Investigating the effect of the Toll-like receptor-4 inhibitor TAK-242 on alveolar bone resorption in severe periodontitis in rats / 口腔疾病防治

Objective@# The goal of this study was to investigate the effect of the Toll-like receptor-4 (TLR-4) inhibitor TAK-242 on bone resorption in severe periodontitis in rats in order to provide an experimental basis for finding new adjuvant treatments for severe periodontitis.@*Methods @# Eighteen three-week-old male Wistar rats were randomly divided into three groups (n=6). One group was the control group, and the other two groups were modelled with severe periodontitis in bilateral maxillary molars ligated with 5-0 silk thread containing P. gingivalis ATCC33277 (periodontitis and TAK-242 groups, respectively). The TAK-242 group was injected with TAK-242 (2 mg/kg) in DMSO every other day through the tail vein from the first day of silk ligation, and the other two groups were injected with DMSO solvent at the same proportion of body weight for 8 consecutive weeks. At the end of the 8th week, rats in the 3 groups were sacrificed, and maxillary specimens were taken. Three-dimensional reconstruction was achieved after micro-CT scanning to measure the distance between the enamel cementum boundary and alveolar crest at specific sites to assess the amount of bone loss. The parameters related to alveolar bone and bone microstructure were analyzed, and the pathological changes of periodontal tissue were observed by hematoxylin-eosin (HE) staining. Alveolar bone resorption was observed by Methyl Green staining, and the distribution of osteoclasts was observed by anti-tartrate acid phosphatase double staining (TRAP).@*Results@#Micro-CT quantitative analysis showed that alveolar bone resorption in the periodontitis group and TAK-242 group was significantly higher than that in the control group. Compared with the periodontitis group, bone loss of the mesial and distal root resorption sites of maxillary first molars was significantly reduced in the TAK-242 group (P < 0.001), the bone mineral density (P < 0.05) and bone volume/total volume fraction (P < 0.01) were significantly increased, and the number of trabeculae and the trabeculae thickness (P < 0.01) were relatively increased. The trabecular separation (P < 0.01) and trabecular structure model index were significantly decreased. In the periodontitis group, the bone exhibited a sparse and porous honeycomb structure, with deterioration of the trabecular structure and a shift towards a rod-strength structure. In the TAK-242 group, the bone microstructure was improved, the bone volume was enriched, the distribution of trabeculae was relatively denser and the trabecular structure shared more similarities with the control group. HE staining displayed that the attachment loss and bone absorption were significantly higher in the periodontitis group and TAK-242 group than in the control group. Compared with the periodontitis group, MG staining displayed significantly alleviated bone absorption in the TAK-242 group. TRAP staining showed that osteoclast infiltration decreased in the TAK-242 group compared with the periodontitis group (P < 0.001)@*Conclusions @#The TLR-4 inhibitor TAK-242 can alleviate bone resorption in severe periodontitis and improve the porous, sparse and disorganized inflammatory bone trabecular structure in rats.

Cognitive impairment related to arterial stiffness in cardiovascular disease patients with severe periodontitis / Deterioro cognitivo relacionado a la rigidez arterial en pacientes con enfermedad cardiovascular y periodontitis grave

ABSTRACT Severe periodontal disease (SPD) associated with systemic peripheral inflammation, cognitive impairment (CI) and arterial stiffness (AS) has been recognized. The aim of this study was to investigate whether CI and arterial stiffness (AS) occur in cardiovascular disease (CVD) patients with SPD. A crosssectional case-control study included hospitalized patients with CVD. Demographic characteristics, CVD and atherogenic risk factors were recorded. SPD was diagnosed by clinical and radiographic dental examinations. Dental clinical attachment level (CAL) and CAL % were recorded. A Mini-Mental State Examination test (MMSE) assessed cognition, a MMSE score of < 27 was set as the cut-off point of CI; a score > 27 was considered as no CI. Patients were categorized into: MMSE<27 (cases) and MMSE>27 (controls). AS was evaluated by pulse wave velocity (PWV). Serum VCAM-1 levels were determined in a random sample. Results: This study comprised 91 patients (cases, n=26; 29.6%; controls, n=65, 71.4%); aged 73±8 vs. 73±7 years, respectively (p=0.73), of whom 53.8% and 36.9% respectively, were women; SPD was found to be a risk factor for CI; the presence of SPD increased the risk for MMSE <27 by an average 5.39 times (model 1). PWV was associated with MMSE < 27 in the three models. The risk of having MMSE < 27 increased an average of2.404-fold for each 1-unit increase in PWV SPD and AS had significant and independent associations on the risk for development CI. MMSE negatively correlated with CAL% (r=0.69) and PWV (r=0.70). PWV positively correlated with CAL% (r=0.67). Serum VCAM-1 levels were higher in SPD with lower MMSE scores. In conclusion, SPD increases the risk of development of cognitive decline in CVD patients. PWV was directly associated with the risk of cognitive decline. These findings denote a significant opportunity to improve periodontal health in order to avert CI in CVD patients.

