The long-term effectiveness of periodontal therapy in a clinical practice

Effectiveness of a 30-year periodontist's primary care for 1946 patients during five-year follow-up

OBJECTIVE

To evaluate the effect of the periodontal primary care (PPC) on the improvement of periodontal probing depth based on a periodontist's 30-year practice.

MATERIALS AND METHODS

We enrolled a total of 2,894 patients who underwent periodontal basic treatment between 1987 and 2017 with 84.5% retention rate. The study population was composed of 80% (n = 1,946) of retained patients with complete re-evaluation up to five-year follow-up. The outcome was measured by the improvement of probing depths (graded as 1:1-3 mm; 2:4-6 mm; 3: ≥7 mm) before and after PPC on both sextant and patient levels. Whether a better improvement was seen in the surgical group and the non-smoker group opposed to their comparators was assessed with various multi-variable regression models.

RESULTS

On patient (sextant) level, 82% (38%) improved, 13% (59%) unchanged, and 5% (3%) deteriorated. Adjusted better improvement of probing depth was noted for the surgical group by 63% and non-smoker by 31% compared with their counterparts. The similar findings were found for the outcomes based on continuous probing depth scores.

CONCLUSIONS

We demonstrate the improvement of probing depth scores with a periodontal primary care offered for the retained patients and larger effect for the surgical group and non-smoker patients.

Different Regenerative Responses of Two Platelet Concentrates in the Treatment of Human Periodontal Infrabony Defects: A Clinico-Radiographic Study

Background:

Platelet concentrates usage in the treatment of intrabony defects has been improved due to advancement of research. Many generation of platelet concentrates were used, but research regarding advanced platelet-rich fibrin (A-PRF) regarding periodontal treatment is scanty.

Aim:

The purpose of the study was to evaluate and compare PRF and A-PRF in the treatment of human periodontal infrabony defects (IBDs) both clinically and radiographically.

Materials and Methods:

Twenty-eight patients having IBDs were divided into Group A (PRF) and Group B (A-PRF). Clinical parameters such as plaque index, gingival index, probing pocket depth (PPD), and clinical attachment level (CAL) were recorded at baseline and 3 and 6 months and radiographic examination at baseline and 6 months were also recorded to evaluate defect fill, resolution, and change in the alveolar crest height. Then, all the data were tabulated in a Microsoft Excel sheet and subjected to statistical analysis. Mean and standard deviations of the clinical and radiographic parameters were calculated, and unpaired t-test was performed to assess intergroup comparison at different time intervals.

Results:

Intragroup comparison showed statistically significant improvement in PPD and CAL at 3 and 6 months while statistically significant improvement was observed in mean defect fill and resolution in Group B.

Conclusion:

Individually, both the materials have shown promising results. However, statistically, PRF group (Group A) showed better treatment outcome in terms of bone fill and A-PRF group (Group B) in terms of soft tissue healing.

Periodontal diseases

Periodontal diseases comprise a wide range of inflammatory conditions that affect the supporting structures of the teeth (the gingiva, bone and periodontal ligament), which could lead to tooth loss and contribute to systemic inflammation. Chronic periodontitis predominantly affects adults, but aggressive periodontitis may occasionally occur in children. Periodontal disease initiation and propagation is through a dysbiosis of the commensal oral microbiota (dental plaque), which then interacts with the immune defences of the host, leading to inflammation and disease. This pathophysiological situation persists through bouts of activity and quiescence, until the affected tooth is extracted or the microbial biofilm is therapeutically removed and the inflammation subsides. The severity of the periodontal disease depends on environmental and host risk factors, both modifiable (for example, smoking) and non-modifiable (for example, genetic susceptibility). Prevention is achieved with daily self-performed oral hygiene and professional removal of the microbial biofilm on a quarterly or bi-annual basis. New treatment modalities that are actively explored include antimicrobial therapy, host modulation therapy, laser therapy and tissue engineering for tissue repair and regeneration.

Commentary: prognosis revisited: a system for assigning periodontal prognosis

Prognosis is an integral part of the periodontal practice because it directly influences treatment planning. However, there is limited direct evidence in the literature regarding the assignment of periodontal prognosis. There are several important concepts to consider in developing a system of periodontal prognosis. Traditional systems are based on tooth loss and may have limited use for patient management. On the other hand, prognosis can be based on stability of the periodontal supporting apparatus, which is influenced by more evidence-based factors and may be more useful for patient management. Other important concepts include the timing of the projection (short and long term) and the consideration of individual teeth versus the overall dentition. Historically, several authors have formulated and investigated their own prognostication systems. Results were variable, but they generally showed that systems based on tooth loss were unpredictable over the long term. Therefore, the purpose of this report is to review relevant literature and propose a new periodontal prognostication system.

