Mucogingival conditions in the natural dentition: Narrative review, case definitions, and diagnostic considerations.

BACKGROUND: Mucogingival deformities, and gingival recession in particular, are a group of conditions that affect a large number of patients. Since life expectancy is rising and people are retaining more teeth both gingival recession and the related damages to the root surface are likely to become more frequent. It is therefore important to define anatomic/morphologic characteristics of mucogingival lesions and other predisposing conditions or treatments that are likely to be associated with occurrence of gingival recession. OBJECTIVES: Mucogingival defects including gingival recession occur frequently in adults, have a tendency to increase with age, and occur in populations with both high and low standards of oral hygiene. The root surface exposure is frequently associated with impaired esthetics, dentinal hypersensitivity and carious and non-carious cervical lesions. The objectives of this review are as follows (1) to propose a clinically oriented classification of the main mucogingival conditions, recession in particular; (2) to define the impact of these conditions in the areas of esthetics, dentin hypersensitivity and root surface alterations at the cervical area; and (3) to discuss the impact of the clinical signs and symptoms associated with the development of gingival recessions on future periodontal health status. RESULTS: An extensive literature search revealed the following findings: 1) periodontal health can be maintained in most patients with optimal home care; 2) thin periodontal biotypes are at greater risk for developing gingival recession; 3) inadequate oral hygiene, orthodontic treatment, and cervical restorations might increase the risk for the development of gingival recession; 4) in the absence of pathosis, monitoring specific sites seems to be the proper approach; 5) surgical intervention, either to change the biotype and/or to cover roots, might be indicated when the risk for the development or progression of pathosis and associated root damages is increased and to satisfy the esthetic requirements of the patients. CONCLUSIONS: The clinical impact and the prevalence of conditions like root surface lesions, hypersensitivity, and patient esthetic concern associated with gingival recessions indicate the need to modify the 1999 classification. The new classification includes additional information, such as recession severity, dimension of the gingiva (gingival biotype), presence/absence of caries and non-carious cervical lesions, esthetic concern of the patient, and presence/absence of dentin hypersensitivity.

Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.

BACKGROUND: A variety of systemic diseases and conditions can affect the course of periodontitis or have a negative impact on the periodontal attachment apparatus. Gingival recessions are highly prevalent and often associated with hypersensitivity, the development of caries and non-carious cervical lesions on the exposed root surface and impaired esthetics. Occlusal forces can result in injury of teeth and periodontal attachment apparatus. Several developmental or acquired conditions associated with teeth or prostheses may predispose to diseases of the periodontium. The aim of this working group was to review and update the 1999 classification with regard to these diseases and conditions, and to develop case definitions and diagnostic considerations. METHODS: Discussions were informed by four reviews on 1) periodontal manifestions of systemic diseases and conditions; 2) mucogingival conditions around natural teeth; 3) traumatic occlusal forces and occlusal trauma; and 4) dental prostheses and tooth related factors. This consensus report is based on the results of these reviews and on expert opinion of the participants. RESULTS: Key findings included the following: 1) there are mainly rare systemic conditions (such as Papillon-Lefevre Syndrome, leucocyte adhesion deficiency, and others) with a major effect on the course of periodontitis and more common conditions (such as diabetes mellitus) with variable effects, as well as conditions affecting the periodontal apparatus independently of dental plaque biofilm-induced inflammation (such as neoplastic diseases); 2) diabetes-associated periodontitis should not be regarded as a distinct diagnosis, but diabetes should be recognized as an important modifying factor and included in a clinical diagnosis of periodontitis as a descriptor; 3) likewise, tobacco smoking - now considered a dependence to nicotine and a chronic relapsing medical disorder with major adverse effects on the periodontal supporting tissues - is an important modifier to be included in a clinical diagnosis of periodontitis as a descriptor; 4) the importance of the gingival phenotype, encompassing gingival thickness and width in the context of mucogingival conditions, is recognized and a novel classification for gingival recessions is introduced; 5) there is no evidence that traumatic occlusal forces lead to periodontal attachment loss, non-carious cervical lesions, or gingival recessions; 6) traumatic occlusal forces lead to adaptive mobility in teeth with normal support, whereas they lead to progressive mobility in teeth with reduced support, usually requiring splinting; 7) the term biologic width is replaced by supracrestal tissue attachment consisting of junctional epithelium and supracrestal connective tissue; 8) infringement of restorative margins within the supracrestal connective tissue attachment is associated with inflammation and/or loss of periodontal supporting tissue. However, it is not evident whether the negative effects on the periodontium are caused by dental plaque biofilm, trauma, toxicity of dental materials or a combination of these factors; 9) tooth anatomical factors are related to dental plaque biofilm-induced gingival inflammation and loss of periodontal supporting tissues. CONCLUSION: An updated classification of the periodontal manifestations and conditions affecting the course of periodontitis and the periodontal attachment apparatus, as well as of developmental and acquired conditions, is introduced. Case definitions and diagnostic considerations are also presented.

