Interdisciplinary esthetic approach in clinical dental rehabilitation.

During the esthetic evaluation of smile, the presence of diastemas, tooth color, size and shape, and the amount of gingival exposure are important factors to be considered. A 23-year-old female patient was referred to us with a dissatisfaction with her smile. After clinical examination revealed esthetic alterations as generalized tooth yellowish discoloration, a slight diastema in the upper anterior region, and a shortened appearance of maxillary dental crowns, providing a gingival smile. The proposed treatment consisted of an esthetic rehabilitation for resolution of gummy smile and closure of diastema in anterior teeth by the use of digital planning as a guide for the accomplishment of integrated procedures. The result obtained by the multidisciplinary treatment associating periodontal surgical procedure for esthetic crown lengthening with in-office bleaching and direct restorations with composite resin, by digital planning, provided evident harmonization between tooth color and shape and gingival contour, enabling more harmonious smile esthetics.

Short-term effect of non-surgical periodontal treatment on local and systemic cytokine levels: Role of hyperglycemia.

BACKGROUND: The effect of non-surgical periodontal treatment on oral and systemic inflammatory mediators in subjects with periodontitis and hyperglycemia remains largely unknown. Therefore, the aim of this clinical study was to compare the short-term effect of non-surgical periodontal treatment on serum, saliva and GCF inflammatory markers levels in GP subjects with or without hyperglycemia. METHODS: Sixty subjects divided into four groups of equal size were selected to participate: type 2 diabetics with generalized periodontitis (T2DM + GP), pre-diabetics with GP (PD + GP), normoglycemic subjects with GP (NG + GP), and healthy controls. GCF, serum, and saliva samples were obtained at baseline and 30 days after scaling and root planning (SRP) and the levels of interleukin-1ß (IL-1 ß), IL-8, IL-6, IL-2, IL-5, IL-4, IL-10, Interferon gamma (IFN-γ), Granulocyte macrophage colony-stimulating factor (GM-CSF) and Tumor necrosis factor-alpha (TNF-α) were determined by ultrasensitive multiplex assay. Clinical periodontal measurements were recorded. RESULTS: SRP yielded significant improvement of all periodontal parameters for all GP groups (p < 0.01). A significant reduction in GCF levels of several cytokines were observed; however, only IL-1B and IFN-γ were consistently reduced post-treatment across all GP groups. Salivary levels of IL-1ß were significantly reduced in all GP groups following treatment. No significant differences were observed for serum levels after SRP. CONCLUSIONS: Periodontal treatment reduced local inflammatory markers, specifically IL-1B and IFN-γ, irrespective of the diabetes status. Periodontal treatment had no significant effect on serum levels of the inflammatory markers evaluated in this study.

Esthetic treatment of buccal exostoses: a case report.

Buccal exostoses are benign bony protuberances that may grow over time but rarely result in functional alterations. The diagnosis is established by a combination of medical history and clinical and radiographic features of the affected region. This case report describes the surgical treatment of bilateral bone projections on the buccal surface of the maxilla that represented an undesirable esthetic alteration to the patient. The surgical procedures, which were performed at separate appointments for the left and right sides, involved reflection of full-thickness flaps and careful osteotomy with a carbide spherical drill and a Rhodes chisel. At completion of the procedures, flat buccal bone ridges with a clear esthetic improvement were observed. At the follow-up examination (3 months postsurgery on the left side and 1 month on the right), the presence of stable periodontal tissue-positioned where it was located during the immediately postoperative period-indicated a satisfactory clinical result.

Impacto do tratamento periodontal no controle glicêmico em pacientes portadores de diabetes mellitus tipo 2 / Impact of periodontal treatment on glycemic control in individuals with type 2 diabetes mellitus

A proposta desse estudo prospectivo de 12 meses foi avaliar o efeito do tratamento da inflamação periodontal sobre o controle glicêmico de indivíduos com diabetes mellitus tipo 2. Sessenta e quatro pacientes em tratamento para diabetes e com periodontite Crônica foram randomizados em 2 grupos onde receberam raspagem supra e subgengival (grupo tratamento, n=32) ou apenas raspagem supragengival (grupo controle, n=32). Os indivíduos foram examinados clinicamente por dois examinadores calibrados no momento inicial e aos 3, 6 e 12 meses. Os parâmetros clínicos avaliados foram: índice de placa visível, índice gengival, profundidade clínica de sondagem e nível clínico de inserção. Coletas de sangue para exame de hemoglobina glicada (HbA1c) foram realizadas no momento inicial, 3, 6 e 12 meses após o tratamento periodontal. Dados relacionados às características demográficas, ao tempo de diabetes, medicações utilizadas e índice de massa corpórea (IMC) foram coletados de todos os pacientes. O controle de placa bacteriana realizado pelos pacientes foi avaliado mensalmente durante todo o período de avaliação. Ambas as terapias resultaram na melhora de todos os parâmetros clínicos periodontais (p<0,001) em todos os tempos avaliados, porém o grupo tratamento apresentou melhora estatisticamente significante em relação ao controle (p<0,01). Não foram observadas diferenças significantes na HbA1c em nenhum dos grupos durante os 12 meses de avaliação.

