By Judy Carroll, RDH, and Howard M. Notgarnie, RDH, EdD
Figure 1: Pre-treatment radiographs
Chronic periodontitis is the most common form of periodontitis, and aggressive periodontitis causes rapid destruction of the supporting structures of the teeth.1 The chronic, inflammatory nature of periodontitis is a likely mechanism that makes it a risk factor for cardiovascular disease,2 preeclampsia,3 and cancers of the skin, breast, lung, esophagus, and gallbladder.4 From 2009 through 2012, periodontitis was present in 46% of US adults and severe periodontitis in 8.9% of US adults.5 Demographic characteristics showing an increased risk for periodontitis were male, nonwhite, poor, uneducated, and elderly.5 Treatment of periodontitis has been scaling and root planing (SRP), surgical intervention, and the use of chemotherapeutic and biologic agents.1
Traditional SRP followed by periodontal surgery can save teeth and regenerate periodontal structures supporting those teeth.6 Periodontal regeneration consists of two histologically identifiable improvements-cementum and connective-tissue growth-and two clinically identifiable improvements-bone growth and coronal migration of the epithelial attachment.7 Although SRP is often done in preparation for surgery,1 visually enhancing nonsurgical techniques with a periodontal endoscope might further improve outcomes while decreasing costs and morbidity when the surgical option can be avoided.
This case report documents a nonsurgical protocol to achieve reattachment of periodontal tissues that had been lost to periodontitis.
Case description
The patient was 45 years old with at least one known family member having periodontitis. He had a normal level of C-reactive protein (2.0 mg/L), slight elevation of blood pressure (146/87 mmHg), low-density lipoproteins (130 mg/dL), and slight deficiencies of vitamin D and thyroxin. He used an appliance to control bruxism and had a history of orthodontic treatment, although malocclusion was still present. A periodontist had recommended extraction of teeth Nos. 18 and 31, which had vertical defects on the distal surfaces (see Figure 1). On both teeth, recession was less than 1 mm on all surfaces, and pocket depths were at least 7 mm on the buccal and distal surfaces. Tooth No. 18 had 11.8 mm bone loss on the distal surface, a Class II buccal furcation with a 10 mm pocket, and a Class I lingual furcation with a 5 mm pocket. Tooth No. 31 had 8.4 mm bone loss on the distal surface and a Class II furcation with an 8 mm pocket on the buccal surface (see Table 1).
The dental hygiene diagnosis was localized, severe chronic periodontitis. Occlusal trauma was a contributing factor to the initiation of periodontitis; occlusal trauma and mucogingival deformity were contributing factors to disease progression.
Protocol-The patient took 20 mg doxycycline twice a day for 180 days beginning two weeks prior to clinical treatment. Dental hygiene care comprised SRP on teeth Nos. 18 and 31, with adjunctive therapy of enamel matrix derivative (EMD) under local anesthetic. A periodontal endoscope enhanced treatment site visualization during SRP, removal of granulomatous tissue, preparation of the root surfaces with ethylenediaminetetraacetic acid (EDTA), and application of EMD. The patient returned to his dental hygienist of record for periodontal maintenance.
Evaluation-A six-month evaluation demonstrated reattachment (see Figure 2). The radiograph of tooth No. 18 exhibited 7.4 mm bone loss on the distal surface, reflecting an increased bone height of 4.4 mm. For tooth No. 31, the radiograph exhibited 6.2 mm bone loss, reflecting an increased bone height of 2.2 mm. Epithelial attachment gain was clinically evident as well (see Table 2). Pocket depths had marked improvement with elimination of furcation involvement on both teeth, decreased mobility of tooth No. 18, and no increase in recession. The patient also submitted three-year post-treatment radiographs taken by the dental hygienist of record (see Figure 3) with evidence of bone stability.
Periodontal Endoscopy
Bacteria in plaque, particularly Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythia, and Treponema denticola, initiate a host immune response and promote a plaque biofilm resistant to antimicrobial agents.8 The host's response to bacterial pathogens associated with periodontitis can destroy periodontal tissues.8-10 This host response includes matrix metalloproteinases (MMPs) that destroy collagen, allowing leukocytes to enter the area and fight infection.11 Golub et al. demonstrated that tetracycline analogues reduce collagen destruction associated with MMP function.12 Subantimicrobial doses of doxycycline inhibit the destructive mechanisms of MMPs,11,13-15 thereby making it effective as an adjunct to SRP.8,10
Inflammation inhibits extracellular matrix formation and decreases the ability of stem cells from the periodontal ligament and dental follicle to differentiate into cementoblasts, osteoblasts, and fibroblasts.16 EMD is a biologic agent composed of proteins, primarily amelogenins, derived from pig tooth germs.17,18 EMD promotes stem cell differentiation and blast cell activity,18,19 thereby speeding bone growth.20,21
The effectiveness of EMD is unclear. Use of EMD as an adjunct to flap debridement did not improve radiographic bone growth compared with flap debridement alone22 or compared to the use of nanohydroxyapatite as an adjunct to periodontal surgery.23 However, EMD did reduce postsurgical recession24 and gene expression of inflammatory markers when occlusal forces were not excessive,25 and it enhanced effectiveness of nanohydroxyapatite as an adjunct to periodontal surgery.26
Evidence that nonsurgical application of EMD promotes periodontal regeneration has been equivocal. In one clinical study, EMD as an adjunct to SRP increased attachment primarily by long junctional epithelium rather than bone growth.27 In another study, researchers using EMD found no significant difference in pocket depth or gain of attachment compared with controls receiving only SRP.28 On the other hand, a nonsurgical approach on four single-rooted teeth generated histological and clinical evidence of periodontal regeneration, although the amount of regeneration was not sufficient to save those teeth.7
Periodontal endoscopy might play a role in the success of this protocol to achieve periodontal reattachment. The periodontal endoscope aids the clinician in gingival retraction and visualization of dental root surfaces.29,30 Studies have demonstrated efficacy of a periodontal endoscope as a tool for detection of calculus. A periodontal endoscope improved clinicians' ability to detect31 and remove32 calculus compared to tactile detection and instrumentation. After in vivo treatment using the periodontal endoscope and six months' healing, calculus was absent on 35 of subjects' 36 specimens examined in vitro after extraction.33 Growth of new bone and junctional epithelium was evident with lack of inflammation.33 Patients perceived less pain during periodontal endoscopy examination than by tactile examination with a probe,34 thus there is potential for improved compliance with treatment recommendations.
Figure 2: Six-month post-treatment radiographs and photos
Figure 3: Three-year post-treatment radiographs
Combining systemic host modulation and targeted administration of enamel matrix derivative with periodontal endoscopy was effective as a nonsurgical protocol to achieve attachment gain. Because evaluation in this case was clinical, we do not know if periodontal regeneration has occurred. Histological studies subsequent to this protocol could establish the effective presence or absence of true periodontal regeneration. RDH
Judy Carroll, RDH, is the founder and clinical director of PerioPeak Innovations. She has been a clinical practitioner for 26 years and teaches advanced endoscopic techniques and comprehensive integrative periodontal therapy using a multidisciplinary approach. Howard M. Notgarnie, RDH, EdD, is president-elect of the Colorado Dental Hygienists' Association. He has been practicing clinically for 24 years and has given presentations at local, national, and international dental hygiene meetings.
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