Periodontics - A Quarterly Newsletter on Dental SpecialtiesJADA Specialty Scan

Keeping it clean
How prophylaxis care varies with different implant types

A dentist examining a patient's mouth

The effectiveness of different instruments for implant prophylaxis fluctuates according to implant surface and complete cleaning shouldn’t be expected from all methods, according to new research published in the March/April 2014 issue of the International Journal of Oral & Maxillofacial Implants.

Regular prophylaxis maintenance therapy is essential to long-term implant success. The goal is to prevent inflammation while avoiding wear on the implant surface over time.

Considering the wide range of instruments available for treatment, the study authors aimed to evaluate the effectiveness of different instruments on two implant surfaces: polished and acid etched. Their first hypothesis was that all tested instruments completely clean biofilm from a surface. The second was that the instruments’ cleaning ability does not differ from one surface to the other.

To investigate, they grew biofilm layers of Streptococcus mutans on 80 titanium disks, half of which had polished surfaces and the other half acid-etched. They grouped the disks according to surface type, and one investigator cleaned disks in each of the groups with one of the seven prophylaxis instruments, as follows:

Afterwards, an investigator who could identify surface type but not the instruments used for prophylaxis analyzed each group of disks.

The results showed significant differences in cleaning effectiveness between groups. Instruments were not able to clean implant surfaces completely, and three of the seven instruments exhibited significant differences in cleaning effectiveness between surface structures. Among their findings:

“Professional prophylaxis should result in a thoroughly clean surface; therefore, the use of efficient and damage-free cleaning methods would be advantageous,” the authors said in discussion.

They concluded that cleaning effectiveness with less than 4 percent of remaining biofilm was not found for all tested implant prophylaxis instruments and that cleaning ability of the devices varied depending on the implant surface structure.


Consulting Editor: Dr. Eros Chaves
Professor and Chair,
Department of Periodontics
University of Oklahoma Health Sciences Center
College of Dentistry

The Consulting Editor assists in the selection of scientific editorial content. Neither he nor the American Academy of Periodontology has a connection with any product mentioned or any advertising that appears in this newsletter.

Bone quality and dental implants

The template calls for the image at 160 by 160 but adjustments can be made

Identifying a potential weakness in bone density prior to implant placement is central to avoiding a rare but serious complication—implant displacement into an osseous void.

A case report in the February 2014 issue of Clinical Advances in Periodontics describes the displacement and management of a dental implant in the corpus of the mandible during implant surgery.  Study authors from Louisiana State University believe the report may be just the third in the periodontal literature describing this rare complication.

Their study centered on a 66-year-old African American woman whose treatment involved implants to replace her first molars.  An X-ray revealed normal bone density, and a scan taken less than a year before the surgery showed no evidence of osteoporosis. Bone quality was classified at D2. In addition, the prepared osteotomy showed that all bony walls were intact.

Yet after the implant carrier was removed from its platform, the implant was no longer visible.

Case report authors described the steps that led to a successful outcome. The patient healed normally and did not report any neurologic symptoms through the two-month follow-up period.

In an attempt to understand the cause of the displacement, researchers analyzed the original cone-beam computed tomography data and used imaging software capable of quantitative bone analysis later. It revealed low bone quality at the surgical site—D4. In discussion, authors noted that the finding concurs with previous research demonstrating that bone density may vary markedly when different areas of a designated implant site are compared.

In an area of low-bone density, a grafting procedure should be considered before implant placement,” the authors advised.


Kill ‘em Quick, Dead and Often
Duane C. Keller DMD, CDA Anaheim - May 16 1-4pm. An easy, minimally invasive strategy to manage oral biofilms benefits patients. With the Perio Protect Method, patients use Perio Trays to deliver medication into pockets. Research shows that the prescription tray delivery combined with SRP leads to more significant pocket depth and bleeding reductions than SRP alone. This presentation explains how the chemical therapy is incorporated into individualized treatment plans.



A review of grafting techniques

A well-known feature of good healing after extractions is full closure over grafted sockets.

Although various soft-tissue techniques have been supported by the dental literature, comparative studies of the options are scarce, researchers publishing in the November 2013 issue of Clinical Advances in Periodontics found.

Because of unique esthetic concerns for the upper front teeth, scientists formed a basis for their review with a focused clinical question: How can the soft tissue be managed with autogenous options after tooth extraction in the anterior maxilla?

