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Periodontics - A Quarterly Newsletter on Dental SpecialtiesJADA Specialty Scan

Surgical crown lengthening and healing

How long after surgical crown lengthening should patients and clinicians wait to begin final restorative procedures?

Researchers conducted a literature review to find best evidence on the subject by searching PubMed, the Cochrane Database, EBSCO and Scopus from June 2013 until January 2014. They also discussed the case of a 59-year-old woman who underwent esthetic crown lengthening of the anterior maxillary teeth followed by prosthodontic rehabilitation. Seven articles were ultimately reviewed in the research published in the May 2015 issue of the Clinical Advances in Periodontics.

“Determining the minimum time necessary for gingival margin stability is critical to ensure minimal treatment delays and adequate continuity of care while allowing for adequate healing to produce optimal functional and esthetic results from prostheses,” authors said.

Although researchers found that the studies investigated positional changes of the gingival margin and changes to the alveolar bone, evidence about the effect of healing time on the final position of the gingival margin—which can be influenced by numerous factors—was less detailed.

“Postoperative healing and maturation of the periodontal tissues after surgical crown lengthening involves bone remodeling in terms of density with possible crestal height resorption and corresponding soft tissue changes in the form of regrowth, stability, or recession,” authors said. “…a certain healing time must elapse for these changes to take effect.”

The body of literature showed that six to 12 weeks of healing are typically deemed sufficient before impressions and placement of final restorative margins in posterior areas and three to six months is accepted as a more appropriate healing time on anterior teeth.

“These clinical standards propose that esthetic concerns are the main parameter that governs this decision, whereas the same influencing biologic and surgical factors may play an essential role in the healing process irrespective of tooth location in the arch,” authors said. They advised that proper understanding of the length of the postoperative healing phase is lacking and is seldom based on scientific data.

Among conclusions they said that healing time after surgical crown lengthening should not differ between anterior and posterior areas of the mouth.

Read the original article.


Consulting Editor: Eros Chaves, DDS
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.

Body weight and periodontal disease

Patients who are overweight or obese may be more inclined than their slimmer peers to develop periodontitis, according to research published in the June 2015 issue of the Journal of Periodontology.

Increases in weight for populations worldwide have raised concerns about its impact on overall health. Studies have shown that obesity, defined as body mass index, or BMI, (weight in kilograms divided by the square of body height in meters) ≥30 is often accompanied by low-grade inflammation. An adult is considered overweight when BMI is ≥ 25. Periodontitis is a chronic inflammatory disease. Like obesity, it is one of the most common chronic disorders in the world.

Scientists found a lack of prospective evidence summarizing the results of studies about the association between overweight/obesity and periodontitis. Interested in the time-dependent association and how weight changes may affect the disease’s development, they conducted a systematic review. They examined research assessing the relationship between the disease and overweight, obesity, weight gain and waist circumference (WC).

They conducted a literature search of PubMed/Medline and Web of Knowledge for studies published in English that included overweight or obesity as the exposure and periodontitis as the outcome. In addition to their primary focus on overweight, obesity, weight gain and WC, they also extracted and analyzed data on inflammatory markers, age, socioeconomic status, smoking, gender, oral hygiene and diabetes.

Eight prospective cohort studies (longitudinal studies), and five clinical trials (intervention studies) were examined. Among the primary findings, three of the longitudinal studies found a direct association between obesity at baseline and subsequent periodontitis and two studies found a direct association between overweight and periodontitis development. One of the studies reported a 27-year progression in worsening attachment loss, alveolar bone loss and probing depth for obese compared with normal weight men.

Two intervention studies found that the response to nonsurgical periodontal treatment was better among lean than obese participants, whereas three other studies did not find significant differences.

Authors said their results suggest that overweight, obesity, weight gain and increased waist circumference may be risk factors for development or worsening of periodontal measures such as probing depth, alveolar bone loss, attachment loss and plaque index.

“Evidence from longitudinal studies, with a follow-up of ≥ 20 years was clearer than evidence from studies with shorter follow-ups or from intervention studies,” authors said in discussion. “Long-term follow-up minimizes the risk of reverse causation or confounding from chronic disease at baseline. Short-term longitudinal studies might not allow for an appropriate temporal sequence of overweight/obesity before periodontitis.”

