The effect of occlusal discrepancies on periodontitis. I. Relationship of initial occlusal discrepancies to initial clinical parameters.

BACKGROUND: A causal relationship between occlusal discrepancies and periodontal disease has been postulated in the past. However, animal studies and clinical studies have not been able to clearly demonstrate or rule out this potential relationship. METHODS: The records from a private practice limited to periodontics were reviewed to find patients who had complete periodontal examination records, including occlusal analysis, that were recorded at least 1 year apart. Patients who fit these criteria were divided into a group who had none of the recommended treatment (untreated n = 30), those that had only nonsurgical treatment (partially treated n = 18), and a control group that had complete all recommended treatment (surgically treated n = 41). The data for each tooth of each patient, including occlusal status, were placed in a database and analyzed using the generalized estimating equations (GEE) method to test for associations between initial occlusal discrepancies and various initial clinical parameters while adjusting for significant confounders. RESULTS: Teeth with initial occlusal discrepancies were found to have significantly deeper initial probing depths (P < 0.0001), significantly worse prognoses (P < 0.0001), and significantly worse mobility than teeth without initial occlusal discrepancies. In addition, this association between initial occlusal discrepancies and initial periodontal condition was found to hold for various subsets considered as well, including posterior teeth only and when only patients with good oral hygiene were considered. CONCLUSIONS: This study indicates that there is a strong association between initial occlusal discrepancies and various clinical parameters indicative of periodontal disease. Based on adjustments made for other known risk factors for periodontal disease, such as smoking, poor oral hygiene, etc., this study provides some evidence that occlusal discrepancy is an independent risk factor contributing to periodontal disease.

The effect of occlusal discrepancies on periodontitis. II. Relationship of occlusal treatment to the progression of periodontal disease.

BACKGROUND: A causal relationship between occlusal discrepancies and periodontal disease has been postulated in the past. However, minimal data are available concerning the effect of treatment of occlusal discrepancies on periodontitis. METHODS: The records from a private practice limited to periodontics were reviewed to find patients who had complete periodontal examination records, including occlusal analysis, that were recorded at least 1 year apart. Patients who fit these criteria were divided into a group that had none of the recommended treatment (untreated n = 30), those who had only non-surgical treatment (partially treated n = 18), and a control group that had completed all recommended treatment (surgically treated n = 41). The data for each tooth of each patient, including occlusal status, were placed in a database and analyzed using the generalized estimating equations method. RESULTS: Worsening in overall clinical condition, as measured by worsening in prognosis, indicated that teeth with no initial occlusal discrepancies and teeth with treated initial occlusal discrepancies were only about 60% as likely to worsen in overall clinical condition over time compared to teeth with untreated occlusal discrepancies. Teeth with untreated occlusal discrepancies were also shown to have a significantly greater increase in probing depth per year than either teeth without initial occlusal discrepancies or teeth with treated initial occlusal discrepancies (P < 0.001). In addition, teeth with untreated occlusal discrepancies had a significant increase in probing depth per year (P < 0.001), whereas teeth without initial occlusal discrepancies and teeth with treated initial occlusal discrepancies had no significant increase in probing depth per year (P > 0.05). CONCLUSIONS: This study provides strong evidence of an association between untreated occlusal discrepancies and the progression of periodontal disease. In addition, this study shows that occlusal treatment significantly reduces the progression of periodontal disease over time and can be an important adjunct therapy in the comprehensive treatment of periodontal disease.

Longitudinal comparison of the periodontal status of patients with moderate to severe periodontal disease receiving no treatment, non-surgical treatment, and surgical treatment utilizing individual sites for analysis.

BACKGROUND: The progression of periodontal disease without treatment and the response of existing periodontal disease to various types of treatment have been studied extensively. Many past studies have used the mean of the patient's probing depths or attachment levels to evaluate disease progression as opposed to following changes in individual sites or teeth. The purpose of the current study was to evaluate the response of individual teeth to treatment or non-treatment. METHODS: The records from a private periodontal practice were reviewed to find patients with complete periodontal examinations that were recorded at least 1 year apart. Patients who fit these criteria were divided into those who had none of the recommended treatment (untreated, n = 30); those who had only non-surgical treatment (partially treated, n = 20); and a control group who had completed all recommended treatment (surgically treated, n = 41). The data for each tooth of each patient were placed in a database and analyzed using the method of generalized estimating equations (GEE) to test for associations between increase or decrease in probing depths and various initial clinical parameters while adjusting for significant confounders. RESULTS: Teeth that received no treatment or non-surgical treatment showed significant increases in probing depths, worsening of prognosis, worsening of furcation involvement, and increases in mobility when compared to surgically treated teeth. Teeth that received surgical treatment showed significant decreases in probing depths. No significant difference was noted between teeth that had no treatment and teeth that had non-surgical treatment. CONCLUSIONS: When individual teeth are used as the basis for analysis, teeth that receive no treatment or non-surgical treatment show a significant worsening of probing depths, furcations, mobility, and prognosis when compared to teeth that receive surgical treatment, while surgically treated teeth show significant improvement in probing depths.

Treatment of periodontal destruction associated with a cemental tear using minimally invasive surgery.

