Comparative Efficacy of Different Flapless Ridge Preservation Techniques: A Systematic Review and Meta-Analysis.

Although the efficacy of ridge preservation is well documented, there is a lack of robust evidence regarding the influence of different surgical techniques. Flapless approaches are thought to be better at preserving soft tissue architecture and have been suggested for mild to moderate defects. This review investigates the efficacy of different flapless techniques for ridge preservation in mild to moderate defects with <50% buccal bone loss. PubMed, EMBASE, and Cochrane Library databases were searched to obtain relevant articles published in English from 1974 to December 2019. The primary outcome was horizontal and vertical hard tissue dimensional changes. Soft tissue changes were evaluated as a secondary outcome. The Bio-Col technique, subperiosteal tunnel technique, and hard tissue with autogenous soft tissue graft/collagen matrix technique were identified. Eight studies were included, and quantitative analyses were performed for 4 studies for the primary outcome variables. The meta-analysis revealed significant reductions for horizontal changes (weighted mean difference [WMD] = 2.56 mm, 95% CI [2.18, 2.95]), vertical mid-buccal (WMD = 1.47 mm, 95% CI [1.04, 1.90]), and vertical mid-lingual (WMD = 1.28 mm, 95% CI [0.68, 1.87]) in favor of flapless ridge preservation techniques. Subgroup analysis based on technique suggests minimal hard tissue differences. The efficacy of flapless ridge preservation techniques on soft tissue changes was inconclusive. In conclusion, flapless ridge preservation techniques are effective for mild to moderate defects. The technique or material used to close the extraction socket does not seem to significantly affect hard tissue changes, while the effect on soft tissue changes warrants further investigation.

The efficacy of probiotics in the management of intra-oral halitosis: a systematic review.

OBJECTIVES: To evaluate the efficacy of probiotics in reducing halitosis of dental origin. METHODS: MEDLINE, EMBASE, and CENTRAL were searched up to and including June 2020. Randomised placebo-controlled, double-blinded clinical trials in systemically healthy adult patients who were given any form of probiotics to manage halitosis of dental origin were included. Primary outcome measures were organoleptic scores and volatile sulphur concentration levels. Secondary outcome measures were microbiologic parameters and quality of life (QOL). RESULTS: Of the 301 potentially relevant articles, eight articles were selected for the review. The risk of bias assessment showed that two studies were of low risk of bias, four studies had some concerns, and two studies had a high risk of bias. The beneficial effect of probiotics could neither be confirmed in periodontally treated patients administered with up to 8 weeks of probiotics, nor in periodontitis patients who received both non-surgical periodontal therapy and adjunctive probiotics up to 90 days. Microbiological findings 1 month after probiotics administration and QOL measures showed no significant differences compared to control. Considerable heterogeneity was observed among probiotic administration protocols. CONCLUSIONS: The available evidence suggests no convincing benefit for the use of probiotics in the management of halitosis. Standardised protocols on recruitment of halitosis subjects and organoleptic measurements are required for future studies on probiotics as an intervention. CLINICAL RELEVANCE: The lack of well-conducted studies with a low risk of bias precludes any clinical recommendation. Further research is needed to verify the efficacy of probiotics in the management of intra-oral halitosis.

Adjunctive probiotics after periodontal debridement versus placebo: a systematic review and meta-analysis.

OBJECTIVE: To comprehensively investigate the efficacy of adjunctive probiotics compared to placebo, using conventional and novel treatment outcomes. MATERIALS AND METHODS: Three databases (MEDLINE, EMBASE, and CENTRAL) were searched. Outcomes included percent change in the total number of deep sites before and after therapy, change in mean probing pocket depth (mm), percentage patients requiring additional therapy, risk for disease progression, and microbiological and immunological results. Meta-analysis was conducted to evaluate treatment effects wherever appropriate. RESULTS: Ten studies were selected from 818 records. Meta-analysis showed that adjunctive probiotics had no additional benefit for percentage change of the total number of deeper sites (≥5 mm, ≥6 mm, ≥7 mm) before and after therapy. No significant difference was observed for mean probing pocket depth reduction at 3 and 6 months. Statistically significant beneficial odds ratios for need for additional therapy (OR = 0.19, 95% CI [0.07-0.56]) and risk of disease progression (OR = 0.32, 95% CI [0.14-0.73]) were observed with probiotic administration. Immunological rather than microbiological outcomes correlated more consistently with clinical findings. No adverse events were reported. CONCLUSIONS: Adjunctive probiotics are safe in systemically healthy individuals and could offer additional patient-level benefits compared to placebo, hence its use can sometimes be justified.