Short-chain fatty acids from periodontal pathogens suppress histone deacetylases, EZH2, and SUV39H1 to promote Kaposi's sarcoma-associated herpesvirus replication.

UNLABELLED: Periodontal pathogens such as Porphyromonas gingivalis and Fusobacterium nucleatum produce five different short-chain fatty acids (SCFAs) as metabolic by-products. We detect significantly higher levels of SCFAs in the saliva of patients with severe periodontal disease. The different SCFAs stimulate lytic gene expression of Kaposi's sarcoma-associated herpesvirus (KSHV) dose dependently and synergistically. SCFAs inhibit class-1/2 histone deacetylases (HDACs) and downregulate expression of silent information regulator-1 (SIRT1). SCFAs also downregulate expression of enhancer of zeste homolog2 (EZH2) and suppressor of variegation 3-9 homolog1 (SUV39H1), which are two histone N-lysine methyltransferases (HLMTs). By suppressing the different components of host epigenetic regulatory machinery, SCFAs increase histone acetylation and decrease repressive histone trimethylations to transactivate the viral chromatin. These new findings provide mechanistic support that SCFAs from periodontal pathogens stimulate KSHV replication and infection in the oral cavity and are potential risk factors for development of oral Kaposi's sarcoma (KS). IMPORTANCE: About 20% of KS patients develop KS lesions first in the oral cavity, while other patients never develop oral KS. It is not known if the oral microenvironment plays a role in oral KS tumor development. In this work, we demonstrate that a group of metabolic by-products, namely, short-chain fatty acids, from bacteria that cause periodontal disease promote lytic replication of KSHV, the etiological agent associated with KS. These new findings provide mechanistic support that periodontal pathogens create a unique microenvironment in the oral cavity that contributes to KSHV replication and development of oral KS.

Obesity and periodontitis: a link.

Obesity and periodontitis are both diseases that represent significant health problems. Obesity currently impacts approximately one-third of the United States population and periodontitis affects an estimated 50% of the same population, ages 30 and over. It has been suggested that the possible relationship between obesity and periodontitis lies in the diseases' underlying inflammatory processes. The aim of this paper is to present those inflammatory pathways and to review the literature that has examined the association between obesity and periodontitis.

Investigating the Influence of Periodontal Disease on the Association Between Complex Multimorbidity and Health: A Cross-Sectional Study.

Aims and Objectives: The aim of this study was to evaluate whether periodontal disease (PD) moderates the association between complex multimorbidity (MM) and fair/poor general health in a US representative sample of older individuals. Materials and Methods: This study identified 937 participants who were at least 60 years of age from the 2013-2014 National Health and Nutrition Examination Survey. A multivariable logistic regression model was used to estimate the association between complex MM (including chronic conditions, functional limitations, and geriatric syndromes) and self-reported fair/poor general health. Subsequently, we specified interactions between complex MM and PD to determine whether PD moderates the effect of complex MM on fair/poor general health. Results: Nineteen percent of participants reported fair/poor general health. Complex MM was associated with 2.2 times greater odds of self-reported fair/poor health. However, PD was neither independently associated with fair/poor health nor an effect modifier for the association between complex MM and fair/poor general health. Age, white race, those with at least a high-school education level, a family income-to-poverty ratio of at least 2, former smoking status, and being married were significantly associated with fair/poor general health. Conclusion: Complex MM, but not PD, was associated with greater odds to report fair/poor general health, and PD did not moderate the association between complex MM and fair/poor general health. People with complex MM are more likely to have worse general health; however, PD did not strengthen this association. Further studies are needed to evaluate whether treatment for PD for people vulnerable to the development of complex MM has a positive effect on their general health.

