Retrospective analysis of the long-term effect of subgingival air polishing in supportive periodontal therapy.

AIM: Glycine powder air polishing (GPAP) procedure has become popular. Aim of the analysis was to compare the clinical outcomes during supportive periodontal therapy (SPT) of subgingival application of GPAP with those using sole conventional mechanical debridement (SC). MATERIAL AND METHODS: Over a median SPT period of 5.3 years (re-evaluation through last observation), the GPAP cohort (n = 263) received supra- and subgingival biofilm removal with GPAP. Supragingival calculus was removed using curets and sonic scalers here. Patients in the SC cohort (n = 264) were treated with sonic scalers, curets and rubber cup polishing only. Changes in, that is pocket probing depth (PPD) and furcation involvement were assessed retrospectively. A bootstrapping equivalence testing method in line with the principle of the two one-sided tests (TOST) procedure was used to compare clinical outcomes. RESULTS: The GPAP procedure was statistically equivalent to SC regarding the number of sites with stable PPDs (83.3%; IQR 68.8%, 91.0% vs. 84.0%; IQR 77.8%, 90.0%). However, in the GPAP cohort, a trend towards deterioration in furcation status (no equivalence) was noted. CONCLUSIONS: In periodontal maintenance, the use of GPAP instead of mechanical plaque removal does not improve the clinical outcome. It seems to be contraindicated to treat furcation defects with GPAP only.

Non-interventional study to collect data for the application of lidocaine gel 2% during scaling and root planing and professional mechanical plaque removal.

OBJECTIVES: Evaluation of the safety and efficacy of a topical lidocaine gel 2% (LG) during scaling and root planing (SRP) and professional mechanical plaque removal (PMPR). MATERIALS AND METHODS: The anesthetic effects as well as unwanted effects of LG prior to or during SRP and PMPR were evaluated in an observational, non-randomized, non-interventional study design. A total of 385 treatments were recorded in 68 study centers all over Germany. Rating of the anesthetic effect of LG by treating personnel and patients using a four-item verbal rating scale (VRS), tolerability, safety (adverse effects), and need for additional local injection anesthesia (ALI). RESULTS: In SRP as well as in PMPR, application of LG allowed a sufficiently pain-free therapy in more than 90% of the patients as stated on the VRS (SRP: 97.8%, PMPR: 93.75%). Overall, ALI was needed in only 4.23% of the patients treated (SRP: 5.3%, PMPR: 2.62%). One adverse effect occurred within the observation. CONCLUSIONS: Application of LG may offer a safe and effective way to achieve pain-free therapy in periodontal patients. CLINICAL RELEVANCE: Patient compliance is key to the success of periodontal maintenance therapy. Effective and safe pain control during various kinds of periodontal therapy might increase patient compliance and therefore contribute to the long-term treatment success, among other factors. With regard to the patients observed in this study, 47% had previously received periodontal maintenance therapy and were therefore familiar with the treatment and the associated pain.

Evaluation of an ex vivo porcine model to investigate the effect of low abrasive airpolishing.

OBJECTIVES: Evaluation of an ex vivo porcine model to investigate the influence of periodontal instrumentation on soft tissue. MATERIAL AND METHODS: In each of 120 pig mandibles, one molar tooth was chosen at random and instrumented. For subgingival debridement, two different low abrasive airpolishing powders (glycine d90 = 25 µm, erythritol d90 = 14 µm, n = 30 teeth each), curets, and a piezoelectric ultrasonic scaler were used (n = 30 teeth each). Thirty teeth in 30 other mandibles served as the untreated control. Gingival biopsies were histologically assessed for destruction using a four-graded scale. RESULTS: The porcine model was deemed suitable for the planned investigation. Hand instrumentation and ultrasonic scaling caused higher tissue damage than both low abrasive airpolishing modes (Fisher's exact test, p = 0.0025). Glycine powder led to less, yet non-statistical noticeable gingival changes compared to erythritol-based powder (Fisher's exact test, p = 0.39). CONCLUSION: An animal model using pig jaws may be used as a preliminary model to analyze histological effects of periodontal instrumentation in advance of studies performed in human tissues. Among the techniques assessed, low abrasive airpolishing (LAA) caused the smallest tissue damage. CLINICAL RELEVANCE: To avoid gingival damage using LAA, histological observations of gingival tissue are needed. Since numerous powders for LAA have been developed and it may be expected that additional products will follow, it appears to be useful to establish ex vivo animal models to prove the powders safety.

