Peri-implant radiographic bone level and associated factors in Spain.

OBJECTIVES: To evaluate radiographic bone level (RxBL) at dental implants and its associated factors in Spain. MATERIAL AND METHODS: This cross-sectional study was performed by a network of sentinel dentists from regions of Spain. RxBL was defined as the distance from the implant shoulder to the first clearly visible contact between the implant surface and the bone. Radiographic measurements were performed by two trained and experienced periodontists. Implant and patient data were also collected. Descriptive, bivariate, discriminative and multivariate analyses were done. RESULTS: A total of 49 sentinel dentists provided data 275 patients. Mean RxBL from 474 implants (5-13 years) was 1.87 mm (range: 0.00-13.17 mm). Statistically significant associations between RxBL and clinical output variables (bleeding on probing, oedema, plaque, probing depth, suppuration, keratinized tissue) were found. In the multiple regression analysis, statistically significant associations for RxBL were found for smoking habit, implant diameter, years of follow-up and type of prosthesis (p < 0.01). CONCLUSIONS: Peri-implant RxBL ranged from 0 to 13.17 mm. It was significantly associated with clinical output variables and with some potentially predictor variables, at patient- (smoking >10 cigarettes/day) and implant- (diameter, years of follow-up, Toronto bridge) levels.

Connective Tissue Grafts with Nonincised Papillae Surgical Approach for Periodontal Reconstruction in Noncontained Defects.

This case report presents the preliminary results of combining a modification of the nonincised papillae surgical approach (NIPSA), attempting to improve outcomes in the treatment of teeth with advanced periodontal support loss. The modification added a connective tissue graft (CTG) in the buccal aspect of these unfavorable cases caused by deep buccal bone dehiscence, soft tissue deficiencies, or tooth malposition (especially when positioned outside the bony contour). Deep, intrabony, noncontained defects affecting the maxillary incisors were treated in four patients. At the 1-year follow-up, all cases showed an improvement in the marginal soft tissue with considerable reductions in periodontal pocket depth and gains in clinical attachment. NIPSA plus CTG seem to improve clinical outcomes in deep, noncontained intrabony defects.

Supra-alveolar attachment gain in the treatment of combined intra-suprabony periodontal defects by non-incised papillae surgical approach.

AIM: To assess the effectiveness of non-incised papillae surgical approach (NIPSA) in periodontal reconstructive surgery of combined intra-suprabony defects. MATERIALS AND METHODS: Patients with deep periodontal defects treated with NIPSA (n = 20) were analysed. Defects were treated with enamel matrix derivative plus xenograft. Clinical outcomes were assessed before surgery and at 12 months. Wound closure was assessed one week post-surgery. Supra-alveolar attachment gain (SUPRA-AG) was recorded at 12 months post-surgery. RESULTS: Non-incised papillae surgical approach showed significant improvements in clinical attachment gain (5.9 ± 2.38 mm; p < 0.001), recession reduction (0.25 ± 0.44; p < 0.05) and tip of the papillae coronal displacement (0.4 ± 0.5; p < 0.05). It also showed complete wound closure of the apical mucosal incision in the 85% of the cases, with no interproximal tissue necrosis. SUPRA-AG (1.9 ± 1.74) showed a positive tendency, associated with complete intrabony defect resolution. CONCLUSIONS: Non-incised papillae surgical approach promoted primary intention healing, wound stability and space provision for optimal periodontal reconstruction, preserving supra-alveolar soft tissue integrity.

Adherence to supportive periodontal treatment.

Like any other chronic disease, periodontal disease can be treated, but not eradicated. Personal maintenance of periodontal health requires the continuous elimination of bacterial accumulation at the gingival level, which demands periodical professional assistance. Of upmost importance is the patient being able to actively follow the counsel of the care providers. Thus, patient compliance, adherence, and persistence are paramount for the long-term success of periodontal therapy. Unfortunately, in medicine as well as in dentistry, most studies show that, sooner rather than later, an unacceptable percentage of patients quit maintenance care. However, different studies have shown that there are behavioral techniques which may significantly improve the degree of motivation, compliance and persistence of patients with oral hygiene and supportive periodontal treatment. The right interval between maintenance visits has not been determined yet, but should be implemented according to patient needs, which do not necessarily coincide with the standard three-month interval historically accepted as adequate. Adherence to periodontal maintenance results in reduction of plaque and bleeding on probing, and potentially slowing down or halting the disease progression. Finally, based on numerous retrospective studies, patient compliance could be considered a disease-modifying factor positively affecting tooth survival. However, a lack of randomized clinical trials means this last statement is still open to question.

