Systemic Impact of Subgingival Infection Control in Periodontitis Patients with Cardiovascular Disease: A Narrative Review.

INTRODUCTION: Periodontitis, an infectious inflammatory condition, is a key contributor to sustained systemic inflammation, intricately linked to atherosclerotic cardiovascular disease (CVD), the leading cause of death in developed nations. Treating periodontitis with subgingival mechanical instrumentation with or without adjunctive antimicrobials reduces the microbial burden and local inflammation, while also potentially bringing systemic benefits for patients with both periodontitis and CVD. This review examines systemic effects of subgingival instrumentation with or without antimicrobial products in individuals with periodontitis and CVD, and explores intricate pathogenetic interactions between periodontitis and CVD. MATERIAL AND METHODS: English-language databases (PubMed MEDLINE and Cochrane Library) were searched for studies assessing the effects of nonsurgical periodontal therapies in periodontitis patients with or without CVD. RESULTS: While the ability of periodontal therapy to reduce mortality- and morbidity-related outcomes in CVD patients with periodontitis remains uncertain, some studies indicate a decrease in inflammatory markers and blood cell counts. Subgingival mechanical instrumentation delivered over multiple short sessions carries lower risks of adverse effects, particularly systemic inflammation, compared to the full-mouth delivery, making it a preferable option for CVD patients. CONCLUSIONS: Subgingival mechanical instrumentation, ideally conducted in a quadrant-based therapeutic approach, to decontaminate periodontal pockets has the potential to reduce both local and systemic inflammation with minimal adverse effects in patients suffering from periodontitis and concurrent CVD.

Exploring Periodontal Conditions, Salivary Markers, and Systemic Inflammation in Patients with Cardiovascular Diseases.

(1) Background: This cross-sectional investigation appreciated the role of serum C-reactive protein (CRP), several hematologic-cell markers, and salivary inflammation-related molecules [calprotectin (S100A8/A9), interleukin-1ß (IL-1ß), kallikrein] to predict periodontitis in patients with atherosclerotic cardiovascular disease (ACVD), arrhythmia, or both. Also, we appreciated the relationship between the inflammatory burden and periodontal destruction with the type of cardiac pathology. (2) Methods: Demographic, behavioral characteristics, periodontal indicators, blood parameters, and saliva samples were collected. (3) Results: All 148 patients exhibited stage II or III/IV periodontitis. Stage III/IV cases exhibited significantly increased S100A8/A9 levels (p = 0.004). A positive correlation between S100A8/A9 and IL-1ß [0.35 (<0.001)], kallikrein [0.55 (<0.001)], and CRP [0.28 (<0.001)] was observed. Patients with complex cardiac involvement had a significantly higher number of sites with attachment loss ≥ 5 mm [19 (3-30)] compared to individuals with only arrhythmia [9 (3.25-18)] or ACVD [5 (1-12)] [0.048♦ {0.162/0.496/0.14}]. (4) Conclusions: Severe, extensive attachment loss may be indicative of patients with complex cardiac conditions, which underscores the essential role of periodontal status in relation to systemic diseases. The correlations between the rising trends of the inflammatory parameters suggest a potential interconnection between oral and systemic inflammation.

Insights into the Relationship between Periodontitis and Systemic Sclerosis Based on the New Periodontitis Classification (2018): A Cross-Sectional Study.

(1) Background: This study aimed to assess the periodontitis burden in systemic sclerosis patients and the possible association between them, and the degree to which some potential risk factors and two potential diagnostic biomarkers may account for this association. (2) Methods: This cross-sectional study included a test group (systemic sclerosis patients) and a control group (non-systemic sclerosis patients). Both groups benefited from medical, periodontal examination and saliva sampling to determine the salivary flow rate and two inflammatory biomarkers (calprotectin, psoriasin). A systemic sclerosis severity scale was established. (3) Results: In the studied groups, comparable periodontitis rates of 88.68% and 85.85%, respectively, were identified. There were no significant differences in the severity of periodontitis among different systemic sclerosis severity, or in the positivity for anti-centromere and anti-SCL70 antibodies. Musculoskeletal lesions were significantly more common in stage III/IV periodontitis (n = 33, 86.84%) than in those in stage I/II (n = 1, 100%, and n = 3, 37.5%, respectively) (p = 0.007). Comparable levels of the inflammatory mediators were displayed by the two groups. There were no significant differences in calprotectin and psoriasin levels between diffuse and limited forms of systemic sclerosis. (4) Conclusions: Within the limitations of the current study, no associations between systemic sclerosis and periodontitis, or between their risk factors, could be proven.

