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 active 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.

Training in the use of the water jet and cold atmospheric plasma jet for the decontamination of dental implants.

OBJECTIVES: Clinical trials testing new devices require prior training on dummies to minimize the "learning curve" for patients. Dentists were trained using a novel water jet device for mechanical cleaning of dental implants and with a novel cold plasma device for surface functionalisation during a simulated open flap peri-implantitis therapy. The hypothesis was that there would be a learning curve for both devices. MATERIALS AND METHODS: 11 dentists instrumented 44 implants in a dummy-fixed jaw model. The effect of the water jet treatment was assessed as stain removal and the effect of cold plasma treatment as surface wettability. Both results were analysed using photographs. To improve treatment skills, each dentist treated four implants and checked the results immediately after the treatment as feedback. RESULTS: Water jet treatment significantly improved from the first to the second implant from 62.7% to 75.3% stain removal, with no further improvement up to the fourth implant. The wettability with cold plasma application reached immediately a high level at the first implant and was unchanged to the 4th implant (mean scores 2.7 out of 3). CONCLUSION: A moderate learning curve was found for handling of the water jet but none for handling of the cold plasma. CLINICAL RELEVANCE: Scientific rational for study: Two new devices were developed for peri-implantitis treatment (Dental water jet, cold plasma). Dentists were trained in the use of these devices prior to the trial to minimize learning effects. PRINCIPAL FINDINGS: Experienced dentists learn the handling of the water jet very rapidly and for cold plasma they do not need much training. PRACTICAL IMPLICATIONS: A clinical study is in process. When the planned clinical study will be finished, we will find out, if this dummy head exercise really minimised the learning curve for these devices.

Can vitamins improve periodontal wound healing/regeneration?

Periodontitis is a complex inflammatory disorder of the tooth supporting structures, associated with microbial dysbiosis, and linked to a number if systemic conditions. Untreated it can result in an irreversible damage to the periodontal structures and eventually teeth loss. Regeneration of the lost periodontium requires an orchestration of a number of biological events on cellular and molecular level. In this context, a set of vitamins have been advocated, relying their beneficial physiological effects, to endorse the biological regenerative events of the periodontium on cellular and molecular levels. The aim of the present article is to elaborate on the question whether or not vitamins improve wound healing/regeneration, summarizing the current evidence from in vitro, animal and clinical studies, thereby shedding light on the knowledge gap in this field and highlighting future research needs. Although the present review demonstrates the current heterogeneity in the available evidence and knowledge gaps, findings suggest that vitamins, especially A, B, E, and CoQ10 , as well as vitamin combinations, could exert positive attributes on the periodontal outcomes in adjunct to surgical or nonsurgical periodontal therapy.

Efficacy of mechanical/physical approaches for implant surface decontamination in non-surgical submarginal instrumentation of peri-implantitis. A systematic review.

AIM: To evaluate the efficacy of non-surgical submarginal peri-implant instrumentation with mechanical/physical decontamination compared to non-surgical submarginal instrumentation alone or with placebo decontamination in patients with peri-implantitis. MATERIALS AND METHODS: Three focused questions were addressed, and a systematic search for randomized controlled clinical trials (RCTs), controlled clinical trials, and prospective cohort studies with definitions of peri-implantitis and a minimal follow-up of 6 months was conducted. The main outcome variables were reduction in pocket probing depth (PD) and bleeding on probing (BOP). Suppuration on probing, marginal peri-implant bone level changes, patient-related outcomes and adverse events, implant survival, treatment success, and disease resolution were assessed as secondary outcomes. RESULTS: Out of 239 findings, full-text articles were assessed for eligibility, and 9 (n = 9 RCTs) were included in the present review. Five studies evaluated the effects of various laser types, and in four studies efficacy of air-abrasive mechanisms and of a novel ultrasonic device was determined. At 6 months, PD reductions were observed in nine studies but only Er, Cr:YSGG laser-treated group showed statistically significant higher reductions compared to the control group. BOP was statistically significantly reduced at 6 months in two studies following the application of Er:YAG laser compared to controls. One study reported statistically significant reduction in BOP following application of air-polishing device compared to control treatment. No statistically significant differences between treatment groups were reported for the secondary outcome variables. Owing to the large heterogeneity of study designs, no meta-analysis was performed. CONCLUSIONS: Available evidence on the efficacy of non-surgical submarginal peri-implant instrumentation with mechanical/physical decontamination is limited by the small number of controlled studies and the high heterogeneity of study protocols. Clinical and patient-reported benefits remain to be demonstrated.

