Showing papers in "Periodontology 2000 in 2018"
TL;DR: To limit the use of antibiotics and to avoid accumulation of harmful effects by repeated therapy, further efforts must be made to optimize procedures addressing the microbial colonization and recolonization of the periodontal pocket.
Abstract: The aim of this paper was to evaluate strategies for periodontal therapy from the perspective of periodontal disease being a consequence of microbial colonization of the periodontal pocket environment. In classic bacterial infections the diversity of the microbiota decreases as the disease develops. In most cases of periodontitis, however, the diversity of the flora increases. Most incriminating bacteria are thought to harm tissues significantly only if present in high numbers over prolonged periods of time. Clinical trials have repeatedly demonstrated that scaling and root planing, a procedure that aims to remove subgingival bacterial deposits by scraping on the tooth surface within the periodontal pocket, is effective. At present, for the therapy of any form of periodontal disease, there exists no protocol with proven superiority, in terms of efficiency or effectiveness, over scaling and root planing plus systemic amoxicillin and metronidazole. Some exponents advocate rationing these drugs for patients with a specific microbial profile. However, the evidence for any benefit of bacteriology-assisted clinical protocols is unsatisfactory. Treated sites are subject to recolonization with a microbiota similar to that present before therapy. The degree and speed of recolonization depends on the treatment protocol, the distribution patterns of periodontal microorganisms elsewhere in the oral cavity and the quality of the patient's oral hygiene. To limit the use of antibiotics and to avoid accumulation of harmful effects by repeated therapy, further efforts must be made to optimize procedures addressing the microbial colonization and recolonization of the periodontal pocket.
186 citations
TL;DR: The potential role of dental health-care professionals in helping patients control the risk factors that are identical for periodontitis and diabetes is explored, and various topics that still need exploration in future research are suggested.
Abstract: This report provides a comprehensive overview of the adverse effects of hyperglycemia on the periodontium. It combines data from literature reviews of original data from two large, population-based epidemiologic studies with comprehensive periodontal health assessment. Emphasis is placed on the exploration of hitherto sparsely reported effects of prediabetes and poorly controlled (uncontrolled) diabetes, in contrast to the umbrella term "diabetes." This stems from the realization that it is not simply having a diagnosis of diabetes that may adversely affect periodontal health. Rather, it is the level (severity) of hyperglycemia that is the determining factor, not the case definition of the diagnosis of diabetes or the type of diabetes in question. Importantly, based on existing evidence this paper also attempts to estimate the improvements in periodontal probing depth and clinical attachment level that can be expected upon successful nonsurgical periodontal treatment in people with chronic periodontitis, with and without diabetes, respectively. This exploration includes the implentation of new systematic reviews and meta-analyses that allow comparison of such intervention outcomes between hyperglycemic and normoglycemic subjects. Based on both existing literature and original analyses of population-based studies, we try to answer questions such as: Is there a glycated hemoglobin concentration threshold for periodontitis risk? Does short-term periodontal probing depth reduction and clinical attachment level gain after scaling and root planing depend on glycemic control in type 2 diabetes? Are short-term scaling and root planing outcomes in people with hyperglycemia/diabetes inferior to those in people without diabetes? Do periodontitis patients with diabetes benefit more from the use of adjuvant antibiotics with nonsurgical periodontal treatment than people without diabetes? Does hyperglycemia lead to greater tooth loss in patients in long-term post-periodontal treatment maintenance programs? Throughout this review, we compare our new findings with previous data and report whether the results of these new analyses corroborate, or are in discord with, similar scientific reports in the literature. We also explore the potential role of dental health-care professionals in helping patients control the risk factors that are identical for periodontitis and diabetes. Finally, we suggest various topics that still need exploration in future research.
123 citations
TL;DR: This article describes in detail the process of patient selection, indications, contraindications, diagnosis, treatment planning and treatment execution required to achieve functional and esthetic success with immediate implant placement and provisionalization.
Abstract: An inevitable loss of soft and hard tissue after tooth extraction often results in a compromised site for anterior implant esthetics in both vertical and horizontal dimensions. Immediate implant placement and provisionalization has been a viable option for replacing failing maxillary anterior teeth as it preserves the vertical existing osseous and gingival architecture. With the simultaneous addition of soft- and hard-tissue grafts, the peri-implant horizontal tissue topography can also be maintained. The esthetic success of immediate implant placement and provisionalization procedures is influenced by a number of factors that can be identified as patient-dependent or clinician-dependent. This article describes in detail the process of patient selection, indications, contraindications, diagnosis, treatment planning and treatment execution required to achieve functional and esthetic success with immediate implant placement and provisionalization.
117 citations
TL;DR: The transmucosal component of the restored implant shares some common features with teeth, namely the presence of a junctional epithelium and a connective tissue component, but there are some important differences that make implants more susceptible to disease initiation and progression.