BACKGROUND: A patient presented with moderate probing depth, pain on occlusal contact, and a fistula on a mandibular bicuspid. The probing depth increased 2 mm over a 3-month period despite relief of the occlusal trauma and resolution of the fistula. A radiograph showed an apparent separation of the cementum in the area of the pocket. METHODS: The lesion was treated using a minimally invasive surgical approach to place a bone graft. RESULTS: The probing depth was reduced to 2 mm with less than 1 mm of increased recession. A histologic examination of the damaged calcified tissue confirmed that it was cementum. CONCLUSIONS: The increasing probing depth associated with a cemental tear seems to indicate that this phenomenon contributed to loss of attachment and bone. Removal of the detached cementum in combination with bone grafting using a minimally invasive surgical approach appears to have successfully corrected the periodontal destruction.

Aerosol and splatter production by focused spray and standard ultrasonic inserts.

BACKGROUND: Control of contamination in the dental office has sometimes deterred practitioners from using ultrasonic scalers. Recent studies point to the aerosol and splatter produced during ultrasonic scaling as a vehicle for the possible transmission of bloodborne pathogens. A recently introduced ultrasonic insert that focuses the spray produced during scaling may reduce this aerosol contamination. An aerosol reduction device (ARD) that is attached to the ultrasonic handpiece has been shown to reduce the contamination cloud by placing suction in close proximity to the ultrasonic tip. The purpose of this study was to compare the contamination produced by a standard insert (S) and the new focused spray (F) insert with and without the use of the aerosol reduction device (ARD). METHODS: The testing was conducted in vitro within a plastic enclosure using a dye in the coolant spray. After mock scaling of a dentoform model, the number of contaminated squares on the enclosure was counted and recorded. RESULTS: Analysis of the data indicated no significant difference (P >0.05, Mann-Whitney U test) between the S or F inserts in the amount of contamination produced. When the aerosol reduction device was used, there was a significant reduction (P <0.05, Mann-Whitney U test) in the amount of contamination for both inserts with a greater reduction for the standard insert. CONCLUSIONS: The traditional style of ultrasonic insert (S) and the newer focused coolant water insert (F) produce an equal amount of aerosol contamination. The amount of aerosol contamination produced by both inserts is copious. The ARD significantly reduced contamination with both styles of inserts. These findings support the use of a large bore high-volume evacuator whenever an ultrasonic scaler is used.

A minimally invasive surgical approach for periodontal regeneration: surgical technique and observations.

Increasingly, patients referred to periodontists have undergone some form of non-surgical periodontal treatment prior to their referral. As a result of this, there is an increased need to treat isolated, rather than generalized, periodontal defects. A surgical technique that utilizes small incisions and a limited access approach for treating isolated periodontal defects is described. Results from the use of the minimally invasive surgical (MIS) technique for periodontal regeneration in a comparison study appear to be similar to those where a more traditional surgical approach has been used. Some of the apparent advantages and disadvantages of using the MIS approach are discussed.

Long-term results of a minimally invasive surgical approach for bone grafting.

A retrospective analysis of the results obtained from regenerative surgery performed utilizing a minimally invasive surgical approach was performed. Bone grafting procedures were performed at 194 sites in 87 patients using small incisions and minimal flap reflection. There were 44 females with a mean age of 52.7 years and 43 males with a mean age of 54.9 years. The mean healing time at which data were collected was 21.7 months. Postsurgical data were collected at the time of routinely scheduled supportive periodontal therapy (SPT) appointments by 2 evaluators. Mean changes in probing depth and attachment levels were evaluated utilizing a Wilcoxon sign rank test. Mean improvement in probing depth was 4.58 mm (P <0.0001) and attachment level was 4.87 mm (P <0.0001). These improvements were seen for all levels of initial prognosis (good to poor) and appeared to be stable over time. The postsurgical gingival margin was at or within 1 mm of the cemento-enamel junction (CEJ) for 58% of the sites treated. This was interpreted to indicate good retention of soft tissue height postsurgically. It was concluded that the minimally invasive approach for bone grafting yielded results that were equivalent to more traditional surgical approaches utilizing longer incisions and greater reflection.

Aerosol reduction during air polishing.

OBJECTIVES: Concern has been expressed about the obvious aerosol cloud that is generated during air polishing of teeth. These concerns have included infection control, potential systemic effects, and environmental surface contamination associated with the particles of sodium bicarbonate powder, water, and patient-generated material. This in vitro study evaluated an aerosol reduction device designed for use during air polishing. METHOD AND MATERIALS: Eight artificial teeth on a Dentoform model were polished with and without the aerosol reduction device. The polishing was performed within a plastic enclosure that had a grid on the sides. The water supply for the air polisher contained a 1% fluorescein solution. The aerosol contamination was determined by counting the number of squares that showed fluorescent spots under an ultraviolet light. RESULTS: The mean contamination without the aerosol reduction device was 175.59 cm2. The mean contamination with the aerosol reduction device was 4.37 cm2, a greater than 97% reduction in aerosol contamination. CONCLUSION: The aerosol reduction device significantly decreased the contamination produced during air polishing.