In vitro characterization of multipotent mesenchymal stromal cells isolated from palatal subepithelial tissue grafts.

The aim of this study was to analyze whether the mesenchymal stromal cells (MSCs) isolated from palatal tissue grafts harvested in order to cover gingival recessions have the basic characteristics of stem cells. The palatal tissue cells were processed using a special culture medium that stimulated the development of only undifferentiated cellular lines. Cells at passage 4 were evaluated by flow cytometry to examine the expression of specific surface markers and were tested for multilineage differentiation capacity. These cells collected at passage 4 were also investigated for the capacity to cluster into embryoid body aggregates. Palatal MSCs displayed positive staining for the mesenchymal markers CD29, CD73, CD105, CD 49e, and CD44, but did not express hematopoietic markers CD34/45. The palatal MSCs successfully differentiated into osteogenic, adipogenic, and chondrogenic lineages. When seeded in special conditions, palatal MSCs propagated into unattached spheres resembling embryoid body aggregates consisting both of differentiated and undifferentiated cells as revealed at the ultrastructural evaluation. It is concluded that the isolated palatal MSCs fulfilled the basic criteria defining the stem cells. This new source of stem cells characterized here for the first time opens new perspectives on possible applications in basic research and in regenerative medicine.

Clinical and Radiological Characterization of the Long-Term Association between Unaffected/Minimally Affected Implants and History of Severe Periodontitis: A Retrospective Study.

OBJECTIVES: The objectives of this research were to compare, retrospectively, the clinical and radiographic modifications of periodontal parameters and peri-implant conditions and to analyze the relationship between the changes in periodontal parameters and peri-implant conditions over a mean follow-up period of 7.6 years in a treated population with progressive/uncontrolled periodontitis and at least one unaffected/minimally affected implant. MATERIALS AND METHODS: Nineteen partially edentulous patients having 77 implants inserted, with a mean age of 54.84 ± 7.60 years, were matched for age, gender, compliance, smoking status, general health, and implant characteristics. Periodontal parameters were evaluated in the remaining teeth. Means per teeth and implants were used when making comparisons. RESULTS: Statistically significant differences were observed between baseline and final examination in teeth for tPPD, tCAL and MBL. Furthermore, at 7.6 years, statistically significant differences existed between implants and teeth with regard to iCAL and tCAL (p = 0.03). Multiple regression analyses were performed and revealed a significant association regarding iPPD and CBL with smoking and periodontal diagnosis. In addition, FMBS was significantly associated with CBL. Unaffected/minimally affected implants were found more frequently in the posterior mandible, with longer lengths (>10 mm) and small diameters (<4 mm), including in screwed multi-unit bridges. CONCLUSIONS: The study results appear to reflect minimally affected mean crestal bone-level loss around implants in comparison to the marginal bone-level loss around teeth when exposed to uncontrolled severe periodontal disease over a mean period of observation of 7.6 years, while the unaffected/minimally affected implants seemed to benefit from a combination of clinical factors, including posterior mandibular position, smaller diameters, and screwed multi-unit restorations.

Impact of Treatment on Systemic Immune-Inflammatory Index and Other Inflammatory Markers in Odontogenic Cervicofacial Phlegmon Cases: A Retrospective Study.

Cervicofacial odontogenic infections can have an aggressive evolution with life-threatening complications. Management in many cases can be a challenge for clinicians, implying an extra focus on individual inflammatory parameters. The aim of this study is to evaluate the evolution of inflammatory markers for the included diagnosed odontogenic cervicofacial phlegmon cases at the moment of hospitalization and after receiving surgical and pharmaceutical treatment. MATERIALS AND METHODS: A total of 39 patients diagnosed with odontogenic cervicofacial phlegmons that were admitted to the Maxillofacial Surgery Department of the Emergency Hospital from Timisoara were included in the study. The main focus was the parameters represented by the systemic immune-inflammatory index (SII) based on neutrophil, platelet, and lymphocytes count; the neutrophil-lymphocyte ratio (NLR); C-reactive protein level (CRP); and white blood cell count (WBC) before and after the treatment as potential prognosis factors. RESULTS: The results of the study after analyzing the included parameters revealed a significant difference between the calculated values of the SII, NLR, CRP, and WBC at admission and at time of discharge, being directly influenced by the treatment. CONCLUSIONS: SII, NLR, CRP, and WBC dynamic changes in severe cervicofacial odontogenic infections can be influenced by receiving accurate surgical and pharmacological treatment, with the potential to become future severity prognosis indexes.