Pterostilbene complexed with cyclodextrin exerts antimicrobial and anti-inflammatory effects.

Resveratrol (RES) is a natural polyphenol with potential as an adjunctive therapeutic modality for periodontitis. However, its inferior pharmacokinetics and toxicity concerns about its commonly used solvent dimethyl sulfoxide (DMSO) hinder translation to clinical applicability. Our study aimed to investigate the comparative antimicrobial properties of RES and its analogues (pterostilbene [PTS], oxyresveratrol [OXY] and piceatannol [PIC]), utilizing 2-hydroxypropyl-ß-cyclodextrin (HPßCD) as a solubiliser, which has a well-documented safety profile and FDA approval. These properties were investigated against Fusobacterium nucleatum, a key periodontal pathogen. PTS demonstrated the most potent antibacterial effects in HPßCD, with MIC > 60-fold lower than that of RES, OXY and PIC. In addition, PTS inhibited F. nucleatum biofilm formation. PTS exerted antimicrobial effects by eliciting leakage of cellular contents, leading to loss of bacterial cell viability. PTS also conferred immunomodulatory effects on F. nucleatum-challenged macrophages via upregulation of antioxidant pathways and inhibition of NF-κB activation. Given the superior antimicrobial potency of PTS against F. nucleatum compared to RES and other analogues, and coupled with its immunomodulatory properties, PTS complexed with HPßCD holds promise as a candidate nutraceutical for the adjunctive treatment of periodontitis.

Influence of periodontal maintenance and periodontitis susceptibility on implant success: A 5-year retrospective cohort on moderately rough surfaced implants.

OBJECTIVES: To investigate the effect of defined versus undefined periodontal maintenance after implant therapy on the prevalence of peri-implant complications. MATERIAL AND METHODS: Two hundred patients who underwent dental implant therapy in the National Dental Centre Singapore (NDCS) from 2005 to 2012 were recruited. One hundred patients had regular periodontal maintenance (defined maintenance programme group, DMP), and the other 100 patients had no documentation of periodontal maintenance (undefined maintenance programme group, UMP). Full-mouth bleeding scores (FMBS), periodontal probing depths (PPD) and peri-implant probing depths (PiPD) were evaluated within 6 months of prostheses delivery (T0 ) and at re-examination (T1 ). Peri-implant bone level changes were analysed radiographically. RESULTS: The mean follow-up time was 6.8 years. Five out of 289 implants were lost (cumulative survival rate = 98.3%). 6.0% of DMP patients and 20.0% of UMP patients had peri-implantitis (p = .003). Peri-implantitis was defined as bleeding on probing, increase in PiPD and peri-implant bone loss ≥ 0.5 mm. At the implant level, 4.0% of the DMP group implants and 17.2% of the UMP group implants were diagnosed with peri-implantitis (p = .0003). One implant in the DMP group and 13 implants in the UMP group had bone loss ≥ 2 mm (p < .0001). Multivariate regression showed that absence of regular maintenance (OR = 0.24, p = .003) was significantly associated with peri-implantitis. CONCLUSIONS: Regular periodontal maintenance was associated with a lower prevalence of peri-implantitis and peri-implant bone loss. Patients with treated periodontitis without regular maintenance after implant placement were at higher risk for developing peri-implantitis.

An Overview of Different Interdental Cleaning Aids and Their Effectiveness.

Optimisation of plaque control is essential for the success of non-surgical and surgical periodontal therapy. This cannot be achieved with brushing alone; hence, there is a need for adjunctive interdental cleaning aids. The aim of this paper is to provide an overview of different interdental cleaning aids and review the literature for consensus on their effectiveness. A literature search of articles in English, up to December 2018, was conducted in Pubmed. High-quality flossing is difficult to achieve, and ineffective routine use of floss may not confer significant benefits over brushing alone. Interdental brushes are more effective than brushing as a monotherapy. They are at least as good if not superior to floss in reducing plaque and gingivitis. Although they are effective for patients regardless of their periodontal status (healthy or active), they are especially indicated in periodontal patients where widened embrasures are common. Added benefits include ease of use, patient acceptance, and recontouring of interdental tissues. Rubberpiks do not demonstrate inferiority to conventional interdental brushes. Wooden interdental aids appear to offer no significant advantage over brushing with respect to plaque removal; they may, however, reduce gingival bleeding. Oral irrigators are a promising tool for reducing gingival inflammation, despite minimal changes to plaque levels. For cleaning around dental implants, oral irrigators and interdental brushes are preferred over floss.

