Efficacy of periodontal soft tissue augmentation prior to orthodontic treatment on preventing gingival recession: study protocol for a randomised controlled trial.

INTRODUCTION: In adult patients with thin phenotype, gingival recession is obvious in the mandibular incisors after a large amount of lingual tooth movement. A systematic review indicated that soft tissue augmentation before orthodontic treatment might yield satisfactory results with respect to the progression of gingival recession. However, the studies included had a low-to-moderate level of evidence. This study was designed to investigate the efficacy of soft tissue augmentation prior to orthodontic treatment on the prevention of gingival recession. METHOD AND ANALYSIS: This is a single-centre, single-blind, randomised controlled, double-armed parallel group comparison trial. This study was initiated in December 2021 and end in December 2025 (anticipated). Patients with mild crowding in the lower arch and a thin gingival type was enrolled and randomly assigned in a 1:1 ratio to either group A (having soft tissue augmentation prior to orthodontic treatment) or group B (having orthodontic treatment only). The planned number of enrolled patients was 48 (24 patients × 2 groups). The primary endpoint was the mean change in recession of the gingival margin. Secondary endpoints included the probing depth, gingival phenotype, frequency of complete root coverage, gingival thickness, width of the keratinised gingiva, clinical attachment level, gingival recession class, full-mouth plaque score, alveolar bone thickness in the faciolingual dimension of the lower anterior teeth and lower incisor inclination. ETHICS AND DISSEMINATION: The study protocol was approved by the Ethical Committee of the Shanghai Stomatological Hospital (certificate number (2021)016). The study was conducted in accordance with the Declaration of Helsinki, the Clinical Trials Act and other current legal regulations in China. Written informed consent was obtained from all the participants. The results of this study will be reported in journal publications. TRIAL REGISTRATION NUMBER: ChiCTR2100050892.

A Novel Surgical Approach to Modify the Periodontal Phenotype for the Prevention of Mucogingival Complications Related to Orthodontic Treatment.

Certain bone morphologies and soft tissue thickness (ie, phenotype) are considered to be risk factors for the development of gingival recessions following orthodontic tooth movement. Preoperative evaluation of the periodontal phenotype, in the frame of orthodontic treatment plan, identify teeth at high risk for mucogingival complications related to orthodontic therapy. The new surgical technique is illustrated in a clinical case. A patient with a thin phenotype without visible gingival recession had bone dehiscences in the anterior mandible. Prior to orthodontic treatment, simultaneous bone and soft tissue augmentation was performed using the combination of a highly cross-linked ribose porcine type I collagen membrane and a subepithelial palatal connective tissue graft. Two years after augmentation surgery and initiation of orthodontic treatment, a thick buccal tissue with a wide band of attached gingiva was observed without any clinical signs of root prominences, indicating a substantial change in periodontal phenotype. The clinical findings were corroborated by the 3D analysis, demonstrating substantial bone apposition on the buccal aspect of all roots in the treated area. The described surgical technique offers a valuable approach for regenerating hard and soft tissues in deficient areas prior to orthodontic therapy, thus preventing the development of gingival recessions.

A novel cervical tooth wear and recession index, the cervical localisation code, and its application in the prevention and management of dentine hypersensitivity.

OBJECTIVES: To design and validate a new index to assess tooth wear (TW) in the cervical region and its association with gingival recession (GR), for use both in research studies and as resource in General Dental Practice, with focused prevention and management strategiesparticularly related to aetiology of dentine hypersensitivity provided for each Code score. METHODS: Codes to reflect clinical presentations of the cervical region in health and disease recording both TW and GR were defined. Validation of the Code was undertaken by 3 trained examiners who scored buccal and lingual surfaces of eligible teeth in 42 adult healthy volunteers. Each volunteer underwent 4 identical clinical examinations, being assessed twice by the examiner who performed the first and last exam. RESULTS: Cervical Localisation Code definitions were A: no GR, no coronal TW, B: no GR, distinct coronal TW, C: GR but no coronal TW, D: GR with distinct coronal and root TW. For validation 2073 eligible tooth surfaces were scored. There were only 57 within and 201 between examiner disagreements, the most common being between scores C and D. CONCLUSIONS: The Cervical Localisation Code was used reproducibly by three independent examiners. It will provide focussed data on the cervical region in research studies allowing the association of patient reported dietary and lifestyle factors with specific lesion types, and a tool to aid the management of clinical scenarios, specifically those that lead to dentine hypersensitivity in general dental practice. CLINICAL SIGNIFICANCE: Exposure of dentine at the cervical margin by TW and/or GR often results in dentine hypersensitivity, however current TW indices do not record TW location or GR presence. The Cervical Localisation Code captures both parameters and suggests likely aetiology for dentine hypersensitivity and guide clinical management of the cervical region.

