The convergence of regenerative medicine and rehabilitation: federal perspectives.

Regenerative rehabilitation is the synergistic integration of principles and approaches from the regenerative medicine and rehabilitation fields, with the goal of optimizing form and function as well as patient independence. Regenerative medicine approaches for repairing or replacing damaged tissue or whole organs vary from utilizing cells (e.g., stem cells), to biologics (e.g., growth factors), to approaches using biomaterials and scaffolds, to any combination of these. While regenerative medicine offers tremendous clinical promise, regenerative rehabilitation offers the opportunity to positively influence regenerative medicine by inclusion of principles from rehabilitation sciences. Regenerative medicine by itself may not be sufficient to ensure successful translation into improving the function of those in the most need. Conversely, with a better understanding of regenerative medicine principals, rehabilitation researchers can better tailor rehabilitation efforts to accommodate and maximize the potential of regenerative approaches. Regenerative rehabilitative strategies can include activity-mediated plasticity, exercise dosing, electrical stimulation, and nutritional enhancers. Critical barriers in translating regenerative medicine techniques into humans may be difficult to overcome if preclinical studies do not consider outcomes that typically fall in the rehabilitation research domain, such as function, range of motion, sensation, and pain. The authors believe that encouraging clinicians and researchers from multiple disciplines to work collaboratively and synergistically will maximize restoration of function and quality of life for disabled and/or injured patients, including U.S. Veterans and Military Service Members (MSMs). Federal Government agencies have been investing in research and clinical care efforts focused on regenerative medicine (NIH, NSF, VA, and DoD), rehabilitation sciences (VA, NIH, NSF, DoD) and, more recently, regenerative rehabilitation (NIH and VA). As science advances and technology matures, researchers need to consider the integrative approach of regenerative rehabilitation to maximize the outcome to fully restore the function of patients.

Vitamin E and periodontal disease.

Vitamin E levels in patients with and without periodontal disease were measured. There was no significant difference in the levels of serum vitamin E between these two groups. These data do not provide support for the treatment of inflammatory periodontal disease with vitamin E.

A quantitative measurement of bacteremia and its relationship to plaque control.

Despite the improvement in the patients' oral hygiene, there was no significant decrease in the frequency of bacteremia. There was no significant difference in bacteremia between brushing, flossing, or deplaquing either before or after initial periodontal preparation and plaque control in 21 healthy subjects. Utilizing more sophisticated bacteriologic techniques for the cultivation of obligate anaerobes, a relatively high frequency of anaerobic bacteremia was found.

A prospective multicenter clinical trial comparing one- and two-stage titanium screw-shaped fixtures with one-stage plasma-sprayed solid-screw fixtures.

