Scaling and root planing vs. conservative surgery in the treatment of chronic periodontitis.

A renewed interest in conservative surgical techniques has been fueled by new technology, changes in referral patterns to periodontists and a desire to achieve periodontal health in the least invasive, most cost-efficient manner possible. Trends suggest that an increasing amount of periodontal care is being provided in the offices of general dentists. If true, it is likely that patients receiving care in these offices will be offered simpler surgical treatment modalities that do not require an extensive armamentarium. The purpose of this article was to review the effectiveness of six relatively simple surgical techniques - gingivectomy, flap debridement, modified Widman flap, excisional new attachment procedure, modified excisional new attachment procedure and laser-assisted new attachment procedure - and to compare the results obtained using these procedures with the well-known clinical benefits of scaling and root planing. The intent was to determine whether the benefits of surgical procedures in the hands of most general dentists extend beyond those of conventional nonsurgical therapy.

Clinical reliability of the "furcation arrow" as a diagnostic marker.

BACKGROUND: The radiographic entity known as the "furcation arrow" has long been used in practice even though little is known about its usefulness as a clinical indicator. The definitive study of the furcation arrow suggests that its presence on a radiograph reliably predicts furcation invasion, but this has not been confirmed in an in vivo investigation. The purpose of this study was to evaluate the furcation arrow in a clinical setting, testing the assertion that the furcation arrow image is an accurate predictor of furcation invasion. Specifically, we sought to determine the following. First, what is the prevalence of furcation arrow images in the radiographs of maxillary molars with periodontitis? Second, what is the interexaminer agreement on what constitutes a furcation arrow? Third, how does the presence or absence of a furcation arrow correlate with the true clinical status of the furcation? Fourth, what is the sensitivity and specificity of the furcation arrow as a diagnostic indicator? METHODS: Eighty-nine patients requiring surgical treatment of periodontitis in the maxillary molar regions were included in this study. Before surgery, one of five calibrated examiners viewed periapical and bitewing radiographs of the surgical site and recorded the presence or absence of a furcation arrow at each proximal furcation. Before administering anesthesia, the same examiner recorded a Hamp index value of each proximal furcation, with a second Hamp index taken after flap reflection and debridement. After surgery, each of the four remaining examiners independently reviewed the radiographs for furcation arrows. Descriptive statistical analysis was performed to correlate the appearance of the furcation arrow image to the actual degree of furcation invasion as determined by the intrasurgical Hamp index. RESULTS: A total of 164 maxillary molars were examined, providing 328 interproximal furcations; 111 (33.8%) furcations were determined at surgical debridement to have a furcation invasion of Hamp degree 1 or greater. Of the 111 furcation invasions, 43 (38.7%) were predicted by a furcation arrow image seen by at least three of the five examiners. When comparing the appearance of the radiographic image to the extent of furcation invasion, 20 of 64 (31.3%) Hamp 1 furcation invasions and 23 of 47 (48.9%) Hamp 2 and 3 furcation invasions were predicted by furcation arrows observed by at least three of five examiners. The multirater kappa statistic for interexaminer agreement on the presence or absence of the image was 0.489. The sensitivity of the furcation arrow image as a diagnostic marker was 38.7%, and the specificity was 92.2%; the positive predictive value of the image was 71.7%, and the negative predictive value was 74.6%. Of the 324 furcations used to compare clinical indices, the agreement of preanesthesia and postdebridement Hamp indices was 0% for degree 3, 83.7% for degree 2, and 98.4% for degree 1 furcation lesions. CONCLUSIONS: These data suggest that the furcation arrow has limited usefulness as a diagnostic marker of furcation invasion. The image is difficult to interpret and highly subjective and can correctly predict furcation invasions only approximately 70% of the time when present on the radiograph. In addition, when furcation invasions are truly present, the furcation arrow is seen in <40% of sites.

Human periodontal fibroblast response to enamel matrix derivative, amelogenin, and platelet-derived growth factor-BB.