Loss of tooth substance during root planing with various periodontal instruments: an in vitro study

Ultrasonic and power-driven instrumentation is gaining in significance as an acceptable alternative to manual periodontal root treatment. Some question whether they do not remove too much tooth substance. Various ultrasonic scalers, hand instruments and two power-driven systems were compared by assessing the loss of tooth substance due to root instrumentation. Quantitative analysis of this effect of the instruments used was performed on 20 freshly extracted, non-periodontally involved, large human molars. In the first study, 40 specimens were randomly assigned to four groups of treatment: combined use of ultrasonic scaler and Periopolisher diamond-coated inserts (US-POL), hand instruments (MANUAL), Perioplaner-Periopolisher system (PPL-POL) and Periokit ultrasonic-designed scalers (PERIOKIT). The second study involved two treatment groups, ultrasonic scaler alone and hand instruments, each allocated with 20 teeth (small root fragments). An unpaired two-tailed t test was carried out for both studies to compare the average weight loss of root substance with the modes of instrumentation. The level of significance was set at p<or=0.05. The overall results of the first and second experimental trials did not reveal obvious differences in weight loss between the manual, ultrasonic or power-driven root treatments. Based on the results of these two comparative studies, the power-driven inserts or the various ultrasonic scalers tested did not remove more tooth substance than conventional hand instruments. They may thus be a useful alternative for the debridement of root surfaces.

Position PaperPeriodontal Maintenance

The purpose of this paper is to provide an overview of the role of periodontal maintenance procedures in the treatment of periodontal diseases. Reliance on this position paper in patient management will not guarantee a successful outcome, as periodontal diseases typically involve complex causes and symptoms. Ultimately, decisions regarding the diagnosis, treatment, and management of disease, as well as subsequent preventive therapy, must be made by the treating practitioner based on specific circumstances presented by the patient.

The nonsurgical treatment of patients with periodontal disease: results after five years

BACKGROUND

In a previous study involving patients seen at the dental clinic of the Detroit Receiving Hospital, the authors found that 87 percent of teeth initially recommended for surgery or extraction were spared those treatments by a combination of debridement and short-term usage of antimicrobial agents. The objective of the present study was to determine how long the surgery-sparing benefits of less invasive treatment would persist.

METHODS

Ninety of these patients were scheduled for maintenance therapy at three-month intervals over a five-year period. They were evaluated periodically for surgical needs by a clinician who was not aware of the nonsurgical periodontal treatment the patient had received.

RESULTS

The initial treatment benefits were sustained, as the number of teeth needing periodontal surgery or extraction was 0.06 teeth per patient after 1.1 year, 0.22 after 2.3 years, 0.51 after 3.6 years and 0.86 after 5.1 years.

CONCLUSIONS

A noninvasive treatment regimen for an anaerobic infection in teeth seriously compromised by periodontal disease resulted in a reduced need for surgery or tooth extraction for at least five years after completion of the initial treatment.

Position paper: Guidelines for periodontal therapy

The American Academy of Periodontology offers the following Guidelines for Periodontal Therapy. These guidelines are intended to fulfill the Academy's obligation to the public and to the dental profession. This paper sets forth the clinical objectives and scope of periodontal therapy. These guidelines are designed to give guidance to state legislatures and agencies that regulate the practice of periodontology and should be considered in their entirety.

Periodontal disease as a specific, albeit chronic, infection: diagnosis and treatment

Periodontal disease is perhaps the most common chronic infection in adults. Evidence has been accumulating for the past 30 years which indicates that almost all forms of periodontal disease are chronic but specific bacterial infections due to the overgrowth in the dental plaque of a finite number of mostly anaerobic species such as Porphyromonas gingivalis, Bacteroides forsythus, and Treponema denticola. The success of traditional debridement procedures and/or antimicrobial agents in improving periodontal health can be associated with the reduction in levels of these anaerobes in the dental plaque. These findings suggest that patients and clinicians have a choice in the treatment of this overgrowth, either a debridement and surgery approach or a debridement and antimicrobial treatment approach. However, the antimicrobial approach, while supported by a wealth of scientific evidence, goes contrary to centuries of dental teaching that states that periodontal disease results from a "dirty mouth." If periodontal disease is demonstrated to be a risk factor for cardiovascular disease and stroke, it will be a modifiable risk factor since periodontal disease can be prevented and treated. Since the antimicrobial approach may be as effective as a surgical approach in the restoration and maintenance of a periodontally healthy dentition, this would give a cardiac or stroke patient and his or her physician a choice in the implementation of treatment seeking to improve the patient's periodontal condition so as to reduce and/or delay future cardiovascular events.