BACKGROUND: Brånemark fixtures were originally placed in two stages, whereas titanium plasma-sprayed (TPS) solid-screws are placed in one stage. Long-term survival rates for both types of implants are excellent. Excellent survival rates have also been reported for machined screw-shaped (MS) titanium implants placed in one stage. A small number of studies have compared different implant systems and methods of implant placement. PURPOSE: The purpose of this study is to report clinical outcomes from a prospective longitudinal, multicenter study comparing Brånemark MS fixtures (Nobel Biocare, Yorba Linda, California, USA) placed in either one or two stages with a one-stage TPS system (ITI Straumann, Waldenburg, Switzerland). METHODS: A protocol was designed to compare implant survival rates, changes in crestal bone for titanium MS fixtures placed in one and two stages, and plasma-sprayed solid-screw fixtures placed in one surgical stage. Twenty-nine patients ranging in age from 24 to 82 years received MS fixtures in one stage. The average age for males was 58 years (n = 11), whereas the ages for females (n = 18) ranged from 15 to 84 years (average 58 years). Twenty-nine patients received machined titanium fixtures placed in two stages. There were 20 females ranging in age from 23 to 74 years (average 54 years) and 9 females ranging from 24 to 74 years (average 46 years). Twenty-five patients received TPS fixtures. There were 15 males, ranging in age from 57 to 79 (average 70), and 10 females, ranging in age from 40 to 83 years (average 62 years). Bone quality and quantity were determined from radiographs and during site preparation. Patient age, sex, location of implant placement according to jaw, length of fixtures, and number of lost fixtures were entered onto computer code sheets and continuously entered into a locked computer system. For one- and two-stage MS fixtures, nonstandardized periapical radiographs were taken at abutment connection and follow-up. Solid screws were x-rayed at prostheses connection and follow-up. The average time between implant restoration and radiographic follow-up was 15 months. The x-rays were scanned into a computer, and a program designed to measure radiographs was used to determine changes in crestal bone. Measurements for one- and two-stage MS fixtures were made from the top of the implant shoulder to the first bone to implant contact mesial and distally. Plasma-sprayed screws were measured from the bottom of the implant to the coronal most bone to implant contacts mesial and distally. Mesial-distal radiographic measurements were averaged and changes were compared using the t-test for related samples. RESULTS: This report presents data from the 2- to 3-year follow-up examinations. Twenty-nine patients received 80 one-stage MS fixtures. Between 0 and 1 year, two fixtures were lost, resulting in a 97.5% cumulative survival rate (CSR). The CSR remained unchanged through the 2- to 3-year follow-up. Twenty-eight patients received 78 two-stage MS fixtures. One implant was lost prior to loading and two were lost between 0- and 1-year follow-up, yielding a 96.2% CSR at the end of 1 year. The CSR remained unchanged through the 2- to 3-year follow-up. Twenty-three patients received 78 solid-screw plasma-sprayed screws. One implant was lost prior to loading and one between the 0- to 1-year follow-up, accounting for a 97.4% CSR at the 2- to 3-year follow-up. Changes in bone crest measurements for one-stage titanium threaded fixtures were insignificant (-0.11 mm, p = .08, maxillary; 0.07 mm, p = .42, mandibular). For two-stage MS fixtures, crestal bone loss was insignificant in maxillae (-0.16 mm, p = .92) and significant in mandibles (-0.43 mm, p = .000). There was significant bone loss for TPS implants in maxillae and mandibles (maxillae, 1.31 mm, p = .04; mandibles, 0.98 mm, p = .000). CONCLUSIONS: Cumulative survival rates for MS fixtures placed in one and two stages as well as one-stage TPS screws up to the 2- to 3-year follow-up examination were similar, indicating excellent clinical results. Radiographic measurements for changes in crestal bone loss were clinically insignificant for fixtures placed in one stage. For two-stage fixtures, maxillary changes were insignificant, whereas mandibular bone loss was statistically significant but clinically insignificant. Changes in crestal bone loss for TPS implants were statistically significant.

Common medical emergencies: a dilemma in dental education.

A four-week hospital-based program offers a comprehensive course for dental students in the evaluation and management of medical emergencies. The program first emphasizes medical evaluation with the taking of accurate, comprehensive patient histories and the performance of physical examinations; information about supportive care, including intravenous techniques and airway maintenance, is given. The diagnostic signs and treatment of common medical emergencies, as taught in the program, are described.

Surgical-orthodontic management of an unerupted maxillary incisor.

Satisfactory functional and esthetic results were attained, with proper consideration of surgical, periodontal, and orthodontic principles in the treatment of a patient with an unerupted maxillary central incisor. Gingival attachment was maintained and integrity of the dental arch was restored.

Patient evaluation.

This article has focused on the various aspects of patient evaluation that is a vital component in the total care of the dental patient. It must be emphasized that dentists are ultimately responsible for the overall management of the patients that they are treating, and only by careful selection and treatment plan can the practitioner maximize the benefits while minimizing the dangers inherent in outpatient anesthesia.

Biologic and clinical considerations for autografts and allografts in periodontal regeneration therapy.

Although complete periodontal regeneration is unpredictable with any regenerative therapy currently used, periodontal bone grafts show strong potential. A large body of clinical evidence clearly indicates that grafts consistently lead to better bone fill than nongrafted controls. Regardless of which material is used, the average bone fill is 3 mm, or about 60% defect fill according to reported studies. In addition, histologic analyses now show conclusively that regenerative treatment with bone grafting leads to some degree of regenerated bone, cementum, and periodontal ligament. Although bone grafts and other periodontal treatments have improved clinicians' ability to promote osteogeneration, the outcomes are still somewhat unpredictable. Part of the problem is that it is still unclear how periodontal disease affects the supporting bone's regenerative potential and what specific biologic factors are involved. In recent years, however, clinicians have begun to learn much more about how periodontal regeneration works on a cellular and molecular level. This is a key step to developing strategies and materials that allow clinicians to promote periodontal regeneration predictably. Since its introduction during the last decade, GTR has been an invaluable addition to the armamentarium, as has the recognized importance of early wound stability. As more is learned about the biologic process of periodontal regeneration, new materials and techniques, such as growth factors, absorbable membranes, and new graft materials, are expected to make the task of periodontal regeneration even more predictable. It is likely that some combination of techniques may eventually prove to yield the best results.

Successful periodontal treatment for the elderly.

