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The scientific basis of periodontal treatment.

The development of periodontal treatment based on knowledge of the aetiology and pathogenesis of the diseases is reviewed. Emphasis is laid on the role of microorganisms and especially on the significance of their immunological interactions with the host. It is concluded that, despite increasing knowledge of the pathogenesis, microbiology and immunology of periodontal diseases, the methods of treatment have not changed essentially during the past 30 years. Oral hygiene instruction, scaling and root planing are still the methods of choice.

Aggressive Periodontitis↗

Roentgen stereophotogrammetry in high tibial osteotomy for gonarthrosis.

In three cases operated with high tibial osteotomy for medial gonarthrosis the exact method of roentgen stereophotogrammetry with tantalum balls as bone markers (Selvik 1974) was used to study angular and translational movement in three dimensions at the operation and during the healing period. Tibial osteotomy caused angular and translational movements even in planes where correction was not intended, and the stereo technique revealed that stability was not present when knee mobilisation started. Correlation between the stereo values and conventional radiographic measurements were best in the frontal plane (root mean square value of discrepancies 1.3 degrees). Roentgen stereophotogrammetry gives superior information compared with the conventional radiographic technique, but it is concluded that the latter has sufficient accuracy for the clinical assessment of corrections in the frontal plane.

Aged↗

Comparative histologic analysis of coronally advanced flap with and without collagen membrane for root coverage.

BACKGROUND: Guided tissue regeneration (GTR)-based root coverage has been utilized to correct gingival recession defects with promising results. However, limited histologic information is available. Therefore, the aims of this study were to clinically and histologically evaluate the efficacy of GTR-based root coverage using collagen membrane (GTRC) and to compare the healing response to that of coronally advanced flaps (CAF). METHODS: Standardized gingival recession defects were surgically created on the labial surfaces of the maxillary cuspids of 8 mongrel dogs. Plaque was allowed to accumulate for 8 weeks to develop a plaque-infected recession defect. Full-mouth scaling and root planing was then performed coincident with 4 weeks of oral hygiene. Defects were randomly assigned to receive either GTRC or CAF surgery. Four dogs each were sacrificed at 4 and 16 weeks post-treatment. Clinical measurements included: percent root coverage, the amount of keratinized gingiva (KG), and probing depth (PD). Sulcular depth, junctional epithelium and connective tissue attachment, new cementum formation, and new bone formation were evaluated histomorphometrically. RESULTS: Clinically, both treatments (CAF and GTRC) achieved statistically significant (P <0.05) root coverage compared to baseline. KG was significantly increased in CAF-treated sites at 16 weeks, while no significant differences were found for other clinical parameters between treatments. Histometrically, GTRC showed a statistically significant increase of new attachment and newly formed connective tissue when compared to CAF at 16 weeks. CONCLUSION: Within the limits of this preclinical study, both GTRC and CAF can be successfully used for the treatment of gingival recession defects.

Absorbable Implants↗

Favorable healing following space creation in rhBMP-2-induced periodontal regeneration of horizontal circumferential defects in dogs with experimental periodontitis.

BACKGROUND: Recombinant human bone morphogenetic protein-2 (rhBMP-2) is believed to be capable of inducing periodontal regeneration. However, the risk of aberrant healing events, such as root resorption and ankylosis, has been reported. We hypothesized that implantation of BMP-containing carriers directly on the root planed surface may be the cause of unfavorable healing. The purpose of this study was to evaluate the influence of a 1 mm spacer membrane, which separated the rhBMP-2 in polymer-coated gelatin sponge (PGS) and the root surface, on periodontal regeneration of experimentally induced horizontal defects in dogs. METHODS: Horizontal circumferential periodontal defects were surgically created, and experimental periodontitis was induced in 72 maxillary and mandibular premolars of four male beagle dogs. The recipient sites of each quadrant received: 1) rhBMP-2/PGS (B group) (rhBMP-2 at 1.0 mg/ml, total implant volume/ site approximately 7.2 microl) (n = 24); 2) rhBMP-2/PGS with a spacer membrane (PB group) (n = 24); and 3) physiological saline (PS)/PGS as a control (P group) (n = 24). One quadrant was left untreated. Dogs were sacrificed at 12 weeks post-surgery, and healing was evaluated histologically. RESULTS: Both groups treated with rhBMP-2/PGS demonstrated enhanced new bone formation and connective tissue attachment with cementum regeneration when compared to the control group. Sites treated with rhBMP-2/PGS showed a greater degree of bone formation than sites treated with rhBMP-2/PGS and spacer membrane, although the latter sites showed no ankylosis. CONCLUSIONS: Implantation of rhBMP-2/PGS enhances bone formation and connective tissue attachment in horizontal circumferential defects. In addition, the use of a spacer membrane reduces the degree of bone formation, but minimizes ankylosis.