Women's health: periodontitis and its relation to hormonal changes, adverse pregnancy outcomes and osteoporosis.

PURPOSE: To examine the literature with respect to periodontitis and issues specific to women's health, namely, hormonal changes, adverse pregnancy outcomes and osteoporosis. MATERIALS AND METHODS: The literature was evaluated to review reported associations between periodontitis and genderspecific issues, namely, hormonal changes, adverse pregnancy outcomes and osteoporosis. RESULTS: Collectively, the literature provided a large body of evidence that supports various associations between periodontitis and hormonal changes, adverse pregnancy outcomes and osteoporosis; however, certain shortcomings were noted with respect to biases involving definitions, sample sizes and confounding variables. Specific cause and effect relationships could not be delineated at this time and neither could definitive treatment interventions. CONCLUSION: Future research must include randomised controlled trials with consistent definitions, adequate controls and sufficiently large sample sizes in order to clarify specific associations, identify cause and effect relationships, define treatment options and determine treatment interventions which will lessen the untoward effects on the at-risk populations.

Identification of oral bacterial DNA in synovial fluid of patients with arthritis with native and failed prosthetic joints.

OBJECTIVE: We examined the presence of bacterial DNA in synovial fluids of native or clinically aseptically failed prosthetic joints from patients having periodontal disease and arthritis to determine whether there is bacterial spread from the oral cavity to the joints. METHODS: A total of 36 subjects were enrolled in the study. Among these, 11 were diagnosed with rheumatoid arthritis (RA) and 25 were diagnosed with osteoarthritis (OA). Eight patients with OA and 1 patient with RA had failed prostheses. Synovial fluid was aspirated from the affected hip or knee joint. Pooled subgingival plaque samples were collected, followed by clinical periodontal examination. Bacterial DNA was extracted from the collected synovial fluid and dental plaque samples were followed by polymerase chain reactions and DNA sequence analysis of the 16S-23S rRNA genes. RESULTS: Of the 36 patients, bacterial DNA was detected in the synovial fluid samples from 5 patients (13.9%): 2 with RA (1 native and 1 failed prosthetic joints) and 3 with OA (1 native and 2 failed prosthetic joints). Of these 5 patients, 2 were diagnosed with periodontitis and had identical bacterial clones (Fusobacterium nucleatum and Serratia proteamaculans, respectively) detected in both the synovial fluid and the dental plaque samples. Fusobacterium nucleatum was the most prevalent, detected in 4 of the 5 positive samples. No cultures were done and no patients were treated with antibiotics or developed clinical infection. CONCLUSIONS: The present findings of bacterial DNA in the synovial fluid suggest the possibility of organisms translocating from the periodontal tissue to the synovium. We suggest that patients with arthritis or failed prosthetic joints be examined for the presence of periodontal diseases and be treated accordingly.

Combinations of chronic conditions, functional limitations and geriatric syndromes associated with periodontal disease.

OBJECTIVE: To identify complex multimorbid conditions, including chronic conditions, functional limitations and geriatric syndromes, associated with the presence and severity of periodontal disease (PD), after accounting for a series of demographic and behavioural characteristics. DESIGN: This cross-sectional study used secondary data from a nationally representative sample, classification and regression tree analysis and random forest identified combinations of specific conditions constituting complex multimorbidity associated with the presence and severity of PD. SETTING: US National Health and Nutritional Examination Survey (2013-2014). PARTICIPANTS: Individuals 60 years of age or older who completed a periodontal examination. RESULTS: Among 937 participants aged 60 and over, the prevalence of PD was 72.6%. PD was associated with sociodemographic factors and limitations in instrumental activities of daily living. Male sex and non-white race were the two most critical predictors of stage III/IV PD. Other important factors included age, education level and the federal poverty level. CONCLUSIONS: Rather than chronic conditions or geriatric syndromes, PD was associated with sociodemographic factors and functional limitations. Accounting for the co-occurrence of sociodemographic and functional limitations will help recognise older adults who are at an increased vulnerability to the severity of PD.

