The simplified papilla preservation flap in the regenerative treatment of deep intrabony defects: clinical outcomes and postoperative morbidity.

BACKGROUND: The aims of the present multi-center, randomized, controlled clinical trial were: 1) to compare the efficacy of the simplified papilla preservation flap with and without a barrier membrane in deep intrabony defects; 2) to evaluate the postoperative morbidity and surgical complications; and 3) to preliminarily test the impact of baseline tooth mobility on clinical outcomes. METHODS: This parallel group, randomized, multi-center, controlled clinical trial involved 112 patients in 8 periodontal practices in 4 countries. A deep intrabony defect in each patient was accessed with the simplified papilla preservation flap. In the test defects, a bioabsorbable membrane was positioned. Patients' experiences with the surgical procedure and postoperative period were evaluated with a questionnaire. Clinical outcomes included clinical attachment level (CAL) and probing depth (PD) changes. RESULTS: Complete observations were available for 55 test and 54 control defects. CAL gains at 1 year were 3.5 +/- 2.1 mm in the guided tissue regeneration (GTR) group and 2.6 +/- 1.8 mm in the control group (P = 0.0117). CAL gains > or = 4 mm were observed in 50.9% of GTR sites and 33.3% of control sites. A significant center effect of 2.1 mm was observed (P= 0.01). Initial PD (P= 0.01) and baseline tooth mobility (P= 0.036) were significant covariates. During the procedure, 30.4% of test and 28.6% of controls reported feeling moderate pain, and subjects estimated the hardship of the procedure at 24 +/- 25 visual analog scale (VAS) units in the test group, and at 22 +/- 23 VAS in controls. In terms of the investigated outcomes, differences between test and control groups were not statistically significant. Among the postoperative complications, edema was most prevalent at week 1, and more frequently associated with the test treatment (P= 0.01). In the test group, 53.6% of membranes were exposed at week 3. CONCLUSIONS: The present study further supports the added benefits of guided tissue regeneration with respect to access flap alone in the treatment of deep intrabony defects, as well as the general efficacy of GTR in different clinical settings. Furthermore, our study indicates a possible influence of baseline tooth mobility on clinical outcomes.

[Metronidazole in the treatment of refractory periodontitis]. / Metronidazol bij de behandeling van refractaire parodontitis.

In this article the clinical and microbiological effects of systemic metronidazole in the treatment of refractory periodontitis in adult patients is discussed. For this study, 27 adult patients with detectable Bacteroides forsythus and culture negative for Actinobacillus actinomycetemcomitans were selected. After renewed supra- and subgingival debridement, patients were treated with systemic metronidazole (500 mg TID) for 7 days. Mean probing pocket depth, probing attachment level and bleeding index significantly improved after metronidazole therapy. Patients that became culture negative for B. forsythus showed a significant better therapy response in comparison to subjects that had detectable B. forsythus post-therapy. The maximum clinical response was observed in patients that became negative for B. forsythus, Porphyromonas gingivalis and Prevotella intermedia after renewed debridement and metronidazole therapy. It is concluded that systemic metronidazole therapy can be effective in refractory adult periodontitis. Microbiological analyses of the subgingival microflora in these patients can assist in selecting patients that may benefit from systemic metronidazole therapy.

Generalizability of the added benefits of guided tissue regeneration in the treatment of deep intrabony defects. Evaluation in a multi-center randomized controlled clinical trial.

BACKGROUND: Several studies have shown that GTR therapy of intrabony defects results in significantly better outcomes than access flap alone. Most of the available data, however, have been produced in highly controlled research environments by a small group of investigators. Generalizability of results to different clinicians and different subject populations has not been evaluated so far. METHODS: This parallel group study involved 143 patients recruited in a practice-based research network of 11 offices in 7 countries. It was designed to evaluate: 1) the applicability of the documented added benefits of GTR in the treatment of intrabony defects to different populations, and 2) the generalizability of the expected results to different clinicians. GTR was compared to access flap alone. Defects, one in each patient, were accessed with a previously described papilla preservation flap in both the test and control group. In addition, GTR sites received application of a bioabsorbable poly-D,L-lactide-co-glycolide membrane. A stringent plaque control regimen was enforced in all patients during the 1-year observation period. Outcomes included gains in clinical attachment (CAL) and reductions in probing depth. RESULTS: Observed gains in CAL were 2.18 +/- 1.46 mm for access flap and 3.04 +/- 1.64 mm for the GTR-treated group. The treatment-associated difference was statistically significant (P = 0.03) after correcting for both center effect and defect anatomy. Among the various centers, a 1.73 mm difference in CAL gain was observed. This is a clinically relevant amount, which underlines the significance of center variability in the outcome of periodontal surgical procedures. A frequency distribution analysis of the obtained CAL gains indicated that GTR treatment of deep intrabony defects decreased, with respect to the access flap control, the probability of obtaining only a modest attachment gain at 1 year. Conversely, CAL gains of 4 mm or more were observed in more than 40% of GTR-treated defects and in less than 20% of the controls (P < 0.0001). CONCLUSIONS: These data indicate that GTR therapy of deep intrabony defects performed by different clinicians on various patient populations resulted in both greater amounts and improved predictability of CAL gains than access flap alone.

Effects of metronidazole in patients with "refractory" periodontitis associated with Bacteroides forsythus.

The aim of the present study was to monitor the microbiological and clinical effects of renewed supra- and subgingival debridement in conjunction with systemic metronidazole therapy (500 mg TID for 7 days) in 27 "refractory" periodontitis patients, culture positive for Bacteroides forsythus and negative for Actinobacillus actinomycetemcomitans. Clinical evaluation included assessment of plaque, bleeding upon probing, probing pocket depth and clinical attachment loss at the deepest, bleeding site in each quadrant. Microbiological evaluation was carried out by anaerobic cultivation of subgingival plaque samples from the same sites. 6 months after renewed debridement and systemic metronidazole (RD+M), a statistically significant improvement of all clinical parameters was observed, except for the plaque index. After RD+M, B. forsythus was suppressed below detection level in 17 of the 27 patients, P. gingivalis in 9 out of 15 patients and P. intermedia in 14 of the 21 patients. Before RD+M, 12 patients harboured simultaneously B. forsythus, P. gingivalis as well as P. intermedia. Out of these, 6 patients were culture negative for the 3 species after therapy and showed the greatest reduction in pocket depth (3.1 mm) and gain of clinical attachment level (2.5 mm). In the treatment of refractory periodontitis, associated with patients culture positive for B. forsythus and negative for A. actinomycetemcomitans, metronidazole can significantly improve the clinical and microbiological parameters.