Philipp Sahrmann

Current Status and Perspectives of Mucogingival Soft Tissue Measurement Methods

UNLABELLED The morphologic and metric assessment of mucogingival soft tissue dimensions is of great multidisciplinary clinical and academic interest, in order to quantify and monitor gingival changes while in treatment, e.g., during periodontal, restorative, prosthetic, orthodontic, or implant therapy. Pink esthetics play an increasingly important role in the overall treatment success, and therefore have to be monitored throughout therapy. The purpose of this article was to identify and summarize methods, which aim at quantifying gingival dimensions in terms of morphology, thickness, and volume, with respect to their accuracy and practicability. The introduced measurement methods should further facilitate personalized treatment planning and monitoring. CLINICAL SIGNIFICANCE Mucogingival esthetics play an increasingly important role whenever treatment results are evaluated. Several qualitative and (semi)quantitative methods for measuring soft tissue dimensions are available. New methods like CAD/CAM (computer-aided design and computer-aided manufacturing) technologies are emerging and allow practitioners to reliably monitor their patients soft tissues throughout therapy. Future improvements may help to develop better treatment strategies in terms of optimized preservation and creation of gingival morphology, especially in the esthetic zone.

Systematic review on the effect of rinsing with povidone-iodine during nonsurgical periodontal therapy.

BACKGROUND AND OBJECTIVE The existing literature is inconsistent regarding whether there is any additional effect of povidone-iodine (PVP-iodine) as an adjunctive to scaling and root planing, and, if there is an effect, what its size is. Therefore, the aim of this study was to assess the additional effect of PVP-iodine as an adjunct to scaling and root planing compared with water, saline or no rinse in the treatment of chronic periodontitis. MATERIAL AND METHODS An electronic literature search of the databases PubMed, EMBASE and the Cochrane Central Library, and a handsearch, were performed (up to November 2008). Two reviewers independently identified and selected screened abstracts for possible inclusion, and assessed randomized, controlled clinical trials comparing the additional benefit of PVP-iodine with water, saline rinsing or no rinsing in the nonsurgical periodontal therapy of patients with chronic periodontitis. A fixed-effects meta-analysis was conducted in the absence of statistically significant heterogeneity. RESULTS A small, but statistically significant additional beneficial effect of the adjunctive use of PVP-iodine with enhanced probing pocket depth reductions of 0.28 mm (95% confidence interval: 0.08 to 0.48, p = 0.007) was found. There was no significant heterogeneity between studies (I(2) = 0%). However, most of the studies included in the meta-analysis were of low quality, and the treatment modalities showed various differences such as the use of PVP-iodine at different concentrations and application modalities. Nevertheless, single-rooted teeth, in particular, showed an additional benefit after scaling and root planing with PVP-iodine, particularly when the treatment was repeated during the healing stage. CONCLUSION The adjunctive use of PVP-iodine during scaling and root planing may increase the clinical pocket depth reduction, although the clinical significance is small to moderate.

In vitro cleaning potential of three different implant debridement methods

OBJECTIVES To assess the cleaning potential of three different instrumentation methods commonly used for implant surface decontamination in vitro, using a bone defect-simulating model. MATERIALS AND METHODS Dental implants were stained with indelible ink and mounted in resin models, which represented standardized peri-implantitis defects with different bone defect angulations (30, 60 and 90°). Cleaning procedures were performed by either an experienced dental hygienist or a 2nd-year postgraduate student. The treatment was repeated 20 times for each instrumentation, that is, with a Gracey curette, an ultrasonic device and an air powder abrasive device (PAD) with glycine powder. After each run, implants were removed and images were taken to detect color remnants in order to measure planimetrically the cumulative uncleaned surface area. SEM images were taken to assess micromorphologic surface changes (magnification 10,000 ×). Results were tested for statistical differences using two-way ANOVA and Bonferroni correction. RESULTS The areas of uncleaned surfaces (%, mean ± standard deviations) for curettes, ultrasonic tips, and airflow accounted for 24.1 ± 4.8%, 18.5 ± 3.8%, and 11.3 ± 5.4%, respectively. These results were statistically significantly different (P < 0.0001). The cleaning potential of the airflow device increased with wider defects. SEM evaluation displayed distinct surface alterations after instrumentation with steel tips, whereas glycine powder instrumentation had only a minute effect on the surface topography. CONCLUSION Within the limitations of the present in vitro model, airflow devices using glycine powders seem to constitute an efficient therapeutic option for the debridement of implants in peri-implantitis defects. Still, some uncleaned areas remained. In wide defects, differences between instruments are more accentuated.

