Periodontal diseases present with a wide range of clinical variability and severity. Individual susceptibility seems to be of major importance in determining the manifestation and progression of the disease. A better understanding of the molecular mechanisms of action of the immune system is of paramount importance to our ability to prevent and treat occurrence and recurrence of periodontal diseases. Recent advances in immunobiology are very promising for the identification of special categories of patients at risk for periodontal breakdown. This review discusses the most recent studies in this field and the possible clinical applications of recent advances.
Recent advances and research in the etiology and clinical treatment of orofacial pain and temporomandibular disorders are reviewed.
The emphasis in periodontal treatment generally has shifted in recent years from periodontal surgery towards periodontal medicine. Because the major periodontal disease group is the chronic inflammatory group, and the major direct cause of chronic inflammation is dental plaque, much of the new research is directed at more ergonomic and economic means of plaque control that have the efficacy of traditional methods. As a result, the field of plaque chemotherapy is expanding concurrent with the modes of application of anti-plaque chemical agents to their interdental and subgingival sites of intended action. Since the rediscovery of subgingival irrigation some 15 years ago, the technique has been shown to provide an efficient means of subgingival application of anti-plaque agents, and it has also been used to apply anti-inflammatory compounds. It was never intended to stand alone. It was and is meant to be used as an adjunct to professional debridement, but one that simplifies home-care oral hygiene for the patient. This, indeed, is part of the aim of all chemical anti-plaque adjunctive therapy. It requires the use of appropriate anti-plaque agents in sufficient concentration and with sufficient periodicity to be clinically effective. It is only ineffective if dose or periodicity is inadequate, or if mechanical plaque control is unrealistically good--that is, unlikely to be maintained long term by the majority of patients. Subgingival irrigation enables the patient for the first time to deal with bursts of periodontitis activity when professional help is not readily available. Although irrigation per se may dilute plaque toxins, it is still clinically inadequate without a suitable chemical adjunct. Subgingival irrigation with a suitable antimicrobial agent currently constitutes an effective adjunct to the simplified oral hygiene regimen that does not require unrealistic levels of interdental or subgingival home-care cleaning by the patient.
The synthetic biomaterials commonly used as an interface or surface for soft- and hard-tissue attachment and integration are commercially pure titanium, titanium alloy (usually Ti6A14V), and hydroxyapatite. This review attempts to address the following questions: Do the epithelium and connective tissue attach or adapt to these synthetic surfaces? Is there a seal or just a cuff in terms of the soft-tissue interface? Is hydroxyapatite, commercially pure titanium, or Ti6A14V more predictable and retentive? Is one better than the other or are all the same? Is there an advantage of one surface over the other in terms of bone-to-implant contact or shear strength when stressed? How about bone density and fixture length; is one surface better than any other?
The lack of predictive value in periodontal disease detection has stimulated intense research efforts in the development of diagnostic tests. Present methodology using periodontal probes or radiographs to determine disease susceptibility fails to allow an accurate periodontal risk assessment. The analysis of gingival crevicular fluid components offers great potential as a source of factors that may be involved in active periodontal bone loss. Over the past decade investigators have begun to identify several molecules associated with active periodontal tissue destruction. Recent advances in orthopedics and osteoporosis have provided new biochemical markers of bone resorption, including oral bone loss. The development of new diagnostic test strategies that target the analysis of bone-specific markers offers great promise to accurately assess active disease.
This review of the current periodontal literature evaluates clinical regeneration with guided tissue barriers in infrabony defects and furcations. A meta-analysis was conducted by calculating weighted means with confidence intervals for each treatment group. Clinical improvement in infrabony defects was best for polylactic acid/polyglactin (PLA/PGA) barriers, with a mean pocket reduction of 5.3 mm and a mean gain in clinical probing attachment level of 4.7 mm. For furcations, special attention was given to the frequency of either complete or partial (> or = 50%) furcation closure. Complete furcation closure was an infrequent result of guided tissue regeneration, occurring in only 7% to 19% of furcations treated with barriers. For the time period reported, the best clinical results in furcations and infrabony defects occurred with PLA/PGA-type barriers. However, there were no statistically significant differences among the various barriers in infrabony defects or furcations.
