Combined periodontal regeneration of molar severely compromised by furcation, intrabony defects and attachment loss to the apex: a case report / Regeneración periodontal combinada de molar gravemente comprometido por furcación, defectos intraóseos y pérdida de inserción en el ápice: reporte de un caso

Introduction: Clinicians tend to encounter unfavorable situations in the treatment of teeth with severe attachment loss. Periodontal regeneration has been a successful therapeutic approach in treatments that require a long-term prognosis improvement. This case shows the benefits of combined regenerative periodontal therapy in a patient with a molar severely compromised by furcation, intrabony defects and attachment loss to the apex. Case Report: The clinical case included an endo-periodontal, class III furcation and intrabony defects in a generalized periodontitis, Stage III Grade C patient. After non-surgical periodontal treatment and re-evaluation, a full-thickness flap and surgical debridement were performed. Dental root surface was treated with EDTA and enamel matrix derivatives and the defects were filled with allograft and platelet-rich fibrin, additionally a collagen membrane was applied over the graft. After a 12-month follow-up there was a resolution of the intrabony defects and periodontal regeneration. Clinical and radiographic evaluation also showed the partial resolution of the class III furcation defect. Conclusion: Combined periodontal regeneration can be a therapeutic approach to improve the prognosis and prevent the extraction of molars severely compromised by furcation, intrabony defects and attachment loss to the apex.

Introducción: Los clínicos tienden a encontrar situaciones desfavorables en el tratamiento de dientes por pérdida de inserción severa. La regeneración periodontal ha sido un enfoque terapéutico exitoso en tratamientos que requieren una mejora del pronóstico a largo plazo. Este caso demuestra los beneficios de la terapia periodontal regenerativa combinada en un paciente con un molar gravemente comprometido por furcación, defectos intraóseos y por pérdida de inserción hasta el ápice. Reporte de caso: El caso clínico incluyó un defecto endoperiodontal, furcación clase III y defectos intraóseos en una Periodontitis estadio III generalizada grado C. Tras el tratamiento periodontal no quirúrgico y la reevaluación, se realizó un colgajo de espesor total y un desbridamiento quirúrgico. La superficie de la raíz dental se trató con EDTA y derivados de la matriz de esmalte y los defectos se rellenaron con aloinjerto y fibrina rica en plaquetas, adicionalmente se aplicó una membrana de colágeno sobre el injerto. Después de un seguimiento de 12 meses hubo resolución de los defectos intraóseos y regeneración periodontal. La evaluación clínica y radiográfica también mostró la resolución parcial del defecto de furcación de clase III. Conclusión: La regeneración periodontal combinada puede ser un abordaje terapéutico para mejorar el pronóstico y prevenir la extracción de molares severamente comprometidos por furcación, por defectos y hasta el ápice.

Comparison of cone-beam computed tomography, clinical and surgical analysis for detection of maxillary molar furcation / Comparação da avaliação clínica, cirúrgica e por tomografia computadorizada de feixe cônico na detecção de lesões de furca em molares superiores

ABSTRACT The aim of this study was to compare the performance of conebeam computed tomography (CBCT), clinical and surgical probing in assessing maxillary molar furcation involvement (FI). Furcation defects (n= 120) were assessed through CBCT, clinical and intra-surgical evaluation (ISE). Furcation Involvement, vertical and horizontal bone loss were assessed through clinical probing, CBCT and probing during ISE. Three trained radiologists evaluated CBCT images and intra- and interobserver agreement were calculated by Kappa test and Intraclass Correlation Coefficient (ICC). McNemar and Wilcoxon tests were used to compare clinical probing, ISE and CBCT. Accuracy, sensitivity, specificity, positive and negative predictive values were calculated to detect FI. Clinical findings showed 28 sites with Degree I, 25 sites with Degree II, and 8 sites with Degree III. Good intra- (k=1.00) and interobserver agreement (k=0.773) were observed. Intraobserver and interobserver agreement for horizontal bone loss were moderate, k=0.485 and k=0.549, respectively. Intra-surgical findings showed Degree I at 21 sites, and Degree II and Degree III FI at fifteen sites each. Clinical evaluation showed 75% agreement with ISE and 78% with CBCT. Accuracy for clinical detection of FI was 75%, while for CBCT evaluation ranged from 72.5% to 77.5%, considering the 3 observers. Significant differences were found at distal sites using CBCT (p<0.05). Clinical evaluation and CBCT showed similar results for the presence or absence of FI. Concerning horizontal and vertical bone loss, CBCT was not considered a precise examination method for incipient bone defects.