Abstract: The integrity of the peri-implant soft-tissue seal is crucial for maintaining peri-implant tissue health. Whilst the transmucosal component of the restored implant shares some common features with teeth, namely the presence of a junctional epithelium and a connective tissue component, there are some important differences. A key difference is the nature of the relationship of the connective tissue with the implant surface, whereby there is 'adaptation' of collagen fibers in a parallel orientation in relation to the implant, but insertion of fiber attachment perpendicularly into cementum in the case of teeth. This, combined with reduced cellularity and vascularity in the peri-implant connective tissue, may make implants more susceptible to disease initiation and progression. Furthermore, the presence of a subgingival connection between the implant and the abutment/restoration poses some specific challenges, and maintaining the integrity of this connection is important in preserving peri-implant tissue health. Implant design features, such as the nature of the connection between the implant and the abutment, as well as the surface characteristics of the abutment and implants, may influence the maintenance of the integrity of soft tissue around implants. Iatrogenic factors, such as incorrect seating of the abutment and/or the restoration, and the presence of residual subgingival cement, will lead to loss of soft-tissue integrity and hence predispose to peri-implant disease.
114 citations
TL;DR: The identification of pro-resolving lipid mediators as well as small molecule biologicals that influence inflammatory responses offers the best potential, at the present time, for the development of novel host response modulators in periodontal therapy, but much research remains to be done to confirm safety and efficacy.
Abstract: Host modulation therapy refers to a treatment concept in which drug therapies are used as an adjunct to conventional periodontal treatment to ameliorate destructive aspects of the host inflammatory response. This strategy is not new in the treatment of periodontitis. Previously, nonsteroidal anti-inflammatory drugs have been investigated in this regard, with evidence of reductions in alveolar bone resorption when these drugs are used for prolonged periods of time. However, the risk of significant unwanted effects precludes the use of both nonselective nonsteroidal anti-inflammatory drugs and the selective cyclooxygenase-2 inhibitors as adjunctive treatments for periodontitis. Currently, the only available adjunctive host response modulator that is licensed for the treatment of periodontitis is subantimicrobial dose doxycycline, which functions as an inhibitor of matrix metalloproteinases. Although clinical benefits have been shown in carefully conducted randomized controlled trials, the efficacy of subantimicrobial dose doxycycline in routine clinical practice has yet to be determined. Anti-cytokine therapies have been developed for use in the treatment of rheumatoid arthritis, the pathogenesis of which bears many similarities to that of periodontitis; however, the significant risk of unwanted effects (as well as cost and lack of human trials in the treatment of periodontal diseases) precludes the use of any of the currently available anti-cytokine therapies in the treatment of periodontitis. The identification of pro-resolving lipid mediators as well as small molecule biologicals that influence inflammatory responses offers the best potential, at the present time, for the development of novel host response modulators in periodontal therapy, but much research remains to be done to confirm safety and efficacy.
113 citations
TL;DR: Regular maintenance and good oral hygiene are essential for a predictable outcome and long-term stability in peri-implant pockets, and a more informed decision can be made regarding whether to use a resective or a regenerative surgical technique.
Abstract: Peri-implant and periodontal pockets share a number of anatomical features but also have distinct differences. These differences make peri-implant pockets more susceptible to trauma and infection than periodontal pockets. Inadequate maintenance can lead to infections (defined as peri-implant mucositis and peri-implantitis) within peri-implant pockets. These infections are recognized as inflammatory diseases, which ultimately lead to the loss of supporting bone. Diagnostic and treatment methods conventionally used in periodontics have been adopted to assess and treat these diseases. Controlling infection includes elimination of the biofilm from the implant surface and efficient mechanical debridement. However, the prosthetic supra-structure and implant surface characteristics can complicate treatment. Evidence shows that when appropriately managed, peri-implant mucositis is reversible. Nonsurgical therapy, with or without the use of antimicrobials, will occasionally resolve peri-implantitis, but for the majority of advanced lesions this approach is insufficient and surgery is indicated. The major objective of the surgical approach is to provide access and visualize the clinical situation. Hence, a more informed decision can be made regarding whether to use a resective or a regenerative surgical technique. Evidence shows that following successful decontamination, surgical treatment to regenerate the bone can be performed, and a number of regenerative techniques have been proposed. After treatment, regular maintenance and good oral hygiene are essential for a predictable outcome and long-term stability.
105 citations
TL;DR: In this article, the authors investigated the role of inflammatory and immune cells and macromolecules in the formation of a pocket in periodontitis, and they found that the inflammatory cells are discharged at the sulcus bottom and face a relatively small biofilm surface in the gingival sulcus.
