Administração de Lactobacillus para casei 28.4 como terapia adjuvante no tratamento da periodontite: desenvolvimento in vitro de formulação probiótica usando gellan gum e ensaio clínico randomizado placebo controlado / Administration of Lactobacillus paracasei 28.4 as adjuvant therapy in the treatment of periodontitis: in vitro development of the probiotic formulation using gellan gum and placebo-controlled randomized clinical trial

A periodontite é uma doença inflamatória do periodonto associada ao acúmulo de biofilme dental, com consequente disbiose da microbiota oral e alteração da resposta imuno-inflamatória. O controle da periodontite realizado por meio do tratamento periodontal não-cirúrgico altera o ambiente subgengival e pode ser associado a terapias adjuntas. O uso de probióticos como terapia adjuvante a esse tratamento parece favorecer a modificação do biofilme bacteriano e resposta imuno-inflamatória. Entretanto, os probióticos empregados até o momento não são próprios da cavidade oral e, por isso, a busca por cepas originadas da microbiota oral tem ganhado espaço na tentativa de favorecer a aderência e colonização permanente dessas bactérias. Recentemente, a cepa de Lactobacillus paracasei 28.4 foi isolada da cavidade oral, exibindo atividades antimicrobianas promissoras sobre o controle de patógenos orais. O presente estudo teve como objetivos o desenvolvimento de uma formulação probiótica de L. paracasei 28.4 incorporado em gellan gum para uso humano, bem como a avaliação dos efeitos clínicos da administração desta formulação como adjuvante no tratamento periodontal. Para tal, o trabalho foi dividido em 2 etapas, contemplando uma etapa laboratorial (parte A), para desenvolvimento da formulação probiótica; e um ensaio clínico randomizado (parte B, n=40), envolvendo um protocolo de tratamento periodontal não cirúrgico associado à terapia adjunta probiótica ou placebo. Os resultados da parte A permitiram encontrar a melhor forma de apresentação e armazenamento da formulação de gellan gum. Na parte B, aos 3 e 6 meses de acompanhamento, os dois grupos apresentaram melhoras significativas dos parâmetros periodontais (índice de sangramento, índice gengival, profundidade de sondagem e ganho de nível de inserção) em relação ao baseline, sem diferença estatística na comparação intergrupo. Como conclusão, uma formulação probiótica segura e possível de ser aplicada na prática clínica foi obtida; no entanto, sua administração não promoveu efeitos clínicos adicionais ao tratamento de pacientes com periodontite generalizada estágios III/IV e graus B/C (AU)

Periodontitis is an inflammatory disease of the periodontium associated with the accumulation of dental biofilm, with consequent dysbiosis of the oral microbiota and alteration of the immune-inflammatory responseThe control of periodontitis carried out through non-surgical periodontal treatment alters the subgingival environment and can be associated with adjunctive therapies.The use of probiotics as an adjuvant therapy in the periodontal treatment seems to favor the modification of the bacterial biofilm and modulation of the immuneinflammatory response. However, the probiotics used so far are not specific to the oral cavity and, therefore, the search for strains originating from the oral microbiota has gained space to favor the adherence and permanent colonization of these bacteria. Recently, strain of Lactobacillus paracasei 28.4 was isolated from the oral cavity itself, showing promising antimicrobial activities in the control of oral pathogens. The present study aimed to develop and characterize a probiotic formulation of L. paracasei 28.4 incorporated into gellan gum for human use, as well as to evaluate the clinical effects of administering this formulation as an adjuvant in the treatment of periodontitis. To this end, the study was divided into 2 stages, comprising a laboratory stage (part A), for the development of the probiotic, and a randomized clinical trial (part B, n=40) contemplating a non-surgical periodontal treatment protocol associated with adjunctive probiotic therapy or placebo. The results from part A made it possible to find the best way to present and store the gellan gum formulation. In part B, at 3 and 6 months of follow-up, both groups showed significant improvements in periodontal parameters (bleeding index, gingival index, probing depth and attachment level gain) in relation to baseline, with no statistical difference in the intergroup comparison. In conclusion, a safe probiotic formulation that can be applied in clinical practice was obtained; however, its administration did not promote additional clinical effects in the treatment of patients with stage III/IV and grades B/C generalized periodontitis (AU)

Comparison between connective tissue graft and xenogeneic acellular dermal matrix to treat single gingival recession: A data reanalysis of randomized clinical trials.