RESUMO Este estudo teve como objetivo comparar o desempenho da tomografia computadorizada de feixe cônico (TCFC), sondagem clínica e cirúrgica na avaliação do envolvimento da furca de molares superiores (EF). Defeitos de furca (n= 120) foram avaliados por meio de TCFC, avaliação clínica e intra-cirúrgica (IC). O envolvimento da furca, perda óssea vertical e horizontal foram avaliados através de sondagem clínica, TCFC e sondagem durante IC. Três radiologistas treinados avaliaram as imagens de TCFC e a concordância intra e interobservador foi calculada pelo teste Kappa e Coeficiente de Correlação Intraclasse (ICC). Para comparação da sondagem clínica, IC e CBCT foram utilizados os testes de McNemar e Wilcoxon. A precisão, sensibilidade, especificidade, valores preditivos positivos e negativos foram calculados para a detecção de EF. Os achados clínicos mostraram 61 sítios com EF, sendo 28 Grau I, 25 locais de Grau II e 8 locais de Grau III. Observou-se boa concordância intra- (k = 1,00) e interobservador (k = 0,773). A concordância intraobservador e interobservador para perda óssea horizontal foi moderada, k = 0,485 e k = 0,549, respectivamente. Os achados intra-cirúrgicos mostraram EF grau I em 21 sítios e grau II e grau III em quinze sítios cada. A avaliação clínica mostrou 75% de concordância com IC e 78% com CBCT. A acurácia para detecção clínica de EF foi de 75%, enquanto para avaliação de CBCT variou de 72,5% a 77,5%, considerando os 3 observadores. Diferenças significativas foram encontradas em sítios distais em CBCT (p<0,05). A avaliação clínica e a TCFC mostraram resultados semelhantes para a presença ou ausência de EF. Em relação à perda óssea horizontal e vertical, a TCFC não foi considerada um exame preciso para defeitos ósseos incipientes.

The accuracy of linear measurements in cone beam computed tomography for assessing intrabony and furcation defects: a systematic review and meta-analysis / La precisión de las mediciones lineales en la tomografía computarizada de haz cónico para evaluar defectos intraóseos y de furcación: una revisión sistemática y un metanálisis

Objective: This study aims to assess the accuracy of the linear measurements of intrabony and/or furcation defect quantified by cone beam computed tomography (CBCT). Material and Methods: A systematic search of the literature was conducted by two authors independently from the PubMed, Scopus, and EBSCO for full articles published in journals between January 2003 and March 2017. Eligible studies were assessed for quality and heterogeneity using the QUADAS-2 tool. A meta-analysis was performed to identify the accuracy of CBCT in the measurement of intrabony defects. The effect size was estimated and reported as the standardised mean difference (SMD). Results: A total of 105 titles and abstracts were screened. Of those, 11 articles met the inclusion criteria for the systematic review while only four were selected for meta-analysis. The overall effects of standardized mean difference and 95% CI was -0.03 [95% CI -0.67 to 0.60] with a x2 statistic of 0.49 with 3 degrees of freedom (p>0.05), I2= 0.01%. Conclusion: CBCT is highly accurate and reproducible regarding linear measurements for assessing intrabony defects with a weighted standardized mean difference of 0.03 mm. More randomised controlled trials are required to assess the accuracy of CBCT in assessing patients with periodontal defects.

