Predictors of long-term outcomes in patients undergoing periodontal maintenance.

AIM: This retrospective study aimed to characterize the baseline status of patients following periodontal maintenance, analysing the association between the long-term outcome of these patients, smoking, bruxism, and the main clinical and radiographic variables. MATERIAL AND METHODS: A sample of 174 patients with moderate to severe periodontitis was refined into homogeneous subsamples according to smoking and bruxism and the rate of tooth loss due to periodontal disease (TLPD): 0, 1-2, and >2 teeth. The association and the distribution (χ² test) of the variables within the subsamples were analysed. RESULTS: Smoking and bruxism were significantly associated with higher TLPD rates. Vertical and circumferential bone defects (p < .0001), and abfractions (p < .0001) were associated with bruxism and particularly with bruxism and TLPD >2. Furcation defects (p = .0002), fewer radio-opaque subgingival calculus (χ² p < .0001), a lower mean Gingival index (χ² p = .027), and increased mean recessions >1.5 mm (χ² p = .0026) were associated with smoking and higher TLPD rates. The mean baseline mobility, abfractions, and recessions characterized two basic types of TLPD. CONCLUSIONS: Smoking, bruxism, and routine clinical and radiological parameters can be used to characterize the baseline status of patients with worse outcomes.

Maintenance periodontal therapy after systemic antibiotic and regenerative therapy of generalized aggressive periodontitis. A case report with 10-year follow-up.

Aggressive periodontitis (AgP) is an inflammatory disease characterized by rapid attachment loss and bone destruction. This case report presents the 10-year results in a subject with generalized AgP treated by a regenerative periodontal therapeutic approach and the adjunctive use of antibiotics, following a systematic maintenance periodontal therapy. The use of enamel matrix derivatives (EMD) and adjunctive antibiotic therapy to treat AgP yielded improvements in clinical parameters and radiographic bony fill. This combined therapeutic approach following a systematic supportive periodontal therapy supports the long-term maintenance of teeth with previous advanced periodontal defects, demonstrating successful stability after 10-years follow-up. Clinical Relevance: The combined treatment protocol using EMD plus adjunctive antibiotic therapy, associated with a systematic supportive periodontal therapy, benefits the long-term maintenance of teeth with previous advanced periodontal defects in subjects presenting AgP, supporting this approach as an alternative in the treatment of AgP.

The utility of gingival crevicular fluid matrix metalloproteinase-8 response patterns in prediction of site-level clinical treatment outcome.

BACKGROUND: Different gingival crevicular fluid (GCF) matrix metalloproteinase (MMP)-8 response patterns were studied among non-smoking and smoking patients with chronic periodontitis (CP) and generalized aggressive periodontitis (GAgP) to test the utility of GCF MMP-8 levels predicting the site-level treatment outcome. METHODS: Data from four independent longitudinal studies were combined. Altogether, the studies included 158 periodontal sites from 67 patients with CP and 32 patients with GAgP, and GCF samples were collected at baseline, after the treatment, and during the 6-month maintenance period. All GCF samples were analyzed by immunofluorometric assay for MMP-8. Different site-level MMP-8 response patterns were explored by the cluster analysis. Most optimal MMP-8 cutoff levels were searched with receiver operating characteristic analyses, and the predictive utility of defined levels was tested. RESULTS: Distinct types of MMP-8 response patterns were found in both smokers and non-smokers. MMP-8 levels exceeding the optimal cutoff levels separately defined for smokers and non-smokers indicated increased risk for compromised treatment outcome at baseline and during the maintenance period. Seventy-one percent of non-smokers (positive likelihood ratio of 4.22) and 88% of smokers (positive likelihood ratio of 5.00) with positive test results at both baseline and the maintenance period had compromised treatment outcome. The double-positive result indicated 46% and 39% point risk increase for the compromised outcome, respectively. CONCLUSION: GCF MMP-8 analysis with defined cutoff levels could be used to predict the site-level treatment outcome and for longitudinal monitoring of the disease status during the maintenance period.

Treatment of aggressive periodontitis.

