April 7, 2017
Comparison of gingival augmentation surgical sites with untreated contralateral homologous sites
Sites treated using gingival augmentation procedures result in coronal displacement of gingival margins with reduction in recession up to complete root coverage. Contralateral untreated sites show a tendency to increase in existing recession or develop new recession during the 18- to 35-year follow-up. These findings are from a study published in the December 2016 issue of Journal of Periodontology.
Researchers designed the split-mouth study to compare the long-term periodontal conditions of sites treated with gingival augmentation procedures and untreated homologous contralateral sites. They examined 47 patients with 64 test sites. Lack of attached gingivae associated with recessions was treated with marginal free gingival grafts (MFGGs) or submarginal free gingival grafts (SMFGG) (test group). The contralateral homologous sites with or without gingival recession and with attached gingivae were left untreated (control group).
The 47 patients underwent surgical augmentation procedures using MFGGs or SMFGGs in test sites. MFGGs were used when existing free gingiva was found to be very thin. The coronal part of the graft was positioned at the presurgical level of gingival margin after removing existing free gingivae. SMFGGs were used when free gingiva was considered thick. The graft was sutured at a submarginal level without removing marginal free gingivae.
Researchers recorded patient-, tooth-, and site-related variables for each patient at baseline, 1 year after surgery, during the follow-up period (10-27 years), and at the end of the follow-up period (18-35 years). Patient-associated variables included age, sex, and tobacco smoking. Tooth-associated variables included survival, position, and type. Site-associated variables included gingival recession depth, keratinized tissue (KT) width, and probing depth.
The 64 test group sites underwent gingival augmentation procedures; 47 with SMFGGs, and 17 with MFGGs. Of the 64 treated sites, 14 were in the maxillary arch and 50 were in the mandibular arch. Patients were recalled every 4 to 6 months for follow-up. Gingival recession depth, KT width, and probing depth were measured at baseline, 1 year postoperative (T1), during follow-up (10-27 years) (T2), and at the end of the follow-up period (18-35 years) (T3). The authors conducted multilevel regression analyses.
At the end of T3, 83% of the 64 treated sites showed recession reduction, while 48% of the 64 untreated sites showed an increase in recession. Treated sites ended with the gingival margin 1.7 millimeters more coronal and KT width 3.3 mm wider than untreated sites. In grafted sites, KT width at T3 remained stable compared with T1 values. A patient-perceived benefit in terms of absence of hypersensitivity was noted in 10 of 12 test sites, whereas in control sites dental sensitivity increased slightly with time. The reduction in recession and increase in KT width were statistically significantly higher in treated sites compared with control sites at all 3 time points. Increased KT thickness in grafted sites positively affected oral hygiene practices of patients. Of 47 patients, 39 (83%) reported improved comfort levels on grafted sites during toothbrushing.
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Consulting Editor: Tapan Koticha, BDS
Diplomate, American Board of Periodontology
Director, Graduate Periodontics
University of Oklahoma Health Sciences Center, College of Dentistry
Postoperative pain prevention after surgical implant placement: dexamethasone and ibuprofen
Nonsteroidal ibuprofen taken before and after surgery works as well as steroidal dexamethasone to prevent and control postoperative pain and discomfort after implant placement surgery. Both treatments also reduce the need for rescue medication and increased the time before the first rescue medication was taken. The findings are from a study published in the January issue of Journal of Periodontology.
Researchers wanted to compare the effectiveness of dexamethasone and ibuprofen medication protocols for preventing and controlling pain after implant surgery. To do this, they designed a double-blinded, parallel-group, placebo-controlled, randomized clinical trial that included 117 patients with planned dental implant placement. Six professional postdoctoral periodontal residents specializing in periodontology performed the procedures after the patients received local anesthetic but no sedation. Surgeons were trained to use standardized surgical procedures and sequences.