RESUMEN La enfermedad periodontal severa (EPS) podría estar asociada a la rigidez arterial (RA) y al deterioro cognitivo (DC). Se realizó un estudio transversal de casos y controles y se investigó la presencia de RA y DC en pacientes con enfermedad cardiovascular (ECV) y EPS. En pacientes hospitalizados con ECVse registraron las características demográficas y factores de riesgo aterogénicos. El DC se diagnosticó a través del Mini-Mental State Examination (MMSE). Punto de corte: MMSE<27 (casos); puntaje >27 ausencia de DC (controles). La EPS fue diagnosticada clínica y radiográficamente. Se registraron el nivel inserción clínica (NIC) y NIC %. La RA fue evaluada a través de la velocidad de onda de pulso (VOP). VCAM-1 sérico se determinó en una muestra aleatoria. Se incluyeron 91 pacientes (casos,n=26; 29.6%; controles,n=65, 71.4%); edad promedio: 73±8 vs. 73±7 años, respectivamente (p=0.73); % de mujeres: 53.8 vs. 36.9, respectivamente y EPS (n=54) y ausencia de EP (noEP) en 37. MMSE< 27 en 26 pacientes; 23 de ellos, con EPS. La presencia de EPS aumentó el riesgo de MMSE< 27 en 5.39 veces (modelo 1). La VOP se asoció a MMSE< 27 (Modelo 1, 2 y 3). El riesgo de MMSE< 27 incrementó en promedio en 2.40 veces por cada aumento de unidad de VOP. EPS y RA mostraron asociaciones significativas e independientes sobre el riesgo de DC. MMSE se correlacionó negativamente con NIC % (r=0.69) y POV (r=0.70); y POV, positivamente con NIC % (r=0.67). Los niveles séricos de VCAM-1 fueron más elevados en presencia de EPS y puntajes bajos de MMSE. Puede concluirse que en pacientes con ECV y EPS, el aumento en RA incrementaría el riesgo de DC. Estos hallazgos enfatizan la necesidad de promover y mantener la salud bucal para evitar el DC en pacientes con ECV.

Short-term clinical efficacy observation of adjunctive Er, Cr:YSGG laser application following subgingival scaling in patients with severe periodontitis / 上海交通大学学报（医学版）

Objective · To observe the short-term clinical efficacy of adjunctive Er, Cr:YSGG laser application following subgingival scaling in patients with severe periodontitis. Methods · In this parallel control design clinical trial, 46 patients with severe periodontitis were selected. Baseline examination was performed 2 weeks after supragingival scaling. Then the patients were randomly divided into the test group and the control group, with 23 cases in each group. After ultrasonic subgingival scaling, sites with probing depth (PD) ≥5 mm of patients in two groups received subgingival debridement with Er, Cr:YSGG laser and hand curettes, receptively. The changes in plaque index (PLI), PD, clinical attachment level (CAL), the percentage of bleeding on probing (BOP) positive sites, and the degree of subjective pain during treatment with visual analogue scale (VAS) were compared between two groups at baseline, 6 weeks after treatment, and 3 months after treatment. Results · For sites with PD≥5 mm, PLI, PD, CAL, and the percentage of BOP positive sites significantly reduced for both groups at 6 weeks and 3 months after treatment compared with baseline (all P=0.000). For sites with 5 mm ≤ PD ≤ 6 mm, the CAL of the test group was significantly lower compared with the control group at 6 weeks after treatment (P=0.036). For sites with PD ≥ 7 mm, the PDs of the test group were significantly lower compared with the control group at 6 weeks and 3 months after treatment (P=0.002, P=0.039). The PD reduction between baseline and 6 weeks after treatment was greater in the test group compared with the control group (P=0.015). The CAL of the test group was lower compared with the control group at 6 weeks after treatment (P=0.011). The VAS of the test group was significantly lower than that of the control group (P=0.005). Conclusion · Adjunctive Er, Cr:YSGG laser application following subgingival scaling can achieve similar short-term clinical efficacy compared with traditional hand curettes. Er, Cr:YSGG laser may be beneficial particularly on the reduction of PD and regain of CAL in deep pockets on a short-term basis, which can make the patients more comfortable. Subgingival scaling with adjunctive Er, Cr:YSGG laser application can be an effective way for the non-surgical periodontal therapy.

