Proceedings from the State of the Art Workshop on Surgical Therapy for Periodontitis. Sponsored by National Institute of Dental Research, National Institutes of Health May 13-14, 1981 Workshop background paper

The efficacy of pocket elimination/reduction compared to access flap surgery: A systematic review and meta-analysis

AIM

To assess the efficacy and adverse effects of resective surgery compared to access flap in patients with periodontitis.

METHODS

Randomized controlled trials with a follow-up ≥6 months were identified in ten databases. Screening, data extraction, and quality assessment were conducted by two reviewers. The primary outcome was probing pocket depth, and the main secondary outcome was clinical attachment level. Data on adverse events were collected. Meta-analysis was used to synthesize the findings of trials.

RESULTS

A total of 880 publications were identified. Fourteen publications from nine clinical trials met the inclusion criteria and were included for analysis. Meta-analysis was carried out using all available results. The results indicated superior pocket depth reduction following resective surgery compared to access flap after 6-12 months of follow-up (weighted mean difference 0.47 mm; confidence interval 0.7-0.24; p = .010). After 36-60 months of follow-up, no differences were found between the two treatments in pocket depth and attachment level. The prevalence of adverse effects was not different between the groups. Post-operative recession tended to be more severe for the resective approaches.

CONCLUSION

Resective surgical approach was superior to access flap in reducing pocket depth 6-12 months post-surgery, while no differences between the two modalities were found at 36-60 months of follow-up.

Influence of Soluble Pyrophosphate on Calculus Formation in Adults

The purpose of this double-blind, longitudinal clinical study was to assess the efficacy of a dentifrice containing 3.3% soluble pyrophosphate in inhibiting calculus formation and its effect upon the oral soft tissues. A total of 265 adult volunteers was given a dental prophylaxis. Each was examined for dental calculus and oral soft tissue pathology. The volunteers were then randomly assigned to use either a dentifrice containing soluble pyrophosphate and sodium fluoride or a placebo sodium fluoride formulation for ad libitum home usage. At the two-month completion of the study, 217 subjects were available for examination. The results showed that the group using the dentifrice containing soluble pyrophosphate experienced a significant 26% decrease in calculus formation as compared with the placebo group, with both dentifrices being equally well-tolerated by the oral soft tissues.

The prevalence of periodontitis in a military treatment population

A group of 1,984 males and females (age range 13 to 84) at a military dental clinic were given oral examinations with full-mouth circumferential periodontal probing. Diagnoses were made both for individual quadrants and for the entire mouth using clearly defined diagnostic criteria. The results showed 37% of the subjects had gingivitis only, 33% had early periodontitis, 14% had moderate periodontitis, 15% had advanced periodontitis, 0.5% had juvenile periodontitis, and 0.5% had necrotizing gingivitis. The prevalence of periodontitis increased with age to a peak in the 45- to 50-year-age group. The proportion of periodontitis-affected quadrants, although initially lagging behind the overall case diagnoses, also increased with age.

Estimation of sensitivity and specificity of site-specific diagnostic tests

Clinical trials designed to estimate the sensitivity and specificity of periodontal diagnostic tests often use multiple sites per patient as experimental units of analyses. Since site-specific test results within a patient are dependent observations, a correlated binomial model should be employed to estimate the sensitivity and specificity of these diagnostic tests. Ignoring the within-patient correlation can result in an over- or underestimation of the true standard errors.

Long-term assessment of periodontal surgery versus curettage or scaling and root planing

The various treatments for periodontal disease must be assessed in light of the recently articulated goals of periodontal therapy to preserve teeth for a lifetime and to enhance esthetics and comfort as well as oral health. This article examines the long-term comparisons of periodontal surgery, curettage, and scaling and root planing in improving attachment levels instead of the more traditional pocket depth.

