Journal of Oral Science & Rehabilitation No. 4, 2019
Cover
/ Editorial
/ Contents
/ About the Journal of Oral Science & Rehabilitation
/ Trends in clinical trials on bone regeneration in dentistry—towards an innovative development in dental implant treatment
/ Gingivoplasty and botulinum toxin application result in improvement of severe gummy smile
/ Prevalence of esthetic gingival recession in university health care in a region of Spain
/ Topical doxycycline after nonsurgical instrumentation of deep periodontal pockets: Results from a prospective case series with 12 months’ follow-up
/ Guidelines for authors
/ Imprint
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[1] =>
Volume 5 | Issue 4/2019
ISSN 2365 - 6891 (ONLINE)
Journal of
www.dtscience.com
Oral Science & Rehabilitation
Journal for periodontology, implant dentistry,
dental prosthodontics and maxillofacial surgery
[2] =>
GMT 60588 GB © Nobel Biocare Services AG, 2019. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is
evident from the context in a certain case, trademarks of Nobel Biocare. Please refer to nobelbicare.com/trademarks for more information. Product images are not
necessarily to scale. Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current
product assortment and availability. For prescription use only. Caution: Federal (United States) law restricts this device to sale by or on the order of a licensed dentist. See
Instructions For Use for full prescribing information, including indications, contraindications, warnings and precautions.
Kapitelüberschriften
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Introducing Xeal and TiUltra – two new breakthrough surfaces derived from our decades
of applied anodization expertise. From abutment to implant apex, we have reimagined
surface chemistry and topography to optimize tissue integration at every level.
We’ve now entered the Mucointegration™ era.
2
The new Xeal surface is now
available for the On1™ Base
and the Multi-unit Abutment.
TiUltra is available on our best
selling of
NobelActive®
and& Rehabilitation | Volume 5 – Issue 4/2019
Journal
Oral Science
NobelParallel™ CC implants.
[3] =>
Editorial
Importance of periimplant soft tissue
In Lately, the importance of periimplant tissue has
become increasingly evident in implant dentistry. Until
the early 2000s, researchers and clinicians focused
exclusively on the interaction between the bone and
implant. Thereafter, the main focus became esthetics
and the key role of the muco-prosthetic framework in
relation to it. During the subsequent period, clinicians
have focused their attention on the soft-tissue volume
increment around implant-supported restorations, to
achieve a more stable and esthetic result.
Very recently, for this reason, attention in implant dentistry was focused mostly on the interaction between
the abutment and the connective tissue, and the greatest attention was centered on the abutment’s ability to
adhere to soft tissue, to “fibro-integrate”. This is a dramatic change of perspective because it implies a shift
of attention from the bulk material, or the macroscopic
geometry of the abutment, to its external microcharacteristics: cleanliness, electric properties, microtexture,
wettability.
It is useless to talk about the importance of keratinized
tissue or an adequate amount of connective tissue to
improve the emergence profile of an implant-supported
restoration in the esthetic zone. However, often softtissue grafts were done following the notion of the more,
the better and the scientifically unconfirmed guarantee
of a “periodontal-like” attachment between the abutment and the tissue, whatever material the abutment
was made of. This was done without considering the
high risk of creating a pocket all around the prosthesis.
Maybe the near future will bring us a material (or configuration) that is truly integrable with soft-tissue.
Dr. Luigi Canullo
Associate editor
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
3
[4] =>
Contents
Contents
3
Editorial
6
About the Journal of Oral Science & Rehabilitation
8
Yoichi Yamada et al.
18
Irineu Gregnanin Pedron et al.
24
Alba Rodríguez Lorenzo et al.
38
Roberto Abundo et al.
Dr. Luigi Canullo
Trends in clinical trials on bone regeneration in dentistry—towards an innovative development
in dental implant treatment
Gingivoplasty and botulinum toxin application result in improvement of severe gummy smile
Prevalence of esthetic gingival recession in university health care in a region of Spain
Topical doxycycline after nonsurgical instrumentation of deep periodontal pockets:
Results from a prospective case series with 12 months’ follow-up
44
Guidelines for authors
46
Imprint — About the publisher
4
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
[5] =>
Kapitelüberschriften
is coming to
PRAGUE
21–24 May 2020
Prague, Czech Republic
www.ROOTS-SUMMIT.com
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
5
[6] =>
About
About
the Journal of Oral Science & Rehabilitation
The aim of the Journal of Oral Science & Rehabilitation
is to promote rapid communication of scientific information between academia, industry and dental practitioners, thereby influencing the decision-making in
clinical practice on an international level.
The Journal of Oral Science & Rehabilitation publishes
original and high quality research and clinical papers in
the fields of periodontology, implant dentistry, prosthodontics and maxillofacial surgery. Priority is given
to papers focusing on clinical techniques and with a
direct impact on clinical decision-making and outcomes in the above-mentioned fields. Furthermore,
book reviews, summaries and abstracts of scientific
meetings are published in the journal.
Papers submitted to the Journal of Oral Science &
Rehabilitation are subject to rigorous double-blind
peer review. Papers are initially screened for relevance
to the scope of the journal, as well as for scientific
content and quality. Once accepted, the manuscript
is sent to the relevant associate editors and reviewers of the journal for peer review. It is then returned to
the author for revision and thereafter submitted for
copy editing. The decision of the Editor-in-Chief is
made after the review process and is considered final.
About
Dental Tribune Science
Dental Tribune Science (DT Science) is an online openaccess publishing platform (www.dtscience.com) on
which the Journal of Oral Science & Rehabilitation is
hosted and published.
DT Science is a project of the Dental Tribune International Publishing Group (DTI). DTI is composed of
the leading dental trade publishers around the world.
For more, visit → www.dental-tribune.com
6
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
[7] =>
About
Benefits of publishing in the journal
for authors
There are numerous advantages of publishing in the Journal of Oral Science & Rehabilitation:
• Accepted papers are published as e-papers on www.dtscience.com;
abstracts are published on www.dental-tribune.com.
• Authors’ work is granted exposure to a wide
readership, ensuring increased impact of their
research through open-access publishing
on www.dtscience.com.
• Authors have the opportunity to present and
promote their research by way of interviews
and articles published on both www.dtscience.com
and www.dental-tribune.com.
• Authors can also post videos relating to
their research, present a webinar and blog
on www.dtscience.com.
Information
The journal is published quarterly. Each issue is published as an e-paper
on www.dtscience.com.
Copyright © Dental Tribune International GmbH. Published by Dental Tribune International GmbH. All rights
reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means
without prior permission in writing from the copyright holder.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
7
[8] =>
Trends in clinical trials on bone regeneration
Trends in clinical trials on bone
regeneration in dentistry—towards an
innovative development in dental implant
treatment
Yoichi Yamada,a, b
Sayaka Nakamura-Yamada,a
Michihide Miki,a
Yasushi Nakajimaa &
Shunsuke Babaa
a
b
Department of Oral Implantology, Osaka Dental University,
Osaka, Japan
Department of Infectious Diseases and Applied Immunology,
IMSUT Hospital, Institute of Medical Science, University of
Tokyo, Tokyo, Japan
Corresponding author:
Dr. Yoichi Yamada
Osaka Dental University
1-5-17, Otemae Chuo-ku
Osaka
540-0008 Japan
yamada-yo@cc.osaka-dent.ac.jp
How to cite this article: Yamada Y, NakamuraYamada S, Miki M, Nakajima Y, Baba S. Trends in
clinical trials on bone regeneration in dentistry—
towards an innovative development in dental implant
treatment. J Oral Science Rehabilitation. 2019 Dec;
5(4):8–17.
Abstract
Objective
The aim of this study was to assess the global trends
in clinical trials on bone regeneration in dental implantology.
Materials and methods
An electronic search for clinical studies was conducted
via the ClinicalTrials.gov database. The search strat-
8
egy used the following terms: “bone regeneration”
AND “oral,” and “bone regeneration” AND “dental”.
Furthermore, the selected clinical studies were resurveyed using “bone regeneration” AND “dental implant,”
and “bone regeneration” AND “oral” AND “implant” for
further analysis.
Results
We selected 181 clinical studies related to the field of
bone regeneration in dentistry from ClinicalTrials.gov.