Authors also said that there seems to be an age-independent association because although prevalence and severity of periodontitis increases with age, most of the examined studies adjusted for age. The results also suggested that accumulation of visceral fat may be more strongly associated with periodontitis incidence than BMI.

Among conclusions authors called for more studies focusing on the role of inflammation, gender and socioeconomic status in periodontal disease development.

Read the original article.


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Conditions affecting periodontal bone loss

To more objectively study the relationships between periodontal bone loss and environmental and systemic conditions, scientists from the Netherlands, Belgium and Indonesia studied risk indicators for periodontitis in a group of people living remotely and deprived of oral health care.

The untreated population, also deprived of preventive care, consisted of 98 subjects from West Java, Indonesia, who had also participated in a 2005 study on plasma vitamin C levels. Averaging in age from 39-50 years old, the study included 53 women and 45 men.

Scientists aimed to explore further “in this unique population with a natural development of periodontitis, whether the amount of alveolar and periapical bone loss was related to an array of environmental factors.”

They assessed lifestyle factors with known associations to the development and severity of periodontal disease, such as smoking and nutrition, particularly vitamin C consumption. Insufficient consumption of vegetables and fruits, the two major sources of vitamin C, can lead to depletion or deficiency states for the vitamin. Past research has shown that vitamin D may also be linked to periodontal disease. They also studied potential indicators shown to affect susceptibility and severity of periodontitis—systemic inflammation, pre-diabetes and elevated body mass index—and also considered smoking and dietary habits, blood sampling, microbiological sampling, radiographic examination and body mass index evaluations.

The researchers’ microbiological evaluation showed that P. gingivalis presented in subjects with a 10-fold higher number of bacterial cells compared to other pathogenic bacteria. Nearly half (45%) of subjects had depletion or deficiency of vitamin C and 82 percent showed deficiency of vitamin D3. Seventy percent were in a pre-diabetic state and six percent had untreated diabetes. C-reactive protein (CRP) was high in 21 percent of subjects and 33 percent showed intermediate values.    
They found body mass index, numbers of subgingival P. gingivalis cells, plasma CRP values and number of guava fruit servings to be significant predictors explaining 19.8 percent of the variance of alveolar bone loss (ALB). P. gingivalis and CRP showed a positive relationship with ABL, whereas BMI and guava fruit were negatively related. However, further analysis of the relationship between BMI and ABL showed that BMI was inversely correlated with smoking status.

An inverse relationship was found between the number of guava fruits consumed during the previous month and the amount of ABL. Eating one guava provides an intake of about 400 milligrams of vitamin C. Great variation in the amount of guava intake by participants in the previous month — between 0 and 30 — may have contributed to the significant relationship with ABL, authors said.

Scientists found no relationship between D3 and periodontal breakdown, an area of study without definitive consensus in the literature. Authors called for further research to clarify the vitamin’s role.

The results of their study confirm previous findings that elevated levels of P. gingivalis may be indicative for the risk of periodontitis progression. Furthermore, guava fruit, with its high vitamin C content, may play a protective role in periodontitis of a malnourished population.

Read the original article.


Managing gingivitis

Findings from a systematic review about the prevention of periodontitis through prevention of gingivitis were published in the April 2015 issue of the Journal of Clinical Periodontology.

Because gingivitis and periodontitis are a continuum of the same inflammatory disease, management of gingivitis is a primary strategy. Plaque removal and/or control are therefore fundamentally important in the prevention of periodontal diseases, authors said.

“There is a need to systematically appraise the literature concerning mechanical and chemical methods of controlling the plaque biofilm with a view to reducing gingival inflammation as a primary endpoint.” The report represented the consensus views of a work group of the 11th European Workshop in Periodontology.

The report includes answers to questions based on researchers’ analyses of available and published evidence relating to mechanical and chemical methods of controlling gingival inflammation in patients with and without a history of periodontitis. The scientists propose clinical, research and public health recommendations as a result of their findings.

Read the original article.

Nonsurgical Treatment for Peri-Implant Mucositis and Periodontitis

Infections around dental implants are an increasingly common challenge with few good nonsurgical treatment options. One solution involves prescription tray delivery of hydrogen peroxide gel. Dr. Jeffrey Goldstein offers this tray therapy and his case study illustrates the improvement.

