Tooth loss and pocket probing depths in compliant periodontally treated patients: a retrospective analysis

BACKGROUND/AIMS

This retrospective study determined the treatment outcomes of 142 compliant periodontal patients observed for at least 10 years at the University of Kiel. All patients had been treated for moderate to advanced periodontitis and regularly received supportive periodontal therapy (SPT).

METHODS

Patient- and tooth-related variables [tooth loss and pocket probing depth (PPD)] were analysed.

RESULTS

Of a total of 3353 teeth, 167 were extracted during active treatment and 99 during SPT, mainly for periodontal reasons. Forty-five per cent of the patients did not lose any teeth during 11.7 years of observation. Thirty-seven per cent underwent extractions during active treatment or SPT, 18% both during active periodontal therapy and SPT. Mean tooth loss per patient was 0.07 teeth/year during SPT. Mobility, furcation involvement, smoking, and prescription antibiotics had a negative impact on prognosis. Intraindividual differences in PPD were significant between single- and multirooted teeth with initial PPD > or = 4 mm at baseline, following active treatment and at the end of SPT, and between firm and mobile teeth at baseline. Interindividual differences in mean PPD were only significant between smokers and non-smokers at the end of the observation period.

CONCLUSIONS

Long-term maintenance of our patients was effective. Periodontal disease represented the major cause of tooth loss in a minority of the population.

Anchorage and retentive effects of a bisphosphonate (AHBuBP) on tooth movements in rats

The purpose of this study was to examine the effect of 4-amino-1-hydroxybutylidene-1,1-bisphosphonate (AHBuBP), a potent blocker of bone resorption, on orthodontic tooth movements in rats. In the first experiment, the right and left upper first molars were moved buccally for 3 weeks with a uniform standardized expansion spring under systemic administration of AHBuBP every other day. The total tooth movement during the 3-week experimental period was 40% of that in the control at a dose of 0.5 mg P/kg. In the second experiment, the right and left upper first molars were first moved buccally for 3 weeks without AHBuBP. The spring was then removed and administration of AHBuBP was initiated. The total relapse movement during the 3-week experimental period was 50% of that in the control at a dose of 0.5 mg P/kg. Results of the first and second experiments were both dose dependent. Histologic examination showed that in the experimental animals fewer osteoclasts appeared on the alveolar bone surface, and both bone resorption and root resorption were inhibited. Inhibition of tooth movement was also observed when AHBuBP was applied topically. These results suggest that AHBuBP could be useful in enhancing anchorage or retaining teeth in orthodontic treatment.

Impact of Endodontic Treatments on the Rigidity of the Root

The destabilizing effect of endodontic treatment upon teeth is still controversial. The purpose of this study was to investigate the effects of different steps of endodontic treatments upon the rigidity of teeth. Extracted untreated central maxillary anterior teeth were loaded (3.75 N), and deformations of the root were assessed by Speckle pattern interferometry. The following treatments (with subsequent determination of deformability) were conducted sequentially: access preparation, manual instrumentation (Kerr files ISO-40, ISO-60, ISO-80, ISO-110), and tapered and parallel-sided post preparation. It was found that the teeth were increasingly destabilized by any treatment. While the increased deformability was not significant with the manual enlargement (p > 0.05), we found a significant destabilization after access preparation and post preparation (p < 0.05). A corresponding difference was found after conversion of the post preparation from tapered to parallel-sided (p < 0.05). Both substance loss and modifications of the natural root canal geometry play an important role in tooth rigidity.

Effects of topical administration of a bisphosphonate (risedronate) on orthodontic tooth movements in rats

In orthodontics, undesirable movement of anchor teeth during tooth movement and relapse of moved teeth after treatment are the main causes of unsuccessful results. If these tooth movements could be prevented with pharmacological agents, a less complex orthodontic force system and less extensive retention would be required. The purpose of this study was to examine the effect of topical administration of a bisphosphonate (risedronate), a potent blocker of bone resorption, on orthodontic tooth movements in rats. In the first experiment, both the right and left upper first molars were moved buccally with a standardized expansion spring under administration of risedronate. Risedronate solution was injected into the subperiosteum area adjacent to the left upper first molar. The right first molar served as a control with an injection of 0.9% NaCl solution. The topical administration of risedronate caused a significant and dose-dependent reduction of tooth movement after the orthodontic force was applied. In the second experiment, the right and left upper molars were first moved buccally for three weeks. The spring was then removed, and administration of risedronate was begun. The topical administration of risedronate inhibited relapse of the tooth in a dose-dependent manner. The administration of risedronate did not affect either overall growth of the animals or longitudinal growth of tibiae. These results suggest that topical application of risedronate may be helpful in anchoring and retaining teeth under orthodontic treatment.