Identifying Factors Associated with Periodontal Disease Using Machine Learning.

Objective: This study aimed to identify combinations of chronic conditions associated with the presence and severity of periodontal disease (PD) after accounting for a series of demographic and behavioral characteristics in a nationally representative sample of US adults. Materials and Methods: A cross-sectional study of the 2013-2014 National Health and Nutrition Examination Survey (n = 4555). Outcome measure: PD using clinical attachment loss (measured as none, mild, moderate, or severe). The main independent variables were self-reported chronic conditions, while other covariates included demographic and behavioral variables. Classification and regression tree analysis was used to identify combinations of specific chronic conditions associated with PD and PD with higher severity. Random forest was used to identify the most important variables associated with the presence and severity of PD. Results: The prevalence of PD was 77% among the study population. The percentage of those with PD was higher among younger and middle-aged (< 61 years old) than older (> 61 years old) adults. Age and education level were the two most important predictors for the presence and severity of PD. Other significant factors included alcohol use, type of medical insurance, sex, and non-white race. Accounting for only chronic conditions, hypertension and diabetes were the two chronic conditions associated with the presence and severity of PD. Conclusions: Sociodemographic and behavioral factors emerged as more strongly associated with the presence and severity of PD than chronic conditions. Accounting for the co-occurrence for sociodemographic and behavioral factors will be informative for identifying people vulnerable to the development of PD.

Presence of Specific Periodontal Pathogens in Prostate Gland Diagnosed With Chronic Inflammation and Adenocarcinoma.

Background Intraprostatic inflammation is frequently observed in the prostate and linked to prostatic diseases, including prostatitis, benign prostatic hyperplasia (BPH), and cancer. The etiology of prostate diseases is unclear. Periodontal diseases are associated with an increased risk of prostate diseases. In men, chronic prostatitis and moderate/severe periodontitis have significantly elevated serum prostate-specific antigen (PSA) levels. Treatment of periodontal disease reduced PSA levels in men. The presence of periodontal pathogens deoxyribonucleic acid (DNA) was identified in the prostate fluid of prostatitis patients. These pathogenic bacteria might have the potential to trigger prostatitis progressing to prostatic adenocarcinoma. The mechanism(s) explaining the etiology of association between periodontal disease and prostate cancer remains unclear. However, the presence of periodontal pathogens has not been analyzed in the prostate gland. Objective To identify and compare the presence of specific periodontal pathogens in the areas of BPH, inflammation, and cancer of the prostate glands diagnosed with malignancy. Materials and methods Whole-mount radical prostatectomy sections from men (n=30) were identified for BPH, inflammation, and cancer areas and marked for tissue procurement. The tissues were subjected to DNA isolation and analysis of microbial DNA and total bacterial load for the following pathogens, including Porphyromonas gingivalis strain ATCC 33277, Prevotella intermedia strain B422, Treponema denticola strain 35405, Fusobacterium nucleatum subsp. fusiform strain, Tannerella forsythia strain ATCC 43037, and Campylobacter​​​​​​​ rectus strain ATCC 33238performed real-time PCR. The universal bacterial primer pairs were used to detect genomic DNA (gDNA) from the total bacteria present in the samples. All species-specific primers were designed to target the variable regions of the 16S ribosomal RNA (rRNA). Data were analyzed using the 2-ΔΔCT method, statistically validated using unpaired t-test and ANOVA test. Results A total of 90 samples of prostate tissue specimens were analyzed for periodontal pathogens; only one pathogen (F. nucleatum subsp. fusiform strain ATCC 51190) showed a significant difference compared to the expression of S. epidermidis (internal control). In particular, F. nucleatum expression was 9, 11.9, and 10.3-fold higher in BPH, inflammation, and cancer, respectively, at p-value <0.05. Moreover, the bacterial load abundance/expression was almost similar in BPH (46.8-fold), inflammation (40.9 fold), and cancer (41.5 fold) higher. There was no significant difference in bacterial load (folder change) among the three areas of BPH, inflammation, and cancer (p-valve>0.05). Similarly, there was no significant difference between F. nucleatum (folder change) among the three areas (p-valve>0.05). Conclusion  Fusobacterium nucleatum is identified in the prostates that harbor cancer, chronic inflammation, and BPH.

