Jack G. Caton

Clinical studies on the management of periodontal diseases utilizing subantimicrobial dose doxycycline (SDD).

Periodontitis, the most common chronic inflammatory condition known to mankind, is a disease that results in the destruction of tooth supporting tissues. Periodontitis is initiated by a bacterial biofilm on the tooth surface below the gingival margin. Until fairly recently it was assumed that the bacteria were the primary cause of tissue destruction, however, a large body of research has revealed that it is the patients immune response that is actually responsible for the majority of the breakdown of tooth supporting tissues. Contemporary thinking suggests that successful, long term management of chronic periodontitis may combine both local mechanical and antimicrobial strategies to reduce the microbial bio-burden along with modulation of the host, patients excessive, immuno-inflammatory response to the bacterial exposure known as host modulatory therapy (HMT). Based on extensive literature documenting the enzymatic inhibition and related anti-inflammatory properties of the tetracyclines, a new drug was developed as a host modulatory agent and approved by the United States Food and Drug Administration (FDA) for use as an adjunct to conventional scaling and root planing for the treatment of chronic periodontitis. A subantimicrobial dose of doxycycline (SDD) at 20 mg (Periostat(®)) has been found to be a safe and effective adjunct when taken twice daily for at least 3 months and up to 24 months in randomized placebo controlled clinical trials. Periostat(®) is currently the only FDA approved inhibitor of the matrix metalloproteinases implicated in the plaque-induced pathologic degradation of connective tissue collagen of the periodontal supporting structures. This review paper begins with a brief description of the disease process known as periodontitis followed by an extensive review of the Phase I-IV clinical trial data that established the safety and efficacy of sub-antimicrobial dose doxycycline (SDD) as an adjunct to scaling and root planing for the treatment of periodontitis.

Periodontal Regeneration – Intrabony Defects: A Consensus Report From the AAP Regeneration Workshop

BACKGROUND Treatment of intrabony defects is an important therapeutic goal of periodontal therapy. The goal of this consensus report was to critically appraise the evidence for the available approaches for promoting periodontal regeneration in intrabony defects. In addition to evaluating the effectiveness of new regenerative approaches for intrabony defects, recommendations for future research were defined for this area. METHODS A systematic review was conducted using computerized searches of PubMed and Cochrane databases, supplemented with screening of references in original reports, review articles, and a hand search in selected journals. All searches were focused on regenerative approaches with histologic evidence of periodontal regeneration (proof of principle), clinical trials, and case reports. For purposes of analysis, change in intrabony defect fill was considered the primary outcome variable, with change in clinical attachment as a secondary outcome. The SORT (Strength of Recommendation Taxonomy) grade was used to evaluate the quality and strength of the evidence. During the consensus meeting, the group agreed on the outcomes of the systematic review, pertinent sources of evidence, clinical recommendations, and areas requiring future research. RESULTS The systematic review, which was conducted for the consensus conference, evaluated the effectiveness of the use of biologics for the treatment of intrabony defects. Enamel matrix derivative (EMD) and recombinant human platelet-derived growth factor-BB (rhPDGF-BB) with β-tricalcium phosphate were shown to be efficacious in regenerating intrabony defects. The level of evidence is supported by multiple studies documenting effectiveness. The clinical application of biologics supports improvements in clinical parameters comparable with selected bone replacement grafts and guided tissue regeneration (GTR). Factors negatively affecting regeneration included smoking and excessive tooth mobility. CONCLUSIONS Periodontal regeneration in intrabony defects is possible on previously diseased root surfaces, as evidenced by a gain in clinical attachment, decreased pocket probing depth, gain in radiographic bone height, and overall improvement in periodontal health. These clinical findings are consistent with available histologic evidence. Clinical improvements can be maintained over long periods (>10 years). Although bone replacement grafts have been the most commonly investigated modality, GTR, biologics, and combination therapies have also been shown to be effective. Future research should emphasize patient-reported outcomes, individual response differences, and emerging technologies to enhance treatment results. CLINICAL RECOMMENDATIONS Early management of intrabony defects with regenerative therapies offers the greatest potential for successful periodontal regeneration. The clinical selection and application of a regenerative therapy or combination of therapies for periodontal regeneration should be based on the clinicians experiences and understanding of the regenerative biology and technology. This decision-making process should take into consideration the potential adverse influence of factors, such as smoking, poor oral hygiene, tooth mobility, and defect morphology, on regeneration. Management should be coupled with an effective maintenance program for long-term success.