Hiperplasia gengival associada ao uso de anticonvulsivantes à base de ácido valpróico / Gingival hyperplasia associated with the use of valproic acid-based anticonvulsants

Anticonvulsivantes são drogas capazes de modificar a resposta dos tecidos gengivais a processos inflamatórios na presença ou não de placa bacteriana, induzindo o crescimento gengival. O presente trabalho revisou a respeito das alterações periodontais exacerbadas pela utilização de anticonvulsivantes à base de ácido valpróico. Foram incluídos no estudo todos os trabalhos que pudessem descrever algo a respeito das características bioquímicas e farmacológicas do ácido valpróico e sua correlação com as alterações periodontais hiperplásicas. A pesquisa bibliográfica foi realizada nas bases Scopus, PubMed, BVS, Web of Science e Scielo utilizando os descritores "sodium valproate" "valproic acid" "gingival enlargement" e "gingival hyperplasia". Como resultado, um total de 111 referências foram encontradas e 54 artigos contemplavam todos os critérios de inclusão e foram submetidos a análise qualitativa. Algumas hipóteses sugerem um papel determinante dos fibroblastos, citocinas inflamatórias e também com a síntese de metaloproteinases na resposta tecidual. Concluiu-se que o mecanismo interveniente na histopatogênese do tecido conjuntivo desencadeadas pelo ácido valpróico e com repercussões nos tecidos periodontais ainda é pouco compreendido e apresentam pouca relação com o acúmulo de biofilme dentário, sendo decorrentes mais por mecanismos atribuídos ao próprio medicamento (AU)

Anticonvulsants are drugs capable of modifying the response of gingival tissues to inflammatory processes in the presence or absence of plaque, inducing gingival growth. The present study reviewed the periodontal changes exacerbated by the use of valproic acid-based anticonvulsants. All studies that could describe something about the biochemical and pharmacological characteristics of valproic acid and its correlation with hyperplasic periodontal changes were included in the study. The literature search was carried out in the bases of Scopus, PubMed, BVS, Web of Science and Scielo using the descriptors "sodium valproate" "valproic acid" "gingival enlargement" and "gingival hyperplasia". As a result, a total of 111 references were found and 54 articles covered all the inclusion criteria and were included in the qualitative analysis. Some hypotheses suggest a role of fibroblasts, inflammatory cytokines and also the synthesis of metalloproteinases in the tissue response. It was concluded that the mechanism involved in the histopathogenesis of connective tissue triggered by valproic acid and with repercussions on the periodontal tissues is still poorly understood and presents little relation with the accumulation of dental biofilm, being more due to mechanisms attributed to the drug itself (AU)

A systematic review and meta-analysis of the survival rate of implants placed in previously failed sites.

The aim of this study was to conduct a systematic review and meta-analysis to assess the clinical outcomes of dental implants placed in previously early and late implant failed sites. An electronic literature search was conducted in several databases for articles published up to February 2018. Human clinical trials that received at least one implant in a previously failed site were included. Hence, the PICO question that was aimed to be addressed was: Do patients undergoing implant replacement (second and third attempts) in previous failed sites have survival rates similar to implants placed at first attempts? A random effects model was used to calculate survival weighted means and corresponding 95% Confidence Intervals (CI) among studies. Eleven studies of low to moderate methodological quality were included in this review. Implants placed in sites with history of one and two implant failures had a weighted survival rate (SR) of 88.7% (95%CI 81.7-93.3) and 67.1% (95%CI 51.1-79.9), respectively. Implants placed in sites with a previous early failure revealed a weighted SR of 91.8% (95%CI 85.1-95.6). First implants presented higher SR than implants placed in sites with one or two previous implant failures. In contrast, implants placed in sites with one and two implant failures had similar SR. Within its limitations, this review suggests that replacement implants have moderate SR. Larger prospective studies with well-defined criteria for early and late implant failure are necessary to confirm and expand on these results.

