Periodontal Attachment Apparatus Research Articles

Smoking as an environmental hazard to the periodontal and peri-implant tissues: A brief review

While dental plaque is considered the etiological factor for the development of periodontal and peri-implant diseases, many studies from recent years point to smoking as the most significant environmental factor contributing to disease severity. This effect is evident at the epidemiological level as well as on our understanding of the biological mechanisms involved. The present review presents abundant scientific evidence showing that smoking negatively affects the local blood supply, interferes with the reaction of the immune system to bacterial insult, is toxic to gingival and periodontal ligament cells, impedes the response of the periodontal attachment apparatus to treatment, and is linked to dental implant failure. Over the past 30 years, more than 200 million people have died as a result of smoking tobacco use. There are more than 1 billion current smokers worldwide and these numbers are likely to increase over the coming years. And yet, the effect of smoking on periodontal and peri-implant health has been a controversial issue. It was argued, that it is difficult to prove such an effect due to poor adherence of smokers to oral hygiene, which creates a confounding factor inseparable from the effect of the smoking itself. Unfortunately, even some of the more recent publications cast doubt as for the importance of smoking cessation on peri-implant health, as a prerequisite for a successful treatment. The aim of the present review was to question the validity of these reports by presenting multiple evidence to support the quiet widely accepted common knowledge that is the numerous hazards to the oral biology which are the result of a heavy and prolonged smoking habit.

Evolution of periodontal attachment apparatus - Fossils to final forms

The study of tooth attachment evolution establishes relationship between living & extinct forms of life which provides useful evidence for general affinities between related species. Human dentition, established very early in evolution, and has persisted with little change from its evolutionary vertebrates. Evidences have proven a sure link between the human periodontal apparatus and other vertebral animals that have been used to simulate human oral anatomy. The intention of attempting this review is based on the role of animal models used for experimentation prior to human clinical trials. There are few papers dealing with animal models suitable to periodontal research laboratory. Hence an attempt has been made to briefly present the evolution of tooth attachment based on comprehensive of available minimal literature. The current paper deals with evolution through natural selection, evolution of humans, attachment apparatus and tooth attachment have been presented comprehensively. Keywords: evolution; attachment apparatus; periodontal ligament; periodontal evolution.

Single-Cell Transcriptomic Analysis Reveals Developmental Relationships and Specific Markers of Mouse Periodontium Cellular Subsets.

The periodontium is essential for supporting the functionality of the tooth, composed of diversity of mineralized and non-mineralized tissues such as the cementum, the periodontal ligament (PDL) and the alveolar bone. The periodontium is developmentally derived from the dental follicle (DF), a fibrous tissue surrounding the developing tooth bud. We previously showed through in vivo lineage-tracing experiments that DF contains mesenchymal progenitor cells expressing parathyroid hormone-related protein (PTHrP), which give rise to cells forming the periodontal attachment apparatus in a manner regulated by autocrine signaling through the PTH/PTHrP receptor. However, the developmental relationships between PTHrP+ DF cells and diverse cell populations constituting the periodontium remain undefined. Here, we performed single-cell RNA-sequencing (scRNA-seq) analyses of cells in the periodontium by integrating the two datasets, i.e. PTHrP-mCherry+ DF cells at P6 and 2.3kb Col1a1 promoter-driven GFP+ periodontal cells at P25 that include descendants of PTHrP+ DF cells, cementoblasts, osteoblasts and periodontal ligament cells. This integrative scRNA-seq analysis revealed heterogeneity of cells of the periodontium and their cell type-specific markers, as well as their relationships with DF cells. Most importantly, our analysis identified a cementoblast-specific metagene that discriminate cementoblasts from alveolar bone osteoblasts, including Pthlh (encoding PTHrP) and Tubb3. RNA velocity analysis indicated that cementoblasts were directly derived from PTHrP+ DF cells in the early developmental stage and did not interconvert with other cell types. Further, CellPhoneDB cell-cell communication analysis indicated that PTHrP derived from cementoblasts acts on diversity of cells in the periodontium in an autocrine and paracrine manner. Collectively, our findings provide insights into the lineage hierarchy and intercellular interactions of cells in the periodontium at a single-cell level, aiding to understand cellular and molecular basis of periodontal tissue formation.

Mid-term outcomes and periodontal prognostic factors of autotransplanted third molars: A retrospective cohort study.

