Adjunctive antimicrobial photodynamic therapy for treating periodontal and peri-implant diseases.

BACKGROUND: Periodontitis and peri-implant diseases are chronic inflammatory conditions occurring in the mouth. Left untreated, periodontitis progressively destroys the tooth-supporting apparatus. Peri-implant diseases occur in tissues around dental implants and are characterised by inflammation in the peri-implant mucosa and subsequent progressive loss of supporting bone. Treatment aims to clean the pockets around teeth or dental implants and prevent damage to surrounding soft tissue and bone, including improvement of oral hygiene, risk factor control (e.g. encouraging cessation of smoking) and surgical interventions. The key aspect of standard non-surgical treatment is the removal of the subgingival biofilm using subgingival instrumentation (SI) (also called scaling and root planing). Antimicrobial photodynamic therapy (aPDT) can be used an adjunctive treatment to SI. It uses light energy to kill micro-organisms that have been treated with a light-absorbing photosensitising agent immediately prior to aPDT. OBJECTIVES: To assess the effects of SI with adjunctive aPDT versus SI alone or with placebo aPDT for periodontitis and peri-implant diseases in adults. SEARCH METHODS: We searched the Cochrane Oral Health Trials Register, CENTRAL, MEDLINE, Embase, two other databases and two trials registers up to 14 February 2024. SELECTION CRITERIA: We included randomised controlled trials (RCTs) (both parallel-group and split-mouth design) in participants with a clinical diagnosis of periodontitis, peri-implantitis or peri-implant disease. We compared the adjunctive use of antimicrobial photodynamic therapy (aPDT), in which aPDT was given after subgingival or submucosal instrumentation (SI), versus SI alone or a combination of SI and a placebo aPDT given during the active or supportive phase of therapy. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures, and we used GRADE to assess the certainty of the evidence. We prioritised six outcomes and the measure of change from baseline to six months after treatment: probing pocket depth (PPD), bleeding on probing (BOP), clinical attachment level (CAL), gingival recession (REC), pocket closure and adverse effects related to aPDT. We were also interested in change in bone level (for participants with peri-implantitis), and participant satisfaction and quality of life. MAIN RESULTS: We included 50 RCTs with 1407 participants. Most studies used a split-mouth study design; only 18 studies used a parallel-group design. Studies were small, ranging from 10 participants to 88. Adjunctive aPDT was given in a single session in 39 studies, in multiple sessions (between two and four sessions) in 11 studies, and one study included both single and multiple sessions. SI was given using hand or power-driven instrumentation (or both), and was carried out prior to adjunctive aPDT. Five studies used placebo aPDT in the control group and we combined these in meta-analyses with studies in which SI alone was used. All studies included high or unclear risks of bias, such as selection bias or performance bias of personnel (when SI was carried out by an operator aware of group allocation). We downgraded the certainty of all the evidence owing to these risks of bias, as well as for unexplained statistical inconsistency in the pooled effect estimates or for imprecision when evidence was derived from very few participants and confidence intervals (CI) indicated possible benefit to both intervention and control groups. Adjunctive aPDT versus SI alone during active treatment of periodontitis (44 studies) We are very uncertain whether adjunctive aPDT during active treatment of periodontitis leads to improvement in any clinical outcomes at six months when compared to SI alone: PPD (mean difference (MD) 0.52 mm, 95% CI 0.31 to 0.74; 15 studies, 452 participants), BOP (MD 5.72%, 95% CI 1.62 to 9.81; 5 studies, 171 studies), CAL (MD 0.44 mm, 95% CI 0.24 to 0.64; 13 studies, 414 participants) and REC (MD 0.00, 95% CI -0.16 to 0.16; 4 studies, 95 participants); very low-certainty evidence. Any apparent differences between adjunctive aPDT and SI alone were not judged to be clinically important. Twenty-four studies (639 participants) observed no adverse effects related to aPDT (moderate-certainty evidence). No studies reported pocket closure at six months, participant satisfaction or quality of life. Adjunctive aPDT versus SI alone during supportive treatment of periodontitis (six studies) We were very uncertain whether adjunctive aPDT during supportive treatment of periodontitis leads to improvement in any clinical outcomes at six months when compared to SI alone: PPD (MD -0.04 mm, 95% CI -0.19 to 0.10; 3 studies, 125 participants), BOP (MD 4.98%, 95% CI -2.51 to 12.46; 3 studies, 127 participants), CAL (MD 0.07 mm, 95% CI -0.26 to 0.40; 2 studies, 85 participants) and REC (MD -0.20 mm, 95% CI -0.48 to 0.08; 1 study, 24 participants); very low-certainty evidence. These findings were all imprecise and included no clinically important benefits for aPDT. Three studies (134 participants) reported adverse effects: a single participant developed an abscess, though it is not evident whether this was related to aPDT, and two studies observed no adverse effects related to aPDT (moderate-certainty evidence). No studies reported pocket closure at six months, participant satisfaction or quality of life. AUTHORS' CONCLUSIONS: Because the certainty of the evidence is very low, we cannot be sure if adjunctive aPDT leads to improved clinical outcomes during the active or supportive treatment of periodontitis; moreover, results suggest that any improvements may be too small to be clinically important. The certainty of this evidence can only be increased by the inclusion of large, well-conducted RCTs that are appropriately analysed to account for change in outcome over time or within-participant split-mouth study designs (or both). We found no studies including people with peri-implantitis, and only one study including people with peri-implant mucositis, but this very small study reported no data at six months, warranting more evidence for adjunctive aPDT in this population group.