The antimicrobial treatment of periodontal disease: changing the treatment paradigm

Over the last 100 years, methods of surgical periodontal treatment have enjoyed a history of success in improving oral health. The paradigm of care is based on the "non-specific plaque hypothesis"--that is, the overgrowth of bacterial plaques cause periodontal disease, and the suppression of this overgrowth reduces disease risk. The central feature of this approach to care is the removal of inflamed gingival tissue around the teeth to reduce periodontal pocket depth, thereby facilitating plaque removal by the dentist and by the patient at home. Over the last 30 years, with the recognition that periodontal disease(s) is caused by specific bacteria and that specific antimicrobial agents can reduce or eliminate the infection, a second paradigm has developed. This new paradigm, the "specific plaque hypothesis", focuses on reducing the specific bacteria that cause periodontal attachment loss. The contrast between the two paradigms can be succinctly stated as follows: The antimicrobial therapy reduces the cause, while the surgical therapy reduces the result of the periodontal infection. The specific plaque hypothesis has two important implications. First, with the increasing attention to evidence-based models for prevention, treatment, outcome assessment, and reimbursement of care, increasing attention and financial effort will be channeled into effective preventive and treatment methods. Second, the recent observations that periodontal infections increase the risk of specific systemic health problems, such as cardiovascular disease, argue for the prevention and elimination of these periodontal infections. This review highlights some of the evidence for the specific plaque hypothesis, and the questions that should be addressed if antimicrobial agents are to be used responsively and effectively.

A logistic regression model for the decision to perform access surgery

Access surgery may be recommended to about 80% of patients who present with advanced forms of periodontal disease. In this report, a multivariate logistic regression analysis which incorporated several clinical parameters for each tooth examined, i.e., tooth type, furcation involvement, bleeding on probing, attachment level, probing depth, mobility and BANA test score, was conducted using generalized estimating equations (GEE). This approach identified parameters that were significantly associated at p < 0.05 level with the need for access surgery or extraction for periodontal purposes. The estimated probabilities derived from the GEE model were plotted over the complete spectrum of operating conditions to obtain a receiver-operator characteristic (ROC) curve. At a probability cutpoint of 0.8, the decision threshold for surgery/extraction at the pretreatment examination would have a sensitivity of 76.1% and a specificity of 75.3%. We have taken this 0.8 cut point to look at specific clinical decisions made by our examiners after the patients had received scaling and root planing plus 2 weeks unsupervised usage of systemic antimicrobials. The clinicians' decision was taken as the primary reference standard. The model's estimated decision agreed with the clinicians' decision in 226 of the 284 teeth, for an accuracy of 80%. The specificity was 90% and the sensitivity was 43%.

Refractory periodontitis: critical questions in clinical management

Refractory periodontitis appears to be a patient phenomenon with a clinical pattern that may be the result of different influences including genetic factors and exogenous factors that alter the host response to the bacterial challenge. Different patients may have different mechanisms involved in their disease and therefore may show different response patterns following therapy. Although localized non-responsive sites in otherwise responsive patients should not be considered refractory periodontitis, such sites do present substantial therapeutic problems. Initial evidence suggests that local delivery tetracycline provides significant advantages in the management of such sites. Although refractory periodontitis cases appear to be primarily the result of host alterations, the most predictable approach to therapy at present involves systemic antibiotics in conjunction with local therapy. The goal of antibiotic therapy should be to eliminate from detection the target bacteria that were present prior to therapy. Good plaque control, regular professional maintenance therapy, regular microbial monitoring, and control of risk factors are important aspects of the long term maintenance of these cases.

The influence of supragingival plaque control on clinical and microbial outcomes following the use of antibiotics for the treatment of periodontitis

Although supragingival plaque control is essential to successful periodontal therapy, the role of plaque control following systemic antibiotic use in periodontal disease has not been well defined. This study evaluated, following antibiotic use, which clinical and microbial parameters appeared to be influenced primarily by the antibiotics, independent of plaque control, and which outcomes appeared to be dependent on plaque control. Two hundred thirty-six patients (236) with moderate to severe periodontitis were clinically evaluated and microbial samples were taken by their private-practice periodontists. All patients were treated with scaling and root planing and a variety of systemic antibiotics, which were selected based on the microbial and clinical profile of the patient. Three months after therapy, patients were reevaluated and grouped by post-treatment plaque control, as either having very good oral hygiene (LoPl: N = 143; < or = 10% plaque-covered surfaces) or poor oral hygiene (HiPl: N = 93; > or = 25% plaque-covered surfaces). The two groups had different plaque and bleeding scores initially, but similar numbers of pockets probing > 5 mm and similar microbial patterns. Although the LoPl group had a significantly greater reduction in plaque than the HiPl group, bleeding scores and probing depths changed comparably in both groups after antibiotic therapy. Plaque control influenced outcomes significantly, but in a complex manner. The LoPl group exhibited a significantly greater reduction in certain bacteria, for example P. gingivalis. Interactions between plaque control and specific microbial parameters significantly affected clinical outcomes, although neither alone was sufficient to predict outcomes following antibiotic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosing periodontal diseases