Temperature increase during CO(2) and Er:YAG irradiation on implant surfaces.

Purpose:The purpose of this study was to evaluate the temperature gradient (&Dgr;T) generated by laser irradiation of an implant surface using a carbon dioxide (CO2) and an Erbium:yttrium aluminium garnet (Er:YAG) laser. Materials and Methods:A dental implant was irradiated with a CO2 and an Er:YAG lasers, with variable power settings. Temperature increase was measured in 2 locations of the implant surface: in the cervical area (&Dgr;Tc) and in the apical area (&Dgr;Ta). Results:The CO2 laser showed the following results: after 60 seconds of irradiation with continuous mode, &Dgr;Tc was 13.9°C and &Dgr;Ta was 12.5°C. The Er:YAG laser showed the following results: after 60 seconds of irradiation with continuous mode, the temperature rise &Dgr;Tc was 50.6°C and &Dgr;Ta was 38.6°C. The CO2 laser with continuous mode generated a temperature increase of 10°C after only 36 seconds. The Er:YAG laser with continuous mode produced a more rapid temperature increase and took only 10 seconds to reach the critical threshold. Conclusions:The irradiation of implant surfaces with CO2 and Er:YAG lasers may produce a temperature increase above the critical threshold (10°C) after 10 seconds of continuous irradiation.

Bibliometrics Study on Authorship Trends in Periodontal Literature From 1995 to 2010

BACKGROUND Biomedical research has grown considerably in the last few decades, and the authorship characteristics of the dental literature as a whole and of its specialty fields has changed significantly. Unfortunately, the bibliometrics of the periodontal literature have not been thoroughly investigated. The aim of this study is to investigate the bibliometrics of periodontal literature, assessing the geographic origin, study design, and topics investigated in periodontal research published from 1995 to 2010. METHODS Articles published in periodontal journals during 1995 to 2010 were retrieved through hand search. Inclusion/exclusion criteria were applied. The following variables were extrapolated from each article: number of authors, study design, topic investigated, financial support, and geographic origin. The general linear model assessed the influence of independent variables on number of authors per article, and χ(2) test assessed the statistical difference of the variables over years 1995 to 2010. RESULTS A total of 2,260 articles were reviewed; 2,076 met the inclusion criteria. The number of authors per article increased (P <0.001) from 4.0 (1995) to 5.1 (2010). The proportion of articles published from North America and Europe decreased (P <0.001) from 84.3% (1995) to 58.6% (2010), whereas for Asia and South America the article proportion increased (P <0.001) from 13.8% (1995) to 40% (2010). Research targeting prevention and treatment of periodontal disease is decreasing (P <0.001) in favor of implant-related research. Governmental research funding is increasing (P <0.001). CONCLUSION Periodontal research significantly changed during the last 15 years.