Short-term clinical efficacy observation of adjunctive Er,Cr:YSGG laser application following subgingival scaling in patients with severe periodontitis / 上海交通大学学报（医学版）

Objective • To observe the short-term clinical efficacy of adjunctive Er,Cr:YSGG laser application following subgingival scaling in patients with severe periodontitis. Methods • In this parallel control design clinical trial, 46 patients with severe periodontitis were selected. Baseline examination was performed 2 weeks after supragingival scaling. Then the patients were randomly divided into the test group and the control group, with 23 cases in each group. After ultrasonic subgingival scaling, sites with probing depth (PD) ≥ 5 mm of patients in two groups received subgingival debridement with Er,Cr:YSGG laser and hand curettes, receptively. The changes in plaque index (PLI), PD, clinical attachment level (CAL), the percentage of bleeding on probing (BOP) positive sites, and the degree of subjective pain during treatment with visual analogue scale(VAS)were compared between two groups at baseline, 6 weeks after treatment, and 3 months after treatment. Results • For sites with PD ≥ 5 mm, PLI, PD, CAL, and the percentage of BOP positive sites significantly reduced for both groups at 6 weeks and 3 months after treatment compared with baseline (all P=0.000). For sites with 5 mm ≤ PD ≤ 6 mm, the CAL of the test group was significantly lower compared with the control group at 6 weeks after treatment (P=0.036). For sites with PD ≥ 7 mm, the PDs of the test group were significantly lower compared with the control group at 6 weeks and 3 months after treatment (P=0.002, P=0.039). The PD reduction between baseline and 6 weeks after treatment was greater in the test group compared with the control group (P=0.015). The CAL of the test group was lower compared with the control group at 6 weeks after treatment (P=0.011). The VAS of the test group was significantly lower than that of the control group (P=0.005). Conclusion • Adjunctive Er,Cr:YSGG laser application following subgingival scaling can achieve similar short-term clinical efficacy compared with traditional hand curettes. Er,Cr:YSGG laser may be beneficial particularly on the reduction of PD and regain of CAL in deep pockets on a short-term basis, which can make the patients more comfortable. Subgingival scaling with adjunctive Er,Cr:YSGG laser application can be an effective way for the non-surgical periodontal therapy.

Full mouth rehabilitation of a patient with severe periodontitis using immediate loading after computer aided flapless implant surgery

Oral rehabilitation of a patient having severe periodontitis with alveolar bone resorption and periodontal inflammation presents a challenge to clinicians. However, if appropriate implant placement according to the bone shape is selected, unnecessary bone grafting or soft tissue surgery can be minimized. In recent years, using cone beam CT and software, it has become possible to operate the planned position with the surgical guide made with 3D printing technology. This case was a 70 years old female patient who required total extraction of teeth due to severe periodontitis and performed a full-mouth rehabilitation with an implant-supported fixed prosthesis. During the surgery, the implant was placed in a flapless manner through a surgical guide. Immediate loading of the temporary prosthesis made by CAD/CAM method before surgery was done. Since then, we have produced customized abutments and zirconia prostheses, and have reported satisfactory aesthetic and functional recovery.