Alveolar Bone Loss↗

Histologic evaluation of human intrabony defects following non-surgical periodontal therapy with and without application of an enamel matrix protein derivative.

BACKGROUND: Surgical periodontal treatment with enamel matrix protein derivative (EMD) has been shown to promote periodontal regeneration. However, it is not known whether nonsurgical periodontal therapy with additional subgingival application of EMD may also enhance periodontal regeneration. The purpose of this study was to clinically and histologically evaluate healing of human intrabony defects following non-surgical periodontal treatment with and without application of EMD. METHODS: Sixteen patients, each of whom displayed one advanced intrabony defect around teeth or roots scheduled for extraction, were included in the study. The defects were treated as follows: 1) scaling and root planing with hand instruments and application of EMD; 2) scaling with an ultrasonic instrument and application of EMD; or 3) scaling with an ultrasonic instrument alone. Healing was uneventful in all cases. Six months after surgery, the teeth or roots were extracted together with some of their surrounding soft and hard tissues and processed for histologic evaluation. RESULTS: Clinical examination revealed a probing depth reduction and a gain of clinical attachment after all 3 treatment modalities. The histological evaluation, however, revealed that healing in all 3 procedures was predominantly characterized by formation of a long junctional epithelium along the instrumented root surface and no predictable regeneration of attachment apparatus. CONCLUSION: Within its limits, the present study failed to show periodontal regeneration in advanced human intrabony defects following non-surgical treatment with subgingival application of EMD.

Alveolar Bone Loss↗

Cementodentinal tear: a case report with 7-year follow-up.

BACKGROUND: Cemental tears are an uncommon form of root fracture that can lead to rapid localized attachment loss. Typically, the separation of the fragment occurs at the cementodentinal junction. In this report, we present a case of periodontal involvement associated with a cemental tear-like fragment that proved to be a cementodentinal tear. We also review the literature on the clinical presentation of cemental tear associated periodontal lesions. METHODS: A 52-year-old male presented with acute pain on the maxillary right second premolar. Clinically, probing depth of 7 mm and inflammation were noted on the distal aspect of tooth #4. Radiographic examination revealed separation of cervical root structure on the distal aspect of the tooth, involving two-thirds of the root length. The root fragment was removed, and the localized defect was treated by open flap debridement along with scaling and root planing. The patient was then placed on a regular periodontal maintenance schedule. RESULTS: A postoperative probing depth of 2 mm with 1 mm recession was recorded at 3 months, and maintained for 7 years. Histological examination indicated that the detached root fragment contained dentin with overlying acellular cementum and associated periodontal ligament tissue. The fragment was estimated to represent as much as 20% of the total root surface area. CONCLUSION: Moderate to severe periodontal attachment loss associated with cemental or cementodentinal tears, even ones constituting a significant portion of the root surface, can be successfully treated with conventional periodontal surgical procedures and maintained long term with a proper maintenance regimen.

Bicuspid↗

Lasers in periodontics: use and abuse.

Despite the suggestions that lasers are a desirable alternative to traditional periodontal root instrumentation and the recent FDA approval of the Nd:YAG laser for such application, numerous peer-reviewed articles concerning in vitro and in vivo results strongly suggest caution with respect to clinical application. There appears to be a high potential for laser-induced irreparable physical damage to the root surface. Further, residual char layers resulting from repeated laser exposure or improper choice of parameters may inhibit reattachment of soft tissues to the root surface. In addition, the use of lasers to remove calculus from subgingival pockets appears to be more efficient or predictable than traditional instrumentation and may, in fact, require root planing subsequent to the laser therapy to achieve the desired clinical goal.

Dental Cementum↗

Fluorine concentration changes in human periodontally diseased tooth roots following several treatment times with citric acid.

