Showing papers in "Journal of Clinical Periodontology in 1996"

Dimension of the periimplant mucosa. Biological width revisited.

Abstract: The objective of the present study was to determine the dimension of the mucosal-implant attachment at sites with insufficient width of the ridge mucosa. 5 beagle dogs were used. Extractions of all mandibular premolars were performed and 3 months later, 3 fixtures of the Branemark System were installed in each side. Following 3 months of healing, abutment connection was carried out. On the right or left side of the mandible, abutment connection was performed according to the Branemark System manual (control side). On the contralateral side (test side), an incision not extending through the periosteum was made at the crest of the ridge. The soft tissue was dissected and a critical amount of connective tissue on the inside of the flap was excised. The periosteum was subsequently incised, abutment connection performed, and the trimmed flaps sutured. The sutures were removed after 10 days. After a 6-month period of plaque control, the animals were sacrificed, biopsies sampled and processed for light microscopy. The length of the junctional epithelium varied within a rather narrow range; 2.1 mm (control side) and 2.0 mm (test side). The height of the suprabony connective tissue in this model varied between 1.3+/-0.3 mm (test side) and 1.8+/-0.4 mm (control side). At sites where the ridge mucosa prior to abutment connection was made thin (< or = 2 mm), wound healing consistently included bone resorption. This implies that a certain minimum width of the periimplant mucosa may be required, and that bone resorption may take place to allow a stable soft tissue attachment to form.

Biostimulation of wound healing by low-energy laser irradiation. A review.

Abstract: This paper reviews studies on the basic principles of biostimulation of wound healing by various low-energy lasers. It looks at the mechanism of action of biostimulation as well as the laser's effect on cell proliferation, collagen synthesis, and would healing.

The pathogenesis of drug-induced gingival overgrowth.

Abstract: Gingival overgrowth is a well-documented unwanted effect, associated with phenytoin, cyclosporin, and the calcium channel blockers. The pathogenesis of drug-induced gingival overgrowth is uncertain, and there appears to be no unifying hypothesis that links together the 3 commonly implicated drugs. In this review, we consider a multifactorial model which expands on the interaction between drug and/or metabolite, with the gingival fibroblasts. Factors which impact upon this model include age, genetic predisposition, pharmacokinetic variables, plaque-induced inflammatory and immunological changes and activation of growth factors. Of these, genetic factors which give rise to fibroblast heterogeneity, gingival inflammation, and pharmacokinetic variables appear to be significant in the expression of gingival overgrowth. A more thorough understanding of the pathogenesis of this unwanted effect will hopefully elucidate appropriate mechanisms for its control.

Matrix metalloproteinases and their inhibitors in gingival crevicular fluid and saliva of periodontitis patients

Abstract: Matrix metalloproteinases (MMPs) and serine proteinases seem to be related to tissue destruction in periodontitis. The presence of MMPs in gingival crevicular fluid (GCF) and saliva, however, has not been studied comprehensively with the enzyme-linked immunosorbent assay (ELISA)-technique. We therefore examined the levels of MMP-1, -3, -8 and -9, and their endogenous inhibitor, tissue inhibitor of matrix metalloproteinases (TIMP-1), in GCF and saliva of patients with adult periodontitis (AP) and localized juvenile periodontitis (LJP). Elevated levels of MMP-1 were detected in LJP GCF compared to AP and control GCF. Elevated levels of TIMP-1 were also detected in LJP GCF in comparison to AP and control GCF. Higher MMP-8 levels were detected in AP GCF compared to LJP and control GCF. The relative low levels of MMP-3 were present in all studied GCF samples. Elevated levels of MMP-8 were further detected in saliva of AP compared to LJP and the controls. Both MMP-1 and TIMP-1 were detected in all studied saliva samples, but not significant differences were detected between the studied groups. Our ELISA-results confirm that (i) PMN MMP-8 and MMP-9 are the main collagenase and gelatinase in AP GCF, whereas GCF collagenase in LJP seems to be of the MMP-1-type; (ii) only low levels of TIMP-1, endogenous MMP-inhibitor, are present in AP GCF, which emphasises the importance of doxycycline as a possible adjunctive drug in the treatment of AP patients; (iii) tests based on specific antibodies against PMN MMPs, especially MMP-8, might serve as a reliable method of measuring and monitoring enzyme levels in GCF from different periodontitis patients.

Increased gingival dimensions. A significant factor for successful outcome of root coverage procedures? A 2-year prospective clinical study.

Abstract: The aim of this study was to evaluate whether an increased thickness of the gingiva through the use of a free connective tissue graft, in conjunction with a coronally advanced flap procedure, may positively influence the treatment outcome with respect to (i) root coverage and (ii) long-term stability of the position of the soft tissue margin following treatment of recession type defects. 67 consecutive patients having a total of 103 buccally located recession type defects of at least 3 mm were included in the study. After an initial phase of prophylaxis including instructions in a tooth brushing technique giving minimal apically directed forces to the gingival margin, the recession sites were surgically covered with a coronally advanced flap alone (control sites), or coronally advanced flap combined with a free connective tissue graft taken from the palate (test sites). Clinical examinations, including assessments of oral hygiene, gingival conditions, recession depth, gingival height, probing pocket depth and probing attachment loss, were performed before and 6, 12 and 24 months after surgical treatment. The mean initial recession depth for both treatment groups was about 4.0 mm (SD 1.0) with a gingival height apical to the recession of 1.0 mm (0.5). At the re-examination performed 6 months after surgical treatment, the mean recession depth had decreased to 0.2 mm in both the test and control groups. Complete root coverage was observed at 72% of the test sites and 74% of the control teeth. At teeth treated with the combined surgical procedure, the mean gain in probing attachment amounted to 3.7 mm and the mean gingival height had increased to 3.5 mm (0.6). The corresponding figures for control teeth were 3.6 mm and 1.5 mm (0.5), respectively. At the 24-month follow-up examination, the mean root coverage amounted to 98.9% (test) and 97.1% (control). 88% of the teeth in the test group showed complete root coverage compared to 80% for teeth in the control group. It was concluded that the 2 surgical procedures resulted in similar degree of root coverage and that changes of tooth brushing habits may be of greater importance than increased gingival thickness for long-term maintenance of the surgically established position of the soft tissue margin.