The selected studies were conducted in 27 countries
from 2001 to the present, and the total number of studies
has been increasing since 2011. Analysis of the clinical stage revealed a higher ratio (55.6%) of early study
phases (early phase 1, phase 1, phase 1/2 and phase 2),
but the periodontal field of application appeared more
mature, having more phase 4 trials. Regarding the
bone regeneration methods for dental implantology, the
major technique examined in interventional clinical trials
was guided bone regeneration, followed by alveolar
ridge preservation, and sinus floor elevation. Various
grafting materials, such as autografts, allografts, xenografts, alloplasts and barrier membranes, were examined to determine clinical efficacy. Combinations of
these materials were more frequently used.
Conclusion
Our analysis of the clinical trials registered on the ClinicalTrials.gov database indicated the global clinical
trends in bone regeneration techniques in dentistry.
The randomized clinical trials of guided bone regeneration technique using combination of different bone
grafts materials is conducted the most in dental implantology. These findings could be useful for development of an innovative therapy for bone regeneration.
Keywords: Bone regeneration; clinical trials; ClinicalTrials.gov; dental implants; regenerative medicine.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
[9] =>
Trends in clinical trials on bone regeneration
Introduction
A clinical trial is a study in humans that assesses
safety and effectiveness of a new treatment. It is essential to develop new treatment for therapeutic use.
It is clearly crucial to conduct clinical trials and log the
relevant information on a database for development of
novel medicine. During the 1990s, clinical trial registration was strongly promoted in biomedical research,
with the aim of documenting the existence of all trials
and eliminating publication bias. The International
Committee of Medical Journal Editors required registration of all trials starting enrollment after July 1, 2005,
and of ongoing clinical trials that began enrolling patients before that date.1 The World Health Organization declared support for clinical trial registration and
in 2006 launched the WHO International Clinical Trials
Registry Platform (ICTRP)2. The Clinical Trials Search
Portal provides access to a central database containing the trial registration datasets. Currently, there are
17 data providers of the ICTRP Search Portal, including ClinicalTrials.gov, the EU Clinical Trials Register,
the ISRCTN registry, the Japan Primary Registries
Network, the Australian New Zealand Clinical Trials
Registry, the Brazilian Clinical Trials Registry and the
Chinese Clinical Trial Register (https://www.who.int/
ictrp/search/data_providers/en/).
ClinicalTrials.gov is a database of privately and
publicly funded clinical studies conducted around the
world and is the world’s largest clinical trial registration
database. It is hosted by the National Library of Medicine at the National Institutes of Health in collaboration with the U.S. Food and Drug Administration. It explores 321,732 research studies in 209 countries and
provides information about target diseases, sponsors,
principal investigators, planned schedules and protocols, and enrollment. Moreover, since the database
provides comprehensive information on the content of
the planned clinical trials, one can perform various targeted analyses by extracting and tagging attribute data
from each clinical study plan.3
Alveolar bone loss is often caused by trauma, pathology, chronic or acute infections, severe periodontitis,
and loss of mechanical function after tooth extraction
or tooth loss.4 Since the overall alveolar changes after
tooth extraction may compromise prosthodontic re-
habilitation using tooth-supported fixed or removable
prostheses, as well as implant-supported prostheses,
adequate quality and quantity of bone regeneration
are required, especially in the field of implant dentistry.5 Various materials and surgical treatments have
been developed, but a definitive bone regeneration
technique is not yet established. To the best of our
knowledge, there are no scientific reports that have
comprehensively analyzed and examined the clinical
research trends in bone regeneration in dental implant
treatment.
In this article, the focus was on bone regeneration for an innovative development in dental implant
treatment based on the clinical trials registration database. Since ClinicalTrials.gov is the largest clinical trial
registration database in the world and is one of the
best designed database providers for aggregation and
analysis,6 we chose it to obtain the data for analysis. In
this concise review, we first surveyed country, start year
and clinical stage of clinical studies on bone regeneration in dentistry to identify global translational trends
and followed this with analysis of the details about clinical trials in dental implantology. We aimed to establish
global translational trends, which have thus far been
difficult to interpret. The results of this study could be
useful to learn of the development of new techniques
in dental implantology.
Materials and methods
In this review, an extensive electronic search for clinical
studies was conducted via the ClinicalTrials.gov database. The last search was updated on Nov. 11, 2019.
Medical Subject Headings, combined with free words,
was used to identify the search terms. The following
search terms: “bone regeneration” AND “oral,” and
“bone regeneration” AND “dental” were used for analysis by country, start year and clinical stage of the clinical
studies. In this survey, we excluded duplicate studies
and in vitro or preclinical studies using human subjects.
In clinical stage analysis, the studies that were described
as “not applicable” in the database were excluded. Furthermore, the selected clinical studies were resurveyed
using “bone regeneration” AND “dental implant,” and
“bone regeneration” AND “oral” AND “implant.” We excluded studies that were not related to bone regeneration by reading the descriptions of the individual studies.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
9
[10] =>
Trends in clinical trials on bone regeneration
Fig. 1
Completed
Withdrawn
Terminated
Active, not recruiting
Recruiting
Not yet recruiting
Enrolling by invitation
Unknown status
Fig. 2
10
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
[11] =>
Trends in clinical trials on bone regeneration
Results
We first surveyed ClinicalTrials.gov to identify translational trends in bone regeneration in dentistry. Initially,
181 studies were selected through a primary database
search. After excluding duplicate studies, 144 studies
remained. We excluded in vitro or preclinical studies
using human subjects by carefully reading the descriptions of the individual studies, and 142 studies were
used for their content for analysis. First, we classified
the entire list of clinical studies on bone regeneration
in dentistry by country (Fig. 1). The selected clinical
studies were conducted in 27 countries, and the major
country was the U.S. (32 studies), followed by Egypt
(24 studies), Brazil (10 studies), India (10 studies), and
Italy (10 studies).
In order to analyze the clinical research trends regarding bone regeneration in dentistry, the selected
studies were sorted by start year (Fig. 2). This analysis
showed that bone regeneration therapy was performed
in dentistry from 2001 to the present. The first study
was a clinical trial on periodontal tissue regeneration
using fibroblast growth factor-2 conducted in Japan.
The total number of studies has been increasing since
2011. The clinical studies were classified according
to their current status. Some studies were withdrawn
and the reasons given were the following “Principal investigator and sponsor did not reach an agreement,”
“Lack of pediatric recruitment ability,” “Administrative
changes precluded enrollment,” and “It was not approved by IRB [institutional review board].”
To determine progress in testing novel methods of
bone regeneration in dentistry, the clinical stage was
analyzed (Fig. 3). Among the selected studies, 79
studies were not applicable. Early phase 1, phase 1,
phase 1/2 and phase 2 studies made up 55.6% of
bone regeneration studies in dentistry. There were 17
phase 4 clinical trials, 9 of which were conducted in
order to evaluate the efficacy of various products in the
treatment of periodontal bone defects. The products
Early phase 1
Phase 1
Phase 1/2
Phase 2
Phase 2/3
Phase 3
Phase 4
Fig. 3
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
11
[12] =>
Trends in clinical trials on bone regeneration
A
Observational
Observational
Randomized parallel assignment
Randomized sequential assignment
Nonrandomized parallel assignment
Single-group assignment
Interventional
B
GBR
ARP
SFE
Others
Fig. 4
used in periodontal treatment were as follows: atorvastatin gel, biological amniotic membrane, rosuvastatin,
decalcified freeze-dried bone allograft and cerabone
bone (botiss biomaterials), alendronate, simvastatin
gel, amnion–chorion allograft membrane, and bipha-
12
sic calcium phosphate (Straumann BoneCeramic,
Straumann) combined with enamel matrix proteins
(Straumann Emdogain, Straumann). Guided bone regeneration (GBR) using autografts (autogenous dentinal graft), allografts (enCore Combination Allograft
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
[13] =>
Trends in clinical trials on bone regeneration
[Osteogenics Biomedical], cancellous block allograft
plus a demineralized bone matrix allograft [Optecure
+ccc, Exactech]), and xenografts (deproteinized bovine
bone mineral [Geistlich Bio-Oss, Geistlich]) and collagen membranes (Geistlich Bio-Gide) was also evaluated in phase 4 clinical trials.
In the next step, we focused on bone regeneration
studies in patients requiring dental implant placement.