Objetivo: Este estudio tiene como objetivo evaluar la precisión de las mediciones lineales de defectos intraóseos y/o de furcación cuantificados por tomografía computarizada de haz cónico (CBCT). Material y Métodos: Dos autores, independientemente realizaron una búsqueda sistemática de la literatura en PubMed, Scopus y EBSCO, para obtener artículos completos publicados en revistas entre Enero de 2003 y Marzo de 2017. Los estudios elegibles se evaluaron para determinar la calidad y la heterogeneidad utilizando la herramienta QUADAS-2. Se realizó un metanálisis para identificar la precisión de CBCT en la medición de defectos intraóseos. El tamaño del efecto se estimó y se informó como la diferencia de medias estandarizada (DME). Resultados: Se seleccionaron un total de 105 títulos y resúmenes. De ellos, 11 artículos cumplieron con los criterios de inclusión para la revisión sistemática, mientras que solo cuatro fueron seleccionados para el metanálisis. Los efectos generales de la diferencia de medias estandarizada y el IC del 95% fueron -0.03 [IC del 95%: -0.67 a 0.60] con una estadística X2 de 0.49 con 3 grados de libertad (p>0.05), I2= 0.01%. Conclusión: CBCT es altamente preciso y reproducible con respecto a mediciones lineales para evaluar defectos intraóseos con una diferencia de medias estandarizada ponderada de 0.03 mm. Se requieren más ensayos controlados aleatorios para evaluar la precisión de CBCT en la evaluación de pacientes con defectos periodontales.

Comparison of clinical values in decision making between cone beam CT and conventional approach in furcation involvement of maxillary molar / 中华口腔医学杂志

Objective@#To compare the use of cone beam computed tomography (CBCT) and conventional approach (clinical probing and periapical radiograph) in assessing furcation involvement (FI) of maxillary molars and making treatment decisions.@*Methods@#Thirty-two subjects were selected from the pool of patients at the Department of Periodontology, Tianjin Stomatology Hospital & Hospital of Stomatology, NanKai University from January 2015 to December 2016. All the patients have a diagnosis of generalized chronic periodontitis. Ninety-five maxillary molar with FI from the radiography database were analysed. Two doctors used conventional approach and CBCT images to assess FI and make treatment decision respectively. If the clinical and radiographic findings did not clearly indicate a distinct periodontal therapy, two treatment options were considered.@*Results@#There was statistical difference of the FI diagnosis between traditional group and CBCT group assessment of the 95 molars (P=0.000). Thirty-five maxillary molars (36.8%, 17 patients) got two treatment recommendations by conventional approach but 7 (7.4%, 5 patients) by CBCT-based approach. When with the less invasive treatment recommendation, there was statistical difference between conventional approach and CBCT-based approach (P=0.001). An agreement was observed in 63.2% (60/95) of the teeth, while in another 29.5% (28/95) the CBCT-based treatment decision was more invasive than the conventional approach. When with the more invasive treatment recommendation, there was also statistical difference between two approaches (P=0.045). An agreement was observed in 86.3% (82/95) of the teeth, while in another 3.2% (3/95) the CBCT-based treatment decision was more invasive than the conventional approach.@*Conclusions@#CBCT images of maxillary molars may provide detailed information of FI and a reliable basis for treatment decision.

Influência de drogas quimioterápicas na evolução da periodontite experimental em ratos / Influence of chemotherapeutics drugs on the evolution of experimental periodontitis in rats

