Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: Consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.

Periodontal health is defined by absence of clinically detectable inflammation. There is a biological level of immune surveillance that is consistent with clinical gingival health and homeostasis. Clinical gingival health may be found in a periodontium that is intact, i.e. without clinical attachment loss or bone loss, and on a reduced periodontium in either a non-periodontitis patient (e.g. in patients with some form of gingival recession or following crown lengthening surgery) or in a patient with a history of periodontitis who is currently periodontally stable. Clinical gingival health can be restored following treatment of gingivitis and periodontitis. However, the treated and stable periodontitis patient with current gingival health remains at increased risk of recurrent periodontitis, and accordingly, must be closely monitored. Two broad categories of gingival diseases include non-dental plaque biofilm-induced gingival diseases and dental plaque-induced gingivitis. Non-dental plaque biofilm-induced gingival diseases include a variety of conditions that are not caused by plaque and usually do not resolve following plaque removal. Such lesions may be manifestations of a systemic condition or may be localized to the oral cavity. Dental plaque-induced gingivitis has a variety of clinical signs and symptoms, and both local predisposing factors and systemic modifying factors can affect its extent, severity, and progression. Dental plaque-induced gingivitis may arise on an intact periodontium or on a reduced periodontium in either a non-periodontitis patient or in a currently stable "periodontitis patient" i.e. successfully treated, in whom clinical inflammation has been eliminated (or substantially reduced). A periodontitis patient with gingival inflammation remains a periodontitis patient (Figure 1), and comprehensive risk assessment and management are imperative to ensure early prevention and/or treatment of recurrent/progressive periodontitis. Precision dental medicine defines a patient-centered approach to care, and therefore, creates differences in the way in which a "case" of gingival health or gingivitis is defined for clinical practice as opposed to epidemiologically in population prevalence surveys. Thus, case definitions of gingival health and gingivitis are presented for both purposes. While gingival health and gingivitis have many clinical features, case definitions are primarily predicated on presence or absence of bleeding on probing. Here we classify gingival health and gingival diseases/conditions, along with a summary table of diagnostic features for defining health and gingivitis in various clinical situations.

Early bone healing around 2 different experimental, HA grit-blasted, and dual acid-etched titanium implant surfaces. A pilot study in rabbits.

PURPOSE: To compare early bone healing around different experimental titanium implant surfaces and to evaluate the role of a calcium phosphate-coated implant surface because it relates to bone-implant contact (BIC). METHODS: An experimental hydroxyapatite (HA) grit-blasted and dual acid-etched titanium surface (BAE-1) was compared to an experimental HA grit-blasted and dual acid-etched surface treated with nanometer-scale crystals of HA (BAE-2). Both experimental implant surfaces were implanted onto the tibias of 4 New Zealand white rabbits. The animals were killed at 1,6, 21, and 90 days after the implant surgery. Descriptive histology was performed at the healing responses of both implant surfaces. Quantitative morphology assessment provided measurements of BIC, number of bone multicellular units (BMUs), average penetration of BMUs, and maximum penetration of BMUs that were manually made using imaging computer software. RESULT: The overall BIC for the BAE-2 implant was higher than that for the BAE-1 implant at 21 days of healing. However, there was no significant difference at 90 days of healing. CONCLUSION: It is concluded from this animal pilot study that the bioactive BAE-2 implant surface provided a better BIC with healthy bone remodeling at 21 days of healing.

Comparison of the anatomic crown width/length ratios of unworn and worn maxillary teeth in Asian and white subjects.

STATEMENT OF PROBLEM: Various aspects of anatomic tooth dimensions have been examined in a number of studies where data are primarily based on the measurements obtained from white subjects. Additional factors such as ethnicity should be considered to produce a more comprehensive analysis. PURPOSE: The purpose of this study is to compare the anatomic crown dimensions of extracted maxillary teeth in Asian and white populations. MATERIAL AND METHODS: The width/length ratio (%) was calculated with standardized digital images of extracted maxillary anterior teeth from 157 Asian and 142 white subjects. Statistical analysis was performed to compare the 4 tooth groups (central incisiors, lateral incisiors, canines, and premolars) of the 2 ethnicities. The distribution of the outcome variables were examined for normality with the Kolmigorov-Smirnov test. Independent sample t tests were used to examine differences in outcomes in Asian and white subjects. RESULTS: There was a significant difference (P<.05) in the width/length ratios of all maxillary anterior teeth in Asian and white subjects. In addition, there was a significant difference in the width of unworn central incisors and the length of worn lateral incisors and canines. CONCLUSIONS: Ethnicity influences width/length ratios for all 4 anterior maxillary teeth. Anterior maxillary teeth in Asian subjects appear to be more slender when compared with those in white subjects.