Prevalence of Peri-Implant Disease in Patients with Stage III or IV Periodontitis: Results of a Long-Term Follow-Up from a Specialized Periodontal Practice.

The aim of this study was to examine the conditions of implants that had been in function for 5-17 years in stage III/IV periodontitis patients of a specialized periodontal practice. There were 83 patients (43 female/40 male, mean age 64.4 (9.69) years), with a total of 213 implants, who participated in the study. Assessments included periodontal and peri-implant probing depths, bleeding and plaque scores, and a radiographic examination. Smoking habits, participation in a supportive care program (SCP), and the Implant Disease Risk Assessment (IDRA) scores were recorded. A total of 44 patients presented with stage III periodontitis, and 39 with stage IV. In all, 85% of patients had adhered to regular SCP. On an implant/patient level, peri-implant health was found in 37.1.7% (79 implants)/24.1% (20 patients), peri-implant mucositis in 58.7% (125 implants)/66.3% (55 patients), and peri-implantitis in 4.2% (9 implants)/9.6% (8 patients). IDRA scores showed 30.5% of implants at moderate and 69.5% at high risk. The present long-term analysis shows a high prevalence of peri-implant disease in patients treated for advanced periodontitis. These findings underline the challenges involved in the long-term maintenance of oral health in stage III/IV periodontitis patients restored with dental implants.

Three-year results following regenerative periodontal surgery of advanced intrabony defects with enamel matrix derivative alone or combined with a synthetic bone graft.

OBJECTIVES: This study aims to compare the clinical outcomes of a combination of enamel matrix derivatives (EMD) and a synthetic bone graft (biphasic calcium phosphate) with EMD alone in wide and deep one- and two-wall intrabony defects 36 months after treatment. MATERIAL AND METHODS: Thirty patients with chronic periodontitis and one wide (≥ 2 mm) and deep (≥ 4 mm) intrabony defect had been recruited in three centres in Germany. During surgery, defects were randomly assigned to EMD/synthetic bone graft (SBG) (test) or EMD (control). Assessments at baseline, after 6, 12 and 36 months, included bone sounding, relative clinical attachment levels, probing pocket depths and recessions. RESULTS: After 36 months, defects in both groups were significantly improved (p < 0.001) with regard to defect fill, attachment gain and probing pocket reduction. In the EMD/SBG group, a mean defect fill of 2.6 mm (±1.7) was measured, and in the EMD group, the defect fill was 2.3 mm (±1.5). A mean gain in clinical attachment of 4.1 mm (±3.6) and 3.8 mm (±2.2) was observed in the test and in the control group, respectively. There were no statistically significant differences in any of the investigated parameters between the two treatment modalities. CONCLUSIONS: The clinical improvements of advanced intrabony defects obtained with both regenerative modalities could be maintained over a period of 3 years. The combination of EMD with SBG did not show any advantage compared to the use of EMD alone.

Er:YAG laser treatment in supportive periodontal therapy.

OBJECTIVE: To assess clinical and microbiological outcomes of an Er:YAG laser in comparison with sonic debridement in the treatment of persistent periodontal pockets in a prospective randomized controlled multicentre study design. MATERIAL AND METHODS: A total of 78 patients in supportive periodontal therapy with two residual pockets were included, 58 were available for the whole follow-up period. Root surfaces were instrumented either with a sonic scaler (Sonicflex(®) 2003 L) or with an Er:YAG laser (KEY Laser(®) 3). Clinical attachment levels (CAL), Probing depths (PD), Plaque control record (PCR) and Bleeding on probing (BOP) were assessed at baseline, 13 and 26 weeks after treatment. In addition, microbiological analysis was performed employing a DNA diagnostic test kit (micro-IDent(®) Plus). RESULTS: Probing depths and CAL were significantly reduced in both groups over time (p < 0.05), without significant differences between the groups (p > 0.05). BOP frequency values decreased significantly within both groups (p < 0.05), with no difference between the laser and the sonic treatment (p > 0.05). PCR frequency values did not change during the observation period (p > 0.05). Microbiological analysis failed to expose any significant difference based on treatment group or period. CONCLUSION: Employing both sonic and laser treatment procedures during supportive periodontal care, similar clinical and microbiological outcomes can be expected.

