The use of a bovine bone mineral in periodontal osseous defects: case reports.

This article reviews the clinical and radiographical results of 12 periodontal patients treated with a bovine bone graft, Bio-Oss. Thirty-two periodontal intrabony osseous defects of various sizes and morphology were surgically treated and evaluated at 6 months. The patients responded well to the use of the bovine bone mineral with good tissue response and an improvement of the intrabony defects. There was an overall mean probing pocket reduction in the deepest sites of 2.34 mm (S.D. +/- 1.59) and a mean gain in probing attachment levels of 1.84 mm (S.D. +/- 1.09). There was a difference in the sites treated with the bovine bone alone compared to sites treated with the bone mineral and barrier membranes, but these differences were not significant. These preliminary findings seem favorable for bovine bone mineral as an alternative graft material to allogenic bone grafts from human tissue banks in treating intrabony defects.

Inhibition of experimental gingivitis in beagle dogs with topical salivary histatins.

Histatins, histidine-rich proteins found within parotid and submandibular secretions, are a novel class of endogenous peptides with antimicrobial properties. This masked, randomized, placebo-controlled preclinical investigation examined the effect of 3 topical histatins on the development of plaque and gingivitis in beagle dogs. 16, female, 1-year-old beagles were brought to optimal gingival health by mechanical scaling and polishing followed by rigorous daily tooth brushing. At the conclusion of this pretreatment period, dogs were randomly divided into 4 groups for the application of test formulations, and were placed on a plaque-promoting diet. Test agents included 3 synthetic salivary histatins (histatin 5, P-113 and P-113D) which were incorporated in hydroxypropyl methylcellulose gel at a concentration of 0.125%, and a placebo, or negative control, which was the gel vehicle alone. Throughout the 10-week treatment period, test formulations (2.0 ml) were applied 2 x daily to all premolar teeth using a Monojet syringe. Plaque formation and gingival inflammation were assessed using the plaque (PI) and gingival (GI) indices on days 0, 7, 14, 21, 28, 42, 56 and 70. Furthermore, bleeding to probing was recorded as a percent of sites (%BOP) and according to the modified sulcus bleeding index (mSBI). Comparisons among groups and between group pairs (active versus placebo) were made with Kruskal-Wallis tests with the average of data over the interval, days 14-42, being the primary focus of the analysis. From baseline to day 7, all groups expressed similar indices. Thereafter, overall significant differences among the groups were noted at day 42 for PI, at days 21, 28, 42 and 70 for GI, and at days 14 and 28 for %BOP (p < 0.05). In particular, beagles treated with P-113 demonstrated significantly lower PI scores at day 42 (p < 0.05), significantly lower GI scores from days 21 through 42 (p < 0.05), and significantly lower %BOP scores at days 14 and 28 (p < 0.05) compared to beagles treated with placebo. Beagles treated with P-113D exhibited significantly lower GI at day 42 compared to the placebo (p < 0.05). For the primary analysis conducted over the midtreatment interval (days 14-42), significant differences were detected for all parameters except mSBI (p < 0.05). Accordingly, significantly lower PI scores were found for P-113, lower GI scores for P-113 and P-113D, and lower %BOP for P-113 and P-113D compared to placebo (p < 0.05). These data indicate that in the beagle model, salivary histatins, P-113 and P-113D, topically applied, can significantly reduce clinical signs of plaque formation and gingival inflammation.

Hypothetical considerations in the regenerative treatment of molar furcation defects.

Treatment of the molar furcation defect is a challenge to the dental professional. Responses of molar furcation sites to both closed and open surgical debridement have not been shown to result in significant clinical improvement or bone fill. Regenerative techniques using grafting materials, guided tissue regeneration with resorbable and nonresorbable membranes, coronally positioned flaps, and combination techniques are more frequently used to treat class II molar furcations. The clinical responses to these surgical approaches have shown varied results. This article reviews some of the studies on regeneration in furcation defects as well as some of the uniqueness and complexities of the furcation problem. The bone morphology differences in molar bifurcation and trifurcation defects are discussed, and a bone morphologic classification is presented in an effort to standardize future regenerative studies in class II furcations.