Biomechanical properties of periodontal tissues in non-periodontitis and periodontitis patients assessed with an intraoral computerized electronic measurement device.

OBJECTIVE: To identify tooth mobility (TM) by time-dependent tooth displacement using an electronic intra-oral loading device (ILD) in periodontally healthy and periodontally compromised patients. MATERIALS AND METHODS: Twenty-eight untreated periodontitis and 20 periodontally healthy patients [25 female and 26 male; ages: 20-81 years], contributing with 68 teeth (periodontitis: nteeth = 28; non-periodontitis: nteeth = 40), participated in the study. TM was measured in vivo by displacing central or lateral incisors to a maximum of 0.2 mm orally over durations of 0.5 s, 1 s, and 10 s with the ILD. The maximum force (Fmax) was extracted from the measured force/deflection curves for every single measurement. RESULTS: Differences in TM-ILD values were found for periodontitis as compared to non-periodontitis patients derived from the same loading durations (differences of 3.9 (0.5 s), 3.1 (1 s), 2.8 (10 s), (95% CI for 0.5 s (1.2-6.7), p = 0.024; 1 s (1.4-6.0), p = 0.067; 10 s (0.2-5.3), p = 0.001), rejecting the null hypothesis of no difference (T-test) for durations of 0.5 and 10 s. There was a significant correlation of TM-ILD (Fmax) with BOP at 0.5 s (- 0.52) and with attachment loss at all time durations (- 0.47 at 0.5 s; - 0.57 at 1 s; - 0.47 at 10 s). CONCLUSIONS: This clinical investigation could demonstrate that time-dependent tooth displacements using a new computerized electronic device were associated with attachment loss and bleeding on probing. CLINICAL RELEVANCE: ILD can improve the monitoring of tooth mobility, as TM-ILD values reflect qualitative (inflammatory status interpreted by BOP) and quantitative parameters (interpreted as the amount of CAL loss) of periodontal disease.

Reliability of probing depth assessments at healthy implant sites and natural teeth.

AIM: To evaluate the intra- and inter-examiner reliability in the assessment of probing depth (PD) measurements at healthy dental implant sites and periodontally healthy natural teeth. MATERIALS AND METHODS: Five patients exhibiting 21 dental implants were enrolled in the study. Eight experienced examiners performed duplicate PD measurements at six sites of all implants and of preselected natural teeth. Intra-examiner accuracy was estimated using intra-examiner correlation coefficients (ICCs) with 95% confidence intervals (CI). A gold standard (GS) examiner was set. Inter-examiner accuracy compared to the GS examiner was assessed using pairwise inter-examiner ICCs. RESULTS: The intra-examiner ICC ranged from 0.759 (95% CI, 0.692-0.812) to 0.863 (95% CI, 0.826-0.892) for the measurements at teeth and from 0.712 (95% CI, 0.580-0.800) to 0.841 (95% CI, 0.774-0.888) for the PDs assessed at implants. The inter-examiner ICCs for tooth measurements varied from 0.197 (95% CI, - 0.280 to 0.511) to 0.791 (95% CI, 0.560-0.892). The corresponding values for the assessments at implants varied from 0.576 (95% CI, 0.286-0.734) to 0.794 (95% CI, 0.708-0.855). CONCLUSIONS: The intra- and inter-examiner reproducibility of repeated PD measurements assessed by experienced examiners tended to be higher for the measurements at periodontally healthy teeth compared to healthy dental implant sites. CLINICAL RELEVANCE: Experienced examiners demonstrated a higher degree of reliability of probing measurements around teeth compared to dental implants.

Clinical, microbiological, and immunological effects of 3- or 7-day systemic antibiotics adjunctive to subgingival instrumentation in patients with aggressive (Stage III/IV Grade C) periodontitis: A randomized placebo-controlled clinical trial.

