Periodontics - A Quarterly Newsletter on Dental SpecialtiesJADA Specialty Scan

Natural teeth vs. implants: reviewing the options

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Today’s dentists have many options for treating patients with periodontally compromised teeth. Current literature shows that extraction and dental implant therapy is a popular choice.
However, such decisions should be carefully weighed against therapies directed at preserving the natural dentition, scientists publishing in the June 2014 issue of the Journal of Periodontology reported.

Finding few studies comparing the bone loss of teeth versus that of implants in the same patients, the authors pursued their own investigation. They compared bone loss around dental implants and adjacent teeth at the time of implant crown insertion and at the 10-year follow-up in relation to patients’ initial prognosis—periodontally compromised patients (PCP) or periodontally healthy (PHP). Other factors assessed were smoking history, type of implant and the impact of peri-implant bone loss on the radiographic crestal bone level (BL) of adjacent teeth.

Enrolled in the study were 120 patients who had received a dental implant in a single-unit gap between January and July 1997 at either the University of Federico II in Naples, Italy, or at the University of Milan. They were divided into two groups according to periodontal condition—PCP or PHP.

The two groups of PCPs were treated for chronic periodontitis, one with an N-implant and the other with an S-implant. The two groups of PHPs also were treated with either an N-implant or an S-implant and so categorized. Each of the four groups was then divided between smoking and nonsmoking patients, creating results for eight categories of subjects.

The scientists evaluated radiographs taken at the time of crown insertion and compared them with radiographs taken 10 years later. They calculated the radiographic crestal bone change by subtracting the crestal bone level at baseline from the crestal BL at the 10-year follow-up. They evaluated differences between groups, including dissimilarities in bone loss at implants and adjacent teeth.

The results showed that the highest implant survival rate was for the PHPs—95 percent for both smokers and nonsmokers, decreasing to 90 percent and 85 percent for PCP nonsmokers and smokers, respectively, and 100 percent for all adjacent teeth.

In all eight patient categories, teeth showed a significantly more stable radiographic bone level compared with adjacent dental implants. The scientists also found that bone level changes didn’t occur in teeth adjacent to implants with advanced bone loss.

The finding of higher radiographic crestal BL at implants than at teeth and the finding that teeth with a history of treated periodontitis display long-term results at least as good as, if not even better than implants, agrees with early findings reported in the literature, the authors said.

“Even if difficult to compare, data in the literature on long-term success and survival rates of dental implants seem to indicate that implant therapy does not yield better results compared with more or less advanced periodontal procedures aimed at maintaining the natural dentition,” the scientists noted.

Among their conclusions, the authors said, “Provided that periodontitis has been treated and that patients comply with a regular periodontal maintenance protocol, the long-term prognosis of teeth is at least as good as that of dental implants. This observation is also valid for teeth with reduced periodontal support. As a consequence, great caution should be exercised when considering tooth extraction for periodontal reasons in favor of implant therapy.”


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 but has no connection with any product mentioned or any advertising that appears in this newsletter.

Crown design and peri-implantitis

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Published papers about peri-implantitis continue to accumulate, yet the body of research focusing on dental implant crown design and contour as a risk factor for the complication remains insufficient, scientists publishing in the May 2014 issue of Clinical Advances in Periodontics reported.

The importance of proper crown design and the risks of soft-tissue inflammation and peri-implantitis when implant-supported crowns are overcontoured should not be underestimated, according to the findings. Authors said such inadvertently induced characteristics can promote bacterial biofilm buildup and restrict hygiene access needed for both the patient and the provider to prevent peri-implant mucositis and peri-implantitis.

Research detailing the risks and resolutions of overcontoured restorations formed the foundation for the scientists’ deductions and was presented in case studies centering on non-submerged one-stage implants on posterior sites.

“It is known that inadequate subgingival margins will change the microflora and lead to periodontal disease around natural teeth,” the authors said. “The same restorative principle is recognized for crown design over implant fixtures.”

On the importance of crown design, they noted a lack of published, randomized clinical studies addressing its specific effect in peri-implantitis. They encouraged more research to investigate its role in peri-implant tissue health, the need for peri-implantitis treatment and dental implant survival.

The authors called for periodontists to take a more active role in placing and maintaining dental implant fixtures. “A dental implant team approach with open and constant communication by periodontists, restorative dentists, and dental technicians is vital for the success of a dental implant,” they said.

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Multirooted teeth: risks and outcomes after therapy

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Managing periodontitis in multirooted teeth is a challenging undertaking. Their anatomical features make adequate access for plaque control problematic for clinicians and patients alike.

Reports in the literature show that once furcation involvement in multi-rooted teeth reaches Level 1—up to 3 millimeters (mm) horizontally, the probability of tooth loss significantly increases. However, more recent evidence showed good long-term survival rates of multi-rooted teeth with furcation involvement at Level 1, particularly after non-surgical mechanical debridement.

With such findings top-of-mind, a team of researchers conducted a retrospective long-term clinical study. Their first goal was to determine the impact of the degree of FI on the longevity of multi-rooted teeth. The second was to assess risk factors associated with the loss of multi-rooted teeth in a sample of patients treated for periodontitis and enrolled in regular supportive periodontal therapy (SPT).