Cellular therapy in periodontal regeneration.

Periodontitis is a chronic inflammatory condition leading to destruction of the tooth supporting tissues, which if left untreated may cause tooth loss. The treatment of periodontitis mainly aims to arrest the inflammatory process by infection control measures, although in some specific lesions a limited periodontal regeneration can also be attained. Current regenerative approaches are aimed to guide the cells with regenerative capacity to repopulate the lesion and promote new cementum and new connective tissue attachment. The first phase in periodontal tissue regeneration involves the differentiation of mesenchymal cells into cementoblasts to promote new cementum, thus facilitating the attachment of new periodontal ligament fibers to the root and the alveolar bone. Current regenerative approaches limit themselves to the confines of the lesion by promoting the self-regenerative potential of periodontal tissues. With the advent of bioengineered therapies, several studies have investigated the potential use of cell therapies, mainly the use of undifferentiated mesenchymal cells combined with different scaffolds. The understanding of the origin and differentiation patterns of these cells is, therefore, important to elucidate their potential therapeutic use and their comparative efficacy with current technologies. This paper aims to review the in vitro and experimental studies using cell therapies based on application of cementoblasts and mesenchymal stem cells isolated from oral tissues when combined with different scaffolds.

Treatment trends in periodontics.

This volume of Periodontology 2000, entitled "Treatment Trends in Periodontics", evaluates the importance of nonsurgical periodontal therapy and defines its role as the key etiologic treatment of the disease. The need for scaling and root planing is mandatory step during the initial phase of therapy, as is self-care by the patient. Only after reevaluation of the outcome achieved by nonsurgical procedures should surgery be considered, and the concept of "critical probing depth" is emphasized. The chapters in this volume discuss different aspects of periodontal surgery, including regeneration and plastic periodontal procedures, and, looking toward the future, cell therapy in periodontics is explored. The impact of periodontal therapy on systemic diseases is reviewed, and the role of occlusion in periodontal disease is revisited and discussed. Topics on implants include their placement in fresh extraction sockets, socket healing with or without implant placement, and research on osseointegration. The important topic of maintenance care of teeth and implants for long-term therapeutic success is thoroughly evaluated, as is the efficacy of dentifrices in oral hygiene. The editors convey a nutshell review of the concepts of what periodontal treatment should entail, based on scientific evidence generated during half-a-century of work in periodontics.

Periodontal Disease in Pregnancy: The Influence of General Factors and Inflammatory Mediators.

PURPOSE: To determine the influence of plaque and progesterone on periodontitis in pregnant women and their relationship with inflammatory mediators. MATERIALS AND METHODS: A longitudinal observational study of 60 pregnant women was undertaken in two observation periods. During the third trimester, plaque Index (PI), bleeding on probing (BOP), probing pocket depth (PPD), and clinical attachment level (CAL) were assessed, and the basal levels of progesterone, CRP, IL-6 and TNF-α in plasma were measured. The second observation phase was carried out 6 weeks after childbirth, when periodontal indices, progesterone and serum levels of CRP were again evaluated. RESULTS: Periodontal disease was moderate in 18.3%. PI and toothbrushing proved to have a correlation with the severity of periodontitis. High levels of CRP were significantly correlated (p < 0.05), with a greater BOP (r = 0.360) and PPD (r = 0.321). There was no correlation between IL-6 or TNF-α with periodontal parameters. After childbirth, progesterone was drastically reduced, BOP and PPD improved and CRP showed a significant reduction of 2.63 mg/l (p < 0.05). CONCLUSIONS: Periodontal disease is prevalent during pregnancy. PI and frequency of toothbrushing are correlated with the severity of periodontitis in pregnant women. Pregnancy showed an increased in the level of CRP, which was positively correlated with BOP and PPD. All periodontal indices and CRP level statistically significantly decreased after childbirth, together with a marked reduction of progesterone and without changes in PI.