Mesenchymal stem cell exosomes enhance periodontal ligament cell functions and promote periodontal regeneration.

Mesenchymal stem cells (MSCs) are potential therapeutics for the treatment of periodontal defects. It is increasingly accepted that MSCs mediate tissue repair through secretion of trophic factors, particularly exosomes. Here, we investigated the therapeutic effects of human MSC exosome-loaded collagen sponge for regeneration of surgically created periodontal intrabony defects in an immunocompetent rat model. We observed that relative to control rats, exosome-treated rats repaired the defects more efficiently with regeneration of periodontal tissues including newly-formed bone and periodontal ligament (PDL). We also observed that concomitant with this, there was increased cellular infiltration and proliferation. We therefore postulated that MSC exosomes enhanced regeneration through increased cellular mobilisation and proliferation. Using PDL cell cultures, we demonstrated that MSC exosomes could increase PDL cell migration and proliferation through CD73-mediated adenosine receptor activation of pro-survival AKT and ERK signalling. Inhibition of AKT or ERK phosphorylation suppressed PDL cell migration and proliferation. Our findings demonstrated for the first time that MSC exosomes enhance periodontal regeneration possibly by increasing PDL migration and proliferation. This study suggests that MSC exosome is a viable ready-to-use and cell-free MSC therapeutic for the treatment of periodontal defects. STATEMENT OF SIGNIFICANCE: Mesenchymal stem cell (MSC) therapies have demonstrated regenerative potential for the treatment of periodontal defects. However, translation of cellular therapies is hampered by challenges in maintaining optimal cell vitality and viability from manufacturing and storage to final delivery to patients. Although the use of MSCs for tissue repair was first predicated on their differentiation potential, the therapeutic efficacy of MSCs has increasingly been attributed to its paracrine secretion, particularly exosomes or small extracellular vesicles. In this study, MSC exosome-loaded collagen sponge enhanced periodontal regeneration in an immunocompetent rat periodontal defect model without any obvious adverse effects. These findings provide the basis for future development of MSC exosomes as a cell-free strategy for periodontal regeneration.

Effects of root debridement and adjunctive photodynamic therapy in residual pockets of patients on supportive periodontal therapy: A randomized split-mouth trial.

BACKGROUND: The study aims to compare the effects of adjunctive photodynamic therapy (PDT) with scaling and root debridement alone on periodontal parameters and inflammatory cytokines in residual pockets of patients undergoing maintenance therapy. METHODS: 27 subjects, each with at least 2 residual pockets ≥5mm, were recruited for this randomized, split-mouth controlled trial, providing total of 72 sites. Probing pocket depth (PPD), recession, clinical attachment loss (CAL), plaque and bleeding on probing of all sites were examined at baseline, 3 and 6 months. Gingival crevicular fluids (GCFs) were collected to determine levels of IL-1ß, IL-6, IL-8, TNF-α and MMP-8 via enzyme-linked immunosorbent assay. At baseline, all sites received subgingival instrumentation and polishing. In addition, test sites received a single application of PDT using Fotosan® with toluidine blue O solution photosensitizer. At 3 and 6 months, site level analysis was performed for changes in clinical parameters and cytokine level. RESULTS: Based on mixed model analysis, at 3 months, test sites showed significant reduction in CAL (p=0.016) and PPD (p=0.027) (from 6.14±0.28mm to 5.49±0.20mm and 5.42±0.16mm to 4.65±0.18mm respectively) compared to control sites (from 6.32±0.24mm to 6.08±0.17mm and 5.32±0.13mm to 5.15±0.15mm respectively). At 6 months, these differences were no longer significant (p=0.510). Adjunctive PDT did not offer additional reduction in levels of GCF cytokines. CONCLUSIONS: A single application of PDT to residual pockets provided a modest improvement of CAL and PPD over 3 months. Application of adjunctive PDT may lead to faster resolution of residual pockets and may be recommended for periodontal patients with slower healing capacity.