Tooth autotransplantation is a valid method for replacing non-restorable teeth. This study aimed to assess mid-term survival and success of autotransplanted third molars and the clinical periodontal parameters and factors predicting successful periodontal attachment apparatus regeneration. In total, 36 patients who had undergone extraction and subsequent autotransplantation of 36 third molars using virtual planning and computer-aided rapid prototyping models by an oral surgeon and endodontist were eligible. Probing pocket depth (PPD), gingival recession (REC), clinical attachment level (CAL), pulpal and periapical healing, root resorption, and radiographic bone loss (RBL) were evaluated. Additionally, a questionnaire evaluated patient-reported outcomes. The mean age of the participants was 30.2 years with a mean follow-up duration of 29.42 ± 14.56 months. The overall survival and success rates were 97.2% and 91.7%, respectively. No statistically significant differences were found in success and survival rates between open and closed apex groups or between compromised and intact buccal bone groups. No signs of pulp necrosis were found in the open apex group. Progressive replacement resorption was detected in one closed apex case. The mean PPD was 2.7 ± 0.45mm for all transplanted teeth. REC was 0.13mm higher in transplanted teeth than in previous hopeless teeth. CAL changes were neither clinically relevant (-0.17 ± 0.66mm) nor statistically significant. The reported patient satisfaction was high. Autotransplantation of third molars is a predictable treatment method, with a 2.5-year cumulative tooth survival and success of 97.2% and 91.7%, respectively, which were not influenced by recipient site integrity or root development.

Periodontal Disease and Tooth Wear in a Sample of German Soldiers with Posttraumatic Stress Disorder.

Dental symptoms of post-traumatic stress disorder (PTSD) patients include a majority of painful temporomandibular joint and masticatory muscle findings, restricted mouth opening, and pronounced attritions. Traumatic occlusal force resulting in injury of the teeth and/or the periodontal attachment apparatus may exceed the adaptive capacity of the individual person or site. This observational cross-sectional study in soldiers with PTSD and a non-PTSD control group after military deployments aimed to evaluate a possible relationship between bruxism and periodontal diagnosis. Ninety-six in-patients and 27 out-patients (21 women, 102 men) with specialist-confirmed PTSD and bruxism after up to 17 foreign assignments, and 36 male non-PTSD controls with up to 15 foreign assignments underwent general dental, functional, and periodontal examinations. All three groups showed no statistically significant differences in terms of age (34.8 ± 8.6 years), number of teeth (n: 26.3 ± 3.4), status of dentition (DMFT 9.7 ± 6.6), incidence of periodontitis (36%) and recessions (n: 5.8 ± 5.7). From the control group to the out-patient group to the in-patient group, the proportion of smokers and tobacco use increased statistically significantly, as did the extent of attrition. In the in-patient group, with statistically significantly lower educational levels, the number of perceived prophylaxis sessions was statistically significantly reduced in the last two years. Taking into account the retrospective recording of the last traumatic event, the average time of five years until therapy does not seem to have any consequences for the frequency and severity of inflammatory periodontal disease, recession, and wedge-shaped defects in soldiers with bruxism in PTSD, regardless of the need for in-patient or out-patient treatment.

Periodontal bioengineering with mesenchymal stem cells

Current periodontal regenerative therapies aim at restitution ad integrum of the periodontal attachment apparatus, which involves periodontal ligament, root cementum, and alveolar bone. Guided tissue regeneration, bioactive agents and bone replacement grafts have been utilized in an attempt to fully restore the lost periodontal tissues. But their predictability has been limited and dependent on patient- and defect-related factors. Consequently, the treatment of most periodontal defects still lacks satisfactory and predictable outcomes. Cell therapies, based on the use of mesenchymal stem cells (MSCs), represent a promising therapeutic strategy in light of recently available published preclinical investigations and clinical studies. The application of MSCs in humans is being performed by two different strategies: (1) the ex vivo culture of undifferentiated MSCs from autologous or allogeneic sources, subjected to specific cell expansion and characterization/differentiation tests to obtain the required cell counts for transplantation; and (2) the use of autologous tissue grafts and micrografts, which apart from MSCs, contain other biologically active cell populations and their extracellular matrix. This review evaluates the current status of MSCs therapy applied for periodontal regeneration, describing not only their mechanism of action, but also their efficacy and safety according to the published evidence.

