BACKGROUND:The purpose of this study was to determine whether periodontal residents could enhance their ability to assess the pain levels experienced by their patients from probing, using visual analog scale (VAS) to record pain. We hypothesized that with increasing experience by repeated comparisons of the patients' VAS pain ratings with independent ratings by the residents, they would improve their ability to assess their patients' pain experiences.METHODS:For each of three periodontal residents, 40 consecutive patients with periodontal disease were asked to express the degree of pain they experienced during the probing. Independently, the residents rated the pain levels they perceived that the patients experienced. Subsequently, the residents compared the two VAS ratings and discussed differences in ratings with the patients. Descriptive statistics and intraclass correlation coefficients were used to analyze the findings.RESULTS:Differences between patients' and residents' VAS scores gradually became smaller over time for two of the residents. Results for the third resident were less compelling.CONCLUSIONS:This study indicated that the training program improved the residents' ability to estimate the pain experiences of their patients, at least for two of the three participating residents. This training program, using periodontal probing as a model, could serve as an educational tool for students and practitioners who want to improve their sensitivity to their patients' pain experiences.

BACKGROUND:The aims of the present study were to identify the level of pain experienced by patients from probing during periodontal examination, and to determine to what extent the examining periodontist and the dental assistant could estimate the degree of pain experienced by the patients.METHODS:For each of three periodontists, 20 patients referred for periodontal diagnosis and treatment were selected. The periodontist carried out his examination, which included probing at six sites per tooth. Following probing, the patients rated the pain using a visual analog scale (VAS). The periodontist and the dental assistant who helped out during the examination independently rated the pain level they perceived that each patient experienced, also using a VAS.RESULTS:Most patients showed low pain responses to probing. However, using an arbitrary threshold of VAS > or =40 mm to indicate significant pain, some patients had a painful experience. Differences were observed between the pain levels expressed by the three groups of patients. While two of the three periodontists were able to appraise the pain experienced by their patients, the third was not.CONCLUSIONS:It seems important that the periodontist at the first encounter with the patient should be sensitive to the discomfort the examination may entail. This may influence the patients' decision to accept the required treatment, and may also affect the patients' attitude to and co-operation with the subsequent treatment.

BACKGROUND:The aim of the present study, performed during periodontal recall visits, was to compare the levels of pain experienced by patients during periodontal probing using probes with tip diameters of either 0.40 mm or 0.63 mm.METHODS:Three groups of 20 adult patients were examined by three different therapists. Diagonal maxillary/mandibular quadrants were probed with a 0.40 mm and a 0.63 mm probe, respectively. At the completion of probing of each quadrant, the patients were asked to describe their pain using a visual analog scale (VAS).RESULTS:Most patients showed low VAS pain scores for both probes. However, using an arbitrary threshold of VAS > or =40 mm to indicate significant pain, some patients had a painful experience. Lower median pain responses following probing with the 0.63 mm probe compared to the 0.40 mm probe were observed for patients of therapist 1, and for the quartile of all 60 patients that showed the highest VAS scores. For therapist 2 and 3 groups, no differences were found. The pain levels expressed by the three groups of patients varied, confirming results of our previous studies, which also observed differences in patients' pain experiences following probing by different therapists.CONCLUSIONS:The ability to deliver dental care with a minimum of patient discomfort would seem to be an essential part of the skills of individual clinicians. We would like to suggest that dental therapists periodically evaluate this part of their skill by asking patients to express their pain experiences following various procedures using VAS scales.

BACKGROUND:The aims of this study were to determine: 1) the degree of pain experienced by patients during probing and debridement; 2) whether the treating hygienists could estimate the degree of pain experienced by the patients; and 3) whether the patients' pain responses could be predicted by factors such as the patients' age, gender, number of residual periodontal lesions, and answers to a questionnaire on dental anxiety.METHODS:Prior to periodontal maintenance procedures, two groups of 20 adult patients to be treated by two hygienists completed an anxiety questionnaire. Subsequently, measurements of probing depths were performed, followed by pain ratings by each patient using a visual analog scale (VAS). The hygienists also completed a VAS, estimating the pain level they perceived their patient to have experienced. The same protocol was repeated for instrumentation (debridement).RESULTS:Most patients showed low pain responses to both probing and instrumentation. However, using an arbitrary threshold of VAS > or = 40 mm, 20% to 33% of the patients had a significant pain experience. The hygienists were quite accurate in their relative estimates of their patients' pain experiences. Regression analyses disclosed that significant portions of the pain responses could be predicted by the patients' answers to one of the dental anxiety questions.CONCLUSIONS:Recognition of patients who are likely to experience significant pain during periodontal treatment may be facilitated by the use of one question on dental anxiety. During treatment, the ability to gauge and respond to patients' pain experiences would seem to be an important component of a therapist's clinical skills.