Fact or Fiction? Powered Toothbrushing is More Effective than Manual Toothbrushing.

PURPOSE: To answer the question of whether powered toothbrushing is more effective than manual toothbrushing, this paper reviews various aspects of powered toothbrushes in terms of efficacy, safety, acceptability and special considerations for certain patient groups. Future research directions and gaps in the current knowledge are also discussed. MATERIALS AND METHODS: The literature review was conducted using PubMed. A hand search of the references of the retrieved articles was also performed. RESULTS: Powered toothbrushes have been found to be as effective as manual toothbrushes in removing plaque and reducing gingival inflammation. They are safe with no adverse effects on hard or soft tissues. Among the powered toothbrushes, there is evidence to suggest that rotation-oscillation toothbrushes may be more effective than others. The results seem to suggest that certain special-needs patient groups, such as the elderly and the disabled, may benefit from the use of powered toothbrushes. CONCLUSION: Powered toothbrushes are as effective as manual toothbrushes in facilitating oral hygiene. They may be recommended for certain patient groups to improve the efficacy of oral hygiene measures. More data on the safety and acceptability of powered toothbrushes are necessary.

Implant maintenance for the prevention of biological complications: Are you ready for the next challenge?

With increasing knowledge of wound biology and material sciences, the provision of dental implants as a treatment modality has become increasingly predictable and more commonly used to replace missing teeth. However, without appropriate follow up, peri-implant diseases could develop and affect the long-term success of implants. Currently, there is not enough focus on the prevention of peri-implant diseases, as compared to the definition of the disease, its prevalence, and treatment. In the present study, we aim to summarize various factors influencing the successful maintenance of dental implants and highlight current gaps in knowledge. Factors influencing the successful maintenance of dental implants can be divided into three categories: implant-, dentist-, and patient-related factors. Patients with dental implants are often more dentally aware, and this offers an advantage. Compared to gingiva, peri-implant mucosa responds at a different pace to the bacterial challenge. Dental practitioners should be aware of how treatment protocols affect long-term success, and be vigilant in detecting peri-implant diseases at an early stage. Compared to periodontal maintenance, less longitudinal studies on implant maintenance are available, and therefore, there is a tendency to rely heavily on information extrapolated from the periodontal literature. More studies on the significance of implant maintenance care are required.

Sequential platelet-derived growth factor-simvastatin release promotes dentoalveolar regeneration.

OBJECTIVES: Timely augmentation of the physiological events of dentoalveolar repair is a prerequisite for the optimization of the outcome of regeneration. This study aimed to develop a treatment strategy to promote dentoalveolar regeneration by the combined delivery of the early mitogenic factor platelet-derived growth factor (PDGF) and the late osteogenic differentiation factor simvastatin. MATERIALS AND METHODS: By using the coaxial electrohydrodynamic atomization technique, PDGF and simvastatin were encapsulated in a double-walled poly(D,L-lactide) and poly(D,L-lactide-co-glycolide) (PDLLA-PLGA) microspheres in five different modes: microspheres encapsulating bovine serum albumin (BB), PDGF alone (XP), simvastatin alone (SB), PDGF-in-core and simvastatin-in-shell (PS), and simvastatin-in-core and PDGF-in-shell (SP). The microspheres were characterized using scanning electronic microscopy, and the in vitro release profile was evaluated. Microspheres were delivered to fill large osteotomy sites on rat maxillae for 14 and 28 days, and the outcome of regeneration was evaluated by microcomputed tomography and histological assessments. RESULTS: Uniform 20-µm controlled release microspheres were successfully fabricated. Parallel PDGF-simvastatin release was noted in the PS group, and the fast release of PDGF followed by the slow release of simvastatin was noted in the SP group. The promotion of osteogenesis was observed in XP, PS, and SP groups at day 14, whereas the SP group demonstrated the greatest bone fill, trabecular numbers, and thickest trabeculae. Bone bridging was evident in the PS and SP group, with significantly increased osteoblasts in the SP group, and osteoclastic cell recruitment was promoted in all bioactive molecule-treated groups. At day 28, osteogenesis was promoted in all bioactive molecule-treated groups. Initial corticalization was noted in the XP, PS, and SP groups. Osteoblasts appeared to be decreased in all groups, and significantly, a greater osteoclastic cell recruitment was noted in the SB and SP groups. CONCLUSIONS: Both PDGF and simvastatin facilitate dentoalveolar regeneration, and sequential PDGF-simvastatin release (SP group) further accelerated the regeneration process through the enhancement of osteoblastogenesis and the promotion of bone maturation.