ROLE OF SOCKET SHIELD TECHNIQUE IN IMMEDIATE IMPLANTS PLACED IN THE ESTHETIC ZONE – A CASE REPORT

Immediate implant is a valuable treatment of choice to replace non restorable teeth in the esthetic zone with a success rate of 87.5 to 100%. It has several advantages like minimizing the total treatment time, cost effective, and psycosocial benefits. In spite of the exceptional success rates, horizontal buccal bone resorption of about 56% and corresponding palatal bone resorption of 30% has been documented with respect to immediate implants (1) . These morphometric changes negatively influence the aesthetic outcome of dental implants. The use of modified surgical procedures such as the flapless technique, various hard tissue augmentation procedures, guided bone regeneration (GBR) and titanium reinforced barriers as well as various bone promoting molecules have been tried for bone preservation, with each method having its own benefits and drawbacks. Recently socket-shield technique (SST) otherwise called partial extraction therapy by Hurzeler et al in 2006 was described where buccal segment of the root is retained as a shield in situ, which aids in preserving periodontal attachment apparatus thus preserving the vascularity of buccal bone when compared to other conventional techniques. Here we present a case of non-restorable tooth in the maxillary aesthetic zone managed with placement of immediate implant using socket shield technique and evaluating the hard tissue health and aesthetic outcome (2).

EVALUATION OF VARIATION IN SLOT SIZE BETWEEN COMMERCIALLY AVAILABLE BRACKET SYSTEMS

Immediate implant is a valuable treatment of choice to replace non restorable teeth in the esthetic zone with a success rate of 87.5 to 100%. It has several advantages like minimizing the total treatment time, cost effective, and psycosocial benefits. In spite of the exceptional success rates, horizontal buccal bone resorption of about 56% and corresponding palatal bone resorption of 30% has been documented with respect to immediate implants (1) . These morphometric changes negatively influence the aesthetic outcome of dental implants. The use of modified surgical procedures such as the flapless technique, various hard tissue augmentation procedures, guided bone regeneration (GBR) and titanium reinforced barriers as well as various bone promoting molecules have been tried for bone preservation, with each method having its own benefits and drawbacks. Recently socket-shield technique (SST) otherwise called partial extraction therapy by Hurzeler et al in 2006 was described where buccal segment of the root is retained as a shield in situ, which aids in preserving periodontal attachment apparatus thus preserving the vascularity of buccal bone when compared to other conventional techniques. Here we present a case of non-restorable tooth in the maxillary aesthetic zone managed with placement of immediate implant using socket shield technique and evaluating the hard tissue health and aesthetic outcome (2).

Antibiotics for Periodontal Infections: Biological and Clinical Perspectives

The review is to highlight the use of antibiotics in periodontal infections and prevent indiscriminate use of antibiotics. Periodontitis is the most common disease of the periodontal attachment apparatus, and its etiological factor can be related to the existence of virulent microorganisms in the dental plaque biofilm which harbors millions of microorganisms. In addition, the pathogenesis of this disease is greatly influenced by the host immune response that leads to the cyclic destruction and healing pattern. Periodontitis is mostly treated through mechanical debridement using surgical and nonsurgical therapy. However, many times, this treatment does not render desired results due to poor patient compliance, altered immune response, or other host-related factors. This leads to the administration of antibiotics as an adjunct to mechanical debridement. Antibiotics are useful in eliminating periodontopathic microbes, but these agents should be cautiously used and prescribed only if indicated. Indiscriminate use of antibiotics can lead to unforeseen adverse effects as well as the development of resistant strains of microorganisms. Hence, it is crucial for the dentists to know the indications, contraindications, undesirable effects, correct choice, and dosage of the antimicrobial agent before prescribing it to their patients thereby ensuring the success of periodontal therapy. Thus, the clinician should keep in mind that the antibiotics are merely adjuncts to mechanical therapy and not its replacement.