Ultrasonic determination of gingival thickness. Subject variation and influence of tooth type and clinical features.

Abstract: The objectives of the present study were (I) to determine the validity and reliability of measuring gingival thickness (GTH) with a recently developed, commercially available ultrasonic device: (II) to measure GTH in relation to tooth type and age of proband;(III) to correlate GTH with varying forms of pre-molars, canines and incisors. Ultrasonic measurements were performed in 200 periodontally healthy, male probands representing 3 different age groups (20–25, 40–45, 55–60 years). In the maxilla, mean GTH varied between 0.9 mm (canines, 1st molars) and 1.3 mm (2nd molars). In the mandible respective mean values ranged between 0.8 mm (canines) and 1.5 mm (2nd molars). No differences in means and standard deviations (0.36–0.39 mm) were observed in different age groups. In order to correlate GTH with other clinical parameters and form of tooth, in 42 probands of the youngest age group, presenting with no attrition or abrasion, no artificial crown restorations and (following prophylaxis) no overt gingivitis and no periodontal probing depth in excess of 3 mm. detailed clinical measurements and stone model cast analyses were performed. By stepwise multiple linear regression analysis, 24% (p < 0.0001) of the variation of GTH was explained by probing depth, recession, width of gingiva and tooth type. The ratio of the width of the crown to its length was not included into the model. When performing analysis of covariance with the subject as factor, the model was improved, now explaining 41% of the variation of GTH. In this model, the influence of periodontal probing depth was decreased, and recession was not included. It was concluded that there are individual differences in GTH (i.e., different biotypes). However, thickness mainly depends on tooth type and is correlated with width of gingiva. There appears to be no association with shape and form of the tooth. Validity and reliability of measuring GTH with the ultrasonic device was found to be excellent.

Factors affecting the healing response of intrabony defects following guided tissue regeneration and access flap surgery

Abstract: Identification and control of significant factors determining clinical outcomes is of paramount importance to improve expected results of a variety of therapeutic procedures. The aim of this investigation was to identify, with a multivariate approach, factors associated with healing outcomes of 3 periodontal surgical procedures in deep intrabony defects. 45 patients with evidence of deep intrabony defects were randomly assigned to 3 treatment groups: access flap (group C), conventional guided tissue regeneration (GTR) with non-resorbable expanded polytetrafluoroethilene (ePTFE) membranes (group B), and GTR with self supporting membranes combined with the modified papilla preservation technique (group A). In both GTR procedures, membranes were positioned coronal to the interproxymal alveolar crest. Primary outcome variables (i.e., probing attachment level gains at 1 year and the amount of newly formed tissue present at membrane removal) were explained in terms of a series of patient, defect morphology and surgical factors, using a multivariate approach. Highly significant treatment effects were observed, indicating that the 3 tested therapeutic modalities resulted in significant differences in primary outcome variables. Detailed analysis assessing the significance of the tested factors in determining the healing outcomes following each procedure was performed with a stepwise elimination approach of non-significant factors. The results indicated that: (i) the need to create and maintain space should be a key objective of regenerative approaches based upon the principles of guided tissue regeneration; (ii) control of patient's oral hygiene and residual periodontal infection in the oral cavity are strongly associated with clinical outcomes of both regenerative and conventional surgical procedures and should receive proper attention.

Medical Status and complications in relation to periodontal disease experience in insulin-dependent diabetics

Abstract: The aim of this study was to define a population of diabetics exhibiting an increased risk of developing severe periodontitis by comparing the medical status of 2 groups of diabetics, 1 with no/minor periodontal disease and 1 with severe periodontal disease. The case-control study consisted of 2 parts, a baseline study and a follow-up study. 39 case-control pairs were selected. They were adult, long-duration, insulin-dependent diabetics matched according to sex, age and diabetes duration. One individual in each pair (the CASE) exhibited severe periodontal disease while the other (the CONTROL) exhibited gingivitis or only minor alveolar bone loss. The median age of the cases was 58 years (range 36 to 70 years) and of the controls 59 years (range 37 to 69 years). The median disease duration in cases and controls was 24 years and 25 years, respectively. The median follow-up time was 6 years. The medical variables analysed were weight, insulin dose, systolic and diastolic blood pressure, vibratory threshold, triglycerides, total-cholesterol, HDL-cholesterol, creatinine, HbA1, proteinuria, ECG, retinopathy, stroke, transient ischemic attacks (TIA), angina, myocardial infarct, heart failure, hypertension, intermittent claudication, foot ulcer, death, cause of death, and smoking habit. Biochemical analyses and clinical variables used as a routine in the monitoring of diabetics failed to differentiate between diabetics with severe and minor periodontal disease. In the follow-up study, significantly higher prevalences of proteinuria and cardiovascular complications such as stroke, TIA, angina, myocardial infarct and intermittent claudication were found in the case group. An association between renal disease, cardiovascular complications and severe periodontitis seems to exist. This indicates that a closer cooperation between the diabetologist and the dentist is necessary in monitoring the diabetic patient.

The effect of periodontal therapy in diabetics. Results after 5 years.