Surgical improvements in periodontics have been achieved because of advances in basic science, animal and clinical research, and the insight of outstanding clinicians. Industry continues to develop new surgical materials, improving the quality of sutures and needles and in turn, supporting advances in all surgical specialties. The purpose of this article is to review sutures and suturing by focusing on both materials and methods as they relate to the present practices of surgical periodontics and dental implants.
Periodontal diseases present with a wide range of clinical variability and severity, Individual susceptibility seems to be of major importance in determining the manifestation and progression of the disease. A better understanding of the molecular mechanisms of action of the immune system is of paramount importance to our ability to prevent and treat occurrence and recurrence of periodontal diseases. Recent advances in immunobiology are very promising for the identification of special categories of patients at risk for periodontal breakdown. This review discusses the most recent studies in this field and the possible clinical applications of recent advances.
Breath odor research has recently received increasing attention from periodontologists. Because a large portion of the adult population suffers from gingivitis and eventually periodontitis, the etiologic factor in all cases at risk must be considered. The first patient visit should, therefore, systematically include examination of the paranasal cavities and throat to avoid unnecessary time loss and frustration. Metabolic diseases and imaginary malodor should also be considered, Not only the mere presence of a chairside volatile sulfide monitor but also of that of an ear, nose, and throat specialist and eventually a psychiatrist or psychologist who determines whether a breath odor clinic merits its denomination. Volatile sulfur components are an important cause of breath malodor but they are not the sole cause, This explains why organoleptic and gas chromatographic diagnosis scores better than a portable sulfide monitor. Other than etiologic therapy, masking can be achieved for a number of hours by toothpastes containing a combination of triclosan and zinc chloride.
Although the relationship between diabetes and periodontal disease has been the subject of much debate, the consensus of recent studies is that diabetic patients have an increased risk of periodontal disease, particularly when metabolic control is poor. This paper reviews recently published studies in this area and concludes that not only is metabolic control a risk factor in disease susceptibility but that it may also influence the outcome of periodontal therapy.
The use of clinical practice guidelines has received considerable attention in medicine and dentistry for improving clinical decision making and cost-effective care. Leaders in dentistry are increasingly calling for improved standardization of treatment through the development of clinical practice guidelines based on empiric clinical evidence. Guidelines have been shown to minimize treatment variability and ensure the quality and cost-effectiveness of care. Other potential applications include educating individuals or groups; development of quality indicators; improved allocation of resources such as insurance payment decisions; and reduced risk of liability for negligent care. Recently, a series of evidence-based clinical algorithms and practice guidelines were developed for regenerative periodontal treatment. Such guidelines have the potential to improve outcomes of periodontal care for providers, patients, and other interested parties. This review discusses the rationale for guideline development and the role of clinical practice guidelines in the area of periodontal decision making and provision of care.
The main goal in the treatment of periodontitis is to control the subgingival infection. Systemic periodontal antibiotic therapy aims to reinforce mechanical debridement procedures and to support the host defense system in overcoming the infection that remains after conventional mechanical treatment. In particular, patients with early onset periodontitis and patients with refractory periodontitis may benefit from systemic antimicrobial therapy. Outside clinical parameters, the use of microbiologic information can assist in selecting the most optimal antibiotic regimen based on the presence and levels of selected periodontal pathogens.
Evidence reported in the period covered by this review, and here summarized with a meta-analysis, indicated that guided tissue regeneration (GTR) management of deep intrabony defects resulted in clinically significant and predictable gains in tooth support. Controlled randomized clinical trials demonstrated that GTR therapy was associated with significantly greater improvements in clinical attachment than access flap procedures alone. A series of recent investigations have also indicated that the magnitude and possibly the predictability of the expected outcomes are dependent upon a variety of patient, defect, and procedure-associated factors. Substantial evidence has been provided that clinical improvements obtained with GTR can be maintained over time.
Peri-implantitis is an inflammatory process affecting the tissues around an osseointegrated implant in function, resulting in loss of supporting bone. A review of the literature currently available leads to the conclusion that microorganisms play a major role in this disease. Gram-negative anaerobic bacteria, particularly fusobacteria, spirochetes, and black-pigmenting organisms such as Prevotella intermedia are often found in diseased sites. Several treatment modalities are presently being evaluated. Treatment aimed at a reduction of the anaerobic bacteria improves clinical conditions. Furthermore, case reports indicate a possibility for successful treatment with guided tissue regeneration procedures. However, to date histologic evidence of true reosseointegration has not been obtained. Incomplete surface decontamination seems to be the major obstacle for regrowth of bone onto previously exposed implants. It appears reasonable to attempt interception of destructive peri-implantitis as early as possible and to stop progression by removal of the bacterial deposits.
