Local immunoglobulin synthesis in juvenile periodontitis: initial findings.

An electro-immunoassay technique was used to determine simultaneously immunoglobulin G (IgG) and albumin concentrations in serum and extracts of gingival tissue comprising the pocket wall. Assays of samples obtained from seven patients with juvenile periodontitis (mean age, 18 years) indicated that local synthesis accounted for 72% of the IgG found in the gingiva.

Clinical human comparison of expanded polytetrafluoroethylene barrier membrane and freeze-dried dura mater allografts for guided tissue regeneration of lost periodontal support. I. Mandibular molar Class II furcations.

The response of mandibular Class II facial furcations to guided tissue regeneration treatment with expanded polytetrafluoroethylene barrier membrane (e-PTFE) or freeze-dried dura mater allograft (FDDMA) barriers was evaluated in 11 pairs of molars in 11 patients. Following initial preparation, full thickness flaps were raised in the area being treated, the bone and furcation defects debrided of granulomatous tissue, and the involved root surfaces mechanically and chemically prepared. By random allocation, e-PTFE or FDDMA barriers were fitted over the furcations, secured in place, and the host flap repositioned or coronally positioned. Postsurgical deplaquing was performed every 10 days leading up to e-PTFE removal at about 6 weeks (the resorbable FDDMA did not require removal). Continuing supportive periodontal therapy was provided until surgical re-entry at one year for documentation and any further necessary treatment. Direct clinical measurements demonstrated essentially similar clinical results with both barrier materials for bone and soft tissue changes (few statistically or clinically significant differences). Exceptions were the amount of horizontal furcation fill and the change in the width of the keratinized gingiva, both of which were better with FDDMA (P less than 0.05). Improvements in open probing attachment levels observed at the time of e-PTFE removal were lost over the intervening months, more so for the vertical than the horizontal component of the furcation lesion. Intrapatient comparisons suggested better horizontal furcation responses with FDDMA. The findings of this study suggest equal clinical results with e-PTFE and FDDMA barriers utilizing the GTR technique. These results in Class II mandibular furcations are less favorable than those reported by others. Barrier techniques to handicap the race between different tissues of the periodontal complex appear to be of some clinical benefit and deserve further evaluation.

Longitudinal evaluation of the excisional new attachment procedure in humans.

Evaluation of the Excisional New Attachment Procedure (ENAP) was extended to 3 years postoperatively. Generally, there was an overall mean increase in sulcus depth of 0.5 mm; an overall mean increase in recession of 0.1 mm; and an overall mean decrease in the amount of previously gained new attachment of 0.6 mm between 1 year and 3 years after surgery. These values reflected a statistically significant, but clinically insignificant, difference in mean sulcus depth and mean attachment level between the two evaluation periods. Only one tooth site demonstrated clinical findings worse than those determined preoperatively. These results are similar to those of other longitudinal studies.

Clinical evaluation of HTR polymer bone replacement grafts in human mandibular Class II molar furcations.

A biocompatible microporous composite of PMMA (poly-methyl-methacrylate), PHEMA (poly-hydroxyl-ethyl-methacrylate), and calcium hydroxide (HTR) or autogenous osseous coagulum (AOC) bone replacement grafts were evaluated in 15 pairs of mandibular molar Class II furcations in 9 patients. Following initial preparation, full thickness flaps were raised to gain access to the furcations; mechanical hand and ultrasonic root and defect debridement and chemical (tetracycline) root preparation were performed; paired furcations in each patient were randomly grafted with either HTR or AOC; and the host flaps replaced or slightly coronally positioned. Weekly, then monthly, deplaquing was performed until surgical re-entry at 6 to 12 months. Both treatments improved the clinical status of the treated furcations. Direct clinical measurements demonstrated essentially equivalent clinical results with both bone replacement graft materials related to most hard and soft tissue changes in the furcations. Differences in favor of HTR were found for horizontal residual furcation depth (2.4 mm vs. 3.9 mm), horizontal furcation fill (1.9 mm vs. 0.8 mm), and percent horizontal furcation fill (44.4% vs. 17.1%) (all P < or = 0.05 paired t test). These favorable results with HTR polymer are similar to several reports with other graft materials and with GTR barriers, and suggest that HTR polymer may be a useful therapeutic adjunct in the clinical management of grade II mandibular molar furcations.

HTR polymer grafts in human periodontal osseous defects. I. 6-month clinical results.