Severe periodontitis complicated with oral lichen planus: A case report and literature review / 吉林大学学报(医学版)

Objective; To analyze the clinical manifestion and treatment method of one patient with severe periodontitis complicated with oral lichen planus, and to clarify the effect of combined treatment method and the importance of regular follow-up. Methods; The clinical manifestion of the patient was that the bilateral moral teeth had become looseness and the gum had bled for six months, and the patients had a history of oral lichen planus in gum for 2 years old. The probing depth (PD) of all the teeth was 5-6 mm and the attachment loss (AL) was 8-9 mm, with II °-IE "mobility and bleeding on probing (BOP) (+). The teeth was treated with the regular basis periodontal treatment combined with gingival triamcinolone acetonide injection treatment. When the inflammation situation remained stable, the delayed implantation was performed and the crown restoration treatment was done for 26, 27, 36 and 37. The splinting treatment was done for 31 and 41 II mobile teeth. The regular follow-up periods were 1 week, 2 weeks, 1 month, 3 months, and 6 months after treatment during periodontal maintenance. Results; After combined treatment and regular follow-up, the PD of both anterior and premolar were 4 mm, and the BOP was negative. The clinical symptom of oral lichen planus of the patient was relieved, and there were no symptoms of congestion and erosion on the gum. After the inflammation situation was controlled, the chewing function of the left molar region was restored by implantation rehabilitation. A 3-month-follow-up cycle and excellent treatment compliance were beneficial for the control of disease. The optimal follow-up period of gingival condition maintained best was once per 2 weeks. Conclusion: The combined treatment can relieve the clinical symptoms of the patient with severe periodontitis complicated with oral lichen planus. Regular follow-up and excellent treatment compliance are conducive to controlling the condition of disease.

Combination of periodontal, orthodontic and endodontic therapy in upper anterior teeth with hopeless prognosis and long-time follow-up:a case report / 北京大学学报(医学版)

It is complicated to decide the treatment plan of hopeless anterior teeth in esthetic zone due to severe periodontitis, periodontal-endodontic combined lesion or teeth trauma.The optional treatment plan for this kind of teeth includes retention after periodontal treatment, extraction and implant treatment, extraction and prosthodontic treatment and so on.To make an appropriate treatment plan, patients'' periodontal conditions, periodontal biotype, local anatomy, esthetic demand, economic condition and social psychological status should be comprehensively considered.A combine of periodontal, endodontic and orthodontic therapy may achieve a good treatment effect in hopeless anterior teeth with severe periodontal destruction, tooth extrusion and occlusal trauma.In this case, a 20-year-old female who presented with symptoms of bleeding on brushing and upper incisors loosening for 1 month came to the Department of Periodontology, Peking University School and Hospital of Stomatology.The clinical examinations revealed that the patient''s right upper incisor had signs of mobility (Ⅲ°), intrusion of 1-2 mm, and probing depth (PD) of 9-10 mm.The periapical radiograph showed that the alveolar bone of right upper incisor absorbed horizontally to the apex.And the patients showed Angle Ⅱ° malocclusion with Ⅱ° overbite in anterior teeth and maxillary protrusion.A diagnosis of aggressive periodontitis and Angle Ⅱ° malocclusion was made.The treatment of this patient lasts for 5 years which include periodontal initial therapy, orthodontic therapy, guided tissue regeneration (GTR) of right upper incisor and supportive periodontal therapy and the clinical result is fine.A hopeless upper incisor was successfully retained and the longtime clinical condition was stable.The strategy of retention of hopeless upper anterior teeth, the relationship of periodontal treatment and orthodontic treatment, and the indications of periodontal and orthodontic combined therapy were also discussed on the basis of this case.Generally, the positive factors in retention of hopeless teeth includes young age, absence of systemic conditions, strong motivation for maintaining the tooth, single root anatomy, integrated dentition, good response to cause-related therapy, intrabony alveolar bone defect, thick periodontal biotype, and regular supportive periodontal therapy.And in the progress of orthodontic therapy, regular supportive periodontal therapy and good plaque control is extremely important.

Paillion- Lefèvere Syndrome: A Case Report.

Papillon-Lefèvere Syndrome (PLS) is one of the rare autosomal recessive disorders of keratinization (1-4 cases per million). It is inherited as an autosomal-recessive condition with one-third of the patients showing consanguinity of the parents and diagnosed in both sexes. Lesions are characterized by palmo-plantar hyperkeratosis and severe destructive periodontal disease affecting the primary and permanent teeth. This paper reports a case of a 13 -year-old African boy presented to the outpatient clinic of Qassim University with diffuse keratotic plaques of his soles extending to the dorsal surface, localized keratotic plaques of his palm and severe inflammation of the gingiva with premature teeth loss and looseness of remaining teeth.