Periodontitis Burden in Diffuse Versus Limited Systemic Sclerosis Subtypes: A Pilot Study.

INTRODUCTION: This study aimed to evaluate the periodontal status of a group of Romanian systemic sclerosis (SSc) patients and to investigate the relationships between periodontitis and SSc subtypes. MATERIALS AND METHODS: This observational study included patients diagnosed with limited SSc (lcSSc) and diffuse SSc (dcSSc). Demographic data were collected from medical records. Each participant underwent a full-mouth periodontal examination including Bleeding on Probing (BoP) index, Oral Hygiene (OH) index, Probing Depth (PD), Gingival Recession (GR), and Clinical Attachment Loss (CAL). The periodontal status was defined according to presently recognised case definition system. RESULTS: The study included 30 patients with lcSSc and 30 patients with dcSSc with a mean age of 52.45±11.75 years. The overall periodontitis frequence in our SSc group was 95%. The frequency of stage III/IV periodontitis was higher in the dcSSc group (90%) than in the lcSSc group (60%). Within the group of SSc patients, significant positive correlations were observed between age, BoP index, OH index, the number of missing teeth, mean PD, mean CAL on one side and periodontitis diagnosis on the other side (r=0.588, p=0.001; r=0.399, p=0.002; r=0.388, p=0.002; r=0.574, p=0.001; r=0.444, p=0.001; r=0.571, p=0.001). A significant positive correlation existed between the diagnostic of periodontitis and SSc subtypes (r=0.327, p <0.001). CONCLUSIONS: Periodontitis was highly prevalent in both lcSSc and dcSSc groups. More stage III/IV periodontitis cases were detected dcSSc group of patients.

The Treatment of Severe Periodontitis Using a Local Antiseptic Desiccant and Subgingival Mechanical Instrumentation: A Pilot Study.

This randomized, split-mouth, controlled clinical study assessed the additional clinical benefits of a local desiccant antimicrobial agent (HY) combined with subgingival mechanical instrumentation (SRP) vs. SRP alone in treating severe periodontitis. Patients with stages III and IV periodontitis received full-mouth periodontal examinations at baseline and after a three-month follow-up. Two randomly selected hemiarches in each periodontitis patient were treated with SRP plus HY and were included in the test group, while the other two hemiarches received only SRP and were included in the control group. In thirty patients, the analyses of the evolution of the periodontal parameters over time showed statistically significant mean differences for the probing depths and clinical attachment level values resulting from all the examined sites, as well as from the interproximal sites (p < 0.001) in both the test and control groups. The intergroup comparisons of the same four parameters showed no significant differences (p = 0.322, p = 0.36, p = 0.516, and p = 0.509, respectively). Based on these study results, no additional benefits were obtained after HY subgingival applications.

Evaluation of Pentraxin 3 and Serum Amyloid A in the Gingival Crevicular Fluid of Patients with Periodontal Disease and Obesity.

BACKGROUND: Pentraxin 3 (PTX3) is associated with periodontal tissue inflammation, a condition that precedes alveolar bone resorption. It is also elevated in obese tissues and is a useful biomarker of proinflammatory status. Serum amyloid A (SAA) is a proinflammatory and lipolytic adipokine. Adipocytes strongly express SAA, which suggests that it may have a significant role in the production of free fatty acids and local and systemic inflammation. MATERIALS AND METHODS: We statistically analyzed the gingival crevicular fluid (GCF) values of PTX3 and SAA in patients with periodontal disease, who were diagnosed with obesity, and compared them with the values of inflammatory markers from patients diagnosed with one of the diseases and with healthy patients. RESULTS: The patients with obesity and periodontitis had significantly higher levels of PTX3 and SAA than the patients diagnosed with either obesity or periodontitis. CONCLUSIONS: These two markers are involved in the association between the two pathologies, as evidenced by the correlations between these levels and some clinical parameters.

A Local Desiccant Antimicrobial Agent as an Alternative to Adjunctive Antibiotics in the Treatment of Periodontitis: A Narrative Review.