Abstract: The conversion of junctional epithelium to pocket epithelium is regarded as a hallmark in the development of periodontitis. Knowledge of factors contributing to the initiation and progression of pocket formation is important and may result in the development of better preventive measures and improve healing outcomes after therapeutic interventions. The periodontal pocket is a pathologically deepened gingival sulcus. In healthy periodontal conditions, the defense mechanisms are generally sufficient to control the constant microbiological challenge through a normally functioning junctional epithelium and the concentrated powerful mass of inflammatory and immune cells and macromolecules transmigrating through this epithelium. In contrast, destruction of the structural integrity of the junctional epithelium, which includes disruption of cell-to-cell contacts and detachment from the tooth surface, consequently leading to pocket formation, disequilibrates this delicate defense system. Deepening of the pocket apically, and also horizontal expansion of the biofilm on the tooth root, puts this system to a grueling test. There is no more this powerful concentration of defense cells and macromolecules that are discharged at the sulcus bottom and that face a relatively small biofilm surface in the gingival sulcus. In a pocket situation, the defense cells and the macromolecules are directly discharged into the periodontal pocket and the majority of epithelial cells directly face the biofilm. The thinning of the epithelium and its ulceration increase the chance for invasion of microorganisms and their products into the soft connective tissue and this aggravates the situation. Depending on the severity and duration of disease, a vicious circle may develop in the pocket environment, which is difficult or impossible to break without therapeutic intervention.
98 citations
TL;DR: The clinician is often confronted with a challenge regarding the optimal decision-making process for providing a solution using dental implants, because, after tooth extraction, alveolar bone loss and structural and compositional changes of the covering soft tissues, as well as morphological alterations, can be expected.
Abstract: In the esthetic zone, in the case of tooth extraction, the clinician is often confronted with a challenge regarding the optimal decision-making process for providing a solution using dental implants. This is because, after tooth extraction, alveolar bone loss and structural and compositional changes of the covering soft tissues, as well as morphological alterations, can be expected. Ideally, the therapeutic plan starts before tooth extraction and it offers three options: spontaneous healing of the extraction socket; immediate implant placement; and techniques for preserving the alveolar ridge at the site of tooth removal. The decision-making process mainly depends on: (i) the chosen time-point for implant placement and the ability to place a dental implant; (ii) the quality and quantity of soft tissue in the region of the extraction socket; (iii) the remaining height of the buccal bone plate; and (iv) the expected rates of implant survival and success. Based on scientific evidence, three time-periods for alveolar ridge preservation are described in the literature: (i) soft-tissue preservation with 6-8 weeks of healing after tooth extraction (for optimization of the soft tissues); (ii) hard- and soft-tissue preservation with 4-6 months of healing after tooth extraction (for optimization of the hard and soft tissues); and (iii) hard-tissue preservation with > 6 months of healing after tooth extraction (for optimization of the hard tissues).
96 citations
TL;DR: This review focuses on the pathological changes that occur during the progression of gingivitis into periodontitis through discussing the molecular, cellular and immunohistochemical aspects of the inflammatory process.
Abstract: Two common diseases - gingivitis and periodontitis - affect the periodontium. Symptoms of disease entities are used for distinguishing various forms of gingivitis and periodontitis. Gingivitis follows a linear and progressive course when a healthy individual stops oral care, as shown by the experimental gingivitis model. It is not known if and when gingivitis transforms into periodontitis. A very limited number of studies present direct evidence regarding the histological changes over time and how they correlate to the clinical transition from gingivitis to periodontitis. This review focuses on the pathological changes that occur during the progression of gingivitis into periodontitis through discussing the molecular, cellular and immunohistochemical aspects of the inflammatory process. Molecular pathways regulating periodontal inflammation also determine the outcomes of disease and healing. Treatment of inflammatory diseases, particularly periodontitis in which extensive tissue damage could result from the inflammatory process, needs to target full restoration of the lost tissues. This can only be accomplished by a thorough understanding of the activation and resolution of periodontal disease and of the molecular events that occur during these phases.
82 citations
TL;DR: The long axis of the implant, aiming at the incisal edge of the future restorations, is the most appropriate implant position when a shoulder-less abutment is used and allows a restorative crown morphology with a cervical contour resembling a natural tooth.