Periodontal reconstructive surgery of deep intraosseous defects using an apical approach. Non-incised papillae surgical approach (NIPSA): A retrospective cohort study.

BACKGROUND: The objective of this study was to compare a minimally-invasive surgical technique (MIST) and a non-incised papilla surgical approach (NIPSA) in periodontal reconstructive surgery of deep intraosseous defects. METHODS: Data on 30 patients with a deep intraosseous defect treated with MIST (n = 15) or NIPSA (n = 15) were analyzed retrospectively. All patients met the same inclusion criteria and were treated following the same protocol, except for the surgical management of soft tissue (MIST versus NIPSA). Clinical parameters at baseline and at 1-year post-surgery, early healing at 1 week, and postoperative pain were assessed. RESULTS: NIPSA and MIST resulted in significant clinical attachment gain (CAG) (P < 0.001) and probing depth reduction (PDr) (P < 0.001) at 1-year post-surgery. However, NIPSA resulted in significantly lower recession of the tip of the interdental papilla compared with MIST (P < 0.001). Smoking negatively influenced early healing in both techniques (P < 0.05). CONCLUSIONS: NIPSA and MIST both resulted in significant improvements in clinical parameters. NIPSA showed significant soft tissue preservation. NIPSA may represent a promising papillae preservation technique in the treatment of intraosseous periodontal defects.

Prevalence and risk indicators of peri-implant diseases in Spain.

AIM: To evaluate the prevalence of peri-implant diseases in Spain, as well as the associated risk indicators. MATERIAL AND METHODS: This is a cross-sectional study using a network of sentinel dentists, who randomly selected 10 patients with implants (placed, at least, 5 years before), which were clinically and radiographically evaluated. Case definitions were established for peri-implant mucositis [bleeding on probing (BOP) and no bone level ≥2 mm] and peri-implantitis (BOP plus bone level ≥2 mm). Potential predictor variables, at univariate and multivariate levels, were explored by means of binary logistic regression. RESULTS: A total of 49 sentinel dentists provided complete data from 474 implants in 275 patients. At implant level, prevalences for peri-implant mucositis and peri-implantitis were 27% (95% confidence interval [CI] 22-32) and 20% (95% CI: 15-24), respectively, with 17% of implants (14-21) with bone level ≥2 mm without BOP. At patient level, prevalences were 27% (22-32), 24% (19-29) and 18% (13-22), respectively. In the multiple regression analysis, statistically significant associations for peri-implantitis (p < 0.10) were found for gender, peri-implant supportive therapy, implant location, diameter and surface, type of prosthesis and access to interproximal hygiene. CONCLUSIONS: In this representative subject sample across Spain, the prevalence of peri-implant diseases was high (51%).

A Two-Step Surgical Approach with Flattening of the Root Surface to Treat Localized Gingival Recessions Affecting Mandibular Incisors: A Case Series Report.

Root coverage in the anterior mandible is challenging due to a thin gingiva, shallow vestibule, and/or high frenulum. This case series reports on the flattening of the root surface to create a new emergence profile conceived with a two-step surgical approach aimed at providing more space for the graft, increasing the thickness of the gingival margin, and getting extra soft tissue in the open area of the recession. A total of 10 patients with recessions affecting the mandibular incisors were treated to evaluate this two-step approach, which included odontoplasty of the root followed by a connective tissue graft. At 1 year, the mean coverage was 100% in Class II recessions, and 80.5% in Class III. The mean keratinized tissue increase was 5.80 ± 1.75 mm. This surgical approach could be proposed as an alternative when treating mandibular anterior teeth with root prominence or with a buccally tilted position.

Nonincised Papillae Surgical Approach (NIPSA) in Periodontal Regeneration: Preliminary Results of a Case Series.