The demographic reality of a rapidly growing elderly population segment presents the practicing dentist with certain imperatives and challenges. Familiarity with the healthy aging process and common medical conditions of the aged is becoming increasingly essential. Customized treatment plans and modifications in techniques and home care aids require flexibility and creativity. In addition, it should not be overlooked that this demographic reality also presents the practicing dentist with new opportunities for practice-building as well as personal and professional satisfaction.

Immediate loading of bilaterally splinted titanium root-form implants in fixed prosthodontics--a technique reexamined: two case reports.

A load-free healing period has been advocated as a prerequisite to achieving osseointegration. This article reports two cases in which immediate loading of a specially designated additional, or "expendable," set of titanium root-form implants was successfully utilized to support provisional fixed restorations in the maxilla and the mandible. This immediate-loading protocol is suggested as a reliable adjunctive therapeutic modality for offering implant patients access to fixed interim restorations during the healing phase of the primary fixtures. Another advantage of this approach is that it provides protection from potential transmucosal overload of the primary implants as well as any sites undergoing osseous regenerative procedures.

The problem-oriented record: clinical application in a teaching hospital.

A dental team-care concept that incorporates the problem-oriented system has been instituted at The Medical College of Pennsylvania. The program, as described, is designed to achieve the following goals: 1) to enhance communication between doctors and auxiliaries and thus maintain continuity in patient care and improve the quality of care; 2) to identify all problems related to the care of a patient; 3) to evaluate the educational and technical ability of the residents and students; 4) to achieve an effective dental auxiliary utilization program; 5) to increase faculty involvement in the delivery of patient care; 6) to organize an effective system of peer review; 7) to maintain complete, accurate and systematic medical-dental records; and 8) to encourage an interdisciplinary approach to health care delivery.

Teeth or implants: a 1990s dilemma.

Using endosseous implants to replace missing teeth is a highly predictable process when the precepts defined by Brånemark are followed. The question of whether or not to extract periodontally compromised teeth, however, remains controversial. This article presents a case report illustrating some of the concerns involved when treating a patient with a combination of natural teeth and implants, and proposes several compelling questions regarding the treatment decisions made in this case.

The relationship between periodontal disease and systemic conditions.

In this year's report of the United States Surgeon General on oral health in America, two major themes evolved: 1) oral health means much more than healthy teeth, and 2) oral health is integral to general health. This article describes how oral diseases, in particular periodontal diseases, are associated with other health problems, including cardiovascular disease, diabetes mellitus, complications of pregnancies, and osteoporosis.

The periodontal-medical risk relationship.

The evidence of a periodontal-medical risk warrants serious consideration. As dentists increase their knowledge about the link between periodontal disease and other systemic diseases, they will be able to prevent periodontal disease in more patients as well as develop better treatments for the disease. It is important for physicians and dentists to improve their collaboration to provide better patient care. Physician awareness of the increased risk for dental complications in certain patients will benefit their patients' overall well-being.

Treatment planning and site development for the implant-assisted periodontal reconstruction.

Implants can be used to recreate an edentulous dentition that is esthetic, comfortable, and functional by augmenting the total surface area of load carrying abutments. Traditionally, implants were placed in areas of the mouth where adequate amounts of bone were present. Today, clinicians are strategically planning and developing implant sites to optimize oral health. This article will describe methods of treatment planning and site development for the reconstruction of the implant-assisted periodontal restoration.

Outcome failures of endosseous implants from a clinical training center.

In an effort to provide realistic clinical information from a "real-world" environment, the present retrospective study was undertaken to assess outcome failures after implant placement in a dental school clinical training center. A database was kept of the clinical information and was analyzed according to established parameters for implant outcomes. The demographics showed that over a period of 6 years, 80 different operators with a wide range of clinical experience had inserted 1,263 implants in a diverse patient pool of 380 individuals. Analysis of the outcomes showed a cumulative survival rate of 91.3%. The time of explantation, the type, size, and location of implants lost, and failure rates in smoking patients were also analyzed. The results indicated that the use of implants by operators with different levels of experience did not affect favorable outcomes.

Bone grafts and growth and differentiation factors for regenerative therapy: a review.

Guided bone regeneration, tissue grafts, regenerative barrier membranes, and bone substitute materials have been used to restore inadequate hard and soft tissue structures to make them conducive to proper implant placement. Polypeptide growth and development factors (GDFs) have successfully been applied exogenously to periodontal defects to attract preosteoblasts to the site and accelerate their proliferation to stimulate angiogenesis. This article provides an overview of current modalities for restoring lost bone and soft tissue during the treatment of periodontal disease.