A Review of the Role of Probiotic Supplementation in Dental Caries.

Dental diseases are among the common health issues experienced around the world. Dental caries is one of the most predominant oral diseases worldwide. Major factors associated with caries development include poor oral hygiene, the content of specific carbohydrates in the diet, dental biofilm formation, the cariogenic microbial load, reduction in salivary flow, insufficient fluoride exposure, gingival recession, genetic factors, and lack of personal attention to one's dental health. Several preventive measures have been implemented to reduce the risk of the development of caries. Probiotics are live microbes that when administered in suitable amounts confer health benefits on the host; they are recognized as potential adjunct therapeutic agents for several diseases. The present manuscript summarizes recent findings on the role of probiotics in dental caries prevention and the possible mechanisms of probiotic effects. Review of the literature indicates the regular consumption of probiotic products significantly reduced the risk of caries by inhibiting cariogenic bacteria and enriching commensal microbes in the oral cavity. Buffering the salivary pH, production of bacteriocin and enzymes (dextranase, mutanase, and urease), the capacity of competing for the adhesion and colonization on tooth surfaces are the possible mechanisms behind the beneficial effect of probiotics. Further studies are necessary to address the efficacy of long-term probiotic supplementation on the control of dental diseases and the influence of childhood probiotic supplementation on the risk of caries development.

Association between traditional oral hygiene methods with tooth wear, gingival bleeding, and recession: A descriptive cross-sectional study.

BACKGROUND: Oral hygiene maintenance is crucial for prevention of various oral diseases. Oral hygiene practices across the country vary largely and people in peri-urban and rural areas use traditional methods of oral hygiene like powders, bark, oil and salt etc. Their effect on oral soft and hard tissues need to be studied to understand their beneficial and/ or harmful effects on maintenance of oral hygiene and prevention or causation of oral diseases. OBJECTIVES: This study aimed to assess the plaque-cleaning efficacy, gingival bleeding, recession and tooth wear with different traditional oral hygiene methods as compared to use of toothpaste-toothbrush, the most accepted method of oral hygiene practice. STUDY DESIGN: Hospital based cross sectional analytical study. Results: Total 1062 traditional oral hygiene method users were compared with same number of toothpaste-brush users. The maximum number in the former group used tooth powder (76%) as compared to other indigenous methods, such as use of bark of trees etc and out of tooth powder users; almost 75% reported using red toothpowder. The plaque scores and gingival bleeding & recession were found to be more in traditional oral hygiene method users. The toothwear was also more severe among the toothpowder users. CONCLUSIONS: Traditional methods were found to be inferior in plaque control as was documented by increased bleeding and gingival recession. Its effect on hard tissues of teeth was very damaging with higher tooth wear scores on all surfaces.

A multicenter randomized, controlled clinical trial comparing the use of displacement cords, an aluminum chloride paste, and a combination of paste and cords for tissue displacement.