Citric acid conditioning of exposed cementum has become an important adjunct to the clinical management of periodontal disease, and aggressive root planing is recommended to remove hypermineralized and endotoxin-laden diseased cementum. A nuclear resonance reaction technique was used to examine fluorine concentration changes subsequent to application of citric acid (pH 1.0) to the periodontal disease-exposed cementum surfaces of human tooth roots. The technique does not require the test teeth to be sectioned, thereby permitting longitudinal assessments of changes in fluorine concentration and minimizing measurement errors due to the considerable biological variation found between individuals. Initial fluorine concentrations ranged from 0.9%-2.4%, and maxima occurred within 4-6 microns of the surface, suggesting the presence of a hypermineralized layer. Within 60 sec, the citric acid had effectively removed the hypermineralized layer and the previously observed fluctuations in fluorine concentration leveled out at 0.3%-0.5%. Although the results indicated rapid removal of the hypermineralized layer and establishment of fluorine levels normally found in healthy cementum, the experimental design did not permit appraisal of potential effects upon the organic components of periodontally-exposed cementum.

Citrates↗

Evaluation of consecutively placed unloaded root-form and plate-form implants in adult Macaca mulatta monkeys.

The present paper describes 18 consecutively-treated non-human primates (Macaca mulatta) as part of a balanced block design study of 36 animals to examine osseointegration in root- and plate-form implants prepared by atraumatic preparation of bone. Clinical measurements around selected teeth and digital radiology were utilized to monitor periodontal disease and bone deposition around the unloaded implants. Once a month scaling procedures were utilized as a means of preventing further advance of periodontal disease. Results indicate that once-monthly regimen of scaling and root planing can prevent attachment loss of natural teeth and will not interfere with the healing of either type of implant; once-monthly scalings produce significant reduction in redness (P < .05) and reduced probing depths (P = .01). A second finding is that both root and blade implants show radiographic evidence of osseointegration in this primate model. The quantitative analysis demonstrates bone gain is not stabilized until 6 months after healing. The data may indicate that occlusal loading of mandibular implants at 3 months may be premature.

Alveolar Bone Loss↗

The effect of root conditioning with minocycline HCl in removing endotoxin from the roots of periodontally-involved teeth.

Noting the acid-conditioning effect of minocycline on the root surface, we investigated the ability of minocycline to remove endotoxin on untreated, diseased cementum in vitro. Root surface specimens affected by periodontal disease were immersed in minocycline solution (10 mg/ml, 50 micrograms/ml, and 5 micrograms/ml) for 10 minutes, 1 day, 3 days, and 7 days, and endotoxin eluted was determined by the limulus amoebocyte lysate (LAL) assay. Specimens serving as controls were treated by immersion in pyrogen-free water, agitation, polishing, or exposure to citric acid (pH 1.0) for 3 minutes. When the period of immersion was the same, the root treatment with minocycline (10 mg/ml) yielded a significantly higher rate of neutralization of endotoxin than that with a 5 micrograms/ml or 50 micrograms/ml solution. However, the detoxifying effect of this method was less adequate than that of polishing or treatment with citric acid solution. There was variability in the effects of polishing among the teeth tested. To obtain the expected effect of the root treatment with minocycline solution; i.e., removal of the endotoxin, the combining of minocycline with a mechanical root preparation, such as polishing or root planing, seems to be effective.

Analysis of Variance↗

Effect of diode laser irradiation on root surfaces in vitro.

OBJECTIVE: The objective of this study was to evaluate possible morphological alterations of root surfaces after GaAlAs-diode laser (809 nm) irradiation under standardized in vitro conditions. MATERIALS AND METHODS: Root specimens obtained from extracted periodontally diseased teeth were scaled and root planed with curettes followed by air-powder abrasive treatment prior to lasing. The variable parameters were power output (0.5-2.5 W) and exposure time (10-30 sec per specimen). Additionally, the effect of a saline solution and a human blood film on the root surface was investigated. The root segments were analyzed by means of a reflected light microscope. Photographs before and after irradiation were taken and evaluated. The scale of carbonization was quantified using a grid laid over the photographs. Specimens with distinct morphological changes were analyzed with a scanning electron microscope. RESULTS: Lasing dry specimens and specimens moistened with saline resulted in no detectable alterations, irrespective of irradiation time and power output applied. Depending on different settings, irradiation caused severe damages to the root surface when segments were covered by a thin blood film. Irradiation at a power output of 1 Watt and below had barely any negative effect on the root surface, whereas lasing at 1.5, 2.0, and 2.5 Watt resulted in partial or total carbonizations of the root samples. The angle of irradiation had a significant effect on the scale of the root surface damage (Mann-Whitney U test,p < 0.05). CONCLUSION: The diode laser may cause damage to periodontal hard tissues if irradiation parameters are not adequate.

