Changes In Probing Attachment Level Research Articles

Enamel matrix derivative (Emdogain®) for periodontal tissue regeneration in intrabony defects

Enamel matrix derivative (Emdogain®) for periodontal tissue regeneration in intrabony defects

Enamel matrix derivative (Emdogain(R)) for periodontal tissue regeneration in intrabony defects.

Periodontitis is a chronic infective disease of the gums caused by bacteria present in dental plaque. This condition induces the breakdown of the tooth supporting apparatus until teeth are lost. Surgery may be indicated to arrest disease progression and regenerate lost tissues. Several surgical techniques have been developed to regenerate periodontal tissues including guided tissue regeneration (GTR), bone grafting (BG) and the use of enamel matrix derivative (EMD). EMD is an extract of enamel matrix and contains amelogenins of various molecular weights. Amelogenins are involved in the formation of enamel and periodontal attachment formation during tooth development. To test whether EMD is effective, and to compare EMD versus GTR, and various BG procedures for the treatment of intrabony defects. We searched the Cochrane Oral Health Group Trials Register, CENTRAL, MEDLINE and EMBASE. Several journals were handsearched. No language restrictions were applied. Authors of randomised controlled trials (RCTs) identified, personal contacts and the manufacturer were contacted to identify unpublished trials. Most recent search: February 2009. RCTs on patients affected by periodontitis having intrabony defects of at least 3 mm treated with EMD compared with open flap debridement, GTR and various BG procedures with at least 1 year follow up. The outcome measures considered were: tooth loss, changes in probing attachment levels (PAL), pocket depths (PPD), gingival recessions (REC), bone levels from the bottom of the defects on intraoral radiographs, aesthetics and adverse events. The following time-points were to be evaluated: 1, 5 and 10 years. Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two authors. Results were expressed as random-effects models using mean differences for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI). It was decided not to investigate heterogeneity, but a sensitivity analysis for the risk of bias of the trials was performed. Thirteen trials were included out of 35 potentially eligible trials. No included trial presented data after 5 years of follow up, therefore all data refer to the 1-year time point. A meta-analysis including nine trials showed that EMD treated sites displayed statistically significant PAL improvements (mean difference 1.1 mm, 95% CI 0.61 to 1.55) and PPD reduction (0.9 mm, 95% CI 0.44 to 1.31) when compared to placebo or control treated sites, though a high degree of heterogeneity was found. Significantly more sites had < 2 mm PAL gain in the control group, with RR 0.53 (95% CI 0.34 to 0.82). Approximately nine patients needed to be treated (NNT) to have one patient gaining 2 mm or more PAL over the control group, based on a prevalence in the control group of 25%. No differences in tooth loss or aesthetic appearance as judged by the patients were observed. When evaluating only trials at a low risk of bias in a sensitivity analysis (four trials), the effect size for PAL was 0.62 mm (95% CI 0.28 to 0.96), which was less than 1.1 mm for the overall result. Comparing EMD with GTR (five trials), GTR showed statistically significant more postoperative complications (three trials, RR 0.12, 95% CI 0.02 to 0.85) and more REC (0.4 mm 95% CI 0.15 to 0.66). The only trial comparing EMD with a bioactive ceramic filler found statistically significant more REC (-1.60 mm, 95% CI -2.74 to -0.46) at the EMG treated sites. One year after its application, EMD significantly improved PAL levels (1.1 mm) and PPD reduction (0.9 mm) when compared to a placebo or control, however, the high degree of heterogeneity observed among trials suggests that results have to be interpreted with great caution. In addition, a sensitivity analysis indicated that the overall treatment effect might be overestimated. The actual clinical advantages of using EMD are unknown. With the exception of significantly more postoperative complications in the GTR group, there was no evidence of clinically important differences between GTR and EMD. Bone substitutes may be associated with less REC than EMD.