Trap door: an alternative procedure to the triangular distal wedge for the elimination of distal periodontal pockets adjacent to edentulous areas.

The study compared a novel trap door (TD) technique with the triangular distal wedge (TW) procedure for the elimination of distal periodontal pockets adjacent to edentulous areas. Thirteen patients with suprabony pockets ≥ 5 mm at the distal surface of terminal molars bilaterally were included in this prospective, single-blinded, randomized clinical trial using a split-mouth design. The authors demonstrated the efficacy of an alternative TD technique in the elimination of the distal pockets adjacent to the terminal molars.

Guided tissue regeneration-based root coverage with a platelet concentrate graft: a 3-year follow-up case series.

BACKGROUND: A platelet concentrate graft (PCG) was applied underneath the barrier membrane in guided tissue regeneration (GTR)-based root coverage procedures. The purpose of this case study was to assess the effectiveness of the technique and the long-term outcomes. METHODS: Thirty-seven Miller Class I or II recession defects in six patients were treated using the PCG and a collagen membrane covered by an advanced mucogingival flap. Clinical parameters, such as vertical gingival recession depth (VRD), clinical attachment level (CAL), probing depth (PD), and width of keratinized tissue (WKT), were recorded presurgery (at baseline [BL]) and at 6 and 36 months of follow-up. The Wilcoxon signed-rank test and the Mann-Whitney test were used to assess statistical significance (alpha = 0.05). RESULTS: Between BL and 6 months, there was a statistically significant reduction in VRD (from 2.81 +/- 0.88 mm to 0.30 +/- 0.48 mm) and PD (from 2.59 +/- 0.50 mm to 1.14 +/- 0.35 mm), as well as an improvement in CAL (from 5.41 +/- 0.86 mm to 1.43 +/- 0.66 mm). These results remained stable over the following 30 months. There was no statistically significant change in WKT during the initial 6 months; however, the increase in WKT was statistically significant at the 36-month follow-up. When comparing the healing between the maxillary and mandibular teeth at 6 months, the VRD reduction was statistically significantly greater in the maxillary teeth, but the difference was not statistically significant 30 months later. The average root coverage at 6 and 36 months was 89.86% +/- 15.85% and 85.86% +/- 18.16%, respectively, with complete root coverage in 24 (64.86%) and 21 (56.76%) of the 37 teeth. CONCLUSIONS: The GTR-based technique using PCG was effective in reducing gingival recession. The outcomes remained stable for 3 years.

Treatment of gingival recession using platelet concentrate with a bioabsorbable membrane and coronally advanced flap: a report of two cases.

The aim of this report is to present a new treatment strategy for gingival recession. The use of platelet concentrate gel in a collagen sponge carrier combined with a bioabsorbable membrane and coronally advanced flap procedure is demonstrated in two patients. In both patients, the recession defects treated were equal to or greater than 2 mm. Complete root coverage was achieved in both cases. The patients were satisfied with the esthetic result and appreciated the excellent soft tissue contour and texture. This technique requires further investigation.

Strategies for developing a culture of mentoring in postdoctoral periodontology.

