Periodontal therapy reduces the severity of active rheumatoid arthritis in patients treated with or without tumor necrosis factor inhibitors

BACKGROUND

Rheumatoid arthritis (RA) and periodontitis are common chronic inflammatory conditions. Recent studies showed a beneficial effect of periodontal treatment on the severity of active RA. This study was undertaken to further examine the effect of non-surgical periodontal treatment on the signs and symptoms of RA in patients treated with or without anti-tumor necrosis factor-alpha (anti-TNF-alpha) medications. The effect of anti-TNF-alpha therapy on periodontitis also was assessed.

METHODS

Forty participants diagnosed with moderate/severe RA (under treatment for RA) and severe periodontitis were randomly assigned to receive initial non-surgical periodontal therapy with scaling/root planing and oral hygiene instructions (n = 20) or no periodontal therapy (n = 20). To control RA, all participants had been using disease-modifying anti-rheumatic drugs, and 20 had also been using anti-TNF-alpha before randomization. Probing depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), gingival index (GI), plaque index (PI), RA disease activity score 28 (DAS28), and erythrocyte sedimentation rate (ESR) were measured at baseline and 6 weeks later. Linear mixed models were used to identify significant differences between subjects who received periodontal treatment and those who did not.

RESULTS

Patients receiving periodontal treatment showed a significant decrease in the mean DAS28, ESR (P <0.001), and serum TNF-alpha (P <0.05). There was no statistically significant decrease in these parameters in patients not receiving periodontal treatment. Anti-TNF-alpha therapy resulted in a significant improvement in CAL, PD, BOP, and GI.

CONCLUSIONS

Non-surgical periodontal therapy had a beneficial effect on the signs and symptoms of RA, regardless of the medications used to treat this condition. Anti-TNF-alpha therapy without periodontal treatment had no significant effect on the periodontal condition.

Epidemiology of periodontal disease: a review and clinical perspectives

The purpose of this paper is to assimilate epidemiological evidence for the prevalence of periodontal disease in human populations, and for comprehensive understanding of the disease for health care providers. Periodontal disease is a pathological condition affecting the supporting structures of teeth. It is characterised by a bacterial challenge that can instigate a destructive host response leading to periodontal attachment loss, bone loss and ultimately, possible tooth loss. The specifics of the disease process are obscured by our incomplete understanding of the role of various risk factors. Periodontal epidemiology literature lacks consistency in methodology of research, which includes various definitions for periodontal disease and health; different approaches to measuring periodontal indices of pocket depth, and attachment loss; inconsistent study designs and lack of adjustments to known risk factors. These inconsistencies do not allow for effective comparison of epidemiological studies, which is essential to find strong associations of risk factors with periodontal disease, which in turn is necessary for the interpretation of risk and causality. This paper will address several areas within the topic of periodontal disease epidemiology, including definitions of periodontal disease instituted by researchers, approaches to epidemiological studies in periodontitis, and risk factors in periodontal disease. Consideration is given to aspects of design and analyses relevant to evaluation of reports in the literature. For the clinical practitioner this review provides a theoretical framework to approach patients with comprehensive knowledge of not only the disease presentation, but also the environmental factors that govern past history, present condition and future response to treatments and interventions.

The deceptive nature of root coverage results

BACKGROUND

The purposes of this article are to: 1) propose a new method of reporting root coverage data; 2) compare existing root coverage techniques using the proposed data analysis method; and 3) discuss additional refinements to root coverage data analysis. Past studies have equated percent defect coverage with root coverage. This gives deceptive information about the magnitude of the residual recession defect. Defect coverage of 67% could actually amount to 92% root coverage.

METHODS

The use of mean root lengths will permit the determination of true root coverage data. This should be reported in addition to defect coverage data. Also including frequency data will provide a better assessment of the predictability of the surgical techniques.

RESULTS

A comparison table of root coverage studies demonstrates that the connective tissue graft is the most effective and predictable method that has been tested.

CONCLUSIONS

Further refinements to data analysis may help researchers identify the determinants of predictable root coverage.

Periodontitis--the risks for its development

The relationships between periodontitis and systemic disease and conditions, environmental factors, and behavioral influences are evolving rapidly. Success in preventing and treating periodontal diseases may well rest to a large extent on our understanding of the relevant influences which may exacerbate and perpetuate the disease process. As researchers work to clarify these relationships, we as practitioners must continue to alter our treatment in the best interests of the patient's overall health. The impact of recent findings on the development and progression of periodontitis relevant to diabetes mellitus, HIV, genetic susceptibility, smoking, stress, and osteoporosis is reviewed.