Clinical evaluation of mineral trioxide aggregate in the surgical management of degree I and degree II furcation defects

Background: Mineral trioxide aggregate (MTA) is known as a strong bioactive material which induces hard tissue formation. It does not get contaminated with tissue fluids or blood and has low cytotoxicity with good antibacterial effects. Objectives: This study aims to evaluate the clinical effectiveness of MTA in the surgical management of Degree I and Degree II furcation defects. Methods: Individuals were 15 patients exhibiting clinical and radiographic evidence of Degree I and Degree II furcation defects. The pocket probing depth, plaque index, gingival index, relative vertical clinical attachment level, relative horizontal clinical attachment level, and gingival recession level of subjects were recorded at baseline, 3 months, and 6 months. Data were analyzed at a significance level of P < 0.05 using paired t-test. Results: The purpose of this study was to maintain furcation involved teeth with the use of MTA. Regeneration of periodontal attachment apparatus by MTA was not the goal of the treatment technique used in this study. However, MTA application results improvement in the recorded clinical parameters. Conclusion: MTA is effective in obliterating the Degree I and Degree II furcation defects. There are no signs and symptoms of any adverse effect to this treatment.

Application of Periodontal Ligament-Derived Multipotent Mesenchymal Stromal Cell Sheets for Periodontal Regeneration.

Periodontitis is a chronic inflammatory disorder that causes destruction of the periodontal attachment apparatus including alveolar bone, the periodontal ligament, and cementum. Dental implants have been routinely installed after extraction of periodontitis-affected teeth; however, recent studies have indicated that many dental implants are affected by peri-implantitis, which progresses rapidly because of the failure of the immune system. Therefore, there is a renewed focus on periodontal regeneration aroundnatural teeth. To regenerate periodontal tissue, many researchers and clinicians have attempted to perform periodontal regenerative therapy using materials such as bioresorbable scaffolds, growth factors, and cells. The concept of guided tissue regeneration, by which endogenous periodontal ligament- and alveolar bone-derived cells are preferentially proliferated by barrier membranes, has proved effective, and various kinds of membranes are now commercially available. Clinical studies have shown the significance of barrier membranes for periodontal regeneration; however, the technique is indicated only for relatively small infrabony defects. Cytokine therapies have also been introduced to promote periodontal regeneration, but the indications are also for small size defects. To overcome this limitation, ex vivo expanded multipotent mesenchymal stromal cells (MSCs) have been studied. In particular, periodontal ligament-derived multipotent mesenchymal stromal cells are thought to be a responsible cell source, based on both translational and clinical studies. In this review, responsible cell sources for periodontal regeneration and their clinical applications are summarized. In addition, recent transplantation strategies and perspectives about the cytotherapeutic use of stem cells for periodontal regeneration are discussed.

The clinical efficacy of deproteinized bovine bone mineral with 10% collagen in conjunction with localized piezosurgical decortication enhanced orthodontics: A prospective observational study.

Evidence exists on the clinical efficacy and safety of periodontally accelerated osteogenic orthodontics (PAOO) with "Piezocision"-a minimally invasive, flapless alternative to corticotomy for alveolar bone augmentation. Allograft has been extensively studied for alveolar bone augmentation in Piezocision; however, the use of deproteinized bovine bone mineral with 10% collagen (DBBM-C) in Piezocision for PAOO has not been investigated. This study is a prospective, observational, cohort study of 19 patients of Angle Class I malocclusion with a total of 692 teeth assessed for maintenance of health of the periodontal attachment apparatus. Patient-centered pain, sensitivity, and satisfaction outcomes, digital photographs and radiographs, and changes in probing depth, clinical attachment level, width of keratinized tissue, percussion sensitivity, pulp vitality tests, radiographic pathology, and root-crown-ratio were all recorded. Overall treatment was significantly faster (5 to 7days between clear aligner tray changes), periodontal parameters remained stable, and alveolar bone loss was not observed. Visual analog score for healing, sensitivity/duration, bleeding/duration, swelling/duration, appearance, and inflammation, demonstrated no significant differences between DBBM-C and control (no bone graft) groups. Patient-centered outcomes revealed high levels of satisfaction with Piezocision. Piezocision-treated teeth with DBBM-C tended to exhibit less root resorption, although it was not statistically significant (P=0.074). Within the limits of the study, our results show that the use of DBBM-C with piezosurgically enhanced orthodontics is effective and safe. This study was not designed to demonstrate equivalence with other materials that might be used in Piezocision. To understand whether there is an advantage to using DBBM-C, additional studies may be required.