AIM: To evaluate the clinical non-inferiority of a 3-day protocol of systemic antibiotics adjunctive to subgingival instrumentation (SI) compared with a 7-day-protocol in patients with Stage III/IV Grade C periodontitis. MATERIALS AND METHODS: Fifty systemically healthy patients (32.7 ± 4.3 years) with aggressive periodontitis (AgP; Stage III/IV Grade C periodontitis) were treated by SI and adjunctive amoxicillin and metronidazole and were randomly assigned to Group A: (n = 25) 500 mg antibiotics (AB) 3 times a day for 3 days, followed by placebo 3 times a day for 4 days, or Group B: (n = 25) 500 mg AB 3 times a day for 7 days. Clinical, microbial, and immunological parameters were assessed at baseline, 3 months, and 6 months, and patient-related outcomes were assessed after 2 weeks. The primary outcome variable was the number of residual sites with pocket depth (PD) ≥6 mm at 6 months. RESULTS: For the primary outcome variable (the number of residual sites with PD ≥6 mm at 6 months), the null hypothesis was rejected and non-inferiority of the 3-day AB protocol compared with the 7-day AB protocol was demonstrated (the upper limits of the 95% confidence interval for intention to treat analysis: [-2.572; 1.050] and per protocol analysis: [-2.523; 1.318] were lower than the assumed margin of Δ = 3.1). Comparable clinical improvements were obtained for all parameters with both antibiotic protocols (p > .05). All investigated periodontopathogens and pro-inflammatory host-derived markers were statistically significantly reduced without differences between the treatments (p > .05). CONCLUSIONS: These findings indicate that in patients with AgP (Stage III/IV Grade C periodontitis), a 3-day systemic administration of amoxicillin and metronidazole adjunctive to SI may lead to non-inferior clinical outcomes after 6-months with fewer adverse events compared with a 7-day-protocol.

Clinical outcomes following periodontal surgery and root surface decontamination by erythritol-based air polishing. A randomized, controlled, clinical pilot study.

AIM: To evaluate the outcomes following surgical periodontal treatment and root surface decontamination by means of air polishing using an erythritol powder or conventional mechanical root debridement. MATERIAL AND METHODS: Thirty systemically healthy patients (44.38 ± 8.2 years old, 11 smokers, 19 women) diagnosed with periodontitis stages III-IV were included. Each patient, with one single-rooted tooth, with one probing pocket depth (PD) ≥ 6 mm associated with horizontal bone loss, was treated by means of simplified papilla preservation flap (SPPF) and randomized to either test treatment (careful removal of the calculus with the tip of a blade, air polishing of the root surfaces with erythritol) or to the control group (scaling and root planing with hand curettes, ultrasonic instruments). PD, clinical attachment (CAL), bone sounding (BS), and radiographic bone level (BL) were evaluated at baseline and 12 months postsurgically. RESULTS: Twenty-seven patients completed the 12-month follow-up (test: n = 14, control: n = 13). In both groups, statistically significant improvements were obtained (p < 0.05, mean CAL gain/PD reduction: test, 2.50 ± 1.60 mm/3.00 ± 0.96 mm; control, 2.85 ± 1.21 mm/3.38 ± 1.12 mm). No statistically significant differences were observed between the groups for any of the investigated parameters (p < 0.05). CONCLUSION: Within their limits, the present results indicate that the use of air polishing with an erythritol powder during periodontal surgery may represent a valuable minimally invasive adjunct following calculus removal by means of hand and ultrasonic instruments or a valuable alternative to these, for root surfaces without calculus. CLINICAL RELEVANCE: The use of air polishing with an erythritol powder during periodontal surgery appears to represent a valuable minimally invasive adjunct following calculus removal by means of hand and ultrasonic instruments or a valuable alternative to these, for root surfaces without calculus.

Use of platelet-rich fibrin for the treatment of periodontal intrabony defects: a systematic review and meta-analysis.