Dental education in the United States and Canada is currently experiencing a crisis with respect to faculty recruitment and retention. The major reasons for the status of dental and specialty education are lower salaries and lack of interest. To make up for this deficit in the specialty of periodontology, our current educators need to utilize strategies targeted towards an existing potential teaching resource: the postdoctoral students in periodontology. The intent of this article is to review the current crisis in dental faculty recruitment and retention, show how it affects the specialty of periodontics, and describe how creating a culture of mentoring may facilitate more engagement of periodontal residents in the teaching process during their postdoctoral training. The strategies utilized to develop a culture of mentoring in the Department of Periodontology at Tufts University are presented. They include methodologies to develop and enhance residents' mentoring skills, thereby helping to compensate for the shortage of periodontists involved in academics. Measurement of the mentoring strategy is presented from data obtained from an online survey of third-year predoctoral students' perceptions of their interaction with residents as their clinical instructors. Moreover, the numbers of program alumni engaged in teaching prior to and after the mentoring program was initiated are also presented as an outcome of the mentoring program. Developing a culture of mentoring in postdoctoral periodontology programs can be an important tool to enable individuals to become more involved in the process of teaching and mentoring during their postdoctoral training. This outcome could ameliorate the deficit of periodontists engaged as formal educators. Moreover, development and expansion of a culture of mentoring in a periodontolgy program may encourage recent graduates to become more involved in teaching subsequent to graduation.

Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: Consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.

Periodontal health is defined by absence of clinically detectable inflammation. There is a biological level of immune surveillance that is consistent with clinical gingival health and homeostasis. Clinical gingival health may be found in a periodontium that is intact, i.e. without clinical attachment loss or bone loss, and on a reduced periodontium in either a non-periodontitis patient (e.g. in patients with some form of gingival recession or following crown lengthening surgery) or in a patient with a history of periodontitis who is currently periodontally stable. Clinical gingival health can be restored following treatment of gingivitis and periodontitis. However, the treated and stable periodontitis patient with current gingival health remains at increased risk of recurrent periodontitis, and accordingly, must be closely monitored. Two broad categories of gingival diseases include non-dental plaque biofilm-induced gingival diseases and dental plaque-induced gingivitis. Non-dental plaque biofilm-induced gingival diseases include a variety of conditions that are not caused by plaque and usually do not resolve following plaque removal. Such lesions may be manifestations of a systemic condition or may be localized to the oral cavity. Dental plaque-induced gingivitis has a variety of clinical signs and symptoms, and both local predisposing factors and systemic modifying factors can affect its extent, severity, and progression. Dental plaque-induced gingivitis may arise on an intact periodontium or on a reduced periodontium in either a non-periodontitis patient or in a currently stable "periodontitis patient" i.e. successfully treated, in whom clinical inflammation has been eliminated (or substantially reduced). A periodontitis patient with gingival inflammation remains a periodontitis patient (Figure 1), and comprehensive risk assessment and management are imperative to ensure early prevention and/or treatment of recurrent/progressive periodontitis. Precision dental medicine defines a patient-centered approach to care, and therefore, creates differences in the way in which a "case" of gingival health or gingivitis is defined for clinical practice as opposed to epidemiologically in population prevalence surveys. Thus, case definitions of gingival health and gingivitis are presented for both purposes. While gingival health and gingivitis have many clinical features, case definitions are primarily predicated on presence or absence of bleeding on probing. Here we classify gingival health and gingival diseases/conditions, along with a summary table of diagnostic features for defining health and gingivitis in various clinical situations.

Use of guided tissue regeneration in the treatment of a lateral periodontal cyst with a 7-month reentry.

BACKGROUND: The lateral periodontal cyst (LPC) is an unusual cyst of odontogenic origin, most frequently encountered in the mandible between the roots of canines and premolars. The most common treatment for LPC is surgical enucleation. This article reports a case of an LPC treated with guided tissue regeneration (GTR) and bone allograft. METHODS: A 74-year-old woman presented for periodontal examination. Radiographs revealed a cystic lesion with LPC characteristics. After surgical incisions and flap reflection, the cyst was removed and sent for biopsy. Because of the anatomy of the resulting intrabony defect, GTR was considered the ideal treatment. RESULTS: The biopsy revealed the histologic features of an LPC. Radiographs at 7 months post-treatment indicated bone fill of the initial defect. Although some attachment loss occurred, the reentry demonstrated a high percentage of bone fill of the defect after 7 months. CONCLUSION: Depending on the anatomy of the defect left after the removal of an LPC, GTR, along with bone grafting, can be a very useful tool for its treatment by reducing the attachment loss observed after simple enucleation of the cyst.

Assessment of pain associated with the surgical placement of dental implants.