OBJECTIVES: There are few studies comparing xenogeneic acellular dermal matrixes (XDMs) with connective tissue graft (CTG) to treat single gingival recession (GR). The present study involved a reanalysis of previous studies and comparison of CTG or XDM to treat single RT1/GR. MATERIALS AND METHODS: Fifty patients from three previous randomized clinical trials treated either by CTG (n = 25) or XDM (n = 25) were evaluated after 6-month. Clinical, patient-centered, and esthetic parameters were assessed. Pearson's correlation and regression analyses were also performed. RESULTS: Greater recession reduction (RecRed), percentage of root coverage (%RC), and complete root coverage (CRC) were observed in the CTG group (p ≤ 0.02). Gingival thickness (GT) and keratinized tissue width (KTW) gains were higher in the CTG group. The CTG group showed better esthetic at 6-month. Logistic analyses reported that GT([OR] = 1.6473 ) and papilla height (PH) (OR = 8.20) are predictors of CRC. GT*XDM interaction was a negative predictor of CRC (OR = 7.105-5 ). GT at baseline acted as a predictor of RecRed in both groups (p = 0.03). The XDM graft impacted RecRed and %RC negatively. Baseline PH was a predictor of %RC for both grafts. CONCLUSION: CTG was superior for treating RT1/GR, providing better root coverage outcomes and tissue gains over time. GT, PH, and graft type were classified as predictors of CRC. CLINICAL SIGNIFICANCE: CTG presented better outcomes to treat single RT1 gingival recession when compared to the XDM.

New Volume-Stable Collagen Matrix and Modified Coronally Advanced Flap to Treat Multiple Gingival Recessions Associated With Partially Restored Non-Carious Cervical Lesions: A Case Report.

INTRODUCTION: Gingival recession (GR) is a prevalent problem that is related to esthetic demands and dentin hypersensitivity. Frequently, GR is associated with non-carious cervical lesion (NCCLs) forming a combined defect (CD), which requires restorative and surgical treatment. Connective tissue graft procedures allow predictable root coverage but can result in patient discomfort. CASE PRESENTATION: This first case report describes multiple GRs associated with B+ NCCL at teeth #4 and #6 of a 27-year-old patient with a thin periodontal phenotype. The aim of this report was to evaluate the 6-month outcome of a new volume-stable collagen matrix (VCMX) combined with modified coronally advanced flap (MCAF) and partial restoration to treat CDs. After 6 months, significant improvement was observed regarding CD coverage (69.05%), recession reduction (2.25 mm), gingival thickness gain (0.74 mm), and keratinized tissue width gain (0.75 mm). In addition, excellent esthetic evaluation and patient comfort were achieved by using the biomaterial. CONCLUSION: VCMX associated with MCAF and partial restoration may be an option to treat multiple recession defects plus B+ NCCLs.

Use of Platelet-Rich Fibrin Membranes With Single Implant Placement for Peri-Implant Mucosal Thickness Augmentation: A Case Series Study.

INTRODUCTION: The use of platelet-rich fibrin (PRF) membranes has been evaluated for different purposes. However, few studies aimed to assess the effect of PRF membranes on peri-implant mucosal thickness augmentation. Thus, the aim was to evaluate whether the use of PRF membranes placed using the same surgical procedure of single implant installation in the anterior area of the maxilla can result in peri-implant mucosal thickness increase. CASE SERIES: Eight patients received single maxillary implants (anterior area), covered by three PRF membranes (2,500 rpm/12 minutes, RCFmax = 719.71 g). Clinical parameters (baseline and 3 months postoperative) and patient-centered parameters were evaluated. The buccal peri-implant mucosal thickness (BMT) and ridge defect (RD) parameters showed a statistically significant difference, with a gain of 0.7 ± 0.3 mm in BMT and reduction of 0.8 ± 0.3 mm in RD. Supracrestal tissue height (STH) was >3 mm after 3 months. Postoperative pain and number of analgesics showed low values (0.95 ± 1.06 and 1.92 ± 2.75), respectively, using a visual analog scale (VAS). CONCLUSION: The use of three PRF membranes along with single implant placement in the anterior maxilla led to an increase in the BMT.