OBJECTIVES: This study aims to compare the treatment outcomes of periodontal intrabony defects by using platelet-rich fibrin (PRF) with other commonly utilized modalities. MATERIALS AND METHODS: The eligibility criteria comprised randomized controlled trials (RCTs) comparing the clinical outcomes of PRF with that of other modalities. Studies were classified into 10 categories as follows: (1) open flap debridement (OFD) alone versus OFD/PRF; (2) OFD/bone graft (OFD/BG) versus OFD/PRF; (3) OFD/BG versus OFD/BG/PRF; (4-6) OFD/barrier membrane (BM), OFD/PRP, or OFD/enamel matrix derivative (EMD) versus OFD/PRF; (7) OFD/EMD versus OFD/EMD/PRF; (8-10) OFD/PRF versus OFD/PRF/metformin, OFD/PRF/bisphosphonates, or OFD/PRF/statins. Weighted means and forest plots were calculated for probing depth (PD), clinical attachment level (CAL), and radiographic bone fill (RBF). RESULTS: From 551 articles identified, 27 RCTs were included. The use of OFD/PRF statistically significantly reduced PD and improved CAL and RBF when compared to OFD. No clinically significant differences were reported when OFD/BG was compared to OFD/PRF. The addition of PRF to OFD/BG led to significant improvements in CAL and RBF. No differences were reported between any of the following groups (OFD/BM, OFD/PRP, and OFD/EMD) when compared to OFD/PRF. No improvements were also reported when PRF was added to OFD/EMD. The addition of all three of the following biomolecules (metformin, bisphosphonates, and statins) to OFD/PRF led to statistically significant improvements of PD, CAL, and RBF. CONCLUSIONS: The use of PRF significantly improved clinical outcomes in intrabony defects when compared to OFD alone with similar levels being observed between OFD/BG and OFD/PRF. Future research geared toward better understanding potential ways to enhance the regenerative properties of PRF with various small biomolecules may prove valuable for future clinical applications. Future research investigating PRF at histological level is also needed. CLINICAL RELEVANCE: The use of PRF in conjunction with OFD statistically significantly improved PD, CAL, and RBF values, yielding to comparable outcomes to OFD/BG. The combination of PRF with bone grafts or small biomolecules may offer certain clinical advantages, thus warranting further investigations.

Compressive stress in periodontal ligament under orthodontic movements during periodontal breakdown.

INTRODUCTION: This analysis aimed to assess quantitatively and qualitatively the compressive stress (S3) in periodontal ligament in a gradual periodontal breakdown (0-8 mm) under orthodontic movements. Correlations between the applied forces, the level of bone resorption, the decrease of force magnitude, and S3 increase were also conducted. METHODS: On the basis of cone-beam computed tomography examinations (voxel size, 0.075 mm), nine 3-dimensional models of the second mandibular premolar with intact periodontium were created and then individually subjected to various levels of horizontal bone loss. Orthodontic forces (intrusion: 0.2 N; extrusion, rotation, tipping: 0.6 N; translation: 1.2 N) were applied on the brackets. Finite elements analysis was performed, and S3 stresses were quantitatively and qualitatively determined. RESULTS: Translation and rotation induced the highest stress apically and cervically, whereas intrusion determined the lowest. Apical stress was lower than cervical stress. In intact periodontium, only intrusion and extrusion exhibited S3 stresses lower (apically and cervically) than maximum hydrostatic pressure (MHP) and maximum tolerable stress (MTS). In reduced periodontium, S3 stress (except for intrusion) exceeded MHP and MTS. CONCLUSIONS: In reduced periodontium, forces of 0.2 N seems safe to be used. Forces of 0.6-1.2 N may produce stresses exceeding both MTS and MHP, endangering the periodontium. S3 failure criterion (despite its widely use) seems not to be adequate for accurate quantitative results when evaluating the stress in the periodontal ligament while remaining adequate for qualitative results. An overall correlation between the applied force, S3 increase, and periodontal breakdown applicable to all 5 movements could not be established-this was possible only for sole movements.

Incidence of Malocclusion among Young Patients with Gingival Recessions-A Cross-Sectional Observational Pilot Study.