A multi-centre randomized controlled clinical trial on the treatment of intra-bony defects with enamel matrix derivatives/synthetic bone graft or enamel matrix derivatives alone: results after 12 months.

OBJECTIVES: Comparison of the clinical and radiographic outcomes of a combination of enamel matrix derivatives (EMD) and a synthetic bone graft (EMD/SBG) with EMD alone in wide (≥2 mm) and deep (≥4 mm) one- and two- wall intra-bony defects 12 months after treatment. MATERIALS AND METHODS: Seventy-three patients with chronic periodontitis and one wide (≥2 mm) and deep (≥4 mm) intra-bony defect were recruited in five centres in Germany. During surgery, defects were randomly assigned to EMD/SBG (test) or EMD (control). Assessments at baseline, after 6 and 12 months included bone sounding, attachment levels, probing pocket depths, bleeding on probing, and recessions. Changes in defect fill were recorded radiographically. RESULTS: Both treatment modalities led to significant clinical improvements. In the EMD/SBG group a mean defect fill of 2.7 ± 1.9 mm was calculated, in the EMD group the defect fill was 2.8 ± 1.6 mm. A mean gain in clinical attachment of 1.7 ± 2.1 mm in the test group and 1.9 ± 1.7 mm in the control group after 1 year was observed. Radiographic analysis confirmed for both groups that deeper defects were associated with greater defect fill. CONCLUSION: The results show comparable clinical and radiographic outcomes following both treatment modalities 12 months after treatment.

Open or submerged healing of implants with platform switching: a randomized, controlled clinical trial.

AIM: The temporal pattern of bone-level alterations in conventionally restored implants is dependent upon healing mode (open or submerged). This study examined the influence of healing on marginal bone levels at implants with a medium-rough surface including the implant collar and a clearance-fit implant-abutment connection restored according to a platform-switching concept. MATERIAL AND METHODS: Two implants were placed in the posterior mandible of 21 test subjects, randomly assigned to open (OH) or submerged (SH) healing. Standardized radiographs were obtained after implant surgery, before re-entry, after crown mounting, 1 and 2 years after implant surgery, and evaluated for implant-bone-level alterations (ΔIBL). Bacterial samples of the implants' inner cavities were analysed by cultivation. STATISTICS: Brunner-Langer Model, equivalence testings by Wilcoxon's (equivalence range ±0.4mm). RESULTS: After 2 years, ΔIBL were -0.47±0.46mm (OH) and -0.54±0.38mm (SH). At the 1-year follow-up, all implants were contaminated with bacteria. ΔIBL (p<0.001) and the amount of bacterial contamination (p<0.001) significantly depended on time, but not on healing mode. ΔIBL of OH and SH were equivalent at all time points (all p0.044). CONCLUSIONS: Platform-switched implants showed very limited peri-implant bone-level alterations. The healing-mode neither affected the total amount nor the temporal patterns of ΔIBL. Thus, the results for the tested implants with a non-rigid implant-abutment connection were similar to results reported previously for implants with a rigid implant-abutment connection.

Comparison of cone-beam computerized tomography and intraoral radiographs for determination of the periodontal ligament in a variable phantom.

OBJECTIVES: This in vitro study assessed the visualization quality of the periodontal ligament space in cone-beam computerized tomography (CBCT) compared with intraoral radiographs (CR). STUDY DESIGN: A phantom mimicking variable periodontal ligament spaces (0-0.42 mm) was radiographed using CBCT and CR. Fifteen datasets of each modality were randomly mixed and presented twice to 19 experienced examiners and once to 19 inexperienced examiners. RESULTS: Zero-millimeter gaps were recognized in 84.4% of CBCT and in 81.6% of CR images. On CBCT scans, gaps of 0.19 mm were identified with an accuracy of 93%-100% compared with 70.2%-81.7% using CR. Experienced examiners recognized gaps of >or=0.19 mm on CBCT repeatedly with nearly 100% accuracy. CONCLUSION: Compared with CR, CBCT provides better visualization of simulated periodontal ligament space in this phantom.