Effect of short-time povidone-iodine application on osteoblast proliferation and differentiation.

Background and Objective: Povidone-iodine [polyvinylpyrrolidone-iodine complex (PVP-I)] is a broad-spectrum antimicrobial agent, frequently used in dentistry. In this study we investigated the short- and longterm effects on osteoblast number, viability, and function after short exposure to PVP-I with and without additional bone-morphogenetic protein-2 (BMP-2). Material and Methods: Confluent osteoblast-like cell line (MC3T3-E1, subclone 24) cultures were exposed to pure PVP-I solution (7.7 mg/ml) and dilutions of 1:10, 1:100 and 1:1000 for 10 seconds and washed with phosphate buffer solution. Cell proliferation and viability was determined by MTT and differentiation status by alkaline phosphatase (ALP) activity 6 days after initial plating. In a separate experiment, long-term cell proliferation, viability and function were assessed 4 weeks after PVP-I treatment by MTT and deposited calcium using an Alizarin-red staining test. Results: PVP-I decreased ALP activity substantially. Stimulation by BMP-2 recovered ALP activity to near control levels at 1:100 and 1:1000 dilutions of PVP-I. The MTT assay showed reduced proliferation of the preosteoblastic cells for all treatments, irrespective whether BMP-2 was used or not. Only at PVP-I dilutions of 1:1000 proliferation rate was back to normal levels (95.6±2.4 %). No adverse long-term effect of PVP-I on mineralization of the extracellular matrix (Alizarinred) for dilutions higher than 1:100 was observed. Interestingly, undiluted and 1:10 diluted PVP-I even showed a significant increase in mineral deposition, especially in the presence of BMP-2. Conclusion: Short-time application of PVP-I in concentrations of 1:10 and higher lead to decreased viability and impaired differentiation. However, surviving cells showed good recovery and mineralization potential.

Success of 6-mm Implants with Single-Tooth Restorations: A 3-year Randomized Controlled Clinical Trial

The aim of the study was to test whether implants of 6 mm in length perform equally well as 10-mm implants in terms of survival and marginal bone-level changes when supporting single crowns. Patients with a posterior single-tooth gap were randomly allocated to either the placement of a 6-mm (test) or 10-mm implant (control). The treatment protocol allowed for internal sinus lift but not for lateral bone augmentation. After a healing period of 10 wk, implants were loaded with screw-retained single crowns. Survival rates, number of pockets ≥5 mm, and bleeding-on-probing were assessed clinically. The change of marginal bone level and crown-to-implant ratios were analyzed by 2 examiners. Longitudinal intragroup analyses for marginal bone levels were performed applying the Wilcoxon signed rank test. Intergroup differences at baseline and at 3 y were compared using the Mann-Whitney U test. The effect of implant length and crown-to-implant ratio on changes of marginal bone level also was determined. Of 94 implants placed (47 test and 47 control), 78 implants (40 test and 38 control) were available for follow-up examination at 3 y of loading. One test implant was lost during the second year. Hence, implant survival was not significantly different between the 2 groups after 3 y (98% test; 100% control). We found no significant change in the crestal bone level from baseline to 3 y for test and control implants with −0.19 ± 0.62 mm and −0.33 ± 0.71 mm, respectively. The intergroup difference was not significant. Crown-to-implant ratios were not associated with a statistically significant difference in marginal bone loss. However, the number of sites with pockets ≥5 mm was significantly higher in the test group. Based on the 3-y assessment, the use of 6-mm implants can be considered a viable option when reconstructing posterior single tooth gaps (German Clinical Trials Registry: DRKS00006290).