An estimate of periodontal treatment needs in the U.S. based on epidemiologic data

It has generally been assumed, based on previous epidemiologic and utilization studies as well as the increasing elderly population, that there would be an increasing need for periodontal treatment. Analysis of a more recent household epidemiologic survey conducted in 1981 indicates that the need for treatment of periodontitis is less than previous estimates. These epidemiologic data have been translated into treatment needs through a series of conversion rules derived from previous studies and current patterns of treatment, and applied to the 1985 U.S. population. The total periodontal services needed for scaling, surgery, and prophylaxes would require 120 to 133 million hours and $5 to $6 billion annually if the total population were treated for periodontitis over a 4-year period. Only 11% of the total hours needed would be for scaling and surgery whereas 89% would be needed for prophylaxes. Expenditures for periodontal treatment total approximately 10% of the amount being spent on dental care in 1985. On the basis of these data, it seems unlikely that there will be a substantial increase in the need for periodontal treatment in a growing and aging U.S. population. These figures represent the upper limits of treatment need and are reduced by factoring in current utilization of periodontal treatment.

Autoimmunity to collagen in adult periodontal disease

Although it has been documented that exogenous antigens of microbial origin are involved in the induction of the local inflammatory responses in human adult periodontitis (AP), endogenous antigens may contribute to the chronicity of this common disease. In this study, we used the enzyme-linked immunospot (ELISPOT) test to enumerate antibody-secreting cells to human collagen Types I-VI by cells isolated from the gingivae and peripheral blood of AP patients. Analyses of dissociated cells from gingivae of 39 AP patients revealed the presence of high numbers of cells that secrete antibodies to Type I collagen, and to a lesser extent, Type III. Although the majority of such cells produced specific antibodies of the IgG class, IgA- and IgM- anti-collagen -secreting cells were also detected. When compared to the total antibody-producing cells, the numbers of cells forming specific antibodies to collagen Type I were surprisingly high. In contrast, anti-collagen antibody-producing cells were rarely detected in the peripheral blood of patients with adult periodontal disease and only low levels of anti-collagen antibodies were present in the serum. The finding of local production of anti-collagen antibodies in AP suggests that autoimmunity may contribute to the pathogenesis of this common disease.

Effects of an air-powder abrasive device used during periodontal flap surgery in dogs

An air-powder abrasive system, the Prophy-Jet, is a commercially available product product intended for use during dental prophylaxis procedures. The purpose of this investigation was to assess the effects on periodontal tissues when the device is used as an adjunct to hand instrumentation in root preparation during periodontal surgery. The degree of tissue injury was assessed by evaluating clinical healing and by histometric analysis of the intensity of the inflammatory response at selected healing times. Surgical sites subjected to Prophy-Jet treatment tended to have slightly lower histometric inflammation scores than control sites treated by hand instrumentation alone. As judged by the inflammatory response and clinical healing, additional effects to surgical exposure of tissues of the periodontium were benign. Use of the Prophy-Jet instrument during periodontal surgery is effective and well tolerated.

Trypsin-like activity in subgingival plaque. A diagnostic marker for spirochetes and periodontal disease?

Taxonomic screening of subgingival plaque organisms with various enzyme assays have shown that Treponema denticola, Bacteroides gingivalis and an unspeciated Capnocytophaga species possess a trypsin-like enzyme (TLE) that can be detected by the hydrolysis of N-benzoyl-DL-arginine-2-naphthylamide (BANA). As these organisms can be considered to be periodontopathic, it was of interest to determine whether this BANA hydrolyzing enzyme could be detected directly in subgingival plaque samples. Subgingival plaque samples were collected from single sites of known pocket depth, and after dispersal by vortexing, aliquots were incubated overnight with BANA and were counted microscopically. The color reactions were developed with fast garnet, read by the eye and classified as positive (red to red-orange), negative (yellow) and questionable. In the BANA-positive plaques, the spirochetes averaged 43% of the microscopic count, whereas in the BANA negative plaques the spirochetes averaged 8% of the microscopic count. The average pocket depth of BANA-positive plaques was 6.7 mm, whereas the average pocket depth of BANA-negative plaques was 4.5 mm. When both of these parameters were combined, the presence of a positive BANA reaction was usually indicative of subgingival plaques containing greater than 34% spirochetes removed from sites that had probing depths of 7 mm or more. Seventy-one per cent of the plaques removed from untreated periodontal patients were BANA-positive, while only 8% of the plaques removed from successfully treated patients seen at maintenance recall visits were BANA-positive.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of an air-powder abrasive system on root surfaces in periodontal surgery