The study presented a review of soft-tissue grafting options that included free gingival grafts (FGGs), free connective tissue grafts (FCTGs), palatal pedicle tissue grafts and coronally advanced flaps. The authors also outlined a decision tree that summarizes the different hard and soft tissue options for clinicians managing such cases.


Investigating the causes of implant failures

Although the replacement of missing teeth with dental implants generally results in good outcomes, causes of dental implant failures vary among studies and are known to originate from multiple epidemiological sources.
Researchers in Seoul, South Korea, surmised that examining long-term clinical data in one institution might lead to better understanding of these causes and reduce their occurrence in the future.

Aiming to analyze the characteristics and causes of implant failure, they conducted a multifactorial evaluation by analyzing clinical and radiographic data of patients from one institution over a 19-year period. They investigated the causes of implant failure and related risk factors to determine how they vary according to timing, condition and additional procedures performed.

The findings of their retrospective study were published in the March/April issue of the International Journal of Oral & Maxillofacial Implants.

Scientists evaluated the correlations between risk factors and implant failure by reviewing the charts of 879 patients receiving one or more implant —for a total of 2,796—at the Dental Hospital of Yonsei University College of Dentistry between February 1991 and May 2009. Included among the data collected and analyzed were patient age, sex, medical history, habits, bone quality, primary stability, implant size and surface, additional surgical procedures, prosthetic type, clinical symptoms, implant failure data, and causes of implant failure. The researchers also compared follow-up radiographs with those that were taken at baseline.

They found 150 implant failures in 91 patients. Early failures accounted for 57.3 percent and late failures for 42.7 percent. Inflammation was the main cause of early failures, at 47 percent. Overloading was the main cause of late failures, at 53 percent.

Not only were the primary reasons for failure different between early and late implant failures, but the risk factors associated with the causes differed.

Noting possible limitations of the retrospective study design, authors advised, “Future studies should employ larger samples and should investigate implants that failed for unknown reasons. Prospective randomized controlled trials involving multiple centers should be performed to clarify the correlations between implant failure and risk factors.”


Treating multiple gingival recessions

How do different treatment plans for multiple gingival recessions compare?
A double-blinded randomized controlled clinical trial designed to address that question was described in the April 2014 issue of the Journal of Clinical Periodontology.

Researchers from the University of Bologna, Italy, sought to compare short- and long-term root coverage and esthetic outcomes of the coronally advanced flap (CAF), alone or in combination with a connective tissue graft (CTG) for the treatment of multiple gingival recessions.

To investigate, they enlisted 50 patients—29 females and 21 males—referred to the dental clinic on a consecutive basis between January 2004 and January 2006. Each participating patient had multiple recession defects affecting adjacent teeth in one quadrant of the upper jaw. Half of the patients were randomly assigned to the control group and received only CAF treatment. The remaining 25 patients received both CAF and CTG.
Scientists measured gingival recession depth (RD), probing depth (PD), clinical attachment level (CAL) and keratinized tissue height one week prior to surgery and at intervals of six months and one year (short-term), as well as at five years (long-term) after surgery. Patients and an independent periodontist evaluated esthetics at one year (short-term) and five years (long-term) after surgery.

There was no significant difference between the two groups of patients in terms of complete root coverage or recession depth at six months or one year follow-up intervals. However, five years after surgery, researchers observed a higher recession reduction in the group that had received CAF and CTG in combination. This group also demonstrated a 3.22 times greater probability to achieve complete root closure than the group that had received CAF alone.

Another significant result among the clinical measurements taken: patients treated with CAF alone had better color-match scores at one and five-year intervals.

In discussion, authors noted that the color-match evaluation could be attributed to greater keloid formation in the CTG-treated sites. Patient satisfaction regarding esthetics was very high for both treatment groups with no difference between their perceptions at one and five years.
In discussion, authors observed that patients’ post-surgical maintenance habits related to the treatment provided could be a contributing factor in the surgical outcomes.

AAP marks 100 years!

American Academy of Periodontics logo

The American Academy of Periodontology is celebrating its centennial this year.

The AAP will gather in San Francisco for its 2014 Annual Meeting, Sept. 19-22. The meeting will feature continuing educational opportunities, updates on scientific research and insights into the future of the profession.

For more information about the Annual Meeting and other AAP events, contact the Meeting Department:


Joint symposium on saving dentition

Three dental specialty organizations will come together for a joint symposium on preserving natural dentition July 19-20 at Chicago’s Swissotel.