Radiographic evaluation of alveolar crest obscured by dental implants.

This study evaluated the diagnostic accuracy of periapical, tomographic, and cross-sectional occlusal radiographic techniques in the assessment of facial and lingual bone loss at implant obscured sites. An edentulous dry human mandible was prepared with implants in the incisor, premolar, and molar regions. Successive round bur sizes (No. 1 to 6) were used to create circumferential infrabony periodontal defects in the alveolar crest adjacent to the implants. Periapical radiographs were made with custom stents and imaged each site in a conventional parasagittal orientation. Linear tomograms imaged sites in a cross-sectional coronal orientation. Cross-sectional occlusal radiographs imaged anatomy in the axial plane. Radiographic anatomy mesial and distal to each implant was masked with opaque tape before evaluation by a panel of six observers. Images were displayed in pairs consisting of an image at baseline and a second image having an equal chance of displaying an increment of bone removal or no bone removal. Image pairs were displayed in random order. A five-point scale was used to evaluate accuracy of detection of the presence or absence of changes in bone density as well as observer confidence in that assessment. ANOVA demonstrated significant variation due to image modality and increment of bone removal. Cross-sectional occlusal views provided significantly greater mean observer confidence scores than either periapical images or tomograms (P < .01). However, tomograms may provide greater utility in actual clinical practice.

Closed versus open debridement of facial grade II molar furcations.

Clinical responses of facial grade II molar furcations to closed (C) versus open (O) debridement were evaluated. 25 teeth were treated at baseline (BL) with scaling/root planning (S/RP) and evaluated at 4 months. 12 of the teeth were then treated with open flap debridement and the remaining teeth were treated with further S/RP. Clinical parameters of plaque, gingival inflammation, bleeding on probing, gingival fluid flow, pocket depth and probing attachment level were taken at BL, 4, 7, 10, 13 and 16 months. Pairwise differences were determined between visits and a t-test was applied to differences for C and O. For both treatment groups, the greatest changes in clinical parameters occurred from BL - 4 months. Plaque and gingival inflammation showed a gradual reduction from BL throughout the study for both groups. A reduction in pocket depth from BL - 16 months was noted in both groups (mid-furcal, C = 1.5 mm, O = 1.2 mm; root prominence, C = 1.02 mm, O = 0.84 mm)! There was a gain in probing attachment level in the midfurcal area for the C group (0.6 mm) while the O group lost (-0.46 mm). There were no statistically significant differences found for any clinical parameter between closed and open debridement. The presence of plaque and bleeding at a furcal site had not significant effect on treatment response.

Subjective criteria and probing attachment loss to evaluate the effects of plaque control and root debridement.

11 adult patients with moderate to advanced periodontitis were treated with oral hygiene instruction and an initial, single episode of root debridement. Before therapy, 3 independent clinicians examined all patients and identified sites that in their opinion probably would not respond to the therapy and would continue to lose attachment. On 2 occasions, 3 and 12 months later, the clinicians re-examined and re-evaluated all patients and all sites. The results of therapy were also monitored by probing attachment level measurements performed every 3rd month. All 11 patients completed 24 months of follow-up, and 6 subjects were available until 36 months. Sites with probing attachment loss after 12, 24 and 36 months were identified using linear regression analysis and compared to the clinicians' prediction of probing attachment loss. The results demonstrated a limited agreement between probing attachment loss determined by linear regression and the clinicians' predictions of probing attachment loss. It appears that the traditional clinical signs and factors used to forecast and identify periodontal disease activity are only moderately associated with probing attachment loss. This suggests that attachment loss may be caused by several factors, at least following initial therapy. The progression of an inflammatory disease of microbial etiology may be only 1 of such causes. Further studies are needed to clarify the nature and cause of probing attachment loss.

The effectiveness of subgingival scaling and root planning. I. Clinical detection of residual calculus.