Abstract: Patient expectations from implant treatment have changed over the years and esthetics plays an important role in defining what is now called success of rehabilitation. Of the many factors that influence the outcome of the rehabilitation, the two main ones are the bone and soft-tissue deficiencies at the intended implant site. Many surgical approaches are described in terms of timing of implant placement and management of regenerative procedures. The aim of this article is to discuss the different implant placement alternatives in the esthetic area, in particular: (i) the timing of implant placement/regenerative procedures/skeletal growth/altered passive eruption; (ii) the correct three-dimensional position of the fixture between the cuspids and in the premolar area; (iii) multiple missing teeth in the esthetic area with single tooth/pontic or cantilevered options/prosthetic compensation; (iv) placement of implants into infected sites; and (v) the influence of abutment and crown morphology on implant position. Combining our long-standing clinical experience and the pertinent literature, the following conclusions can be drawn: Immediate implant placement can be a successful procedure in terms of esthetics but it is technique sensitive and requires an experienced team. Immediate placement is less traumatic to the patient as fewer surgical procedures are involved and patients tend to prefer this clinical approach with regards to quality of life. The diagnostic phase is of utmost importance, with not only bone and soft tissue deficiencies being addressed but also: skeletal growth, dental/implant soft tissue parameters such as altered passive eruption and the morphology of the roots adjacent to the edentulous area. Post-extraction immediate loading is feasible in infected sites. The correct position of the fixture should follow widely accepted guidelines but the abutment morphologies play a role in the vestibular/palatal position of the implant. The long axis of the implant, aiming at the incisal edge of the future restorations, is the most appropriate implant position when a shoulder-less abutment is used and allows a restorative crown morphology with a cervical contour resembling a natural tooth. The use of a shoulder-less abutment gives more space for the tissue to grow compared with the traditional abutment with shoulder finish line.
81 citations
TL;DR: This narrative review presents a brief historical overview of dental calculus formation and its clinical relevance in modern periodontal practice.
Abstract: Dental calculus represents the first fossilized record of bacterial communities as a testimony of evolutionary biology. The development of dental calculus is a dynamic process that starts with a nonmineralized biofilm which eventually calcifies. Nonmineralized dental biofilm entraps particles from the oral cavity, including large amounts of oral bacteria, human proteins, viruses and food remnants, and preserves their DNA. The process of mineralization involves metabolic activities of the bacterial colonies and strengthens the attachment of nonmineralized biofilms to the tooth surface. From a clinical point of view, dental calculus always harbors a living, nonmineralized biofilm, jeopardizing the integrity of the dento-gingival or implanto-mucosal unit. This narrative review presents a brief historical overview of dental calculus formation and its clinical relevance in modern periodontal practice.
TL;DR: Evidence suggests that overweight/obesity contributes to periodontal complications independently of other risk factors, such as age, gender, smoking, or ethnicity, which supports the need for risk assessments for individual patients to facilitate personalized approaches in order to prevent and treatperiodontal diseases.
Abstract: The purpose of this paper was to identify and summarize current evidence describing periodontal complications associated with obesity Electronic searches supplemented with manual searches were carried out to identify relevant systematic reviews Identification, screening, eligibility, and inclusion of studies were performed independently by two reviewers A MeaSurement Tool to Assess systematic Reviews (AMSTAR) was used to assess the quality and risk of bias of the included reviews From 430 titles and abstracts screened, 14 systematic reviews were considered as eligible for inclusion in this meta-review Eight reviews reported on cross-sectional studies investigating the association of obesity and periodontal diseases, 4 included longitudinal studies, 5 addressed response to periodontal therapy, 5 reported on studies investigating biomarkers, and only 2 were related to pediatric population samples Systematic review summaries in the various study design domains (cross-sectional, longitudinal and experimental) report that obese individuals are more likely to have periodontal diseases, with more severe periodontal conditions, than nonobese individuals, with cross-sectional evidence congruent with longitudinal studies showing that obesity or weight gain increases the risk of periodontitis onset and progression Published research on the effect of obesity on responses to periodontal therapy, or systemic or local biomarkers of inflammation, is variable and therefore inconclusive based on the evidence currently available, which suggests that overweight/obesity contributes to periodontal complications independently of other risk factors, such as age, gender, smoking, or ethnicity This evidence supports the need for risk assessments for individual patients to facilitate personalized approaches in order to prevent and treat periodontal diseases
TL;DR: The aim of this review is to analyze the knowledge available on the indications for and the performance of periodontal surgical treatment of residual pockets in terms of 'traditional' (clinical, microbiological), patient-based and systemic health outcomes.
Abstract: The ultimate goal of periodontal therapy is to prevent further disease progression in order to reduce the risk of tooth loss. This objective can be achieved through a number of therapeutic modalities comprising both the nonsurgical and surgical phases of periodontal therapy. Nonsurgical periodontal treatment has been shown to control periodontal infection and to arrest progression of the disease in a significant number of cases. However, despite completion of nonsurgical treatment, a number of periodontal pockets, defined as 'residual', often remain. The presence of residual pockets may jeopardize tooth survival and be a risk factor of further disease progression, and ultimately tooth loss. Therefore, the aim of this review is to analyze the knowledge available on the indications for and the performance of periodontal surgical treatment of residual pockets in terms of 'traditional' (clinical, microbiological), patient-based and systemic health outcomes.
TL;DR: The role of vitamins and minerals and micronutrients in human physiology and the impact of their deficiencies upon periodontal health and disease are reviewed.