Abstract: The present investigation was performed to study the frequency of recurrence of periodontitis in diabetic subjects, who, prior to the initiation of a 5-year period of monitoring, were treated for moderate to advanced periodontal disease. 20 patients with diabetes, type 1 (IDDM) or type 2 (NIDDM) and 20, sex and age matched, controls with similar amounts of periodontal tissue destruction, were selected for the study. Following a screening examination, all patients were subjected to non-surgical periodontal therapy (oral hygiene instruction, supra- and subgingival scaling). 3 months later, the baseline examination for the study was performed. This included assessments of several parameters such as: number of teeth, plaque, gingivitis, probing pocket depth and probing attachment level. 6 months after the baseline examination, all 40 subjects were recalled for a 2nd examination. Sites which at this 6-month examination exhibited bleeding on probing, and had probing depth > 5 mm, were scheduled for additional surgical therapy (modified Widman flap). Following this selective additional therapy, the main period of monitoring was initiated. During this period, a plaque control program was repeated every 3 months. Re-examinations regarding plaque, gingivitis, probing depth and probing attachment level were performed 12, 24 and 60 months after the baseline examination. The findings from the examinations disclosed that diabetics and non-diabetics alike, treated for moderately to advanced forms of adult periodontitis, during a subsequent 5-year period, were able to maintain healthy periodontal conditions. Thus, the frequency of sites which exhibited signs of recurrent disease was similar in the 2 study groups.

Psychosocial factors and adult onset rapidly progressive periodontitis

Abstract: On the basis of clinical observations, some periodontologists have suggested an association between psychosocial factors such as depression, stress and anxiety, and adult onset rapidly progressive periodontitis (RPP). This study investigated more formally possible associations between a number of relevant psychosocial factors and RPP. The significance of the psychosocial variables was assessed by comparing 3 groups: 50 patients with RPP, 50 patients with routine chronic adult periodontitis (RCAP), and 50 patients without significant periodontal destruction (controls). It was anticipated that the RPP group would show higher levels of psychosocial maladjustment than the RCAP and control groups. A between-subjects multivariate analysis of covariance indicated that the combined psychosocial variables were significantly related to the periodontal diagnosis. 2 psychosocial factors, depression and loneliness, were significant in distinguishing between groups. The RPP group presented significantly increased depression and loneliness compared to the RCAP and control groups. Future research is indicated to further clarify the significance of these psychosocial differences in relation to the onset and progression of RPP.

Prevalence of cervical dentine sensitivity in a population of patients referred to a specialist Periodontology Department

Abstract: The reported prevalence of cervical dentine sensitivity (CDS) ranges from 8 to 35%. Detailed epidemiology of the condition, particularly with regard to possible causal factors, is lacking. In particular, no published data appear to exist on its prevalence in periodontal patients. The aim of the present study was therefore to determine the prevalence, distribution and severity of CDS in a population of patients referred to a Periodontology Department of a specialist postgraduate hospital. 507 patients (181 M; 326F, mean age 44.2 (SD 10.31) years) attending a periodontal clinic were assessed for CDS by a questionnaire. The results demonstrated a prevalence of CDS of 84% with no significant gender difference. 71.1% of patients perceived cold as the most common cause of discomfort. A higher prevalence of self-reported discomfort was observed between 40 and 49 years. Of the patients with a reported history of periodontal surgery (34.7%), those treated within 6 months prior to assessment appeared to be more at risk to CDS. Of the patients who received hygienist treatment (88.2%), only 10.5% reported discomfort persisting > or = 3 days after treatment. Generally, patients who complained of varying degrees of discomfort over time (84.5%) did not perceive the condition as severe and consequently did not seek treatment. The prevalence of CDS in these referred patients was very high, suggesting that periodontal diseases and/or treatment effects play a role in its aetiology.

Long‐term stability of clinical attachment following guided tissue regeneration and conventional therapy

Abstract: UNLABELLED 44 patients (34% smokers) presenting with severe periodontitis were treated with full mouth root planing (RPL). In each patient, 1 intrabony defect was treated with guided tissue regeneration (GTR). After 1 year of monthly prophylaxis, full mouth plaque (FMPS) and bleeding (FMBS) scores were 8.3 +/- 4.1% and 5.6 +/- 3.8%. At 1 year, the GTR treated sites were matched, in each patient, with 1 RPL site, in terms of probing attachment level (PAL 6.8 +/- 2.4 mm GTR, and 6.5 +/- 2.3 mm RPL). At this point, 24 patients took part in a supportive periodontal care program. 20 patients did not participate, and received only sporadic care by general dentists. At 5 years, all patients were reexamined. FMPS was 10.5 +/- 6.8% and FMBS 7.7 +/- 6.4%. A significant PAL loss was observed in both sites (1.2 +/- 1.4 mm GTR, 1.3 +/- 1.3 mm RPL, p < 0.0001) between 1 and 5 years. Differences in PAL loss between GTR and RPL sites were not statistically significant. Only a minority of sites (34%), however, lost PAL, while 66% remained stable. 75% of the matched sites (GTR and RPL) within the same patients were concordant in terms of PAL stability. The 23 patients in which both sites remained stable, had good oral hygiene, complied with the recall system, and did not smoke. The 10 patients in which both sites lost PAL showed deteriorating oral hygiene, did not comply with the recall system, and smoked. PAL loss in the GTR and/or RPL sites was consistently observed in patients (losers) showing PAL loss in other teeth. Losers had, in general, negative subjects characteristics, and showed a higher prevalence of tooth loss. IN CONCLUSION (i) GTR and RPL sites showed comparable susceptibility to periodontal breakdown; (ii) stability of outcomes was consistently associated with good oral hygiene, compliance with a supportive periodontal care program, and no cigarette smoking.