Aerosol and splatter contamination from the operative site during ultrasonic scaling.

As concern about indoor air quality increases, attention is being placed on the aerosol and splatter produced during dental procedures. This study quantifies the contamination produced by ultrasonic scalers during in vitro scaling without coolant water. When compared with the handheld curette used as a control, all ultrasonic scalers and tips tested produced significant aerosol and splatter regardless of the type of scaler, the power level or the insert. The ADA-recommended method for controlling contaminated aerosol and splatter is the use of a large-bore high-volume evacuator. This study supports the ADA recommendation of use of a high-volume evacuator whenever ultrasonic scaling is performed.

A minimally invasive surgical approach for periodontal bone grafting.

The term "minimally invasive surgery" has described the use of a surgical opening that is smaller than that routinely used to perform similar surgical procedures. A periodontal minimally invasive surgery technique for the placement of bone grafts in periodontal defects is described. The data from 10 consecutive patients on a routine supportive periodontal therapy schedule are presented. The mean healing time of the bone graft sites was 25.1 months, the mean probing depth reduction was 4.1 mm, and the mean attachment gain was 4.2 mm. Bone grafting using minimally invasive surgery appears to give results that are similar to results reported using other techniques. Minimally invasive surgery may have the advantage of better retention of graft material and maintenance of tissue height. Patient acceptance of surgical treatment recommendations may be higher because of the perception that minimally invasive surgery represents less surgery.

Blood contamination of the aerosols produced by in vivo use of ultrasonic scalers.

Disease transmission and barrier techniques during dental treatment have been areas of recent concern in dentistry. Ultrasonic scalers are known to produce aerosols, and these aerosols are often produced from areas of significant disease activity, including bleeding. This study was performed to determine if these aerosols contain blood from the gingival sulcus. Forty areas consisting of two contiguous periodontally involved teeth (probing depth of at least 5 mm on one site of each tooth) were scaled subgingivally with an ultrasonic scaler for 30 seconds. A high volume evacuator (HVE) tip was positioned 3 to 5 cm away from the operating site and utilized to capture the aerosols produced. The water remaining in and on the HVE tube was tested for occult blood by the guiac resin method. Gingival index, mean probing depth, presence of bleeding with scaling, and presence of visible blood in the HVE tip were recorded. All 40 test sites showed a positive result for blood in the captured aerosols despite the wide variation in the measured parameters. It may be concluded that subgingival scaling on periodontally involved teeth with ultrasonic scalers would be expected to produce aerosols containing blood.

Clinical use of an aerosol-reduction device with an ultrasonic scaler.

The traditional use of ultrasonic scalers has been to remove heavy deposits of calculus. Today, there is an increasing use of ultrasonic scalers in all areas of periodontal treatment, including periodontal maintenance and root planing. Coolant liquid must be used with an ultrasonic scaler because of heat buildup in the ultrasonic handpiece and scaler tip. The coolant liquid causes an infection control problem because of contaminated aerosols and a patient management problem because of water buildup in the patient's mouth. Data demonstrating the presence of blood in ultrasonic aerosols are presented. The clinical use of an aerosol reduction device that fits on an ultrasonic scaler is detailed. This device reduces the aerosol produced by more than 93%. Research that shows a reduction in water buildup in the patient's mouth of more than 76% (P < .01) is presented. The aerosol reduction device appears to greatly reduce many of the problems associated with the coolant liquid used during ultrasonic scaling.

Reduction of aerosols produced by ultrasonic scalers.

There is concern with decreased air quality and potential aerosol contamination in the dental operatory. This problem has been addressed by the Centers for Disease Control and Prevention, which recommends that all sources of blood-contaminated splatter and aerosols be minimized. One of the major sources of potential aerosol contamination in the dental setting is the ultrasonic scaler. This study looks at the use of a high volume evacuator attachment for the ultrasonic scaler handpiece. Artificial teeth were mock-scaled for 1 minute with and without the evacuator attachment. The mock scaling was performed within a plastic enclosure that had a 1 cm grid laid out on 4 sides. Scaling was performed 10 times each by 2 operators. An erythrosin solution was used for the ultrasonic scaler coolant with a coolant volume of 17.5 ml/min. The number of squares containing a red erythrosin spot were counted and considered to represent aerosol contamination. The high volume evacuator attachment produced a 93% reduction in the number of contaminated squares (chi squared significant at P < 0.05). There was no increase in heat transfer to a tooth analogue when the high volume evacuator attachment was used with the ultrasonic scaler as compared to the scaler without the evacuator attachment. It is felt that the high volume evacuator attachment is capable of significantly reducing the amount of aerosol contamination produced within the test system without increased heat transfer to the tooth.

Granulation tissue removal in routine and minimally invasive procedures.

This article reviews the use of a new mechanical surgical instrument, the D'Granulator, designed to quickly and easily remove granulation tissue while maintaining a blood-free field during periodontal and endodontic surgical procedures. A technique for minimally invasive periodontal bone grafting is also given. This technique allows for minimization of soft-tissue trauma and the removal of granulation tissue from periodontal defects using a much smaller surgical incision than that used in standard bone graft techniques.