At present, the diagnosis of periodontal disease requires a clinical evaluation of the patient including visual findings, the use of the periodontal probe, and radiographs. No test is available to evaluate disease activity. In specific cases, adjunctive procedures may also be useful. The identification of pathogenic microorganisms may aid in evaluating the periodontal status of special patients. However, these are not required for an adequate diagnosis of the common adult form of chronic periodontitis.

Periodontal disease activity: a critical assessment

Review of investigations using longitudinal probing and radiographic assessments indicate that the prevalence, magnitude, rate, and temporal patterns of periodontal destruction as well as the ability of clinical and laboratory tests to detect and predict loss of clinical attachment need further investigation. These unresolved issues are discussed and their impact on the practice of periodontics is examined.

The role of periodontal probing depth in clinical decision-making

This retrospective study examines the role of periodontal probing depth in clinical decision-making. The expected values of no treatment and surgical and non-surgical therapies were obtained by combining the probability of each treatment outcome and utility values denoting the preference for each outcome. The expected value for non-surgical therapy was higher for sextants exhibiting a positive response to initial therapy than sextants which did not respond to initial therapy (0.735 versus 0.706). This trend was not observed for sextants treated surgically. Surgical therapy was effective over all levels of disease severity and was the preferred form of therapy with respect to reduction of probing depth except for sextants exhibiting 4 to 5 mm pockets. In this latter situation, the expected value at 3 years for non-surgical and surgical therapy was 0.795 and 0.792, respectively. Neither form of therapy could consistently achieve periodontal probing depths equal to or less than 3 mm throughout a given sextant. This study facilitates the selection of an optimal therapeutic strategy with respect to periodontal probing depth.

Reconstruction of parodontal tissue with chitosan

Chitosan ascorbate, obtained by mixing chitosan with ascorbic acid and sodium ascorbate, was produced in a gel form suitable for the treatment of periodontitis according to current dental surgery. While chitosan ascorbate underwent degradation in vitro, especially in the presence of atmospheric oxygen and at pH 6.0, the protection from oxygen offered by the surgical cements and the physiological pH value permitted chitosan ascorbate to play an important biological role in vivo, where it kept a honeycomb structure, as indicated by SEM on biopsies taken on 10 patients. The proliferation and organization of the cells were thus favoured with a subsequent enhanced capability of reconstructing a histoarchitectural tissue. Chitosan was progressively reabsorbed by the host, with very satisfactory clinical recoveries of the 52 defects treated, for which tooth mobility and pocket depths were significantly reduced.

Periodontics in general practice: perspectives on periodontal diagnosis

Standardized terminology does not exist to differentiate the conditions that constitute "response diagnosis" and "disease diagnosis" described in this review. Therefore, appropriate descriptive terminology is proposed for these two periodontic diagnoses. Diagnostic terms are needed to discern stages of disease. Periodontitis is a chronic disease prone to episodic recurrence that needs a "dynamic diagnosis" that can change with each reevaluation. In addition, the legal ramifications of failing to recognize or adequately described disease recurrence are discussed.

Clinical and microbiological characteristics of treated periodontitis patients on maintenance care

A population of 98 adults previously treated for moderate to advanced adult periodontitis and currently maintained in a recall program for at least one year were recruited for this study. The ultimate purpose of the study is to determine whether the presence of Actinobacillus actinomycetemcomitans, Bacteroides gingivalis, and Bacteroides intermedius in selected periodontal sites can predict the future clinical course of these patients, particularly with respect to disease recurrence. This report presents the clinical design of the study which allows comparisons between sites positive and negative for these species in infected patients, and between sites in infected patients and comparable sites in non-infected patients. In addition, some base line clinical and microbiological data for these patients are presented. The distribution of PII and GI scores tended to be highest for molars, with the remaining teeth having similar scores. Probing depth measurements were greater for mesio-distal than oro-vestibular recordings. A bilaterally symmetrical pattern of increasing probing depth was noted from the midline distally on mesio-distal as well as oro-vestibular surfaces. Sites positive for the target organisms listed above tended to have greater probing depths (mean: 4.14 +/- 0.1 mm) than non-infected sites in the same patients (mean: 3.76 +/- 0.1 mm) or comparable sites in non-infected patients (mean: 3.54 +/- 0.1 mm).