The effect of supragingival plaque control on the subgingival microflora in human periodontitis

Abstract: The aim of the present trial was to study if carefully practiced supragingival plaque control influenced the subgingival microbiota at periodontal sites with suprabony, infrabony, or furcation pockets. 12 subjects, 5 males and 7 females aged 44 to 69 years (mean age 55 years) participated in the study. None of the participants had during the last 12 months received periodontal therapy, and none of the subjects had used antibiotics during a 3-month period preceding the study. Following a screening examination, 6 to 8 sites per subject were selected which had a probing depth of > or = 5 mm. Among these sites, 1-3 sites had a suprabony location, 1-3 sites had an infrabony location, and 1-3 sites were associated with a furcation defect. The selected sites were exposed to a baseline examination at which the following parameters were recorded: plaque, gingivitis, probing pocket depth and probing attachment level. A bacterial sample was obtained from each of the selected sites: 2 sterile paper points were inserted into the pocket and kept in place for 30 seconds. The paper point samples were removed, placed in a vial containing an anaerobically prepared transport medium, and processed using routine procedures. Following the baseline examination, each subject was given a case presentation, received thorough supragingival scaling and was instructed to practice proper plaque control with the use of toothbrush and dentifrice. During the subsequent 30 weeks they were recalled 2-3xper week for professional tooth cleaning. Each session was handled by a dental hygienist and required about 15 min. Re-examinations were performed after 30 weeks. The findings indicated that professionally delivered and frequently repeated supragingival tooth cleaning, combined with careful self-performed plaque control had a marked effect on the subgingival microbiota of moderate to deep periodontal pockets. Thus, at sites with suprabony and infrabony pockets, as well as at furcation sites, the meticulous and prolonged supragingival plaque removal reduced the total number of microorganisms that could be harvested, as well as the % of sites with P. gingivalis.

Increased release of free oxygen radicals from peripheral neutrophils in adult periodontitis after Fc delta-receptor stimulation.

Abstract: The release of free oxygen radicals and degranulation was studied in neutrophils from 14 patients with adult periodontitis and 14 age- and sex-matched healthy controls. The neutrophils were activated by Fc gamma-receptor stimulation, using Staphylococcus aureus opsonized with gamma globulin. Release of oxygen radicals was measured as luminol-enhanced chemiluminescence. Degranulation was assessed as release of elastase, measured with a specific substrate and as release of lactoferrin measured with ELISA. The neutrophils from the patients showed a significantly higher chemiluminescence and a slightly higher release of elastase, whereas the release of lactoferrin was the same in both groups. In contrast, the ratio between the 2 degranulation products, elastase and lactoferrin, was significantly higher in the group with periodontitis. A flow cytometric analysis of the membrane expression of the adhesion molecules CD 11a, CD 11b, CD 15, CD 16, CD 35 and Mel 14 showed no differences in the median immunofluorescence between the 2 groups. This study showed a more than 2-fold higher release of free oxygen radicals from Fc-gamma-receptor stimulated neutrophils compared with healthy controls, which indicates a specific neutrophil-associated host response in adult periodontitis.

Utility of 5 major putative periodontal pathogens and selected clinical parameters to predict periodontal breakdown in patients on maintenance care

Abstract: The predictive utility of 5 major putative periodontopathic microbial species, "superinfecting" organisms, and several clinical periodontal parameters were assessed relative to periodontitis recurrence over a 12-month period in 78 treated adult patients participating in a 3-month maintenance care program. At baseline, pooled subgingival microbial samples were collected from each patient, and whole-mouth evaluations of probing depth, relative periodontal attachment level, furcation involvement, and indices of plaque and gingival inflammation were carried out. 67 (85.9%) subjects were culture-positive at baseline for presence of either Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Campylobacter rectus or Peptostreptococcus micros, with 48 (61.5%) subjects yielding one or more of these species at or above designated threshold proportions of > or = 0.01% for A. actinomycetemcomitans, > or = 0.1% for P. gingivalis, > or = 2.5% for P. intermedia, > or = 2.0% for C. rectus, and > or = 3.0% for P. micros. Subgingival yeasts were recovered from 12 subjects, staphylococci from 7, and enteric rods/pseudomonads from 6; however, no subjects revealed > or = 1.0% baseline proportions of these "superinfecting" organisms in subgingival specimens. Periodontitis recurrence in subjects was defined as any periodontal site exhibiting either a probing depth increase of > or = 3 mm from baseline, or a probing depth increase of > or = 2 mm from baseline together with a loss in relative periodontal attachment of > or = 2 mm from baseline. 15 (19.2%) study subjects showed periodontitis recurrence within 6 months of baseline, and 25 (32.1%) within 12 months. The mere baseline presence of the 5 major test species and "superinfecting" organisms were not significant predictors of periodontitis recurrence over 12 months. However, a 2.5 relative risk for periodontitis recurrence over 12 months was found for subjects yielding one or more of the 5 major test species at or above the designated baseline threshold proportions (p = 0.022, Mantel-Haenszel chi 2 test). The positive predictive value for periodontitis recurrence of a microbiologic analysis encompassing the 5 major test species at or above the designated threshold proportions improved with increasing time from baseline, up to approximately 42% at 12 months. Baseline variables jointly providing in multiple regression analysis the best predictive capability for periodontitis recurrence in subjects over a 12-month period were recovery of one or more of the 5 major test species at or above designated threshold proportions, the proportion of sites per subject with > or = 5 mm probing depth, and the mean whole-mouth probing depth. These findings indicate that one or more of 5 major putative periodontal pathogens in elevated subgingival proportions together with increased probing depth predispose adults on maintenance care to recurrent periodontitis.

Stress and the progression of periodontal disease

Abstract: This study examined the association between occupational stress and the progression of periodontitis in employed adults. 23 regular dental attenders, enrolled in a longitudinal study of periodontal disease, were examined on 2 occasions at an interval of 5.5 (SD 0.6) years. The mean age at the 2nd examination was 41.1 (SD 7.3) years. Clinical measurements of periodontal status including clinical attachment level were made at four proximal sites on all teeth. A questionnaire, the occupational stress indicator, was used at the second examination to assess stress retrospectively. The mean change in clinical attachment level was 0.63 (SD 0.42) mm and 9.6 (SD 8.6)% of sites measured at both examination lost > or = 3 mm of periodontal attachment. Multiple regression analysis was used to explore the relationship between mean loss of periodontal attachment and measures of occupational stress and sociodemographic data. In the final regression model, an increase in loss of periodontal attachment was significantly predicted by increasing age, lower socio-economic status, lower job satisfaction and type A personality. In addition, locus of control was included in the regression model which explained 65% of the variance in the loss of periodontal attachment. The results suggest that occupational stress may have a relationship to the progression of periodontitis.

