Infrabony Pockets Research Articles

Radiographic periodontal attachment loss as an indicator of death risk in the elderly.

Oral infections have been associated with serious systemic diseases and an increased risk of death. Our aims were to investigate whether radiographically-observed apical periodontitis lesions, carious teeth, periodontal attachment loss (horizontal bone loss, furcation lesions, number of teeth with infrabony periodontal pockets, the extent of infrabony periodontal pockets) and the sum of all these findings have any relationships with all-cause mortality within 4-year follow-up. 292 community-dwelling elderly persons aged 76, 81 and 86 years. The number of deaths within 4 years was 54 (18.5%). In the dentate 169 subjects, of whom 32 (18.9%) deceased within 4 years, the mean number of teeth was 15.5 in men and 13.2 in women. The imaging method used was panoramic radiography supplemented by intraoral radiographs. 51% of the dentate subjects had infrabony pockets (mean 1.5, s.d. 2.2), and 40% had periapical periodontitis lesions (mean 1.0, s.d. 1.6). After controlling for age and gender, vertical bone loss judged as advanced infrabony pockets was associated with 4-year all-cause mortality (Odds ratio 2.2,1.0-4.7). Other associations were statistically insignificant. Periodontal attachment loss may indicate an increased risk of death in the elderly.

Muscular reconstruction to improve the deterioration of facial appearance and speech caused by mandibular atrophy: technique and case reports

One of the consequences of severe mandibular atrophy is the loss of attachment of the facial muscles that originate from the alveolar process and basal bone. Another is a loss of vestibular depth and reduction in the width of the attached gingiva. The result is reduced ability to chew, a changed and aged appearance, difficulties with pronunciation, and a reduced range of expressions. The traditional goal of treatment has been to improve the ability to chew. We describe a technique by which all these functions can be improved by a combination of insertion of implants and functional reconstruction of the facial muscles and position of the lips. When the muscles are repositioned, the buccal vestibule is deepened, and the incidence of gingival hyperplasia and infrabony pockets along the posts is eliminated. This treatment, which also rejuvenates the face and improves the ability to speak, should help to overcome the loss of self-confidence and self-esteem of these patients by improving their quality of life.

Radiographic periodontal findings in an elderly Finnish population.

By means of panoramic radiography and additional intraoral radiographs, the occurrence of calculus, the extent of horizontal bone loss, the depth and number of infrabony pockets, the number of furcation lesions, and the number of interproximal restoration overhangs were studied in 169 dentate 76-, 81-, and 86-year-old subjects (54 male and 115 females) living at home. Alveolar bone loss (horizontal or vertical) among the participants was common, and in only 8 subjects (5%) was it judged non-existent. It was slight in 30 subjects (18%), moderate in 53 (31%), and advanced in 78 (46%). Infrabony pockets were found in 51% of the subjects and furcation lesions in 28%. The presence of calculus did not correlate with the other parameters. The number of interproximal overhangs was associated with the number of infrabony pockets and of furcation lesions (R=0.3, p<0.001 and p<0.0001) and the number of infrabony pockets with the number of furcation lesions (R=0.4, p<0.0001). Our study shows that periodontal findings are common in the dentate elderly, and associations recently found between periodontal infections and several serious diseases make radiographic examination an integral part of the oral examination of the elderly patient.

The effect of supragingival plaque control on the subgibgival microflora in human periodontitis