Humans↗

Clinical evaluation of acellular allograft dermis for the treatment of human gingival recession.

BACKGROUND: Periodontal root coverage procedures to treat recession areas are indicated for unesthetic, exposed, and/or painful root surfaces. Many methods, most using autogenous soft tissue grafts, have been utilized, but with associated morbidity at the donor sites. An alternative donor material would reduce the morbidity and provide for sufficient available donor tissue. METHODS: An acellular allogeneic dermal connective tissue matrix (AD) and autogenous palatal connective tissue (CT) were compared as subepithelial grafts for the treatment of gingival recession. Twenty-two patients with similar isolated gingival recession of > or = 2 mm on 2 separate teeth were treated with the subepithelial graft technique. Exposed roots were hand root planed only and, by random allocation, either a fitted AD or fitted CT graft was secured in place and covered by coronally positioned flaps. RESULTS: Mann Whitney U test analysis found the following changes at 6 months for AD and CT, respectively, compared to presurgical conditions: root coverage of 1.7 +/- 1.2 (65.9%) and 2.2 +/- 1.1 mm (74.1%) (both P<0.01), increase in keratinized tissue (KT) of 1.2 +/- 1.3 and 1.6 +/- 1.9 (both P<0.01), and an increase in gingival thickness with both; 83.2% of expected root coverage was obtained with AD and 88.6% with CT (P= 0.43). There were no significant differences between treatments for any parameter. Global assessments by clinicians and patients suggested a more esthetic clinical result with AD. CONCLUSIONS: These results suggest that acellular allogeneic dermal matrix may be a useful substitute for autogenous connective tissue grafts in root coverage procedures.

Adult↗

Cellular reactions in pulpal and periodontal tissues after periodontal wound debridement.

Periodontal wounds in monkeys were prepared with a bur followed by the application of microbially contaminated cotton pellets. 3 weeks later, the wounds were debrided by scaling followed by etching with citric acid or by treatment with carbonate/peroxidate. The cellular reactions in the periodontal tissues and in the pulp 4, 11, 25, 39 and 53 days after treatment were followed with light microscopy. The marginal periodontium showed heavy inflammatory reactions immediately after treatment, regardless of the debridement procedure. 25 days after debridement, a long epithelial junction had been formed. The apical part of the epithelium deviated from the root surface into the connective tissue, delineating a heavily inflamed part of the connective tissue. After 39 to 53 days, most of the experimental wounds were covered by an epithelial lining. The pulpal reactions were generally limited to a production of irregular dentin on the pulpal wall facing the periodontal wound. It was concluded that the marginal healing pattern following various chemical treatments to the root surface followed, in all essential aspects, conventional treatment with scaling and root planing.

Animals↗

Bioerodible injectable poly(ortho ester) for tetracycline controlled delivery to periodontal pockets: preliminary trial in humans.

The semisolid consistency of poly(ortho esters) (POEs) containing tetracycline free base allows direct injection in the periodontal pocket and shows sustained and almost constant in vitro release in phosphate buffer, pH 7.4 at 37 degrees C, for up to 14 days. Total polymer degradation concomitant with drug release was obtained. Formulations containing 10% or 20% (wt/wt) tetracycline were evaluated in a panel of 12 patients suffering from severe and recurrent periodontitis. In the first trial including 6 patients, single-rooted teeth and molar teeth with furcations were treated immediately after scaling and root planing. Patients tolerated both formulations well, experienced no pain during application, and showed no signs of irritation or discomfort during the observation period. However, retention of the formulation was minimal in this first study. An improved clinical protocol followed in the second study (stopping bleeding after scaling and root planning) prolonged the retention of the formulations in the inflamed periodontal pockets. For up to 11 days, tetracycline concentrations in the gingival crevicular fluid were higher than the minimum inhibitory concentration of tetracycline against most periodontal pathogens.

Adult↗

[Treatment of gingival recession with a coronally repositioned flap].