Background and Objectives: Dental occlusion and gingival recession have been studied over the past years especially because of the increasing incidence of occlusal interferences in young patients. The purpose of this pilot study is to investigate any association between occlusal dysfunctions and gingival recessions. Data on gingival phenotype and previous orthodontic treatment were also collected to assess any correlation with the presence of gingival recession. Materials and Methods: Forty systemically healthy subjects, without signs of periodontitis and with gingival recessions, were included in the study. The following parameters were determined: location and extent of the gingival recession, gingival phenotype and functional occlusion by means of observing and registering the occlusal contacts in maximum intercuspation position, protrusive and lateral guidance. Results: Premolars were mostly affected in cases of working-side interferences during lateral guidance (71.19% of the affected teeth during left and 75% during right mandibular movements). The chi-squared exact test applied for the analysis of contingency tables revealed statistically significant associations between excursive interferences during lateral guidance and anterior guidance and the presence of gingival recession on the involved group of teeth. Conclusions: The results suggest that most gingival recessions might be associated with working-side interferences, the highest number of gingival recessions being associated with active interferences during lateral guidance.

Patient-, tooth-, and dentist-related factors influencing long-term tooth retention after resective therapy in an academic setting-a retrospective study.

OBJECTIVES: The aim of this study was to evaluate long-term (≥5 years) tooth survival after resective therapy of multi-rooted, periodontally treated teeth and investigate the influence of patient-, tooth-, and dentist-related risk factors on tooth loss. MATERIALS AND METHODS: A total of 128 patients with root-resected molars were reexamined. Patient-, tooth-, and dentist-related factors were assessed. Tooth survival times were estimated using the Kaplan-Meier method in addition to a Cox proportional hazard frailty model with survival as the dependent outcome to assess an association with predictor variables. RESULTS: Overall, 100 patients with 130 molars were included. The average postoperative reevaluation period was a 9.62 ± 3.08 year showing an overall survival rate of 56.9% after resective therapy. A cumulative survival rate of 69% (95% CI (61%; 77%)) after 5 years decreasing to 48% (95% CI (35%; 61%)) after 15 years was detected. The median survival time of resected molars was 13.83 years (95% CI (8.75; ∞)). Adherence, smoking, and insurance status were detected to significantly influence the risk for loss of molars after resective therapy. CONCLUSIONS: Resective periodontal procedures can still be considered an option to retain periodontally compromised molars. In contrast to dentist- and tooth-related factors, patient-related factors impacted significantly upon tooth survival. CLINICAL RELEVANCE: Periodontally compromised molars could be retained in more than 50% of the cases thus prolonging their life span significantly. This information shall be valuable for clinicians in decision-making, treatment planning, and postoperative management. The weighting of resective therapy to implants especially with regards to the risk of peri-implantitis should be considered.

Use of platelet-rich fibrin for the treatment of gingival recessions: a systematic review and meta-analysis.

OBJECTIVES: The aim of this systematic review and meta-analysis was to compare the use of platelet-rich fibrin (PRF) with other commonly utilized treatment modalities for root coverage procedures. MATERIALS AND METHODS: The eligibility criteria comprised randomized controlled trials (RCTs) comparing the performance of PRF with that of other modalities in the treatment of Miller class I or II (Cairo RT I) gingival recessions. Studies were classified into 5 categories as follows: (1) coronally advanced flap (CAF) alone vs CAF/PRF, (2) CAF/connective tissue graft (CAF/CTG) vs CAF/PRF, (3) CAF/enamel matrix derivative (CAF/EMD) vs CAF/PRF, (4) CAF/amnion membrane (CAF/AM) vs CAF/PRF, and (5) CAF/CTG vs CAF/CTG/PRF. Studies were evaluated for percentage of relative root coverage (rRC; primary outcome), clinical attachment level (CAL), keratinized mucosa width (KMW), and probing depth (PD) (secondary outcomes). RESULTS: From 976 articles identified, 17 RCTs were included. The use of PRF statistically significantly increased rRC and CAL compared with CAF alone. No change in KMW or reduction in PD was reported. Compared with PRF, CTG resulted in statistically significantly better KMW and RC. No statistically significant differences were reported between the CAF/PRF and CAF/EMD groups or between the CAF/PRF and CAF/AM groups for any of the investigated parameters. CONCLUSIONS: The use of CAF/PRF improved rRC and CAL compared with the use of CAF alone. While similar outcomes were observed between CAF/PRF and CAF/CTG for CAL and PD change, the latter group led to statistically significantly better outcomes in terms of rRC and KTW. In summary, the use of PRF in conjunction with CAF may represent a valid treatment modality for gingival recessions exhibiting adequate baseline KMW. CLINICAL RELEVANCE: The data indicate that the use of PRF in conjunction with CAF statistically significantly improves rRC when compared with CAF alone but did not improve KMW. Therefore, in cases with limited baseline KMW, the use of CTG may be preferred over PRF.