HTR polymer was evaluated as a grafting material in periodontal osseous defects in 21 adult patients. Following initial preparation and pre-surgical documentation with standardized measurements, radiographs, and photographs, vertical osseous defects were treated with surgical open flap debridement alone (DEBR) or with DEBR plus placement of HTR polymer graft material. Patients were followed with frequent recalls until surgical re-entry at about 6 months for documentation and any needed remedial therapy. Re-entry data show that use of HTR polymer grafts resulted in significantly better mean defect fill of 2.2 mm (60.8%) compared to 1.0 mm (32.2%) with DEBR alone (P less than .001). Other hard tissue findings such as residual defect depth, crestal resorption, and percent defect resolution showed similar clinically superior results with the use of HTR polymer. Soft tissue findings showed significant differences in favor of HTR for decrease in probing depth and gain in clinical attachment. These results are similar to those reported with other graft materials. Over a 6-month period, HTR polymer was found to show promise for the repair of periodontal osseous defects.

Clinical comparison of hydroxyapatite-coated titanium dental implants placed in fresh extraction sockets and healed sites.

The placement of hydroxyapatite-coated dental implants in fresh extraction sockets was compared to placement in adjacent healed sites in 14 patients. Systematic sequential documentation was obtained regarding periodontal health, radiographic bone levels, and implant stability at the time of implant placement, at uncovering, and from 8 to 24 months (mean 16 months) after loading and restoration delivery. There were no significant differences in any clinical parameter between those implants placed in fresh extraction sockets and those placed in healed areas. Periodontal health, maintenance of crestal bone levels, and implant stability were excellent for implants placed in both types of recipient sites. The results of this study suggest that hydroxyapatite-coated dental implants can be successfully placed in fresh extraction sockets utilizing otherwise standard implant placement techniques, and that they appear to clinically perform equally well in fresh sockets and healed sites.

Clinical evaluation of coralline calcium carbonate as a bone replacement graft material in human periodontal osseous defects.

A resorbable coralline calcium carbonate graft material (CalCarb) was compared to open flap debridement (DEBR) in human periodontal osseous defects. Following appropriate initial preparation procedures, flap surgery with defect and root debridement was performed in 20 patients. Alternating defects in each segment of surgery were treated with each procedure. Appropriate periodontal maintenance schedules were followed, and at 6 to 12 months a re-entry flap surgery was performed for documentation and finalization of treatment. Forty defects which received CalCarb grafts demonstrated significantly better mean defect fill of 2.3 mm (67.7%) versus a mean defect fill of 0.7 mm (25.9%) (P < 0.01) for 39 defects treated with DEBR. Other hard tissue findings showed similar clinically superior results with the use of CalCarb. Relative defect fill results showed 88% positive (50% to 100% defect fill) responses with CalCarb and only 13% positive responses with DEBR. There were 7 times more failures (minimal response) with DEBR than with CalCarb. Soft tissue findings showed no significant differences between treatments. These results are similar to those with other synthetic and natural bone replacement graft materials. However, the ease of handling of the CalCarb material, its resorbability, and its potential for improved bone regeneration may be of clinical advantage.

A clinical and histologic study of healing following the excisional new attachment procedure in rhesus monkeys.

Experimental suprabony periodontal pockets were established around the incisors of Rhesus monkeys and subsequently were treated by the Excisional New Attachment Procedure. Healing was evaluated clinically and histologically for up to 6 months. Clinical examinations demonstrated an overall mean pocket depth reduction from 5.02 mm to 2.82 mm, of which 0.57 mm was recession and 1.59 mm (73.6%) was clinical new attachment. Histologic evaluation of experimental sites consistently revealed a long, thin junctional epithelium with a minimal amount of inflammatory infiltrate in the subjacent, densely fibered, lamina propria. Control areas demonstrated the classic histologic picture of periodontal disease and tended to be progressive in nature clinically.

Histologic evaluation of combining tetracycline and allogeneic freeze-dried bone on bone regeneration in experimental defects in baboons.

Tetracyclines (TTC) have been used both systemically and locally during periodontal bone grafting procedures, but previous work regarding the effect of TTC on new bone formation has been contradictory. The purpose of this study was to determine if the use of locally applied TTC in combination with freeze-dried bone allografts (FDBA) would enhance bone regeneration in an experimental alveolar bone osseous defect grafting system. Pre-weighed freeze-dried bone allograft particles (300-500 mu diameter) were placed in nylon mesh chambers (250 mu pore size) and rehydrated with either 10 micrograms/ml aqueous TTC or sterile distilled water. Empty chambers were used as further controls. The chambers were placed in the posterior mandible of baboons in surgically created windows. After 3 and 5 weeks, the chambers were retrieved, processed histologically, and analyzed histometrically for new bone formation. The TTC-rehydrated FDBA demonstrated much greater (greater than 5x) new bone formation than the water rehydrated FDBA. These results strongly suggest that locally-applied TTC in combination with FDBA enhances new bone formation in experimental alveolar bone defects.