The patient was diagnosed with periodontitis in 2001 and referred to a periodontist, who he refused to see regularly. By 2004 three teeth were no longer salvageable. Implants were placed in 2007. The patient’s periodontal status deteriorated again in 2014, especially around the implants where bleeding pockets measured 4-7 mm.

Dr. Goldstein prescribed Perio Trays (Perio Protect, St. Louis, MO) to place 1.7% hydrogen peroxide gel (Perio Gel, QNT Anderson, Bismarck, ND) deep into the pockets before and after scaling and laser therapy. Perio Trays are customized based on the patient’s probing depths and designed to seal around the periodontal tissues. This helps drive the gel deep into the pockets and keep it in contact with exposed implant and root surfaces.
Perio Tray delivery began Aug. 21, 2014, and continued throughout the course of treatment, dropping from four to two daily 15-minute increments. By Dec. 19, pocket depths and bleeding decreased significantly. The patient continued with Perio Tray usage. On Feb. 20, 2015, all pockets were within normal range except for four 4 mm pockets. There was no bleeding.

June 2014 periodontal status, upper arch

February 2015 periodontal status, upper arch

“I’ve completely changed my approach with these trays,” Dr. Goldstein explains. “I can help patients treat the cause of the disease between visits instead of just treating symptoms.” Additional benefits are reported too. “They tell me their gums feel better and cleaner and probings no longer hurt. While my top priority is patient health, patient satisfaction is important, too.”

Dr. Goldstein was not compensated for this editorial. The Perio Tray by Perio Protect was cleared by the FDA to place doctor-selected medication subgingivally. Successful Perio Protect treatment depends on patient compliance and patient conditions. Your results may vary. Doctors use Perio Protect in conjunction with scaling and when necessary with surgery. For a full report of this case study see www.TheOrkosAward.com/studies. Additional information on prescription tray delivery is available at www.PerioProtect.com.

Save the Date: AAP to meet in Orlando Nov. 14-17

The 101st Annual Meeting of the American Academy of Periodontology will be held Nov. 14-17, 2015, at the Gaylord Palms Resort & Convention Center in Orlando, Florida. Offering over 25 hours of continuing education credits, the 2015 Annual Meeting provides more than 40 different courses relevant to periodontal care; including treatment technique advances, emerging technologies, scientific advancements, practice development and management, clinical applications and more.
To register for the 2015 Annual Meeting or for more information, visit www.perio.org/meetings, call 1-800-282-4867 Ext. 3213, or email meetings@perio.org.


Perio disease effects made loud and clear

With periodontal patient education, it’s all about the pictures. The ADA Flip Guide to Periodontal Disease presents large, vivid graphics so patients understand the havoc this disease can wreak on tissues.

Stages of disease are shown with photos and illustrations; updated treatment graphics show scaling and root planing and perio surgery. The guide also educates patients about hygiene with step-by-step brushing and flossing photos. Use the 14-page guide chairside or pop out the built-in easel and display in a treatment room or reception area.

Flip guide contents can be viewed on this page. To order, call 1-800-947-4746 or go to adacatalog.org. Readers who use the code 15408E before July 31 can save 15 percent on all ADA Catalog products.


$299 Online Personalized Training
Perio Protect Personalized Training reviews the science behind prescription Perio Tray therapy, case study presentations, and treatment protocols.  This 90 minute training is conducted via GoToMeeting.com and can be scheduled Monday through Friday from 9AM to 5PM Central.  This one-on-one option allows you to ask questions so your team feels comfortable incorporating periodontal medicament carriers into your treatment protocol. Click here to learn more.


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 2015. Other Specialty Scan issues are devoted to endodontics, oral pathology, oral and maxillofacial radiology, orthodontics, pediatric dentistry and prosthodontics. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. We welcome feedback on this and all Specialty Scan issues.

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Any statements of opinion or fact are those of the authors and do not necessarily reflect the views of the American Dental Association. Neither the ADA nor any of its subsidiaries have any financial interest in any products mentioned in this publication. Any reference to a product or service, whether in advertisements or otherwise, is not intended as an endorsement or as approval by the ADA or any of its affiliated organizations unless accompanied by an authorized statement that such approval or endorsement has been granted.

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