A new surgical approach has been developed to optimize the preservation of the gingival margin and papillae when treating periodontal defects. The flap is raised by one mucosal incision far away from the marginal tissues. This case series reports on the effectiveness of a nonincised surgical approach (NIPSA) in conjunction with a hydroxyapatite-based graft biomaterial and enamel matrix derivative in treating intrabony defects. Ten defects in 10 patients were treated. The follow-up period ranged from 6 to 18 months (mean: 10.8 ± 4.7 months). Probing pocket depth was 9.6 ± 2.3 mm before surgery and 2.3 ± 0.5 mm postsurgery. Clinical attachment level (CAL) decreased from 10.4 ± 2.7 mm to 3.1 ± 0.87 mm postsurgery. The gingival papilla height, keratinized tissue width, and buccal gingival margin remained stable over time. No wound dehiscence was recorded. Mean Early Healing Index was 1.5 ± 0.7. Results show a substantial CAL gain, limited postsurgical shrinkage, minimal morbidity, and early healing.

Cell therapy with allogenic canine periodontal ligament-derived cells in periodontal regeneration of critical size defects.

AIM: The objective of this in vivo experimental study to evaluate the regenerative potential of a cell therapy combining allogenic periodontal ligament-derived cells within a xenogeneic bone substitute in a similar experimental model. METHODS: In nine beagle dogs, critical size 6-mm supra-alveolar periodontal defects were created around the PIII and PIV. The resulting supra-alveolar defects were randomly treated with either 1.4 × 106 allogenic canine periodontal ligament-derived cells seeded on de-proteinized bovine bone mineral with 10% collagen (DBBM-C) (test group) or DBBM-C without cells (control group). Specimens were obtained at 3 months, and histological outcomes were studied. RESULTS: The histological analysis showed that total furcation closure occurred very seldom in both groups, being the extent of periodontal regeneration located in the apical third of the defect. The calculated amount of periodontal regeneration at the furcation area was comparable in both the test and control groups (1.93 ± 1.14 mm (17%) versus 2.35 ± 1.74 mm (22%), respectively (p = .37). Similarly, there were no significant differences in the amount of new cementum formation 4.49 ± 1.56 mm (41%) versus 4.97 ± 1.05 mm (47%), respectively (p = .45). CONCLUSIONS: This experimental study was unable to demonstrate the added value of allogenic cell therapy in supra-crestal periodontal regeneration.

Changes in Periodontal Parameters and C-Reactive Protein After Pregnancy.

BACKGROUND: This study assesses hormonal, inflammatory, and periodontal changes in pregnant women and postpartum in the absence of periodontal treatment, and seeks to determine any correlations among these parameters. METHODS: A longitudinal, observational study of 117 pregnant women (aged 23 to 42 years) was undertaken in a private gynecologic center between weeks 32 and 35 of pregnancy and 6 to 8 weeks after delivery. Levels of progesterone and C-reactive protein (CRP) in plasma were determined, as well as periodontal indices, including: 1) plaque index (PI); 2) bleeding on probing (BOP); 3) probing depth (PD); and 4) clinical attachment level (CAL). RESULTS: Postpartum progesterone and CRP declined sharply from 90.85 ± 42.51 ng/mL and 3.73 ± 4.01 mg/L to 0.77 ± 1.43 ng/mL and 1.43 ± 1.67 mg/L, respectively. There was also a significant improvement in all periodontal indices (P <0.05) with the exception of PI. During pregnancy mean BOP was 21.03%, mean PD 2.62 mm, and mean CAL 1.20 mm. After delivery mean BOP was 13.25%, mean PD 2.39 mm, and mean CAL 1.14 mm. Percentage of 1- to 3-mm pockets increased (P <0.05), while 4- to 5-mm pockets and pockets >6 mm decreased significantly (P <0.001). Reduction in CRP correlated significantly with decrease in BOP (P <0.001). CONCLUSIONS: Postpartum, there was a dramatic reduction in progesterone and CRP, together with an improvement in BOP, PD, and CAL in the absence of periodontal treatment. Decrease in CRP was related to an improvement in periodontal bleeding.