Periodontitis is one of the most common oral polymicrobial infectious diseases induced by the complex interplay between the altered subgingival microbiota and the host's dysregulated immune-inflammatory response, leading to the initiation of progressive and irreversible destruction of the periodontal tissues and eventually to tooth loss. The main goal of cause-related periodontal therapy is to eliminate the dysbiotic subgingival biofilm in order to arrest local inflammation and further periodontal tissue breakdown. Because, in some cases, subgingival mechanical instrumentation has limited efficiency in achieving those goals, various adjunctive therapies, mainly systemic and locally delivered antimicrobials, have been proposed to augment its effectiveness. However, most adjunctive antimicrobials carry side effects; therefore, their administration should be precociously considered. HybenX® (HY) is a commercial therapeutical agent with decontamination properties, which has been studied for its effects in treating various oral pathological conditions, including periodontitis. This review covers the current evidence regarding the treatment outcomes and limitations of conventional periodontal therapies and provides information based on the available experimental and clinical studies related to the HY mechanism of action and effects following its use associated with subgingival instrumentation and other types of dental treatments.

Current Perspectives on Periodontitis in Systemic Sclerosis: Associative Relationships, Pathogenic Links, and Best Practices.

Systemic sclerosis is a chronic, autoimmune, multisystemic disease characterized by aberrant extracellular matrix protein deposition and extreme progressive microvasculopathy. These processes lead to damage within the skin, lungs, or gastrointestinal tract, but also to facial changes with physiognomic and functional alterations, and dental and periodontal lesions. Orofacial manifestations are common in SSc but are frequently overshadowed by systemic complications. In clinical practice, oral manifestations of SSc are suboptimally addressed, while their management is not included in the general treatment recommendations. Periodontitis is associated with autoimmune-mediated systemic diseases, including systemic sclerosis. In periodontitis, the microbial subgingival biofilm induces host-mediated inflammation with subsequent tissue damage, periodontal attachment, and bone loss. When these diseases coexist, patients experience additive damage, increasing malnutrition, and morbidity. The present review discusses the links between SSc and periodontitis, and provides a clinical guide for preventive and therapeutical approaches in the management of these patients.

Management of SARS-CoV-2 Transmission in Emergency Dental Settings: Current Knowledge and Personal Experience.

The coronavirus disease 2019 (COVID-19) has seen a violent and fast spread worldwide. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has a predominantly respiratory transmission through droplets and aerosol with serious implications for dental settings. This article is based on recent research, guidelines issued by relevant authorities, as well as on the authors' experience acquired through their involvement in setting up an emergency dental care hub in Cluj-Napoca, Romania, during the COVID-19 lockdown. The present article aims to provide a brief description of COVID-19 implications in dental office and to recommend preventive protocols for dental practitioners to ensure a safe and healthful workplace. The recommendations for infection control presented in this article address the specific risks of exposure to SARS-CoV-2. The article provides a special customized guideline covering patient triage and entrance into the dental practice, personnel protection, dental treatment, and after-treatment management. The implementation of strict preventive measures has been found to be efficient in the prevention of SARS-CoV-2 contamination because no infections have been reported among our staff or patients. COVID-19 is a major emergency worldwide marked by a rapid evolution and warranting a need for further assessment of the implications of COVID-19 outbreak in dental practice.

The Cytotoxicity of Dental Restorative Materials on Gingival Stromal Mesenchymal Cells-an In Vitro Study.

BACKGROUND: Due to their minimally invasive high-quality adhesive, aesthetic and mechanical qualities, composite resins are the most frequently used materials in modern restorative dentistry. However, polymerization shrinkage and cytotoxicity are still unresolved drawbacks associated with these biomaterials. PURPOSE: The present study aimed to assess the cytotoxicity of some restorative resin-based materials on gingival mesenchymal stromal cells (gMSCs), assuming that no differences in their behavior will be highlighted. MATERIAL AND METHODS: The cytotoxicity of the tested materials was evaluated by comparing the behavior of gMSCs cultured in normal conditions and in association with disc-shaped material samples indirectly through functionality tests (colony-forming unit-fibroblast assay, migratory potential) and directly through the MTT assay. The results were statistically analyzed with the ANOVA test and Tukey's Honest Significant Difference test. RESULTS: According to the MTT assay, there are no statistically significant differences regarding the viability of gMSCs cultured in normal conditions or in the presence of resin-based material samples. On the other hand, the present study identified a significantly reduced number of colonies formed by the gMSCs cultured in association with BF and B discs, compared to that of gMSCs cultured in normal conditions. Also, the migratory potential was significantly lower for control gMSCs when compared to ZE-gMSCs and significantly higher for ZE-gMSCs when compared to BF-gMSCs or BFL-gMSCs. CONCLUSIONS: The results of the present study highlight a possible risk of cytotoxicity when using resin based-materials in dental practice, but they cannot be directly extrapolated to in vivo situations.