STATEMENT OF PROBLEM: Gingival recession after soft tissue displacement for impression making in fixed prosthodontics may pose a problem for treatment success in the esthetic areas of the mouth. Knowledge about the soft tissue reaction of common gingival displacement methods is limited. PURPOSE: The purpose of this clinical randomized controlled trial (RCT) was to evaluate changes in the marginal soft tissue height with 3 different gingival tissue displacement techniques for definitive impression making of natural teeth. MATERIAL AND METHODS: A total of 67 individuals were randomized to 3 groups. In test group 1 (P; n=22), only aluminum chloride paste was used to displace the gingiva. In test group 2 (CP; n=23), a cord was inserted, and aluminum chloride paste was also used. In the control group (C; n=22), 2 cords were used to displace the gingiva (double-cord technique). Clinical measurements of the gingival position were made before treatment began and at 30 ±10 days after prosthesis delivery. Study casts were fabricated at different stages of the treatment, standardized photographs were made, and changes in the buccal gingival position were measured using graphics editing software. In addition, the participants' perception of the clinical procedure and the technicians' evaluation of the die preparation were recorded. One-way ANOVA models were applied to compare the response variables among the groups: (a) the position of the gingival margin (millimeters), (b) mean probing pocket depth (millimeters), (c) gingival thickness (millimeters), (d) amount of keratinized tissue (millimeters), and (e) mean changes in gingival margin height (millimeters). Unpaired t tests were also used to compare the mean values between groups. For comparisons between different categories, chi-square tests were performed (α=.05 for all tests). RESULTS: In the period between impression and delivery, a minor gain in gingival height of 0.058 mm (±0.13 SD) for P and 0.013 mm (±1.19 SD) for CP. However, a minor gingival recession of 0.049 mm (±0.13 SD) was reported for group C. The results for all groups showed that 21% of abutment teeth gained >0.1 mm in gingival height, 58% had stable gingival height (0 ±0.10 mm), 21% showed minor gingival recession (0.1 to 0.5 mm), and no abutment teeth showed moderate or severe gingival recession (>0.5 mm). The incidence of minor gingival recession was 8% in group P, 23% in group CP, and 32% in group C (P=.015). Fifteen participants (24%) experienced some discomfort after the procedure. The differences between the groups were not significant (P>.05). The laboratory technicians found the definitive die preparation significantly more challenging for group P (visual analog scale [VAS], 79) and CP (VAS, 82) than group C (mean VAS, 93; P=.003). CONCLUSIONS: Minor or moderate gingival recession (<1 mm) is more likely to occur when conventional cords are used during impression making. However, the laboratory technicians found the die preparation significantly less challenging when the double-cord technique was used than when impressions were made using the paste displacement technique.

A new multiple anti-infective non-surgical therapy in the treatment of peri-implantitis: a case series.

BACKGROUND: Peri-implantitis is a frequent disease that may lead to implant loss. The aim of this case series was to evaluate the clinical results of a new non-surgical treatment protocol. METHODS: Fifteen patients with dental implants affected by peri-implantitis were treated with a multiple anti-infective non-surgical treatment (MAINST) which included two steps: 1) supra-gingival decontamination of the lesion and sub-gingival treatment with a controlled-release topical doxycycline; 2) after one week, a session of supra and sub gingival air polishing with Erythritol powder and ultrasonic debridement (where calculus was present) of the whole oral cavity was performed along with a second application of topical doxycycline around the infected implant. Primary outcome measures were: implant failure; complications and adverse events; recurrence of peri-implantitis; secondary outcome measure were presence of Plaque (PI), Bleeding on Probing (BOP), Probing Pocket Depth (PPD). Recession (REC), Relative Attachment level (RAL). RESULTS: Neither implant failure nor complications nor adverse events were reported. Statistically (P<0.01) and clinically significant reductions between baseline and 1 year of PI (100% vs. 13.9%, 95% CI: 72.4% to 93.7%); BOP (98.5% vs. 4.5%, 95% CI: 85.4% to 98.5%) and PPD (7.89 vs. 3.16 mm, 95% CI: -5.67 to -3.77), were detected. At baseline, all 15 patients had a PPD>5 mm at the affected implant(s), whereas only 3.7% at 3-month follow-up a PPD>5 mm, and none at 6 and 12 months. CONCLUSIONS: Within the limits of this study, the MAINST protocol showed improvement of clinical parameters for the treatment of peri-implantitis, which were maintained for up to 12 months.

Risk Indicators and Prevention of Implant Soft-Tissue Complications: Interproximal Papillae Loss and Midfacial Implant Mucosal Recessions.

Achieving a long-term esthetic implant restoration in the maxillary anterior area is sometimes unpredictable. This article reviews several risk indicators of implant mucosal recession and loss of interproximal papillae, and how to prevent these risks. Results obtained from the literature suggest that the following factors are strongly related to implant soft-tissue complications: buccally positioned implant placement, a thin gingival biotype, lack of an adequate amount of keratinized mucosa, implant placement after ridge augmentation procedures, an increased distance of tooth bone peak to the contact point, and an inadequate horizontal implant-tooth distance. Factors that have been shown to favor longterm stability and improve implant esthetic outcomes include implant placement in an ideal 3-dimensional position, use of platform-switching implant/abutment designs, and performing soft-tissue grafting. Careful assessment of the above factors and adoption of suggested guidelines are critical to executing successful implant placement with favorable esthetic outcomes while minimizing soft-tissue complications.