Bacterial colonization of barrier material and periodontal regeneration.

Abstract: The objective of this study was to evaluate the relationship between the presence of bacteria on the tooth-facing surface of ePTFE barriers and the clinical outcome of membrane supported reconstructive periodontal surgery. 20 systemically healthy subjects affected by chronic periodontitis were enrolled. One tooth site per patient, associated with an angular bony defect and a probing attachment loss of > 4 mm, was selected to be treated by means of a guided tissue regeneration procedure using an ePTFE barrier membrane. Antibiotics (Augmentin 1 g/day) for 2 weeks were prescribed. In addition to the use of chlorhexidine for post-surgical plaque control, all patients were recalled once a week for professional tooth cleaning. The barrier material was harvested for SEM analysis after 4-6 weeks. Professional tooth cleaning and reinforcement of sel-performed oral hygiene measures were given at 1 mouth intervals after membrane removal. For each treated site, the difference in probing attachment loss between baseline examination and a follow-up examination after 6 months of healing was calculated. The results of the SEM-analysis revealed that bacterial colonization was evident in the collar area of all the retrieved membranes. In the mid part of the membranes 30 out of 60 microscopic fields (50%) demonstrated microbial colonization, and in the most apical part 9 out of 60 fields (15%). Regression analysis indicated that gain in probing attachment level was positively correlated to initial attachement loss and negatively correlated to microbial colonization of the mid part of the membranes. It was concluded that bacterial colonization in the mid part of the ePTFE membrane reduced the potential gain in probing attachment following GTR-therapy with almost 50%.

Root surface etching at neutral pH promotes periodontal healing

Abstract: The purpose of the present investigation was to examine whether an etching agent operating at neutral pH (EDTA) can enhance healing compared to a low pH etching agent (citric acid) in an animal model. Maxillary molars and premolars, in total 32 teeth, in 4 monkeys were divided between test (EDTA or citric acid treatment) and matched control groups. Periodontal surgery on both palatal and buccal roots using the dehiscence model was performed with or without root surface etching. Healing results were evaluated histomorphometrically after 8 weeks. The statistically significant differences between EDTA treated surfaces (n=15) and control surfaces (n=11) were approximately 10% less failure (gingival recession and periodontal pocket), 10 to 15% more total histological attachment (long epithelial junction, connective tissue and reparative cementum), approximately 20% less long epithelial junction and approximately 20% more connective tissue in roots etched with EDTA. The statistically significant differences between citric-acid-treated surfaces (n=14) and control surfaces (n=11) were approximately 10% more connective tissue and 15% less long epithelial junction in the citric acid etched roots. Thus, etching with EDTA appeared to improve healing, avoiding the superficial necrotizing effect on exposed periodontal tissues by citric acid documented in previous studies. Although etching at present is not routinely applied in conventional periodontal therapy, future potential applications of etching at neutral pH may include exposure of the collagenous matrix of dentin for retention of biologically active substances, such as growth factors. Such treatment may be argued to produce a biocompatible surface more conducive to periodontal membrane cell colonization after removal of root-surface- associated smear without compromising the vitality of the surrounding periodontium.

Periodontal Diagnosis in Treated Periodontitis. Why, When and How to Use Clinical Parameters

Abstract: The objective of clinical periodontal diagnosis in maintenance patients is to monitor the risk for periodontal disease progression. Risk for progression should be continuously monitored at the patient, tooth and site level at each recall appointment. At the patient level, the significance of systemic diseases, cigarette smoking, compliance with the recall program, loss of support in relation to the patient's age, full mouth plaque and/or bleeding scores, and prevalence of residual pockets are of key importance. At the tooth and tooth-site levels, residual periodontal support, inflammatory parameters and their persistence, presence of ecological niches with difficult access such as furcations, and presence of iatrogenic factors have to be put into proportion with the patient's overall risk profile. The information gathered by clinical monitoring and continuous multilevel risk assessment facilitates an immediate appreciation of the periodontal health status of an individual and the possible risk for further infection and/or disease progression in the dentition and at a particular tooth or site.

Rationale of mechanical plaque control

Abstract: Patients who have received extensive periodontal treatment also demonstrate a high susceptibility to periodontal disease. Maintenance of periodontal health following therapy includes a lifelong supportive care consisting of daily removal of the microbial plaque by the patient, supplemented by professional care in an individually designed programme. Mechanical supragingival plaque control by self care is of utmost importance. The goal is to create a positive attitude by information and motivation to give the patient knowledge and confidence. The patient should be advised to use appropriate aids and technique. A soft brush, an interspace brush, interdental tooth brushes or tooth picks are recommended m periodontal patients. Professional tooth cleaning involves removal of supragingival plaque from ail tooth surfaces using mechanically driven instruments and fluoride prophy paste and, when indicated, removal of calculus and subgingival plaque. Disclosing solution is used to visualize the plaque to the patient and to the clinician in order to reinforce instruction in oral hygiene. Oral hygiene measures alone seem to have limited effect on the subgingival microflora in cases of severe disease. In shallow and moderately deep pockets a good plaque control can change the subgingival flora towards a more “healthy” composition. Subgingival plaque removal is performed with hand- and/or ultrasonic instruments. Cracks within the cementum, grooves, fissures, resorption lacunae, furcations may create difficulties in cleaning the root surface. Ultrasonic instrumentation has a beneficial effect in creating a smooth surface without extensive removal of cementum. Besides, the cavitational activity contributes to plaque removal which makes the instrument further suitable during maintenance therapy. The result of the de-bridement is assessed on the healing response in the tissues. The frequency of maintenance visits must be given on an individual basis according to the needs of every special patient. The visit includes plaque evaluation (disclosion), oral hygiene instruction, probing depth measurements, registration of bleeding on probing, scaling (plaque removal) if indicated, tooth polishing, fluoride application and radiographs if indicated. The goal is to identify and treat signs of recurrence of periodontal disease in order to prevent further loss of attachment.