A fogágybetegség és a peri-implant betegségek új klasszifikációja

Az új klasszifikációs rendszer több ponton módosította, illetve felülírta a plakk okozta fogágybetegség 1999-es nevezéktanát és klasszifikációját. A korábban krónikus és agresszív parodontitist egységesen parodontitisnek nevezte el és ezen belül két dimenziós diagnosztikai kategóriát különít el, nevezetesen (staging) stádium és (grading) osztály fokozatot. A stádium (staging) az első vizsgálat során felmért parodontális állapot súlyosságát és a kezelés szempontjábóla komplexitását foglalja magába. Az osztály (grading) pedig további információval szolgál a betegség biológiai hátteréről, az anamnézisről, a betegség progressziójáról, a rizikófaktorokról, a további progresszió rizikójáról, a lehetséges kezelési eredményeket negatívan befolyásoló tényezőkről, valamint mindazokról a rizikófaktorokról, amelyeket maga a betegség vagy a parodontális kezelés jelent a páciens általános egészségi állapotára.A necrotizáló fogágybetegség, amelyhez klinikailag jellemző egyedülálló jelek (papilla necrozis, spontán vérzés és fájdalom) társulnak megváltozott szervezeti immun válasszal, továbbra is a korábbi, 1999-es klasszifikáció diagnózisát használja. Az endo-parodontális léziók körébe az új besorolás azokat a patológiás folyamatokat sorolja, amelyben egy adott fognál a pulpa és a parodontium között valamilyen kommunikációs csatorna nyílik meg. Ez lehet akut és krónikus lefolyású. Ezen belül olyan alcsoportokat állít fel, amelyek hatással vannak a folyamat lefolyására és a kezelési lehetőségekre. A parodontális abscessus olyan akut folyamat, amelyben a sulcus/tasak falszövetében genny gyűlik össze, amely nagyon rapid szöveti destrukciót eredményez és nagy a veszélye a folyamat tovaterjedésének.

Autocrine regulation of mesenchymal progenitor cell fates orchestrates tooth eruption

Formation of functional skeletal tissues requires highly organized steps of mesenchymal progenitor cell differentiation. The dental follicle (DF) surrounding the developing tooth harbors mesenchymal progenitor cells for various differentiated cells constituting the tooth root-bone interface and coordinates tooth eruption in a manner dependent on signaling by parathyroid hormone-related peptide (PTHrP) and the PTH/PTHrP receptor (PPR). However, the identity of mesenchymal progenitor cells in the DF and how they are regulated by PTHrP-PPR signaling remain unknown. Here, we show that the PTHrP-PPR autocrine signal maintains physiological cell fates of DF mesenchymal progenitor cells to establish the functional periodontal attachment apparatus and orchestrates tooth eruption. A single-cell RNA-seq analysis revealed cellular heterogeneity of PTHrP+ cells, wherein PTHrP+ DF subpopulations abundantly express PPR. Cell lineage analysis using tamoxifen-inducible PTHrP-creER mice revealed that PTHrP+ DF cells differentiate into cementoblasts on the acellular cementum, periodontal ligament cells, and alveolar cryptal bone osteoblasts during tooth root formation. PPR deficiency induced a cell fate shift of PTHrP+ DF mesenchymal progenitor cells to nonphysiological cementoblast-like cells precociously forming the cellular cementum on the root surface associated with up-regulation of Mef2c and matrix proteins, resulting in loss of the proper periodontal attachment apparatus and primary failure of tooth eruption, closely resembling human genetic conditions caused by PPR mutations. These findings reveal a unique mechanism whereby proper cell fates of mesenchymal progenitor cells are tightly maintained by an autocrine system mediated by PTHrP-PPR signaling to achieve functional formation of skeletal tissues.

Rehabilitation of Lower Anterior Teeth with Implant Therapy in Localized Aggressive Periodontitis

Periodontitis is the most common, destructive, inflammatory diseases of supporting tissues of the teeth in humans, with profound effects on general health. Aggressive periodontitis (AgP) comprises a rare, rapidly progressing form of periodontitis, characterized by severe destruction of periodontal attachment apparatus and tooth loss at an early age. Considering the psychological problems which these patients have during the early stages of their life, the chief aim of the treatment is to achieve functional, esthetic, and phonetic rehabilitation. Dental implant is a widely used treatment option that provides functional and esthetic resolution. Implant placement in patients with a history of AP might be considered a viable option to restore oral function; however, the risk for implant failure is significantly higher. This report presents rehabilitation of lower anterior teeth with implant therapy in a 24-year-old systemically healthy male with a history of localized AP, who had previously received complete periodontal therapy for periodontal stabilization