Coverage of Buccal Tissue Dehiscences on Endosseous Implants: Decision-Making Process and Case Report.

INTRODUCTION: Dehiscences on facial aspects of implants are an esthetic concern and, just as importantly, may make maintaining adequate home-care measures and implant health more difficult, especially when bordered by inadequate and mobile soft tissue margins. CASE PRESENTATION: This report describes a new approach, the laterally rotated flap, and a tunnel subepithelial connective tissue graft, used to correct soft tissue dehiscences and gain keratinized mucosa on endosseous implants. Soft tissues were maintained in a stable condition 3 years after treatment. CONCLUSIONS: Although there are few controlled clinical studies that support any surgical technique for covering dehiscences on implants, some results show a tendency for improvement. The techniques presented in this case report provided promising results.

Surgical treatment of localized gingival recessions using coronally advanced flaps with or without subepithelial connective tissue graft.

BACKGROUND: A coronally advanced flap with subepithelial connective tissue graft is the gold standard surgical treatment of gingival recessions, since it offers a higher probability of achieving complete root coverage compared with other techniques. However, optimum short- and middle-term clinical results have also been obtained with coronally advanced flaps alone. The aim of the present study was to evaluate the results obtained by the surgical treatment of localized gingival recessions using coronally advanced flaps with or without subepithelial connective tissue graft. MATERIAL AND METHODS: The reduction of recession height was assessed, together with the gain in gingival attachment apical to the recession, and total reduction of recession, in a comparative study of two techniques. Twenty-two gingival recessions were operated upon: 13 in the control group (coronally advanced flap) and 9 in the test group (coronally advanced flap associated to subepithelial connective tissue graft). RESULTS: After 18 months, the mean reduction of recession height was 2.2 ± 0.8 mm in the control group and 2.3 ± 0.7 mm in the test group, with a mean gain in gingival attachment of 1.3 ± 0.9 mm and 2.3 ± 1.3 mm, respectively. In percentage terms, the mean reduction of recession height was 84.6 ± 19.6% in the control group and 81.7 ± 17.8% in the test group, with a mean gain in gingival attachment of 20.5 ± 37.4% and 184.4 ± 135.5%, respectively. CONCLUSIONS: Significant reduction of gingival recession was achieved with both techniques, though the mean gain in gingival attachment (in mm and as a %) was greater in test group.

Relationship between diabetes and periodontal infection.

Periodontal disease is a high prevalent disease. In the United States 47.2% of adults ≥ 30 years old have been diagnosed with some type of periodontitis. Longitudinal studies have demonstrated a two-way relationship between diabetes and periodontitis, with more severe periodontal tissue destruction in diabetic patients and poorer glycemic control in diabetic subjects with periodontal disease. Periodontal treatment can be successful in diabetic patients. Short term effects of periodontal treatment are similar in diabetic patients and healthy population but, more recurrence of periodontal disease can be expected in no well controlled diabetic individuals. However, effects of periodontitis and its treatment on diabetes metabolic control are not clearly defined and results of the studies remain controversial.

Healing of a xenogeneic collagen matrix for keratinized tissue augmentation.

AIM: To evaluate histologically the healing of a xenogeneic collagen matrix (CM) used to augment the width of keratinized tissue around teeth. MATERIALS AND METHODS: The gingiva on the buccal aspect of mandibular and maxillary premolars was surgically excised on 12 minipigs. After 1 month of plaque accumulation, the resulting defects were randomly treated by a periosteal retention procedure (control site) or by placing a collagen matrix after an apically repositioned flap (CM) (test site). Clinical and histological outcomes were evaluated at 1, 4 and at 12 weeks. RESULTS: Clinically, no gain of keratinized tissue was noted in either group. Histometrically, the thickness of the gingival unit was significantly higher in the test group at 1 month, although these differences were not significant at 3 months. There was a tendency in the test group towards less bone resorption (0.7 mm) and apical displacement (0.5 mm) of the gingival margin at 3 months. CONCLUSIONS: The tested CM demonstrated uneventful healing, being resorbed within the surrounding tissues in absence of significant inflammation. When compared with periosteal retention alone, the CM group attained similar clinical and histological outcomes.