Evaluation of acceptance and preference of topical lidocaine application versus articaine injection anesthesia after nonsurgical periodontal treatment: A randomized clinical trial.

BACKGROUND: To compare acceptance and preference of topical lidocaine gel anesthesia with articaine injection anesthesia in patients with moderate periodontitis undergoing scaling and root debridement. METHODS: Ninety-one patients completed this randomized multicenter split-mouth controlled study and underwent two separate periodontal treatment sessions on different days, one with a topical intrapocket lidocaine gel application and the other with an articaine injection anesthesia in a different order depending on randomization. Parameters measured were the patients' preference for topical lidocaine gel anesthesia or injection anesthesia with articaine (primary efficacy criterion), their maximum and average pain, and their intensity of numbness as well as experience of side effects; the probing depth; and the dentists' preference and their evaluations of handling/application, onset and duration of anesthetic effect, and patient compliance. RESULTS: After having experienced both alternatives, 58.3% of the patients preferred the topical lidocaine gel instillation into the periodontal pockets. The safety profile of the lidocaine gel differed positively from the safety profile of articaine injection in type and frequency of adverse drug reactions. The dentists' acceptance and preference regarding either anesthetic method studied were balanced. CONCLUSIONS: Instillation of lidocaine gel into the periodontal pocket is a preferred alternative to injection anesthesia for most of the patients and an equivalent alternative for dentists in nonsurgical periodontal therapy.

Periodontal healing of a horizontal root fracture: a case report with a two-year follow-up.

BACKGROUND: For traumatized teeth exhibiting crown-root fractures, there is a growing body of evidence that re-fastening the coronal part may result in successful treatment. However, data on the long-term impact of these bonding procedures on the periodontium are scarce. A case report of a young female patient presenting with an isogingivally- and horizontally-fractured lower incisor with a two-year follow-up is presented. METHODS: The tooth fragment was reattached to the remaining root using an adhesive technique after flap elevation and endodontic therapy. No attempt was made to splint the coronal fragment to the neighboring teeth. RESULTS: Despite the subgingival location of the bonding surface, uneventful periodontal healing was clinically monitored during the observation period. The coronal fragment was retained successfully for a period of more than two years. CONCLUSIONS: Even for tooth fractures below the gingival margin, the combined approach of surgery and adhesive techniques can be used successfully to restore a severely traumatized tooth.

Effect of glycine powder air-polishing on the gingiva.

OBJECTIVES: Safety and efficacy of glycine powder air-polishing (GPAP) in removing subgingival biofilm have been previously demonstrated. The hypothesis that GPAP results in less gingival erosion than sodium bicarbonate air-polishing (SBAP) or hand-instrumentation was assessed. MATERIAL AND METHODS: In each of 10 patients, eight teeth with a residual probing depth of at least 5 mm following initial periodontal therapy were randomly assigned to the following interventions: GPAP (test), SBAP (positive control), hand-instrumentation (positive control), or no treatment (negative control). In each group, gingival biopsies were taken immediately after instrumentation and one 14 days later. Damaged gingival epithelium (GE) was assessed by light microscopy and quantified by a histological score (values 1-4). Differences between groups were evaluated using the marginal homogeneity test. RESULTS: GPAP resulted in minor erosions of the GE (scores 1 and 2), whereas positive control specimens displayed moderate to severe erosions (scores 2-4). Differences between GPAP and positive controls were significant (p<0.05). Fourteen days following instrumentation GE under assessment was found to be intact in all groups. CONCLUSION: The data indicated that GPAP results in less gingival erosion than SBAP or hand instrumentation, further supporting the safety of this new debridement technique.

Subgingival debridement efficacy of glycine powder air polishing.