This study evaluated the ability of clinicians to detect residual calculus following subgingival scaling and root planing and compared the clinical detection to the microscopic presence and surface area occupied by calculus found on teeth extracted after instrumentation. Interexaminer and intraexaminer reproducibility in clinically detecting subgingival calculus was also determined. One hundred one extracted teeth with 476 instrumented tooth surfaces were evaluated stereomicroscopically for the presence of calculus and the percent surface area with calculus was determined by computerized imaging analysis; 57% of all surfaces had residual microscopic calculus and the mean percent calculus per surface area was 3.1% (0 to 31.9%). Shallow sites had greater surface area of calculus than moderate and deep sites. The difference was not significant. The interexaminer and intraexaminer clinical agreement in detecting calculus was low. There was a high false negative response (77.4% of the surfaces with microscopic calculus were clinically scored as being free of calculus) and a low false positive response (11.8% of the surfaces microscopically free of calculus were clinically determined to have calculus). This study indicates the difficulties in clinically determining the thoroughness of subgingival instrumentation.

The effectiveness of subgingival scaling and root planing. II. Clinical responses related to residual calculus.

This study related 3-month clinical changes following scaling and root planning to the presence or absence of calculus on the root surfaces detected after extraction. Seven patients provided 646 sites evaluated for plaque, bleeding upon probing (BOP), probing pocket depth (PPD), and probing attachment level (PAL) at baseline and monthly following instrumentation. The teeth were extracted and evaluated for the presence and the percent surface area of calculus. Diagnostic sensitivity and predictability values for initial and residual PPDs, loss of PAL, and BOP in detecting residual calculus were determined. Calculus was found on 376 surfaces with a mean percent surface area of 3.13%. Predictability values were similar for all PPD ranges, while sensitivity decreased with increasing PPD. Probing attachment level changes were found to be unrelated to the presence or the amount of residual calculus. Bleeding upon probing had high levels of predictability, but sensitivity values were low. None of the clinical parameters evaluated in this study provided both a high level of predictability and sensitivity in detecting residual calculus.

Histological evaluation of periodontal probe penetration in untreated facial molar furcations.

The purpose of this investigation was to histologically determine the position of the periodontal probe tip when probing the deepest interradicular pocket depth in grade II and III facial molar furcation sites. Facial furcation pockets (5.8 mm +/- 1.3) were probed with a pressure-sensitive probe set at 50 g pressure. The probe tip was attached to the tooth with an acid etched composite resin. Surgical block biopsies were removed, fixed, decalcified and processed for histological sectioning. Buccolingual serial sections (6 mu) were cut from 9 biopsies and apicocoronal serial sections were cut from 3 biopsies. The sections were histometrically analyzed. The probe tip penetrated the inflamed furcation connective tissue an average depth of 2.1 mm (+/- 0.6). The probe tip was located 0.4 mm (+/- 1.4) apical to the crest of the interradicular bone. The % of inflammatory cell infiltrate in the connective tissue (ICT) around the probe tip was 56% (+/- 15%). There was no correlation between the % of ICT and the depth of probe penetration. This investigation demonstrated that probing of untreated facial molar furcation sites does not measure the attachment level of the interradicular root surfaces, but rather records the depth of probe penetration into the inflamed furcation connective tissue.

Inter-examiner reproducibility of probing pocket depths in molar furcation sites.

This investigation was designed to determine the reproducibility of probing pocket depths in maxillary facial and mandibular facial and lingual grade II and III molar furcation sites. 80 untreated molar teeth with 102 furcation invasions due to periodontitis were probed with a pressure-sensitive periodontal probe by 3 examiners. 8 sites per furcation were measured by each examiner at a single examination. The sequence of examiner probing was rotated in order to evaluate the effect of sequential probing. Tracings were made from radiographs of the inter-root separations in order to classify the interradicular space and to determine the effect of root separation on reproducibility. Data was analyzed by regression analysis. Pearson correlations, intraclass correlations, and the Student-Newman-Keuls test. Analysis indicated a high reproducibility of the maxillary facial and mandibular facial and lingual furcation sites in this untreated adult sample. No effect was due to probing sequence. The mid-root prominences, the line angles, and the internal surface sites of the furcation roots were recordable and reproducible, while the horizontal measurements were not consistently recordable. The reproducibility of the facial and lingual furcation sites that were probed decreased with an increase in probing pocket depth and an increased degree of root separation.

Bleeding on probing and probing depth as indicators of the response to plaque control and root debridement.