Despite etiological differences between aggressive and chronic periodontitis, the treatment concept for aggressive periodontitis is largely similar to that for chronic periodontitis. The goal of treatment is to create a clinical condition that is conducive to retaining as many teeth as possible for as long as possible. When a diagnosis has been made and risk factors have been identified, active treatment is commenced. The initial phase of active treatment consists of mechanical debridement, either alone or supplemented with antimicrobial drugs. Scaling and root planing has been shown to be effective in improving clinical indices, but does not always guarantee long-term stability. Antimicrobials can play a significant role in controlling aggressive periodontitis. Few studies have been published on this subject for localized aggressive periodontitis, but generalized aggressive periodontitis has been subject to more scrutiny. Studies have demonstrated that systemic antibiotics as an adjuvant to scaling and root planing are more effective in controlling disease compared with scaling and root planing alone or with supplemental application of local antibiotics or antiseptics. It has also become apparent that antibiotics ought to be administered with, or just after, mechanical debridement. Several studies have shown that regimens of amoxicillin combined with metronidazole or regimens of clindamycin are the most effective and are preferable to regimens containing doxycycline. Azithromycin has been shown to be a valid alternative to the regimen of amoxicillin plus metronidazole. A limited number of studies have been published on surgical treatment in patients with aggressive periodontitis, but the studies available show that the effect can be comparable with the effect on patients with chronic periodontitis, provided that proper oral hygiene is maintained, a strict maintenance program is followed and modifiable risk factors are controlled. Both access surgery and regenerative techniques have shown good results in patients with aggressive periodontitis. Once good periodontal health has been obtained, patients must be enrolled in a strict maintenance program that is directed toward controlling risk factors for disease recurrence and tooth loss. The most significant risk factors are noncompliance with regular maintenance care, smoking, high gingival bleeding index and poor plaque control. There is no evidence to suggest that daily use of antiseptic agents should be part of the supportive periodontal therapy for aggressive periodontitis.

New attempts to modify periodontal risk assessment for generalized aggressive periodontitis: a retrospective study.

BACKGROUND: Periodontal risk assessment (PRA) model was designed for risk evaluation of treated patients with periodontal disease. However, its use on generalized aggressive periodontitis (GAgP) had been scarcely reported. This study aims to investigate the association of original PRA/modified PRA (MPRA) and compliance of periodontal maintenance with long-term treatment outcomes of Chinese patients with GAgP. METHODS: Eighty-eight patients from a GAgP cohort, who completed active periodontal treatment (APT) and accepted reevaluation 3 to 11 years (mean of 5.5 years) afterward, were enrolled. PRA was modified (three strategies involving replacement of bleeding on probing with bleeding index >2, counting sites with probing depth ≥6 mm and changing method of bone loss [BL] calculation) to classify patients into different risk groups based on data at the first recall after APT. PRA and three MPRA models were investigated regarding long-term association with tooth loss (TL) and alteration of bone level (∆BL). RESULTS: Based on original PRA, 87 patients (98.8%) had a high-risk profile. According to three MPRA models, annual TL per patient values were greater in high-risk groups than in low-to-moderate risk groups (MPRA-1, 0.20 ± 0.33 versus 0.04 ± 0.14; MPRA-2, 0.18 ± 0.32 versus 0.05 ± 0.14; MPRA-3, 0.17 ± 0.32 versus 0.05 ± 0.15; P <0.05). By MPRA-1, irregular compliers with low-to-moderate risk profile had greater ∆BL (0.027 ± 0.031, indicating bone increment) than those with high risk (-0.012 ± 0.064, tendency for BL). For regular compliers, no significant differences of annual TL or ∆BL were found between risk groups. CONCLUSIONS: MPRA models could be used for evaluating the long-term outcomes of Chinese patients with severe GAgP, especially irregular compliers. High-risk patients of MPRAs exhibited more TL and less bone fill than low-to-moderate risk ones.

See you in three months! The rationale for the three monthly periodontal recall interval: a risk based approach.

UNLABELLED: There is significant evidence to support the regular review of patients with chronic periodontitis. There is, however, comparatively little evidence to demonstrate how often such reviews should take place. This paper looks at the periodontal healing period, the risks of periodontal progression and current thinking about maintenance programmes. It thus attempts to establish some guidelines that practitioners may use when calculating recall intervals. CLINICAL RELEVANCE: The choice of individual, patient-focused recall intervals is essential to limit disease progression and maintain healthy periodontal tissues.

Aggressive periodontitis: the historic quest for understanding.