BACKGROUND: Glycine powder air polishing (GPAP) has been shown to be significantly more effective in reducing the subgingival cultivable microflora in shallow periodontal pockets compared to curets and is safe when applied directly to root surfaces. The purpose of this study was to assess the subgingival debridement efficacy of GPAP in periodontal pockets with various depths. METHODS: In each of 60 patients with severe periodontitis, one tooth with a probing depth (PD) > or =6 mm was randomly assigned to one of the following interventions: GPAP performed in teeth instrumented 3 months earlier (I); GPAP performed in previously non-instrumented teeth (NI); or no treatment (control). GPAP was performed for 5 seconds per surface. After extraction, teeth were stained with 0.5% toluidine blue, and subgingival debridement efficacy was assessed. RESULTS: Overall, median debridement depth was 2.00 mm in I teeth and 1.86 mm in NI teeth, and the median debrided root surface was 49.24% and 45.64%, respectively. In anatomic PDs (APDs) of 2 to 3 mm, relative debridement depth (debridement depth/APD) ranged from 65% to 80% and 60% to 75% in I and NI teeth, respectively; the corresponding values for debrided root surface were 60% to 70% and 50% to 60%. In control teeth, virtually all subgingival root surfaces were stained. Clinical PD measurements were a median of 1.05 mm deeper than APD. CONCLUSION: GPAP for 5 seconds per surface is effective in removing most of the subgingival biofilm in periodontal pockets with an APD < or =3 mm.

Impact of the Daily Use of a Microcrystal Hydroxyapatite Dentifrice on De Novo Plaque Formation and Clinical/Microbiological Parameters of Periodontal Health. A Randomized Trial.

AIM: This 12-week prospective, randomized, double-blind, two-center trial evaluated the impact of a microcrystalline zinc hydroxyapatite (mHA) dentifrice on plaque formation rate (PFR) in chronic periodontitis patients. We hypothesized that mHA precipitates cause delayed plaque development when compared to a fluoridated control (AmF/SnF2), and therefore would improve periodontal health. MATERIAL & METHODS: At baseline and after 4 and 12 weeks, PFR and other clinical and microbiological parameters were recorded. Seventy periodontitis patients received a mHA or AmF/SnF2 dentifrice as daily oral care without hygiene instructions. Four weeks after baseline, participants received full mouth debridement and continued using the dentifrices for another 8 weeks. RESULTS: Primary outcome PFR did not change statistically significantly from baseline to weeks 4 and 12, neither in mHA (n = 33; 51.7±17.2% vs. 48.5±16.65% vs. 48.4±19.9%) nor in AmF/SnF2-group (n = 34; 52.3±17.5% vs. 52.5±21.3% vs. 46.1±21.8%). Secondary clinical parameters such as plaque control record, gingival index, bleeding on probing, and pocket probing depth improved, but between-group differences were not statistically significant. Microbiological analyses showed similar slight decreases in colony-forming units in both groups. CONCLUSION: In patients with mild-to-moderate periodontitis, periodontal therapy and use of a mHA-or AmF/SnF2 dentifrice without instructions induced comparable improvements in periodontal health but did not significantly reduce the PFR. TRIAL REGISTRATION: ClincalTrials.gov NCT02697539.

The role of cathepsin C in Papillon-Lefèvre syndrome, prepubertal periodontitis, and aggressive periodontitis.

We have previously reported that loss-of-function mutations in the cathepsin C gene (CTSC) result in Papillon-Lefèvre syndrome, an autosomal recessive condition characterized by palmoplantar keratosis and early-onset, severe periodontitis. Others have also reported CTSC mutations in patients with severe prepubertal periodontitis, but without any skin manifestations. The possible role of CTSC variants in more common types of non-mendelian, early-onset, severe periodontitis ("aggressive periodontitis") has not been investigated. In this study, we have investigated the role of CTSC in all three conditions. We demonstrate that PLS is genetically homogeneous and the mutation spectrum that includes three novel mutations (c.386T>A/p.V129E, c.935A>G/p.Q312R, and c.1235A>G/p.Y412C) in 21 PLS families (including eight from our previous study) provides an insight into structure-function relationships of CTSC. Our data also suggest that a complete loss-of-function appears to be necessary for the manifestation of the phenotype, making it unlikely that weak CTSC mutations are a cause of aggressive periodontitis. This was confirmed by analyses of the CTSC activity in 30 subjects with aggressive periodontitis and age-sex matched controls, which demonstrated that there was no significant difference between these two groups (1,728.7 +/- SD 576.8 micro moles/mg/min vs. 1,678.7 +/- SD 527.2 micro moles/mg/min, respectively, p = 0.73). CTSC mutations were detected in only one of two families with prepubertal periodontitis; these did not form a separate functional class with respect to those observed in classical PLS. The affected individuals in the other prepubertal periodontitis family not only lacked CTSC mutations, but in addition did not share the haplotypes at the CTSC locus. These data suggest that prepubertal periodontitis is a genetically heterogeneous disease that, in some families, just represents a partially penetrant PLS.