Abstract: Periodontitis is a complex chronic inflammatory noncommunicable disease, initiated by the development of a dysbiotic microbial plaque biofilm below the gingival margin. Whilst the pathogenic biofilm is a "necessary cause" of periodontitis, it is insufficient on its own to cause the disease, and a destructive immune-inflammatory response is a key to the translation of risk to destructive events. Other exposures or "component causes" include individual genetic predisposition, lifestyle (including smoking and nutrition), and environmental factors. Dietary nutrients are essential for life as they provide crucial energy sources in the form of macronutrients, as well as important cofactors in the form of micronutrients, which regulate the functionality of enzymes during the regulation of anabolic and catabolic processes in human cells. Moreover, micronutrients can regulate gene transcription factors, such as the proinflammatory nuclear factor kappa B and the anti-inflammatory nuclear factor (erythroid-derived 2)-like 2. This review focuses on the role of vitamins (vitamin A, carotenoids, the vitamin B complex, vitamins C, D, and E, and coenzyme Q10) and minerals (calcium, magnesium, iron, zinc, potassium, copper, manganese, and selenium) in human physiology and the impact of their deficiencies upon periodontal health and disease.
TL;DR: The results suggest that nonsurgicalperiodontal intervention provided to pregnant women is safe and improves periodontal status without preventing adverse pregnancy outcomes.
Abstract: The goal of this review is to summarize the results of randomized trials reported since 2010 that assessed the effect of periodontal interventions on at least one systemic outcome in human subjects of any age, gender or ethnicity Oral outcome measures included gingivitis, pocket depth, clinical attachment loss and/or radiographic bone loss and oral hygiene indices Studies were excluded if the trial was not completed or if treatment was not randomized The results suggest that nonsurgical periodontal intervention provided to pregnant women is safe and improves periodontal status without preventing adverse pregnancy outcomes Nonsurgical periodontal intervention was also found to provide modest improvement in glycemic control in individuals with type 2 diabetes mellitus and periodontitis Also, improving oral care through mechanical or chemical control of dental-plaque biofilm formation can contribute to the prevention of respiratory infections in differing clinical settings, including hospitals and nursing homes, and in patients with chronic obstructive pulmonary disease No clinical trials were reported that tested the effect of periodontal interventions on medical outcomes of atherosclerosis, cardiovascular diseases, stroke, rheumatoid arthritis, Alzheimer's disease, chronic kidney disease or malignant neoplasia
TL;DR: This article presents an evidence-based, prosthetically driven approach for the treatment of edentulous ridges with horizontal defects and the classification of bony defects, the main augmentation techniques, the selection criteria among different surgical procedures for different types of bONY defects, and the advantages, disadvantages and limitations of each technique.
Abstract: The rehabilitation of partially or totally edentulous patients with implant-supported prostheses has become routine, with excellent long-term outcome. A proper implant position is mandatory to achieve good functional and esthetic outcome and may require an adequate amount of alveolar bone and surrounding soft tissue. When this is lacking because of atrophy, sequelae of periodontal disease, traumas or congenital malformations, increased bone volume and/or keratinized mucosa can be obtained by guided bone regeneration, bone-grafting techniques and alveolar bone expansion. This article presents an evidence-based, prosthetically driven approach for the treatment of edentulous ridges with horizontal defects. The classification of bony defects, the main augmentation techniques, the selection criteria among different surgical procedures for different types of bony defects, and the advantages, disadvantages and limitations of each technique, are described in detail.
TL;DR: This volume of Periodontology 2000 explores how new advances in the understanding of periodontitis within a medical model can evolve into new treatment strategies tailor-made for individual patients and not merely based on wholesale treatment paradigms.
Abstract: Personalized medicine is a medical model that involves the tailoring of healthcare - with medical decisions, practices, and/or products being customized to an individual patient. In this model, diagnostic testing is often employed for selecting appropriate and optimal therapies based on the context of a patient's genetic content or other epidemiologic, sociologic, molecular, physiologic, or cellular analyses. With the advent of major advances in periodontal medicine, including genomic discoveries and greater understanding of the multifactorial nature of periodontitis, it seems that the time is ripe to use personalized medicine as a model for personalized periodontics. This volume of Periodontology 2000 explores how new advances in our understanding of periodontitis within a medical model can evolve into new treatment strategies tailor-made for individual patients and not merely based on wholesale treatment paradigms.
TL;DR: The application of proteomic technologies in characterizing the molecular networks present in gingival crevicular fluid, their potential for discovery of biomarkers that are meaningful for clinical practice, and the associated technical challenges are discussed.