Effects of non-surgical periodontal therapy on periodontal laboratory and clinical data as well as on disease activity in patients with rheumatoid arthritis.

OBJECTIVES: To compare the effect of non-surgical periodontal therapy on clinical and inflammatory parameters in patients with moderate to severe chronic periodontitis (CP) and rheumatoid arthritis (RA) (RA-CP) with that in CP patients without RA. MATERIAL AND METHODS: Eighteen patients with RA-CP and 18 systemically healthy patients with CP were treated with scaling and root planing (SRP) within 24 h. At baseline, and at 3 and 6 months after SRP, clinical periodontal parameters, inflammatory markers, and microorganisms in subgingival biofilm were assessed. In addition, disease activity markers of RA (DAS28, CRP, ESR) and specific antibodies (RF) were monitored in the RA-CP group. RESULTS: In both groups, non-surgical therapy yielded to statistically significant improvements in all investigated clinical periodontal variables; in RA patients, a statistically significant decrease in serum-CRP was seen at 3 months. At all time-points, levels of inflammatory markers in GCF were higher in RA-CP than in CP patients. Counts of Porphyromonas gingivalis, Tannerella forsythia, and Treponema denticola decreased statistically significantly in CP but not in the RA-CP group. Changes of DAS28 correlated positively with those of P. gingivalis and negatively with the plaque index. CONCLUSIONS: Within their limits, the present data suggest that (a) non-surgical periodontal therapy improves periodontal conditions in CP patients with and without RA and (b) in patients with RA, eradication of P. gingivalis in conjunction with a high level oral hygiene may transiently decrease disease activity of RA. CLINICAL RELEVANCE: In patients with RA and CP, non-surgical periodontal therapy is a relevant modality not only to improve the periodontal condition but also to decrease RA activity.

Histologic evidence of periodontal regeneration in furcation defects: a systematic review.

OBJECTIVE: To systematically review the available histologic evidence on periodontal regeneration in class II and III furcations in animals and humans. MATERIALS AND METHODS: A protocol including all aspects of a systematic review methodology was developed including definition of the focused question, defined search strategy, study inclusion criteria, determination of outcome measures, screening methods, data extraction and analysis, and data synthesis. The focused question was defined as follows: "What is the regenerative effect obtained by using or not several biomaterials as adjuncts to open flap surgery in the treatment of periodontal furcation defects as evaluated in animal and human histological studies?" SEARCH STRATEGY: Using the MEDLINE database, the literature was searched for articles published up to and including September 2018: combinations of several search terms were applied to identify appropriate studies. Reference lists of review articles and of the included articles in the present review were screened. A hand search of the most important dental journals was also performed. CRITERIA FOR STUDY SELECTION AND INCLUSION: Only articles published in English describing animal and human histological studies evaluating the effect of surgical treatment, with or without the adjunctive use of potentially regenerative materials (i.e., barrier membranes, grafting materials, growth factors/proteins, and combinations thereof) for the treatment of periodontal furcation defects were considered. Only studies reporting a minimum of 8 weeks healing following reconstructive surgery were included. The primary outcome variable was formation of periodontal supporting tissues [e.g., periodontal ligament, root cementum, and alveolar bone, given as linear measurements (in mm) or as a percentage of the instrumented root length (%)] following surgical treatment with or without regenerative materials, as determined histologically/histomorphometrically. Healing type and defect resolution (i.e., complete regeneration, long junctional epithelium, connective tissue attachment, connective tissue adhesion, or osseous repair) were also recorded. RESULTS: In animals, periodontal regeneration was reported in class II and III defects with open flap debridement alone or combined with various types of bone grafts/bone substitues, biological factors, guided tissue regeneration, and different combinations thereof. The use of biological factors and combination approaches provided the best outcomes for class II defects whereas in class III defects, the combination approaches seem to offer the highest regenerative outcomes. In human class II furcations, the best outcomes were obtained with DFDBA combined with rhPDGF-BB and with GTR. In class III furcations, evidence from two case reports indicated very limited to no periodontal regeneration. CONCLUSIONS: Within their limits, the present results suggest that (a) in animals, complete periodontal regeneration has been demonstrated in class II and class III furcation defects, and (b) in humans, the evidence for substantial periodontal regeneration is limited to class II furcations. CLINICAL RELEVANCE: At present, regenerative periodontal surgery represents a valuable treatment option only for human class II furcation defects but not for class III furcations.