Risk indicators for periodontal disease in a racially diverse urban population

Abstract: A cross-sectional study of 117 subjects from a dental clinic serving a diverse population (i.e., Whites, African-Americans, Native-Americans, and Asians) was performed to evaluate risk indicators of periodontal disease. Gingival crevicular fluid (GCF) and subgingival plaque were taken at the same visit from 4 posterior sites of the most diseased sextant in each subject. Age, smoking packyears, beta-glucuronidase (beta G), neutrophil elastase (NE), myeloperoxidase (MPO), Fusobacterium nucleatum (F. nucleatum), and Porphyromonas gingivalis (P. gingivalis) were significantly (p < 0.05-0.005) correlated with attachment loss. Probing depth was significantly correlated with smoking packyears, beta G, NE, MPO, F. nucleatum and Prevotella intermedia (P. intermedia) (p < 0.05-0.005). Mean NE value of Whites was lower than the mean NE values of African-Americans, Native-Americans and Asians (p < 0.05). Whites had a lower mean beta G value compared to African Americans, and a lower mean MPO value compared to African Americans and Native Americans. The %s of patients positive for F. nucleatum, P. intermedia and Eikenella corrodens (E. corrodens) were higher in Native Americans compared to Whites. Step-wise multiple regression analysis was performed to construct models for the estimation of probing depth and attachment loss. The most parsimonious regression models which had the best R2 values included the following variables and accounted for the indicated % of variability: models 1 and 2: beta G, race, and F. nucleatum accounted for 50% of the variability in mean probing depth and 39% of the variability in a single site (first molar) for probing depth, respectively; model 3: age, beta G, and F. nucleatum accounted for 53% of the variability in mean attachment loss; model 4: age, NE, and F. nucleatum explained 35% of the variability in a single site (first molar) for attachment loss. The results suggest that age, race, smoking packyears, beta G, NE, MPO, F. nucleatum, P. gingivalis and P. intermedia are risk indicators for periodontal disease in this racially diverse urban population. Regression models which include multiple variables (i.e., demographic factors, GCF enzymes and periodontopathic bacteria) can be used to estimate periodontal disease status.

A longitudinal study of various crevicular fluid components as markers of periodontal disease activity.

Abstract: In order to examine the relationship of possible crevicular biochemical parameters to attachment loss (ALOSS), 330 sites from 8 untreated adult patients were monitored longitudinally at 3-month intervals, for up to 1 year. Attachment levels were measured with a force-sensing probe and an acrylic stent in duplicates at each study point. Crevicular samples were collected and used for the determination of the following 11 markers: number of polymorphonuclear leukocytes (PMNs), prostaglandin E2 (PGE2), osteocalcin (OC), alkaline phosphatase (ALP), collagenase (COL), beta-glucuronidase (BG), antigenic and functional elastase (AEL and FEL), alpha-1 antitrypsin (a1AT), alpha-2 macroglobulin (a2M) and aspartate aminotransferase (AST). 10 sites with ALOSS of > or = 1.5 mm per 3 months (active sites) and 43 sites with negligible changes (inactive sites) were identified. Total amounts of ALP, BG and COL were found to be significantly higher in active as compared to inactive sites, prior to significant ALOSS, without any significant differences in crevicular fluid volume and clinical indices. When biochemical parameters were expressed as ratios to the number of PMNs, PGE2/ PMNs was significantly elevated in active sites. The capacity of such individual parameters to distinguish between active and inactive sites was limited. However, linear discriminant analysis using total amounts of PGE2, COL, ALP, a2M, OC and AEL showed more significant diagnostic values (sensitivity: 80%, specificity: 91%). These findings suggest that the combination of several biochemical parameters in crevicular fluid could give more information to predict future clinical ALOSS.

Determinants of gingival overgrowth severity in organ transplant patients. An examination of the rôle of HLA phenotype.

Abstract: The role of HLA phenotype as a risk factor for drug-induced gingival overgrowth was investigated in a cohort of 172 transplant recipients. Clinically significant overgrowth warranting surgical correction was observed in 72 patients (42%). Using stepwise regression modelling. 6 clinical parameters were identified as significant risk factors for the severity of gingival overgrowth. These were; age. sex. creatinine plasma level, duration of therapy, papilla bleeding index and concomitant medication with a calcium channel blocking drug. 3 HLA alleles were also identified as risk factors when adjusted for other clinically significant risk factors (HLA -DR2, A24, B37). However, when the p-values for the HLA variables were corrected to compensate for the use of multiple significance testing, only HLA-B37 remained statistically significant at the 5% level. Organ transplant patients are at risk of developing gingival overgrowth, with approximately 25% medicated with cyclosporin alone requiring corrective gingival surgery. This figure more than doubles in patients concomitantly medicated with a calcium blocking drug. The data at present available would suggest that the severity of gingival overgrowth is also significantly associated with the HLA-B37 phenotype.