Enamel matrix derivative effects on palatal mucosa wound healing: Randomized clinical trial.

BACKGROUND: This study was conducted to evaluate the clinical, immunologic, and patient-centered outcomes of enamel matrix protein derivative (EMD) on excisional wounds in palatal mucosa. MATERIALS: Forty-four patients in need of ridge preservation were randomly allocated into two groups: control group (n = 22): open palatal wound after free gingival graft (FGG) harvest and EMD group (n = 22): open palatal wound after FGG harvest that received 0.3 ml of EMD. Clinical and patient-centered parameters were analyzed for 3 months post-treatment. Wound fluid levels of inflammatory markers were assessed 3 and 7 days postoperatively. RESULTS: No significant inter-group difference was observed in remaining wound area and re-epithelialization. EMD and control groups achieved wound closure and re-epithelialization 30 days postoperatively (p < .001), without inter-group differences. Similarly, number of analgesics and Oral Health Impact Profile scores did not present significant inter-group differences (p > .05). EMD appeared to selectively modulate wound fluid levels of monocyte chemoattractant protein-1, macrophage inflammatory protein-1α, matrix metallopeptidase 9, and tissue inhibitor of metalloproteinases-2. CONCLUSION: Within the limits of the present study, it can be concluded that EMD application to excisional palatal wounds using the investigated protocol does not provide clinical healing benefits, despite an apparent modulation of selected inflammatory markers.

Rethinking the decision-making process to treat gingival recession associated with non-carious cervical lesions.

The presence of a tooth-surface defect, such as a non-carious cervical lesion (NCCL), associated with sites of gingival recession (GR) defects creates a combined soft tissue/tooth defect (CD) that requires a different treatment plan. This study aimed to critically review the literature regarding the available treatment protocols for CDs and suggest a new decision-making process. NCCLs were classified as Class A-: the cementoenamel junction (CEJ) was visible and the root surface discrepancy was < 0.5 mm (no step); Class A+: CEJ was visible and the root surface discrepancy was > 0.5 mm (with a step); Class B-: unidentifiable CEJ without a step; Class B+: unidentifiable CEJ with a step. NCCLs affecting both root and crown surfaces (Class B) lead to CEJ destruction and consequently eliminate an important landmark used before and after root coverage procedures. The depth of the root surface discrepancy is vital owing to its possible impact on soft tissue adaptation after healing, which, in turn, may influence the treatment options, namely the use of graft and/or composites to compensate for the discrepancy. Clinically, a step with horizontal depth greater than 0.5 mm should be recognized as the minimum threshold value to define this condition. Extremely deep defects tend to assume a V-shaped topography. Therefore, extremely deep V-shaped defects were classified into subclasses A+V, a V-shaped defect, and B+V, a V-shaped defect with loss of CEJ, for management considerations. The treatment options, supported by the literature, and a decision-making process to deal with each condition are presented.

Microcurrent electrotherapy improves palatal wound healing: Randomized clinical trial.

BACKGROUND: This study was conducted to assess the clinical, immunological, and patient-centered outcomes of microcurrent electrotherapy on palatal wound healing. METHODS: This was a parallel, double-masked randomized clinical trial, in which 53 patients with ridge preservation indications were selected and randomly assigned to one of two groups. In the control (sham) group (n = 27), palatal wounds, after free gingival grafts (FGG) harvest, received sham application of electrotherapy. In the test (electrotherapy treatment [EE]) group (n = 26), palatal wounds, after FGG harvest, received application of microcurrent electrotherapy protocol. Clinical parameters, patient-centered outcomes, and inflammatory markers were evaluated, up to 90 days postoperatively. RESULTS: The EE group achieved earlier wound closure (P <0.001) and epithelialization (P <0.05; P = 0.03) at 7 and 14 days after harvest when compared with the sham group. Painful symptomatology was reported less frequently in the EE group than in the sham group at 3-day follow-up (P = 0.008). Likewise, an improvement in Oral Health Impact Profile was reported 2 days after the procedure by the EE group (P = 0.04). In addition, favorable modulation of inflammatory wound healing markers occurred when electrotherapy was applied. CONCLUSION: Within the limits of the present study, it can be concluded that the use of a low-intensity electrotherapy protocol may accelerate palatal wound healing and decrease patient discomfort after FGG harvest.