Abstract: The discovery of biomarkers for periodontal disease requires an in-depth understanding of the molecular basis of the initiation and progression of the disease. The gingival crevicular fluid is a biological medium suitable for identifying and measuring such biomarkers because it can be easily and noninvasively sampled from the immediate vicinity of the affected tissues. An ever-expanding pool of gingival crevicular fluid proteins associated with periodontal health or disease has been catalogued over the years, particularly with the recent implementation of proteomic technologies. 'Proteomics' refers to the large-scale study of entire arrays of proteins expressed by a genome and present in a cell, tissue, biological fluid or organism. Hence, such technologies provide a broad qualitative and quantitative insight of the proteins present in gingival crevicular fluid. Pertinent studies have amassed on the information gathered to date on protein signatures in periodontal health and disease, and have confirmed the nature of the immunological host response. This review discusses the application of proteomic technologies in characterizing the molecular networks present in gingival crevicular fluid, their potential for discovery of biomarkers that are meaningful for clinical practice, and the associated technical challenges.
TL;DR: An overview on the various possibilities for self-care of residual pockets in patients with periodontitis is provided.
Abstract: Treatment of periodontitis aims to control the infection caused by the periodontal pathogenic flora and includes mechanical debridement of root surfaces to disrupt the supragingival and subgingival biofilm. As periodontal pockets of ≤ 5 mm can be perform in a stable condition and may not need additional therapy, the ability and the willingness of the patient to perform good oral hygiene on a long-term basis are of utmost importance for ensuring long-term success of periodontal treatment. In this context, the aim of all home-care measures must be the optimal control of plaque biofilm in order to prevent or treat gingival inflammation as a primary stage of periodontitis. Despite the fact that toothbrushing and other mechanical cleaning practices are the most important elements for preventing periodontal diseases or their progression, other factors, including education, motivation, manual dexterity and compliance with professional recommendation, provision of time and socio-economic status, as well as risk factors, play a role. The present article provides an overview on the various possibilities for self-care of residual pockets in patients with periodontitis.
TL;DR: The different treatment approaches, reported in the literature, to treat buccal soft-tissue dehiscence are described, with more focus on the prosthetic-surgical-prosthetic approach.
Abstract: Soft-tissue dehiscence at the facial aspect of an osteointegrated implant is a common complication which impacts on the final esthetic result. The etiology and ways of diagnosing this condition are still controversial. Many factors seem to influence the position of the peri-implant soft-tissue margin, and some of these have been studied more carefully than others. Various surgical and combination surgical-prosthetic approaches have been described to treat soft-tissue dehiscence, with the latter appearing to be more predictable. This paper focuses on the factors affecting peri-implant soft-tissue margins and describes the different treatment approaches, reported in the literature, to treat buccal soft-tissue dehiscence, with more focus on the prosthetic-surgical-prosthetic approach.
TL;DR: The purpose of this article is to introduce the successive development of the approach along with underlying ideas on surgical wound healing and to present contemporary clinical scenarios in step-by-step photograph-illustrated sequences, which aim to provide clinicians with guidance to help them integrate tunneling flap procedures into their daily clinical routine.
Abstract: Diverse clinical advancements, together with some relevant technical innovations, have led to an increase in popularity of tunneling flap procedures in plastic periodontal and implant surgery in the recent past. This trend is further promoted by the fact that these techniques have lately been introduced to a considerably expanded range of indications. While originally described for the treatment of gingival recession-type defects, tunneling flap procedures may now be applied successfully in a variety of clinical situations in which augmentation of the soft tissues is indicated in the esthetic zone. Potential clinical scenarios include surgical thickening of thin buccal gingiva or peri-implant mucosa, alveolar ridge/socket preservation and implant second-stage surgery, as well as soft-tissue ridge augmentation or pontic site development. In this way, tunneling flap procedures developed from a technique, originally merely intended for surgical root coverage, into a capacious surgical conception in plastic periodontal and implant surgery. The purpose of this article is to provide a comprehensive overview on tunneling flap procedures, to introduce the successive development of the approach along with underlying ideas on surgical wound healing and to present contemporary clinical scenarios in step-by-step photograph-illustrated sequences, which aim to provide clinicians with guidance to help them integrate tunneling flap procedures into their daily clinical routine.
TL;DR: There is no evidence to suggest that clinical methods to provide periodontal therapies have been developed especially for older individuals, and there is evidence that aging can be associated with periodontally healthy conditions through life and with a high level of tooth retention and function.
Abstract: The present literature review on periodontal complications in aging focuses on the diagnosis, etiology and development of periodontal complications as a complete entity. In addition, the review also focuses on some of the common systemic diseases that either may further add to periodontal complications or, as result of anti-inflammatory treatment, limit the expression of periodontal disease. There is no evidence to suggest that clinical methods to provide periodontal therapies have been developed especially for older individuals. There is evidence that aging can be associated with periodontally healthy conditions through life and with a high level of tooth retention and function. Periodontal complications that are difficult to manage are usually associated with concurrent medical diseases and complications, or with socio-economic factors that limit the ability to provide dental care for the aging population. Currently, some systemic medical conditions are managed with anti-inflammatory medications with positive effects, while slowing the progression and expression of chronic periodontitis. The lack of data from clinical studies on how to manage periodontal complications in aging is obvious.