Prevalence of Periimplant Diseases.

PURPOSE: To report the prevalence of periimplant diseases (ie, periimplant mucositis and periimplantitis). MATERIAL AND METHODS: A literature search was performed in MEDLINE through PubMed database of the US National Library of Medicine for articles published until March 2018 using Medical Subject Heading (MeSH) search terms complemented by free terms and in different combinations. RESULTS: A wide range of prevalences of periimplant diseases has been reported in the literature. Subject-based estimated weighted mean prevalences and ranges were reported to amount to 43% (range: 19%-65%) for periimplant mucositis and to 22% (range: 1%-47%) for periimplantitis. CONCLUSION: Differences in case definitions impact on extent and severity of periimplant diseases and make comparisons among studies difficult. Convenience samples rather than randomly selected population samples are often analyzed to estimate prevalence of periimplant diseases. More recent studies report implant- and subject-based prevalences of periimplant diseases.

Soft-Tissue Management as Part of the Surgical Treatment of Periimplantitis: A Narrative Review.

BACKGROUND: The data on the importance of soft-tissue management during surgical treatment of periimplantitis are still limited, and no clinical recommendations are yet available. AIM: To give an overview on the rationale for periimplant soft-tissue augmentation procedures in the light of potential benefits/risks of the presence/absence of keratinized/attached mucosa (KAM) providing recommendations for the clinician. RESULTS: The available evidence indicates that the presence of KAM favors periimplant tissue health evidenced by improved bleeding scores and facilitation of self-performed plaque removal, less mucosal recessions, and more stable marginal bone levels over time. Therefore, the rationales to augment KAM are (a) to optimize the possibility for performing an adequate level of oral hygiene, (b) to help maintaining periimplant soft-tissue health and stability, and (c) to improve esthetics. Various techniques with autogenous or xenogeneic membranes have been described so far for KAM augmentation. Additional soft-tissue grafting in conjunction with a combined regenerative and resective surgical procedure seems to be effective in treating and controlling advanced periimplantitis lesions and improving or maintaining the esthetic outcomes. CONCLUSIONS: The limited available data seem to indicate that the best outcome to improve the width of KAM, and the bleeding and plaque scores, as well as to maintain the periimplant marginal bone level is the use of an apically positioned flap combined with a free gingival graft in nondiseased periimplant sites. However, at present, it is unknown: (a) to what extent soft-tissue grafting may additionally improve the outcomes after surgical (resective or regenerative) treatment of periimplantitis compared with the same approaches without soft-tissue grafting, and (b) if considered, when should soft-tissue grafting be performed (eg, before or during surgical treatment of periimplantitis). CLINICAL RECOMMENDATIONS: Both soft-tissue resective and regenerative approaches may lead to successful outcomes depending on the clinical indication and defect location. However, the selection of one or another surgical approach should be based on defect type (eg, intrabony and suprabony) and location (esthetic or nonesthetic areas). The presence of an adequate width and thickness of KAM may facilitate soft-tissue (flap) management. In patients with a thin phenotype or lack of an adequate width of KAM, soft-tissue grafting may improve the clinical outcomes.

Finite element analysis of the dental pulp under orthodontic forces.