The purpose of this study was to compare the effectiveness of an air-powder abrasive technique to conventional root planing during periodontal surgery. 7 patients scheduled for multiple extractions of periodontally-involved teeth were selected. Full thickness mucoperiosteal flaps were reflected, and proximal surfaces of 32 teeth were either ultrasonically scaled and exposed to the air-powder abrasive, or ultrasonically scaled and then manually root planed. Following extraction, teeth were stained for residual plaque and photographed, or prepared for scanning electron microscopy. The air-powder abrasive technique used for surgical root preparation was found to produce a root surface favorably comparable to manual root planing with regard to removal of plaque, calculus, and exposed cementum. A mean of 80 micron of cementum was abraded away after 40 s of exposure to the air-powder spray. The air-powder abrasive spray demonstrated an advantageous ability to remove plaque and cementum from areas of difficult access, such as furcations and root flutings.

An epidemiological investigation into the relative importance of age and oral hygiene status as determinants of periodontitis

The objective of this study was to assess the relative effects of age and oral hygiene on the progression of periodontitis by estimating incidence from age-specific prevalence. This study analyzed data from a representative national sample of 14,690 dentate Americans, aged from 15 to 74, seen in the first National Health and Nutrition Examination Survey (NHANES I) in 1971-1974. Results showed that the rate of increase in the estimated incidence of periodontitis with age, throughout all age groups, is much higher among subjects with poor oral hygiene than among those with good oral hygiene. Oral hygiene was confirmed as the most important predictor for periodontitis; in all age groups, more than 95% of those examined with good oral hygiene did not have periodontitis. It was concluded that the effect of age on the progression of periodontitis could therefore be considered negligible when good oral hygiene is maintained.

Calculus revisited. A review

Although there is no doubt that gingivitis can develop in the absence of supragingival calculus, it is not clear to what extent the presence of mineralized deposit enhances gingival inflammation. Partial inhibition of plaque mineralization can be accomplished by chemical agents, but there has been no demonstration in humans of a reduction in gingivitis. It remains to be established what level of inhibition (if any) is required to have more than a cosmetic effect. Since the accepted scenario is that apical growth of supragingival plaque precedes the formation of subgingival calculus, there is no longer an issue of whether subgingival calculus is the cause or the result of periodontal disease. Subgingival mineralization results from the interaction of subgingival plaque with the influx of mineral salts that is part of the serum transudate and inflammatory exudate. This chronology, however, should not be the basis for relegating calculus to the ash heap. Morphologic and analytical studies point to the porosity of calculus and retention of bacterial antigens and the presence of readily available toxic stimulators of bone resorption. When coupled with the increased build up of plaque on the surface of the calculus, the combination has the potential for extending (beyond that of plaque alone) the radius of destruction and the rate of displacement of the adjacent junctional epithelium. The centrality of thorough scaling and root planing in the successful maintenance of periodontal health supports the view that subgingival calculus contributes significantly to the chronicity and progression of the disease, even if it can no longer be considered as responsible for initiation.