The aim of the present trial was to study if carefully practiced supragingival plaque control influenced the subgingival microbiota at periodontal sites with suprabony, infrabony, or furcation pockets. 12 subjects, 5 males and 7 females aged 44 to 69 years (mean age 55 years) participated in the study. None of the participants had during the last 12 months received periodontal therapy, and none of the subjects had used antibiotics during a 3-month period preceding the study. Following a screening examination, 6 to 8 sites per subject were selected which had a probing depth of > or = 5 mm. Among these sites, 1-3 sites had a suprabony location, 1-3 sites had an infrabony location, and 1-3 sites were associated with a furcation defect. The selected sites were exposed to a baseline examination at which the following parameters were recorded: plaque, gingivitis, probing pocket depth and probing attachment level. A bacterial sample was obtained from each of the selected sites: 2 sterile paper points were inserted into the pocket and kept in place for 30 seconds. The paper point samples were removed, placed in a vial containing an anaerobically prepared transport medium, and processed using routine procedures. Following the baseline examination, each subject was given a case presentation, received thorough supragingival scaling and was instructed to practice proper plaque control with the use of toothbrush and dentifrice. During the subsequent 30 weeks they were recalled 2-3xper week for professional tooth cleaning. Each session was handled by a dental hygienist and required about 15 min. Re-examinations were performed after 30 weeks. The findings indicated that professionally delivered and frequently repeated supragingival tooth cleaning, combined with careful self-performed plaque control had a marked effect on the subgingival microbiota of moderate to deep periodontal pockets. Thus, at sites with suprabony and infrabony pockets, as well as at furcation sites, the meticulous and prolonged supragingival plaque removal reduced the total number of microorganisms that could be harvested, as well as the % of sites with P. gingivalis.

Infrabony pockets and reduced alveolar bone height in relation to orthodontic therapy.

Experimental animal studies have shown that orthodontic movement of teeth into infrabony pockets may be detrimental to the periodontal attachment. After elimination of subgingival plaque infection in the experimental animals, no additional loss of connective tissue attachment occurred. An experimental model has shown that a tooth with normal periodontal support can be orthodontically moved into an area of reduced bone height with maintenance of height of connective tissue attachment level and alveolar bone support. The results from these experimental studies have been tested clinically.

Periodontal tissue response to orthodontic movement of teeth with infrabony pockets

The aim of this study was to evaluate the effect of orthodontic tooth movement on the level of the connective tissue attachment in sites with infrabony pockets. The experiment was carried out in four beagle dogs. The second and fourth premolars were extracted. After healing, angular bony defects were prepared at the mesial aspect of the third premolars. The exposed root surface was scaled and planed, and a notch was prepared at the bottom of the defect. Plaque-collecting cotton floss ligatures were placed around the neck of the teeth and maintained in situ for 3 weeks, followed by an additional 2 months of plaque accumulation before the orthodontic tooth movement was initiated. In each dog, one premolar was moved away from the angular bony defect and one premolar into and through the angular bony defect. The maxillary third premolars served as control teeth and were not subjected to orthodontic tooth movement. After orthodontic treatment (5 to 6 months), the teeth were stabilized for a period of 2 months before biopsy sampling. Clinical, radiographic, and histologic evaluations revealed that it was possible to establish and maintain an infrabony pocket with a subcrestal, plaque-induced inflammatory lesion during the entire course of the study. While the control teeth had maintained their attachment levels, all but one of the orthodontically moved teeth showed additional loss of attachment.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of Periodontal Defects With an Absorbable Membrane (Polyglactin 910) With and Without Osseous Grafting: Case Reports

The purpose of these reports is to illustrate the possible use of polyglactin 910 as an absorbable membrane for periodontal healing. Eleven surgical sites in 10 patients are reported. Vicryl mesh was used on all sites, and osseous allograft material was used in 8 of these sites. Radiographic evaluation and sounding with anesthesia indicate improvement in the treated areas. Few adverse effects were seen at the treated sites. Therefore, polyglactin offers promise as a material for use in periodontal therapy, especially in deep infrabony pockets. Further controlled studies comparing polyglactin 910 and other resorbable materials as barrier membranes are needed to establish their safety and efficacy.

Histological investigation of the tissue response to hydroxyapatite used as an implant material in periodontal treatment

Patients with severe periodontitis and who had one or more teeth with infrabony pockets were treated by periodontal surgery with implantation of hydroxyapatite particles into the bone defects at the time of surgery. Subsequently, in three patients it was found necessary to extract a tooth for reasons not related to the previous periodontal treatment. Specimens that included the local soft tissues and crestal bone attached to the teeth were obtained at 22, 40 and 80 weeks after placement of the implant. They were decalcified and stained with haematoxylin and eosin and examined under light microscopy. The healing response was found, to vary between specimens, and between sites within the same specimen. The early stage of healing showed the implant particles surrounded by collagen. Subsequently, varying degrees of resorption of the periphery of the particles was seen, and at some sites bone deposition was observed. These different healing responses were found to be progressing concurrently at sites in close proximity. Further work is needed to confirm the histological findings described in the paper.