Twenty-four studies were selected through a database search, and 1 study was excluded because the
technique was aimed at periimplantitis treatment not
bone regeneration. In total, 23 studies were used for
the analyses. The number of clinical studies according
to study design is shown in Figure 4A. Most of them
were interventional studies (21 studies). An overview of
the interventional clinical trials on bone regeneration in
dental implantology is shown in Table 1. Among these
interventional studies, 16 were parallel design randomized controlled trials. Regarding the bone regeneration
methods, the major technique examined in interventional clinical trials was GBR (12 studies), followed by alveolar ridge preservation (ARP; 5 studies), and sinus floor
elevation (SFE; 3 studies; Fig. 4B). The characteristics
of the interventions are shown in Table 2. The results
indicated that various grafting materials and procedures
were examined to determine clinical efficacy. The grafting materials included autografts (bone marrow-derived
cells, dentinal graft and platelet-rich fibrin), allografts
(freeze-dried bone allograft, cortico-cancellous allogeneic block [PHOENIX, TBF] and MinerOss [BioHorizons],
xenografts (deproteinized bovine bone mineral
[Geistlich Bio-Oss]), and alloplasts (biphasic calcium
sulfate [BONDBONE, MIS Implant Technologies],
calcium phosphosilicate alloplastic bone and nanocrystalline synthetic hydroxyapatite [NanoBone, ARTOSS]).
Combinations of these materials were more frequently
used (5 studies). The usefulness of membranes was
also examined for the GBR and ARP techniques.
Discussion
In general, a new treatment should go through several
procedures before it will be approved for therapeutic
use. After tests and treatments are assessed in preclinical research, they go through a series of clinical
trials in humans. To date, there are no clear reports on
comprehensive clinical development trends in specific
fields of regenerative medicine using a clinical trial reg-
istry. In this study, we focused on bone regeneration
in dentistry, especially in dental implantology, based
on the data obtained from ClinicalTrials.gov. We used
data available on the ClinicalTrials.gov registry as the
primary source in order to conduct comprehensive and
chronological research, classification and analysis of
clinical trials registered in this field, including assessing global research trends in bone regeneration. The
clinical trials were conducted all over the world. Although ClinicalTrials.gov is the most global database
in the world, there are other data providers. Since
clinical trials tend to be registered in the database of
their own country, many studies in the U.S. might be
registered on ClinicalTrials.gov, but fewer studies in
Japan, Australia or Germany, among others, might be
registered.
Generally, clinical trials have 4 phases: phases 1–4.
Phase 0/early phase 1 has been introduced to assist
in eliminating ineffective products early in the development process and is not considered to replace formal
phase 1 safety and tolerance studies.7 Phase 1 trials
may involve the first administration to humans, usually
to small numbers of healthy volunteers or to patients,
in order to test safety and tolerance. If a new treatment is found to be reasonably safe in a phase 1 clinical trial, it can then be tested in a phase 2 clinical
trial to find out whether it works. Phase 2 trials may
be undertaken in a larger group of human patients to
further assess safety and efficacy. Treatments that
have been shown to work in phase 2 studies usually
must succeed in 1 more phase of testing (phase 3)
before they are approved for general use. Phase 3
trials usually involve a large group of patients, in order
to compare the safety and effectiveness of the new
treatment against the current standard treatment.
When a phase 3 clinical trial (or sometimes a phase 2
trial) shows that a new treatment is more effective and/
or safer than the current standard one, it can be submitted for approval. Our results indicated a higher ratio
of early study phases (early phase 1, phase 1, phase
1/2 and phase 2) in the field of bone regeneration. The
periodontal field of application appeared more mature,
having more phase 4 studies. In the U.S., more than
47% people ≥ 30 years of age have periodontal disease,
and the prevalence increases to 70% among those of
≥ 65 years of age.8 A similar trend is found in other countries.8, 9 Since there is a strong need for periodontal treatment, clinical trials in periodontitis might be accelerated.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
13
[14] =>
Trends in clinical trials on bone regeneration
Study design
Randomized
parallel assignment
Randomized
sequential
assignment
NCT no.
Intervention
NCT00755911
Socket preservation with bone marrow-derived tissue repair
cell therapy plus Gelfoam carrier (Pfizer) or only Gelfoam
carrier
NCT00900718
Socket preservation with synthetic bone grafting material
(Straumann BoneCeramic) or DBBM‡ (Bio-Oss)
NCT01012921
GBR§ with PEG†† membrane (Straumann MembraGel,
Straumann) or standard collagen membrane (Bio-Gide)
NCT01572298
GBR with allograft (MinerOss) alone or with autograft and
allograft
NCT01603693
DBBM (Bio-Oss) alone or in combination with biphasic calcium
sulfate (BONDBONE)
NCT01616953
Alveolar defects secondary to clefts or trauma, autogenous
bone grafting or bone marrow-derived cell therapy
NCT01628367
GBR around dental implants placed in fresh extraction sockets
with or without nonresorbable PTFE membrane
NCT01942304
Sinus augmentation with calcium phosphosilicate alloplastic
bone putty or anorganic bovine bone mineral
NCT02613663
Immediate implant using nanocrystalline hydroxyapatite (NanoBone) or autogenous bone
NCT03179683
Bilateral sinus lift and simultaneous dental implant placement
with diode laser application
NCT03302143
GBR with autogenous bone and DBBM (Bio-Oss) or GBR with
freeze-dried bone allograft
NCT03432702
Horizontal ridge augmentation using GBR with or without autogenous block graft
NCT03785717
Horizontal guide bone regeneration with or without shock
waves
NCT03946020
GBR with DBBM (Bio-Oss) in combination with autogenous
bone or DBBM alone
NCT04131894
Socket preservation with autogenous dentinal graft or mixture
of PRF‡‡ and autogenous dentinal graft or empty as control
NCT04133090
Injectable PRF-enriched allograft material or autogenous block
bone graft
NCT03290638
Socket preservation with dehydrated human amnion–chorion
membrane or type I bovine collagen membrane
Table 1 → continues on the next page
14
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
[15] =>
Trends in clinical trials on bone regeneration
Study design
Nonrandomized
parallel assignment
Single-group
assignment
NCT† no.
Intervention
NCT00163605
Sinus lift procedures with bone substitute macroporous biphasic calcium phosphate fibrin sealant vapor-heated solvent/detergent treated 4 IU/mL thrombin
NCT03357705
Alveolar ridge preservation with nanocrystalline synthetic hydroxyapatite or bovine collagen sponge
NCT03076138
Gene-activated bone substitute consisting of octacalcium
phosphate and plasmid DNA encoding VEGF§§ for maxillofacial
bone regeneration
NCT03879967
Alveolar ridge augmentation with cortico-cancellous allogeneic
blocks (PHOENIX) and autogenous chips and demineralized
bovine bone (Bio-Oss)
Table 1: Overview of clinical trials on bone regeneration in dental implantology.
DBBM = deproteinized bovine bone mineral.
GBR = guided bone regeneration.
††
PEG = polyethylene glycol.
‡‡
PRF = platelet-rich fibrin.
§§
VEGF = vascular endothelial growth factor.
‡
§
No. of cases per technique
Graft type
GBR†
ARP‡
SFE§
Others
Autografts
1
2
–
1
Allografts
1
–
–
–
Alloplasts
1
2
2
–
Autografts + allografts
2
–
–
–
Autografts + xenografts
1
–
–
–
Xenografts + alloplasts
1
–
–
–
Autografts + allografts + xenografts
1
–
–
–
Membranes
2
1
–
–
Others
2
–
1
–
GBR = guided bone regeneration.
ARP = alveolar ridge preservation.
§
SFE = sinus floor elevation.
†
Table 2: Characteristics of interventions.
‡
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
15
[16] =>
Trends in clinical trials on bone regeneration
A randomized controlled clinical trial is a study design
that uses control patients who receive no treatment,
the conventional treatment or a placebo. Randomization is the best way of ensuring that the results of trials
are not biased by the way participants in each group are
selected, so randomized controlled trials are the most
reliable way to compare treatments. In this study, of the
23 trials on bone regeneration in dental implantology
screened, 21 studies were interventional studies, 17 of
which employed randomized assignment. The results
indicated that the rate of randomized assignment was
high (73.9%) in dental implantology studies.
Loss of bone width and depth can affect how successful the implant will be. In order to regenerate adequate bone volume for dental implant placement, the
GBR technique is often performed. Most studies aiming
for lateral bone augmentation have used the principles
of GBR by combining different bone grafts and barrier
membranes.4 However, the ideal graft or membrane
material remains unclear.4 The results of our study indicated that 57% of interventional clinical trials on bone
regeneration in dental implantology (12 studies) used
the GBR technique. Most studies on GBR treatment
(41.7%) combined different bone grafts: autografts and
allografts; autografts and xenografts; xenografts and
alloplasts; and autografts, allografts and xenografts.