Clinical evaluation of the use of calcium sulfate in regenerative periodontal surgery for the treatment of Class III furcation involvement

The purpose of this study was clinical evaluation of the effectiveness of a composite graft, consisting of demineralized freeze-dried bone and doxycycline hyclate (4:1 by vol.) in combination with a resorbable calcium sulfate barrier in the treatment of Class III furcation involvement. A total of 24 sites in seven patients having adult periodontitis with at least two mandibular molars with class III furcation involvement were randomly allocated into two equal groups. The experimental sites received the composite graft in the furcation area covered by the barrier buccally and lingually. The control sites were treated by surgical debridement only. Baseline preoperative data, including probing depth, clinical attachment level, gingival recession and radiographic bone level, were recorded. During surgery, direct linear and volumetric measurements of the defects were taken. At 12 months postoperatively, all sites were surgically re-entered and all measurements were again recorded. Student's t-test and analysis of variance of the data showed: (1) The experimental sites had a significant (P < .05) gain in clinical attachment while the control sites did not (1.44 + 0.33 mm vs. 0.11 + 0.35 mm); (2) the control sites showed greater (P < .05) gingival recession than the experimental sites (0.93 + 0.43 vs. 0.31 + 0.26); (3) when compared to control sites, the experimental group showed significantly (P < .05) greater vertical defect fill (2.24 + 0.79 mm vs. 0.45 + 0.82 mm) and volumetric fill (37.2% vs. 7.5%). In conclusion, the combined composite graft and resorbable barrier utilized in this study may have a favorable effect on the treatment outcome of mandibular class III furcations 12 months postoperatively when compared to surgical debridement only.

Assessment of familial patterns of microbial infection in periodontitis

The purpose of this article is to review approaches to the assessment of familial patterns of microbial infection and disease in periodontitis, and to identify statistical methods appropriate to such considerations of family data. Previous studies have provided evidence for the presence of familial aggregation of periodontal pathogens and periodontitis and have alluded to possible transmissibility of these organisms within families. Modern statistical techniques permit the appropriate analysis of the correlated data inherent in families, properly allowing for these statistical dependencies while including the possibility of adjustment for risk factors which may also aggregate in families. Such approaches as multiple linear regression, multivariate logistic regression, and regressive modeling provide the necessary tools to assess the familial aggregation of risk factors and disease in periodontitis. In particular, regressive models permit the analysis of familiality (membership to family) as a risk factor without reference to a specific underlying biologic mechanism, and also permit the possibility of adjustment for covariates, such as age and access to dental care. They also allow consideration of specific mechanisms, e.g., susceptibility genes of major effect. Using such techniques, it is possible to more completely explore and describe familial patterns of periodontal infection and other aspects of periodontal disease.

Severity of localized juvenile periodontitis as related to polymorphonuclear chemotaxis and specific microbial isolates

The purpose of this study was twofold: (a) to determine if an association exists between severity of localized juvenile periodontitis (LJP) and impairment of polymorphonuclear leukocyte (PMN) chemotaxis and/or colonization by specific microbial isolates; (b) to determine if the number of specific microbial isolates, i.e., Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Fusobacterium nucleatum, Eikenella corrodens, and Campylobacter rectus correlates to clinical severity of sites with LJP. Thirty-six first molars in nine subjects with LJP were examined. A clinical severity score was computed based on attachment level and vertical bone loss. The mean score of the four sites was designated as the clinical severity score for each subject. A DNA probe was used to quantitate colonization by A. actinomycetemcomitans, P. gingivalis, P. intermedia, F. nucleatum, E. corrodens, and C. rectus. The chemotaxis of isolated peripheral blood PMNs was measured in Boyden chambers using the leading front technique. It was found that the clinical severity score ranged from 7.8 for mild involvement to 32.5 for severe LJP. The chemotaxis result for each patient (micron/90 min) was expressed as a percentage of the value for a paired healthy control and ranged from 40% to 104%. Four of the nine subjects had chemotaxis values less than 70% of control. Linear regression analysis showed: (a) no significant correlation between PMN chemotaxis and severity of LJP in subjects (r = .14); (b) a significant correlation (r = 0.43) between severe sites with LJP and number of specific microbial isolates. Sites with severe LJP had present at least five different microbial isolates as compared with non-severe sites (P < .05). No particular trend of colonization by periodontopathogens was seen in non-severe sites. Further, severe sites of LJP displayed a statistically significant greater colonization by P. intermedia, E. corrodens, and C. rectus than did non-severe sites (P < .05). It may be concluded that neither the degree of PMN chemotactic impairment nor A. actinomycetemcomitans is a reliable indicator of the severity of LJP.