The Impact of the COVID-19 Pandemic on Romanian Postgraduate Periodontal Residency Teaching: Past Experience, Present Imperatives and Future Considerations in a Multicentric Evaluation.

The aims of this study were to identify the challenges in periodontology postgraduate residency programs during the COVID-19 pandemic by identifying the modifications of educational instruments, to evaluate the impact of hybrid education on periodontology postgraduate programs in terms of resident-centred outcomes, and to evaluate the education efficiency of an innovative teaching approach. Resident doctors from three Romanian dental faculties were included in study groups based on the intensity of clinical training. A web-based questionnaire was used to collect information on residents' perception about teaching activity. Important educational changes were identified. Moreover, residents learned a periodontal procedure through online training and then performed it on preclinical models three times. The working times were recorded. Statistical analysis was performed. Resident doctors were unsatisfied with clinical practice during the pandemic year, but they positively valued the development of online courses. Learning efficiency improved by repeating the same procedure on preclinical models, as proved by the significant decrease of the working times. E-learning was appreciated as an important component of the new hybrid teaching approach. Reorganization and further emphasis on both preclinical and medical practice, targeted to aid residents perform more accurate and efficient procedures, are recommended.

Periodontitis in Ischemic Stroke Patients: Case Definition Challenges of the New Classification Scheme (2018).

The identification of the associative relationships between ischemic stroke (IS) and risk factors such as advanced age and periodontitis is essential to design real screening protocols and to address them using primary and secondary preventive policies. This study primarily aimed to evaluate the diagnostic performance of the 2018 European Federation of Periodontology/American Academy of Periodontology (EFP/AAP) case definition in detecting periodontitis against the 2012 Centers for Disease Control and Prevention/American Academy of Periodontology (CDC/AAP) case definition in a group of IS patients. Secondarily, we report the periodontal status of IS patients and the associative relationship with respect to some risk factors. Patients with their first IS were assessed based on demographic data, medical, oral risk factors and periodontal parameters. The two case definitions were applied to identify the periodontitis burden. The agreement between the two case definition systems, as well as the misclassification ratio, were calculated. A total of 141 patients were included. According to the 2012 CDC/AAP and the 2018 EFP/AAP case definitions, a frequency of periodontitis of 98.5% and 97.8% based on two modalities of inclusion of cases in the severity groups, sensitivity values of 98.54% or 100%, and specificity values of 25% or 14.7% were calculated. Thus, the new case definition system has a higher capacity to detect periodontitis, especially the well-established forms.

Correction: Self-reported and clinical periodontal conditions in a group of Eastern European postpartum women.

[This corrects the article DOI: 10.1371/journal.pone.0237510.].

Effects of Monomer Composition of Urethane Methacrylate Based Resins on the C=C Degree of Conversion, Residual Monomer Content and Mechanical Properties.

(1) Background: This study investigated the influence of Bis-GMA, TEGDMA, UDMA, and two different polyethylene glycol (PEG)-containing, UDMO-based co-monomers on the Young's modulus and flexural strength, degree of methacrylate C=C double bond conversion and residual monomer elution of experimental dental resins. (2) Methods: Urethane methacrylate-based monomer was synthesised via a radical chain growth polymerization mechanism using PEG in order to improve the mechanical properties. Dental resins were formulated using Bis-GMA, UDMA, or UDMO as base monomers combined with TEGDMA as a dilution monomer and DMAEM + CQ as the photo-initiator system. Degree of conversion (DC), mechanical properties, and residual monomer content of light-activated methacrylate resin formulations were evaluated and statistically analysed by ANOVA and a Tukey's test. (3) Results: PEG-containing UDMO resins had lower Young's modulus and elastic strength than UDMA-derived resin for all irradiation times. The highest DC (67,418%) was observed for the PEG-containing UDMO-based resin formulation when light cured for 40 s. For all samples, DC increased with the photo-polymerization time. The amount of residual monomer decreased after increasing the light-curing period from 20 to 40 s, resin with UDMO content 0.01 mol of PEG having the smallest amount of free eluted monomer. (4) Conclusions: A strong structure-property relationship exists in photo-cured dimethacrylate-based dental resins. The time and quantity of the photochemical initiation system can influence the physical-mechanical properties of the resins but also the monomers in their composition.