In humans, approximately 50% of the bone volume
is lost after tooth extraction during the first year.10, 11
The alveolar bone resorption may not allow optimal
positioning of dental implants.12,13 Maxillary sinus floor
augmentation via SFE is a surgical procedure to gain
the bone mass required in order to place dental implants. There is consensus that some threshold of
osseous deficiency, vertical, horizontal or both, exists
at a site where a sinus bone graft is required for successful implant treatment regardless of residual bone
quality.14 Although this procedure is considered safe,
various complications may arise during or after the
surgery, such as perforation of the sinus membrane.15
ARP is performed after tooth extraction in an attempt
to maintain the alveolar ridge height and width. ARP
is a less invasive technique than SFE. The results of
this study showed that the start dates of SFE clinical
trials were from 2004 to 2013, whereas those of ARP
studies were from 2006 to 2017. These results indicated a shift from SFE to ARP for bone regeneration in
dental implantology.
16
In this study, we utilized the most global clinical trial
database, ClinicalTrials.gov, to capture the largest
trends in bone regeneration studies in dental implantology. The limitation of this study is that registered trials
make up only a part of all existing trials. It has been
suggested that only 50% of clinical studies indexed in
PubMed that involved administration of cells for regenerative medicine indicated any clinical trial identifier.16
In addition, since ClinicalTrials.gov does not provide
comprehensive results of clinical trials, it is impossible
to analyze the results of the trials themselves.
Conclusion
In conclusion, these results on clinical trials registered
on the ClinicalTrials.gov registration site showed the
global trends in clinical trials on bone regeneration in
implant dentistry. ClinicalTrials.gov, a publicly accessible database, is useful for detailed characterization and
analysis of clinical trials. This study revealed that the
periodontal field of application was more accelerated,
having more phase 4 studies. As for implant dentistry,
the most frequently conducted study was the randomized clinical trials of GBR technique using combination
of different bone grafts materials. The present study
has potential implications for understanding the clinical
trends in the development of therapeutic bone regeneration techniques in dental implantology. In the future,
further studies would be needed for further development
of an innovative therapy in dental implant treatment.
Competing interests
The authors declare that they have no competing
interests.
Figure legends
Fig. 1 – The number of clinical trials on bone regenera-
tion in dentistry according to country.
Fig. 2 – The number of clinical trials on bone regenera-
tion in dentistry according to start year. The current
status of the studies is also color-coded.
Fig. 3 – Phases of clinical trials on bone regeneration in
dentistry.
Study design (A) and bone regeneration
method (B) of clinical trials on bone regeneration in
Fig. 4 –
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
[17] =>
Trends in clinical trials on bone regeneration
dental implantology. GBR = guided bone regeneration;
ARP = alveolar ridge preservation; SFE = sinus floor
elevation.
References
1. Dickersin K, Rennie D. The evolution of trial registries
and their use to assess the clinical trial enterprise.
→ JAMA.
2012 May 2;307(17):1861–4.
2. International Clinical Trials Registry Platform Search
Portal [Internet]. Version 3.6.
→ Geneva: World Health Organization. c2006 – [cited
2019 Nov 24]. Available from: http://apps.who.int/trialsearch/.
3. Negoro T, Takagaki Y, Okura H, Matsuyama A.
Trends in clinical trials for articular cartilage repair by
cell therapy.
→ NPJ Regen Med.
2018 Oct 11;3:17. doi: 10.1038/s41536-018-0055-2.
4. Sanz-Sánchez I, Ortiz-Vigón A, Sanz-Martín I,
Figuero E, Sanz M. Effectiveness of lateral bone
augmentation on the alveolar crest dimension: A
systematic review and meta-analysis.
→ J Dent Res.
2015 Sep;94(9 Suppl):128S–42S.
5. Atieh MA, Alsabeeha NH, Payne AG, Duncan W,
Faggion CM, Esposito M. Interventions for replacing
missing teeth: alveolar ridge preservation techniques
for dental implant site development.
→ Cochrane Database Syst Rev.
2015 May 28;(5):CD010176. doi: 10.1002/14651858.
CD010176.pub2.
6. Tasneem A, Aberle L, Ananth H, Chakraborty S,
Chiswell K, McCourt BJ, Pietrobon R. The database
for aggregate analysis of ClinicalTrials.gov (AACT) and
subsequent regrouping by clinical specialty.
→ PLOS ONE.
2012;7(3):e33677. doi: 10.1371/journal.pone.0033677.
7. Therapeutic Goods Administration (AU). Australian
clinical trial handbook: guidance on conducting clinical
trials in Australia using ‘unapproved’ therapeutic goods.
Version 2.2.
→ Woden: Therapeutic Goods Administration; 2018. 61 p.
10. Schropp L, Kostopoulos L, Wenzel A. Bone healing
following immediate versus delayed placement of titanium implants into extraction sockets: a prospective clinical study.
→ Int J Oral Maxillofac Implants.
2003 Mar–Apr;18(2):189–99.
11. Tan WL, Wong TL, Wong MC, Lang NP. A systematic
review of post-extractional alveolar hard and soft tissue
dimensional changes in humans.
→ Clin Oral Implants Res.
2012 Feb;23 Suppl 5:1–21.
12. John V, De Poi R, Blanchard S. Socket preservation
as a precursor of future implant placement: review of
the literature and case reports.
→ Compend Contin Educ Dent.
2007 Dec;28(12):646–53; quiz 654, 671.
13. Mecall RA, Rosenfeld AL. Influence of residual ridge
resorption patterns on implant fixture placement and
tooth position.
→ Int J Periodontics Restorative Dent.
1991;11(1):8–23.
14. Yamada Y, Nakamura S, Ito K, Kohgo T, Hibi H, Nagasaka T, Ueda M. Injectable tissue-engineered bone
using autogenous bone marrow-derived stromal cells
for maxillary sinus augmentation: clinical application
report from a 2–6-year follow-up.
→ Tissue Eng Part A.
2008 Oct;14(10):1699–707.
15. Tükel HC, Tatli U. Risk factors and clinical outcomes
of sinus membrane perforation during lateral window
sinus lifting: analysis of 120 patients.
→ Int J Oral Maxillofac Surg.
2018 Sep;47(9):1189–94.
16. Monsarrat P, Vergnes JN, Planat-Bénard V, Ravaud P,
Kémoun P, Sensebé L, Casteilla L. An innovative, comprehensive mapping and multiscale analysis of registered trials for stem cell-based regenerative medicine.
→ Stem Cells Transl Med.
2016 Jun;5(6):826–35.
8. Lamster IB, Pagan M. Periodontal disease and the
metabolic syndrome.
→ Int Dent J.
2017 Apr;67(2):67–77.
9. Albandar JM. Global epidemiology and risk factors
of periodontal diseases, and preliminary assessment of
the periodontal status in Japan.
→ J Jpn Health Care Dental Association.
2004;6:42–55.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
17
[18] =>
Gingivoplasty and botulinum toxin in gummy smile
Gingivoplasty and botulinum toxin
application result in improvement
of severe gummy smile
Irineu Gregnanin Pedron,a
Marcelo do Lago Pimentel Maiab
Estevam Rubens Utumi,c
João Marcelo Ferreira de Medeiros,d
Caleb Shitsukae &
Leopoldo Penteado Nucci da Silvaf
a
b
c
d
e
f
Bottoxindent Institute, and Department of Periodontology and
Integrated Clinic, Universidade Brasil, São Paulo, Brazil
Professor and speaker, Department of Implantology,
Derig Implants Co., São Paulo, Brazil.
Private practice, São Paulo, Brazil
Department of Endodontics and Integrated Clinic,
Universidade Brasil, São Paulo, Brazil
Department of Pediatric Dentistry and Cariology,
Universidade Brasil, and Centro Universitário das Faculdades
Metropolitanas Unidas, São Paulo, Brazil
Department of Periodontology, Uniceplac, Brasília, Brazil
Corresponding author:
Dr. Irineu Gregnanin Pedron
Bottoxindent Institute
Rua Flores do Piauí, 508
São Paulo—SP
08210-200
Brazil
conservative therapeutic options for the treatment of
gummy smile.