BACKGROUND: The ideal goal of clinical therapy in periodontal defects is regeneration of all lost structures. For regeneration to occur, cell proliferation, migration, and extracellular matrix synthesis are prerequisites. Attempts at regeneration of periodontal defects by guided tissue regeneration using bone grafts and membranes have not always yielded predictable results. Recently, attempts at engineering the defects using various materials have shown promising results. Two such approaches have been used to regenerate periodontal defects, one using extracellular matrix such as enamel matrix proteins and the other using growth factors. However, to our knowledge, no study has looked at combining these two approaches to achieve potentially even greater regeneration. METHODS: Primary human periodontal ligament (PDL) fibroblasts were explanted, and alkaline phosphatase (ALK PHOS) activity was determined. Phenotypically different cell lines were incubated for 1, 3, 6, and 10 days in 0.2% fetal bovine serum (FBS) media containing different concentrations of either enamel matrix derivative (EMD), amelogenin, platelet-derived growth factor-BB (PDGF-BB), EMD+PDGF-BB, or amelogenin+PDGF-BB. A culture of 0.2% FBS alone served as a negative control, and a culture of 10% FBS served as a positive control. Cell proliferation was measured using a Coulter counter to determine the cell number. The effects on a wound-fill model were evaluated by scraping a 3-mm wide cell-free zone in PDL monolayers across the diameter of the tissue-culture plate and determining PDL cell migration into the cell-free zone using computer assisted histomorphometry. RESULTS: Compared to the control, only EMD+PDGF-BB significantly increased PDL cell proliferation in an ALK PHOS (-) cell line (P<0.001), and EMD alone, EMD+PDGF-BB, and amelogenin+PDGF-BB significantly increased PDL cell proliferation in an ALK PHOS (+) cell line (P<0.001) with EMD+PDGF-BB showing a trend for greater proliferation than either PDGF or EMD alone. Individually, EMD and amelogenin had no significant effect on PDL cell proliferation. In the wound-fill experiment, all factors and their combinations except amelogenin significantly enhanced cell migration compared to the control (P<0.05) at the wound edge. In addition, EMD+PDGF-BB had additive effects on the ALK PHOS (-) cell line at the wound edge. At the center of the wound, neither EMD nor amelogenin had a significant wound-fill effect. However, the combination of EMD+PDGF-BB additively increased wound fill for both ALK PHOS (+) and ALK PHOS (-) cells. CONCLUSIONS: The combination of EMD and PDGF-BB produces greater proliferative and wound-fill effects on PDL cells than each by themselves. If these combined effects can be translated clinically, one may see greater regeneration in periodontal defects with this combination. However, amelogenin does not have significant effects on PDL cell proliferation or migration by itself. This may suggest that either another enamel matrix component in EMD may be responsible for some of its clinical effects, or that amelogenin alone may not trigger the regenerative potential of periodontal tissues and that it requires a combined interaction with other enamel matrix components of EMD to direct the regenerative process.

Palatal neurofibroma associated with localized periodontitis.

BACKGROUND: Neurofibromatosis type 1 (NF1) is the most common form of neurofibromatosis. While typically considered a dermatologic disorder, intraoral signs of neurofibromatosis occur quite commonly. This clinical entity can be confused with periodontitis because of the presence of periodontal pockets. In this report, we present the case of a palatal neurofibroma with radiographic involvement in a patient with NF1. METHODS: A 40-year-old female patient was referred from her general dentist to evaluate advanced periodontitis in the maxillary left quadrant. The patient's medical history was significant for a soft tissue lesion excised from her back 11 years previously and diagnosed as a neurofibroma. Subsequent medical examination at that time confirmed a systemic diagnosis of NF1. A comprehensive periodontal evaluation was performed, and panoramic and periapical radiographs were taken. Teeth were tested for vitality. An incisional biopsy was completed for histopathologic examination. RESULTS: The periodontal evaluation revealed the presence of 6 to 9 mm probing depths adjacent to teeth #14 and #15. Panoramic and periapical radiographs showed a circumscribed 0.8x0.9-cm unilocular radiolucency superimposed over the root of tooth #13 and extensive horizontal bone loss on the distal side of #15. Incisional biopsy confirmed the presence of a neurofibroma, and because of the extent of the lesion, the patient was referred to the Oral and Maxillofacial Surgery service for complete excision. CONCLUSIONS: Neurofibromas can cause extensive destruction of alveolar bone, mimicking periodontitis. Due to the potential systemic and genetic implications, the diagnosis of neurofibroma requires appropriate medical referral.

Post-surgical infections: prevalence associated with various periodontal surgical procedures.

BACKGROUND: Of the various adverse outcomes that may be encountered following periodontal surgery, the risk of infection stands at the forefront of concern to the surgeon, since infection can lead to morbidity and poor healing outcomes. This paper describes a large-scale retrospective study of multiple surgical modalities in a diverse periodontal practice undertaken to explore the prevalence of clinical infections post-surgically and the relationship between diverse treatment variables and infection rates. METHODS: A retrospective review of all available periodontal surgical records of patients treated in the Department of Periodontics at Wilford Hall Medical Center, San Antonio, Texas, was conducted. The sample comprised 395 patients and included 1,053 fully documented surgical procedures. Surgical techniques reviewed included osseous resective surgery, flap curettage, distal wedge procedures, gingivectomy, root resection, guided tissue regeneration, dental implant surgery, epithelialized free soft tissue autografts, subepithelial connective tissue autografts, coronally positioned flaps, sinus augmentations, and ridge preservation or augmentation procedures. Infection was defined as increasing and progressive swelling with the presence of suppuration. The impact of various treatment variables was examined including the use of bone grafts, membranes, soft tissue grafts, post-surgical chlorhexidine rinses, systemic antibiotics, and dressings. Results were analyzed using Fisher's exact test and Pearson's chi-square test. RESULTS: Of the 1,053 surgical procedures evaluated in this study, there were a total of 22 infections for an overall prevalence of 2.09%. Patients who received antibiotics as part of the surgical protocol (pre- and/ or post-surgically) developed eight infections in 281 procedures (2.85%) compared to 14 infections in 772 procedures (1.81%) where antibiotics were not used. Procedures in which chlorhexidine was used during post-surgical care had a lower infection rate (17 infections in 900 procedures, 1.89%) compared to procedures after which chlorhexidine was not used as part of post-surgical care (five infections in 153 procedures, 3.27%). The use of a post-surgical dressing demonstrated a slightly higher rate of infection (eight infections in 300 procedures, 2.67%) than non-use of a dressing (14 infections in 753 procedures, 1.86%). Despite these trends, no statistically significant relationship was found between post-surgical infection and any of the treatment variables examined, including the use of perioperative antibiotics. CONCLUSIONS: The results of this study confirm previous research demonstrating a low rate of postoperative infection following periodontal surgical procedures. Although perioperative antibiotics are commonly used when performing certain regenerative and implant surgical procedures, data from this and other studies suggest that there may be no benefit in using antibiotics for the sole purpose of preventing post-surgical infections. Further large-scale, controlled clinical studies are warranted to determine the role of perioperative antibiotics in the prevention of periodontal post-surgical infections.