Periodontal Manifestation of Type Ib Glycogen Storage Disease: A Rare Case Report.

INTRODUCTION: Glycogen storage diseases (GSD) are genetic metabolic disorders of glycogen metabolism. There are >15 types based on the enzyme deficiency and the affected organ. Glycogen storage disease Type Ib is the only type associated with neutropenia and periodontitis. This type is caused by a deficiency of glucose-6-phosphate (G6P) translocase which prevents the transport of G6P across the endoplasmic reticulum. As a result, glycogen cannot be metabolized into glucose with its subsequent accumulation in tissues. The affected organs involved in Type Ib are the liver, kidney, and intestine. CASE PRESENTATION: A 5-year-old Jordanian boy from a consanguineous family referred to the periodontal clinic in February 2014 with an established diagnosis of GSD-Ib. The systemic manifestations include hepatomegaly, hypoglycemia, hyperprolactenemia, inflammatory bowel disease, osteoporosis, and neutropenia. Oral manifestations include severe gingival inflammation and recurrent oral ulceration disease. CONCLUSIONS: The clinical signs and symptoms of periodontal disease in GSD Type Ib are similar to those found in patients diagnosed with neutropenia. Future studies are needed to clarify whether severe generalized inflammation of the gingiva in children is part of the GSD Type Ib or is a separate entity caused by neutrophil dysfunction.

Accelerated osteogenic orthodontics technique: a 1-stage surgically facilitated rapid orthodontic technique with alveolar augmentation.

PURPOSE: Demineralization of a thin layer of bone over a root prominence after corticotomy surgery can optimize the response to applied orthodontic forces. This physiologic response is consistent with the regional acceleratory phenomenon process. When combined with alveolar augmentation, one is no longer strictly at the mercy of the original alveolar volume and osseous dehiscences, and fenestrations can be corrected over vital root surfaces. This is substantiated with computerized tomographic and histologic evaluations. Two case reports are presented that demonstrate the usefulness of the accelerated osteogenic orthodontics technique in de-crowding and space closing for the correction of dental malocclusions. MATERIALS AND METHODS: Orthodontics is combined with full-thickness flap reflection, selective alveolar decortication, ostectomy, and bone grafting to accomplish complete orthodontic treatment. RESULTS: Rapid tooth movement was demonstrated in both cases and stability up to 8 years of retention. CONCLUSION: The accelerated osteogenic orthodontics technique provides for efficient and stable orthodontic tooth movement. Frequently, the teeth can be moved further in one third to one fourth the time required for traditional orthodontics alone. This is a physiologically based treatment consistent with a regional acceleratory phenomenon and maintaining an adequate blood supply is essential.

Autogenous bone grafting in a patient on long-term oral bisphosphonate therapy: case report.

A 66-year-old patient was referred to the Periodontal Clinic at Case Western Reserve University for implant placement in the mandibular left first molar area. The patient reported a history of oral bisphosphonate intake for the last 7 years for the treatment of osteoporosis. Autogenous bone block grafting was planned to augment the ridge before implant placement. The surgery was performed under local anesthesia, and the implant was successfully placed 8 months after ridge augmentation. Healing was uneventful postoperatively, and the buccolingual width of the ridge increased significantly, allowing placement of a 5-mm-diameter dental implant. The patient showed proper healing of both the donor site and the recipient site, in spite of the long-term oral bisphosphonate therapy, with no resulting osteonecrosis of the jawbone.

Impact of Implant and Site Characteristics on the Pattern of Bone Loss in Peri-implantitis.