Patients were assigned to receive 1 of 3 different protocols: 600 milligrams of ibuprofen 1 hour before surgery and another 600 mg 6 hours after the first dose, 4 mg dexamethasone 1 hour before surgery and another 4 mg 6 hours after the first dose, or placebo. Rescue medication (1,000 mg acetaminophen) was made available to each patient, and they were instructed to take it if necessary. Pain intensity was evaluated via a 101-point numeric rating scale and a visual analog scale. Discomfort was evaluated using a 4-point oral rating scale hourly for the first 8 hours after surgery and 3 times daily for the following 3 days. Patients rated their discomfort using a 4-point oral rating scale.
Patients treated with ibuprofen and dexamethasone reported less pain in the morning than patients in the placebo group on days 1 to 4 via the visual analog scale and the numeric scale. All patients in the placebo group required rescue medication. No side effects were reported for any medications used.
Despite the fact that randomized measures were used, researchers noted that patients in the placebo group were older than those in the ibuprofen group, surgery time was longer in the dexamethasone group than for the other groups, and more anesthetic carpules were used in the dexamethasone group than in the other groups. They also noted that men were the majority in all groups, and they speculated that men tend to report pain less than women.
The study’s main limitation lies in the perception of pain itself. “Pain is a highly subjective parameter, and parallel-group studies tend to yield highly variable data,” the authors noted. “Thus, crossover trials are preferred when pain intensity or score is assessed.”
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Early-bird registration extended for the AAP 2017 Annual Meeting
Save up to $233 when you register between now and May 3 for the 103rd Annual Meeting of the American Academy of Periodontology, Sept. 9-12, 2017, in Boston. Don’t miss your opportunity to hear the latest in periodontal innovation and discuss trending topics in the specialty. This year’s program will feature more than 50 courses and 20 new speakers.
Get a sneak peek at this year’s sessions and register now! For more information, visit perio.org/meetings or e-mail firstname.lastname@example.org.
Validating a periodontal and tooth profile classification system for patients
New clinical definitions of periodontal disease subtypes have been proposed based on multiple periodontal and dental diagnostic factors. In the February issue of Journal of Periodontology, researchers from the University of North Carolina at Chapel Hill (UNC) describe developing a custom latent class analysis (LCA) using periodontal and tooth profiles to generate clinical definitions that reflect disease patterns in the population at individual and tooth levels. The classification could provide tools to integrate several data sets to assess risk of developing periodontitis regression and tooth loss.
Researchers used bioinformatics tools to define periodontal profile classes (PPCs) and tooth profile classes (TPCs) in a group of people by using detailed clinical measures at the tooth level, including periodontal measurements and tooth loss. To identify PPC, researchers studied the full-mouth clinical periodontal measurements of 6,793 people who participated in the Dental Atherosclerosis Risk in Communities study. They developed a custom LCA procedure to identify clinically distinct PPCs and TPCs. The researchers used 3 validation cohorts: National Health and Nutrition Examination Survey for 2009 to 2010 (3,750 people) and 2011 to 2012 (3,338 people) and the Piedmont Study population (7,785 people).
Researchers used a person-level LCA to identify classes of people based on 7 tooth-level clinical parameters. This tooth-level analysis enabled refinement of the individual tooth status at a person-level within each PPC for risk assessment modeling. The tooth-level LCA classified teeth into 7 latent TPCs, based on 14 categorical clinical parameters similar to those referenced above.
The LCA method identified 7 distinct periodontal profile classes (PPCs A to G) and 7 distinct tooth profile classes (TPCs A to G) ranging from health to severe periodontal disease status. The method enabled them to identify classes with common clinical manifestations hidden under current periodontal classification schemas. Class assignment was robust with small misclassification error in the presence of missing data. The PPC algorithm was applied and confirmed in 3 distinct cohorts.
Researchers noted that their proposed person-level LCA model includes tooth-level data on 7 clinical parameters with 7 PPCs that reflect typical tooth loss and disease patterns seen by clinicians. The method uses no a priori assumptions of disease patterns to define disease states. Unlike principal component analyses that define traits within a population, the researchers’ method defines distinct categories of members (people or teeth) with previously hidden combinations of traits to create mutually exclusive latent classes.