Multiphasic Collagen Scaffolds for Engineered Tissue Interfaces

AbstractHard–soft tissue interfaces pose unique challenges for regeneration due to architectural, mechanical, and compositional changes between tissues, which are difficult to incorporate into tissue engineering scaffolds. Multiphasic scaffolds are needed to better mimic structural and chemical changes through the incorporation of layers with distinct properties. A particular challenge in the production of multilayered constructs is achieving cohesion between layers. Herein, a novel system is developed, which combines sequential collagen self‐assembly and diffusion gradients in mineralization to produce multiphasic collagen scaffolds that have intrinsic connectivity and porosity between layers, with no need for adhesives or heat treatments. The scaffolds incorporate mineralized layers, wherein the mineralized collagen fibrils have intrafibrillar oriented mineral resembling bone, alongside unmineralized layers. The interface between mineralized and unmineralized layers is sharp and well defined, with nonmineralized fibrils inserting into the mineralized layer to create mechanical interlock and cohesion. Inspired by the complex architecture of the periodontal attachment apparatus (bone–ligament–cementum), it is demonstrated that the model system can be applied to the development of a trilayered collagen scaffold with potential for periodontal regeneration.

Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions

A variety of systemic diseases and conditions can affect the course of periodontitis or have a negative impact on the periodontal attachment apparatus.

Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.

A variety of systemic diseases and conditions can affect the course of periodontitis or have a negative impact on the periodontal attachment apparatus. Gingival recessions are highly prevalent and often associated with hypersensitivity, the development of caries and non-carious cervical lesions on the exposed root surface and impaired esthetics. Occlusal forces can result in injury of teeth and periodontal attachment apparatus. Several developmental or acquired conditions associated with teeth or prostheses may predispose to diseases of the periodontium. The aim of this working group was to review and update the 1999 classification with regard to these diseases and conditions, and to develop case definitions and diagnostic considerations. Discussions were informed by four reviews on 1) periodontal manifestions of systemic diseases and conditions; 2) mucogingival conditions around natural teeth; 3) traumatic occlusal forces and occlusal trauma; and 4) dental prostheses and tooth related factors. This consensus report is based on the results of these reviews and on expert opinion of the participants. Key findings included the following: 1) there are mainly rare systemic conditions (such as Papillon-Lefevre Syndrome, leucocyte adhesion deficiency, and others) with a major effect on the course of periodontitis and more common conditions (such as diabetes mellitus) with variable effects, as well as conditions affecting the periodontal apparatus independently of dental plaque biofilm-induced inflammation (such as neoplastic diseases); 2) diabetes-associated periodontitis should not be regarded as a distinct diagnosis, but diabetes should be recognized as an important modifying factor and included in a clinical diagnosis of periodontitis as a descriptor; 3) likewise, tobacco smoking - now considered a dependence to nicotine and a chronic relapsing medical disorder with major adverse effects on the periodontal supporting tissues - is an important modifier to be included in a clinical diagnosis of periodontitis as a descriptor; 4) the importance of the gingival phenotype, encompassing gingival thickness and width in the context of mucogingival conditions, is recognized and a novel classification for gingival recessions is introduced; 5) there is no evidence that traumatic occlusal forces lead to periodontal attachment loss, non-carious cervical lesions, or gingival recessions; 6) traumatic occlusal forces lead to adaptive mobility in teeth with normal support, whereas they lead to progressive mobility in teeth with reduced support, usually requiring splinting; 7) the term biologic width is replaced by supracrestal tissue attachment consisting of junctional epithelium and supracrestal connective tissue; 8) infringement of restorative margins within the supracrestal connective tissue attachment is associated with inflammation and/or loss of periodontal supporting tissue. However, it is not evident whether the negative effects on the periodontium are caused by dental plaque biofilm, trauma, toxicity of dental materials or a combination of these factors; 9) tooth anatomical factors are related to dental plaque biofilm-induced gingival inflammation and loss of periodontal supporting tissues. An updated classification of the periodontal manifestations and conditions affecting the course of periodontitis and the periodontal attachment apparatus, as well as of developmental and acquired conditions, is introduced. Case definitions and diagnostic considerations are also presented.

Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.