Objetivo: Este estudo avaliou comparativamente a influência dos quimioterápicos 5-fluotouracil (5-FU) e Cisplanina (CIS) para tratamento de câncer no periodonto saudável, sobre a evolução da periodontite experimental (PE) e as funções hepáticas e renais de ratos portadores de PE submetidos ao tratamento com os quimioterápicos 5-FU ou CIS. Materiais e Métodos: foram utilizado 90 ratos machos distribuídos em 6 grupos. Grupo SPE-SS (n = 15): animais que receberam injeções de 0,5 ml de solução salina 0.9% (SS) sem indução da PE (grupo Sham). Grupo PE-SS (n = 15): animais que receberam injeções s de 0,5 ml de SS e indução da PE após a primeira injeção. Grupo SPE-5FU (n=15): animais que receberam injeções de 5-Fluorouracil (5- FU) sem indução da PE. Grupo PE-5FU (n = 15): animais que receberam injeções de 5- FU e indução da PE após a primeira injeção. Grupo SPE-CIS (n = 15): animais que receberam injeções Cisplatinas (CIS) sem indução da PE. Grupo PE-CIS (n = 15): animais que receberam injeções de CIS e indução da PE após a primeira injeção. Para indução da PE foi adaptado um fio de algodão número 24 ao redor dos primeiros molares inferiores direito e esquerdo. Decorridos 07, 15 e 30 dias após a primeira injeção intraperitoneal (SS ou quimioterápicos) os animais foram eutanaziados. Foi realizada coleta sanguínea para análises hematológia e bioquímicas de aspartato aminotransferase (AST), alamina aminotransferase (ALT), creatinina e uréia previamente as injeções e aos 07 e 30 dias, totalizando 60 dos 90 ratos. Foram coletadas as mandíbulas contendo os primeiros molares inferiores e processadas de acordo com as análises propostas. Para a análise fotométrica avaliou-se a perda óssea alveolar ao redor do primeiro molar inferior. Para a análise de microtomografia computadorizada (µCT) avaliou-se a porcentagem de volume de tecido ósseo (PVTO) na região de furca. As hemimandíbulas contralaterais foram utilizadas para análises histomorfométrica e imunoistoquímicas na região de furca e avaliou-se a porcentagem de área sem osso (PASO), características histológicas e análises dos biomarcadores (TRAP, RANKL, OPG, TNF-α, IL-1ß, PCNA, BAX e HIF-1α,). Os dados obtidos foram submetidos à análise estatística (p<0,05). Resultado: ambos os quimioterápicos 5-FU e CIS contribuíram para o agravamento da evolução da PE por duas vias: aumentando a intensidade e duração do processo inflamatório; e diminuindo a capacidade de reparo tecidual por redução do "turnover" celular e vascular, resultando de forma significativa na maior perda óssea, que comparativamente foi maior nos animais que receberam aplicação sistêmica de 5-FU do que de CIS. Adicionalmente a PE associada ao 5-FU apresentou de maneira significante maiores níveis de ALT e AST aos 30 dias e associada a CIS apresentou de maneira significante maiores níveis de Uréia e não apresentou diferença significativa nos níveis de Creatinina. Conclusão: ambos os quimioterápicos, 5-FU ou CIS, exacerbaram a severidade da periodontite, sendo que os danos periodontais causadas pelo 5-FU foram comparativamente maiores e mais intensos do que os causados pela CIS. Adicionalmente, podemos concluir que a PE agravou de forma sinérgica as condições debilitantes hepáticas e renais ocasionadas pelos quimioterápicos(AU)