Particle size of periodontal bone grafting materials.

Samples of autogenous bone obtained by high speed burs, low speed burs, hand chisels and bone blending; freeze-dried bone purchased from a tissue bank and alloplastic materials, such as Calcitite, Durapatite, Periograf and Synthograft used as donor material for periodontal bone grafting procedures, were evaluated histometrically. Particle sizes ranged from a mean of 210 X 105 mu for bone blend to 1559 X 783 mu for hand-chisel samples. Except for those two materials, all of the others were in the 300 to 500 microns (0.3-0.5 mm) range that seems to be preferred for use in periodontal defects.

Histologic evaluation of periodontal healing in humans following regenerative therapy with enamel matrix derivative. A 10-case series.

BACKGROUND: Enamel matrix derivative (EMD) has been developed as a stimulus of periodontal regeneration. Human histology following its use has not been evaluated on pathologically altered root surfaces. METHODS: Ten intrabony defects in 8 patients were evaluated at 2 centers. Teeth with advanced adult periodontitis that were treatment planned for extraction were treated with sulcular incisions; full-thickness flap reflection; debridement of granulomatous tissue from the defect; placement of a notch in the root at the apical extent of calculus; mechanical root planing; conditioning with citric acid; application of EMD; wound closure with sutures; and placement of a periodontal dressing. Biweekly to monthly recalls were made until removal of small block section biopsies at about 6 months. The biopsies were fixed, decalcified, step-serial sectioned at 6 microns to 8 microns, and stained with hematoxylin and eosin or Masson's trichrome. RESULTS: Histologic evaluation of the region coronal to the base of the calculus notch showed evidence of regeneration (new cementum, new bone, and new periodontal ligament) in 3 specimens, new attachment (connective tissue attachment/adhesion only) in 3 specimens, and a long junctional epithelium in 4 specimens. No evidence of root resorption, ankylosis, or untoward inflammation was seen. CONCLUSIONS: The results of this study fulfill the proof of principle that use of EMD can result in periodontal regeneration on previously diseased root surfaces in humans, but on an inconsistent basis.

Multi-center evaluation of bioabsorbable collagen membrane for guided tissue regeneration in human Class II furcations.

Clinical data related to GTR therapy for Class II furcations were analyzed from 7 treatment centers that evaluated one of two possible treatment pairs, either bioabsorbable collagen membrane (Type I bovine tendon collagen) (COLL) versus control surgical debridement (DEBR) or COLL versus expanded polytetrafluoroethylene (ePTFE). After initial preparation and re-evaluation, full thickness flaps were reflected, the defects debrided, and the roots planed. Furcations and associated bony defects in each patient were randomly assigned to one of the 2 treatments in each pair, and the flaps closed. Patients received quarterly periodontal maintenance until surgical re-entry at 6 to 12 (mean 11.1) months. Data from 59 pairs of Class II furcations were analyzed via paired t, Wilcoxon signed rank, and RM ANOVA tests. COLL showed better results than DEBR for vertical defect fill, percent defect resolution, and horizontal furcation fill. When COLL was compared to ePTFE in furcations across patients, no differences were found. Both COLL and ePTFE resulted in an improvement in clinical furcation Class about 50% of the time (compared to 7% frequency with DEBR). COLL use yielded 8 and ePTFE yielded 1 clinically-complete furcation closures. COLL barriers resulted in generally favorable clinical results in furcation defects, appeared to be better than DEBR alone, and were at least similar to and often better than ePTFE. COLL of the type used in this study appears to be a useful and beneficial material for regenerative therapy in Class II furcation type periodontal defects.

Evaluation of a counter-rotational powered brush in patients in supportive periodontal therapy.

In order to evaluate the effectiveness of a counter-rotational powered brush (CRPB) during the supportive periodontal therapy (SPT) phase of periodontal treatment, 40 treated patients in SPT but with insufficient plaque control were randomly divided into equal experimental or control groups. All subjects used the same toothpaste, but the CRPB group did not use any interproximal aids. Gingivitis (MGI), plaque, and bleeding on probing (BOP) were scored at baseline and 1, 3, and 6 months prior to prophylaxis in conjunction with regular SPT visits. While both groups improved from baseline, CRPB use achieved significantly lower mean plaque scores and BOP at 6 months as analyzed by repeated measures ANOVA. The CRPB also showed consistent statistically superior percentage changes from baseline resulting in a general 50% improvement in clinical conditions compared to a 20 to 25% improvement for control oral hygiene methods. CRPB use resulted in at least a 50% improvement from baseline twice as often as did the control. The results of this study demonstrate more substantial and consistent improvement in periodontal conditions and plaque control effectiveness with the CRPB than the control methods that included interproximal hygiene aids. It appears that the CRPB may be a useful adjunct in maintaining reduced plaque levels and favorable gingival conditions in patients in the SPT phase of periodontal therapy.