[How to analyze periodontal morphotypes in order to reduce the risk of periodontal recession]. / Savoir analyser le morphotype parodontal pour minimiser les risques de récessions parodontales.

INTRODUCTION: The periodontal morphotype is a leading feature to be born in mind during surgical, implant, prosthetic, restorative as well as orthodontic treatment. A fragile morphotype will rapidly trigger severe and worrying clinical repercussions for the patient. MATERIALS AND METHODS: In order to minimize the risks involved, sound knowledge of the different morphotypes and of the techniques for clinically evaluating them is a major requirement. These factors need to be regularly reassessed since morphotypes can vary throughout the course of treatment. RESULTS: Detecting and controlling mucogingival risk factors will enable an appropriate clinical approach designed to avoid the onset of secondary recessions or other gingival pathologies.

Implant placement post extraction in esthetic single tooth sites: when immediate, when early, when late?

Implant placement in post-extraction sites of single teeth in the esthetic zone has been a topic of great interest in the field of implant dentistry since 1990. Triggered by the development of guided bone regeneration, the concept of immediate implant placement became quite popular in the 1990s. In the past 12 years, however, the dental community has begun to focus increasingly on the esthetic outcomes of post-extraction implant placement and several studies indicated a significant risk for the development of mucosal recessions with immediate implants. Parallel with this, significant progress has been made in the understanding of tissue biology in terms of hard and soft tissue alterations post extraction, based on preclinical, clinical and radiological studies. This knowledge has helped better to understand the etiology of these esthetic complications with immediate implant placement. The present review first analyzes the various phases of the development of therapeutic strategies over the years for post-extraction implant placement in single tooth sites in the esthetic zone. It presents the current knowledge concerning the terminology with immediate, early and late implant placement, the risk factors for the development of esthetic complications, and the selection criteria for the various treatment options. In the second part, clinical recommendations are given, since a clinician active in this field of implant therapy can use all treatment options depending on the preoperative analysis including a 3D cone beam computed tomography. The selection criteria for all four treatment options are presented and documented with typical case reports to illustrate the current treatment approaches applied in daily practice.

Bristle splaying and its effect on pre-existing gingival recession-a 12-month randomized controlled trial.

OBJECTIVE: The link between bristle splaying and gingival recession is unclear. METHODS: In a 12-month, parallel group, randomized, controlled clinical trial, 110 systemically healthy participants with pre-existing gingival recessions (pre-GR) were assigned to brush their teeth with either a manual (MT) or a powered toothbrush (PT). Every 3 months, toothbrushes and brush heads were replaced. Wear was measured using the Bristle-Splaying-Index (BSI), matched between groups and correlated to the change of pre-GR. RESULTS: Data from 109 subjects (PT, 55; MT, 54) were analyzed. The overall mean BSI was found to be significantly lower (p < 0.001) in the PT group (median 5.5; second and third quartile 1.9-10.0) as compared to the MT group (21.5; 15.0-30.5). After 12 months, pre-GR decreased significantly in the PT group (∆0.2 ± 0.1 mm; p < 0.001) and remained stable in the MT group (∆0.1 ± 0.1 mm; p > 0.05). In the MT group, higher BSI values were associated with a higher risk for increasing or stable recession over 12 months: odds ratio (95 % CI) = 27.9 (1.7; 452.9); p = 0.019. CONCLUSION: After a mean using time of 3 months, the PT group demonstrated a lower BSI than the MT group, and the greater bristle splaying was associated with a higher risk of increased (or stable) GR in subjects using a MT but not a PT. CLINICAL RELEVANCE: Compared to a manual toothbrush, powered toothbrushes seem to be utilized with less force and can be considered safe to use in patients with pre-existing gingival recession.

Maintaining Osseointegration: Understanding, preventing, and treating Risk Factors for Peri-implant Diseases.

The dental implant is a predictable way of restoring fully and partially edentulous patients and has shown high success rate for managing a broad range of clinical conditions. Improving implant surfaces has revolutionized the osseointegration of implants and changed the focus of implant research from osseointegration more toward the risk factors associated with the failure of implants in the long-term.