Multicenter follow-up study of the transmandibular implant

The purpose of this multicenter study was to review the results of treatment and identify complications in edentulous patients who were treated with the transmandibular implant. A total of 190 patients were treated in four university departments. These patients presented for treatment with mandibular bone heights that ranged from 4 to 18 mm (mean, 10 mm). After postoperative periods that ranged from 3 months to 5 years, 182 of the 190 implants (95.8%) were stable and functional. Three implants were removed due to perioperative fractures in mandibles with 4 to 6 mm of bone height. Five were removed due to infection which occurred within the first 3 months after surgery. Reversible complications that developed in 22.2% of the patients were treated successfully. The 182 implants in function demonstrated no mobility and no infrabony pockets around any of the transmucosal posts. The results of this study demonstrate that the transmandibular implant has acceptable predictability and reliability for reconstruction of patients with severe atrophy of the mandibular alveolar process.

Periodontal disease in the prehistoric Ipiutak and Tigara skeletal remains from Point Hope, Alaska.

Two large groups of prehistoric Eskimo skeletons from Point Hope, Alaska, were evaluated for dental wear and several measures of periodontal disease. Occlusal attrition was found to increase steadily with increasing age. Crown height decreased proportionately. Assessing periodontal disease by inspecting apparent alveolar recession was judged ineffective due to possible supereruption. Infrabony pockets, the result of severe localized periodontal disease indicated that in Ipiutak people between the ages of 25 and 30, and Tigara people between 35 and 40, more dental sites were affected by periodontal disease than were not. This suggests a cultural, genetic, or dietary difference between the two groups. Male/female differences were slight in all parameters studied.

Immunoglobulins in Periodontal Tissues: II. Concentrations of Immunoglobulins in Granulation Tissue From Pockets of Periodontosis and Periodontitis Patients

In recent years evidence in the literature has indicated that the immune response may play an important role in the initiation and progression of the periodontal diseases. A study was initiated to determine the IgA, IgG, and IgM concentrations in the granulation tissue removed from deep infrabony pockets of patients with periodontosis and advanced periodontitis. Comparison of mean immunoglobulin levels between the periodontosis and periodontitis groups revealed a statistically significant increase (P less than 0.05) for IgG in the granulation tissue from the periodontosis group. The possible implications of these findings are discussed.

Treatment of compromised teeth: A multidisciplinary approach

Treatment for uprighted abutment teeth that may have infrabony pockets can be considered complete when the following criteria are met: 1. 1. The uprighted tooth is in its proper vertical axis. 2. 2. There is a significant decrease in soft-tissue pocket depth. 3. 3. Crestal leveling is evident radiographically. 4. 4. Adequate space has been created to accommodate a pontic (minimally 6.5 mm.). The advantages of employing this orthodontic-periodontal technique are as follows: 1. 1. Leveling of the osseous crest fosters pocket elimination obviating the necessity for removal of a great deal of supporting bone. Concomitantly, a significant decrease in pocket depth usually eliminates the need for periodontal surgery. 2. 2. The resulting occlusal forces are placed in favorable axial inclinations. 3. 3. There is an improved crown-to-root ratio, since the uprighted and extruded tooth is reduced to the level of the occlusal plane. This reduction is sufficient to improve considerably the prognosis of a questionable abutment tooth. 4. 4. A pontic space is created for an esthetic and properly contoured pontic. 5. 5. Parallelism is attained, so that the marginal integrity is more easily accomplished. 6. 6. The orthodontic procedures are relatively uncomplicated, efficient, and esthetic, provided there is little or no lower anterior crowding. 7. 7. The restorative dentist has a proper abutment tooth with a good prognosis for his prosthesis.