Clinical evaluation of systemic doxycycline and ibuprofen administration as an adjunctive treatment for adult periodontitis

The objective of this study was to compare the efficacy of a systemic antibiotic (doxycycline) and a non-steroidal anti-inflammatory drug (ibuprofen), administered either separately or combined, as an adjunctive treatment of scaling/root planing (SRP). Thirty-two subjects diagnosed with generalized moderate adult periodontitis and having at least 2 teeth with > or =5 mm probing depth were randomly divided into 4 groups. Each group was treated with oral doxycycline and/or ibuprofen for 6 weeks as follows: group 1, doxycycline 200 mg the first day followed by 100 mg per day; group 2, ibuprofen 800 mg per day; group 3, doxycycline plus ibuprofen scheduled as in groups 1 and 2; group 4, one placebo capsule/day (control). A split mouth design was utilized in each subject such that half of the teeth received one session of scaling/root planing (SRP), while the other half received no SRP. Plaque index (PI), gingival index (GI), probing depth (PD), and clinical attachment level (CAL) using a customized acrylic stent were recorded at baseline and at 3, 6, 12, and 24 weeks following SRP. Analysis using ANOVA and Student t-test showed statistical significance (P< or =0.05) from baseline data in: 1) gains of 0.4 mm and 0.5 mm of CAL for groups 1 and 3, respectively; 2) reduction of 0.7 mm PD for group 3; 3) reduction of 0.4 and 0.1 GI scores for groups 1 and 3, respectively; and 4) gain of 0.5 mm CAL and reductions of 0.4 mm PD and 0.2 GI score for the SRP group when compared to the no SRP group at 24 weeks. It may be concluded that the adjunctive use of systemic doxycycline alone or in combination with ibuprofen results in a statistically significant, yet modest clinical, improvement beyond that obtained by scaling/root planing.

Regression of nifedipine-induced gingival hyperplasia following switch to a same class calcium channel blocker, isradipine

Patients with nifedipine-induced gingival hyperplasia (GH) often require continued calcium channel blocker therapy. Switches to diltiazem and verapamil have been described; however, these drugs are of a different chemical class and present therapeutic limitations in some patients. The purpose of this study was to evaluate the effect on nifedipine-induced GH of a switch to a dihydropyridine derivative with a low incidence of GH. Fourteen patients with nifedipine-induced GH were given a medical exam and a periodontal exam. The following parameters were assessed: probing depth (PD), gingival margin (GM), gingival thickness (GT), plaque index (PI), and gingival index (GI). Intraoral photographs, study models, and a gingival biopsy for histological examination were taken. Following baseline measures, patients were randomized to continued treatment with nifedipine or an equivalent dose of isradipine in a single-blind fashion. Biweekly periodontal parameters were taken for 8 weeks. At the end of 8 weeks, some patients elected to receive 4 weeks of open label isradipine therapy, with biweekly examination continuing through the open label phase. The isradipine treatment arm showed a mean decrease in PD of 0.59 mm at week 8 (P < 0.05). No other measured parameter (GM, GT, PI, GI) was significantly changed, compared either to baseline or to the alternate treatment arm. Clinically, 60% of patients treated with isradipine exhibited a decrease in hyperplasia, while 66% of patients treated with nifedipine demonstrated an increase in hyperplasia, a significant difference (P < 0.05). When combined with open label data, patients switching therapy to isradipine exhibited an increase in GM (increase in recession) of 0.74 mm from baseline to week 12 (P < 0.05). No patients treated with isradipine exhibited an increase in gingival overgrowth. All patients exhibited adequate control of hypertension. We conclude that in hypertensive patients with nifedipine-induced GH, switching hypertensive therapy to isradipine may result in a regression of GH. When coupled with aggressive oral hygiene treatment, this drug may provide a reasonable option for patients requiring dihydropyridine treatment.

Prognosis and actual treatment outcome of periodontally involved teeth

The purpose of this study was to determine to what extent a given long-term prognosis of a periodontally involved tooth is in agreement with the actual outcome after periodontal therapy. Five hundred and eighty teeth in 24 subjects diagnosed with adult periodontitis and treated 5-13 years ago were evaluated. Subject's age, gender, race, plaque index, gingival index, missing teeth, tooth mobility, probing depth, presence of furcation, alveolar bone level, and frequency of supportive periodontal therapy were recorded. A prognosis was then determined for each tooth and compared to the initial prognosis using the same measures retrieved from the subject's record. Results of the study suggest that (1) it is less common to project accurately the progress of individual teeth when a prognosis is other than good; and (2) it is more difficult to predict correctly the outcome of multirooted teeth than single-rooted ones.