19 adult periodontitis patients were treated with plaque control and a single episode of root debridement. Results of this treatment were monitored in non-molar sites, molar flat surface sites, and molar furcation sites by probing attachment level measurements every 3rd month for 24 months. After 24 months, sites with probing attachment loss were identified using linear regression analysis. Clinical scores for supragingival plaque, bleeding on probing, suppuration on probing, and probing depth, obtained from these sites during the 24-month study, were analyzed to determine if they could be used diagnostically as indicators of probing attachment loss. The results demonstrated that the diagnostic accuracy for these clinical indicators was generally low at all 3 anatomical site locations. A possible explanation for this limited diagnostic accuracy may be that some areas of probing attachment loss following basic periodontal therapy are caused by factors other than the progression of an inflammatory periodontal disease of microbial etiology.

The effect of plaque control and root debridement in molar teeth.

The healing response of non-molar sites, molar flat surface sites, and molar furcation sites was investigated in 19 adult periodontitis patients following a periodontal therapy of plaque control and root debridement. A total of 2472 sites were monitored by recordings of dental plaque, bleeding on probing, probing depth, and probing attachment levels every 3rd month for 24 months. The results demonstrated that in sites with initial probing depth of 4.0 mm or greater, molar furcation sites responded less favorably to the therapy as compared to molar flat surface sites or non-molar sites. This was demonstrated by higher mean scores for bleeding on probing, less reduction in probing depth, and a mean loss of probing attachment of 0.5 mm over 24 months. Site analyses using linear regression showed a higher % of deeper sites with probing attachment loss for the molar furcations than either molar flat surface or non-molar sites. Among sites initially 7.0 mm or deeper, 21% of molar furcations were identified as showing probing attachment loss as compared to 7% of the molar flat surface sites and 11% of the non-molar sites.

An evaluation of tricalcium phosphate implants in human periodontal osseous defects of two patients.

This study evaluated the use of tricalcium phosphate (TCP) ceramic implant material in periodontal osseous defects. Thirteen defects in two patients were treated with mucoperiosteal flaps and placement of TCP. The defects were evaluated clinically and radiographically utilizing standardized probe placement and radiographic technique. Clinically, there was a mean probing pocket reduction of 4.5 mm as a result of a mean gain of clinical probing attachment level of 2.0 mm and a mean gingival recession of 2.5 mm. Radiographically, there was a mean "fill" of 1.8 mm. Six teeth were removed by block biopsy for histologic analysis, three at 3 months, one at 6 months and two a 9 months. The TCP particles were well tolerated and encapsulated by fibrous connective tissue, but the particles did not stimulate new bone growth. The junctional epithelium ended 1.62 mm coronal to the apical extent of a reference notch placed at the base of the defect. Although new cementum was observed, there was limited evidence of new attachment.

Summary of an International Symposium on phenytoin-induced teratology and gingival pathology.

Phenytoin has been the preferred drug for treating grand mal epilepsy for more than 40 years. The metabolism of this drug, its teratogenic potential, and its role in the pathogenesis of gingival overgrowth are discussed.

Periodontal osseous defects associated with vitally submerged roots.

1. Vital roots associated with periodontal osseous defects can be clinically submerged beneath a soft tissue flap. 2. Connective tissue fibers filled the submerged osseous defects and were oriented parallel to the root surfaces in the majority of cases. 3. New cementum lined the root surface at the base of two successfully submerged defects, but was not apparent on the dentin amputation sites of any submerged roots. 4. Eight of the nine clinically submerged defects exhibited positive radiographic changes. The six control defects showed no positive radiographic changes. 5. All successfully submerged defects showed histologic evidence of new bone formation. New bone formation was not apparent in any of the control defects or nonsubmerged defects. 6. Either no epithelium or only a narrow band of epithelium was associated with the successfully submerged roots. A connective tissue inflammatory infiltrate was not present within the submerged defects. 7. The defects of all control teeth and nonsubmerged experimental roots contained epithelial downgrowth accompanied by a chronic inflammatory response in the connective tissue. 8. Pulpal tissues associated with submerged roots appeared vital without significant degenerative or inflammatory changes. Pulpal tissue was continuous with overlying connective tissue.