Effect of alendronate on periodontal disease in postmenopausal women: a randomized placebo-controlled trial

BACKGROUND

We investigated the effect of oral alendronate (ALN) treatment on radiological and clinical measurements of periodontal disease in postmenopausal women without hormone replacement therapy.

METHODS

We evaluated the effect of 6 months of ALN treatment in 40 postmenopausal women, 55 to 65 years old with established periodontal disease, in a controlled, double-masked, prospective study. Volunteers were paired by age and randomized to receive ALN (10 mg/day) or placebo for the study period. Periodontal mechanical treatment was carried out in both groups. At baseline and after treatment, clinical evaluation, hormone blood levels, distance from the crestal alveolar bone (CAB) to the cemento-enamel junction (CEJ), calcaneus bone mineral density (BMD), hormone levels, serum N-telopeptide (NTx), and bone-specific alkaline phosphatase (BSAP) were assessed.

RESULTS

Periodontal disease conditions improved in both groups, but greater improvement in probing depth (-0.8 +/- 0.3 mm versus -0.4 +/- 0.4 mm, P = 0.02) and gingival bleeding (-0.3% +/- 0.13% versus -0.2% +/- 0.06%, P = 0.006) was found in the ALN treated group. Calcaneus BMD increased in the ALN treated group (68 +/- 47 mm3 versus -26 +/- 81 mm3, P = 0.0006). CAB-CEJ distance diminished in the ALN group (-0.4 +/- 0.40 mm versus 0.60 +/- 0.53 mm, P = 0.00008). Marginal reduction in both NTx and BSAP levels was found in the ALN group (-9.4 +/- 6.6 nmol versus -4.3 +/- 4.7 nmol bone collagen equivalents, P = 0.08, and -7.7 +/- 8.4 versus -1.5 +/- 5.0 U/l, P = 0.1, respectively). Hormone levels were unchanged after treatment. Similar improvement of calcaneus BMD and CAB-CEJ distance with ALN treatment was found in obese and non-obese women.

CONCLUSION

ALN treatment improved periodontal disease and bone turnover in postmenopausal women.

Human neutrophil collagenase MMP-8 in peri-implant sulcus fluid and its inhibition by clodronate

The exact molecular mechanisms of the loosening of a dental implant are not well-known. The characteristics of implant sulci are similar to those of periodontal sulci regarding gingival crevicular fluid (GCF) and peri-implant sulcular fluid (PISF). Proteolytic enzymes, matrix metalloproteinases (MMPs), participate in peri-implant tissue remodeling. Clodronate is a well-tolerated bisphosphonate-group drug currently used in bone-resorption-related diseases in humans. The mechanisms of bisphosphonate action are not clarified. Collagenase activity in diseased PISF was significantly higher than in the clinically healthy group. Immunoblotting disclosed that diseased PISF contained increased immunoreactives MMP-8 compared with the healthy PISF. The residual latent collagenase activity in the diseased PISF was activated by gold thioglucose and inhibited completely by 100 microM of doxycycline closely resembling pure neutrophil collagenase (MMP-8). The presence of MMP-8 in diseased but not in clinically healthy PISF may prove to be a useful biochemical indicator to monitor peri-implant health and disease. Pure human neutrophil collagenase (MMP-8) and the MMP-8 present in PISF and in the GCF of both loosening implants and periodontitis-affected teeth were efficiently inhibited in vitro by clodronate (50% inhibition [IC50] was achieved by 150 microM of clodronate), an osteoactive, antiresorptive bisphosphonate. Furthermore, the new finding suggests an extended and hitherto-undescribed potential for clodronate in preventing the loosening of both implants and teeth, based on a dual beneficial effect: prevention of both bone resorption/osteolysis and of soft tissue/dental ligament destruction. Potential new therapeutic indications based on the collagenase-inhibiting effect of clodronate provide potential new therapeutic indications for a variety of diseased involving connective tissue breakdown, such as periodontal disease, arthritides, and tumor invasion.