INTRODUCTION: To evaluate the stress at the apical third of the pulp and neurovascular bundle (NVB) during 5 types of orthodontic movement at different levels of bone loss. Furthermore, correlations among bone loss, orthodontic appliances, and stress increase were assessed. METHODS: Based on cone-beam computed tomography datasets, 10 models of the mandibular second premolar were created. Each of these models was subjected to a gradual horizontal bone loss simulation (0-8 mm). Orthodontic forces of 20 g, 60 g, and 120 g were applied during the finite element analysis (FEA). For each bone loss level, stress values were evaluated with the use of Abaqus at the apical third of the pulp and the NVB. RESULTS: The stress manifested at the apical third of the pulp was smaller than that at the NVB. The highest apical NVB stress was found for rotation (0.000546 N/mm2 for 8 mm bone loss) whereas the lowest stress resulted after translational movements (2.35E-04 MPa for 8 mm bone loss). The FEA showed that Proffit's indicated orthodontic forces did not significantly disturb the pulpal blood flow and damage the apical NVB. Up to a doubling of the NVB stress, bone loss correlated with the force reduction to obtain similar stress levels compared with teeth with no bone loss. CONCLUSIONS: The present findings indicate that the stress manifested at the apical third of the pulp is smaller than that at NVB. Rotational movements induce the highest stress and translational forces develop the lowest stress related to the physiologic capillary blood pressure. Furthermore, in situations with reduced periodontium, lower forces are needed to reach the maximum tolerable stress compared with teeth with intact periodontium.

Association of Oral-Health Related Quality of Life and General Health Assessment in Patients with Rheumatoid Arthritis.

PURPOSE: To determine the impact of oral health related quality of life (OHRQoL) on general health in patients suffering from rheumatoid arthritis (RA). MATERIALS AND METHODS: Ninety-one patients with RA (mean age 52.82 ± 11 years, 75.82% female, 20.87% smokers) and 30 systemically healthy patients (control) were evaluated for their OHRQoL by means of the Geriatric Oral Health Assessment Index (GOHAI) and the Oral Health Impact Profile (OHIP)-14 questionnaires. Self-perceived RA status was assessed using the Routine Assessment of Patient Index Data 3 (RAPID3). RESULTS: The mean SC-GOHAI score was 3.69 ± 2.47 for RA subjects and 1.36 ± 2.69 in the control group. Statistically significant differences were seen between RA and control groups (p < 0.05). RA patients with and without periodontitis (PA) exhibited similar SC-GOHAI (Simple Count GOHAI) scores (p = 0.980). No statistically significant differences were observed between any of the groups, either for the OHIP 14-extent or for the OHIP 14-prevalence. RAPID3 scores showed that the majority of the RA patients (65.93%) had high disease severity (RAPID3 >12, mean RAPID3 score 14.39 ± 5.14). Statistically significantly higher values were recorded for general health assessment (PTGE, p = 0.009) and fatigue (FT, p = 0.004) in RA with PA as compared to those without. SC-GOHAI with values between 5 and 8 was statistically significantly associated with high severity health impairment (RAPID3 >12, p = 0.014, OR: 8.64). CONCLUSION: Within their limits, the present findings indicate that: a) moderate OHRQoL as assessed by GOHAI may contribute to high severity impairment of health in RA patients, and b) the GOHAI questionnaire may represent a more adequate tool than OHIP-14 for assessing OHRQoL in patients suffering from RA.

Coverage of mucosal recessions at dental implants.

Facial peri-implant mucosal recessions represent an increasing complication in implant dentistry and may negatively affect the esthetic outcome and patient satisfaction. The aim of the present paper is to provide a review on the potential causes of facial peri-implant mucosal recessions and to provide a rationale for treatment along with possible treatment options. The available data indicate that soft tissue augmentation around dental implants is possible, but at present there is no evidence demonstrating that the augmented soft tissues are able to influence the peri-implant bone levels (e.g. to limit peri-implant bone loss). Therefore, the rationale to cover or correct peri-implant mucosal recessions are (i) to optimize the possibility for performing an adequate level of oral hygiene, and (ii) to improve esthetics. At present, there is very limited evidence supporting any specific treatment modality for covering peri-implant soft tissue recessions. The limited available data indicate that only shallow peri-implant mucosal recessions (e.g. up to 2 mm) may be treated successfully by means of a coronally advanced flap and subepithelial connective tissue graft or with guided bone regeneration, while no data are available supporting the possibility of covering deep and large peri-implant mucosal recessions.