BACKGROUND This research report evaluates clinical changes resulting from local delivery of doxycycline hyclate (DH) or traditional scaling and root planing (SRP) in a group of patients undergoing supportive periodontal therapy (SPT). METHODS In all, 141 patients received either DH (67) or SRP (74) treatment in sites > or =5 mm on one-half of their dentition at baseline and month 4. RESULTS Clinical results were determined at month 9. Baseline mean probing depth recordings were similar between the two groups (DH = 5.9 mm; SRP = 5.9 mm). Mean month 9 results showed similar clinical results for attachment level gain (DH 0.7 mm; SRP 0.8 mm) and probing depth reduction (DH 1.3 mm; SRP 1.1 mm). Percentage of sites showing > or =2 mm attachment level gain at month 9 was 24.7% in the DH group and 21.2% in the SRP group. Thirty-nine percent (39%) of DH sites and 38% of SRP sites showed > or =2 mm probing depth reduction. When treated sides of the dentition were compared to untreated sides, DH showed a difference in disease activity (> or =2 mm attachment loss) from 19.3% (untreated) to 7.2% (treated); and SRP from 14.3% (untreated) to 8.1% (treated). CONCLUSIONS Results show that both DH without concomitant mechanical instrumentation and SRP were equally effective as SPT in this patient group over the 9-month study period.

This paper examines the effects of smoking on the treatment outcomes of two nonsurgical therapies: (1) scaling and root planing alone (SRP) or (2) controlled-release of subgingivally delivered doxycycline hyclate in a polylactic acid based polymer gel. Subjects from 2 9-month multicenter studies were classified as nonsmokers (never smoked: 100 subjects), former smokers (137 subjects), and current smokers (> or = 10 cigarettes/day: 121 subjects). Clinical parameters were analyzed for treated sites with baseline probing depths > or = 5 mm and for a subset of treated sites with baseline probing depths of > or = 7 mm. Clinical parameters (plaque levels, clinical attachment levels, pocket depths, and bleeding on probing) were analyzed at baseline, 4, 6, and 9 months. In the doxycycline treated group in general, there were neither marked significant differences in clinical attachment gain nor differences in probing depth reduction among the 3 smoking groups. On the other hand, in the scaling and root planing treated group in general, there were significant differences in clinical attachment gain and pocket depth reduction, with non-smokers responding better than former smokers and current smokers at 6 and 9 months. These differences in clinical response between scaling and root planing alone versus controlled-release of locally-delivered doxycycline hyclate among these 3 smoking groups are discussed in relation to treatment implications for smokers.

This article presents the perspective of a private practice clinician who participated in the phase III clinical trials of Atridox (doxycycline hyclate) 10%. The selection of periodontal cases most likely to benefit from treatment with Atridox as part of overall comprehensive case management is discussed. Atridox may be used either before or after scaling and root planing or, in more rare circumstances, as a stand-alone therapy. Preparation of the material is discussed, and guidance for optimal application is provided.

Background: The clinical efficacy and safety of doxycycline hyclate (8.5% w/w) delivered subgingivally in a biodegradable polymer (DH) was compared to placebo control (VC), oral hygiene (OH), and scaling and root planing (SRP) in 2 multi‐center studies.Methods: Each study entered 411 patients who demonstrated moderate to severe periodontitis. Patients had 2 or more quadrants each with a minimum of 4 qualifying pockets ≥5 mm that bled on probing. At least 2 of the pockets were ≥7 mm. Treatment with DH, VC, OH, or SRP was provided at baseline and again at month 4. Clinical parameters were recorded monthly.Results: DH and SRP resulted in nearly identical clinical changes over time in both studies. Mean 9 month clinical attachment level gain (ALG) was 0.8 mm for the DH group and 0.7 mm for the SRP group in Study 1, and 0.8 mm (DH) and 0.9 mm (SRP) in Study 2. Mean probing depth (PD) reduction was 1.1 mm for the DH group and 0.9 mm for the SRP group in Study 1 and 1.3 mm for both groups in Study 2. Frequency distributions showed an ALG ≥2 mm in 29% of DH sites versus 27% of SRP sites in Study 1 and 31% of DH sites versus 34% of SRP sites in Study 2. PD reductions ≥2 mm were seen in 32% of DH sites versus 31% of SRP sites in Study 1 and 41% of DH sites versus 43% of SRP sites in Study 2. Comparisons between DH, VC, and OH treatment groups showed DH treatment to be statistically superior to VC and OH. Safety data demonstrated a benign safety profile with use of the DH product.Conclusions: Results of this trial demonstrate that treatment of periodontitis with subgingivally delivered doxycycline in a biodegradable polymer is equally effective as scaling and root planing and superior in effect to placebo control and oral hygiene in reducing the clinical signs of adult periodontitis over a 9‐month period. This represents positive changes resulting from the use of subgingivally applied doxycycline as scaling and root planing was not limited regarding time of the procedure or use of local anesthesia. J Periodontol 1999;70:490‐503.