TL;DR: In this paper, the authors provide accurate descriptions of the surgical and restorative phases of the esthetic crown-lengthening procedure by answering the following questions: what is the ideal surgical flap design? how much supporting bone should be removed? how should the position of the flap margin relate to the alveolar bone at surgical closure? and how the healing phase was managed in relation to the timing and the position in the provisional restoration with respect to the gingival margin.
Abstract: Crown lengthening is one of the most common surgical procedures in periodontal practice. Its indications include subgingival caries, crown or root fractures, altered passive eruption, cervical root resorption and short clinical abutment, and its aim is to re-establish the biologic width in a more apical position. While the procedure in posterior areas of the dentition has been thoroughly investigated, crown lengthening performed for esthetic reasons in the anterior areas is still a matter of debate and an evidence-based technique is not available. This paper provides accurate descriptions of the surgical and restorative phases of the esthetic crown-lengthening procedure by answering the following questions: what is the ideal surgical flap design? how much supporting bone should be removed? how should the position of the flap margin relate to the alveolar bone at surgical closure? and how should the healing phase be managed in relation to the timing and the position of the provisional restoration with respect to the gingival margin?
TL;DR: A narrative review of the etiology, classification and management of altered passive eruption is presented.
Abstract: Altered passive eruption is described as a condition in which the relationship between teeth, alveolar bone and soft tissues creates an excessive display of gingiva, commonly known as a 'gummy smile'. While there are authors who consider altered passive eruption to be a risk to periodontal health, its impact is greatest in terms of oral esthetics. The aim of periodontal management in such cases is not only to improve patient esthetics but also to restore periodontal health by re-establishing the normal relationship between the gingival margin, alveolar bone crest and cemento-enamel junction. The aim of this article is to present a narrative review of the etiology, classification and management of altered passive eruption.
TL;DR: This review provides an update on genome-wide association studies in periodontitis and examines the biological functions of the genes that are nearest to the associations and their implications for disease etiology.
Abstract: This review provides an update on genome-wide association studies in periodontitis. Studies in populations with European ancestry have dominated the landscape of periodontitis genetics studies but, increasingly, studies in Asian populations are being reported. The review also summarizes evidence for suggested associated genetic variations. The loci associated with genome-wide association studies consist of noncoding variations, many of which are predicted to modulate levels of gene expression. In this article, the biological functions of the genes that are nearest to the associations and their implications for disease etiology are also examined. A major challenge in the genetics of periodontitis is identification of the causal variant(s) underlying associations with periodontitis, elucidation of the molecular mechanisms that are potentially affected by the associated variants, and understanding how they contribute to disease phenotypes and traits. This will allow emerging medical initiatives to make clinical use of genetic discoveries. Large collaborative studies, across research centers and across subspecialties and disciplines, will be required to realize the promise of genetic discovery in periodontitis.
TL;DR: In this volume of Periodontology 2000, experienced researchers and clinicians from different subdisciplines of periodontology evaluate: treatment of gingival recession with or without papilla elevation; clinical crown lengthening in the natural dentition and in prosthodontic preparative treatment; periodontal regeneration around natural teeth; and soft-tissue augmentation in edentulous areas.
Abstract: Periodontal plastic surgery comprises an increasing part of clinical periodontology. Clinical trials have traditionally used professionals to judge esthetic outcome, and few studies have addressed patient needs and requests (true end points). Development of universally accepted and validated methods for professional esthetic assessment, together with standardized questionnaires for patient-perceived outcome, may help to provide better insights into the true needs and benefits of periodontal and implant-associated plastic surgery. In this volume of Periodontology 2000, experienced researchers and clinicians from different subdisciplines of periodontology evaluate: treatment of gingival recession with or without papilla elevation; clinical crown lengthening in the natural dentition and in prosthodontic preparative treatment; periodontal regeneration around natural teeth; and soft-tissue augmentation in edentulous areas. Similarly, experts in different areas of implant science address esthetic outcomes with single and multiple implant rehabilitation, alveolar ridge preservation, implant positioning and immediate implant placement in the esthetic zone.
TL;DR: The microbiology, host/inflammatory responses and genetic characteristics of the tobacco-using patient are presented as a framework to aid the practitioner in developing personalized treatment strategies for these patients.
