Classification, reproducibility and prevalence of root proximity in periodontal patients.

AIM: The primary aim of this study is to define and classify root proximity. The secondary aim is to examine the reproducibility of the measurement tools, to study the prevalence per inter-dental area and to examine whether the distance from the cemento-enamel junction (CEJ) to the bone crest (BC) differs between sites with root proximity and their contra-lateral sites without root proximity. MATERIAL AND METHODS: In order to indicate the location of root proximity, a modification of the Shei ruler was developed, dividing the roots into three equal parts. A radiographic template was used to measure the distance between the roots, in this way determining the severity of the root proximity. The reproducibility of the measurement tool was tested, the prevalence was calculated and the distances CEJ-BC for root proximity sites and contra-lateral sites were recorded. RESULTS: A two-digit classification was obtained dividing the root into three locations [apical (A), between (B) and coronal (C)], with each location having the possibility of three different severities of root proximity. The described modification of the Shei ruler and the measurement tool for the severities can be considered as reproducible measurement tools. Root proximity was most prevalent in maxillary molars and between central and lateral incisors in the maxilla and mandible. There was no difference in CEJ-BC distance between the root proximity sites and their contra-lateral sites. CONCLUSION: We can conclude that a two-digit classification for root proximity was established. Root proximity in untreated periodontal patients has no influence on the distance CEJ-BC. However, the location of root proximity becomes important from the moment that periodontal disease has been established at that site. The severity of root proximity is important for choosing treatment options. There is a striking similarity between bone loss patterns and tooth loss and the location of inter-dental spaces where root proximity is most prevalent.

Root proximity as a risk marker for periodontal disease: a case-control study.

AIM: The aim of this study is first, to examine the prevalence, symmetry and spread of root proximity using the measurement tools and classification as described in part I of the study, and second to examine whether root proximity is a risk marker for periodontal disease. MATERIAL AND METHODS: The radiographs of 227 patients were examined. The study consisted of a study group of 197 patients with advanced periodontal disease with at least one site with bone loss more than one third of the root length and 30 controls without periodontal disease. Every inter-proximal space was assessed on the full-mouth radiographs and a score was assigned according to severity and location. Consequently prevalence of severity and location, symmetry, spread and an odds ratio and relative risk for periodontal disease was calculated. RESULTS: Root proximity is a symmetrical and localized but widespread phenomenon in periodontal patients and to lesser extend in the non-periodontal control group. In periodontal patients root proximity was most often encountered in the coronal and intervening part whereas subjects without periodontal disease had more root proximity in the apical and intervening part where it is less critical. Subjects with bilateral root proximity had a 3.6 times higher chance to have periodontitis. CONCLUSION: Root proximity must be taken into consideration as a risk marker for periodontal disease.

Pocket elimination surgery with simultaneous connective tissue graft. A case report with 3-year follow-up.

BACKGROUND, AIMS: The purpose of the present case report was to present 2 ways of treating recession in a periodontal patient combined with regular pocket elimination surgery. The techniques used enabled the operator to reduce the number of surgical sessions and clinically evaluate the 3-year coverage of gingival recessions using a subpedicle connective tissue graft. METHODS: Surgery consisted of pocket elimination procedures to treat adult periodontitis as a way to harvest connective tissue to be placed in the areas of recession. The grafted tissue was covered by the primary flap or left uncovered in a pouch, according to 2 different techniques described in the literature. RESULTS: In this case, we observed that, with this approach, we were successful in reducing the number of surgical session as well as achieving objective and subjective goals of therapy in treated areas.

A possible association of alpha1-antitrypsin deficiency with the periodontal condition in adults.

Alpha1-antitrypsin (alpha1AT) is a serum inhibitor of several neutrophil-derived proteolytic enzymes, the serine proteinases. In certain individuals, a deficiency of this enzyme inhibitor is present, whereby only 10 to 20% of the normal concentration is present in the circulation. The purpose of this study was to evaluate the influence of this alpha1AT deficiency on the periodontal condition in a case control study. 10 patients aged 20-50 years with a mean age of 32 and showing a deficiency of alpha1AT were randomly selected from a national data bank, which contains persons known to be affected with the alpha1AT deficiency state. Control subjects were matched for age, gender and socio-economic status. Full periodontal charting on all subjects was performed on 6 sites per tooth, including probing attachment level, probing depth, bleeding on probing and a plaque score. Analysis of the data revealed no differences with regard to attachment loss between the two groups. The deficiency group showed 9.3% pockets > or =5 mm and the matched control group 5.9%. When these results were covariated with plaque scores, the deficiency group appeared to have a higher number of sites with probing depths > or =5 mm.