Biodegradable barrier films were made by coagulating a solution of poly(DL-lactide) in N-methyl-2-pyrrolidone on porous polyethylene pads wetted with saline solution. The semisolid films were cut into 10 x 10 mm barriers and implanted subcutaneously in rabbits. At monthly intervals, the polymer implant sites were compared histologically to those implanted with USP negative control plastic. The polymer films were retrieved from the surrounding tissue, dried, weighed, and the changes in molecular weight determined using gel permeation chromatography. The molecular weight of the polymer decreased at a relatively constant rate over 5 months; however, no significant mass loss occurred until 5 months postimplantation. Also, no distinct histological differences were noted between the polymer barrier and the control plastic sites until 6 months when histiocytes and multinucleated giant cells showed a modest increase around fragmented polymer films. Similar barrier films also were fitted over naturally occurring buccal dehiscence defects in beagle dogs and the tissue sites compared histologically at 6 months to sham-operated control sites. New bone and dense connective tissues closely approximated segments of the remaining polymer and demonstrated the biocompatibility of the biodegradable films. Histomorphometric analyses of treated sites compared to sham controls showed that the polymer barrier is effective in promoting bone and cementum regeneration in periodontal defects in dogs.

This multi-center single-blind study compared clinical outcomes following guided tissue regeneration (GTR) treating human Class II furcation defects with a new polylactic-acid-based bioabsorbable barrier (test treatment) or a non-absorbable ePTFE barrier (control treatment). Clinical parameters evaluated were change in vertical attachment level (VAL), horizontal attachment level (HAL), probing depth (PD), and gingival margin location (REC). Surgical treatment resulted in clinically and statistically equivalent changes when comparisons were made between test and control treatments. VAL gain was 2.0 mm for test and 1.6 mm for control groups; HAL gain was 2.1 mm for both test and control groups. PD reduction was 2.3 mm for the test group and 2.1 mm for the control group. Test sites experienced an additional 0.3 mm of recession beyond baseline; control sites, 0.5 mm. Within-group comparisons showed that the amount of recession was not significantly different from baseline in the test group. Recession in the control group was significantly different from baseline. All other parameters in both the test and control groups were significantly different from baseline. Evaluation of safety data indicated no significant differences between test and control treatments, although there was a strong trend for the control group to have more postoperative abscess or suppuration than test sites (control = 11; test = 4; P = 0.06).

THE EFFICACY OF A BIOABSORBABLE polylactic acid based barrier was evaluated using naturally occurring buccal Class II furcation defects in beagle dogs. Sixteen furcation sites (8 control and 8 experimental) were treated in 6 adult animals. After full thickness flap reflection, exposed furcations and root surfaces were thoroughly root planed. In experimental sites a customized barrier was formed and fitted to cover the defect. Surgical flaps were replaced slightly coronal to the cemento-enamel junction. Animals were sacrificed at 6 months and specimens processed for histologic evaluation. Histologic and histometric analyses were done using 6 micrograms step serial sections in the buccal-lingual plane, corresponding to the buccal-lingual extent of the furcation. Results were: mean total defect experimental sites 1.92 mm; control sites 1.47 mm. Mean new cementum formation experimental sites 1.36 mm (71% of initial defect); control sites 0.25 mm (17% of initial defect). Mean new bone formation experimental sites 1.42 mm (74% of initial defect); control sites 0.20 mm (14% of initial defect). Mean junctional epithelium formation experimental sites 0.42 mm (22% of initial defect); control sites 1.21 mm (82% of initial defect). Statistical analysis demonstrated significant differences in all healing parameters favoring experimental (barrier-treated) sites. In this model, regeneration (new bone, cementum, and periodontal ligament) of 71% of the original defect in experimental sites and only 14% in control sites demonstrated a response that highly favored use of the barrier.

This paper reviews the clinical and histologic results following the use of bone autografts and allografts in periodontal therapy. Results from case reports and controlled clinical trials are discussed. Reports about bone grafts and combination procedures, including coronally positioned flaps and guided tissue regeneration procedures, are also reviewed. Studies analyzing long-term stability of grafts are discussed, as well as tissue banking procedures and safety considerations when freeze-dried bone allografts are used. Tables summarizing the results and methodologies of clinical trials cited are included to provide a method of comparison between the studies. The analysis of results of clinical trials using bone graft materials indicates that there is a consistent pattern of more bone fill in grafted versus nongrafted sites. However, the magnitude of this fill represents only about 60% of the treated defects.