Molecular microbiological evaluation of subgingival biofilm sampling by paper point and curette

The present clinical study aimed to investigate if there are differences in microbiological outcomes dependent on the subgingival biofilm collection method. Subgingival biofilm samples were collected from the four deepest pockets (>5 mm) of 17 patients with aggressive periodontitis (AgP) and 33 patients with chronic periodontitis (CP), first by paper point and thereafter by curette. Samples obtained with the same method were pooled together from each patient and forwarded for molecular microbiological analysis by a commercially available assay (IAI Pado Test 4.5) that estimates total bacterial load and levels of Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola and Aggregatibacter actinomycetemcomitans. Data analysis included frequency of detection, quantification and correlation of detection levels between the two sampling methods. P. gingivalis, T. forsythia and T. denticola were detected in >90% of the samples, and their detection levels exhibited a strong correlation between sampling methods. The detection consistency of A. actinomycetemcomitans was 56% between the two sampling methods. A. actinomycetemcomitans was more readily detected by paper point compared with curette collection with a stronger correlation between the two methods in AgP. Subgingival biofilm sampling by curette or paper point does not yield differences in the detection of the three ‘red complex’ species. However, A. actinomycetemcomitans was more consistently detected by means of paper point collection, which can be crucial in the decision to administer antibiotics as an adjunctive periodontal treatment.

Comparison of marginal bleeding using a periodontal probe or an interdental brush as indicators of gingivitis

AIM To compare the use of interdental brushes to a periodontal probe in assessing marginal bleeding, in natural gingivitis. MATERIALS AND METHODS Sixty-four consecutive volunteers presenting with gingival inflammation were recruited at their semi-annual recall appointments for this study. All had ≥50% papillary height and no pocketing that exceeded 4 mm. Contra-lateral quadrants (1 & 3 or 2 & 4) were randomly tested for bleeding with one pass-through with an interdental brush or with a periodontal probe inserted 2 mm into the gingival sulcus. The presence or absence of both bleeding and plaque were then recorded. Correlation coefficients were calculated for the interdental brushes and the periodontal probe, and the plaque and bleeding scores. RESULTS The periodontal probe and the interdental brushes showed mean average bleeding scores of 47.39% and 45.74% respectively. The correlation coefficient for the two methods was 0.73 (P < 0.0001). No correlation between plaque and bleeding was found. CONCLUSIONS Interdental brushes can be considered a valid alternative to a periodontal probe in assessing marginal bleeding in gingivitis patients. An interdental brush, sized correctly for each interdental space, is easy to handle, atraumatic to the papillae and will allow gingivitis patients to monitor their own progress, while at the same time performing a beneficial oral hygiene procedure and removing any interdental plaque present.

Three-Dimensional Defect Evaluation of Air Polishing on Extracted Human Roots

BACKGROUND Root surfaces experience continuous abrasive instrumentation during lifelong periodontal maintenance. Periodontists need both effective and minimally abrasive debridement techniques. Air polishing devices might, therefore, constitute a good alternative to mechanical instrumentation. Because little is known of the three-dimensional shape and volume of the abrasion caused by different powders, it is the aim of the study to investigate the three-dimensional extent of these defects. METHODS Cementum-covered roots of 20 extracted human premolars were coated with resin caps, leaving four areas with identical diameter open for instrumentation using bicarbonate powder and glycine powder. Treatment times were 5 and 10 seconds in a first interval and 10 seconds in a second interval. Maximum settings were chosen for power and lavage. The teeth were scanned using microcomputed tomography initially and after every treatment interval. Differences in volume and defect depths were calculated by superimposition of the scans and tested for significance (Wilcoxon test, P <0.001). RESULTS Defect volumes (in mm(3)) presented in medians (interquartile ranges) for the bicarbonate powder after 5, 10, 15, and 20 seconds, respectively, were 0.16 (0.11), 0.28 (0.16), 0.32 (0.18), and 0.41 (0.28), and for glycine powder, 0.00 (0.02), 0.01 (0.05), 0.03 (0.11), and 0.06 (0.1). For each time period, abrasion caused by glycine was significantly lower (five- to 20-fold) compared to defects caused by bicarbonate. CONCLUSIONS In patients with exposed root surfaces, cleaning with bicarbonate powder cannot be recommended. Less abrasive glycine powder, however, demonstrated non-critical substance loss.