Management and prevention of gingival recession.

Gingival recession is highly prevalent worldwide. It increases the risk for root caries and can interfere with patient comfort, function and esthetics. Progressive gingival recession also increases the risk of tooth loss secondary to clinical attachment loss. Although mitigating the causes of gingival recession decreases its incidence and severity, implementing practical management and prevention strategies in the clinical setting can be challenging. Identification of susceptible patients and evaluating them for the presence of modifiable risk exposures are essential first steps in developing action plans for appropriate interventions. This article reviews these steps and introduces chairside tools that can help in the selection of interventions designed to reduce the risk of future gingival recession and may also facilitate patient communication. Practical decision-making criteria are proposed for when and how to monitor gingival recession, for deciding when a patient is a candidate for surgical evaluation or referral to a periodontist, and, if surgery is the treatment of choice, what should be considered as key surgical outcome objectives.

[Gingival recessions and orthodontics]. / Gingivarecessies en orthodontie.

Gingival recessions represent the most visible periodontal disease. The prevalence of gingival recessions is high. The root surface is literally exposed to negative influences such as erosion, abrasion, discoloration and decay. Moreover, gingival recessions can affect the quality of life by increased thermal sensitivity and reduced dento-gingival aesthetics. The aetiology of gingival recessions is complex and considered to be multifactorial. In order to prevent the development of gingival recessions during and after orthodontic treatment, several factors should be taken into account, among which maintenance of optimal oral hygiene and respect for the 'biological envelope' are decisive. Once gingival recessions have developed, orthodontic therapy can play a positive role in their treatment.

Influencia de parámetros clínicos sobre la severidad de la recesión gingival localizada / Clinical parameters related to severity of localised gingival recession

INTRODUCCIÓN: La recesión gingival localizada es un problema de salud bucodental fundamental porque su progresión conduce a la pérdida dentaria. El propósito de este trabajo fue evaluar la influencia de distintos parámetros clínicos sobre la recesión gingival localizada. MATERIAL Y MÉTODOS: Se estudiaron 40 pacientes con recesión gingival localizada en los que se analizaron diversos parámetros clínicos relacionados con la recesión gingival. Para la comparación de variables cuantitativas se utilizó el test de Student (t-Student) y para la de variables cualitativas el test chi-cuadrado. RESULTADOS: En este estudio, según la clasificación de Miller, el 37,5% de los pacientes tenían recesiones de tipo I, el 60% de tipo II y el 2,5% restante, de tipo III. Los siguientes parámetros: edad, frecuencia de cepillado, tipo de cepillo, uso de colutorios y de seda dental, otros hábitos orales y el tratamiento de ortodoncia, no tienen influencia sobre la severidad de la recesión gingival (p > 0,05 en todos los casos). Presentan recesión gingival más severa, los varones (p = 0,03), los sujetos fumadores (p = 0,007) y los que tienen técnicas de cepillado horizontal (p = 0,02). En los cuatro momentos de seguimiento del estudio (inicial, 6, 12 y 18 meses), la profundidad de sondaje, la pérdida de inserción, el índice de placa y el índice de sangrado mejoraron a los 6 meses para luego empeorar en el resto de períodos. DISCUSIÓN: El sexo, el tabaco y la técnica de cepillado son los tres factores que tienen influencia sobre la severidad de la recesión gingival localizada en este estudio

INTRODUCTION: Localised gingival recession is a major problem of oral health because its progression leads to the dental loss. The aim of this study was to evaluate the possible influence of different clinical parameters in localised gingival recession. MATERIAL AND METHODS: Forty patients with localised gingival recession were studied. Data from several clinical parameters related to gingival recession were collected. RESULTS: In this study, 37.5% of patients had recessions of Miller's type I, 60% Miller's type II, and the remaining 2.5% of Miller's type III. Age, frequency of toothbrushing, toothbrushing technique, use of mouthwash and/or dental floss, other oral habits, and orthodontic therapy, have no influence on the severity of gingival recession (p > 0.05 in all cases). More severe gingival recession was observed in males (p = 0.03), smokers (p = 0.007) and those with horizontal toothbrushing techniques (p = 0.02). In the four follow-up periods of the study, probing depth, attachment loss, plaque index and bleeding index improved after 6 months and then got worse in the rest of the follow-up intervals. DISCUSSION: Gender, smoking and toothbrushing technique were the three factors that influenced the severity of localised gingival recession

Peri-implant mucosal recession: Clinical significance and therapeutic opportunities.