Enamel Matrix Derivative for Periodontal Tissue Regeneration in Treatment of Intrabony Defects: A Cochrane Systematic Review

We reviewed the literature on the efficacy of enamel matrix derivative (EMD) in comparison with open flap debridement, guided tissue regeneration (GTR), and bone grafting for the treatment of intrabony defects. We searched four major electronic databases for randomized controlled trials (RCTs) with at least one year of follow-up. Several journals were handsearched with no language restrictions. Outcome measures were: tooth loss, changes in probing attachment levels (PAL), pocket depths (PPD), gingival recessions (REC), marginal bone levels on intraoral radiographs, and postoperative infections. Screening of eligible RCTs, assessment of the methodological quality, and data extraction were conducted in duplicate. No difference in tooth loss was observed. A meta-analysis (eight trials) showed that EMD-treated sites displayed statistically significant PAL improvements (mean difference 1.3 mm) and PPD reduction (1 mm) when compared to flap surgery. When EMD was compared to GTR (six trials), GTR showed a statistically significant reduction of PPD (0.6 mm) and increase of REC (0.5 mm). No difference in postoperative infections was observed. No trials compared EMD with bone grafts alone. EMD is able to significantly improve PAL levels and PPD reduction when compared to flap surgery; however, there is no evidence that more teeth could be saved. There was no evidence of important differences between EMD and GTR.

Enamel matrix derivative (Emdogain) for periodontal tissue regeneration in intrabony defects.

Periodontitis is a chronic infective disease of the gums caused by bacteria present in dental plaque. This condition induces the breakdown of the tooth supporting apparatus until teeth are lost. Surgery may be indicated to arrest disease progression and regenerate lost tissues. Several surgical techniques have been developed to regenerate periodontal tissues including guided tissue regeneration (GTR), bone grafting (BG) and the use of enamel matrix derivative (EMD). EMD is an extract of enamel matrix and contains amelogenins of various molecular weights. There is evidence to show that amelogenins are involved not only in enamel formation, but also in the formation of the periodontal attachment during tooth formation. To test the efficacy of EMD in comparison with open flap debridement, GTR and various BG procedures for the treatment of intrabony defects. We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Several journals were handsearched. No language restrictions were applied. Authors of randomised controlled trials (RCTs) identified, personal contacts and the manufacturer were contacted to identify unpublished trials. Most recent search: January 2003. RCTs on patients affected by periodontitis having intrabony defects treated with EMD compared with open flap debridement, GTR and various BG procedures with at least one year follow up. The outcome measures considered were: tooth loss, changes in probing attachment levels (PAL), pocket depths (PPD), gingival recessions (REC), marginal bone levels on intraoral radiographs and postoperative infections. Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two reviewers. Results were expressed as random effect models using weighted mean differences for continuous outcomes and relative risk for dichotomous outcomes with 95% confidence interval (CI). Heterogeneity was investigated including both clinical and methodological factors. No difference in tooth loss was observed. A meta-analysis including eight trials showed that Emdogain treated sites displayed statistically significant PAL improvements (mean difference 1.3 mm, 95%CI: 0.8 to 1.8) and PPD reduction (1 mm, 95%CI: 0.5 to 1.4) when compared to flap surgery. Comparing Emdogain with GTR (six trials), GTR showed a statistically significant reduction of PPD (0.6 mm) and increase of REC (0.5 mm). No difference in postoperative infections was observed. Emdogain is able to significantly improve PAL levels (1.3mm) and PPD reduction (1mm) when compared to flap surgery, however these results may not have a great clinical impact, since it has not been shown that more periodontally compromised teeth could be saved. There was no evidence of clinically important differences between GTR and Emdogain.

A digital subtraction radiography investigation of upper first molar proximal bone density changes in adolescents.