The treatment of an exposed root surface may be indicated for an aesthetic improvement of a gingival recession. The surgical technic depends on the type of the recession, the quality and the quantity of the keratinized gingiva apically or laterally from the recession. The purpose of this study is to evaluate the minimal quantity of keratinized gingiva necessary to obtain a root coverage. 10 recessions on maxillary cuspids were treated with coronally repositioned flap. Less than 3 mm of keratinized gingiva was present apically to the exposed root surface. All patients received oral hygiene instructions, plaque control and scaling and root planing. Gingival recession, width of keratinized gingiva and loss of attachment were measured at the time of surgery and three months postoperatively. The mean recession was 5.20 mm (+/- SE = 0.36) prior to treatment and the keratinized gingiva was 1.70 mm (+/- 0.16) high at T0. The mean gain of root coverage was 3.43 mm (+/- 0.29) at three months post-operatively. At T0 and 3 months post-operatively, the measures of recessions showed a statistically difference confirming the validity of the technic. The absence of correlation between initial height of keratinized gingiva and the coverage result (r = 0.05) indicates that initial width of keratinized gingiva does not affect the coverage results.

Epithelial Attachment↗

Placement of a porous membrane underneath the mucoperiosteal flap and its effect on periodontal wound healing in dogs.

This study was designed to investigate the healing of surgically induced, horizontal periodontal defects in dogs following placement of a biocompatible, porous polytetrafluorethylene membrane around the roots of the treated teeth and to compare the healing to that of control teeth without membrane. Mandibular premolar teeth of 5 beagle dogs were used for experimentation. Specimen blocks were removed 3 months postoperatively for histological evaluation of contralateral experimental and control teeth. Mean apical migration of junctional epithelium among the experimental surfaces amounted to 0.1 mm as compared to 1.3 mm for the control surfaces. Accordingly, the amount of connective tissue attachment, defined by the distance from the base of the junctional epithelium to the apical termination of root planing, was greater for experimental than for control surfaces. As this increased amount of connective tissue attachment was associated with more coronal bone apposition, a periodontal ligament space was more prevalent in experimental than in control surfaces. A limited amount of ankylosis was observed for both experimental and control surfaces. Root resorption was more prevalent in control than in experimental surfaces. Conceivable reasons for the differences in healing between experimental and control teeth are discussed.

Alveolar Process↗

Responses of four tooth and site groupings to periodontal therapy.

The responses of four tooth/site groupings to periodontal therapy were evaluated. Eighty-two patients with periodontitis were treated in a split mouth design with coronal scaling, root planing, modified Widman surgery, and flap with osseous resectional surgery. Patients were evaluated prior to therapy, 4 weeks post-Phase I therapy, 10 weeks post-Phase II therapy, and at yearly intervals during 2 years of maintenance therapy. The tooth/site groupings evaluated were: 1) interproximal sites of single rooted teeth (T1), 2) facial and lingual sites of single rooted teeth (T2), 3) nonfurcation sites of molar teeth (T3), and 4) furcation sites of molar teeth (T4). Following 2 years of maintenance, no clinically significant differences in probing depth reduction or probing attachment loss were present between the four tooth/site groupings in 1 mm to 4 mm sites. T2 had the greatest decrease of probing depth in 5 mm to 6 mm sites followed by T1, T3 and T4. T1 and T2 showed a greater gain of probing attachment followed by T3 and T4. T1 and T2 had the greatest decrease of probing followed by T3 which was greater than T4 in greater than or equal to 7 mm sites. T4 had significantly less probing attachment gain than the other groups. There was a trend for T1 and T2 to have less gingival bleeding post-therapy and for T2 to have less plaque accumulation than the other groups at both pre- and post-therapy examinations.

Bicuspid↗

External root resorption following partial-thickness connective tissue graft placement: a case report.

We report an unusual case of external root resorption (ERR) that developed in a 37-year-old black male approximately 1 year following routine partial thickness connective tissue graft surgery. The lesion was accessed via flap surgery, thoroughly root planed, and the mucoperiosteal flap replaced. The site healed uneventfully and the patient has been closely observed for over 1 year without symptoms or recurrence of the resorptive lesion and the affected tooth remained vital. Clinicians performing partial-thickness connective tissue grafts should be alert to the possible occurrence of root resorption over extended periods of time. The authors speculate that retention of the donor periosteum with placement on the recipient dentin and root biomodification may limit the resorptive response following connective tissue graft procedures to treat tooth root recession.

Adult↗