Abstract: The use of various forms of tobacco is one of the most important preventable risk factors for the incidence and progression of periodontal disease Tobacco use negatively affects treatment outcomes for both periodontal diseases and conditions, and for dental implants Tobacco-cessation programs can mitigate these adverse dental treatment outcomes and may be the most effective component of a personalized periodontal treatment approach In addition, heavy alcohol consumption may exacerbate the adverse effects of tobacco use In this review, the microbiology, host/inflammatory responses and genetic characteristics of the tobacco-using patient are presented as a framework to aid the practitioner in developing personalized treatment strategies for these patients These personalized approaches can be used for patients who use a variety of tobacco products, including cigarettes, cigars, pipes, smokeless tobacco products, e-cigarettes and other tobacco forms, as well as patients who consume large amounts of alcohol In addition, principles for developing personalized tobacco-cessation programs, using both traditional and newer motivational and pharmacological approaches, are presented
TL;DR: What is known about the etiology and principles of predictable treatment of patients with chronic periodontitis and how to start individualizing risk and treat some of the authors' patients in a more targeted manner are discussed.
Abstract: Key breakthroughs in our understanding of the etiology and principles of predictable treatment of patients with chronic periodontitis first emerged in the late 1960s and carried on into the mid-1980s. Unfortunately, some generalizations of the evidence led many to believe that periodontitis was a predictable result of exposure to bacterial plaque accumulations over time. For a brief period, the initial plaque concept was translated by some to implicate specific bacterial infections, with both concepts (plaque exposure and specific infection) being false assumptions that led to clinical outcomes which were frustrating to both the clinician and the patient. The primary misconceptions were that every individual was equally susceptible to periodontitis, that disease severity was a simple function of magnitude of bacterial exposure over time, and that all patients would respond predictably if treated based on the key principles of bacterial reduction and regular maintenance care. We now know that although bacteria are an essential initiating factor, the clinical severity of periodontitis is a complex multifactorial host response to the microbial challenge. The complexity comes from the permutations of different factors that may interact to alter a single individual's host response to challenge, inflammation resolution and repair, and overall outcome to therapy. Fortunately, although there are many permutations that may influence host response and repair, the pathophysiology of chronic periodontitis is generally limited to mild periodontitis with isolated moderate disease in most individuals. However, approximately 20%-25% of individuals will develop generalized severe periodontitis and probably require more intensive bacterial reduction and different approaches to host modulation of the inflammatory outcomes. This latter group may also have serious systemic implications of their periodontitis. The time appears to be appropriate to use what we know and currently understand to change our approach to clinical care. Our goal would be to increase our likelihood of identifying those patients who have a more biologically disruptive response combined with a more impactful microbial dysbiosis. Current evidence, albeit limited, indicates that for those individuals we should prevent and treat more intensively. This paper discusses what we know and how we might use that information to start individualizing risk and treat some of our patients in a more targeted manner. In my opinion, we are further along than many realize, but we have a great lack of prospective clinical evidence that must be accumulated while we continue to unravel the contributions of specific mechanisms.
TL;DR: This paper reviews studies that examine the relationship between stress and periodontal diseases, and discusses the different measures used to assess stress, which could help in integrating oral and general health promotion policies.
Abstract: Psychosocial stress plays an important role in periodontal disease through biological and behavioral pathways. In this paper we review studies that examine the relationship between stress and periodontal diseases, and discuss the different measures used to assess stress. Self-reported measures, such as the Perceived Stress Scale and the Stress Appraisal Measure, have traditionally been used to assess stress. Frequent and repeated exposure to stressor(s) leads to wear and tear of the body's systems, resulting in what is known as allostatic load. In recent years, few studies examining the relationship between stress and periodontal diseases have used an aggregate variable, including primary and secondary markers of allostatic load, as a biological marker of stress. While research on the relationship between allostatic load and periodontal disease is still developing, as most of the studies used cross-sectional data, this line of research presents a good opportunity for establishing a composite biological indicator as a risk factor for periodontal disease. Such an indicator is also potentially beneficial for personalized periodontics as it will help to target intervention to specific levels of risk and will help in integrating oral and general health promotion policies.
TL;DR: A decision-making process which starts from the clinical observation of the defects and is structured in progressive nodes that will guide the clinician through the most suitable surgical technique to achieve the ideal esthetic outcome is suggested.
Abstract: The primary indication for treatment of gingival recessions is esthetics. In the last decades, patients have become increasingly more demanding in the esthetic outcome expected. In order to obtain a successful final result, periodontal plastic surgery should provide not only complete root coverage but also perfect blending in terms of color and texture. In the literature, many techniques have been demonstrated to be effective in obtaining complete root coverage, and the selection of one surgical technique over another depends on several factors related to the anatomic characteristics of the defect. The purpose of this paper was to suggest a decision-making process which starts from the clinical observation of the defects and is structured in progressive nodes that will guide the clinician through the most suitable surgical technique to achieve the ideal esthetic outcome.