Rigidity of various fixation methods used as dental splints

Horizontal and vertical rigidity of teeth fixed with seven types of dental splints were evaluated by two tooth mobility measuring devices. Altogether 21 dissected sheep mandibles including soft tissues were used for the experiments in which Fermit, flexible wire-composite, Kevlar, Fiber, Protemp, rigid wire-composite and Triad Gel splints were applied to four incisors. The mean rigidity of the central incisors within the splint was measured by means of Mühlemann periodontometer (horizontal mobility) and Periotest (horizontal and vertical mobilities). Mobility values of teeth before splinting were used as covariants and the values with the splints were illustrated as adjusted mobility. Statistical significance between the rigidity of various splints was analyzed by an unpaired t-test. It was shown that the most rigid splints both in horizontal and vertical directions were Triad Gel, rigid wire-composite and Fermit splints. Kevlar and Fiber splint allowed more horizontal movement than other splints. Protemp and flexible wire-composite splints proved to produce adequate lateral support for the fixed teeth and allowed vertical flexibility which is experimentally known to improve periodontal healing of luxated teeth.

Comparison of the flexibility of various splinting methods for tooth fixation

An experimental model was constructed to test the flexibility of the arch bar splint and the Schuchardt splint as compared with a newly introduced wire-composite splint. Vertical movement in 4 flexible incisors was tested by producing compressive forces between 15-95 Newtons on the incisal edges. The thinnest wire-composite splint was also tested for lateral flexibility by producing palatal forces from 2 angles. Movement without the splint served as the control. The tests showed that a 0.3 mm thick wire-composite splint had the flexibility closest to the control, followed by the arch bar splint, and 0.4 mm and 0.5 mm wire-composite splints, while the Schuchardt splint virtually prevented vertical movement. Lateral movement was markedly reduced by the 0.3 mm wire-composite splint as compared with the control with both a 10 degree and a 45 degree force. The experiments showed that a 0.3 mm wire-composite splint can be regarded as acting as a functional fixation allowing slight vertical movement of the teeth during immobilisation; it should be recommended for tooth fixation whenever possible.

Tooth-supported telescopic prostheses in compromised dentitions: a clinical report

This article describes indications for treatment with telescopic restorations on patients with periodontally and endodontically compromised dentitions that require splinting, with special emphasis on treatment that restores the entire dental arch. Stabilization of compromised teeth with fixed splinted restorations is usually inadvisable because of the risk factors involved, such as eventual localized abutment failure. Detachable telescopic prostheses may be preferred as a near equivalent or substitute because they can be detached and repaired without reconstruction of the entire restoration. Retentive and splinting properties of detachable telescopic restorations can be as effective as FPDs. Inner telescopic copings can be cemented as individual crowns to facilitate the procedure. Telescopic restorations can be retrieved by the patient for cleaning and easy access to the entire marginal periodontal circumference of the abutments. This promotes effective home care and oral hygiene. In addition, principles of design and indications, as well as technical and clinical factors, were discussed.

Rationale for stabilization

1. The subjective separation of the normal and the diseased periodontium for splinting purposes is artificial. With the exception of cases of secondary trauma from occlusion, the diseased periodontium should be treated in the same manner as the normal periodontium with regards to splinting. 2. Retionales for stabilization found to be valid are: I. Prevention of mobility A. Post acute trauma. B. In occlusal therapy. II. Prevention of drifting A. Replacement of missing teeth. B. Postorthodontics. III. In treatment of secondary trauma for occlusion. A. For functional stability. B. With unknown effects on the progression of periodontitis. 3. The relationship of trauma from occlusion and periodontitis is unclear at this time. 4. A need exists for a clinical test correlating histologic signs of trauma from occlusion and clinical findings. 5. Temporary splinting generally is not indicated during the initial or surgical phase of treatment of the periodontal patient, because mobility short of secondary trauma from occlusion does not impair healing.

Utilization of dental services as a risk factor for periodontitis

The relation between utilization of dental services from community dentists and the extent and severity of alveolar bone loss is reported for a panel of men followed for over 6 years. Oral health data were collected by the Department of Veterans Affairs, Dental Longitudinal Study, which began in 1969 and still continues. Participants have received regular oral examinations approximately every 3 years. A variety of oral health conditions were assessed, including plaque, calculus, gingival inflammation, probing depth, tooth mobility, clinical attachment level, and alveolar bone loss. Utilization data were abstracted from the dental records of dental offices that participants attended from 1979 through 1988. Multivariate modeling as well as comparisons of high utilizers and non-utilizers indicate that utilization of routine diagnostic and preventive services was not predictive of the extent and severity of periodontitis.