The aim of this in vivo study was to investigate the ability of digital subtraction radiography to monitor changes in proximal bone density, adjacent to the upper first molars, in a group of adolescents using the Digora direct digital radiographic system to acquire images. For 57 adolescents, assessments of changes in probing attachment level at the mesio- and disto-buccal surfaces of both upper first molars and proximal crestal bone density using digital subtraction radiography were made. At the conclusion of this 21-month study attachment loss was identified in 34 (17%) of the 204 sites analysed. For sites with attachment loss a mean decrease in bone density equivalent to 5.51 mm3 aluminium (Al) was found compared to 2.96 mm3 Al for those without (p < 0.001). For the 17 subjects with attachment loss a mean equivalent to 4.66 mm3 Al was lost from the crestal bone compared with 2.56 mm3 Al for the 40 subjects without attachment loss (p < 0.01). The correlation between attachment loss and bone density changes was poor for both sites (r = 0.13), p = 0.067) and mean scores for subjects (r = 0.24, p = 0.069). A visual qualitative assessment of bone density change found that 70.6% of sites with attachment loss compared to 62.4% of those without had a decrease in crestal bone density. This study suggests that it is possible to monitor bone density changes in adolescents, with a developing dentition, using digital subtraction radiography. Further, it is suggested that conventional probing assessments of attachment level may underestimate the level of destructive periodontal disease in this age group.

Evaluating the Validity of Probing Attachment Loss as a Surrogate for Tooth Mortality in a Clinical Trial on the Elderly

Most periodontal trials are based on the assumption that the superior treatment, as judged by short-term intangible changes in probing attachment levels (the surrogate), is also the treatment most likely to affect tooth mortality. This assumption is valid if: (1) the surrogate is informative about tooth mortality, and (2) the surrogate captures a substantial proportion of the treatment effect on tooth mortality (e.g., > 50% or 75%). The goal of this study was to evaluate whether both conditions were satisfied in a randomized controlled trial (RCT) of elders at high risk for dental diseases. The results suggested that the first condition for a valid surrogate was satisfied: Both one- and two-year changes in probing attachment level were informative about tooth mortality risk. A 1-mm loss measured over a one-year period was associated with a 56% increased tooth mortality risk (relative risk = 1.56; 95% confidence interval, 1.08 to 2.26; p = 0.017); a 1-mm loss measured over a two-year period was associated with a 102% increased risk for tooth mortality (relative risk = 2.02; 95% confidence interval, 1.26 to 3.25; p = 0.004). The second condition necessary for a valid surrogate could not be confirmed in the present trial. With 95% confidence, it was concluded that one-year changes in probing attachment level measurements did not capture a significant proportion of the treatment effect (point estimate, 6%; 95% confidence interval;-38% to 53%). No useful statements could be made regarding the proportion of treatment effect captured by two-year changes, due to the width of the confidence interval (point estimate, 18%; 95% confidence interval;-151% to 140%). It is concluded that (1) the evidence surrounding the one-year change in probing attachment level indicates that it can be ruled out as being anything more than a weak surrogate marker for tooth mortality, and (2) further research is required to study the validity of two-year change in probing attachment level as a surrogate marker. Due to characteristics of the population and the treatments investigated, the generalizability of these findings to other RCTs is questionable.

Regenerative surgery of intrabony periodontal defects using ePTFE barrier membranes: scanning electron microscopic evaluation of retrieved membranes versus clinical healing.

Sixteen intrabony defects in 12 patients were treated by gingival flap surgery including root surface debridement and placement of an expanded polytetrafluoroethylene (ePTFE) membrane. The membranes were removed after 4 to 6 weeks and examined by scanning electron microscopy (SEM) for bacterial contamination and adherent connective tissue elements. Twelve months postsurgery, the defect sites were reexamined for changes in probing attachment level and probing bone level. Comparison of ultrastructural findings and clinical observations revealed that extent of bacterial contamination of the membrane correlated inversely with clinical assessment of attachment gain. The results indicate that the extent of oral exposure and bacterial contamination of the ePTFE membrane at the time of removal may be an indicator of the long-term success or failure of the regenerative procedure.