Combined antibiotic (metronidazole) and mechanical treatment effects on the subgingival bacterial flora of sites with recurrent periodontal disease

5 patients in maintenance, 1-3 years after periodontal therapy who showed sites with reinfected pockets and bleeding despite regular recall visits were selected. Darkfield microscopy from 3 sites in each patient showed an average of 41% spirochetes and 21% motile rods. Probing depths ranged from 7 to 9 mm and loss of clinical attachment from 6 to 13 mm in these sites. The patients were given 3 times 250 mg/day of metronidazole (Flagyl) for 10 days. Darkfield microscopy and microbiological cultures of the subgingival plaque were performed twice prior to the study, at the end of the medication and after 3 weeks, 3 and 6 months. The plaque and gingival indices, probing depth and loss of clinical attachment were recorded. During the medication and at 3 and 6 months, the teeth were scaled and root planed. The samples were obtained with 3 paper points and cultured anaerobically in the glove box on non-selective and selective media and representative bacterial colonies identified by aerobic growth, gram stain and rapid biochemical tests. Presumptive pathogenic micro-organisms including Bacteroides were identified. The % of spirochetes, motile rods and non-motile bacteria were enumerated by darkfield microscopy. The clinical results show that administration of metronidazole and repeated root planing significantly decreased gingival inflammation, probing depth and loss of clinical attachment in reinfected sites. After treatment, these sites harbored significantly less spirochetes and more non-motile bacteria, while motile rods tended to return to baseline levels with time. The combined antibiotic and mechanical therapy resulted in a statistically significant decrease of gram-negative rods, Fusobacteria and Bacteroides gingivalis over 6 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Compliance. A review of the literature with possible applications to periodontics

This paper begins with a review of the literature on compliance. The medical literature suggests that patients with chronic illnesses tend to comply poorly, especially if the disease is not perceived by the patient as particularly threatening. The dental literature covers two principal areas: compliance with oral hygiene regimens and utilization of dental care by the public. These works show that most patients surveyed do not clean their teeth as they have been instructed, and most do not receive routine dental care. The reasons for this noncompliance are highly variable but include lack of pertinent information, fear, economics, and the patient's perception of lack of compassion on the part of the dental therapist. In periodontics the majority of studies have focused on the effectiveness of patient oral hygiene along with its modification and on maintenance therapy. Other work in the periodontal literature is discussed in light of the widespread noncompliance shown by our patients. A number of studies have been undertaken on how best to improve compliance. In general, it has been found that patients comply better when they are informed and positively reinforced, and when barriers to treatment are reduced. Suggestions are made for improving compliance in the periodontal office and for tailoring therapy to predicted compliance levels.

Report of Committee on Scientific Investigation of the American Academy of Restorative Dentistry

A few personal points seem appropriate in summary. It is axiomatic that while research solves problems, it also creates them. As an example, it is an accepted fact that dentistry more than any other profession has made serious inroads into putting itself out of business through research. Each year this report takes note of the reduction in dental caries in children, which has thus triggered a change in the nature of general practice. Be this as it may, it is well to acknowledge that major dental diseases are not disappearing, but their patterns in the population are changing, accompanied by an expansion of other services. Despite the optimistic picture painted earlier in this report, it is grossly premature to acclaim the elimination of caries, and thereby a significant segment of restorative dentistry. Of course the younger age groups have been the major beneficiaries of caries reduction. As the child ages from 9 to 16 years, the percentage of mouths free of caries drops by one half. In addition, the disease pattern in the adult population is being altered because of a longer life span and loss of fewer teeth. Unquestionably what we will, and are already seeing, is not an elimination of restorative dentistry but a different target and changes in procedures because of new materials, therapy, and expanded scope of services. There is yet another subtle change in the trend of dental research and it deals with the reduction in the number of dental schools worldwide and smaller class sizes in those schools. Dental research thereby suffers because of the traditional link between education and research. Thus the potential pool of researchers becomes smaller and research monies for training programs for dental investigators, particularly in clinical research, decreases. This year a surprising number of articles are concerned with manpower as it relates to research priorities. So, it is indeed a time that both the profession and the scientific community find filled with controversy and frustration. Yet never has there been a time that offers more in challenges and rewards.