To conduct the study, scientists examined a total of 172 subjects diagnosed with chronic or aggressive periodontitis who were treated at the Department of Periodontology and Fixed Prosthodontics, University of Bern, Switzerland, between 1978 and 2002, and who were available for re-evaluation during 2005.

Complete clinical periodontal and radiographic examinations were performed prior to active periodontal therapy. After subjects were treated according to a comprehensive plan, a re-examination was performed before they were enrolled in an SPT program. The third and last complete periodontal and radiographic examinations were performed 11.5 years after active periodontal therapy on average.

The results showed that furcation involvement of up to 3 mm in a horizontal direction (Level 1), was not a risk factor for tooth loss compared with furcation involvement at Level 0, when the furcation entrance is not probable.

They also found that multi-rooted teeth at higher levels of furcation (Levels 2 and 3), were at a significantly higher risk to be lost at some point between the first examination, undertaken before active therapy, and the last, 11 years later, than those multi-rooted teeth at Level 0.

With respect to smoking status and compliance with SPT, the researchers learned that during SPT, smokers lost significantly more multi-rooted teeth compared with nonsmokers. Also, non-smoking subjects who had FI of Level 0 or Level 1 at the completion of periodontal treatment and were compliant with the SPT program lost significantly fewer teeth than noncompliant smokers.

Overall, 14. 4 percent of multi-rooted teeth were extracted during active periodontal therapy, and an additional 13.7 percent were lost over a mean period of 11.5 years of supportive periodontal therapy.

Outcomes of comparable long-term clinical studies are included in the authors’ research, published in the July 2014 issue of the Journal of Clinical Periodontology. Findings underscored the importance of SPT after active periodontal therapy and showed that even when subjects were enrolled in regular SPT, more multi-rooted teeth compared with single-rooted teeth were lost.


Socket filling and the alveolar ridge

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Does tooth socket filling help prevent post-extraction alveolar ridge volume loss in non-molars?

The answer is increasingly important given the beneficial effect that alveolar ridge preservation (ARP) may provide, researchers publishing in the June 25 online edition of the Journal of Dental Research reported.

The absence of a tooth in its rightful socket can impair chewing, speaking and socializing, and trigger a host of other anatomic changes. The literature shows that post-extraction alveolar ridge loss is irreversible and likely influences tooth replacement therapy, particularly implant-supported restorations.

However, although studies evaluating the efficacy of different socket-filling approaches have been conducted, scientists at the University of Iowa noted that most of those studies were anecdotal case reports, case series or inadequately powered clinical trials.

They sought to determine what is know about the effect of socket grafting to prevent post-extraction ridge volume loss as compared to tooth extraction alone in non-molars. They searched the literature from five electronic databases to identify appropriate randomized clinical trials.  Among inclusion criteria, the studies must have compared alveolar ridge preservation (ARP) post extraction via socket filling to that of untreated sockets, which served as controls, at a minimum healing time of 12 weeks. Principle outcomes measured were mean ridge dimensional changes—horizontal (buccolingual) and vertical (midbuccal, midlingual, mesial, distal)—from tooth extraction to final assessment.

After duplicate and impertinent articles were eliminated, 31 were eligible for assessment. Based on the eligibility criteria, eight randomized clinical trials were selected for qualitative analysis, and data from six of the studies was deemed eligible for quantitative analysis.

The primary finding was that ARP was effective in limiting physiologic ridge reduction as compared with tooth extraction alone of non-molar teeth and relevant in both horizontal and vertical dimensions.

An analyses of subgroups studied showed that flap elevation, use of a membrane and the application of a xenograft or an allograft may contribute to enhance outcomes, particularly on midbuccal and midlingual height preservation.

“Nevertheless, a certain degree of ridge volume loss should be expected even if ARP is applied,” authors advised. “ARP may significantly prevent alveolar bone remodeling post-extraction, but this effect is variable, likely due to the influence of local and systemic factors that are not fully understood yet.”

ADA offers discount on perio brochure

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Now through Aug. 31, the ADA is offering members a newly revised patient brochure on periodontal disease treatment at a 15 percent discount.

Members can order “Periodontal Disease: Don’t Wait Until it Hurts” (W121) through the ADA Catalog, using the promo code 14325E. The 12-panel brochure is available in packets of 50 for $30; retail price is $44. Discounts also are available for higher quantities.

The brochure can be personalized (DAB009) with your name or practice information, and also is available in a Spanish-language version (W222).

Written for the dental patient, the revised brochure offers an overview of the prevention and treatment of periodontal disease, and includes photos showing the stages of disease progression.

Members can preview this and other ADA brochures online at Orders can be placed online or by calling the ADA Member Service Center at 1-800-947-4746. Remember to use the promo code 14325E for the 15 percent discount.

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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 focuses on periodontics, the third in the series on this topic for 2014. Other Specialty Scan issues are devoted to prosthodontics, orthodontics, 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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