A systematic review and meta-analysis of the survival rate of implants placed in previously failed sites

Abstract The aim of this study was to conduct a systematic review and meta-analysis to assess the clinical outcomes of dental implants placed in previously early and late implant failed sites. An electronic literature search was conducted in several databases for articles published up to February 2018. Human clinical trials that received at least one implant in a previously failed site were included. Hence, the PICO question that was aimed to be addressed was: Do patients undergoing implant replacement (second and third attempts) in previous failed sites have survival rates similar to implants placed at first attempts? A random effects model was used to calculate survival weighted means and corresponding 95% Confidence Intervals (CI) among studies. Eleven studies of low to moderate methodological quality were included in this review. Implants placed in sites with history of one and two implant failures had a weighted survival rate (SR) of 88.7% (95%CI 81.7-93.3) and 67.1% (95%CI 51.1-79.9), respectively. Implants placed in sites with a previous early failure revealed a weighted SR of 91.8% (95%CI 85.1-95.6). First implants presented higher SR than implants placed in sites with one or two previous implant failures. In contrast, implants placed in sites with one and two implant failures had similar SR. Within its limitations, this review suggests that replacement implants have moderate SR. Larger prospective studies with well-defined criteria for early and late implant failure are necessary to confirm and expand on these results.

Inflammatory markers in gingival crevicular fluid of periodontitis patients with type 2 diabetes mellitus according to glycemic control: A pilot study.

BACKGROUND: Type 2 diabetes mellitus (T2DM) and periodontitis are inflammatory conditions with a bidirectional association. This pilot study aimed to evaluate whether T2DM and glycemic control interfere in inflammatory markers profiles in gingival crevicular fluid (GCF) in periodontitis patients. MATERIALS AND METHODS: Fourteen diabetic periodontitis patients were enrolled in this study, seven with adequate glycemic control (glycated hemoglobin [HbA1c] <8.0%) (DMA + P) and seven with inadequate control (HbA1c ≥8.0%) (DMI + P). Seven chronic periodontitis patients without diabetes formed the control group (P). GCF was obtained from diseased sites (probing depth >6 mm) of an entirely hemiarch, pooled and cytokines levels determined using multiplex beads immunoassay. Clinical periodontal parameters were analyzed by Mann-Whitney test and levels of cytokines by Kruskal-Wallis and Dunn's multiple comparison tests with confidence level of 95% (P < 0.05). RESULTS: Cytokines profile of GCF obtained from deep periodontal pockets presented high levels of inflammatory cytokines, and there were no statistical differences between levels of interleukin-6 (IL-6), IL-8 and tumor necrosis factor-α according to presence of diabetes or percentage of HbA1c among the groups, despite groups with T2DM and periodontitis exhibit higher levels of PD. CONCLUSION: Within the limitations of this study, inflammatory mediators in GCF are dependent to the local response and do not correlate with the diabetic status.

Supragingival biofilm control and systemic inflammation in patients with type 2 diabetes mellitus.

The objective of this study was to evaluate the effect of strict supragingival biofilm control on serum inflammatory markers and on periodontal clinical parameters in type 2 diabetes mellitus (T2DM) patients with chronic severe periodontitis. Twenty-four individuals with T2DM and periodontitis were randomly allocated to two treatment groups. The supragingival therapy group (ST, n = 12) received supragingival scaling, whereas the intensive therapy group (IT, n = 12) underwent supra- and subgingival scaling, as well as root planing. Patients from both groups received professional oral hygiene instructions every month. Data regarding visible plaque index (VPI), gingival bleeding index (GBI), bleeding on probing (BOP), probing pocket depth (PPD), clinical attachment level (CAL), serum levels of interleukin (IL)-6, IL-17A, IL-8, tumor necrosis factor α (TNF-α), monocyte chemoattractant protein (MCP)-1 enzyme-linked immunosorbent assay (ELISA), and glycated hemoglobin (HbA1c) levels were obtained at baseline and at 6 months post-therapy. Both therapies resulted in the improvement of almost all clinical periodontal parameters (p < 0.05). There were no differences in TNF-α, IL-8, IL-17A and HbA1c levels in either group (p > 0.05), between the two periods. However, MCP-1 levels were significantly reduced in both the ST (p = 0.034) and the IT (p = 0.016) groups, whereas the serum IL-6 levels were significantly reduced only in the IT group (p = 0.001). Strict control of supragingival biofilm has a limited effect on systemic inflammatory markers, and a moderate effect on periodontal clinical parameters.