A Comparative Study of the Incidence of Schneiderian Membrane Perforations during Maxillary Sinus Augmentation with a Sonic Oscillating Handpiece versus a Conventional Turbine Handpiece

BACKGROUND Sonic instruments may reduce perforation rates of the schneiderian membrane during lateral window sinus augmentation procedures. This study compares the incidence of membrane perforations using a sonic handpiece with an oscillating diamond insert versus a turbine handpiece with a conventional rotary diamond stone during lateral window sinus augmentation procedures. MATERIALS AND METHODS A retrospective chart analysis identified all lateral window sinus augmentation procedures done during a defined period. Among these procedures, those performed with a sonic handpiece and an oscillating diamond insert (experimental) and those performed with a conventional turbine and rotary diamond stone (conventional) were selected for this study. Reported occurrences of sinus membrane perforations during preparation of the osteotomy and elevation of the sinus membrane, as well as postoperative complications, were recorded and compared between treatment groups. RESULTS Ninety-three consecutive patients were identified for a total of 130 sinus augmentation procedures (51 conventional, 79 experimental). Schneiderian membrane perforations were noted during preparation of the lateral window osteotomy in 27.5% of the sinuses in the conventional group and 12.7% of sinuses in the experimental group. During membrane elevation, perforations were noted in 43.1% of the sinuses in the conventional group and 25.3% of sinuses in the experimental group. Both differences in perforation rates were statistically significant (p < .05). There was no statistically significant difference in postoperative complications. CONCLUSIONS In this study, the use of a sonic instrument to prepare the lateral window osteotomy during sinus elevation procedures resulted in a reduced perforation rate of the Schneiderian membrane compared with the conventional turbine instrument.

Immediately loaded platform-switched implants in the anterior mandible with fixed prostheses: a randomized, split-mouth, masked prospective trial.

BACKGROUND Platform-switched implants have been demonstrated to maintain marginal bone-level stability after immediate loading. The present study evaluated crestal bone loss and soft tissue stability around ANKYLOS plus® implants (A-implants) and Certain® PREVAIL(TM) (B-implants). MATERIALS AND METHODS Patients were identified to receive three A- or three B-implants on each side of their mandibles, with randomization. All implants were loaded immediately after their insertion and splinted with a cemented provisional prosthesis. Final prostheses were delivered 3 months after implantation. Peri-implant crestal bone loss, gingival recession, and other soft tissue changes were evaluated throughout a 2-year follow-up. RESULTS A total of one hundred seven implants were placed in 18 patients. Two of the group A-implants and one group B-implant failed. At the final 24-month assessment, bone loss of at least 2 mm (mesially or distally) was recorded at 5 of the 44 surviving A-implants (11%) and 33 of the 47 B-implants (70%), a success rate of 88.63% for the A- and 29.78% for the B-implants. CONCLUSIONS Significant changes in the level of the crestal bone loss around immediately loaded platform-switched dental implants seem to be related to the platform shape and size, as well as the implant-abutment connection, when abutments are not removed.

The incidence of membrane perforation during sinus floor elevation using sonic instruments: a series of 40 cases.

This study reports the incidence of complications and sinus membrane perforations when using sonic instruments to prepare the lateral window osteotomy for maxillary sinus augmentation. The charts of 33 consecutive patients (40 sinuses) were reviewed. Sinus membrane perforations were reported in 7 cases (17.5% of procedures), with 3 perforations occurring during preparation of the osteotomy window (7.5% of procedures). Postoperatively, 2 cases of sinus infection (5%) and 2 cases of flap dehiscence (5%) were recorded. This study demonstrates that elevation of the sinus floor with a combination of hand and sonic instruments is feasible and safe, with a limited incidence of complications.

Application of evidence‐based dentistry: from research to clinical periodontal practice

Dentists need to make daily decisions regarding patient care, and these decisions should essentially be scientifically sound. Evidence-based dentistry is meant to empower clinicians to provide the most contemporary treatment. The benefits of applying the evidence-based method in clinical practice include application of the most updated treatment and stronger reasoning to justify the treatment. A vast amount of information is readily accessible with todays digital technology, and a standardized search protocol can be developed to ensure that a literature search is valid, specific and repeatable. It involves developing a preset question (population, intervention, comparison and outcome; PICO) and search protocol. It is usually used academically to perform commissioned reviews, but it can also be applied to answer simple clinical queries. The scientific evidence thus obtained can then be considered along with patient preferences and values, clinical patient circumstances and the practitioners experience and judgment in order to make the treatment decision. This paper describes how clinicians can incorporate evidence-based methods into patient care and presents a clinical example to illustrate the process.