The relativity analysis of the risk factors of the old subjects with severe periodontitis / 实用口腔医学杂志

Objective:To study risk factors of the old subjects with severe periodontitis.Methods:1 60 cases of patients aged 61 ~81 years with severe periodontitis were included in the case group and other 200 cases of age matched individuals without periodontitis were included in the control group.The related risk factors for senile severe periodontitis were analyzed by oral and periodental exami-nation and questionaire survey.Results:Smoking (OR =3.1 601 ,95% CI:1 .051 -1 .31 0),diabetes mellitus(OR =2.1 42,95%CI:1 .621 -5.91 2),bad prosthesis(OR =1 .989,95% CI:1 .21 8 -4.298),merging root bifurcation lesions (OR =3.282,95%CI:1 .01 9 -2.296)and the combination of systemic disease (OR =2.1 96,95% CI:1 .51 6 -2.61 9)factors were closely related to the pathogenesis of elderly severe periodontitis,and were the independent risk factors.Conclusion:Smoking,diabetes mellitus,bad prosthesis,root bifurcation lesions and the combining systemic disease are main risk factors of senile severe periodontitis diseases.

The effect of periodontal flap therapy on the levels of serum TNF-α,IL-6 and CRP in elderly coronary heart disease / 重庆医学

Objective To observe the effect of different periodontal therapies on serum levels of tumor necrosis factor-alpha (TNF-α),interleukin-6(IL-6)and C-reactive protein (CRP)in elderly patients with coronary.Methods Totally 90 elderly patients with severe periodontitis were divided into three groups,the control group performed the treatment of coronary heart disease;the periodontal treatment group performed the treatment of coronary heart disease and periodontal treatment;the combine group per-formed periodontal therapy and flap surgery on the basis of the treatment of coronary heart disease.The obvervational index were compared among three groups.Results All patients′clinical indexes of periodontitis of combination group and basic group has im-proved after treatment,the levels of PD,SBI,CAL,PLI,the percentage of bleeding on probing and probing depth were significantly decreased (P <0.05),and had significant adhesion(P <0.05);the contrast between combination group and basic group,the levels of PD,SBI,CAL,the percentage of bleeding on probing and probing depth had notable difference(P <0.05).All patients′clinical indexes of periodontitis of combination group and basic group had improved after treatment,serum levels of TNF-α,IL-6 and CRP were significantly decreased (P <0.05);the contrast between combination group and basic group,serum levels of TNF-α,IL-6 and CRP have notable difference (P <0.05).Conclusion The periodontal basic therapy and periodontal flap therapy can reduce the ser-um levels of TNF-α,IL-6 and CRP of elderly coronary heart disease (CHD),but compared to the routine medicine maintenance therapy,the effect of periodontal flap therapy is better.

Periodontal disease as a risk factor for coronary artery disease.

Background: To evaluate and compare the serum levels of total cholesterol, triglycerides and LDL in subjects with healthy periodontal disease with that of chronic generalized severe periodontitis. Methods: 30 subjects with a healthy periodontium (control group) and 30 subjects suffering from chronic generalized severe periodontitis (test group) were selected for the study to compare their serum levels of total cholesterol, triglycerides and LDL after obtaining informed consent. Blood samples were collected and sent for the assessment of lipid (total cholesterol, triglyceride, LDL) levels and the data was subjected to statistical analysis. Results: The results of the our study show that there is significantly higher levels of total cholesterol, triglycerides and LDL in chronic generalized severe periodontitis as compared to healthy periodontium. Conclusion: The observation of this study was that there was a statistically highly significant level of total cholesterol, triglyceride and LDL in chronic generalized severe periodontitis as compared to healthy subjects suggesting a relationship between periodontitis and cardiovascular disease.

Prevalência de periodontite grave em pacientes submetidos à angioplastia coronária / Severe periodontitis prevalence in patients undergoing coronary angioplasty