Case presentation
A patient with dentogingival discrepancy and severe
gummy smile was treated with gingivoplasty and application of botulinum toxin in order to optimize the
harmony of the smile. The result was satisfactory regarding the harmony of the smile by combination of
the treatments. The use of each of these treatments
alone could not have achieved the excellence of the
result. Initially, the creation of the new gingival zenith
after gingivoplasty promoted the new dental architecture, favoring gingival, dental and facial harmony for
the patient. Subsequently, the application of botulinum toxin reduced the gummy smile, by the uniform
descent of the upper lip, smoothing the facial lines of
the smile, as could be seen in the nasolabial folds,
adjacent to the nostrils.
Keywords: Botulinum toxin type A; gingival overgrowth; gingivectomy; gingivoplasty; gummy smile;
surgical crown lengthening.
igpedron@alumni.usp.br
Introduction
How to cite this article: Pedron IG, Utumi ER, Ferreira
de Medeiros JM, Shitsuka C, Nucci da Silva LP. Gingivoplasty and botulinum toxin application result in
improvement of severe gummy smile. J Oral Science
Rehabilitation. 2019 Dec;5(4):18–23.
The demand for esthetic procedures has grown exponentially. Dental and medical procedures, besides
pursuing the principle of promoting health, seek to
achieve smile esthetics.1–3 Facial esthetic harmony is
formed by the union of 3 components: teeth, gingiva
and lips.1–4 The smile becomes esthetically pleasing
when these elements are arranged in suitable proportion and gingival exposure is limited to 3 mm. When
gingival exposure is larger than 3 mm, it characterizes a nonesthetic condition called gummy smile, which
affects some patients psychologically.1, 5–7
Abstract
Background
Currently, the search for esthetic excellence has
become the main objective in dental treatment. Gummy
smile is among patients’ complaints, since this condition may influence their self-esteem and social relationships. The development of new techniques such
as the application of botulinum toxin may offer more
18
Several therapeutic modalities have been proposed
for the correction of gummy smile, among them are gingivoplasty,1–7 myectomy6 and orthognathic surgery.6–8
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[19] =>
Gingivoplasty and botulinum toxin in gummy smile
Fig. 2
Fig. 3
Fig. 1
The last 2 procedures are more invasive and present
high morbidity.1 However, the use of botulinum toxin
can be considered a therapeutic alternative to the
larger surgical procedure, as it is a more conservative
and effective, faster and safer method compared with
surgical procedures.1, 5, 9
Botulinum toxin is synthesized by the anaerobic
Gram-positive Clostridium botulinum bacterium and inhibits the release of acetylcholine at the neuromuscular
junction, impeding muscular contraction.1,6–8 There are
7 distinct serotypes of the toxin, and type A is the most
frequently used clinically and is a stronger subtype.1, 6
Botulinum toxin has shown efficiency in the treatment of
gummy smile, as well as of other disorders, such as temporomandibular dysfunction (bruxism, clenching and
masseteric hypertrophy), sialorrhea, facial palsy and
orofacial pain.1, 4–10 The purpose of this article is to
report a case of a patient who presented with severe
gummy smile and was treated by a combination of gingivoplasty and botulinum toxin.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
Fig. 4
19
[20] =>
Gingivoplasty and botulinum toxin in gummy smile
Fig. 6
Fig. 7
Fig. 5
Fig. 8
Case report
A 36-year-old female patient attended the clinic complaining of gummy smile (Fig. 1). Clinically, the patient
presented with an anatomic discrepancy of more
than 4 mm between the length of the maxillary teeth
(Figs. 2 & 3) and severe gummy smile. Initially, the
length of tooth #21 was used as a clinical parameter
and was measured as 8.8 mm (Fig. 4). The gummy
smile was measured as 12.7 mm in height (Fig. 5).
Systemic alterations were not reported. Gingivoplasty was suggested. However, the application of
botulinum toxin was proposed to complement the
result of gingivoplasty, and the patient was counseled
about the recurrence of gummy smile 6 months after
the application. The patient agreed to the proposed
treatment and signed the terms of consent for the
application of botulinum toxin and use of images.
Under local infiltrative anesthesia, gingivoplasty was
performed by determination of the bleeding points with
the aid of a millimeter probe and the union of these
20
Fig. 9
points with an electric scalpel.2 The length of the teeth
was increased, characterizing the gingival zenith. Posteriorly, scraping was performed, resembling the external bevel technique, with the purpose of increasing the
tissue reparation (Figs. 6 & 7). There was no need for
surgical cement, given that the wound repair process
occurs by secondary intention. The patient was instructed on care and analgesics were administered
postoperatively.
After 30 days, satisfactory tissue reparation was observed (Fig. 8) and the patient reported no changes
or complaints. With use of Chu’s proportion gauge
(Hu-Friedy), the improvement of the relation between
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
[21] =>
Gingivoplasty and botulinum toxin in gummy smile
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
21
[22] =>
Gingivoplasty and botulinum toxin in gummy smile
the length and width of the teeth after the gingivoplasty
was observed (Fig. 9). However, the persistence of the
gummy smile was observed too (Fig. 10). The length of
tooth #21 had been increased from 8.8 mm to 9.7 mm
(Fig. 11). The gummy smile had increased because of
the higher dynamics of the upper lip, despite gingivoplasty (Fig. 12).
In the same treatment session, botulinum toxin was
applied. Prior to application, the surface of the skin
was disinfected with ethanol to avoid local infection
and remove the skin oiliness. Posteriorly, local anesthetic (EMLA, Astra) was applied with the purpose of
promoting comfort during the procedure. Botulinum
toxin type A (Botox 200 units, Allergan Pharmaceuticals) was diluted in 2 ml of saline solution, according
to the manufacturer’s instructions, and 2 units were
injected at the recommended site, laterally to each
nostril, at the level of the nose wing, at the insertion of
the levator labii superioris alaeque nasi muscle. After
application, the patient was advised not to lower her
head or engage in physical activity during the first 4 h
after the procedure. After 15 days, the patient was
evaluated. She presented with uniform descent of
the upper lip (Fig. 13) and reported no side effects or
complaints. The clinical effect of botulinum toxin application remained for 6 months.
Discussion
Several etiologies of gummy smile have been suggested, such as vertical excess of the maxilla,1, 4–8 delayed
passive eruption,1,4,6,8 hyperfunction of the muscles involved in smiling1,6,8 and reduced length of the clinical
crowns.1–3 These etiologies may occur singly or in
combination and determine the type of treatment to be
applied. In gummy smile caused by muscular hyperfunction, botulinum toxin is indicated. It is the treatment
of choice owing to its facility and security of application,
besides being a more conservative approach compared with surgical procedures (myectomy or LeFort I
osteotomy).1,4,10
Smiling is performed by several facial muscles,
such as the levator labii superioris, the levator labii
superioris alaeque nasi, and the zygomaticus major
and minor.1,4–9 The fibers of these muscles converge
at the same area, forming a triangle, making it possible to include the 3 muscles in a single injection. The
22
proposed site of the injection was lateral to the nose
wing.1,4,7–9 The toxin, when injected, can spread over
an area of 20 mm, allowing effective extension.1, 4, 5 The
toxin decreases the contraction of the muscles responsible for the elevation of the upper lip, reducing gingival
exposure.4–9
Botulinum toxin is a hydrophilic powder, stored under
vacuum, sterile and stable.1,6,7 Reconstitution is by effortless injection of the diluent (0.9% sodium chloride)
into the bottle. It has to be stored at 2–8°C and used
within 4–8 h in order to guarantee its effectiveness.1,8
Clinical effects present 2–10 days after the injection,
and the maximum visible effect occurs after 14 days
of injection.1, 4, 6 This effect lasts for approximately
3–6 months.1,5,6,8 Contraindications to the use of
botulinum toxin include pregnancy and lactation,
neurodegenerative and autoimmune diseases, and
concurrent use of an aminoglycoside antibiotic that
would enhance the action of the toxin.1, 8
In this report, the result was satisfactory regarding
the harmony of the smile by combination of the treatments—gingivoplasty and application of botulinum
toxin. Each of these treatments in isolation could not
have achieved the same level of excellence. Initially,
the creation of the new gingival zenith after gingivoplasty promoted the new dental architecture, favoring
gingival, dental and facial harmony for the patient. Subsequently, the application of botulinum toxin reduced
the gummy smile, by the uniform descent of the upper
lip, smoothing the facial lines of the smile, as can be
seen in the nasolabial folds, adjacent to the nostrils, by
comparing Figures 1 & 13.
Competing interests
The authors declare that they have no competing interests.
Figure legends
Fig. 1 – Severe gingival exposure, indicating gummy
smile.