Osseous surgery for crown lengthening: a 6-month clinical study.

BACKGROUND: Despite the fact that surgical crown lengthening is a commonly performed treatment, little is known about the specific surgical endpoints of the procedure or the stability of the newly attained crown height over time. Recent clinical reports have ranged across a spectrum from significant tissue rebound to remarkable stability using similar surgical techniques. The purpose of this study was to assess the stability of surgical crown lengthening procedures performed by various surgeons using specific guidelines to determine surgical endpoints. Specifically, we sought to determine the following: 1) What is the immediate increase in clinical crown height following surgery? 2) How stable is the established crown length over a 6-month period? 3) How much supporting bone is removed to establish the new crown length? 4) How does the position of the flap margin relative to the alveolar bone at surgical closure relate to the stability of crown height? METHODS: Twenty-five patients requiring crown lengthening of 43 teeth were included in this study. Clinical indices recorded at eight sites on each molar and six sites on each premolar included plaque, bleeding on probing, probing depth, and relative attachment level from a customized probing stent. Surgical measurements at the same sites included the distance from stent to alveolar bone both before and after osseous surgery and the distance from flap margin to alveolar bone after suturing. Clinical measurements were repeated at 1, 3, and 6 months after surgery. Sites were divided into three groups. All sites on teeth targeted for crown lengthening were labeled treated sites (TT). Interproximal sites on neighboring teeth were labeled adjacent (AA) if they shared a proximal surface with a treated tooth and nonadjacent (AN) if they were on the opposite side, away from the treated tooth. RESULTS: Throughout the entire 6-month healing period, descriptive statistics revealed no significant time or group differences in plaque and bleeding scores. At treated sites, the mean gain of crown height at surgery was 2.27 +/- 1.1 mm. This was reduced to 1.91 +/- 1.08 mm at 1 month, 1.69 +/- 1.02 mm at 3 months, and 1.57 +/- 1.01 mm at 6 months. At adjacent sites, the gain of crown length was 2.18 +/- 0.98 mm, 1.61 +/- 0.98 mm, 1.43 +/- 0.96 mm, and 1.30 +/- 0.96 mm at surgery, 1, 3, and 6 months, respectively. At non-adjacent sites the crown height increased 1.06 +/- 1.07 mm, 1.00 +/- 0.93 mm, 0.84 +/- 1.00 mm, and 0.76 +/- 0.85 mm, respectively. These mean measurements were significantly different for each treatment group at each time interval and appeared not to have stabilized between 3 and 6 months. The mean osseous reduction at treated, adjacent, and non-adjacent sites was 1.13 +/- 0.90 mm, 0. 78 +/- 0.75 mm, and 0.065 +/- 0.69 mm, respectively. Frequency distribution of osseous reduction demonstrated that 23.6% of treated sites had 0 mm, 44.3% had 1 mm, 25.4% had 2 mm, 6.2% had 3 mm, and less than I % had > or = 4 mm of bone removed to establish crown height More bone removal was noted at premolar than at molar sites; however, this was not statistically significant. When tissue rebound following surgery was plotted against post-surgical flap position, it was noted that the closer the flap margin was sutured to the alveolar crest, the greater the tissue rebound during the post-surgical period. This rebound ranged from 1.33 +/- 1.02 mm when the flap was sutured < or = 1 mm from the alveolar crest, to -0.16 +/- 1.15 mm when the flap was sutured > or = 4 mm from the alveolar crest. CONCLUSIONS: These data suggest that there is a significant tissue rebound following crown-lengthening surgery that has not fully stabilized by 6 months. The amount of tissue rebound seems related to the position of the flap relative to the alveolar crest at suturing. These findings support the premise that clinicians should establish proper crown height during surgery without overreliance on flap placement at the osseous crest.