Rethinking the decision-making process to treat gingival recession associated with non-carious cervical lesions

Abstract The presence of a tooth-surface defect, such as a non-carious cervical lesion (NCCL), associated with sites of gingival recession (GR) defects creates a combined soft tissue/tooth defect (CD) that requires a different treatment plan. This study aimed to critically review the literature regarding the available treatment protocols for CDs and suggest a new decision-making process. NCCLs were classified as Class A-: the cementoenamel junction (CEJ) was visible and the root surface discrepancy was < 0.5 mm (no step); Class A+: CEJ was visible and the root surface discrepancy was > 0.5 mm (with a step); Class B-: unidentifiable CEJ without a step; Class B+: unidentifiable CEJ with a step. NCCLs affecting both root and crown surfaces (Class B) lead to CEJ destruction and consequently eliminate an important landmark used before and after root coverage procedures. The depth of the root surface discrepancy is vital owing to its possible impact on soft tissue adaptation after healing, which, in turn, may influence the treatment options, namely the use of graft and/or composites to compensate for the discrepancy. Clinically, a step with horizontal depth greater than 0.5 mm should be recognized as the minimum threshold value to define this condition. Extremely deep defects tend to assume a V-shaped topography. Therefore, extremely deep V-shaped defects were classified into subclasses A+V, a V-shaped defect, and B+V, a V-shaped defect with loss of CEJ, for management considerations. The treatment options, supported by the literature, and a decision-making process to deal with each condition are presented.

Randomized clinical trial evaluating single maxillary gingival recession treatment with connective tissue graft and tunnel or trapezoidal flap: 2-year follow-up.

BACKGROUND: The literature lacks long-term evidence regarding outcomes of the coronally advanced tunnel flap (TUN) combined with connective tissue graft (CTG) when compared to the trapezoidal coronally advanced flap (CAF) and CTG combination. This study presents 2-year results of a randomized clinical trial comparing CTG combined with either CAF or TUN in the treatment of single maxillary gingival recession (GR) defects. METHODS: Thirty-nine patients, each contributing a single Miller Class I or II GR defect, were treated by CAF+CTG (control; n = 19) or TUN+CTG (test; n = 20) and completed the 2-year follow up. Clinical, patient centered, and esthetic evaluations were performed and differences among groups were analyzed. RESULTS: At 2 years, mean root coverage for control and test group was 89.5% ± 14.6% and 87.7% ± 18.4%, respectively (P = 0.5). The corresponding complete root coverage prevalence was 68.4% and 50% (P = 0.4). Dentin hypersensitivity significantly decreased for both groups. The two groups showed improvement in esthetics, as assessed by both professionals and patients, without significant intergroup differences (P > 0.5). TUN+CTG sites were much more likely to present improvement in root coverage between 6 months and 2 years, exhibiting creeping attachment of 0.7 ± 0.6 mm. CONCLUSIONS: At 2 years of follow up, both CAF+CTG and TUN+CTG resulted in significant clinical and esthetic improvements and provided similar results in the treatment of single maxillary GRs.