Fig. 2 – Discrepancy between the lengths of the maxil-
lary teeth.
Fig. 3 – Length of tooth #11 measured with Chu’s pro-
portion gauge.
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Gingivoplasty and botulinum toxin in gummy smile
Fig. 4 – Length of tooth #21 measured with a digital
pachymeter (8.8 mm).
Fig. 5 – Gummy smile measured with a digital pachyme-
ter (12.7 mm).
Fig. 6 – Immediate postoperative photograph of teeth
#21, 22 and 23.
Fig. 7 – Immediate postoperative photograph after gin-
givoplasty.
Fig. 8 – Thirty days after gingivoplasty.
Fig. 9 – Improvement of the relation between the length
and the width of the teeth after gingivoplasty.
Fig. 10 – Persistence of the gummy smile after gingivo-
plasty.
Fig. 11 – Increase of the length of tooth #21.
Fig. 12 – Reduction of the gummy smile by the gingivo-
plasty.
Fig. 13 – Result 15 days after botulinum toxin applica-
tion.
References
6. Polo M. Botulinum toxin type A in the treatment of
excessive gingival display.
→ Am J Orthod Dentofacial Orthop.
2005 Feb;127(2):214–8; quiz 261.
7. Indra AS, Biswas PP, Vineet VT, Yeshaswini T. Botox
as an adjunct to orthognathic surgery for a case of
severe vertical maxillary excess.
→ J Maxillofac Oral Surg.
2011 Sep;10(3):266–70.
8. Jaspers GW, Pijpe J, Jansma J. The use of botulinum
toxin type A in cosmetic facial procedures.
→ Int J Oral Maxillofac Surg.
2011 Feb;40(2):127–33.
9. Sucupira E, Abramovitz A. A simplified method
for smile enhancement: botulinum toxin injection for
gummy smile.
→ Plast Reconstr Surg.
2012 Sep;130(3):726–8.
10. Niamtu J 3rd. Botox injections for gummy smiles.
→ Am J Orthod Dentofacial Orthop.
2008 Jun;133(6):782–3; author reply 783–4.
1. Pedron IG. Toxina botulínica: aplicações em odontologia.
→ Florianópolis: Editora Ponto.
2016. 195 p.
2. Narayan S, Narayan TV, Jacob PC. Correction of
gummy smile: a report of two cases.
→ J Indian Soc Periodontol.
2011 Oct;15(4):421–4.
3. Pedron IG, Utumi ER, Silva LP, Moretto LE, Lima TC,
Ribeiro MA. Cirurgia Gengival Ressectiva no
Tratamento da Desarmonia do Sorriso [Gingival resective surgery to the treatment of disharmony of smile].
→ Rev Odontol Bras Central.
2010 Apr;19(48):87–91. Portuguese.
4. Hwang WS, Hur MS, Hu KS, Song WC, Koh KS,
Baik HS, Kim ST, Kim HJ, Lee KJ. Surface anatomy
of the lip elevator muscles for the treatment of gummy
smile using botulinum toxin.
→ Angle Orthod.
2009 Jan;79(1):70–7.
5. Mazzuco R, Hexsel D. Gummy smile and botulinum
toxin: a new approach based on the gingival exposure
area.
→ J Am Acad Dermatol.
2010 Dec;63(6):1042–51.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
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[24] =>
Gingival recession in Spanish population
Prevalence of esthetic gingival recession in
university health care in a region of Spain
Alba Rodríguez Lorenzo,a
Abel García García,a, b
Pilar Gándara Vila,a
Mercedes Gallas Torreira,a
Cintia Micaela Chamorro Petronacci, a, b
Alejandro Ismael Lorenzo Pousoa,b &
Mario Pérez Sayans a,b
a
Oral Medicine, Oral Surgery and Implantology Unit, Faculty of
Medicine and Dentistry, University of Santiago de Compostela,
Santiago de Compostela, Spain
b
Foundation Health Research Institute of Santiago de Compostela,
Santiago de Compostela, Spain
Corresponding author:
Dr. Mario Pérez Sayáns
Faculty of Medicine and Dentistry
University of Santiago de Compostela
Entrerríos s/n
15782 Santiago de Compostela
Spain
perezsayans@gmail.com
How to cite this article: Rodríguez Lorenzo A, García
García A, Gándara Vila P, Gallas Torreira M, Chamorro
Petronacci CM, Lorenzo Pouso AI, Pérez Sayans M.
Prevalence of esthetic gingival recession in university
health care in a region of Spain. J Oral Science Rehabilitation. 2019 Dec;5(4):24–36.
Abstract
Objective
The objective of the study was to evaluate, in a random
population sample, the prevalence of gingival recession in the anterior zone of patients at the dental faculty
of the University of Santiago de Compostela.
Materials and methods
We designed a cross-sectional epidemiological study.
A random sample of 100 patients at the faculty was
24
studied. We obtained and analyzed data regarding demographics, smoking habit, recession characteristics,
dental history and esthetic importance for the patient.
Results
The prevalence of recession in the anterior zone was
relatively frequent at 26%. There were statistically significant relationships between the location of the recession and smoking habit and number of teeth with
recession. We also observed statistically significant
results between the number of teeth with recession
and sex, molar relationship, periodontal disease and
periodontal biotype. In patients with more than 4 teeth
with recession, most had a nonassessable molar relationship, and most had periodontal disease. It is important to note the significant relationships established
between distance of the recession from the cementoenamel junction, pocket depth and loss of supporting
tissue, and periodontal disease and plaque index.
Conclusion
The presence of recession in the anterior zone was relatively frequent in our setting. There are many factors
related to the presence of recession, such as smoking,
periodontal disease, pocket depth, loss of supporting
tissue and nonassessable molar relationship.
Keywords: Gingival recession; periodontal disease;
periodontal biotype; plaque index.
Introduction
The presence of gingival recession is frequent in the
adult population, causing not only esthetic alterations
but also sensitivity problems and/or root caries.1, 2 We
define gingival recession as the apical migration of the
gingival margin from the cementoenamel junction, resulting in root exposure. Although in adults the presence of gingival recession is frequent, the prevalence,
extent and severity present differences between the
various populations studied, age, sex, oral hygiene
level and brushing technique being among the main
contributing factors.3
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Gingival recession in Spanish population
Upon analyzing the prevalence rates in various
studies, we observed disparate results. In a study
conducted in the U.S. with 9,689 subjects, the prevalence of gingival recession was 58% for individuals
between 30 and 90 years of age, yielding an average
of 22.3% of affected teeth per person.1 Geiger found
that between 78% and 100% of middle-aged individuals have recession, present around between 22% and
53% of the teeth.4 In a longitudinal study conducted in
Barcelona, gingival recession was observed in 85% of
the individuals in the sample, a prevalence that did not
change in a follow-up test performed 10 years later;
however, the average number of teeth with recession
per person varied (a total of 210 in the initial examination and 299 in the second examination), and the
average height of the recession increased, while the
control variable, plaque, decreased.5
Regarding etiology, we know that this condition is determined by both susceptibility factors and anatomical
factors, such as fenestration and dehiscence of the alveolar bone or an abnormal position of the tooth in the
arch. These factors can result in thinner alveolar bone
than usual, which can be more susceptible to resorption.2 Gingival recession is also conditioned by causal
factors, such as physiological and pathological factors;
physiological factors, such as orthodontic movements
of the teeth out of the buccal and lingual cortical bone;2, 6
and pathological factors, such as incorrect brushing
technique and the types of brush and bristles, intraoral and perioral piercings, occlusal trauma or poor
oral hygiene that leads to the accumulation of bacterial
plaque.2, 6–11 Since the presence of gingival recession
is commonly observed in the daily practice at a dental
clinic, we considered it important to study its prevalence owing to the esthetic and health consequences.
Therefore, we analyzed the relationship between different variables (such as smoking habit, periodontal
biotype and molar relationship) and the presence of
recession and its characteristics (such as distance of
the recession from the cementoenamel junction and
number of teeth with recession).
The main objective of this study was to evaluate, in
a random population sample, the prevalence of gingival recession in the anterior zone, whether or not the
recession was symptomatic. The study’s secondary
objective was to study the factors associated with this
recession.
Materials and methods
We designed a cross-sectional epidemiological study
of the prevalence of gingival recession in the anterior
zone of patients at the dental faculty of the University of Santiago de Compostela (USC). This study was
approved by the USC ethics committee (reference no.