Periodontal therapy and systemic inflammation in type 2 diabetes mellitus: a meta-analysis.

AIM: The aim of this systematic review was to assess the effect of periodontal therapy (PT) on serum levels of inflammatory markers in people with type 2 diabetes mellitus (T2DM). METHODS OF STUDY SELECTION: A literature search was carried out using MEDLINE via Pubmed, EMBASE, LILACS and Cochrane Central Register of Controlled Trials (CENTRAL) databases. Randomized-controlled trials (RCTs) and controlled clinical trials (CCTs) evaluating the effect of PT on systemic inflammatory markers were deemed eligible. Case series (CS), reports and pilot trials were excluded. Study quality was assessed using the Cochrane Collaboration's risk assessment tool. Meta-analysis was carried out using random effect methods. RESULTS: The search strategy identified 3,164 potential studies of which 61 were assessed for eligibility and 9 (6 RCTs and 3 CCTs) were included in this systematic review. Three RCTs were classified by the authors as being at low risk of bias and three were "unclear" and classified as uncertain risk of bias. All CCTs were considered to be at a high risk of bias. The meta-analysis showed a statistically significant mean difference (MD) for TNF- α (-1.33 pg/ml, 95% CI: -2.10; -0.56, p<0.001) and CRP (-1.28 mg/l, 95% CI: -2.07; - 0.48, p<0.001) favoring periodontal intervention versus control. CONCLUSION: The results of this meta-analysis support the hypothesis that PT reduces serum levels of TNF- α and CRP in T2DM individuals. The decrease of inflammatory burden has important implications for metabolic control and can, in part, explain the mechanisms linking periodontitis and increased risk for complications in people with T2DM.

Supragingival biofilm control and systemic inflammation in patients with type 2 diabetes mellitus

The objective of this study was to evaluate the effect of strict supragingival biofilm control on serum inflammatory markers and on periodontal clinical parameters in type 2 diabetes mellitus (T2DM) patients with chronic severe periodontitis. Twenty-four individuals with T2DM and periodontitis were randomly allocated to two treatment groups. The supragingival therapy group (ST, n = 12) received supragingival scaling, whereas the intensive therapy group (IT, n = 12) underwent supra- and subgingival scaling, as well as root planing. Patients from both groups received professional oral hygiene instructions every month. Data regarding visible plaque index (VPI), gingival bleeding index (GBI), bleeding on probing (BOP), probing pocket depth (PPD), clinical attachment level (CAL), serum levels of interleukin (IL)-6, IL-17A, IL-8, tumor necrosis factor α (TNF-α), monocyte chemoattractant protein (MCP)-1 enzyme-linked immunosorbent assay (ELISA), and glycated hemoglobin (HbA1c) levels were obtained at baseline and at 6 months post-therapy. Both therapies resulted in the improvement of almost all clinical periodontal parameters (p < 0.05). There were no differences in TNF-α, IL-8, IL-17A and HbA1c levels in either group (p >0.05), between the two periods. However, MCP-1 levels were significantly reduced in both the ST (p = 0.034) and the IT (p = 0.016) groups, whereas the serum IL-6 levels were significantly reduced only in the IT group (p = 0.001). Strict control of supragingival biofilm has a limited effect on systemic inflammatory markers, and a moderate effect on periodontal clinical parameters.

A influência do controle supragengival no nível glicêmico de pacientes portadores de diabetes tipo 2 / The impact of supragingival mechanical control on glycemic level in subjects with type 2 diabetes

O diabetes mellitus (DM) atualmente é considerado pela Organização Mundial da Saúde (OMS) como uma epidemia. Para prevenir as suas complicações e desonerar os sistemas de saúde, tem-se dado mais atenção à saúde primária (ex.: dieta e exercícios físicos) e secundária (ex.: bom controle glicêmico). O controle glicêmico é fundamental para a prevenção das complicações do DM (doenças cardiovasculares, retinopatias, nefropatias, neuropatias etc.). A doença periodontal (DP) é considerada uma das complicações do DM e estudos clínicos e epidemiológicos têm avaliado o impacto do tratamento periodontal no controle glicêmico. Dada à relevância deste assunto, o objetivo foi fazer uma revisão crítica da literatura, assim como relatar um caso sobre a influência do controle mecânico supragengival nos níveis glicêmicos de uma paciente portadora de diabetes mellitus tipo 2 (DM 2).