Calling this the UNC-PPC/TPC classification, the authors suggested that it is a promising and novel way to achieve patient stratification and tailoring of treatment, targeting health promotion efforts and optimizing individual treatment decisions for dental rehabilitation.
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Association between frequent recreational cannabis use and periodontitis in U.S. adults
Cannabis users exhibit deeper probing depths, higher clinical attachment loss (AL) scores, and higher odds of having severe periodontitis compared with nonusers. That key finding was published in the March issue of Journal of Periodontology.
Researchers wanted to measure the relationship between recreational cannabis use and periodontal status in adults 30 years and older living in the United States. They used data from the 2011 to 2012 National Health and Nutrition Examination Survey to measure the relationship between recreational cannabis use (marijuana and hashish) and periodontal disease. The survey sample consisted of 980 men and 958 women aged 30-59 years. Researchers obtained information on cannabis use and other covariates including demographics, additional risk factors, and data on history of periodontal treatment within the year preceding oral examination.
Researchers obtained probing depth and clinical AL measurements from the examination section of the 2011 to 2012 National Health and Nutrition Examination Survey database. These measurements were recorded at 6 sites per tooth for all teeth, excluding third molars. They examined periodontitis using continuous and categorical measures, and they defined periodontitis using the Centers for Disease Control and Prevention/American Academy of Periodontology classification as well as continuous measurements of probing depth and clinical AL. The exposure of interest was self-reported cannabis use, defined as “frequent recreational cannabis” (FRC) use versus “non-FRC use.” Researchers conducted bivariate and multivariable regression models using the entire analytical sample, as well as those who had never used tobacco.
Of 1,938 participants with available cannabis use data and essential covariates, 26.8% were FRC users. The mean number of sites per participant with probing depths greater than or equal to 4 millimeters, 6 mm, and 8 mm and AL of greater than or equal to 4 mm, 6 mm, and 8 mm was significantly higher among FRC users than among non-FRC users. Average AL was higher among FRC users than among non-FRC users. Bivariate analysis showed harmful association between FRC use and severe periodontitis in the entire sample as well as in those who had never smoked. FRC users had a higher number of sites with PDs and AL across thresholds of severity compared with non-FRC users.
“FRC use in absence of tobacco smoking appears to have adverse effects on periodontal tissues,” the authors concluded. “Given worldwide tendency toward decriminalization of recreational cannabis use and the resulting potential increased use among young adults, dental professionals should become aware of its deleterious effects and appreciate the role of marijuana consumption as a potential risk factor for periodontitis.”
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New research: periodontal disease and increased stroke risk
AAP President Dr. Terrence Griffin talks to Dr. Bicuspid about the latest findings in understanding the perio-systemic link and increased stroke risk. Click here to learn more.
Journal of Periodontology study links secondhand smoke to periodontitis
Researchers have found that those who have been exposed to environmental tobacco smoke (also known as secondhand smoke) have a 28% increased likelihood of developing periodontitis. Read the study here, published ahead of print on the Journal of Periodontology Online.
Perfect patient care formula: subtract plaque and tartar, add ADA Perio brochure
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Available for download: clinical and scientific papers from the AAP
The American Academy of Periodontology has developed a suite of resources to be used as guidelines for dentists dealing with periodontal health issues. These resources include: disease classifications, AAP-commissioned reviews, parameters of care, position papers, consensus papers/clinical recommendations, and academy statements.
View and download these materials by clicking here.
JADA+ Specialty Scans and JADA+ Scans
JADA+ Specialty Scans and JADA+ Scans are quarterly newsletters updating dentists on the latest research in selected specialties and disciplines in dentistry. ADA Publishing and the consulting editors from the represented specialties and disciplines aggregate and summarize research from previously published materials, each item attributed to its publication of origin. JADA+ Scan specialties and disciplines include endodontics, oral pathology, orthodontics, pediatric dentistry, periodontics, prosthodontics, radiology, cosmetic/esthetic and osseointegration. 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. View past issues here.
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