Five year evaluation of the excisional new attachment procedure.

Patients treated with the Excisional New Attachment Procedure were evaluated 5 years or more following the procedure. They had received maintenance therapy about four times a year. Clinical measurements of free gingival margin height, pocket depth, and width of keratinized gingiva were made from the cemento-enamel junction in 56 surgical sites and compared to the same parameters recorded presurgically and at 1 and 3 years postsurgically. Probeable depths increased slightly and the amount of previously gained new attachment decreased slightly at each postoperative evaluation period. Only isolated sites were the same as or worse than pretreatment levels. An overall mean net gain in clinical attachment of 1.5 mm was found at 5 years after treatment, and probeable depths approached 3.0 mm at this time. Both of these 5 year findings were statistically and clinically significant improvements over preoperative measurements.

Effect of liquid protein diet on collagen metabolism of the gingiva of young rats.

The effects of liquid protein diet (LPD) on gingival collagen metabolism were evaluated in young rats. Experimental animals received a LPD, while pair-fed and ad libitum groups received a 20% casein diet. Prior to sacrifice at days 23, 35 and 48 post-partum, animals from each group were injected with C14-proline. Gingival tissues from the palate were excised and analyzed for collagen content and collagen synthesis. Results of body-weight changes at day 48 showed a 20% decrease in the LPD group, while pair-fed and ad libitum groups increased 47% and 267%, respectively. Collagen content per gram of gingiva was not significantly different among the three groups. Gingival collagen synthesis, however, did show significant differences among the three groups. It was concluded that while LPD effects on the overall body condition were profound, LPD exerts minimal effect on gingival collagen metabolism in young rats.

Human freeze-dried dura mater allografts as a periodontal biological bandage.

Freeze-dried dura mater allografts (FDDMA) were used as a biologic bandage covering periodontal osseous defects which were grafted with autogenous bone particles. Seven consenting adult patients having multiple one-, two-, and wide three-wall periodontal osseous defects participated in the study. Four to 6 weeks following initial preparation, all defects were treated by full thickness flap surgery, debridement of defects, root planing, intramarrow penetration as needed, and autogenous bone grafts that filled the defects. Randomly selected grafted defects in each patient were then covered with FDDMA (experimental) or by the host flap (RF) (control). Periodontal dressing and systemic tetracycline (250 mg q.i.d.) were used for 7 days. Frequent maintenance was performed until reevaluation at 6 months postsurgically. Soft tissue results showed no significant differences in initial probing pocket depths, recession, or gain of probing attachment. There was a significantly greater amount of probing pocket depth reduction and significantly shallower residual pockets when FDDMA was used. Hard tissue findings indicated that there were no significant differences in initial defect depth, amount of crestal resorption, or amount or percent of defect fill with either treatment. There were significant differences in the percent of defect resolution and the depth of the residual defect in favor of the FDDMA treatment. None of the FDDMA sites were felt to need a secondary surgery to correct residual defects or residual pockets. This study suggests that FDDMA may be beneficial as a "biologic bandage" to cover periodontal osseous defects that were filled with autogenous bone grafts. The trends in this study suggest that FDDMA may be very useful in periodontal regeneration procedures.

5-year evaluation of durapatite ceramic alloplastic implants in periodontal osseous defects.

Six patients who participated in a clinical study comparing the response of periodontal osseous defects to either grafting with Periograf (durapatite) hydroxylapatite (HA) ceramic or debridement alone (DEBR) were followed under an active maintenance program for 5 years. Mean values for gingival recession and attachment levels remained essentially stable following either treatment over the 5 year period. However, mean probeable pocket depths shifted from being significantly (P less than 0.05) shallower for DEBR sites at 6 months and 1 year to being significantly shallower for HA sites at 5 years. The probing pocket depth change for grafted sites was steady and the change from presurgical values was significantly greater than the change for DEBR areas, which became about 1.5 mm deeper over the 5 year postsurgical period. Intrapatient comparisons showed that recession, attachment gain, and pocket depth decrease were most frequently greater for the Periograf-treated sites. Assessment of the pattern of clinical changes during the 5 year postsurgical period demonstrated that the attachment level of grafted sites improved or stayed the same 86% of the time compared to only 62% stability or improvement in the DEBR only sites. In fact, 38% of the DEBR sites were worse at 5 years than at the time of surgery, a 3 times greater failure rate than that found in the HA-grafted sites. Pocket depth measurements showed that 98% of the Periograf-treated sites were better or the same as presurgically (2% worse), while only 80% of DEBR sites showed positive results and 20% had deeper pockets than at the time of surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Zinc concentration in normal and healing gingival tissues in beagle dogs.