Emergencies in orthodontics. Part 1: Management of general orthodontic problems as well as common problems with fixed appliances

Fixed appliance treatment is a popular treatment modality with a burgeoning increase in the numbers of children and adults realizing the benefits that can be gained. Appliance breakage is an unavoidable nuisance which is at best inconvenient, and at worst may result in significant pain or discomfort for the patient. General dental practitioners (GDPs) should have the practical knowledge of how to provide timely and appropriate orthodontic 'emergency treatment'. This will significantly reduce the sometimes considerable inconvenience and discomfort for both the patient and his/her parents, and the inevitable frustration for the clinician providing ongoing care. This first paper will deal with general orthodontic problems that commonly present, as well as some issues specific to fixed appliances. The second paper will deal with the other orthodontic appliances that may be encountered by GDPs in their daily practice. Clinical Relevance: Appropriate handling of an orthodontic 'emergency' by the general practitioner will, on many occasions, provide immediate relief of pain and distress for the patient. This will in turn allow treatment to continue moving in the right direction, thus allowing more efficient and effective use of valuable resources.

Low force cementation

OBJECTIVES

The marginal adaptation of full coverage restorations is adversely affected by the introduction of luting agents of various minimum film thicknesses during the cementation process. The increase in the marginal opening may have long-term detrimental effects on the health of both pulpal and periodontal tissues. The purpose of this study was to determine the effects of varying seating forces (2.5, 12.5, 25 N), venting, and cement types on post-cementation marginal elevation in cast crowns.

MATERIALS

A standardized cement space of 40 microns was provided between a machined gold crown and a stainless steel die. An occlusal vent was placed that could be opened or closed. The post-cementation crown elevation was measured, following the use of two commercially available capsulated dental cements (Phosphacap, and Ketac-cem Applicap).

RESULTS

The results indicate that only the combination of Ketac-Cem Applicap and crown venting produced post-cementation crown elevation of less than 20 microns when 12.5 N seating force was used. Higher forces (25 N) and venting were required for comparable seating when using Phosphacap (19 microns).

CONCLUSIONS

The amount of force required to allow maximum seating of cast crowns appears to be cement specific, and is reduced by effective venting procedures.

Assessment of tooth mobility using small loads. II. Effect of oral hygiene procedures

Tooth mobility at loads between 20 p and 80 p was studied in maxillary incisors and canines in eight subjects with moderate periodontal disease. The periodontal conditions of the investigated teeth exhibited clinical criteria of gingival inflammation and a moderate loss of attachment. None of the subjects showed subjective or clinical signs of occlusal disturbances. In all, 35 teeth were investigated over the 12-week period following periodontal hygiene treatment, including oral hygiene instructions and removal of supra- and subgingival plaque and calculus. During the course of the investigation, a gradual decrease of tooth mobility was observed amounting to a tooth mobility decrease of 65% (using the corrective formula described by Mühlemann 1960) at 50 p load. Tooth mobility curves within the 20--80 p loading area were transformed to lines of regression (Persson & Svensson 1980). Analyses of the lines showed significantly lower tooth mobility values 12 weeks after start of treatment.

Fixed partial dentures supported by periodontally compromised teeth

This study tested the effect of fixed partial dentures on hypermobile abutment teeth with substantially reduced levels of periodontal attachment. One abutment tooth and one control (nonabutment) tooth of the same type and periodontal condition were selected for study in adults. Treatment consisted of periodontal therapy and a 3- or 4-unit fixed partial denture, after which all subjects were placed on a quarterly maintenance schedule. No differences were found between the mean baseline and 24-month measures for all dependent variables at test or control sites.

Current Indications and Methods of Periodontal Splinting

The paper discusses the reasons for using periodontal splints, together with advantages and disadvantages of their use. Different splinting techniques and criteria for selecting the most appropriate method are described. The need for care in planning treatment is emphasized. It is essential that, if the degree of attachment loss is such that splinting is likely to be needed, this is taken into account in the treatment planning at an early stage.

CLINICAL RELEVANCE

Used correctly, periodontal splinting can greatly improve the comfort, prognosis and outcome for a patient with serious periodontal disease. But used incorrectly, splinting can cause further deterioration in periodontal health.