The onset of diabetes and poor metabolic control increases gingival bleeding in children and adolescents with insulin‐dependent diabetes mellitus

Abstract: Gingival health (bleeding on probing) and oral hygiene (plaque percent) were assessed in 2 groups of children and adolescents with insulin-dependent diabetes mellitus (IDDM). 1st study group included 12 newly diagnosed diabetic children and adolescents (age range 6.3-14.0 years, 5 boys and 7 girls). They were examined on the 3rd day after initial hospital admission and at 2 weeks and 6 weeks after initiation of insulin treatment. Gingival bleeding decreased after 2 weeks of insulin treatment (37.8% versus 19.0%, p < 0.001, paired t-test), and remained at the same level when examined 1 month later while glucose balance was excellent. Another group (n = 80) of insulin-dependent diabetic children and adolescents (age range 11.7-18.4 years, 44 boys and 36 girls) with a mean duration of diabetes 6.0 years (range 0.3-15.0 years) were examined 2x at 3-month intervals. Subjects with poor blood glucose control (glycosylated haemoglobin, HbA1, values over 13%) had more gingival bleeding (46.3% on examination 1, 41.7% on examination 2) than subjects with HbA1 values less than 10% (mean gingival bleeding 35.2% and 26.9%, respectively) or subjects with HbA1 values between 10 to 13% (mean gingival bleeding 35.6% and 33.4%, respectively). Differences were significant on both examinations (p < 0.05, Anova), and remained significant after controlling the groups for differences in age, age at the onset of diabetes, duration of diabetes and pubertal stage (Ancova). Results were not related to differences or changes in dental plaque status, supporting the concept that imbalance of glucose metabolism associated with diabetes predisposes to gingival inflammation. An increase in gingival bleeding in association with hyperglycaemia suggests that hyperglycaemia-associated biological alterations, which lower host resistance toward plaque, have apparently taken place. Consequently, although not all gingivitis proceeds into a destructive periodontal disease, prevention of plaque-induced gingival inflammation should be emphasised, particularly in children and adolescents with poorly controlled diabetes.

Full- versus partial-mouth disinfection in the treatment of periodontal infections : a pilot study : long-term microbiological observations

Abstract: A standard periodontal treatment consists of 4 to 6 scalings and rootplanings at a 1- to 2-week interval, which allows reinfection of a previously disinfected area before completion of the treatment. The present pilot study aims to examine the microbiological long-term effects of a full-mouth disinfection. 10 patients with advanced chronic periodontitis were randomly allocated to a test and control group. The patients from the control group received scaling and rootplaning and oral hygiene instructions at a 2-week interval. The full-mouth disinfection (test group) consisted of a full-mouth scaling and rootplaning in 2 visits within 24 h in combination with: tongue brushing with 1% chlorhexidine gel for 1 min, mouth rinsing with 0.2% chlorhexidine solution for 2 min and subgingival irrigation of all pockets (3x in 10 min) with 1% chlorhexidine gel. The patients of the test group were instructed to rinse 2x daily with 0.2% chlorhexidine. Plaque samples were taken at baseline and after 1, 2, 4 and 8 months. Differential phase-contrast microscopy showed a significantly larger reduction of spirochetes and motile organisms in the test group up to month 2 for the single-rooted and up to month 8 for the multi-rooted teeth. Furthermore, the culture data supported the effectiveness of the new treatment strategy. In both groups, the number of anaerobic CFU decreased 1 log around single- and 0.5 log around multi-rooted teeth. The number of anaerobic CFU remained low in the test group, in contrast to the control group. At 1 month, the test group harboured a significantly (p<0.01) lower proportion of pathogenic organisms, but this difference disappeared with time. Moreover, the test sites showed a significantly higher (p<0.02) increase in the proportion of beneficial micro-organisms up to 4 months. These findings suggest that a full-mouth disinfection leads to a significant microbiological improvement up to 2 months, which could be consolidated, although not significant, for the next 6 months.

Prevalence of 6 putative periodontal pathogens in subgingival plaque samples from Romanian adult periodontitis patients

Abstract: The aim of the present study was to determine by standard cultivation procedures the detection frequencies of Porphyromonas gingivalis, Prevotella intermedia, Fusobacterium nucleatum. Actinobacillus actinomycetemcomitans, Bacteroides forsythus, and Capnocytophaga species as well as various enteric rods in subgingival plaque samples form Romanian adult periodontitis patients. DNA probe analysis (AffirmTM DP Microbial Identification Test) was also used, parallel to cultivation, to identify P. gingivalis. A. actinomycetemcomitans, and B. for- sythus, in deep (≥6 mm) and intermediate (4–5 mm) pockets in some of the subjects investigated. Paper points were used to sample 86 deep pockets in 36 patients and 27 intermediate pockets in 9 of the 36 patients. The x2 test was used to test for significance of differences between results obtained by cultivation and DMA analysis in both intermediate and deep pockets. P. gingivalis was recovered in a high percentage of the patients (75,8%) and sites (63.6%) examined, followed by P. intermedia, F. nucleatum, and A. actinomycetemcomitans, respectively. Capnocytophaga species were present in almost all subjects. Enteric rods were recovered in 61.1% of the patients and 55.8% of the sites. Except for this high prevalence of enteric rods, the present group of patients had the periodontal species monitored in %s similar to those commonly perceived in the West. The Affirm M DP Test and cultivation showed poor correlation in detecting P. gingivalis. A. actinomycetemcomitans, and B. forsythus. The cultivation prevalence of P. gingivalis and P. intermedia in deep pockets was similar to their prevalence in intermediate ones. Overall, the prevalence of the periodontal pathogens investigated in the present Romanian periodontitis patients is similar to what has been revealed in matching Norwegian and other Western periodontitis patient populations. The high prevalence of enteric rods in the Romanian patients may have been an artifact resulting from prolonged transport of the samples in VMGA III.

Comparison of a sonic and a manual toothbrush for efficacy in supragingival plaque removal and reduction of gingivitis.