Subgingival plaque removal at interdental sites using a low-abrasive air polishing powder.

BACKGROUND: The aim of the study was to test the efficacy of a novel low-abrasive air polishing powder in subgingival plaque removal at interdental sites during periodontal maintenance therapy (PMT). METHODS: Using a split mouth design, subgingival plaque was removed in 23 PMT patients using a low abrasive powder using a standard air polishing unit (test) or curets (positive control). Before and immediately after treatment, subgingival plaque samples were taken from interdental sites with 3 to 5 mm probing depth (PD) at 2 test teeth and 2 positive control teeth. To evaluate the influence of sampling on the microflora, plaque samples were also taken twice at 2 teeth without therapy with PD of 3 to 5 mm (negative control). PMT treatment and plaque sampling were repeated 3 times at quarterly intervals. Anaerobe cultivation was utilized to assess the mean reduction of total colony forming units (CFU) immediately after treatment. RESULTS: Test treatment resulted in a significantly greater reduction in subgingival bacterial counts (log 1.9 +/- 0.7) than positive control treatment (log 1.1 +/- 0.6) and subgingival plaque sampling alone (log 0.5 +/- 0.5; P < 0.05). Differences between positive and negative control were not significant (P < 0.05). CONCLUSION: The novel low-abrasive air polishing powder is superior to curets in removing subgingival plaque at interdental sites with up to 5 mm probing depth in PMT.

Efficacy and safety of adjunctive local moxifloxacin delivery in the treatment of periodontitis.

BACKGROUND: Moxifloxacin exerts excellent antibacterial activity against most putative periodontal pathogens and has been shown to kill bacteria in biofilm and host cells. METHODS: Patients with chronic periodontitis were randomly assigned to receive a single subgingival application of a 0.125%, 0.4%, or 1.25% moxifloxacin gel or placebo gel immediately after full-mouth scaling and root planing (SRP). Clinical efficacy measurements were assessed in sites with baseline probing depth (PD) of ≥5.4 mm at 6 weeks and 3 months and any adverse events were determined. In addition, putative periodontal pathogens and resistance of subgingival bacteria against moxifloxacin were assessed. RESULTS: Data of 57 patients were included in the statistical analysis. In all treatment groups, the PD decreased from baseline to 3 months, with the greatest reduction seen in patients treated with moxifloxacin 0.4% (1.5 ± 0.6 mm; P = 0.023 compared to placebo), followed by patients receiving moxifloxacin 1.25% (1.2 ± 0.4), moxifloxacin 0.125% (1.1 ± 1.1), and placebo (1.0 ± 0.6). No linear trend for PD reduction with increasing moxifloxacin concentrations was found. Porphyromonas gingivalis showed the greatest reduction in prevalence among the assessed pathogens, without any significant intergroup differences. No correlation or systematic relationship between adverse events, including bacterial resistance against moxifloxacin, and the investigational gels was found. CONCLUSIONS: In periodontal pockets with PD of ≥5.4 mm, a single subgingival administration of a 0.4% moxifloxacin gel as an adjunct to SRP may result in additional PD reduction compared to SRP alone. In addition, the investigated moxifloxacin gels seem to be safe.

Prognostic model for tooth survival in patients treated for periodontitis.

BACKGROUND: In patients with periodontitis, a quantitative prognostic assessment is needed in order to make evidence-based decisions about retaining teeth or extracting and replacing them with a dental prosthesis. METHODS: One hundred and ninety eight patients receiving active periodontal treatment in 1989 or 1990 and complying with supportive periodontal therapy (SPT) over an average of 11.8+/-2.3 years were included in the study. A generalized linear model was established and fitted via generalized estimating equations to identify predictors for tooth loss during SPT. RESULTS: Of the 4559 teeth present at baseline, 166 (3.6%) were extracted during active treatment and 249 (5.5%) during SPT. Baseline findings of diabetes mellitus (OR=4.17), reduced alveolar bone levels (OR=1.04 for each 1% increment), increased tooth mobility (III versus 0: OR=5.52), multiple roots (OR=1.82), and non-vital pulp (OR=2.24) were significant (p<0.05) predictors for tooth loss during SPT. Based on these parameters, a prognostic model was constructed that provides estimates of tooth survival probability when periodontal therapy is rendered. CONCLUSION: Using a multivariate approach, a prognostic model was developed that may be of value for clinical decision making.