Aggressive periodontitis has had many names as well as theories behind its etiology. The current paper looks to investigate this history and show the evolution of both nomenclature and understanding. Going beyond academic debates, emerging trends and conventions are also examined and placed into a clinical perspective. The aim of the paper is to recognize the origins of the elusive disease in order to form a concrete understanding of this multifactorial phenomenon.

Dynamic therapeutic approach for individuals affected with aggressive periodontitis.

Management of patients affected with aggressive periodontitis is complicated by several poorly understood etiological and modifying factors that create difficulty in establishing a universal treatment recommendation. The goal of this manuscript is to underscore the complexity of therapy and to provide some guidelines in the decision-making process and interdisciplinary therapy. A dynamic approach is presented to formulate strategies in diagnosis and treatment planning that is both patient-and site-specific.

Results of a 20-year oral hygiene and prevention programme on caries and periodontal disease in children attended at a private periodontal practice.

OBJECTIVES: The objective of this study was to evaluate the long-term effect of an oral hygiene and prevention programme on caries and periodontal disease in a group of children attended at a private periodontal practice. METHODS: A total of 50 systemically healthy children, 25 males and 25 females, 03-13years old, were invited to join a long-term plaque control programme. All children had no caries and had no evidence of clinical bone loss. The participants were selected amongst children whose parents (mother, father or both) were treated of gingivitis, aggressive periodontitis or chronic periodontitis in a private periodontal practice. Subjects were separated in groups according to their parents' periodontal diagnosis, i.e., gingivitis, aggressive periodontitis or chronic periodontitis. The following outcomes were evaluated: a) probing depth, b) plaque (PI) and gingival (GI) indexes. The plaque control programme applied consisted of a regular maintenance regime at 6-to 12-month interval with an experienced periodontist. RESULTS: In total 30 subjects fulfilled the 20-year period of maintenance. The mean recall frequency was 6.4 (± 3.1) months, and the mean PI and GI were 0.4 (± 0.3) and 0.3 (± 0.3) respectively. The average rate of caries lesions was 1.0 (± 1.4). None of the patients exhibited clinical or radiographic evidences of alveolar bone loss, and no tooth was lost by caries. In addition, there were no statistically significant differences between groups (P>0.05). CONCLUSIONS: Adequate oral hygiene measures and periodic professional plaque control led to low levels of dental plaque, gingivitis and caries lesions.

Maintenance after a complex orthoperio treatment in a case of generalized aggressive periodontitis: 7-year result.

BACKGROUND: Generalized aggressive periodontitis (GAgP) encompasses a distinct type of periodontal disease exhibiting much more rapid periodontal tissue destruction than chronic periodontitis. The best method for management of GAgP may include the use of both regenerative periodontal techniques and the administration of systemic antibiotics. METHODS: The treatment of a case of GAgP over a period of 6.7 years is presented in this case report. Initial periodontal therapy (week 1- 32) consisted of supragingival plaque control and three appointments of scaling and root planing. Based on the periodontal pathogens isolated (5 species), the patient also received metronidazole plus amoxicillin for one week, followed 10 weeks later by metronidazole plus amoxicillin/clavulanate for one week. The patient was put on regular supportive periodontal therapy (SPT) thereafter. Orthodontic treatment was performed after completion of the initial therapy for 96 weeks. Measurements of clinical attachment level, bleeding on probing and plaque index were obtained at every examination. RESULTS: Antimicrobial and mechanical treatment resulted in eradication of all periopathogens and significantly improved all clinical parameters. During orthodontic treatment and active maintenance, there was no relapse of GAgP. The patient participated in SPT for 194 weeks and thereafter decided to discontinue SPT. Twenty-four months later a relapse of GAgP was diagnosed and all teeth had to be extracted. CONCLUSIONS: These results indicate that a combined mechanical and antimicrobial treatment approach can lead to consistent resolution of GAgP. Further studies including a larger number of cases are warranted to validate these findings.

Classical versus contemporary treatment planning for aggressive periodontal disease.