Diagnostic characteristics of crevicular fluid aspartate aminotransferase (AST) levels associated with periodontal disease activity

During a 2-year period pocket depth, probing attachment level, gingival index, and crevicular fluid aspartate aminotransferase (AST) levels were monitored in 25 previously treated periodontitis patients. Probing attachment level change was used retrospectively to identify sites where active periodontal destruction had occurred. The ability of crevicular fluid AST activities at 600, 800, 1000, and 1200 microIU levels to recognize active disease was investigated. Probing attachment level changes observed support the concept that the pattern of periodontal disease activity is episodic and infrequent. A loss of greater than or equal to 2 mm was found at 11% of all studied sites, whereas a gain of greater than or equal to 2 mm was noticed for 15% of sites. 2 subjects had 3 teeth that lost greater than or equal to 2 mm of attachment, whereas 15 subjects demonstrated no teeth with disease activity. The remaining 8 subjects had 1 or 2 sites that lost greater than or equal to 2 mm of attachment. Bayes's theorem and ROC curves were used to exemplify the sensitivity and the specificity of AST assessments. The AST 800 microIU demonstrated a sensitivity of 0.93 and specificity 0.68 and an odds ratio of 15.4 for attachment loss greater than or equal to 2 mm. Under the conditional probability of either 50%, 25% or 10% active disease prevalence, AST 800 microIU has a predictability of 73%, 50% and 24% respectively.

The Effectiveness of Subgingival Scaling and Root Planing II. Clinical Responses Related to Residual Calculus

This study related 3-month clinical changes following scaling and root planning to the presence or absence of calculus on the root surfaces detected after extraction. Seven patients provided 646 sites evaluated for plaque, bleeding upon probing (BOP), probing pocket depth (PPD), and probing attachment level (PAL) at baseline and monthly following instrumentation. The teeth were extracted and evaluated for the presence and the percent surface area of calculus. Diagnostic sensitivity and predictability values for initial and residual PPDs, loss of PAL, and BOP in detecting residual calculus were determined. Calculus was found on 376 surfaces with a mean percent surface area of 3.13%. Predictability values were similar for all PPD ranges, while sensitivity decreased with increasing PPD. Probing attachment level changes were found to be unrelated to the presence or the amount of residual calculus. Bleeding upon probing had high levels of predictability, but sensitivity values were low. None of the clinical parameters evaluated in this study provided both a high level of predictability and sensitivity in detecting residual calculus.

The impact of regression towards the mean on probing changes in studies on the effect of periodontal therapy.

The purpose of this report was to evaluate the magnitude of the regression towards the mean (RTM) relative to the observed changes in probing measurements following periodontal therapy in 2 groups of patients. Regression lines were calculated for observed changes in probing depths and probing attachment levels related to the initial probing depths of the individual sites. Regression lines, adjusted for the RTM effect, were also calculated. For the extreme subgroups of recorded shallow and deep sites, the RTM effect (mm) was found to amount to a maximum of 0.6 mm. It appears unlikely that erroneous conclusions have been made in previous clinical studies evaluating probing depth changes in deep sites, since the RTM accounts for a limited portion of the observed changes. For probing depth changes in shallow sites and for probing attachment level changes in both shallow and deep sites, the RTM accounts for a larger proportion of the observed mm changes. It therefore seems prudent to be careful about interpretation of these changes in clinical studies, where the RTM effect has not been adjusted for. Whenever possible, duplicate initial recordings should be taken to allow determination of and subsequent adjustment for the RTM effect.

Monitoring of subgingival Bacteroides gingivalis and Actinobacillus actinomycetemcomitans in the management of advanced periodontitis.

In a series of clinical trials involving 79 adult periodontitis patients, we evaluated the clinical and microbiological effects of H2O2, NaHCO3, and a commercially available povidine solution, as adjuncts to mechanical periodontal debridement. Each trial included a placebo as a control. The healing response was monitored clinically by measurement of changes in probing attachment levels after treatment. The current report includes data from single-rooted teeth only.In general, healing in severely advanced periodontal lesions (initial pocket depth ≥ 7 mm) was enhanced by the use of the listed topical antimicrobial agents administered subgingivally during mechanical debridement.Correlations were sought between changes in probing attachment levels 12 months after treatment, and the presence of subgingival B. gingivalis and A. actinomycetemcomitans in the periodontal lesions. For a total of 428 lesions included in this report, B. gingivalis was detected in 53.1% of lesions showing probing attachment loss (≥1.5 mm), but in only 4.7% of lesions showing gain (≥ 1.5 mm). Either B. gingivalis or A. actinomycetemcomitans was detected in 70.1% of the lesions showing loss and in only 4.8% of those showing gain. These studies indicate the benefits of the adjunctive antimicrobial therapy described, and the usefulness of specific microbiological monitoring as an aid to clinical measurements in the evaluation of success or failure of treatment of chronic adult periodontitis.