The ultimate goal of supportive periodontal care is to maintain health of the dental and oral soft tissues. It represents a preventive measure for individuals who have never experienced periodontal problems. On the other hand, supportive care is a continuation of therapy for the treated periodontal patient, once health has been reestablished. It aims at optimizing the results of therapy and prevent further destruction following active treatment. Attempts are being made to individualize and tailor supportive periodontal care according to the patient's profile and needs. Recent trends also show increased use of antimicrobials as adjuncts to mechanical procedures for controlling the etiologic agents.
For the past three decades, prostaglandin E2 and other arachidonic acid metabolites have been recognized as important proinflammatory mediators in bone resorption and various forms of periodontal disease. Nonsteroidal anti-inflammatory drugs are chemical compounds that selectively inhibit the synthesis of metabolites of the cyclooxygenase pathway, thereby blocking the production of prostaglandins, thromboxane, and prostacyclin. Inhibiting prostaglandin E2 synthesis with nonsteroidal anti-inflammatory drugs has been unequivocally shown in both animal and human studies to be of primary therapeutic efficacy. Recent lines of nonsteroidal anti-inflammatory drugs research have focused on the development of daily topical administration forms such as gels, toothpastes, and rinses. Furthermore, new studies have implicated prostaglandin E2 in the peri-implantitis process, opening the possibility to manage failing implants with topical nonsteroidal anti-inflammatory drug delivery systems.
There is a debate concerning the role that surgical procedures should play in the treatment of inflammatory periodontal diseases. This review details some of the situations in which surgery can be of benefit. Benefits include obtaining shallower probing depths and therefore reducing the areas that are hospitable to pathogenic bacteria associated with disease. Also, removal of tooth-accumulated materials such as plaque and calculus in probing depths greater than 5 mm is more predictable with surgery. In some forms of aggressive periodontitis, elimination of potentially pathogenic bacteria is found more frequently with surgical procedures. Regeneration of lost bone and attachment apparatus are predictable only with surgery.
The ultimate goal of both resective and regenerative periodontal procedures is the creation of soft- and hard-tissue architecture that is consistent with periodontal health. Osseous resective procedures predictably produce minimal clinical probing depth, but sacrifice periodontal support. An alternative method to treat anatomic defects not easily managed through resection is guided tissue regeneration (GTR). GTR provides clinicians with the opportunity to reverse the disease-related loss of periodontal attachment. However, at present, the outcomes of GTR procedures have not been shown to be predictable. Continued improvements in techniques and materials, and identification of patient-related factors significant to the success of the GTR procedures, should enhance the consistency of the clinical outcomes. An evidence-based approach to the use of both regenerative and resective therapies will enhance the clinical results achieved through these procedures.
Drug-induced gingival overgrowth is an iatrogenic disease caused by the use of phenytoin, cyclosporine, nifedipine, and other medications in the susceptible patient. The gingival overgrowth can be due to three causes: noninflammatory, hyperplastic reaction to the medication; chronic inflammatory hyperplasia; or a combined enlargement due to chronic inflammation and drug-induced hyperplasia. Drug-induced gingival enlargement can be minimized, but not prevented, by elimination of local irritants, meticulous oral hygiene, and regular periodontal recall. If gingival enlargement interferes with function, speech, esthetics, or oral hygiene, tissue reduction can be accomplished by gingivectomy or a flap procedure. Gingival enlargement may recur, especially in the patient with poor oral hygiene.
Recently, there have been case-control and epidemiologic investigations that strongly associate poor dental health with cardiovascular disease, preterm low birth weight infants, and early death from any cause. In a 7-year prospective study, dental disease was a significant predictor of coronary events leading to death after controlling for known coronary disease risk factors. Missing teeth displaces smoking as a risk factor for ischemic heart disease in another study. Periodontal disease was seven times more likely to be associated with a preterm delivery of a low birth weight infant than mother's age, race, number of live births, and use of tobacco or alcohol. This review examines the role of asymptomatic bacteremia as possibly explaining these associations, focusing on the bacterial load on the teeth as mediated via oral hygiene.