The Infrabony Pocket and its Relationship to Trauma from Occlusion and Subgingival Plaque

The role of trauma from occlusion and subgingival plaque in the pathogenesis of the infrabony pocket as observed in the radiograph was studied in 48 teeth which had to be extracted because of advanced periodontal disease. Prior to extraction the teeth were examined with regard to the degree of mobility and the direction of the horizontal components of the masticatory forces. Following extraction, the teeth were stained and examined under the stereomicroscope. When the tooth is adequately stained, the subgingival plaque and the remaining attachment fibers can be distinguished easily from the area of the junctional epithelium. The observations which were made on the extracted teeth were then correlated with what could be seen in the radiograph. The following major observations were made: In the depth of the infrabony pocket there was a close congruence between the front of the subgingival plaque and the borderline of the remaining attachment fibers, the distance varying between 0.2 and 2.0 mm. There was also a close relationship between the front of the subgingival plaque and the alveolar crest adjacent to the tooth as well as between the surface of the subgingival plaque and the opposite vertical wall of the infrabony pocket, the distances ranging between 1 and 3 mm. The horizontal forces were mainly or exclusively oriented bucco-lingually, whereas the infrabony pockets were located mesially or distally, i.e. parallel to the direction of the force and not at a right angle to it as observed in experimental studies. The mobility of the teeth adjacent to which infrabony pockets developed was normal in 42% of the cases, slightly increased in 31%, and only in 11% of the cases was it excessively increased. In 19 cases the infrabony pocket was located on one of the roots of lower molars which were removed by hemisection. In eight of the 12 cases, which were observed for periods from 1 to 10 years, the remaining root functioned well without further development of angular bone defects or infrabony pockets. All of them became markedly firmer as a consequence of successful periodontal treatment. Three of the four remaining roots were extracted because of periapical problems. There was no evidence to indicate that trauma from occlusion had been involved in the pathogenesis of the infrabony pockets.

The angular bone defect and its relationship to trauma from occlusion and downgrowth of subgingival plaque

Sixty-four sets of human teeth were collected with the aim of evaluating the role of trauma from occlusion in the etiology of destructive periodontal disease. Before the jaws were taken out, a careful bite analysis was carried out. After fixation of the jaws, impressions were taken and plaster of Paris models were made. Finally, a set of 14 radiographs were taken. On the basis of the "clinical" records postmortem, the study models and the radiographs, the jaws were sectioned. Only mesio-distal sections were included in the present analysis. The total number of interdental spaces examined was 106. The following observations were made: 1. Before any loss of periodontal fiber attachment has taken place, the configuration of the interdental septum is entirely dependent on the location of the cemento-enamel junction (CEJ) of the two neighboring teeth. The alveolar crest does not approach the apical border of the junctional epithelium closer than about 1 mm. Thus, if the CEJ is located at different levels on two neighboring teeth, the marginal termination of the interdental septum will be oblique, forming an acute angle with the "lowest" tooth. 2. Loss of periodontal fiber attachment could invariably be related to the apical growth of subgingival plaque, and downgrowth of plaque was always associated with an inflammatory process which involved lysis of the attachment fibers within a distance varying between 0.2 and 1.8 mm from the apical border of the plaque. Subsequently, the JE proliferated down to cover the denuded root surface. 3. Reduction in height of the alveolar crest could also be related to the downgrowth of plaque. The distance from plaque to bone was never found to be less than 0.5 mm and never more than 2.7 mm. The configuration of the interdental septum always seemed to be determined by the level of the plaque on the two neighboring tooth surfaces. Thus, if the plaque had reached the same level on both sides, the crest of the interdental septum assumed a horizontal outline; if plaque had proliferated down to different levels, the crest of the interdental septum was oblique and an angular defect hereby established. 4. In the present material no evidence was found to indicate that functional (traumatic) forces can act as a co-factor in the causation of angular defects. In fact, such defects were found equally often adjacent to "nontraumatized" as to "traumatized" teeth. 5. Infrabony pockets were invariably associated with downgrowth of subgingival plaque.