Comparative effectiveness of various regenerative modalities for the treatment of localized juvenile periodontitis

The objective of this study was to assess the effectiveness of surgical debridement versus various guided tissue regeneration techniques for the treatment of localized juvenile periodontitis (LJP). Seven patients, 14 to 18 years old, were selected on the basis of having; 1) vertical bone loss on at least 3 first molars; 2) probing attachment loss > or = 5 mm; 3) presence of Actinobacillus actinomycetecomitans (Aa) as determined by the DNA probe test; 4) no systemic diseases; and 5) not taken antibiotics for 6 months prior to treatment. Each patient was randomly assigned by first molar involvement to one of four treatment modalities: 1) surgical debridement alone (DEBR); 2) ePTFE membrane alone (G); 3) ePTFE membrane plus root conditioning (G + D); or 4) ePTFE membrane plus root conditioning plus composite graft (G + D + B). Standardized clinical attachment level measurements (CAL) were taken at baseline, 6, 12, and 18 months. Hard tissue measurements were evaluated radiographically (RAD) at baseline, 6, 12, and 18 months, and volumetrically at baseline and 12 months post-surgery. At 12 months re-entry, all residual defects were re-treated with a composite graft consisting of calcium sulfate + DFDBA + doxycycline. Results were evaluated 6 months post-retreatment using CAL and RAD measurements. Statistical analysis of the data showed: 1) a significant gain in clinical attachment as well as increased volumetric bone fill of the defects 12 and 18 months following the various treatment modalities when compared to baseline (P < 0.05); and 2) no statistically significant differences among the tested treatment modalities and surgical debridement alone for all parameters (P > 0.05).

Perspectives on soft-tissue management for the prevention and treatment of periodontal diseases

Because of economic issues, public awareness, and patients' desires, current dental practice embodies an array of preventive and therapeutic endeavors for the treatment of periodontal diseases. Evaluation of clinical research and practice experiences documented several findings regarding soft-tissue management. Soft-tissue management can be successful, even in advanced cases of disease, when performed by technically proficient clinicians. Perfect plaque control is not required for the long-term preservation of attachment levels if there is compliance with a strictly supervised maintenance regimen. Although soft-tissue management can be considered a practical, even preferred treatment, it is not uniformly successful for every periodontally diseased site.

Symptomatology and clinical features of hypersensitive teeth

Tooth hypersensitivity is associated with exposure of the dentine to the external environment of the mouth. This exposure can result from loss of enamel by processes including abrasion and erosion, or by denudation of the root surface as a result of gingival recession or periodontal treatments. Dentine hypersensitivity can be described as an adverse reaction or pain in one or more teeth resulting from either a thermal, chemical, bacterial or mechanical stimulus. Painful symptoms arising from exposed dentine are a common finding in adults and reportedly affect as many as one in every seven patients attending for dental treatment. Although predisposition to dentinal hypersensitivity is multifactorial, enamel loss as well as gingival recession may be more severe with advancing age. Because of the greater longevity of people who are also keeping their teeth longer, hypersensitivity is a growing concern. Clinical studies show that individuals with less than adequate plaque control experience more root hypersensitivity to air stimuli than others with better oral hygiene. Although plaque does not alter the pulpal threshold, i.e. has no effect on the pulp, it seems that microbial plaque has an effect on root sensitivity.

Short-term sequential administration of amoxicillin/clavulanate potassium and doxycycline in the treatment of recurrent/progressive periodontitis

The systemic use of a single antibiotic was compared to that of a sequential antibiotic regimen in the treatment of A. actinomycetemcomitans and/or P. gingivalis-associated periodontitis. Eleven patients with recurrent/progressive periodontitis and demonstrating subgingival infection with A.a. and/or P.g. were selected. Six patients received oral administration of doxycycline (Do), 200 mg the first day and 100 mg for 4 days thereafter, and then amoxicillin/clavulanate potassium (Au), 500 mg 3 times daily for 5 days. The other 5 patients received only doxycycline for 10 days. Eight sites with > or = 5 mm probe depth per patient were selected, of which 4 received root planing at time 0. Clinical measurements (GI and PI, probing pocket depth, probing attachment level, and bleeding upon probing/suppuration) and microbial infection levels (2 sites/patient as per DNA probe) for A.a. and P.g. were recorded at 0, 4, 12, and 25 weeks. Clinical data were subjected to statistical analysis of variance and t-tests for significance. The Do + Au groups produced significant reduction in probing pocket depth (PPD) at 4, 12, and 25 weeks (1.1, 1.3, and 1.1 mm, respectively). The Do group produced significant reduction in PPD only at 4 and 12 weeks (0.8 and 0.8 mm); the Do + Au group produced significant gain of 0.8 mm in probing attachment level at 4 and 12 weeks; and the Do + Au group in conjunction with root planing produced the most sustained reduction in PPD and gain in PAL. These findings suggest that the sequential use of multiple antibiotic agents may offer greater promise as an adjunctive treatment approach for the management of recurrent and/or progressive periodontitis than a single antibiotic regimen.