Development of a biochemical profile for gingival crevicular fluid. Methodological considerations and evaluation of collagen-degrading and ground substance-degrading enzyme activity during experimental gingivitis

The potential application of gingival crevicular fluid (GCF) analysis to periodontal diagnosis has been examined for more than 25 years. Unfortunately, the information available has not provided the clinician with a more sensitive means of diagnosing periodontal disease or an effective means of monitoring periodontal therapy. A careful review of the literature on GCF, however, suggests that discrepancies occur in the method of GCF collection, the use of GCF for analysis from pooled or isolated crevicular locations, the method of analyzing the samples and the way in which the data is reported. Studies in our laboratory have suggested a technique for GCF analysis that collects GCF from individual crevices with a filter paper strip inserted for a standard time, determines the volume of GCF collected with a calibrated electronic meter and elutes the material into a larger volume of diluent. This approach allows for detection of site-to-site and patient-to-patient differences in GCF volume while providing sufficient samples to analyze GCF for multiple constituents. We have used this approach to evaluate GCF for vertebrate forms of the enzymes collagenase (latent and active forms), beta-glucuronidase and arylsulfatase during the development of experimental gingivitis in man. Interproximal and midradicular areas were studied. Our results indicate that during the 4 weeks of the gingivitis, the absolute amount of active collagenase in GCF increased 550% at the interproximal sites and 190% in the midradicular sites, and the per cent of active collagenase increased from 15 to 71% at the interproximal sites, and from 16 to 36% at the midradicular sites.(ABSTRACT TRUNCATED AT 250 WORDS)

Periodontal disease awareness

New forms of patient education are needed to increase the periodontal disease awareness of the general public. Patients are more likely to seek professional treatment for periodontal disease when they are aware of its existence. The general practitioner should be encouraged, through the dental literature and continuing education courses, to assume responsibility for the diagnosis and management of the majority of periodontal problems. Increased periodontal awareness by the dentist would be beneficial in three areas: increased periodontal diagnosis and treatment planning would help reduce the number of lawsuits that can result from existing undiagnosed periodontal disease, the number of failures in restorative treatment would be reduced and longevity of existing restorative dentistry increased, and unfilled appointment time in the dentist's schedule could be filled by patients who need periodontal therapy.

Comparison of surgical and nonsurgical treatment of periodontal disease. A review of current studies and additional results after 61/2 years

Many well designed clinical studies have established the effectiveness of periodontal therapy. Surgical procedures have been shown to be effective in treating periodontitis when followed by appropriate maintenance care. Scaling and root planing alone have recently been compared to scaling and root planing plus soft tissue surgery in several longitudinal trials. A review of the literature indicates several important findings including a loss of clinical attachment following flap procedures for shallow (1-3 mm) pockets and no clinically significant loss after scaling and root planing. These studies also generally report either a gain or maintenance of attachment level for both procedures in deeper pockets (greater than or equal to 4 mm). For these pockets, neither procedure has been shown to be uniformly superior with respect to attachment gain. All reports indicate that both treatment methods result in pocket reduction. However, the literature also indicates that scaling and root planing combined with a flap procedure results in greater initial pocket reduction than does scaling and root planing alone. This difference in degree of pocket reduction between procedures tends to decrease beyond 1-2 years. It has been shown that both treatment methods result in sustained decreases in gingivitis, plaque and calculus and neither procedure appears to be superior with respect to these parameters. Additional data from the study at the University of Minnesota indicate that similar results are maintained up to 61/2 years following active therapy. Pocket depth did not change for shallow (1-3 mm) pockets treated by either scaling and root planing alone or scaling and root planing followed by a modified Widman flap. For pockets 4-6 mm, both treatment procedures resulted in equally effective sustained pocket reduction. Deep pockets (greater than or equal to 7 mm) were initially reduced more by the flap procedure. After 2 years, no consistent difference between treatment methods was found in degree of pocket reduction. However, as compared to baseline, pocket reduction was sustained to 61/2 years with the flap and only 3 years with scaling and root planing alone. After 61/2 years, sustained attachment loss in shallow (1-3 mm) pockets was found after the modified Widman flap. Scaling and root planing alone in these shallow pockets did not result in sustained attachment loss. For pockets initially 4-6 mm in depth, attachment level was maintained by both procedures but scaling and root planing resulted in greater gain in attachment as compared to the flap at all time intervals.(ABSTRACT TRUNCATED AT 400 WORDS)