BACKGROUND: Despite increasing popularity and established predictability, limited information is available on the pain experience associated with the surgical placement of dental implants. The aim of this study was to assess patient-reported pain during and after implant insertion and to evaluate factors associated with this pain. METHODS: This was a prospective, two-center study of adult patients scheduled for the surgical placement of one or more implants. Surgery was performed by an experienced periodontist or periodontal graduate students. Mean pain scores were evaluated with the use of a 0 to 10 scale during surgery and 24 hours and 1, 6, and 12 weeks after surgery and compared between the two centers. The association of pain scores at each time-point with patient-, operator-, and surgery-related factors was examined through univariate and multiple logistic regression analyses. RESULTS: Five hundred ten implants were placed in 234 patients during the study. Mean pain scores were highest at 24 hours after surgery (2.01 +/- 0.11) and decreased gradually thereafter. Pain intensity was mild for the majority of patients at all time-points, and only a few patients had moderate or severe pain. Regression analysis revealed that factors significantly associated with pain after 24 hours included operator experience (odds ratio [OR] = 24.86), pain during surgery (OR = 2.81), and female gender (OR = 2.51). After 1 week, pain levels were associated significantly with having pain after 24 hours (OR = 38.69) and having a surgical template used during surgery (OR = 1.11). CONCLUSIONS: Pain experienced by patients following the surgical placement of dental implants was generally mild and gradually decreased with time. Operator experience, female gender, surgical difficulty, and pain at earlier time-points were associated significantly with patient reports of pain.

Effects of platelet concentrate on palatal wound healing after connective tissue graft harvesting.

BACKGROUND: Platelet concentrate (PC) is known to contain growth factors that stimulate cellular proliferation and differentiation. In this double-blind, placebo-controlled, randomized study, the objective was to determine whether PC accelerated connective tissue graft (CTG) wound healing and maintained donor site tissue thickness. METHODS: Twenty healthy adult subjects with multiple bilateral gingival recessions were treated with CTGs and PC combined with CTGs. The donor sites were treated with PC and placebo. Clinical wound healing was observed for an average of 6 weeks. Biopsies were taken from donor sites and submitted for histology and immunohistochemical analysis for type I and III collagens. Palatal tissue thickness, post-surgical complications, and pain level were evaluated. Wilcoxon, Cronbach, one-sample t, and paired-sample t tests were used to assess statistical significance at P <0.05. RESULTS: PC-treated palatal donor sites were 1.10 mm thicker than control sites. PC-treated recipient sites showed accelerated clinical healing compared to controls. PC did not accelerate donor site clinical healing. No significant statistical differences in complication occurrence and perceived pain levels were found between control and PC-treated sites. Biopsy samples revealed that during healing, PC-treated sites contained lower concentrations of inflammatory cells, more type I mature collagen, and less type III immature collagen than control sites. CONCLUSIONS: PC may accelerate wound healing and hasten the regeneration of palatal donor tissue. PC did not influence complication occurrences or mediate pain level. PC has the potential to shorten the treatment time for patients who need multiple CTG procedures.

Use of Allograft with Platelet Concentrate in the Treatment of Multiple Miller Class III Gingival Recession Defects: Report of Three Cases.

Three patients with multiple Miller Class III recession defects with substantial bone loss were treated with hard tissue augmentation with the goal to prevent future recessions. The surgery involved a full-thickness mucoperiosteal coronally advanced flap, bone grafting, and primary flap closure. Freeze-dried bone allograft (FDBA) in combination with plasma rich in growth factors (PRGF) was grafted during the procedure. After more than 6 months, the treated sites showed soft tissue maturation and esthetic tissue blending. Clinically, an increase in convexity of alveolar ridge and soft tissue was observed, as well as a marked reduction in recession depth and gain in width of keratinized mucosa. Cone beam computed tomography showed a gain in buccal bone thickness. The use of FDBA in combination with PRGF appears to have potential for the treatment of Miller Class III defects by providing improved hard and soft tissue profiles.

Postoperative complications following gingival augmentation procedures.