[Antibiotic use in periodontics. Results from a research study]. / Antibioticumgebruik in de parodontale praktijk. Resultaten van een verkennend onderzoek.

The sensitivity of the subgingival plaque for amoxicillin, doxycycline, ofloxacin and clindamycin was estimated by agar diffusion disks and Etest in 22 periodontal patients. The sensitivity of the subgingival plaque varied per patient. Resistance of the subgingival plaque for amoxicillin was observed in 50% of the patients and was significantly related to the use of antibiotics in the previous 6 months. The resistance to clindamycin was 68% and to doxycycline 82%. The resistance of the subgingival plaque to these antibiotics could not be related to the previous use. A decision-tree was constructed including a step wise use of a microscopical spirochete test and an antibiotic sensitivity test of the subgingival microflora for the above mentioned antibiotics. The clinical implications of the observed long lasting antibiotic resistance and the practical use of a decision-tree including a spirochete test and antibiotic sensitivity tests need further investigation.

[How sensible are bacteriological tests in periodontology?]. / Hoe zinvol zijn bacteriologische testen in de parodontologie?

Periodontitis is a mixed infection with subgingival bacteria that belong to the microflora of the host. The bacteriological tests (Microscopy, Culture, Omnigene, Affirm DP and Evalusite) are mainly aimed at spirochetes or A. actinomycetemcomitans, P. gingivalis and P. intermedia. The detection limits of the different tests vary and, therefore, the detection levels are between 0.01-10% of the subgingival microflora. However, threshold levels to distinguish between diseased and carrier state are not established and the low sensitivity and specificity of the tests limit their diagnostic usefulness. The correlation between the tested bacteria and periodontitis does not mean a causal relationship. As a result, the justification of the elimination of the tested bacteria is questionable. The tests of the subgingival plaque do not only add to the microbiological knowledge, but might also promote the overtreatment with antibiotics, such as the in the Netherlands popular combination of amoxicilline and metronidazole. The balance between host and microflora can be restored in most patients by mechanical elimination of the mainly Gram negative anaerobic subgingival plaque. In special occasions metronidazole can be empirically prescribed in order to support the subgingival debridement. In the relatively rare occasions of superinfection, a sensitivity test of the subgingival microbiota is recommended.

Histological evaluation of surgically treated oral tissues after application of a photocuring periodontal dressing material. An animal study.

At present no information is available about biological effects on oral tissues of the photocuring periodontal dressing Barricaid. This animal study examines histologically the tissue responses of surgical areas covered during 7 days with either Barricaid, the eugenol-containing dressing Ward's Wondrpak or the bionert control gel Carboxyl Methyl Cellulose. One group was studied immediately after the removal of the dressings; in the other group, further healing was permitted for another week. Results after 7 days indicate acute inflammatory reactions in the test areas without significant differences between the 2 periodontal dressing materials. The control areas showed to a lesser degree basically the same tissue response. In the 2nd week, generally all areas healed. After 14 days, no differences between test- and control sites could be detected. From a biological point of view, these findings suggest no contra-indication for application of this photocuring dressing material after periodontal surgery.

[Effective treatment of periodontitis]. / De effectieve behandling van parodontitis.

Based upon clinical periodontal parameters and roentgenographic diagnosis a temporary treatment plan is made, which results in a definite one after the initial treatment. Only a rigorous removal of dental plaque guarantees an effective and efficient working manner, which starts with indirect scaling and rootplaning sustained by the personal oral hygiene. If the indirect therapy appears to fail, the roots must be cleaned under direct view. After the active phase, the supportive treatment takes place every three months, assessed to be of equal importance.

The importance of a coordinated restorative and maintenance program following periodontal therapy: a case report.

The problems arising during the maintenance phase of therapy following a combination of periodontal, orthodontic, and restorative treatment are illustrated by this case report. Emphasis is placed on the combined responsibility of the patient, general dental practitioner, and periodontist to recognize signs of recurrent disease at an early stage, thereby allowing corrective measures to be initiated promptly. By applying these principles, even when disease recurs during the maintenance phase, re-treatment is possible and a satisfactory result can be achieved.

Comparison of the antimicrobial effect of the application of chlorhexidine gel, amine fluoride gel and stannous fluoride gel in debrided periodontal pockets.