The effects of the Le Fort I osteotomy on the periodontium

Two age-matched populations of equal size (n = 40), one having orthodontic therapy and the other combined orthodontic therapy and orthognathic surgery, were evaluated for their periodontal status 1 to 10 years posttherapy. The parameters investigated were plaque index, gingival index, tooth mobility, width of keratinized tissue, probing depth, gingival recession, and attachment level. No significant differences were found (P less than .05). Within the surgery group, patients with maxillary osteotomies segmentalized between the central incisors (n = 11) and between the canines and second premolars (n = 12) were evaluated using the same parameters and compared with their nonsegmental counterparts. No significant differences were found for patients with osteotomies segmentalized between the central incisors. However, a statistically significant increase in probe depth and loss of attachment level of up to 0.3 mm was found at the sites of osteotomies segmentalized between the canine and second premolar (P less than .05). This difference was not considered clinically significant.

Doxycycline-tricalcium phosphate composite graft facilitates osseous healing in advanced periodontal furcation defects

The purpose of this study was to compare the effectiveness of a tricalcium phosphate, plaster of paris, and doxycycline composite graft to surgical debridement alone in the treatment of Class II and Class III furcation defects. Fifteen patients with adult periodontitis and at least two mandibular molars with Class II or III furcation defects were selected. A total of 40 sites were treated: 26 were Class II defects and 14 were Class III. Following initial therapy one site was randomly selected to receive the composite graft while the remaining site served as the surgically debrided control. Osseous healing was evaluated by direct measurements from an acrylic stent at the time of graft surgery and at the 6-month reentry. Following surgery each patient was placed on doxycycline 100mg/day for 10 days. The absence of clinical inflammation and infection during the healing process provided additional substantiation of the biocompatibility of the grafting materials. Results after 6 months indicated that sites treated with the composite graft had improved defect fill, defect resolution, probing depths, and clinical attachment levels when compared to the surgically debrided controls. Defect fill was 3.7 times greater in grafted sites and these sites were 4.0 times more likely to have 50% or greater defect fill. The effect of grafting was more pronounced in Class III defects where horizontal defect fill and gain of clinical attachment was achieved only in grafted sites. The plaster of paris functioned well as a binder, preventing particle scatter and facilitating graft retention. Additionally the plaster served as a vehicle to carry and retain the doxycycline at the treated site. These short-term results point to the potential of a composite graft containing tricalcium phosphate, plaster of paris, and doxycycline in promoting healing of furcation lesions.

Periodontics in general practice: professional plaque control

Traditionally the primary emphasis of preventive periodontics was daily patient performed plaque control. Recent studies indicate that frequent professional subgingival toothcleaning is a mandatory treatment for prevention of recurrent periodontitis. Pathogenic subgingival bacterial complexes are disrupted by frequent cleaning and require time to reestablish. Disease progression is prevented if the recall interval does not exceed the time required for reestablishment of a pathogenic plaque. Legally, patients have acquired the duty to comply with the prescribed recall interval. Both the patient and the practitioner will benefit from a preventive program that includes frequent professional subgingival toothcleaning.

Pulpal and root sensitivity rated to periodontal therapy

The purpose of this clinical investigation was to determine if periodontal treatment consisting of scaling, root planing, and periodontal surgery produced any change in pulpal or root sensitivity. Ten patients were tested, with a total of 84 observations. There were 42 periodontally treated teeth, with 42 contralateral teeth serving as control specimens. The teeth were evaluated with stimuli from an electric pulp tester, cold, and air. The electric pulp tester was found to be reliable in assessing the pulpal sensitivity. Neither the amount of periodontal destruction nor the extent of periodontal treatment had any effect on the pulp. Scaling and root planing had no significant effect on root sensitivity. Periodontal surgery was directly related to root sensitivity in terms of the extent of root surface exposure. An association was observed clinically between plaque accumulation after periodontal surgery and root sensitivity.

Crevicular fluid iron changes in treated and untreated periodontally diseased sites

Previous investigations have shown that crevicular fluid iron concentration (CFIC) is higher in periodontally diseased sites. The present study was conducted to determine whether periodontal treatment changes the CFIC to levels found in healthy sites in the same persons. To test the significance of iron content in gingival fluid as an indicator of periodontal disease severity or activity, CFIC was determined for healthy sites and diseased sites treated with scaling and root planing alone or in conjunction with surgery both before and after treatment. CFIC was increased in diseased sites, but the iron concentration in crevicular fluid was not a good indicator of changes in disease severity resulting from periodontal treatment. Treatments produced an increase in the CFIC that may be more related to the status of the microcirculation than to the disease process itself.