PURPOSE: To assess the pattern of bone loss in peri-implantitis in partially edentulous patients and relate patient and implant/site characteristics that may influence such patterns. MATERIALS AND METHODS: In this retrospective study, the records of partially edentulous patients with dental implants were stratified according to sex, age, smoking, and diabetes. Implants were stratified according to site, number of years in function, presence of adjacent implants, diameter, bone-grafted site, and implant platform. All these variables were obtained from previous periodontal charts and radiographs. The implants were then classified into two main groups: (1) bone loss as defined by the presence of progressive marginal bone change found on radiographs at least 12 months following prosthesis placement compared to a baseline with a threshold ≥ 2 threads of bone loss; and (2) no bone loss as defined by no detected bone change or bone level change with a threshold < 2 threads. The bone loss group was further divided into three subgroups according to pattern: vertical, horizontal, and combined. Descriptive analyses were applied to assess the frequency of the pattern of bone loss (horizontal, vertical, and combined). A statistical regression model was used to find if there was a significant correlation between patient/implant characteristics and the pattern of bone loss. RESULTS: A total of 304 charts with 540 implants met the inclusion criteria. One randomly selected implant per patient through Microsoft Excel software was included in this study. Of these, 157 (51.6%) of examined charts were men and 147 (48.4%) were women. The patients' mean age was 63.9 ± 11.4 years (range: 27 to 85 years) at implant placement, and implants had been in function for 12 to 120 months (median: 37 months). The percentage of implants that had bone loss was 24.7% (75 out of 304). The pattern of bone loss was 65%, 22%, and 13% for vertical, horizontal, and combined, respectively. Implants that had been placed in surgically bone-grafted sites had increased odds of vertical bone loss with either narrow or wide implants (OR = 2.5 [P = .04] and 3.1 [P = .01], respectively). The presence of adjacent implants had significantly (P = .003) increased odds of horizontal bone loss (OR = 5.1). CONCLUSION: Approximately one-quarter of dental implants (24.7%) developed bone loss beyond normal physiologic remodeling. Vertical bone loss around single implants was the most common pattern (65%), particularly around implants placed in bone-grafted sites with odds ratio of 2.5 for narrow implants vs 3.1 for wide implants. In the presence of adjacent implants, the odds of horizontal bone loss was 5.1 (P = .003).

Association between oral pathogens and prostate cancer: building the relationship.

BACKGROUND: Chronic inflammation and infections are associated with increased risk of prostate cancer development. There is considerable evidence that proves the interrelationship between bacterial/viral infections and carcinogenesis. Periodontitis is a chronic inflammatory disease triggered by gram-negative anaerobic bacteria. In this narrative review, we investigate the relationship between periodontal disease and prostate cancer by reviewing previous studies of the association and possible mechanisms that may explain this link. METHODS: A comprehensive search for articles published was performed using the key words, "periodontal disease", "prostate disease", "prostate cancer", "prostatic inflammation". Thorough reviews of each study were conducted and assessed for eligibility, and data was summarized. RESULTS: The role of inflammatory responses in the prostate as drivers of malignancy appears to be predisposed by periodontal pathogens and/or periodontitis inflammatory mediators. CONCLUSION: Periodontal diseases might be associated with prostate cancer. However, the mechanism(s) explaining this relationship remains unclear and requires further elucidation.

Periodontal manifestation of leukocyte adhesion deficiency type I.

BACKGROUND: Leukocyte adhesion deficiency type I (LAD-I) is an autosomal recessive immunodeficiency disorder characterized by defects in the integrin receptors of white blood cells that lead to impaired adhesion and chemotaxis. Affected patients are susceptible to recurrent bacterial and fungal infections, impaired pus formation, delayed wound healing, and periodontitis. METHODS: A case of generalized advanced periodontal destruction of the permanent and deciduous dentition in a young Jordanian girl with a severe phenotype of LAD-I is presented in this report. The medical diagnosis was made based on the characteristic clinical and laboratory findings, in particular the total absence of CD18, CD11b, and CD11c as determined by flow cytometry sorting. RESULTS: Periodontal findings in this patient include the early onset of the disease, which affected the primary teeth and permanent dentitions, the intense redness and inflammation of the gingiva, and the rapid periodontal destruction that seems refractory to conventional non-surgical periodontal therapy. CONCLUSION: This report emphasizes the importance of the differential diagnosis of severe immunodeficiency disorders in children and adolescents and mandates the importance of combined care by medical and dental practitioners to prevent tooth loss and control oral infection.