Entitled “Teeth for a Lifetime: Interdisciplinary Evidence for Clinical Success,” the symposium is sponsored by the American Academy of Periodontology, the American Association of Endodontists and the American College of Prosthodontists.

Experts from all three specialties will describe the contemporary evidence and best practices for saving the natural dentition through presentations designed for a multidisciplinary audience.

For more information on the symposium, visit


Facts about periodontal disease

Image: A dentist with a smiling patient

The federal Centers for Disease Control and Prevention report that about half of Americans aged 30 or older suffer from periodontitis. That amounts to about 64.7 million Americans.


Easing periodontal treatment for a patient with Parkinson’s

Perio Trays® by Perio Protect Perio Trays® by Perio Protect

Treating patients with periodontal disease and Parkinson’s is a challenge. Office visits may need to be limited due to tremors, rigidity of muscles, a decreased range of muscle motion, or common tightness of the neck and shoulders.

Follow-up care can be complicated by bradykinesia, a general reduction of spontaneous movement and a defining feature of Parkinson’s causing difficulty with repetitive movements like tooth brushing. Dr. Rebecca Hobbs of Augusta, Ga., recently received a case study award for her excellent care in treating a patient with both diseases.

In exploring treatment options, “Utmost in my mind was providing comfortable care for my patient,” said Dr. Hobbs. “I try to treat each patient the way I would want my family members treated. This patient has special considerations. I wanted to keep his appointments as brief and comfortable as possible, and I also wanted to help make his homecare easier for better and longer-lasting results.”

Homecare was a clear challenge for Dr. Hobbs’s patient. Even if a caregiver is largely responsible for everyday personal hygiene needs, as was the case for this patient, tooth brushing can be difficult and lead to plaque accumulation and gingival inflammation. This patient exhibited generalized red, tender gums, with periodontal pockets measuring 4-6 millimeters.

Patient with Parkinson's presented with generalized 4-6mm pocketing and inflammation.

Dr. Hobbs recommended starting with sealed prescription trays (Perio Tray®, Perio Protect LLC, St. Louis, Mo.) to deliver medication to reduce bacterial infections, plaque and inflammation before scaling. Dr. Hobbs hoped that the special tray delivery would combat the infections in the most comfortable way possible, make homecare more effective, reduce the amount of scaling needed as well as the time to perform it, and reduce the number of office visits required. The Georgia dentist asked her patient to wear the prescriptions trays four times a day for 15 minutes with a small amount of 1.7 percent hydrogen peroxide gel (Perio Gel®, QNT Anderson, Bismarck, ND) and three drops of an antibiotic (Vibramycin®, Pfizer, New York, NY) in each tray.

Two weeks after prescription tray delivery of medication. No mechanical treatment to date.

This schedule was prescribed for two weeks. With help from the caregiver, the patient was able to complete the treatments. At the end of two weeks, the patient returned, and the second image was taken. Inflammation had subsided dramatically and tissue health was significantly improved. The most minimally invasive treatment could then be completed in the least number of office visits needed.

To learn more about the prescription Perio Tray® or the Perio Protect approach to patient care, visit or Additional case studies involving prescription tray delivery and case study award-winners are available at To schedule a live consultation, call 877-434-GUMS (4867).

image: Perio Trays by Perio Protect

Perio Trays by Perio Protect
Prescription Perio Trays are innovative tools for adjunctive periodontal care. They have internal peripheral seals to deliver medication into shallow and deep pockets (>6mm), ideal for patients with generalized pocketing or struggling between maintenance visits. Research shows Perio Tray delivery of 1.7% hydrogen peroxide gel combined with SRP achieves better results than SRP alone. They are comfortable, convenient, easy-to-use. To learn more visit .


What is Specialty Scan?

This is one in a series of quarterly newsletters updating dentists on selected specialties in dentistry. Information presented is aggregated and summarized from previously published materials, each item attributed to its publication of origin. This issue of JADA Specialty Scan is focused on periodontics, the second in the series on this topic for 2014. Other Specialty Scan issues are devoted to orthodontics, periodontics, prosthodontics, endodontics and oral and maxillofacial radiology. The ADA has engaged the specialty organizations in these areas as well as its own divisions of Science and Legal to assist with these newsletters. We welcome your feedback on this and all Specialty Scan issues.

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