The effect of local doxycycline with and without tricalcium phosphate on the regenerative healing potential of periodontal osseous defects in dogs

The purpose of this study was to evaluate the clinical and histological effects of high concentration doxycycline on osseous regeneration in adult beagle dogs. Four 5 mm two-wall periodontal osseous defects were created in the premolar and molar area of each quadrant yielding a total of 48 defects in the three dogs. Ligature-induced periodontitis was maintained for 6 weeks. Two weeks following ligature removal, one of the following graft procedures was randomly assigned to each defect: 1) doxycycline alone (DOX); 2) tricalcium phosphate alone (TCP); 3) a combined graft of DOX plus TCP, or 4), surgically debrided control. All areas received thorough scaling and root planing at the time of surgery. Clinical parameters evaluated at 4, 12, and 20 weeks after the surgical treatment included the gingival index and probing depths. Crevicular fluid was examined at 3, 10, and 28 days postoperatively for tetracycline fluorescence. Direct clinical measurements from the CEJ to a notch placed at the base of the defect and from the CEJ to the alveolar crest were made at the time of surgical treatment and reentry. The reentry procedures were performed at 4, 12, and 20 weeks postoperatively. Immediately following reentry block sections were obtained from each quadrant and prepared for examination with the light microscope. The gingival index and probing depth measurements showed greater improvement in the DOX and DOX + TCP groups. Increased regeneration (new bone, cementum, and periodontal ligament) and reduced alveolar crest resorption were observed more frequently in DOX and DOX + TCP defects, while healing by long junctional epithelium was more common in defects not treated with doxycycline.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Factors influencing periodontal therapy for the geriatric patient

Anatomic changes in the periodontium occur with aging. There is no indication that these changes predispose to periodontal breakdown. In the United States, there is evidence that older individuals are retaining more teeth and that these teeth have less periodontal disease than previous generations of seniors. Studies comparing the healing of older and younger patients have clearly demonstrated that both groups of patients respond equally well to therapy. Proven methods of periodontal therapy include modified Widman surgery, pocket elimination surgery, or nonsurgical scaling and root planing. Surgical treatment may be used with confidence unless there are medical contraindications. In these cases, nonsurgical therapy may be preferred. If there are physical or mental disabilities that make effective home care difficult, antimicrobial agents, such as the extensively tested chlorhexidine rinse, may be valuable adjuncts. In the future, senior adults can look forward to the benefits of regenerative periodontal procedures that seek to regain lost periodontal support. Age alone should not diminish an individual's right to care because the practitioner has qualms about his or her longevity. Successful treatment of periodontitis by surgical and nonsurgical methods has been extensively documented. Senior patients can benefit from these treatments as much as younger patients, and age is not a barrier to effective periodontal therapy.

Significance of the width of keratinized gingiva on the periodontal status of teeth with submarginal restorations

The purpose of this clinical study was to evaluate the periodontal condition of teeth having submarginal restorations associated with either narrow or wide zones of keratinized gingiva. Fifty-eight teeth in 26 individuals were selected and then divided into two groups according to the width of the keratinized gingiva at the midfacial aspect of the tested tooth. Group I consisted of 30 teeth with greater than or equal to 2.0 mm, and Group II consisted of 28 teeth with less than 2.0 mm of keratinized gingiva. Each group was equally subdivided into subgroup "A" having teeth with a full coverage, subgingival type of restoration for at least 2 years, and subgroup "B" representing contralateral homologous teeth, in the same individual, with no subgingival restoration. Clinical examination of individual teeth included determination of plaque and gingival indices, gingival fluid, probing depth, bleeding tendency and bone level. Data were subjected to statistical analysis using the Student t test and a two-way analysis of variance to determine any significant differences in variables between teeth with and without subgingival restorations, in narrow and wide zones of keratinized gingiva. The findings were: (1) teeth with subgingival restorations and narrow zones of keratinized gingiva showed statistically significant higher gingival scores than teeth having submarginal restorations with wide zones of keratinized gingiva. (2) Teeth without subgingival restorations showed no statistical difference between narrow and wide zones of keratinized gingiva (P greater than 0.05).

Periodontics in general practice: perspectives on nonsurgical therapy

Clinical studies have shown that nonsurgical treatment is a highly effective method of periodontal therapy. It can be instituted in both shallow and deep pockets; however, an objective evaluation of post-scaling soft tissue changes should be recorded to determine the response to therapy. Closed scaling and root planing has limitations as a definitive procedure for the removal of calculus from deep pockets and surgical treatment may be indicated for nonresponding sites. The condition of the tissue, not the probing depth, should dictate the course of action. During maintenance therapy all practitioners should recognize unsuccessfully treated or recurrent periodontitis and provide interceptive treatment to avoid a case of "supervised neglect." Periodontal treatments should be provided by the general practitioner. This can result in improved oral health for the patients and constitute a professionally rewarding part of dental practice.