Periodontology 2000Volume 1, Issue 1 p. 100-108 Periodontal regeneration: a review of flap management STEVEN GARRETT, STEVEN GARRETT Professor of Periodontics Graduate Periodontitics Loma Linda University Dental School and Private practice Loma Linda, California USASearch for more papers by this authorGARY BOGLE, GARY BOGLE Associate Professor of Periodontics Graduate Periodontics Loma Linda University Dental School and Private practice Loma Linda, California USASearch for more papers by this author STEVEN GARRETT, STEVEN GARRETT Professor of Periodontics Graduate Periodontitics Loma Linda University Dental School and Private practice Loma Linda, California USASearch for more papers by this authorGARY BOGLE, GARY BOGLE Associate Professor of Periodontics Graduate Periodontics Loma Linda University Dental School and Private practice Loma Linda, California USASearch for more papers by this author First published: February 1993 https://doi.org/10.1111/j.1600-0757.1993.tb00211.xCitations: 16AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume1, Issue1February 1993Pages 100-108 RelatedInformation

Early stages of connective tissue reattachment to surgically denuded cementum and root dentin following citric acid application were studied in fenestration wounds. Block specimens were obtained after seven, 14, and 21 days. Continuity between newly deposited collagen fibrils in the granulation tissue and unmasked dental matrix collagen had been established within seven days by interdigitation of fibrils in an up to 0.5 μm‐wide zone at the cementum or dentin surface. Splicing of collagen at the fibrillar level by direct attachment to the severed end of matrix fibrils or by juxtapositioning of new and old fibrils was seen in rare instances only. At 14 and 21 days, distinct bundles of collagen fibrils inserted deeply into the orifice of dentinal tubules. Arrested and reversed surface resorption was encountered at all time points. At these sites as well, new collagen fibrils interdigitated with denuded matrix collagen, while some resorbed surfaces were characterized by absence of collagen continuity. The results lend continued support to the concept of reattachment based on interdigitation of collagen fibrils. However, since attachment is established even in the absence of this feature, a significant role for specific attachment substances not shown can also be postulated.

Early stages of connective tissue reattachment to surgically denuded cementum and root dentin following citric acid application were studied in fenestration wounds. Block specimens were obtained after seven, 14, and 21 days. Continuity between newly deposited collagen fibrils in the granulation tissue and unmasked dental matrix collagen had been established within seven days by interdigitation of fibrils in an up to 0.5 micron-wide zone at the cementum or dentin surface. Splicing of collagen at the fibrillar level by direct attachment to the severed end of matrix fibrils or by juxtapositioning of new and old fibrils was seen in rare instances only. At 14 and 21 days, distinct bundles of collagen fibrils inserted deeply into the orifice of dentinal tubules. Arrested and reversed surface resorption was encountered at all time points. At these sites as well, new collagen fibrils interdigitated with denuded matrix collagen, while some resorbed surfaces were characterized by absence of collagen continuity. The results lend continued support to the concept of reattachment based on interdigitation of collagen fibrils. However, since attachment is established even in the absence of this feature, a significant role for specific attachment substances not shown can also be postulated.

This study was designed to test the effect of tetracycline on healing subsequent to periodontal surgery. Aqueous solutions of tetracyclines are highly acidic and may therefore represent a suitable substitute for citric acid. Furthermore, tetracyclines react with dental hard tissues to from long-lasting antimicrobial compounds, and they have a retarding effect on pellicle and plaque formation and an antienzymatic effect. The alveolar bone around mandibular premolars was surgically reduced up to 6 mm from the cementoenamel junction in two beagles. The denuded root surfaces were exposed to the oral environment during 3 months without plaque control. Regenerative surgery was then carried out, using root surface conditioning with 1% tetracycline and coronally repositioned flaps. Six months later, histologic evaluation showed connective tissue attachment extending to the cementoenamel junction in most of the specimens. Superficial root resorption was prevalent in the cervical region, below which a collar of replacement resorption partly surrounded the roots in a characteristic manner. Morphometric analysis showed that attachment gain was similar to that obtained with citric acid in a preceding series of seven dogs. These preliminary results indicate that connective tissue attachment gain after topical use of tetracycline is similar to that obtained with citric acid. In addition, the antibacterial capacity and biological effects of tetracycline warrant further study of its possible clinical use in periodontal reconstructive surgery.