Mucogingival conditions in the natural dentition: Narrative review, case definitions, and diagnostic considerations.

BACKGROUND: Mucogingival deformities, and gingival recession in particular, are a group of conditions that affect a large number of patients. Since life expectancy is rising and people are retaining more teeth both gingival recession and the related damages to the root surface are likely to become more frequent. It is therefore important to define anatomic/morphologic characteristics of mucogingival lesions and other predisposing conditions or treatments that are likely to be associated with occurrence of gingival recession. OBJECTIVES: Mucogingival defects including gingival recession occur frequently in adults, have a tendency to increase with age, and occur in populations with both high and low standards of oral hygiene. The root surface exposure is frequently associated with impaired esthetics, dentinal hypersensitivity and carious and non-carious cervical lesions. The objectives of this review are as follows (1) to propose a clinically oriented classification of the main mucogingival conditions, recession in particular; (2) to define the impact of these conditions in the areas of esthetics, dentin hypersensitivity and root surface alterations at the cervical area; and (3) to discuss the impact of the clinical signs and symptoms associated with the development of gingival recessions on future periodontal health status. RESULTS: An extensive literature search revealed the following findings: 1) periodontal health can be maintained in most patients with optimal home care; 2) thin periodontal biotypes are at greater risk for developing gingival recession; 3) inadequate oral hygiene, orthodontic treatment, and cervical restorations might increase the risk for the development of gingival recession; 4) in the absence of pathosis, monitoring specific sites seems to be the proper approach; 5) surgical intervention, either to change the biotype and/or to cover roots, might be indicated when the risk for the development or progression of pathosis and associated root damages is increased and to satisfy the esthetic requirements of the patients. CONCLUSIONS: The clinical impact and the prevalence of conditions like root surface lesions, hypersensitivity, and patient esthetic concern associated with gingival recessions indicate the need to modify the 1999 classification. The new classification includes additional information, such as recession severity, dimension of the gingiva (gingival biotype), presence/absence of caries and non-carious cervical lesions, esthetic concern of the patient, and presence/absence of dentin hypersensitivity.

Tuberosity versus palatal donor sites for soft tissue grafting: A split-mouth clinical study.

OBJECTIVE: To compare postoperative pain associated with palatal and tuberosity donor sites for soft tissue grafting, and to evaluate the outcomes in both the donor and recipient sites. METHOD AND MATERIALS: Twenty healthy nonsmokers requiring bilateral soft tissue grafts were recruited for the study. For the 10 patients who required free gingival graft (FGG), 10 epithelialized grafts were taken from the tuberosity and 10 from the palate. The other 10 patients who required coronally advanced flap (CAF) and connective tissue graft (CTG) received 10 de-epithelialized grafts from the tuberosity and 10 from the palate. A total of 20 receded areas were treated with CAF and CTG. A total of 20 mucogingival defects were treated by FGG. Pain level was reported by the patient using a subjective score on a scale of 0 to 10 (0 = no pain, 10 = very severe pain). The length, width, and thickness of the outcome was measured for the FGG group at 8 weeks. The percentage of root coverage along with the length, width, and thickness of the final outcome was measured for the FGG group as well as the CAF and CTG group. RESULTS: Pain level in the tuberosity donor site was significantly lower than in the palatal donor site during the first 2 postoperative weeks (2.6 ± 2.16 versus 5.9 ± 2.74 respectively, P < .001). Mean gingival thickness of the healed tuberosity donor graft was greater than of the palatal donor grafts in both groups; for CAF and CTG group 2.9 ± 0.5 versus 2.3 ± 0.6 mm, respectively (P = .016); for FGG group 2.7 ± 0.7 versus 2.1 ± 0.7, respectively (P = .026). No differences were observed in the length or width of both grafted sites at an 8-week follow-up. No significant difference in the mean percentage of root coverage resulting from tuberosity or palatal donor sites was noted (67 ± 12% versus 62 ± 13%, respectively, P = .102). CONCLUSION: Soft tissue grafts harvested from the tuberosity site might provide a better option than soft tissue donor grafts obtained from the palate in terms of function and less postoperative pain.

Chronic Periodontitis Case Definitions and Confounders in Periodontal Research: A Systematic Assessment.