Clinical evaluation of porous and nonporous hydroxyapatite in the treatment of human periodontal bony defects

The purpose of this study was to investigate the effectiveness of a synthetic nonporous hydroxyapatite graft material (OrthoMatrix HA-500), a porous replamineform hydroxyapatite graft material (Interpore 200), and a debrided control with respect to defect fill. Twelve adult patients having periodontitis and three similar angular osseous defects as verified by radiographic analysis and clinical probe depths greater than or equal to 5 mm were selected. Clinical parameters gathered prior to surgical intervention and at identified postoperative visits included plaque index, probing depth, and standardized radiographic examination. Customized acrylic stents were used as fixed reference guides for the insertion of endodontic silver points to the base of each defect during both initial and 6-month reentry surgeries. A total of 36 defects were randomly assigned to one of three treatment modalities such that 12 defects received OrthoMatrix HA-500, 12 received Interpore 200, and 12 served as debrided controls. Comparison of nonporous hydroxyapatite, porous replamineform hydroxyapatite, and debrided control treatment modalities revealed a statistically significant improvement (P less than 0.05) in the mean per cent of defect resolved in only those sites treated with nonporous hydroxyapatite. Similar positive trends were seen in the sites treated with nonporous hydroxyapatite for mean reentry defect depth and mean defect fill although these were not statistically significant (P greater than 0.05). No other significant differences were noted.

Variations in subgingival microflora from healthy and intervention sites using probing depth and bacteriologic identification criteria

This investigation studied the changes in probing depths and subgingival microbial flora of clinically healthy and diseased sites before and after scaling and root planing. Thirty-six sites in 18 individuals were studied in two groups of patients, Group I (9 patients) had received no periodontal surgery, while group II had received surgery within the previous 4 years. Neither group had had professional prophylaxis or scaling and root planing within the previous 6 months. Group I had an average probing depth of greater than or equal to 5 mm and group II had an average of less than or equal to 4 mm. Scaling and root planing was performed on both groups at the beginning of the experiment and all patients were instructed in oral hygiene. Plaque and gingival indices, gingival fluid measurements, probing depths and dark field microscopic examination of subgingival plaque were evaluated immediately before scaling and root planing (baseline) and then once every 2 weeks for 2 months. For descriptive analysis of the data, all sites in both groups were classified according to probing depth or bacteriologic criteria. Sites with either greater than or equal to 85% nonmotile bacteria or less than or equal to 4 mm probing depth were presumed "healthy" and others were considered "diseased".(ABSTRACT TRUNCATED AT 250 WORDS)

Periodontal disease in juvenile and adult diabetic patients: a review of the literature

Epidemiologic studies have suggested that the severity of periodontitis is greater in juvenile and adult onset diabetes. In juvenile diabetic patients, the periodontal disease seems to be initiated around puberty and progresses by age. Reviewing the medical literature indicates a similar age of onset for known systemic complications resulting from diabetes. Angiopathy, abnormal collagen metabolism, abnormal PMN function, and altered sulcular microbial flora have been found to be closely associated with the severity of periodontitis in diabetic patients. The association between abnormal neutrophil function and severity of periodontal disease in diabetic patients provides an opportunity for examining the role of neutrophil in periodontal disease. Future investigation in the function of sulcular PMN may shed light on the complex mechanism of periodontal disease.

Endotoxin penetration into root cementum of periodontally healthy and diseased human teeth

This study was undertaken to determine the extent of in vitro penetration of E. coli endotoxin into the root cementum of periodontally healthy and diseased teeth. Freshly extracted teeth were washed in distilled water, scaled and divided into two groups of 16 teeth each. Nine diseased and five healthy teeth in the first group were immersed in various concentrations of E. coli endotoxin for 2 to 12 weeks. They were then prepared for indirect immunofluorescence examination after treatment with anti-endotoxin antibody and rhodamine conjugated secondary antibody. Teeth in the second group were prepared for autoradiographic examination by immersing nine diseased and five healthy teeth in tritium labelled E. coli endotoxin for 2 to 12 weeks. The latter technique also allowed for semi-quantitative study of the depth of endotoxin penetration by creating facets on the root at various depths after endotoxin exposure. This technique was also used to investigate the strength of endotoxin binding to the tooth surface by brushing for 1 minute and re-examining the tooth for the presence of endotoxin. Controls included periodontally diseased and healthy teeth. Results of the study showed that (1) endotoxin adheres to the tooth surface without penetration into the root cementum of either periodontally healthy or diseased teeth, and (2) the binding of the endotoxin to the root surface appears to be weak.