In Vitro Study on the Adhesive Performance of Some Resin-Based Materials Used to Restore Class II Cavities.

The study aimed to evaluate the adhesive performances of two ormocer materials and two micro-hybrid composites placed to restore class II cavities. We tested the null hypothesis, which considered that the adhesive behaviors of tested materials did not differ. On each extracted tooth, two class II cavities were prepared having an enamel located cervical margin and a cementum located cervical margin, respectively, and were restored using two different restoration techniques. The teeth followed a tooth impregnating protocol and were sectioned and evaluated by optical microscopy to highlight the marginal microleakage around restorations. Cervical and occlusal microleakage as well as microleakage ratios were calculated. The microleakage test showed that all tested materials exhibited some degree of dentinal microleakage both on cervical and occlusal areas irrespective of the restoration technique. Some significant differences were recorded in adhesion performance of the materials. The cervical microleakage ratio was significantly increased for one of the micro-hybrid resin composites in comparison with one of the ormocer materials (p = 0.0159). Significantly differences were observed in occlusal microleakage ratios when the two micro-hybrid composites were compared (p = 0.047). The results failed to reject the null hypothesis. The present study could not demonstrate the superiority of ormocer-materials relative to conventional composites.

Cytotoxic Effects on Gingival Mesenchymal Stromal Cells and Root Surface Modifications Induced by Some Local Antimicrobial Products Used in Periodontitis Treatment.

(1) Background: this study aims to test the cytotoxicity of three antimicrobial products used in periodontitis treatment on gingival mesenchymal stem cells (gMSCs) and their influence on root surfaces and gMSC adhesion. We tested the null hypothesis that the effects of the antimicrobials did not differ. (2) Methods: the commercial products based on sulphonic/sulphuric acids, sodium hypochlorite and silver nanoparticles, in five different concentrations, were added to culture medium for growing gMSCs. Cell proliferation capacity was tested using the Cell Counting Kit-8 (CCK8) and their viability was determined by succinate dehydrogenase activity (MTT) assay. Scanning electron microscopy evaluated the adhesion of gMSCs on root samples treated mechanically and with commercial products. (3) Results: the products induced a dose-dependent cytotoxicity in terms of reduced proliferation and viability of gMSCs, as well as cell shape modifications. Significant differences in CCK8 values between the different commercial products were observed. Based on proliferation tests, the null hypothesis was rejected. When MTT values of the three products were compared with each other, no significant differences were observed for any of the five concentrations (p = 0.065, p = 0.067, p = 0.172, p = 0.256, p = 0.060). (4) Conclusions: the three antimicrobials had a certain degree of cytotoxicity on gMSCs. gMSCs repopulated treated root surfaces.

Subepithelial connective tissue graft for root coverage: clinical case reports and histologic evaluation.

If the clinical goal of the periodontal plastic surgery is the complete root coverage of gingival recessions, then the microscopically goal standard is to obtain a true periodontal regeneration. Only the histological examination can reveal cellular events unrolled into the grafted tissue-root surface interface and the nature of the clinically observed attachment. To our knowledge, there are no studies that obtained the biopsies of grafted tissues from humans, in vivo, and so, the aim of the present study was to develop such a method, using a bone marrow biopsy needle. Two patients with gingival recessions were treated with coronally advanced flap and subepithelial connective tissue graft, and the clinical and histological results were observed. Complete root coverage was obtained for both cases. Clinically, the grafted tissues seemed to be attached to the root surfaces. The histological findings revealed dense grafted tissues, providing long-term stability of the area. No ligament or bone, characteristic for periodontal regeneration were observed. However, no sign of healing characterized by a long junctional epithelium was observed either. This indicated that the healing that occurred in our cases was a long connective tissue attachment, which has been shown to be stable over time. However, even if the method we proposed is not invasive, it is very difficult to convince the patient to accept a biopsy elevation once the exposed root surface was covered.