Peri-implant mucosal recessions can be a major esthetic problem in the anterior zone, whereas in the functional zone the coverage of exposed implants is not of primary significance, as methods to clean these structures are more important. In these situations free gingival grafts are often used to deepen the vestibule and increase the amount of attached keratinized mucosa. Complete coverage of mucosal recessions around dental implants is still a challenging procedure, but it seems that recessions up to 2 mm can be successfully grafted with subepithelial connective tissue grafts.

Tissue preservation strategies for fostering long-term soft and hard tissue stability.

As placement of functionally stable dental implants has become routine, concerns have shifted to maintenance of crestal bone and soft tissue stability. This article proposes the development of a tissue preservation philosophy to avoid crestal bone loss and gingival recession and thus foster long-term esthetics around implants. Pillars of this philosophy must include avoidance or minimization of an implant-abutment microgap and micromovement, use of platform switching, appropriate implant positioning relative to the bone crest, and preservation of the papillae when placing both single and multiple implants.

The utility of gingival crevicular fluid matrix metalloproteinase-8 response patterns in prediction of site-level clinical treatment outcome.

BACKGROUND: Different gingival crevicular fluid (GCF) matrix metalloproteinase (MMP)-8 response patterns were studied among non-smoking and smoking patients with chronic periodontitis (CP) and generalized aggressive periodontitis (GAgP) to test the utility of GCF MMP-8 levels predicting the site-level treatment outcome. METHODS: Data from four independent longitudinal studies were combined. Altogether, the studies included 158 periodontal sites from 67 patients with CP and 32 patients with GAgP, and GCF samples were collected at baseline, after the treatment, and during the 6-month maintenance period. All GCF samples were analyzed by immunofluorometric assay for MMP-8. Different site-level MMP-8 response patterns were explored by the cluster analysis. Most optimal MMP-8 cutoff levels were searched with receiver operating characteristic analyses, and the predictive utility of defined levels was tested. RESULTS: Distinct types of MMP-8 response patterns were found in both smokers and non-smokers. MMP-8 levels exceeding the optimal cutoff levels separately defined for smokers and non-smokers indicated increased risk for compromised treatment outcome at baseline and during the maintenance period. Seventy-one percent of non-smokers (positive likelihood ratio of 4.22) and 88% of smokers (positive likelihood ratio of 5.00) with positive test results at both baseline and the maintenance period had compromised treatment outcome. The double-positive result indicated 46% and 39% point risk increase for the compromised outcome, respectively. CONCLUSION: GCF MMP-8 analysis with defined cutoff levels could be used to predict the site-level treatment outcome and for longitudinal monitoring of the disease status during the maintenance period.

Primary and secondary prevention of periodontal and peri-implant diseases: Introduction to, and objectives of the 11th European Workshop on Periodontology consensus conference.

BACKGROUND: Periodontitis prevalence remains high. Peri-implantitis is an emerging public health issue. Such a high burden of disease and its social, oral and systemic consequences are compelling reasons for increased attention towards prevention for individuals, professionals and public health officials. METHODS: Sixteen systematic reviews and meta-reviews formed the basis for workshop discussions. Deliberations resulted in four consensus reports. RESULTS: This workshop calls for renewed emphasis on the prevention of periodontitis and peri-implantitis. A critical element is the recognition that prevention needs to be tailored to the individual's needs through diagnosis and risk profiling. Discussions identified critical aspects that may help in the large-scale implementation of preventive programs: (i) a need to communicate to the public the critical importance of gingival bleeding as an early sign of disease, (ii) the need for universal implementation of periodontal screening by the oral health care team, (iii) the role of the oral health team in health promotion and primary and secondary prevention, (iv) understanding the limitations of self-medication with oral health care products without a diagnosis of the underlying condition, and (v) access to appropriate and effective professional preventive care. CONCLUSIONS: The workshop provided specific recommendations for individuals, the oral health team and public health officials. Their implementation in different countries requires adaptation to respective specific national oral health care models.