A doença periodontal é uma doença infecciosa que acomete os tecidos periodontais e é responsável por cerca de um terço de todas as causas de perdas dentárias no mundo. A doença periodontal pode se apresentar de maneira branda, na forma de gengivite, ou na forma mais nociva, a periodontite, que expõe o indivíduo à intensa carga infecciosa e inflamatória. Nos últimos anos, várias pesquisas têm demonstrado a relação entre o caráter inflamatório das periodontites e a doença aterosclerótica coronariana. Entretanto, a prevalência das doenças periodontais, especialmente das formas mais graves em pacientes coronariopatas, ainda não foi bem estabelecida. Tal fato motivou a realização dessa pesquisa, que teve o objetivo de verificar a prevalência de periodontite grave em pacientes coronariopatas encaminhados para Angioplastia Coronariana no Instituto Nacional de Cardiologia. Foram avaliados 89 pacientes, 67 homens e 22 mulheres, com média de idade de 56 anosA prevalência de periodontite grave encontrada foi de 39,3 porcento. Todos os pacientes apresentaram gengivite, mau controle de placa bacteriana, e 72 porcento dos pacientes apresentaram alguma forma de periodontite, caracterizando uma amostra com más condições de saúde odontológica geral. Na análise da diferença de distribuição da periodontite grave em variáveis sociais, demográficas e cardiológicas, foi encontrada uma associação importante entre periodontite grave e pacientes não-brancos, e periodontite grave e histórico de infarto do miocárdio. Assim, é possível afirmar que os achados dessa pesquisa mostram uma alta prevalência de periodontite grave nos pacientes examinados e que maior atenção deve ser dada ao diagnóstico e tratamento dessa doença em pacientes coronariopatas, especialmente não brancos e com histórico de infarto do miocardio...

Periodontal disease is an infectious disease that affects the periodontal tissues and accounts for about one third of all causes of tooth loss in the world. Periodontal disease can present it mildly, in the form of gingivitis,or more noxious, the periodontitis, whichexposes the subject to intense inflammatory and infectious load. In recent years, many studies have shown the relationship between the inflammatory nature of periodontitis andatherosclerotic disease. Nevertheless,the prevalence of periodontal diseases, especially the more severe forms, in coronary atherosclerotic diseasepatients has not been well established. This issue led to the completion of this research, that aimed to verify theprevalence of severe periodontitis in patients with coronary artery disease referred for coronary angioplasty at the National Institute of Cardiology. We evaluated 89 patients, 67 male and 22female, with a mean age of 56 years. The prevalence of severe periodontitis was found to be 39.3 percent. All patients were diagnosed with gingivitis,showed poor control of bacterial plaque,and 72 percent of patients had some form of periodontitis, featuring asample with poor dental health ingeneral. In the analysis of the difference in distribution of severe periodontitis in varying social, demographic and cardiological, we found a significant association between severe periodontitis and non-white patients and severe periodontitis and history of myocardial infarction. Thus it can be said that the findings of this research show a high prevalence of severe periodontitis in patients examined and that more attention should be given to the diagnosis and treatment of this disease in coronarypatients, especially non - white and with a history of myocardial infarction...

Horizontal attachment loss in extracted teeth due to severe periodontitis / 대한치주과학회지

PURPOSE: The attachment level is strongly associated with tooth loss and provides useful information on patterns of destruction of the periodontium. The presence of horizontal attachment loss would not be detected in clinical measurement. Therefore, the purpose of the present study was to estimate the patterns of periodontal destruction based on the attachemnt area and horizontal attachment loss in extracted teeth due to severe periodontitis. MATERIALS AND METHODS: 307 teeth satisfied the criteria for assessment. An indirect method, based on digital images obtained from a digital camera and an image analysis program, was used to calculate the area of root surface and attachment loss and the extent of horizontal attachment loss. The data were analysed using SPSS. RESULTS: No statistically significant differences among root surfaces were observed in anterior teeth on the loss of attachment area. However, in posterior teeth statistically significant differences in palatal surfaces of maxillary and mandibular premolar and molar surfaces compared with buccal surfaces were observed. Horizontal attachment loss was observed in 21.5% of the teeth examined. Frequency of horizontal attachment loss was highest in the maxillary first premolar (34.8%), followed by the maxillary second premolar (27.3%) and maxillary canine (25%). The mean length of horizontal attachment loss was 1.5mm. CONCLUSION: More meticulous examination will be needed of the palatal surfaces of maxillary and mandibular premolar and molar teeth. The percentage of teeth with horizontal attachment loss greater than 2.1 mm was 5.2%. Considering the length of curette blades, about 5.2% of teeth were not properly debrided. Therefore, Additional supportive therapy such as local drug delivery has to be considered in treatment of the first maxillary, second premolar and canine due to the high prevalence of horizontal attachment loss.