BACKGROUND: Postoperative pain, swelling, and bleeding are the most common complications following soft tissue grafting procedures; however, detailed documentation is sparse in the literature. The aims of this prospective study were as follows: 1) to compare the frequency of complication occurrence after free soft tissue grafting (FSTG) or subepithelial connective tissue grafting (SCTG) procedures; 2) to evaluate the use of an acellular dermal matrix (ADM) as the donor tissue alternative to an FSTG or SCTG; and 3) to identify possible predictors for these complications. METHODS: Seventy-five FSTG and 256 SCTG procedures were performed in 228 patients by a single operator. In five free soft tissue and 84 bilaminar graft procedures, an ADM was used instead of autogenous tissue. Variables such as the duration and location of procedures, smoking history, gender, and age were recorded. Patients were asked to fill out a questionnaire 1 week after the surgeries regarding postoperative pain, swelling, and bleeding. Data were analyzed using the chi2 test and logistic regression analysis. Odds ratios were calculated for moderate and severe adverse outcomes grouped together. RESULTS: The duration of surgical procedures was highly correlated with pain or swelling post-surgically (P = 0.001). Current smokers were three times more likely to experience post-surgical swelling (P = 0.01). Patients who underwent FSTG procedures were three times more likely to develop post-surgical pain (P = 0.002) or bleeding (P = 0.03) compared to those who received SCTG procedures. When an ADM was applied instead of autogenous tissue, the probability of swelling or bleeding was significantly reduced (odds ratio [OR] = 0.46, P = 0.02 and OR = 0.3, P = 0.001, respectively). CONCLUSIONS: Long surgical procedures and smoking may increase the severity and frequency of certain post-surgical complications after gingival augmentation procedures. FSTG procedures incur a higher likelihood for postoperative pain or bleeding than SCTG procedures, whereas the application of an ADM may significantly reduce the probability of swelling and bleeding.

Quantitative evaluation of bone density using the Hounsfield index.

PURPOSE: The primary aims of this retrospective study were to: (1) evaluate bone quality in different segments of the edentulous jaw and correlate it with demographic data and (2) establish a quantitative and objective assessment of bone quality based on the Hounsfield scale. MATERIALS AND METHODS: One hundred one randomly selected computerized tomographic (CT) scans were used for the analysis. Edentulous segments ranging from 10 to 30 mm were selected for evaluation, and the findings were analyzed and correlated to demographics. Implant recipient sites were evaluated visually for bone classification by 2 independent examiners. The same sites were subsequently evaluated digitally using the Hounsfield scale, and the results were correlated with the visual classification. RESULTS: The 4 quadrants of the mouth displayed Hounsfield unit (HU) values ranging from -240 HU to 1,159 HU. The highest unit/mean density value (559 +/- 208 HU) was found in the anterior mandible, followed by 517 +/- 177 HU for the anterior maxilla, 333 +/- 199 HU for the posterior maxilla, and 321 +/- 132 HU for the posterior mandible. There was no association between the Hounsfield value and density and age or gender. When subjective bone quality was correlated to Hounsfield index findings, only the relationship between HU and type 4 bone was found to be significant. CONCLUSIONS: Knowledge of the Hounsfield value as a quantitative measurement of bone density can be helpful as a diagnostic tool. It can provide the implant surgeon with an objective assessment of bone density, which could result in modification of surgical techniques or extended healing time, especially in situations where poor bone quality is suspected.

Reconstructive surgical management of an amalgam tattoo using an acellular dermal matrix graft: case reports.

Amalgam tattoos in the gingiva and mucosa can interfere with esthetics and present a barrier to surface-to-bone contact at implant sites. Two clinical cases are used to illustrate the effectiveness of acellular dermal matrix allografts in the treatment of these lesions. Very esthetic results were obtained with minimal discomfort and postoperative complications because of the prevention of a second surgical site or additional procedure.

A comparative study of root coverage with connective tissue and platelet concentrate grafts: 8-month results.