BACKGROUND: This case report presents a patient with a history of generalized aggressive periodontitis who has been maintained with the same periodontal prostheses for the past 40 years. METHODS: A 39-year-old healthy woman extremely susceptible to inflammatory periodontal disease presented to our office in 1968. Non-surgical therapies were completed to evaluate tissue response and the patient's compliance with oral debridement. A prosthetic consultation was completed and accepted before periodontal surgery was initiated. Several teeth were deemed untreatable and removed at the time of consultation and construction of the provisional maxillary and mandibular prostheses. RESULTS: Clinical decisions were based on this patient's existing periodontal status, the restorability and the strategic value of specific teeth, the occlusal jaw relationship, and the esthetic concerns of the patient. She has been compliant with periodontal maintenance performed every 3 months since the conclusion of active treatment in 1969. CONCLUSIONS: A periodontally compromised dentition punctuated by teeth with limited clinical roots and significant edentulous span requiring splinting was treated successfully with traditional therapies. The result has endured for 40 years with no additional loss of teeth.

Periodontal maintenance therapy: an integral part of dental practice. Case reports on three periodontally involved patients.

Periodontal maintenance therapy is an integral aspect of any general dental or specialist practice. Numerous studies have indicated that periodontal therapy in the absence of a carefully designed maintenance program invariably results in the relapse of the disease condition. Accordingly, dental practices that provide periodontal care without a maintenance program deal with significant patient management and disease management issues. In this article, three cases are presented with varying levels of disease severity but all sharing the common trait of having being enrolled in a good maintenance program with positive treatment outcomes.

Effort and costs of tooth preservation in supportive periodontal treatment in a German population.

OBJECTIVES: Assessment of effort (number of visits) and costs of tooth preservation 10 years after initiation of anti-infective therapy. MATERIAL AND METHODS: Data of 98 patients who had received active periodontal treatment 10 years ago by the same examiner were analysed to gather information on effort and costs of supportive periodontal therapy (SPT). Clinical examination, interleukin-1 (IL-1) polymorphism test, smoking, search of patients' files (i.e. initial diagnosis), as well as a questionnaire on medical history and socioeconomic data were performed. Statistical analysis was performed using multivariate linear regression analysis. RESULTS: During 10 years of SPT patients had 14.8+/-7.4 visits. Number of visits was statistically significantly higher for individuals with a mean plaque control record >or=24 %. The number of subgingival scalings per tooth ranged from 0 to 14 (mean: 1.17). On tooth level several confounders could be identified: tooth type, initial bone loss, furcation involvement, abutment status, and previous regenerative surgery (p

Kindler syndrome and periodontal disease: review of the literature and a 12-year follow-up case.

BACKGROUND: The association of aggressive periodontitis with Kindler syndrome was based on a single case in 1996 and later confirmed with a larger population. Since then, significant research has greatly increased our understanding of the molecular pathology of this disorder. We review recent advances in the molecular mechanisms of the syndrome and present a maintenance case report of a patient who has been followed in our clinic. METHODS: A female patient who was diagnosed with Kindler syndrome and aggressive periodontitis at the age of 16 years has been followed and treated in our clinic for 12 years. Her main treatment has been maintenance therapy following her initial treatment and restorative work previously documented. Gingival biopsies obtained during the recent extraction of hopeless maxillary molars were used for histologic assessment of gingival tissue attachment apparatus and to isolate gingival fibroblasts. Reverse transcription-polymerase chain reaction (RT-PCR) was performed using these cells to confirm the lack of expression of kindlin-1. RESULTS: RT-PCR showed the total loss of kindlin-1 mRNA in cultured gingival fibroblasts, supporting the clinical diagnosis of Kindler syndrome. Tissue biopsies revealed atypical pocket epithelium. Maintenance therapy has been moderately successful. Teeth that were recently lost had a poor prognosis at the initial assessment. The patient's gingiva and oral mucosa continue to be fragile with episodes of sloughing and inflammation. CONCLUSIONS: Periodontitis in Kindler syndrome responds to maintenance therapy, but the gingiva and oral mucosa continue to display an abnormal appearance with white patches. Histologic findings suggest that the junctional epithelium in Kindler syndrome may be abnormal and could explain why these patients have periodontal disease. Attachment loss progressed around teeth with an initial guarded or poor prognosis. Teeth that started with a good or fair prognosis continue to have a fair prognosis. Limited dental implant treatment is being considered.

Seven-year follow-up of 10 children with periodontitis.