Case definitions and criteria of periodontal diseases are not yet consistent worldwide. This can affect the accuracy of any comparison made between two studies. This study determines which are the most common chronic periodontitis case definitions as well as confounding variables that have been reported worldwide in periodontal literature. A systematic assessment on periodontal disease classification and confounders was conducted using all publications in MEDLINE, EMBASE, SCOPUS, and Google Scholar between 1965 and October 2017. Screening of eligible studies and data extraction were conducted in duplicate and independently by two reviewers. The search protocol produced 4,218 articles. Out of these, 492 potentially relevant articles were selected for review. Only 351 studies fulfilled the selection criteria. Combination of probing depth and clinical attachment loss was the most common chronic periodontitis case definitions used (121, studies, 34.5%). CPI/CPITN was the most common classification used. Age was the most common confounder studied in periodontal research (303 studies, 86.3%), followed by gender (268 studies, 76.4%) and race (138 studies, 39.3%). Albumin and creatinine were the least common variables studied (1 or 2 studies each). Different case definitions affect the prevalence and treatment consequences of periodontitis. We need to standardize periodontitis case definitions worldwide to avoid difficulties in case diagnosis and prognosis. Further studies need to be done to assess the association between periodontitis and several potential confounders.

Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.

BACKGROUND: A variety of systemic diseases and conditions can affect the course of periodontitis or have a negative impact on the periodontal attachment apparatus. Gingival recessions are highly prevalent and often associated with hypersensitivity, the development of caries and non-carious cervical lesions on the exposed root surface and impaired esthetics. Occlusal forces can result in injury of teeth and periodontal attachment apparatus. Several developmental or acquired conditions associated with teeth or prostheses may predispose to diseases of the periodontium. The aim of this working group was to review and update the 1999 classification with regard to these diseases and conditions, and to develop case definitions and diagnostic considerations. METHODS: Discussions were informed by four reviews on 1) periodontal manifestions of systemic diseases and conditions; 2) mucogingival conditions around natural teeth; 3) traumatic occlusal forces and occlusal trauma; and 4) dental prostheses and tooth related factors. This consensus report is based on the results of these reviews and on expert opinion of the participants. RESULTS: Key findings included the following: 1) there are mainly rare systemic conditions (such as Papillon-Lefevre Syndrome, leucocyte adhesion deficiency, and others) with a major effect on the course of periodontitis and more common conditions (such as diabetes mellitus) with variable effects, as well as conditions affecting the periodontal apparatus independently of dental plaque biofilm-induced inflammation (such as neoplastic diseases); 2) diabetes-associated periodontitis should not be regarded as a distinct diagnosis, but diabetes should be recognized as an important modifying factor and included in a clinical diagnosis of periodontitis as a descriptor; 3) likewise, tobacco smoking - now considered a dependence to nicotine and a chronic relapsing medical disorder with major adverse effects on the periodontal supporting tissues - is an important modifier to be included in a clinical diagnosis of periodontitis as a descriptor; 4) the importance of the gingival phenotype, encompassing gingival thickness and width in the context of mucogingival conditions, is recognized and a novel classification for gingival recessions is introduced; 5) there is no evidence that traumatic occlusal forces lead to periodontal attachment loss, non-carious cervical lesions, or gingival recessions; 6) traumatic occlusal forces lead to adaptive mobility in teeth with normal support, whereas they lead to progressive mobility in teeth with reduced support, usually requiring splinting; 7) the term biologic width is replaced by supracrestal tissue attachment consisting of junctional epithelium and supracrestal connective tissue; 8) infringement of restorative margins within the supracrestal connective tissue attachment is associated with inflammation and/or loss of periodontal supporting tissue. However, it is not evident whether the negative effects on the periodontium are caused by dental plaque biofilm, trauma, toxicity of dental materials or a combination of these factors; 9) tooth anatomical factors are related to dental plaque biofilm-induced gingival inflammation and loss of periodontal supporting tissues. CONCLUSION: An updated classification of the periodontal manifestations and conditions affecting the course of periodontitis and the periodontal attachment apparatus, as well as of developmental and acquired conditions, is introduced. Case definitions and diagnostic considerations are also presented.