The Presence of the Mandibular Incisive Canal: A Panoramic Radiographic Examination

Purpose:The mandibular incisive canal (MIC) is the anterior extension of the mandibular canal and its presence is of interest in surgical procedures in the chin region. The aim of this study was to investigate the presence of a MIC in panoramic radiographs (OPGs). Methods:One thousand forty-five OPGs were randomly chosen from patient population. The data collected included patient characteristics and MIC presence/absence according to the type of the dentition. Measurements (in mm) were performed evaluating the following: (A) minimum and (B) maximum distance from the alveolar ridge; (C) thickness and (D) length of the canal; and (E) distance (in bilateral cases) between the canals. Results:The MIC was found in 2.7% of the patients. Conclusions:This study demonstrates the frequency of the MIC in OPGs and suggests that this anatomical structure should be considered to prevent injury during surgery.

Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions

BACKGROUND A variety of systemic diseases and conditions can affect the course of periodontitis or have a negative impact on the periodontal attachment apparatus. Gingival recessions are highly prevalent and often associated with hypersensitivity, the development of caries and non-carious cervical lesions on the exposed root surface and impaired esthetics. Occlusal forces can result in injury of teeth and periodontal attachment apparatus. Several developmental or acquired conditions associated with teeth or prostheses may predispose to diseases of the periodontium. The aim of this working group was to review and update the 1999 classification with regard to these diseases and conditions, and to develop case definitions and diagnostic considerations. METHODS Discussions were informed by four reviews on 1) periodontal manifestions of systemic diseases and conditions; 2) mucogingival conditions around natural teeth; 3) traumatic occlusal forces and occlusal trauma; and 4) dental prostheses and tooth related factors. This consensus report is based on the results of these reviews and on expert opinion of the participants. RESULTS Key findings included the following: 1) there are mainly rare systemic conditions (such as Papillon-Lefevre Syndrome, leucocyte adhesion deficiency, and others) with a major effect on the course of periodontitis and more common conditions (such as diabetes mellitus) with variable effects, as well as conditions affecting the periodontal apparatus independently of dental plaque biofilm-induced inflammation (such as neoplastic diseases); 2) diabetes-associated periodontitis should not be regarded as a distinct diagnosis, but diabetes should be recognized as an important modifying factor and included in a clinical diagnosis of periodontitis as a descriptor; 3) likewise, tobacco smoking - now considered a dependence to nicotine and a chronic relapsing medical disorder with major adverse effects on the periodontal supporting tissues - is an important modifier to be included in a clinical diagnosis of periodontitis as a descriptor; 4) the importance of the gingival phenotype, encompassing gingival thickness and width in the context of mucogingival conditions, is recognized and a novel classification for gingival recessions is introduced; 5) there is no evidence that traumatic occlusal forces lead to periodontal attachment loss, non-carious cervical lesions, or gingival recessions; 6) traumatic occlusal forces lead to adaptive mobility in teeth with normal support, whereas they lead to progressive mobility in teeth with reduced support, usually requiring splinting; 7) the term biologic width is replaced by supracrestal tissue attachment consisting of junctional epithelium and supracrestal connective tissue; 8) infringement of restorative margins within the supracrestal connective tissue attachment is associated with inflammation and/or loss of periodontal supporting tissue. However, it is not evident whether the negative effects on the periodontium are caused by dental plaque biofilm, trauma, toxicity of dental materials or a combination of these factors; 9) tooth anatomical factors are related to dental plaque biofilm-induced gingival inflammation and loss of periodontal supporting tissues. CONCLUSION An updated classification of the periodontal manifestations and conditions affecting the course of periodontitis and the periodontal attachment apparatus, as well as of developmental and acquired conditions, is introduced. Case definitions and diagnostic considerations are also presented.