TFG 2016/23).
The data were obtained by collecting specific standardized variables for this study, which were always
measured by 2 specific operators. The operators had
previously performed a calibration for the correct evaluation of the variables. In cases of discrepancy, a third
operator corroborated the results. These variables
were grouped as follows:
• demographics (age, sex, level of education and other demographic information);
• smoking habit (those who had stopped up to 5 years
before the study were considered smokers);
• lesion characteristics (location of the recession, distance of recession from the cementoenamel junction, pocket depth, supporting tissue loss, root caries
and other characteristics);
• dental history (molar and canine relationship, presence or absence of periodontal disease, periodontal biotype and other factors); and
• esthetic importance for the patient.
Next, periodontal disease was evaluated as follows:
1. Regarding periodontal disease, we differentiated
between whether periodontal disease was or was
not present; in cases where it was present, we determined the degree of severity (mild, moderate or
severe). The disease was considered mild when
there was between 1 and 2 mm of supporting tissue loss, moderate when there was between 3 and
4 mm of supporting tissue loss, and severe when
there was greater than 5 mm of supporting tissue
loss.12 Regarding the plaque index, there was also
differentiation between whether or not plaque was
present. In such cases, plaque could be mild or
abundant: Plaque was considered mild when it covered less than one-third of the clinical crown and
abundant when it was equal to or greater than onethird of the crown.13
2. To classify the patient’s periodontal biotype, we distinguished between thin and thick.14 In the thin biotype, the gingival margin was thin and scalloped,
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
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[26] =>
Gingival recession in Spanish population
Variable
Sex
Level of
education
Smoker
Cigarettes/day
No. of missing
teeth
Frequency (n)
Percentage (%)
Male
11
42.3
Female
15
57.7
No formal education
3
11.5
Primary education
4
15.4
THAT–Secondary mandatory
education
(12–16 years old)
2
7.7
EGB–Primary
mandatory education
(8–12 years old)
2
7.7
BACH–Not
mandatory education
(12–16 years old)
2
7.7
FP basic–Basic
technical education
4
15.4
FP superior–Superior
technical education
2
7.7
University students
7
26.9
No
14
53.8
Yes
12
46.2
0
14
53.8
5
2
7.7
6
2
7.7
8
1
3.8
20
4
15.4
30
1
3.8
40
2
7.7
2
1
3.8
3
2
7.7
5
5
19.2
Table 1: Descriptive data of qualitative variables of the study.
→ continues on the next page
26
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Gingival recession in Spanish population
Variable
No. of missing teeth
Left molar relationship
Right molar relationship
Left canine relationship
Frequency (n)
Percentage (%)
6
3
11.5
7
1
3.8
8
4
15.4
9
2
7.7
10
3
11.5
13
1
3.8
15
1
3.8
17
1
3.8
19
1
3.8
27
1
3.8
Not assessable
14
53.8
I
5
19.2
II
2
7.7
III
1
3.8
Crossed
4
15.4
Not assessable
19
73.1
I
4
15.4
II
2
7.7
III
0
0
Crossed
1
3.8
Not assessable
4
15.4
I
13
50.0
II
3
11.5
III
3
11.5
Crossed
3
11.5
Table 1: Descriptive data of qualitative variables of the study.
→ continues on the next page
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
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[28] =>
Gingival recession in Spanish population
Variable
Right canine
relationship
Location of
recession in
maxilla
No. of teeth
with recession
Periodontal
disease
Plaque index
Bleeding on
probing
Suppuration
Miller’s class
Frequency (n)
Percentage (%)
Not assessable
3
11.5
I
14
53.8
II
3
11.5
III
3
11.5
Crossed
3
11.5
Superior
4
15.4
Lower
11
42.3
Both
11
42.3
1
2
7.7
2
7
26.9
3
4
15.4
4
1
3.8
>4
12
46.2
None
9
34.6
Mild
7
26.9
Moderate
4
15.4
Severe
6
23.1
None
6
23.1
Mild
10
38.5
Abundant
10
38.5
No
13
50.0
Yes
13
50.0
No
22
84.6
Yes
4
15.4
I
21
80.8
II
5
19.2
Table 1: Descriptive data of qualitative variables of the study.
→ continues on the next page
28
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
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Gingival recession in Spanish population
Variable
Mobility
Esthetic importance for
patient
Root caries
Tooth
position
Cause of recession
Periodontal
biotype
Frequency (n)
Percentage (%)
No
20
76.9
Yes
6
23.1
No
17
65.4
Yes
9
34.6
No
20
76.9
Yes
6
23.1
Normal
18
69.2
Vestibularized
2
7.7
Lingual/palatal
6
23.1
Brushing
5
19.2
Bruxism
3
11.5
Periodontal disease
8
30.8
Other
8
30.8
Mixed
2
7.7
Thin
12
46.2
Thick
14
53.8
Table 1: Descriptive data of qualitative variables of the study.
Variable
Mean
Standard deviation
Minimum
Maximum
Recession distance (mm)
3.00
1.07
1.00
5.00
Pocket depth (mm)
2.95
1.32
1.00
6.83
Supporting tissue loss (mm)
5.95
2.15
2.00
11.83
Table 2: Descriptive data of quantitative variables of the study.
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29
[30] =>
Gingival recession in Spanish population
Principal variable
Location of recession
in maxilla
Secondary variable
Chi-square test
Sex
0.408
Level of education
0.747
Smoking habit
0.037
Cigarettes/day
0.285
No. of missing teeth
0.388
Left molar relationship
0.416
Right molar relationship
0.811
Left canine relationship
0.264
Right canine relationship
0.297
Periodontal disease
0.696
Plaque index
0.520
Bleeding on probing
0.913
Suppuration
0.651
Miller’s class
0.492
Mobility
0.492
Esthetic importance for patient
0.116
Root caries
0.295
Tooth position
0.178
Cause of recession
0.454
Periodontal biotype
0.091
No. of teeth with recession
0.029
Table 3: Levels of significance for the variable “location of recession in maxilla”.
30
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[31] =>
Gingival recession in Spanish population
Principal variable
No. of teeth
with recession
Secondary variable
Chi-square test
Sex
0.027
Level of education
0.890
Smoking habit
0.344
Cigarettes/day
0.845
No. of missing teeth
0.731
Left molar relationship
0.012
Right molar relationship
0.023
Left canine relationship
0.887
Right canine relationship
0.734
Periodontal disease
0.031
Plaque index
0.061
Bleeding on probing
0.460
Suppuration
0.712
Miller’s class
0.125
Table 1: Descriptive
data of qualitative variables of the study.
0.059
Mobility
Esthetic importance for patient
0.504
Root caries
0.059
Tooth position
0.250
Cause of recession
0.212
Periodontal biotype
0.009
Location of recession in maxilla
0.029
Table 4: Levels of significance for the variable “number of teeth with recession”.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
31
[32] =>
Gingival recession in Spanish population
Recession
distance
Pocket
depth
Supporting
tissue loss
Age
Sex
0.097
0.018
0.027
0.683
Level of education
0.421
0.473
0.233
0.637
Smoking habit
0.131
0.076
0.067
0.274
Cigarettes/day
0.514
0.050
0.165
0.490
No. of missing teeth
0.434
0.593
0.546
0.302
Left molar
relationship
0.620
0.136
0.322
0.626
Right molar
relationship
0.697
0.338
0.452
0.108
Left canine
relationship
0.556
0.383
0.321
0.271
Right canine
relationship
0.433
0.067
0.137
0.069
Periodontal disease
0.007
0.031
0.005
0.173
Plaque index
0.006
0.004
0.001
0.233
Bleeding on probing
0.287
0.026
0.050
0.050
Suppuration
0.069
0.001
0.004
0.069
Miller’s class
0.005
0.003
0.000
0.200
Mobility
0.007
0.002
0.000
0.176
Esthetic importance
for patient
0.200
0.339
0.107
0.367
Root caries
0.095
0.019
0.019
0.219
No. of teeth
with recession
0.131
0.435
0.179
0.133
Location of recession in maxilla
0.555
0.733
0.734
0.084
Table 5: Levels of significance for the quantitative variables “recession distance,” “pocket depth,” “supporting tissue loss” and “age”.
32
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Gingival recession in Spanish population
the papillae were high, the coronal morphology was
long and conical, with a point of fine contact, the root
morphology was convex, and the bony crest was
very thin and scalloped. In the thick biotype, the gingival margin was thick and only slightly scalloped,
the papillae were low, the coronal morphology was
short and square, with a wide contact point, the root
morphology was concave, and the bony crest was
thick.