The present manuscript reports a 7-year follow-up of a kindred in which 10 children (siblings and cousins) had moderate to severe periodontal diseases in primary (9 children) and permanent teeth (1 child). No systemic condition was related to the periodontal diseases. The number of affected teeth per child varied from 1 to 12. Treatments involved local therapy and systemic antibiotics. Treatment of periodontitis in primary teeth led to alveolar bone regeneration and periodontally healthy permanent teeth. Recurrence was suspected only in 1 case. The different aspects related to prevention, diagnosis, and treatments of families with periodontal diseases are discussed. From this manuscript, it is concluded that (1) susceptible families develop a high prevalence of periodontitis; (2) these families should be carefully monitored to provide early treatment to new cases; and (3) treatment of children with periodontitis in the primary dentition may be successful, with no periodontitis developing in the permanent dentition in adolescence.

Five-year maintenance follow-up of early-onset periodontitis patients.

OBJECTIVES: The purpose of this study was to evaluate the clinical and microbiological status of patients with early-onset or aggressive periodontitis (EOP) who had received supportive periodontal care (SPC) every 3-6 months for a period of 5 years, following active periodontal treatment. MATERIAL AND METHODS: The study population consisted of 25 individuals with early-onset periodontitis. Clinical examination and recordings of probing pocket depth (PPD) and clinical attachment level (CAL) were performed at baseline prior to treatment (T0), 3 months following the termination of active periodontal treatment (T1) and annually at the SPC appointments (T2,T3,T4,T5). Microbiological samples were obtained at the 5-year SPC (T5). Subgingival plaque samples for each individual were collected from one deep pocket (>5 mm), based on pretreatment measurements, randomly selected in each quadrant. The levels of Actinobacillus actinomycetemcomitans, Bacteroides forsythus, Porphyromonas gingivalis and Treponema denticola were determined using oligonucleotide probe hybridization. RESULTS: During the 5-year period, the mean of SPC/patient was 12.7 sessions. A significant improvement was observed in PPD, CAL, gingival bleeding index and suppuration following treatment. However, between T1 and T5, 134 sites in 20 patients deteriorated with a CAL loss of> or =2 mm. Out of these 134 sites showing disease progression, microbial samples were randomly obtained in 13 sites (9.7%) from 8 patients. Among other factors, smoking and stress were found to have significant predictive value on the future attachment loss. P. gingivalis, T. denticola and total bacterial load were statistically significantly higher in patients who experienced disease progression during the 5-year maintenance period. CONCLUSIONS: For most EOP patients, regular SPC was effective in maintaining clinical and microbiological improvements attained after active periodontal therapy. However, a small percentage of sites was identified as progressive in 20 patients. Variables found to be related to periodontal progression were the presence of as well as the high bacterial counts of P. gingivalis, T. denticola and total bacterial load, number of acute episodes, number of teeth lost, smoking and stress.

Mouthrinses and periodontal disease.

It is known that mouthwashes can influence gingivitis; however, their role in the three different kinds of periodontitis is unclear. Some solutions have demonstrated some effect on necrotising periodontitis, yet none have been shown to influence early onset periodontitis. The literature provides us with a wide range of in vitro concentrations of substances used pure or in various mixtures in mouthwashes. Although only a few solutions can be used in a curative approach, most mouthwashes represent an essential tool in prophylaxis and thus also in post-periodontal treatment (maintenance phase). However, severe qualitative differences exist between the diverse families of mouthwashes. Many studies have shown that the use of a mouthwash associated with regular tooth cleaning was more beneficial than the utilisation of mouthrinse alone.

Prepubertal periodontitis associated with chronic granulomatous disease.

BACKGROUND: Generalised prepubertal periodontitis is a rare entity that is usually a consequence of severe systemic diseases. Chronic granulomatous disease is one of the extremely rare inherited immunodeficiency diseases, which predisposes the patient to recurrent severe bacterial and fungal infections. AIM: The purpose of this report is to describe a 5-year old male patient suffering from prepubertal periodontitis associated with chronic granulomatous disease, who was referred to the Department of Periodontology for treatment of severe gingival inflammation. METHODS: A detailed past history was obtained and thorough clinical and laboratory examinations were performed. RESULTS: Medical tests revealed the only immunodeficiency sign as the extremely low burst test result. The patient was diagnosed as having an autosomal recessive (AR) form of chronic granulomatous disease. He was put on prophylactic treatment with trimethoprim-sulfamethoxazole (TMP-SMX) and also a periodontal maintenance regimen with regular 1-month intervals. CONCLUSION: This case report emphasises the importance of the differential diagnosis of severe immunodeficiency in the background of prepubertal periodontitis.