Long term effect of systemic tetracycline administration on the severity of induced periodontitis in the rat

The present investigation was undertaken to determine the influence of systemically administered tetracycline on periodontitis in the rat. Thirty Sprague-Dawley rats were arranged into two groups, one group received 21 mg of tetracycline hydrochloride each day for 10 weeks in the drinking water. Periodontitis was induced in the maxillary left segment with a 0.008 inch stainless steel ligature wire and by modifying the normal diet with sucrose. The direct microscopic and histometric measurements obtained were analyzed for statistical significance, which revealed the following: 1. Tetracycline-treated animals demonstrated significantly less resorption of the buccal alveolar bone. There were no statistical differences however, in the amount of alveolar bone resorption palatally or interdentally. 2. Tetracycline-treated animals demonstrated significantly less apical migration of the junctional epithelium on the distal root of the maxillary first molar tooth. 3. Tetracycline-treated animals demonstrated significantly fewer inflammatory cells. In conclusion, long term systemic administration of tetracycline in the rat may be of value in reducing the amount of tissue destruction in experimentally induced periodontitis.

Iron deficiency: an overlooked predisposing factor in angular cheilitis

Clinicians who recommend the use of antifungal agents for angular cheilitis may be treating the symptoms and not the predisposing cause of the disease. Iron deficiency should be considered as part of the differential diagnosis whenever angular cheilitis is encountered, especially in women of child-bearing age.

Quantitative assessment of free gingival grafts with and without periosteum and osseous perforation

Forty free gingival grafts were performed on 5 adult Rhesus monkeys as follows: 10 grafts were placed on recipient sites with periosteum; 10 grafts on periosteum and perforated cortical plate; 10 grafts on bared bone; and 10 grafts on perforated bared bone. All free autografts (7 X 5 X 1 mm) were taken from the palatal mucosa and were sutured in place. Clinical evaluation and photographs were taken at 1, 2, 4, 8, 12, 16, 20 and 24 weeks postoperatively. At 24 weeks, a device was used to measure quantitatively the amount of force necessary to pull the graft 2 mm away from the underlying bone. Biopsy of two grafts of each type were taken for histologic examination. The following conclusions were drawn: 1. There was no difference in the survival or healing pattern of grafts placed on periosteum and grafts placed on bared bone.

Vitamin E and periodontitis in the rat

This investigation was designed to study the effect of vitamin E on the course of periodontitis in thirty-six adult male albino rats. The rats were divided into three groups of twelve and placed on test diets which consisted of pelleted feed that either was deficient in, or contained adequate and high amounts of, vitamin E. After the animals had been on their respective diets for 8 weeks, a local irritant in the form of a stainless steel wire was placed around the maxillary left second molar of each animal. The wire served both as a mechanical irritant and as a collector of plaque and debris. Six weeks after the wire was placed, the animals were killed and the periodontium was examined histologically. Migration of the epithelial attachment, alveolar bone level, and numbers of inflammatory round cells were then evaluated on both sides of the maxilla. Multivariate analysis of variance was used to determine significant difference in the parameters. The results of this experiment indicate that a deficiency of vitamin E does not cause increased destruction of the periodontium in the presence of periodontitis. Moreover, no beneficial effects from the therapeutic use of vitamin E to combat periodontitis were found.

Histomorphologic evaluation of scleral grafts in experimental bony defects

This study was undertaken in order to evaluate and compare the effectiveness and fate of the nonautogenous scleral graft in relation to similar grafts of bone marrow and epithelium-free connective tissue grafts from the palate. One hundred round osseous defects 2 mm in diameter, were surgically created in the calveria of 25 rats. Three defects in each animal were filled with the various graft materials obtained from isogenic rats sacrificed at the time of preparation of the bony defects. The fourth defect was left empty as a control. The animals were sacrificed at varying periods of time up to 150 days. Histomorphologic evaluation of the graft sites demonstrated the following: (a) Scleral grafts had effected a functionally adequate repair, without apparent histopathologic changes. (b) Fresh bone marrow provided the greatest osteogenic activity when used as a graft implant. The sclera had an insignificant osteogenic activity when used as a graft implant. The sclera had an insignificant osteogenic potential. (c) Epithelium-free connective tissue was the least effective, both as an osteogenic or functionally adequate graft.

Influence of obesity and hypertension on the severity of periodontitis in rats

The purpose of this investigation was to evaluate the extent to which obesity and/or hypertension may modify the response of rats' periodontium to chronic gingival irritation. Forty-four normal, spontaneously hypertensive, obese, and obese-hypertensive rats were used. Histopathologic evaluation of the periodontal structure showed both hyperplasia and hypertrophy of the walls of blood vessels supplying the periodontium in the hypertensive and obese-hypertensive animals. The results also indicated that obesity significantly contributed to e severity of periodontal disease. Hypertension alone was not a significant factor. The obese-hypertensive rats showed the most severe periodontal response to local irritation.