Comparação entre dois tipos de enxertos (Mucograft® e Mucoderm®) associados ao retalho posicionado coronariamente no tratamento de recessões gengivais unitárias: estudo clínico controlado randomizado / Comparison of two types of grafts (Mucograft® and Mucoderm®) associated with coronally advanced flap in the treatment of single gingival recessions: randomized clinical trial

A recessão gengival está frequentemente associada à hipersensibilidade dentinária e insatisfações estéticas. Diversas técnicas cirúrgicas foram desenvolvidas a fim de reestabelecer a posição da margem gengival acometida. Dentre elas, a adição de biomateriais aos procedimentos cirúrgicos de retalho posicionado coronariamente (CAF) é considerada uma alternativa promissora. O objetivo do presente estudo foi comparar os efeitos do uso de dois enxertos, matriz colágena (CM, Mucograft®) e matriz dérmica acelular xenógena (XDM, Mucoderm®), no tratamento de recessões gengivais unitárias associados ao CAF. Para tal, 75 pacientes portadores de recessões gengivais unitárias foram selecionados e divididos em três grupos: CAF (n=25, técnica isolada de CAF para recobrimento radicular), CAF+CM (n=25, CAF associado à CM) e CAF+XDM (n=25, CAF associado à XDM). Os parâmetros clínicos e centrados no paciente foram avaliados no baseline e seis meses após o tratamento. Aos seis meses, os três grupos apresentaram porcentagens significativas de recobrimento radicular (78,9±26,2% para CAF, 78,0±28,5% para CAF+CM e 65,6±26,9% para CAF+XDM), sem diferença significativa entre os grupos (p>0,05). O recobrimento radicular completo foi obtido em 52%, 48% e 28% dos casos tratados com CAF, CAF+CM e CAF+XDM, respectivamente (p=0,2). Os grupos que receberam enxerto apresentaram maior ganho de espessura de tecido queratinizado (ETQ; p<0,001). Não foram observadas diferenças no grau de edema tecidual (p=0,9) e desconforto pós-operatório (p=0,2) aos sete dias. Todos os grupos apresentaram redução significativa da hipersensibilidade dentinária (p<0,001) e melhora nas condições de estética (p<0,05), sem diferença significativa entre os grupos (p>0,8). Não houve diferença intergrupo em relação ao tempo cirúrgico (p=0,07). Dentro das limitações desse estudo, concluiu-se que os três tratamentos foram eficazes e que a adição de CM e XDM não promoveu benefícios adicionais ao CAF em termos de recobrimento radicular. Entretanto, a adição dos enxertos parece contribuir para o aumento da espessura de tecido queratinizado(AU)

Gingival recession is frequently associated with dentin hypersensitivity and aesthetic complaint. Different periodontal surgical techniques have been developed in order to reestablish the position of the gingival margin. The addition of biomaterials to coronally advanced flap (CAF) surgical procedures is considered a promising alternative. The aim of this study was to compare the effects of using two biomaterials, collagen matrix (CM, Mucograft®) and xenogeneic acellular dermal matrix (XDM, Mucoderm®) associated with CAF technique for the treatment of single gingival recessions. For this, 75 patients presenting single gingival recessions were selected and allocated into three groups: CAF (n=25, CAF for root coverage alone), CAF+CM (n=25, CAF associated with CM) and CAF+XDM (n=25, CAF associated with XDM). Clinical and patient-centered parameters were assessed at baseline and six months post-procedures. At six months, the groups had significant percentages of root coverage (78.9±26.2% for CAF, 78.0±28.5% for CAF+CM e 65.6±26.9% for CAF+XDM), with no intergroup difference. Complete root coverage was obtained in 52%, 48% and 28% of cases treated with CAF, CAF+CM and CAF+XDM, respectively (p=0.2). The groups which received some graft showed greater gain in keratinized tissue thickness (p<0,001).No differences were observed in tissue edema (p=0.9) and postoperative discomfort (p=0.2) at seven days. All groups showed significant dentin hypersensitivity reduction (p<0.001) and improvements in aesthetic conditions (p<0.05), with no significant difference between groups (p>0.8). There was no intergroup difference for surgical time (p=0.07). Within the limitations of this study, it was concluded that all treatments were effective and the use of CM and XDM did not promoted additional benefits to CAF in terms of root coverage. However, the addition of grafts seems to contribute to the increase of keratinized tissue thickness(AU)

Comparação entre dois tipos de enxertos (Mucograft® e Mucoderm®) associados ao retalho posicionado coronariamente no tratamento de recessões gengivais unitárias: estudo clínico controlado randomizado / Comparison of two types of grafts (Mucograft® and Mucoderm®) associated with coronally advanced flap in the treatment of single gingival recessions: randomized clinical trial