A variety of systemic diseases and conditions can affect the course of periodontitis or have a negative impact on the periodontal attachment apparatus. Gingival recessions are highly prevalent and often associated with hypersensitivity, the development of caries and non-carious cervical lesions on the exposed root surface and impaired esthetics. Occlusal forces can result in injury of teeth and periodontal attachment apparatus. Several developmental or acquired conditions associated with teeth or prostheses may predispose to diseases of the periodontium. The aim of this working group was to review and update the 1999 classification with regard to these diseases and conditions, and to develop case definitions and diagnostic considerations. Discussions were informed by four reviews on 1) periodontal manifestions of systemic diseases and conditions; 2) mucogingival conditions around natural teeth; 3) traumatic occlusal forces and occlusal trauma; and 4) dental prostheses and tooth related factors. This consensus report is based on the results of these reviews and on expert opinion of the participants. Key findings included the following: 1) there are mainly rare systemic conditions (such as Papillon-Lefevre Syndrome, leucocyte adhesion deficiency, and others) with a major effect on the course of periodontitis and more common conditions (such as diabetes mellitus) with variable effects, as well as conditions affecting the periodontal apparatus independently of dental plaque biofilm-induced inflammation (such as neoplastic diseases); 2) diabetes-associated periodontitis should not be regarded as a distinct diagnosis, but diabetes should be recognized as an important modifying factor and included in a clinical diagnosis of periodontitis as a descriptor; 3) likewise, tobacco smoking - now considered a dependence to nicotine and a chronic relapsing medical disorder with major adverse effects on the periodontal supporting tissues - is an important modifier to be included in a clinical diagnosis of periodontitis as a descriptor; 4) the importance of the gingival phenotype, encompassing gingival thickness and width in the context of mucogingival conditions, is recognized and a novel classification for gingival recessions is introduced; 5) there is no evidence that traumatic occlusal forces lead to periodontal attachment loss, non-carious cervical lesions, or gingival recessions; 6) traumatic occlusal forces lead to adaptive mobility in teeth with normal support, whereas they lead to progressive mobility in teeth with reduced support, usually requiring splinting; 7) the term biologic width is replaced by supracrestal tissue attachment consisting of junctional epithelium and supracrestal connective tissue; 8) infringement of restorative margins within the supracrestal connective tissue attachment is associated with inflammation and/or loss of periodontal supporting tissue. However, it is not evident whether the negative effects on the periodontium are caused by dental plaque biofilm, trauma, toxicity of dental materials or a combination of these factors; 9) tooth anatomical factors are related to dental plaque biofilm-induced gingival inflammation and loss of periodontal supporting tissues. An updated classification of the periodontal manifestations and conditions affecting the course of periodontitis and the periodontal attachment apparatus, as well as of developmental and acquired conditions, is introduced. Case definitions and diagnostic considerations are also presented.

Manifestations of systemic diseases and conditions that affect the periodontal attachment apparatus: Case definitions and diagnostic considerations.

This review proposes case definitions and diagnostic considerations of systemic disorders and conditions that affect the periodontal attachment apparatus. Periodontal diseases and certain systemic disorders share similar genetic and/or environmental etiological factors, and affected patients may show manifestations of both diseases. Characterizing these diseases and the nature of the association between them could have important diagnostic value and therapeutic implications for patients. Numerous systemic disorders and certain medications can affect the periodontal attachment apparatus and cause loss of periodontal attachment and alveolar bone. Although many of these disorders are rare or uncommon, they often cause significant loss of periodontal tissue by influencing periodontal inflammation or through mechanisms distinct from periodontitis. Most of these disorders are due to innate mechanisms and some are acquired via environmental factors or lifestyle. Several disorders affect periodontal inflammation through alterations in the host immune response to periodontal infection; others cause defects in the gingiva or periodontal connective tissue, instigate metabolic changes in the host that affect various tissues of the periodontal apparatus, or operate by other mechanisms. For some systemic disorders that are more common, their contribution to the loss of periodontal tissue is modest, while for others, contribution is not supported by clear evidence. Few systemic medications are associated with increased loss of periodontal tissue, and these are typically medications used in the treatment of malignancies. This review identifies systemic diseases and conditions that can affect the periodontal attachment apparatus and cause loss of periodontal supporting tissues and, where possible, presents case definitions for these. Many of these diseases are associated with a profound loss of periodontal attachment and alveolar bone, and for some of these disorders the periodontal manifestations may be among the first signs of the disease. These case definitions may be useful in the early diagnosis of these diseases and may contribute to an improvement in the management of periodontal manifestations and improve the quality of life for these patients.