. A horizontal alveolar bone defect was created in 15 mongrel dogs, which was 5 mm high on each of two buccal sides at the location of mandibular premolar 3, 4, and molar 1. Without bias, the animals were separated into the following groups: (1) cell-scaffold construct as the experimental group; (2) calcium alginate alone as the control group A; (3) untreated as the control group B. Block sections of the defects were collected at 4, 12, and 24 weeks postsurgery, respectively, and processed for gross and histological observation as well as x-ray examination. The results showed that in vitro induced BMSCs exhibited an osteogenic phenotype. Histologically, bone nodule structure was observed in the tissue of the experimental group at 4 weeks postsurgery and the engineered bone became more mature after 12 weeks, which was similar to normal bone. At 12 weeks postsurgery, the height of repaired alveolar bone reached 2.43 +/- 0.93 mm, 0.98 +/- 0.87 mm, 0.78 +/- 0.75 mm for the experimental group, control groups A and B, respectively, with a significant difference between the experimental and control groups (p < 0.01). The average level of buccal alveolar ridge in experimental group, control groups A and B reached 48.59%, 19.74%, and 15.76% of the height of normal alveolus, respectively, with a significant difference between the experimental group and two control groups (p < 0.01). We thus conclude that BMSCs can be induced to become osteogenic and can be used as seed cells to engineer bone tissue and repair experimental alveolar bone defects.

Analysis of 435 screw-vent dental implants placed in 161 patients: software enhancement of clinical evaluation

This paper demonstrates how a computer software program was utilized in a private practice to supplement the clinical evaluation of one implant system. Clinical data were entered into a computer database at the time of implant placement and up to 13 years for follow-up appointments. Data were divided into two groups and subjected to lifetable analyses. The focus group consisted of a machined-titanium, screw-type implant with an internal abutment connection from one manufacturer. The residual database consisted of mixed implant designs with a variety of abutment connections and surfaces from several other manufacturers. Lifetable survival data between the two groups were generated. Cumulative survival rates from 0 to 13 years were 94.2% (n = 435) for the focus group and 90.1% (n = 2339) for the reference group. There were 25 implants lost in the focus group and 11 other implants were deemed "at risk." Survival results from other lifetable analyses are also presented for the two groups. Documentation of empirical clinical data in a computer software database over a period of time can help private practice clinicians better evaluate the dental implant systems used in their practices.

Evaluation of tuned-aperture computed tomography in the detection of simulated periodontal defects

OBJECTIVE

The objective of this study was to compare the diagnostic efficacy of tuned-aperture computed tomography (TACT) and conventional film for the detection of simulated periodontal defects.

STUDY DESIGN

Periodontal defects were created in 15 premolar-molar interproximal sites selected from 8 cadaver jaw segments. Ten observers viewed 45 image pairs (baseline and follow up) in 4 TACT modalities and film to assess the presence of defect. The TACT modalities were 1st and 2nd generation prototype systems (TACT-1 and TACT-2) with circular (C) and random (R) distribution patterns of source projection (TACT-1C, TACT-1R, TACT-2C, TACT-2R). Observer performance and related factors were analyzed by using receiver operating characteristic and analysis of variance.

RESULTS

Mean A(z) values were 0.64 for film, 0.74 for TACT-1C, 0.82 for TACT-1R, 0.64 for TACT-2C, and 0.69 for TACT-2R. TACT-1R was significantly better than film (P < .001), TACT-2C (P < .001) and TACT-2R (P = .007).

CONCLUSION

TACT-1R provided the best diagnostic performance in the detection of simulated periodontal defects among the 5 modalities compared in this study.

Enamel matrix derivative in the treatment of human intrabony osseous defects

BACKGROUND

There is limited information available from clinical trials regarding the performance of enamel matrix derivative (EMD) in the treatment of periodontal intrabony defects. This randomized, double-blind, placebo-controlled, split-mouth study was designed to compare the clinical and radiographical effects of EMD treatment to that of placebo-controlled treatment for intrabony defects.

METHODS

Sixteen patients were included, each of whom had 1 or 2 pairs of intrabony defects located contralaterally in the same arch. Thirty-six intrabony defects were randomly assigned treatment with flap surgery plus EMD or flap surgery plus placebo. At baseline and at the 12-month follow-up evaluation visit, clinical and radiographic measurements were determined. Data were statistically analyzed using the Wilcoxon-signed rank test (alpha = 0.05).

RESULTS

At the 12-month visit, bleeding on probing for the EMD group was 0.11 +/- 0.32 compared to the placebo group, 0.61 +/- 0.50 (P <0.05). Probing depth reduction was greater in the EMD group (3.00 +/- 0.97 mm) compared to the placebo group (2.22 +/- 0.81 mm) (P <0.05). Mean values for clinical attachment gain in the EMD and the placebo groups were 1.72 +/- 1.07 mm and 0.83 +/- 0.86 mm, respectively (P <0.05). Vertical relative attachment gain was 38.5 +/- 22.6% in the EMD group and 21.4 +/- 25.2% in the placebo group (P<0.05). Radiographic bone density gain was greater in the EMD (20.2 +/- 16.6%) compared to the placebo group (-3.94 +/- 23.3%) (P<0.01).

CONCLUSIONS

Treatment with flap surgery and EMD, compared to flap surgery with placebo, produced a significantly more favorable clinical improvement in intrabony periodontal defects.

Potential application of low-dose doxycycline to treat periodontitis in post-menopausal women

The purpose of this paper is two-fold: (1) to review the evidence that osteoporosis and post-menopausal estrogen deficiency are associated with progressive alveolar bone loss and an elevated risk of tooth loss; and (2) to propose the use of tetracyclines, specifically low-dose doxycycline (LDD) (and, perhaps in the future, the chemically modified tetracyclines), to mitigate alveolar bone loss in post-menopausal osteoporotic/osteopenic women. Design concepts for a randomized clinical trial to study the effects of LDD on progressive alveolar bone loss in this patient population are reviewed. Since osteoporosis affects over 20 million people in the United States, progressive alveolar bone loss in this patient group represents a potentially significant public health problem unique from common adult periodontitis. Stopping progressive alveolar bone loss is essential to prevent both tooth loss and micro-architectural deterioration of alveolar bone.