The effect of orthodontic tilting movements on the periodontal tissues of infected and non‐infected dentitions in dogs

Abstract The aim of the present investigation was to study (1) whether it was possible, by orthodontic tooth movement, to shift a supragingivally located plaque into a subgingival position, and (2) periodontal tissue reactions around tilted and intruded plaque‐infected teeth.The experiments were performed on five dogs which were fed a diet that allowed dental plaque accumulation. The lower third premolars (3P and P3) were extracted and a phase of experimental periodontal breakdown was initiated on day 0. The periodontal pockets around the lower fourth premolars (4P and P4) were eliminated on day 210. During surgery, a notch was prepared in the root at the level of the marginal alveolar bone in order to facilitate measurements in radiographs and histological sections. After 60 days of healing with plaque control, i.e. on day 270, orthodontic appliances producing tipping forces on 4p and P4 were inserted. From day 270 to day 450, plaque was allowed to accumulate on 4P (test = T) while P4 (control = C) was brushed twice daily. The dogs were sacrificed on day 450. Following sacrifice, tissue sections comprising 4P, 1M and P4, M1 were produced and subjected to microscopic analysis.The present investigation showed that it was possible by orthodontic tooth movement to shift a supragingivally located plaque into a subgingival position. The mesial‐apical movement of the plaque‐infected teeth resulted in the formation of infrabony pockets. In four out of five dogs the displacement of the plaque‐infected tooth resulted in an apical shift of the connective tissue attachment. When similar orthodontic forces were acting on plaque‐free teeth, the tilting movement did not result in the formation of infrabony pockets. In only two dogs did the treatment result in loss of connective tissue attachment.

Radiographic assessment of proximal infrabony pocket topography.

A method for determining the topography of interproximal infrabony pocket lesions has been presented, utilizing three intraoral radiographys. Three periapical films for the urea to be examined should be taken in a standard manner, one with the central beam angulation horizontal, another at -20degrees and the third at +20degrees. Following processing, the dried films should be examined, commencing with the -0degrees film and comparing the width of the transitional zone with that of the -20degrees film and then the film exposed with the central beam angulation at +20degrees. Following this sequence, if the transitional zone decreases in width between the 0degree and -20degrees film, then the bony destruction is greater for the buccal plate. Should the transitional zone increase in width when the above sequence of examining the film is undertaken, the bone destruction is greater for the lingual plate of bone. In each case the third film will confirm the diagnosis. In the case of horizontal bone destruction in a buccolingual direction, the transitional zone will be absent or of minimal width on the 0degree film when compared with the film exposed at +20degrees and -20degrees.

Intraoral cancellous bone autografts in the treatment of infrabony pockets.

One hundred infrabony pockets with one- and two-wall bony defects were treated for reattachment. Mucoperiosteal flaps were raised, the tooth surfaces were scaled and planed, and the defects curetted. Flaps were sutured tightly and the sites protected with a surgical dressing. Antibiotic coverage was used in each case. Pre- and postoperative measurements were taken by the same clinician from the cemento-enamel junction to the base of the pocket. In 56 defects cancellous bone from the same patient was placed in the defect, and in 44 defects the treatment consisted only of open curettage without bone grafts. The results showed a trend towards more favourable clinical results using bone grafts; especially in the two-wall bony defects.

Osseous repair of an infrabony pocket without new attachment of connective tissue.

This report describes the osseous repair of an infrabony pocket without new attachment of connective tissue between the new bone and root surface. While the width of the connective tissue between the new bone and root surface was of approximately normal dimensions, junctional epithelium was present on the root surface.

The periodontium and the canine function theory

A clinical evaluation of the canine function theory and balanced occlusion theory was presented. Both theories were evaluated from the periodontal point of view. The canine function theory claims that the canine teeth must support the forces of mastication during eccentric movements of the mandible away from centric occlusion. The balanced occlusion theory claims that the forces of mastication must be supported with as many teeth as possible during eccentric movements of the mandible away from centric occlusion. The evidence presented showed that the canine teeth were incapable of supporting excessive functional forces. Vertical bone loss, with accompanying infrabony pocket formation, occurred. Canine interferences were shown to be a major etiologic factor in temporomandibular joint dysfunctions. Removal of the canine interferences, and the establishment of a balanced occlusion resulted in a complete remission of all symptoms. The canine function theory claims that the periodontal ligament of the canines has a “protective mechanism” capable of protecting the periodontium from periodontal breakdown due to excessive functional forces. The clinical evidence presented does not support this claim. From the periodontal point of view, the dentition should be treated according to the principles of the balanced occlusion theory.

Clinical and Roentgenographic Evaluation of the Post Treatment Healing of Infrabony Pockets

Clinical and Roentgenographic Evaluation of the Post Treatment Healing of Infrabony Pockets