The clinical and microbiological effect of locally-applied chlorhexidine gel 2%, amine fluoride gel 1.25%, stannous fluoride gel 4% or placebo gel in 40 periodontal pockets of 10 patients were studied. The gels were applied 3 x within 10 min. after mechanical debridement of the pockets. The treatment effect on the subgingival microflora was evaluated by microscopic and culture studies of the subgingival plaque samples. In addition, supragingival plaque, bleeding after probing and probing pocket depth were scored. Examination were carried out before and during a period of 36 weeks after treatment. At the start, the cultured microflora consisted mainly of anaerobic Gram-positive bacteria. Following treatment, the clinical parameters were significantly reduced. Concomitantly, the %s of spirochetes, motile rods and non-motile rods decreased significantly. A significant decrease was also found in the total anaerobic count, whereas the facultative counts remained at the same level found before treatment. This suggested that the treatment resulted in a mainly facultative subgingival microflora. The % Gram-negative rods showed a significant reduction after treatment, but returned to base line at week 12. Statistical analysis of the bacteriological and clinical examinations failed to demonstrate any significant differences between the 4 treatment groups. Thus, in comparison to the placebo gel, subgingival application of chlorhexidine gel 2%, amine fluoride gel 1.25% or stannous fluoride gel 4% did not augment the effect of mechanical debridement on bacteriological and clinical parameters during the experimental period of 36 weeks. However the indicated treatments resulted in a facultative subgingival microflora which is compatible with the host.

Short-term bactericidal activity of chlorhexidine gel, stannous fluoride gel and amine fluoride gel tested in periodontal pockets.

The short-term bactericidal effect of 2% chlorhexidine gel, 4% stannous fluoride gel or amine fluoride gel containing 1.25% fluoride on the subgingival microflora was determined in 40 periodontal pockets of 10 patients. The antimicrobial gels or placebo gel were applied in 5-9 mm deep periodontal pockets 3 times within 10 min. Before and 30 min after the applications, samples were taken of the subgingival microflora for determination of the total number of bacteria as well as the number of black pigmented Bacteroides. Reductions of the total number of bacteria were found in all test groups. The reductions found in the pockets treated with chlorhexidine gel or stannous fluoride gel were significantly greater than the reduction found in the pockets treated with a placebo gel. A significant reduction of black-pigmented Bacteroides was found after treatment with chlorhexidine gel or amine fluoride gel. It is concluded that 2% chlorhexidine gel or 4% stannous fluoride gel has a more than 99% reduction effect on the microflora of periodontal pockets within 30 min after application.

Clearance of a topically applied fluorescein gel from periodontal pockets.

The clearance of a fluorescein gel applied with an irrigation technique in periodontal pockets was studied. In order to evaluate the time a drug remains in a periodontal pocket, the alteration in concentration of this drug in a given time period was investigated. After application of the gel in 4 pockets of 10 patients, samples were taken from 1 of the 4 pockets at 5, 10, 20 and 40 min. The results show that in the 1st phase, directly after application, most of the gel disappeared from the pocket, while in the 2nd phase, the fluorescein gel is washed out with a calculated 50% reduction time of 12.5 min. The rapid clearance of the gel observed after irrigation might provide a partial explanation of the minor effect of pocket irrigation on the subgingival microflora.

[Sharpening of periodontal instruments]. / Het slijpen van parodontale instrumenten.

Sharp hand instruments are the first pre-requisite for scaling and root planing. Different sharpening techniques are reported, and the time at which an instrument is evaluated for its sharpness or dullness is indicated. The shape and form of several instruments are described together with the appropriate sharpening technique.

Bactericidal concentrations of chlorhexidine-digluconate, amine fluoride gel and stannous fluoride gel for subgingival bacteria tested in serum at short contact times.

In vitro inhibitory and bactericidal concentrations in serum of chlorhexidine-digluconate, amine fluoride gel, stannous fluoride gel, stannous fluoride, metronidazole and amoxicillin were determined against Bacteroides gingivalis, Bacteroides intermedius, Fusobacterium nucleatum, Actinobacillus actinomycetemcomitans and Capnocytophaga sputigena. The minimal inhibitory concentration was assessed by the agar dilution technique. The killing curves and minimal bactericidal concentration of the antimicrobial agents in inactivated bovine serum were determined after 5, 10, 20 and 60 minutes contact time. The minimal inhibitory concentration varied amongst the tested bacteria. A concentration of 128 micrograms/ml chlorhexidine digluconate, 20 mg/ml amine fluoride gel, 1 mg/ml stannous fluoride, 128 micrograms/ml metronidazole and 4 micrograms/ml amoxicillin inhibited the growth of the tested species. The minimal bactericidal concentration in serum for B. gingivalis, B. intermedius, F. nucleatum, A. actinomycetemcomitans and C. sputigena after 10 min contact time was 5 mg/ml for chlorhexidine digluconate and 100 mg/ml for amine fluoride gel. A concentration of 200 mg/ml stannous fluoride gel in serum was bactericidal for the tested species after 10 min contact time, with exception of F. nucleatum.