BACKGROUND: Gingival recession presents destruction of both soft and hard tissues. The objectives of this randomized clinical trial were to assess the clinical efficacy of platelet concentrate grafts (PCG) in the treatment of Miller Class I or II buccal gingival defects and to compare their soft tissue healing with those of subepithelial connective tissue grafts (SCTG). METHODS: Seventeen arches in 15 patients with bilateral gingival recessions were treated with SCTG and PCG covered by coronally advanced flaps. Vertical recession depth (VRD), clinical attachment level (CAL), clinical probing depth (PD), and width of keratinized tissue (KTW) were measured preoperatively and 8 months postsurgery. Surveys on post-surgical discomfort level (PSDL) and manual platelet count were also performed. Esthetic outcomes were also evaluated. Paired t test, repeated measures analysis of variance (ANOVA), and chi-square and signed-rank tests were used to access statistical significance (alpha = 0.05). RESULTS: Mean VRD statistically significantly decreased from 2.43 mm presurgery to 0.48 mm with PCG (80% root coverage) and from 2.48 mm to 0.17 mm with SCTG (95% root coverage). No statistically significant differences between the treatments were found for VRD, CAL, and KTW, while mean PD was significantly shallower in the PCG group (1.05 mm) than that in the SCTG group (1.79 mm). Complete coverage was achieved in 60% of the PCG group and in 65.5% of the SCTG group. PSDL was significantly lower in the PCG group 1 month post-surgery. Platelet counts demonstrated a five-fold increase in PC. Soft tissue in the PCG group demonstrated superior contour and texture matching when compared to the SCTG group. CONCLUSIONS: The platelet concentrate graft may be an alternative graft material for treating gingival recession. Treatment with this graft may result in better esthetic appearance.

Treatment of gingival recession with a platelet concentrate graft: a report of two cases.

The goal of this report is to present a novel treatment strategy for mucogingival defects. The use of platelet concentrate gel in a collagen sponge carrier, combined with a coronally positioned flap procedure, is presented in two cases. Complete root coverage was achieved in both cases. Optimal esthetic results, with excellent soft tissue contour and texture, were observed. The patients were satisfied with the appearance. This technique warrants further investigation.

Hard and soft tissue augmentation in implant therapy using acellular dermal matrix.

The use of acellular dermal matrix to correct soft and hard tissue defects involving implants is described through three case reports. Correction of a ridge deformity caused by a root fracture, submerging of an existing implant and correction of recession defects around adjacent teeth, and ridge preservation for implant placement are presented. The use of acellular dermal matrix prevented the need for a second surgical site for donor material and the possible attendant postoperative complications. It also enhanced patient comfort and satisfaction with the procedure. All three cases demonstrated excellent functional and esthetic results for both the patients and professionals involved in the therapy.

Comparison of double-flap incision to periosteal releasing incision for flap advancement: a prospective clinical trial.

PURPOSE: The aim of this study was to evaluate the efficacy and morbidity of two periodontal releasing incision techniques in vertical ridge augmentation. MATERIALS AND METHODS: Twenty-three vertical and horizontal defects (Seibert Class III) were selected to compare the double-flap incision (DFI) to the conventional periosteal releasing incision (PRI). An incision technique was randomly assigned for flap advancement. The amount of flap advancement, the incidence of postsurgical complications, and the level of patient discomfort were compared. Flap advancement was measured with a UNC-15 probe as the difference between the initial elevated flap and the final advanced flap. Postsurgical complications including premature membrane exposure, infection, paresthesia, and continuous discomfort were noted at follow-up visits. A visual analog scale (VAS) was used to quantify the amount of pain, swelling, and bleeding in the patients. RESULTS: An average of 9.64 ± 0.92 mm flap advancement was accomplished for DFI, whereas PRI advancement averaged 7.13 ± 1.45 mm (P < .001). Premature membrane exposures occurred in two sites in the PRI group and one site in the DFI group. Paresthesia, infection, and continuous discomfort were noted in one site each in the PRI group. The difference between groups in the incidence of postoperative complications (PRI, 5; DFI, 1) was not significant (P < .082). The mean pain, swelling, and bleeding scores for DFI (1.55 ± 1.21, 1.91 ± 0.94, and 0.40 ± 0.12, respectively) were lower than those of the PRI group (3.75 ± 2.63, 3.25 ± 1.29, and 1.16 ± 0.34, respectively) (P = .019, P = .010, and P = .061, respectively). CONCLUSIONS: Flap advancement was facilitated and morbidity was decreased in the DFI group. The technique may have potential to serve as an alternative to PRI to overcome some of the latter's limitations.