Aminoguanidine inhibits the AGE-RAGE axis to modulate the induction of periodontitis but has limited effects on the progression and recovery of experimental periodontitis: a preliminary study.

BACKGROUND: Advanced glycation end products (AGE) have been found in inflamed gingival tissue and have been shown to interfere with the integrity of extracellular matrix and cell-matrix interactions. This study aims to investigate the modulatory effect of aminoguanidine (AG), an AGE inhibitor, in various stages of experimental periodontitis. METHODS: Thirty-six Sprague-Dawley rats were used. AG or normal saline (NS) was systemically administered in the induction, progression, and recovery phases of ligature-induced periodontitis. Dynamic changes of the periodontium were evaluated by microcomputed tomography, histology, and immunohistochemistry of the receptor for AGE (RAGE). Molecular mechanisms were evaluated by myeloperoxidase activity, gene expression of RAGE, and markers associated with tissue repair and homeostasis, including vascular endothelial growth factor (VEGF), type I collagen, fibronectin, and periostin. RESULTS: AG appeared to inhibit the degradation of the collagen matrix in the induction phase but promoted collagen reorganization in the progression and recovery phases of experimental periodontitis. In the induction sites, periodontal bone loss was significantly reduced (P <0.05), with significantly reduced RAGE (P <0.05) and significantly elevated fibronectin and periostin levels (P <0.01). No significant alterations in the levels of myeloperoxidase, VEGF, and collagen were noted. In the progression and recovery sites, similar trends were observed, with insignificant differences relative to NS-treated animals. CONCLUSIONS: AG reduced periodontal bone loss during the induction of experimental periodontitis, and the effects appeared to be insignificant in the progression and recovery phases. This modulation was related to the inhibition of the AGE-RAGE axis to resume cell-matrix interactions and maintain tissue integrity.

Dual delivery of PDGF and simvastatin to accelerate periodontal regeneration in vivo.

The emphasis on periodontal regeneration has been shifted towards the harmonization of bioactive molecules and physiological phases during regeneration. This study investigated whether the combination and sequential-release of platelet-derived growth factor (PDGF, mitogen) and simvastatin (differentiation factor) facilitated periodontal regeneration. PDGF and simvastatin were encapsulated in double-walled poly-( d,l-lactide) and poly-(d,l-lactide-co-glycolide) (PDLLA-PLGA) microspheres using the co-axial electrohydrodynamic atomization technique. Critical-sized periodontal defects on rat maxillae were filled with microspheres encapsulating BSA-in-core-shell (BB), PDGF-in-shell (XP), simvastatin-in-core and BSA-in-shell (SB), simvastatin-in-core and PDGF-in-shell, or unfilled with microspheres (XX), and examined at 14 and 28 days post-operatively. The resultant microspheres were around 15 µm diameter with distinct core-shell structure, and the fast-release of PDGF followed by slow-release of simvastatin was noted in the SP group. The SP group demonstrated significantly greater bone volume fraction and decreased trabecular separation compared to the XX group at day 14, and milder inflammatory cells infiltration and elevated tartrate-resistant acid phosphatase level were noted at day 28. Fibers were also well-aligned and obliquely inserted onto the root surface similar to native periodontal ligament with signs of cementogenesis in the SP group. In conclusion, the combination and sequential-release of PDGF-simvastatin accelerates the regeneration of the periodontal apparatus.

Tooth loss in compliant and non-compliant periodontally treated patients: 7 years after active periodontal therapy.