Longitudinal study of untreated periodontitis (I). Clinical findings.

The principal aim of this study was to investigate the use of certain clinical and microbiological criteria to predict periodontal breakdown during a 1-year period. A further aim was to establish whether the act of collecting subgingival plaque samples periodically throughout the observation period would have any effect on the clinical or microbiological variables. Only the clinical data is presented in this paper. The study population comprised 11 volunteers (aged 32-51 years) with persistent advanced periodontitis and inadequate plaque control in spite of a previous intensive course of hygiene therapy. From the left jaw quadrants, 89 teeth were selected, yielding 148 bleeding pockets of 4 mm depth or more. From the right jaw quadrants, 74 teeth were selected, yielding 117 bleeding pockets of 4 mm depth or more. All subjects were examined on 7 occasions at 2-monthly intervals when plaque index scores, dichotomous measurements of gingival redness, pocket depths and attachment levels were recorded. Bacteriological sampling was carried out at each visit for each site only in the left jaw quadrants while the right jaw quadrants were sampled only at the first and last visits. During the study, no subgingival instrumentation was performed, except at 3 sites which exhibited loss of attachment of 3 mm. These teeth were withdrawn from the study for ethical reasons. At the completion of the study, the sequential changes in probing attachment level at each site were subjected to regression analysis to determine the direction and extent of attachment change which had taken place at each site.(ABSTRACT TRUNCATED AT 250 WORDS)

Longitudinal study of untreated periodontitis (II). Microbiological findings.

11 volunteer subjects with advanced chronic periodontitis participated in a 1-year longitudinal clinical and microbiological study. Subgingival plaque was collected at each of 7 visits from 148 pre-selected sites in the left jaw quadrants (test sites) and on the first and last visits, only from 117 sites in the left jaw quadrants (control sites). All sites were examined clinically at each of the 7 visits, and the microbiological markers investigated were the % spirochaetes and % black pigmented Bacteroides species in subgingival plaque. At the completion of the study, the sequential changes in probing attachment level at each site were subjected to regression analysis to determine the direction and extent of attachment change. Possible correlations between attachment change and % spirochaetes or % black-pigmented bacteroides were investigated using both individual sites and individual subjects. No significant differences were observed in either of the microbial variables between test and control sites. Possible correlations between the microbiological markers and attachment changes were investigated at baseline, at the 12-month visit and using the microbial data accumulated over all 7 visits. Significant differences were observed only at the 12-month visit when the % spirochaetes of both test and control sites were significantly lower in subjects showing the greatest improvement in attachment level. Overall, these results indicate that quantification of either spirochaetes or black-pigmented Bacteroides species cannot be used reliably to identify or predict disease-active sites.

Subgingival spirochete and leukocyte counts as indicators of response to therapy

The aim of this study was to determine whether changes in probing attachment levels are related to subgingival spirochete or leukocyte counts in periodontal pockets. Following initial clinical recordings and therapy consisting of oral hygiene instruction and root debridement, the probing attachment levels of proximal sites of 120 single-rooted teeth in 7 patients were measured every 3 months for 12 months. The measurements of each site were subjected to regression analysis, which determined whether the site was deteriorating, improving, or non-changing. Subgingival washings were taken of 19 deteriorating, 22 improving, and 127 non-changing sites to determine the number and % of spirochetes and the number of leukocytes at each site. Improved probing attachment levels were associated with reduced numbers of spirochetes and leukocytes. However, the ranges of individual measurements of subgingival washing variables overlapped considerably between groups. Spirochete and leukocyte counts related better to the 12-month probing depths than to changes in probing attachment levels during the preceding 12 months. These findings suggest that none of the tested subgingival washing parameters are suitable indicators of changes in attachment levels on an individual site basis.