An estimate of pocket closure and avoided needs of surgery after scaling and root planing with systemic antibiotics: a systematic review.

BackgroundRelevant benefits of adjunctive medication of antibiotica after conventional root surface debridement in terms of enhanced pocket depth (PD) reduction have been shown. However, means and standard deviations of enhanced reductions are difficult to translate into clinical relevant treatment outcomes such as pocket resolution or avoidance of additional surgical interventions. Accordingly, the aim of this systematic review was to calculate odds ratios for relevant cut-off values of PD after mechanical periodontal treatment with and without antibiotics, specifically the combination of amoxicilline and metronidazol, from published studies. As clinical relevant cut-off values “pocket closure” for PD ≤ 3mm and “avoidance of surgical intervention” for PD ≤ 5 mm were determined.MethodsThe databases PubMed, Embase and Central were searched for randomized clinical studies assessing the beneficial effect of the combination of amoxicillin and metronidazole after non-surgical mechanical debridement. Titles, abstracts and finally full texts were scrutinized for possible inclusion by two independent investigators. Quality and heterogeneity of the studies were assessed and the study designs were examined. From published means and standard deviations for PD after therapy, odds ratios for the clinically relevant cut-off values were calculated using a specific statistical approach.ResultsMeta-analyses were performed for the time points 3 and 6 month after mechanical therapy. Generally, a pronounced chance for pocket closure from 3 to 6 months of healing was shown. The administration of antibiotics resulted in a 3.55 and 4.43 fold higher probability of pocket closure after 3 and 6 months as compared to mechanical therapy alone. However, as the estimated risk for residual pockets > 5 mm was 0 for both groups, no odds ratio could be calculated for persistent needs for surgery. Generally, studies showed a moderate to high quality and large heterogeneity regarding treatment protocol, dose of antibiotic medication and maintenance.ConclusionWith the performed statistical approach, a clear benefit in terms of an enhanced chance for pocket closure by co-administration of the combination of amoxicillin and metronidazole as an adjunct to non-surgical mechanical periodontal therapy has been shown. However, data calculation failed to show a benefit regarding the possible avoidance of surgical interventions.

Povidone-iodine gel and solution as adjunct to ultrasonic debridement in nonsurgical periodontitis treatment: an RCT pilot study.

OBJECTIVES Polyvinylpyrrolidone-iodine (PVP-iodine or povidone- iodine) enhances the treatment outcomes of initial periodontal treatment but the degree of benefit varies in the literature. A main reason might be the concentration of the dosage form and its contact time with the periodontal tissues. In this randomized pilot study the effect of repeated subgingival application of PVP-iodine during scaling and root planing (SRP) was assessed. Changes of clinical parameters and microbiotic taxa after 3 months were analyzed. METHOD AND MATERIALS In a split-mouth design 12 patients with generalized, severe periodontitis were treated with SRP combined with subgingival application of either PVP-iodine or water. Test and control sides were isolated with a special rubber dam technique. Irrigations were reapplied during SRP. Periodontal probing depth (PD) and recessions were documented before treatment and after 3 months. Samples of subgingival bacteria before SRP and after 1 week, 1 month, and 3 months were analyzed. RESULTS Three months after SRP, changes for PD and recession in deep pockets were significantly higher in the PVP-iodine group (P = .012 and .044 respectively). The number of these pockets was reduced from 73 at baseline to 8 in the test and 19 in the control group. In both groups, bacterial taxa were reduced after 1 week. One month after SRP only taxa of Porphyromonas gingivalis in the PVP-iodine group were lower than at baseline. After 3 months, all taxa regained baseline values. CONCLUSION PVP-iodine reapplied frequently during SRP might enhance pocket depth reduction in initially deep pockets.