Powder emission rates of four air polishing devices.

OBJECTIVES: Although highly effective in plaque and stain removal, the use of air polishing devices (APDs) on denuded root surfaces may lead to clinically relevant loss of tooth substance. As the amount of powder emitted by an APD may have a significant impact on the safety and efficacy of the instruments, the purpose of the study was to quantify the amount of powder emitted by APDs depending on their powder filling status and powder setting. METHODS: Four different APDs were filled to maximum level and the cumulative amount of powder emitted, depending on instrument settings and filling status, was quantified during 15 subsequent 120-s periods of use. Differences in powder emission were analyzed using anova repeated measures. RESULTS: Exact powder dosage was possible in one APD only (Dentsply Prophyjet) where emission rates also remained constant over the first five periods assessed. In the three other APDs assessed (EMS Air-Flow, Satellec Air-Max, KaVo Prophyflex II powder emission depended on the amount of powder present in the powder chamber and declined with ongoing use. Changes in powder setting had a significant impact on powder emission in all APDs assessed, apart from the KaVo Prophyflex II unit. CONCLUSIONS: Powder emission of APDs may vary greatly depending on the amount of powder present in the powder bowl. Therefore, instrument powder setting may not be a reliable parameter for safety and efficacy adjustments. This should be considered in clinical applications as well as in future research.

Antimicrobial effects of mechanical debridement.

Self-performed plaque removal using manual or powered toothbrushes and interdental cleaning devices is improved in subjects that have received oral hygiene instructions. Personal oral hygiene coupled with regular professional supragingival debridement may further improve the level of plaque control but still fails to achieve a completely plaque-free dentition. Both patient-performed and professional supragingival plaque removal has an effect on subgingival microbiota that is limited to the marginal 3 mm of the periodontal pocket. At sites with 4 mm or more of probing depth, only subgingival scaling leads to a significant reduction of the bacterial load. The subgingival microflora can be further reduced by pocket elimination surgery. Due to the sequence of bacterial recolonization that occurs following mechanical debridement, the level of periodontal pathogens such as B. forsythus, P. gingivalis and T. denticola may be reduced for several months. Mechanical debridement also influences the patient's immune system response, resulting in antibody titers and avidity against periodontal pathogens. As a basis for the restoration and maintenance of periodontal health, repeated subgingival debridement, as performed in supportive periodontal therapy, can reduce the number and proportions of periodontopathogenic bacteria in subgingival plaque. However, intensive subgingival scaling and root planing should be avoided in sites that probe less than 3 mm, as this is likely to traumatize the periodontium and cause attachment loss.

Safety and efficiency of novel sonic scaler tips in vitro.

BACKGROUND: The aim of the study was to evaluate a novel sonic scaler tip for subgingival root surface instrumentation combining high efficiency in calculus removal with minimized risk of root damage through subgingival debridement. METHODS: A metal sonic scaler tip with a paddle-like working end covered with spheroid convexities of 0.8 mm diameter and 0.3 mm height was designed from the aspect of optimized adaptation to the root anatomy (tip-end dimension: 3.0 x 1.5 x 0.6 mm). Using a customary sonic scaler tip as control, instrument efficiency was quantified by measuring the time needed to completely remove calculus on extracted teeth (n=52) under standardized conditions. To quantify the amount of calculus removed, the mean calculus area per tooth was measured on photographs taken before instrumentation. The tips safety was evaluated instrumenting calculus-free root surfaces in vitro (n=18, lateral forces 0.5, 1, 2 N, 20 s instrumentation time, tip angulation 0 degrees ) with subsequent laser-optical determination of resulting root substance loss. RESULTS: Debridement efficiency was significantly higher for the novel tip (0.78+/-0.81 mm2/s completely debrided) than for the conventional tip (0.42+/-0.33 mm2) (Mann-Whitney test, p<0.05). Concerning instrument safety, the novel tip caused significantly less root substance loss than the conventional tip. CONCLUSION: The novel scaler tip appears to be significantly more efficient in calculus removal and less damaging to the root surface than the assessed conventional tip.