Abstract: A new sonic electric toothbrush (Sonicare) and a traditional manual toothbrush were compared for efficacy in removing supragingival plaque and reducing gingival inflammation in a 12-week, single-blind clinical trial. 60 subjects with a gingival index (GI) of > 1.5 and no probing depths > 5 mm were randomly assigned to use either the manual or sonic brush, instructed in its use, and asked to brush each morning and evening for 2 minutes. Plaque scores were taken at baseline and at 1, 2, 4, and 12 weeks using the Turesky modification of the Quigley-Hein plaque index. Gingival inflammation was assessed by the GI, bleeding tendency score, presence or absence of bleeding on probing, volumetric measurements of gingival crevicular fluid (GCF), and aspartate aminotransferase (AST) levels in GCF. Repeated measures multivariate analyses of variance were used to detect time- and device-dependent differences for all clinical assessments between the 2 groups over the 5 visits. Both types of brush were effective in removing supragingival plaque. The sonic brush was statistically superior, on a percentage reduction basis, in removing supragingival plaque from the dentition taken as a whole (F-statistic; p = 0.012) and was particularly better in hard-to-reach areas such as posterior teeth (F-statistic; p = 0.003) and interproximal sites (F-statistic; p = 0.004). Both devices were equally effective in reducing gingival inflammation. The sonic brush exhibited less tendency to cause gingival abrasion than the manual brush (1 incident with sonic, 5 incidents with manual), confirming the safety of this product as an oral hygiene device.

Fibrin glue application in conjunction with tetracycline root conditioning and coronally positioned flap procedure in the treatment of human gingival recession defects

Abstract: A split-mouth clinical study was designed to determine the effect of fibrin glue (FG) in addition to tetracycline HCI (TTC) root conditioning and the coronally positioned flap (CPF) procedure in the treatment of maxillary buccal recession defects. 11 patients presenting with a pair of Class I or II recession defects were selected. After initial therapy, defect-specific and full-mouth oral hygiene standards and gingival condition, recession depth, recession width, probing depth, attachment level, and width of keratinized gingiva were recorded. The surgical procedure included elevation of a full split thickness flap, root debridement and root conditioning with a 10 mg/ml TTC solution for 4 minutes. According to a randomization list, in each patient, 1 defect was treated with topical FG application, while the paired defect did not receive FG. The flap was adapted and sutured coronally to the cemento-enamel junction without tension. Healing was evaluated 6 months postsurgery. Significant recession depth reduction and attachment gain were observed for both treatments. Average root coverage amounted to 65% in FG treated defects and 55% in defects treated with TTC conditioning only. There were no clinical and statistical significant differences between the treatments for any parameter considered. This study suggests that FG may not meaningfully enhance the outcome of the CPF procedure with TTC root conditioning.

Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans and Treponema denticola detection in oral plaque samples using the polymerase chain reaction.

Abstract: Detection of putative pathogens is critical for delineating the etiology and progression of periodontitis. In the present study, we have used a polymerase chain reaction (PCR) assay utilizing primers specific for the lkt A gene of Actinobacillus actinomycetemcomitans, the fimbrial gene of Porphyromonas gingivalis, and tdp A gene of Treponema denticola in order to determine the presence of these pathogens in subgingival plaque samples from periodontitis sites. These gene specific primers were also used to assess the detection of different strains of bacteria in the PCR assays. Primers for P. gingivalis detected P. gingivalis strain 33277, but no product was detected when primers were used with extracts from 4 species of Capnocytophaga, 3 species of Prevotella, 2 species of Porphyromonas other than P. gingivalis, Bacteroides levii, Escherichia coli, 3 strains of A. actinomycetemcomitans and 3 strains of T. denticola. PCR analysis using primers for the lkt A gene of A. actinomycetemcomitans also did not result in a product with any of these bacteria with the exception of a positive result with 3 different strains of A. actinomycetemcomitans. Primers selected from the tdp A gene of T. denticola did not identify any of the bacteria strains tested except T. denticola serovars a, b, and c. Thus, these primers were shown to amplify gene segments that are specific to either P. gingivalis (33277), A. actinomycetemcomitans (33384, 43717 and 43718) or T. denticola (35405, 33521 and 35404). The PCR assay may be used to rapidly detect the presence of periodontal pathogens in the future.

Toothbrushing force in relation to plaque removal

Abstract: This was a 2-part study. The purpose of the 1st part was to examine the relationship between brushing force and plaque removal efficacy comparing a regular manual toothbrush (M) with an electric toothbrush the Braun/Oral-B Plak Control (B). The study consisted of a single oral prophylaxis followed by 5 experiments which differed solely in respect to toothbrushing force. At baseline (after 24-h plaque accumulation), the amount of dental plaque was evaluated and subsequently, the subject's mouth was brushed by a dental hygienist. Brushing was carried out in a random split-mouth order. Either the 1st and 3rd quadrants or the 2nd and 4th quadrants were brushed with 1 toothbrush and the 2 remaining quadrants with the other. The available time for the brushing procedure was 2 min. After brushing, the amount of remaining dental plaque was assessed. The force used in experiment 1 through 5 was 100, 150, 200, 250, 300 g, respectively. The results show that when brushing force is increased, more plaque is removed with either of the two brushes. Except for the high brushing force (300 g), the electric toothbrush removed more plaque than the manual brush. The purpose of the 2nd part was to evaluate the habitual brushing force which individuals use with various toothbrushes. Besides a manual toothbrush (M), 3 electric toothbrushes were examined, the Rotadent (R), Interplak (I) and Braun (B). 20 subjects were selected on the basis of being 'good brushers' (plaque score at screening < 25%). At baseline, each subject randomly received 1 of the 4 brushes. They were allowed a training period of 3 weeks at the end of which they were asked to abstain from brushing for at least 24 h. The plaque (Turesky modification of the Quigley & Hein) was scored, after which the subjects brushed their teeth (2 min) with the assigned toothbrush equipped with a strain gauge. A computer set-up measured (100 Hz) and calculated the mean brushing force. After brushing, the amount of remaining plaque was assessed. The design of the study was a 4-way cross-over. The results show that with a manual brush, considerably more force is used than with the electric brushes (R = 96, I = 119, B = 146, M = 273). No significant relation between brushing force and plaque removal was demonstrated for any of the brushes.