Previous studies have shown that the administration of zinc (Zn) may enhance the healing of gingival and other wounds. This study was undertaken to determine if Zn concentration ([Zn]) is increased in healing gingival tissues and if oral supplementation of Zn would result in a local increase in [Zn] within these tissues. On Day 0, biopsies were obtained from the maxillary left buccal gingiva of each of 10 beagle dogs. Gingival biopsies were taken from the healing original biopsy sites on Day 14. On Day 15, oral supplementation of Zn gluconate (250 mg/day, equivalent to 32.5 mg of elemental Zn) was begun in seven dogs. Three dogs remained as unsupplemented controls. Two weeks later (Day 28), normal gingival biopsies were obtained from the right side of the maxilla and on Day 42 final biopsies were taken from the same healing sites. In addition, serum samples were obtained on Days 0, 14, 28 and 42. All samples were analyzed for Zn content using atomic absorption spectrophotometry. The [Zn] of healing tissues was significantly higher (P less than 0.0005) than normal tissues. This was also true when healing tissues were compared to normal tissues during the Zn supplementation phase (Day 28 vs. Day 42; P less than 0.005). Zn supplementation resulted in significant increases in Zn levels in normal (Day 0 vs. Day 28; P less than 0.05) and healing tissues (Day 14 vs. Day 42; P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of durapatite ceramic as an alloplastic implant in periodontal osseous defects. I. Initial six-month results.

Eight patients received a new polycrystalline ceramic form of pure hydroxylapatite (Durapatite) as a bone implant material in various types of infrabony defects following internally beveled full thickness flaps, root planing, and defect debridement. All osseous margins and defects were measured from the CEJ using a standardized periodontal probe. Similarly debrided defects that were not implanted served as controls. Defect selection as either experimental or control site was based on either split-mouth or alternating defects design. Periodontal dressing and systemic tetracycline were used for 10 days. Results for documentation and plaque control were at 10, 20, and 30 days, and 3 and 6 months. Measurements relating to defect changes were made at the 6-months surgical re-entry. For evaluation purposes original defect depths were divided into three groups. In Group I (less than 3 mm) defect fill was 1.2 mm (60%) for the implanted defects and 0.6 mm (40.5%) for the control sites (significantly different at P less than 0.05). In Group II (3--6 mm) defect fill of 1.7 mm (48.5%) for implanted sites was significantly better than the 0.1 mm (11.1%) for the control sites. In the deepest group (Group III greater than or equal to 6 mm) Durapatite placement yielded 2.6 mm (39.9%) of defect fill while debridement alone resulted in 1.3 mm (14.8%) of fill. Hard tissue changes demonstrated a substantial advantage for use of Durapatite over controls, while soft tissue changes were similar for both. The clinical impression at re-entry and the numerical data indicate that pure hydroxylapatite ceramic has a definite potential as an alloplastic implant in the treatment of periodontal osseous defects.

A quantitative study of cementum removal with hand curettes.

An in vitro study was conducted to quantitatively measure the depth of root surface removal using curettes of standardized sharpness and with definite stroke number. Extracted periodontally healthy teeth from patients 10 to 15, 16 to 25, and 26 to 40 years old had periodontal ligament remnants removed with dry gauze before being secured in a vertical position during root planing. The force applied to the root surface was measured with a tension load cell. The "bright line" test was used to assess curette sharpness. After histologic processing, the thickness of cementum adjacent to the root defect, the cementum (if any) in the root defect, total amount of cementum removed, and depth of root defect were measured by a microscopic ocular grid. Teeth from each age range were evenly distributed into 6 groups of 10 teeth each. In the majority of teeth from the 20 stroke group through the 70 stroke group, complete cementum removal was observed at the site of planing. However, in some sections from each group, fragments of cementum remained on the root surface. A positive relationship (r/s = 1) was found between the number of strokes and the force applied to the root surface and the mean depth of defect (P less than 0.05). However, an inverse relationship existed between mean force per stroke and mean defect depth (r/s = -.99) such that as mean force per stroke increased, the mean defect depth decreased. As the root surface became smoother with an increasing number of strokes, the forces increased and were more consistent.(ABSTRACT TRUNCATED AT 250 WORDS)