Effect of splinting on abutment tooth movement

The effect of splinting on abutment tooth movement was investigated in an in vitro study. An acrylic resin mandibular model with missing molars and a removable partial denture framework were constructed. The roots of the premolars and edentulous ridges were coated with silicone rubber. A modified Ney surveyor was used for load application, and abutment tooth movement measurements were made with a macroperiodontometer. Four conditions were tested by applying unilateral loadings: 1. Single abutments of both sides 2. Load side double abutment 3. Nonload side double abutment 4. Double abutments of both sides The results showed that a significant decrease in the magnitude of movement resulted when the abutment teeth were splinted.

Restoration and retention of maxillary anteriors with severe root resorption

BACKGROUND

The authors describe the treatment of three patients who had severe apical root resorption of maxillary lateral incisors caused by ectopically erupting canines. Ectopically erupting canines derive from a normal path of eruption and may cause resorption of the adjacent teeth.

CASE DESCRIPTION

The authors present the three cases of severe root resorption caused by ectopically erupting canines. They then discuss various prosthetic options; the indications, advantages and disadvantages of various treatment modalities; the long-term retention and esthetic concerns of the patients; and the inherent limitations of restorative treatment.

CLINICAL IMPLICATIONS

Increased tooth mobility and long-term retention are significant concerns in cases of patients who have severe root resorption. Attaining stability with lingual splinting can cause esthetic problems. An interdisciplinary approach is necessary to provide optimal care for the patient.

A stress-relieved resin-bonded fixed partial denture

Reports of bonding failures with resin-bonded fixed partial dentures (commonly called the "Maryland Bridge") are common. Failures are due to individual tooth mobility as much as they are to bonding inadequacy. The incorporation of stress relievers in the design of resin-bonded fixed partial dentures has created a dramatic reversal in bonding failures.

Does temporary splinting before non-surgical therapy eliminate scaling and root planing-induced trauma to the mobile teeth?

The objective of this study was to determine whether temporary splinting of periodontitis-affected mobile teeth, prior to non-surgical mechanical therapy, affects treatment outcome by eliminating scaling and root planing-induced trauma to the teeth. Mandibular anterior teeth of 29 patients (15 females; 14 males; age range 30 to 48 years) with adult periodontitis were evaluated. Clinical measurements were performed at 4 sites per tooth including mesial, distal, buccal and lingual aspects at baseline, 3 and 6 months after treatment. The following clinical parameters were analyzed: plaque index (PI), gingival index (GI), bleeding on probing (BOP), pocket depth (PD), probing attachment level (PAL), gingival margin level (GML) and tooth mobility (TM). Patients were randomly divided into 3 groups: i) group 1 (n = 8) received scaling and root planing (SRP) only, ii) group 2 (n = 10) received scaling and root planing before splinting and iii) group 3 (n = 11) received scaling and root planing after splinting. Statistical analysis revealed that there were no significant differences among the groups for either bleeding on probing or probing attachment level values at any of the time intervals. At the end of the study, the greatest decrease in pocket depth was noted in group 2 (1.24+/-0.10 mm) which was thought to be the result of gingival recession (0.73+/-0.07 mm). Group 1 was the only group that showed reduction in tooth mobility at 3 months compared to baseline (1.67+/-0.55 PTV units). Group 3 displayed the least reduction in tooth mobility during the entire study period (0.26+/-0.44 PTV units). In conclusion, splinting of mobile teeth before SRP, and thereby elimination of potential SRP-induced trauma to the mobile teeth, did not show any adjunctive effect on healing when compared to splinting after SRP. Thorough debridement of root surfaces, even performed in the presence of increased mobility, resulted in improvements in clinical parameters, i.e. mechanical manipulation of mobile teeth during periodontal treatment did not affect clinical outcome negatively.

Oral conditions and aptitude to receive implants in patients with removable partial dentures: a cross-sectional study. part I. oral conditions

The relationship between a removable partial denture (RPD) and damage caused to residual oral structures is the subject of on-going research. A group of patients wearing RPD, treated in the same way in the same department, were recalled to evaluate their oral hygiene and to compare the clinical condition of abutment teeth with that of non-abutment teeth. The study shows that most patients were unable to maintain high standards of oral hygiene. In the group of patients with non-optimal hygiene the clinical condition of abutment teeth was worse than that of non-abutment teeth. In the group of patients with optimal oral hygiene the condition of abutment teeth and non-abutment teeth was almost identical. To increase the standards of oral hygiene it is strongly advisable to recall and follow up patients on a regular basis.