A Latin American perspective of periodontology.

Periodontal diseases occur worldwide, and Latin American populations are significantly affected by different manifestations of periodontal disease. The interest in periodontics and periodontal therapy first developed in the early 1930s in the southernmost countries of Latin America, and spread, as the years went by, throughout the region. Today, periodontal research is vibrant in Latin America. The aim of this volume of Periodontology 2000 was to present an overview of the periodontal research currently being performed in different countries of Latin America. The epidemiology of periodontal diseases in adults, children and adolescents, and the pathogenesis of such diseases (including microbiological characteristics and risk factors), are discussed. The role of systemic antibiotic therapy and the effect of smoking are discussed in relation to the progression and the treatment of periodontitis. In addition, the benefit of lasers in periodontal therapy is evaluated. Latin American research groups have been active in exploring new venues of regenerative periodontal treatment, addressing the role of cementum proteins, growth factors and oral mesenchymal stem cells in tissue engineering. Finally, basic research to study cancerization is reported.

Efect of periodontal disease and non surgical periodontal treatment onC-reactive protein. Evaluation of type 1 diabetic patients

Objectives: The purpose of this study was to analyze how anti-infectious periodontal treatment affects C reactiveprotein (CRP) values in patients with type 1 diabetes, and correlate baseline CRP levels with periodontal diseaseseverity.Study Design: A cohort of fifty three subjects with type 1 diabetes and moderate to severe periodontitis wererecruited. Periodontal parameters were measured, and blood samples were obtained to evaluate high-sensitivityC-reactive protein (hs-CRP). Group 1 was treated with scaling, root planning, and systemic administration ofdoxycycline. Group 2 received only scaling and root planning.Results: Hs-CRP was reduced after periodontal treatment in group 1 (-0.22 mg/l) and 2 (-0.21 mg/l ) but thisreduction was not statistically significant, even in the patients with the best response to periodontal treatment.However, significant correlation appeared between hs-CRP and mean probing pocket depth (PPD) (p=0, 01) andmean clinical attachment level (CAL) (p=0,03).Conclusions: Non-surgical periodontal treatment couldn’t reduce hs-CRP values, however, it was found an associationbetween advanced periodontitis and elevated blood hs-CRP levels in patients with type 1 diabetes. It canbe speculated that periodontal disease increases production of pro-inflammatory mediators in patients with type1 diabetes, but other producing sources of these pro-inflammatory substances may exist (AU)

Efect of periodontal disease and non surgical periodontal treatment on C-reactive protein. Evaluation of type 1 diabetic patients.

OBJECTIVES: The purpose of this study was to analyze how anti-infectious periodontal treatment affects C reactive protein (CRP) values in patients with type 1 diabetes, and correlate baseline CRP levels with periodontal disease severity. STUDY DESIGN: A cohort of fifty three subjects with type 1 diabetes and moderate to severe periodontitis were recruited. Periodontal parameters were measured, and blood samples were obtained to evaluate high-sensitivity C-reactive protein (hs-CRP). Group 1 was treated with scaling, root planning, and systemic administration of doxycycline. Group 2 received only scaling and root planning. RESULTS: Hs-CRP was reduced after periodontal treatment in group 1 (-0.22 mg/l) and 2 (-0.21 mg/l ) but this reduction was not statistically significant, even in the patients with the best response to periodontal treatment. However, significant correlation appeared between hs-CRP and mean probing pocket depth (PPD) (p=0, 01) and mean clinical attachment level (CAL) (p=0,03). CONCLUSIONS: Non-surgical periodontal treatment couldn' t reduce hs-CRP values, however, it was found an association between advanced periodontitis and elevated blood hs-CRP levels in patients with type 1 diabetes. It can be speculated that periodontal disease increases production of pro-inflammatory mediators in patients with type 1 diabetes, but other producing sources of these pro-inflammatory substances may exist.