Objective: This study evaluated the influence of chemotherapy with 5-fluorotouracil (5- FU) and Cisplanin (CIS) for the treatment of cancer in healthy periodontium, on the evolution of experimental periodontitis (EP), and liver and kidney function of rats with EP treated with chemotherapeutic agents. Materials and Methods: 90 male rats were distributed in 6 groups. Group SPE-SS (n = 15): animals that received injections of 0.5 ml of 0.9% saline solution (SS) without PE induction (Sham group). Group PE-SS (n = 15): animals that received injections s of 0.5 ml of SS and induction of PE after the first injection. Group SPE-5FU (n = 15): animals receiving injections of 5-Fluorouracil (5- FU) without induction of PE. Group PE-5FU (n = 15): animals receiving injections of 5- FU and induction of PE after the first injection. SPE-CIS group (n = 15): animals that received Cisplatin injections (CIS) without PE induction. PE-CIS group (n = 15): animals that received CIS injections and PE induction after the first injection. For EP induction a cotton thread number 24 was fitted around the first right and left lower first molars. After 07, 15 and 30 days after the first intraperitoneal injection (SS or chemotherapeutic) the animals were euthanized. Blood samples were collected for hematological and biochemical analyzes of AST, ALT, creatinine and urea before injections and at 07 and 30 days. The mandibles containing the mandibular first molars were collected and processed according to the proposed analyzes. For the photometric analysis, alveolar bone loss (ABL) around the lower first molar was evaluated. For the analysis of computerized microtomography (µCT) the percentage of bone tissue volume (PBTV) in the furcation region was evaluated. The contralateral hemimandibula were used for histomorphometric and immunohistochemical analyzes in the furcation region and the percentage of bone-free area (PBFA), histological characteristics and biomarkers analysis (TRAP, RANKL, OPG, TNF-α, IL-1ß, PCNA, BAX and HIF-1α). Data were submitted to statistical analysis (p <0.05). Results: Both chemotherapy 5-FU and CIS contributed to the worsening of the evolution of EP by two routes: increasing the intensity and duration the inflammatory process; and decreased tissue repair ability by reducing cell and vascular turnover, resulting in significantly greater bone loss, which was comparatively higher in animals treated with 5-FU than in CIS. Additionally, 5-FU associated PE significantly increased ALT and AST levels at 30 days and associated CIS significantly increased Urea levels and showed no significant difference in Creatinine levels. Conclusion: both chemotherapy, 5-FU or CIS, exacerbated the severity of periodontitis, and periodontal damage caused by 5-FU was comparatively bigger and faster than those caused by CIS. In addition, we can conclude that PE has synergistically aggravated the liver and kidney debilitating conditions caused by chemotherapy(AU)

Clinical and cone beam computed tomography comparison of NovaBone Dental Putty and PerioGlas in the treatment of mandibular Class II furcations.

Objective: The objective of this study is to compare the putty form of bioactive glass (NovaBone Dental Putty) and particulate form (PerioGlas) in the resolution of Class II furcation defects. Background: Use of bone regeneration materials is becoming common in periodontal surgeries including furcation defects and the promising role of bioactive allograft materials has encouraged their presentation in different morphologic forms with their own advantages and disadvantages giving the operator ample of choices in his/her periodontal armamentarium. Materials and Methods: A total of 28 patients with 40 Class II furcation defects were enrolled in the study and were randomly allocated to two groups with 20 sites in each group. Measurement of defects was done using clinical and cone beam computed tomography (CBCT) methods. The patients were followed-up at 6 months. Intergroup comparisons were done using Mann-Whitney U-test. Results: There was no significance between group differences in clinical parameters and defect size at the baseline. After 6 months, particulate form showed a mean resolution of 50.48 ± 16.47% and 51.11 ± 9.48%, respectively for vertical defect and horizontal defect while putty form showed a mean resolution of 43.48 ± 9.33% and 42.88 ± 11.09%, respectively. Mean resolution in furcation width was 40.15 ± 13.00% for particulate form as compared with 36.27 ± 11.41% in putty form. Statistically, there was no significant difference between two groups except for the horizontal defect fill where PerioGlas showed statistically better results. Conclusion: Putty form was comparable to particulate form for resolution of Class II furcation defects.

Effects of collagen membrane in the treatment of class Ⅱ-Ⅲ furcation defects / 实用口腔医学杂志

Objective: To evaluate the effects of guided tissue regeneration(GTR) in the treatment of degree Ⅱ-Ⅲ furcation defects with collagen membranes.Methods: 11 sites with Ⅱ-Ⅲ furcation defects were treated with collagen membranes(group of GTR); 10 sites received flap operation(group of FO). Clinical indexes, radiographs and gingival crevicular fluid(GCF) was collected before surgery and 3 months after treatment. Alkaline phosphatase(ALP) in GCF was measured. The data were analyzed statistically. Results: 3 months after surgery, the clinical parameters of PD, PFD and AL were decreased(P0.05). The decreace of the clinical parameters measured in group GTR was more than that in group FO(P