AIMS: To investigate the incidence and reasons for tooth loss during active periodontal therapy (APT) and periodontal maintenance (PM) in a specialist institution. MATERIAL AND METHODS: Retrospective data were collected from 273 patients [all compliers (AC)] and cross-sectional data from 39 patients after discontinuation of PM [non-compliers (NC)] for at least 7 years after APT. Descriptive statistics and regression analysis were performed. A comparison was made between AC and NC. The prognostic factors associated with tooth loss during PM were identified. RESULTS: AC lost 1.3 teeth/patient during APT and 0.9 teeth/patient during PM (mean 10.7 years). Tooth loss due to periodontitis was 0.03 teeth/patient/year. The age of 60 was a significant predictor of tooth loss during PM (odds ratio of 2.1). NC lost 1.1 teeth/patient during APT and 2.7 teeth/patient during discontinuation (mean 9.6 years). Tooth loss due to periodontitis was 0.22 teeth/patient/year, a sevenfold increase (p<0.05) compared with AC. Regression analysis failed to identify any significant predictors for tooth loss during the discontinuation of PM. CONCLUSIONS: In this study, the provision of PM led to minimal tooth loss, especially due to periodontitis, for a mean period of 10 years after APT. The completion of APT without PM may predispose patients to lose more teeth compared with patients who undergo PM.

The width of the attached gingiva--much ado about nothing?

OBJECTIVES: This narrative review aims to outline the concepts on the significance of the width of attached gingiva around teeth and implants to enable the clinician to decide on the need for gingival augmentation in different clinical scenarios. DATA AND SOURCES: An electronic search was done on PUBMED & Cochrane Database using the keywords from 1972 to November 2009. A manual hand search was also done in Journal of Periodontology and Journals of Clinical Periodontology for relevant articles under this topic. Any relevant paper from the references was hand searched. A total of 1167 references were obtained, 103 full text papers was retrieved of which 59 articles was selected for this review. CONCLUSIONS: The width of attached gingiva is not significant to maintain periodontal health in the presence of adequate oral hygiene. However, thin gingival tissues around teeth with restorations or undergoing labial orthodontic tooth movement may be more susceptible to recession. The functional need for attached gingiva around implants has not been established but its aesthetic value has been widely accepted.

Diabetes as a risk factor for periodontal disease: current status and future considerations.

INTRODUCTION: Over the past decade, there has been an emerging interest in the interrelationship between systemic conditions and oral health. Diabetes is perhaps one of the best documented conditions that have been closely linked with periodontal disease. This paper reviews the role of diabetes as a risk factor in periodontal disease. The treatment implications in the management of periodontal disease as an integral component of diabetes care is also discussed in light of the current understanding of the pathogenesis of these 2 chronic conditions. MATERIALS AND METHODS: Epidemiological, clinical and laboratory studies examining the relationship between diabetes and periodontal diseases were selected from both medical and dental journals. RESULTS: The severity of periodontal destruction has been shown to be related to the direct and indirect effects of glycaemic control, with other factors also being implicated. Although some studies have pointed towards a bi-directional relationship between glycaemic control and periodontal health, it is still not clear if improvement in periodontal health could lead to improved metabolic control. CONCLUSION: Diabetes and periodontal disease are closely related in many ways, though the effect of periodontal disease on diabetes control remain to be determined, with larger intervention studies. In light of the increasing evidence of the relationship between diabetes and periodontal disease, management of oral health should form an integral part of diabetes management.

Salivary biomarkers associated with academic assessment stress among dental undergraduates.

This study aims to assess the difference in self-perceived stress before and after an academic assessment and its association with the marks scored and to study the association of salivary cortisol, Immunoglobulin A (IgA), and chromogranin A (CgA) with stress levels before and after the assessment. Thirty-one third-year dental undergraduates indicated how stressed they felt on a 5-point rating scale just prior to and immediately after a one-hour written test. Five-minute unstimulated whole saliva samples were also collected at those times to measure salivary cortisol, IgA, and CgA. Students rated significantly higher stress scores before (median [inter quartile range]: 3[1]), compared to after the test (2[2]) (p = 0.015). Higher cortisol levels (mean: 6.32 nmol/l) were observed before than after the exam (mean: 5.16 nmol/l) (p = 0.015). No significant differences were noted between the pre- and post-test saliva samples for salivary IgA and CgA levels. A negative correlation was seen between post-test stress scores and test marks (Spearman's r = -0.325, p = 0.07). Dental students perceived a higher level of stress prior to the test, which declined after that. Pre-test stress scores were associated with raised salivary cortisol, but not IgA or CgA. Students who perceived higher levels of stress after the test generally had poorer results.