A recessão gengival está frequentemente associada à hipersensibilidade dentinária e insatisfações estéticas. Diversas técnicas cirúrgicas foram desenvolvidas a fim de reestabelecer a posição da margem gengival acometida. Dentre elas, a adição de biomateriais aos procedimentos cirúrgicos de retalho posicionado coronariamente (CAF) é considerada uma alternativa promissora. O objetivo do presente estudo foi comparar os efeitos do uso de dois enxertos, matriz colágena (CM, Mucograft®) e matriz dérmica acelular xenógena (XDM, Mucoderm®), no tratamento de recessões gengivais unitárias associados ao CAF. Para tal, 75 pacientes portadores de recessões gengivais unitárias foram selecionados e divididos em três grupos: CAF (n=25, técnica isolada de CAF para recobrimento radicular), CAF+CM (n=25, CAF associado à CM) e CAF+XDM (n=25, CAF associado à XDM). Os parâmetros clínicos e centrados no paciente foram avaliados no baseline e seis meses após o tratamento. Aos seis meses, os três grupos apresentaram porcentagens significativas de recobrimento radicular (78,9±26,2% para CAF, 78,0±28,5% para CAF+CM e 65,6±26,9% para CAF+XDM), sem diferença significativa entre os grupos (p>0,05). O recobrimento radicular completo foi obtido em 52%, 48% e 28% dos casos tratados com CAF, CAF+CM e CAF+XDM, respectivamente (p=0,2). Os grupos que receberam enxerto apresentaram maior ganho de espessura de tecido queratinizado (ETQ; p<0,001). Não foram observadas diferenças no grau de edema tecidual (p=0,9) e desconforto pós-operatório (p=0,2) aos sete dias. Todos os grupos apresentaram redução significativa da hipersensibilidade dentinária (p<0,001) e melhora nas condições de estética (p<0,05), sem diferença significativa entre os grupos (p>0,8). Não houve diferença intergrupo em relação ao tempo cirúrgico (p=0,07). Dentro das limitações desse estudo, concluiu-se que os três tratamentos foram eficazes e que a adição de CM e XDM não promoveu benefícios adicionais ao CAF em termos de recobrimento radicular. Entretanto, a adição dos enxertos parece contribuir para o aumento da espessura de tecido queratinizado(AU)

Gingival recession is frequently associated with dentin hypersensitivity and aesthetic complaint. Different periodontal surgical techniques have been developed in order to reestablish the position of the gingival margin. The addition of biomaterials to coronally advanced flap (CAF) surgical procedures is considered a promising alternative. The aim of this study was to compare the effects of using two biomaterials, collagen matrix (CM, Mucograft®) and xenogeneic acellular dermal matrix (XDM, Mucoderm®) associated with CAF technique for the treatment of single gingival recessions. For this, 75 patients presenting single gingival recessions were selected and allocated into three groups: CAF (n=25, CAF for root coverage alone), CAF+CM (n=25, CAF associated with CM) and CAF+XDM (n=25, CAF associated with XDM). Clinical and patient-centered parameters were assessed at baseline and six months post-procedures. At six months, the groups had significant percentages of root coverage (78.9±26.2% for CAF, 78.0±28.5% for CAF+CM e 65.6±26.9% for CAF+XDM), with no intergroup difference. Complete root coverage was obtained in 52%, 48% and 28% of cases treated with CAF, CAF+CM and CAF+XDM, respectively (p=0.2). The groups which received some graft showed greater gain in keratinized tissue thickness (p<0,001).No differences were observed in tissue edema (p=0.9) and postoperative discomfort (p=0.2) at seven days. All groups showed significant dentin hypersensitivity reduction (p<0.001) and improvements in aesthetic conditions (p<0.05), with no significant difference between groups (p>0.8). There was no intergroup difference for surgical time (p=0.07). Within the limitations of this study, it was concluded that all treatments were effective and the use of CM and XDM did not promoted additional benefits to CAF in terms of root coverage. However, the addition of the grafts seems to contribute to the increase of keratinized tissue thickness(AU)