3. For the variable “cause of the recession,” we studied
different causes, such as brushing technique,5,15 periodontal disease, bruxism, orthodontic treatment16
and piercing, as well as mixed causes and other
causes. In this last category, we included anomalous
tooth positions, other direct traumatic factors and all
cases in which recession was not related to any of
the causes already mentioned. We considered the
cause of recession to be mixed when the recession
was due to 2 or more causes. For the collection of
these data, we used an exploration kit consisting of
a mirror, an exploration probe and a CP12 periodontal probe.
Sample size
The study was conducted during a period of 8 months
between September 2016 and April 2017. For calculation of the sample size, the proportion of patients
exposed to the etiological factors and who had gingival recession according to the literature was taken
into account, that is, 35%. Therefore, we would have to
obtain an odds ratio of 0.290; for a statistical power of
80%, we would need a sample of 86 patients. A random
sample of 100 patients was analyzed from patients at
the USC dental faculty, of which 26 had gingival recession, symptomatic or nonsymptomatic in the anterior
zone. In these 26 patients, an additional evaluation of
the recession characteristics was performed. To participate in this study, the patients’ consent was obtained
to proceed with the data collection.
Statistical analysis
All data were coded and analyzed using the SPSS
program (Version 20.0, IBM Corp.). Descriptive statistics were calculated using the frequencies and percentages for the categorical variables and the means
and the standard deviations for the quantitative variables. Contingency tables were constructed using the
chi-square test. Statistical analysis was performed by
comparing means in nonparametric analysis using the
Mann–Whitney test and 1-way analysis of variance. All
the differences in which the value of P was less than or
equal to 0.05 were considered statistically significant.
Results
The descriptive results of the study are summarized
in Tables 1 and 2. The prevalence of recession in the
anterior zone in patients at the USC dental faculty was
26% (n = 100). The average age of the patients in this
study was 53.35 years. Of the total patients with gingival recession in the anterior zone, 57.7% were women.
Regarding smoking habit, 14 of the 26 patients who
had recession in the anterior zone were nonsmokers.
When we considered the molar relationship presented
by the patients, both the left and right molar relationships were generally not assessable: 53.8% (left molar
relationship) and 73.1% (right molar relationship).
Among the 26 patients, 46.2% had more than 4 teeth
with recession. Approximately 65% of the patients
had periodontal disease, and almost 77% had plaque.
However, the vast majority did not have suppuration of
the teeth with recession (22 of 26 patients). All instances
of recession in our study were classified as Miller class
I or II. A total of 76.9% of the teeth with recession did
not present with either mobility or root caries. Most
teeth with recession had normal positioning in the arch
(69.2%), and 65.4% of the patients did not regard the
recession as esthetically important. The main cause
of recession, in up to 30% of cases, was periodontal
disease, and 53.8% of the patients had a thick periodontal biotype. We established 6 main variables: location of the recession in the maxilla, number of teeth
with recession, age, distance of the recession from the
cementoenamel junction (in millimeters), pocket depth
and supporting tissue loss (Tables 3–5). There were
statistically significant relationships between location
of the recession in the maxilla and smoking habit
and number of teeth with recession (chi-square test,
P = 0.037). When recession were present in both arches,
most patients were smokers and most had more than
4 teeth with recession. We also observed statistically
significant associations between the number of teeth
with recession and sex (chi-square test, P = 0.027),
molar relationship (chi-square test, P = 0.012 and
P = 0.023), periodontal disease presence (chi-square
test, P = 0.031) and periodontal biotype (chi-square
test, P = 0.009). In patients with more than 4 teeth with
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
33
[34] =>
Gingival recession in Spanish population
recession, 53.84% had a nonassessable molar relationship and 65.38% had periodontal disease; 50% of
them had severe periodontal disease.
cause an excess of force on the anterior teeth and, as
a consequence, the appearance of recession around
more of those teeth.
We observed that patients with 2 teeth with recession had a thick periodontal biotype, whereas among
individuals with more than 4 teeth with recession,
83.7% had a thin periodontal biotype.
Regarding smoking habit and its established relationship with the location of the recession in the
maxilla, when patients had recession in both arches,
more than 70% were smokers or had been until less
than 5 years before. The same did not occur in patients who only had recession in 1 arch; more than
80% were nonsmokers. We have found studies in
which the same relationship was established, including two that suggest the possible local effect of cigarettes.6, 19
Regarding the other main variables, it is worth
mentioning the statistically significant relationships
established between distance of the recession from
the cementoenamel junction, pocket depth and loss
of supporting tissue, and periodontal disease and
plaque index. The greater the severity of the periodontal disease and the higher the plaque index, the
greater the measurements of recession distance,
pocket depth and loss of supporting tissue. Statistically
significant relationships were also observed between
these 3 main variables and Miller’s class and the
presence or absence of mobility. In the case of a
Miller class II recession with or without mobility,
the average recession distance, pocket depth and
supporting tissue loss were significantly higher.
Discussion
In this study, which used a sample of 100 patients
with an average age of 53.35 years, we obtained a
prevalence of recession in the anterior zone of 26%.
Comparison with other studies is difficult because
most of them did not limit the study only to the
presence of recession in the anterior zone. Even
so, when comparing the prevalence rates with other
research, taking the 26% into account, we noted
that our prevalence rate was relatively lower.1, 5,17
In our study, recession was more frequent in
women (57%) than in men. However, among
patients with more than 4 teeth with recession, more
than half were men. In our study, the number of
missing teeth in relation to the presence of recession
did not present a statistical relationship, as in other
studies reviewed.18 However, we did find a strong
association between molar relationship and the
number of teeth with recession. A large portion of the
patients with more than 4 teeth with recession had a
nonassessable molar relationship. This finding makes
us think that the absence of the molars is likely to
34
In our study, we noted that all instances of recession were classified into Miller class I or II, a finding
that coincides with that of another study, in which
most of the teeth observed were also classified as
Miller class I or II.19 Most studies argue that a thin
periodontal biotype is a predisposing factor for recession.8, 20 However, in this present study, more than
half of the patients had a thick periodontal biotype
and still had recession. However, the majority of
patients with more than 4 teeth with recession
had a thin periodontal biotype. The number of teeth
with recession, the recession distance, the pocket
depth and the supporting tissue loss presented strong
associations with the presence of periodontal disease.
The exposure of the root to the oral cavity either
directly by recession or by the presence of a
periodontal pocket was directly related to an increased risk of root caries.21 At the same time, our
research revealed a relationship between the loss
of supporting tissue and pocket depth. Based on
the results obtained, the previous literature supports some of the established relationships, such
as between the location of the recession in the
maxilla and smoking or the relationships between
supporting tissue loss, periodontal disease and
plaque index. However, we also made findings in
opposition to those of previous studies, as in the
case of the relationship between the presence of
recession and the periodontal biotype. One of the
limitations of this study is the limited number of
published studies to which to compare some of
the relationships established between variables in
our work.
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Gingival recession in Spanish population
Conclusion
The prevalence of recession in the anterior zone was
relatively frequent in our setting, at 26% in this study.
Comparison with other studies was difficult because
others were not limited only to the anterior zone. There
are many factors related to the presence of recession,
such as smoking, periodontal disease, pocket depth,
loss of supporting tissue and nonassessable molar
relationship. It is necessary to identify these factors
incipiently to prevent recession and associated complications. To make more powerful inferences, it would
be necessary to conduct studies in broader subpopulations.
Competing interests
The authors declare that they have no competing interests.
Legends
Table 1 – Descriptive data of qualitative variables of the
study.
Table 2 – Descriptive data of quantitative variables of the
study.
Table 3 – Levels of significance for the variable “location
of recession in maxilla”.
Table 4 – Levels of significance for the variable “number
of teeth with recession”.
Table 5 – Levels of significance for the quantitative vari-
ables “recession distance,” “pocket depth,” “supporting
tissue loss” and “age”.
References
1. Albandar JM, Kingman A. Gingival recession, gingival bleeding, and dental calculus in adults 30 years of
age and older in the United States, 1988–1994.
→ J Periodontol.
1999 Jan;70(1):30–43.
2. Bouchard P, Malet J, Borghetti A. Decision-making
in aesthetics: root coverage revisited.
→ Periodontol 2000.
2001;27:97–120.
3. Cairo F, Pagliaro U, Nieri M. Treatment of gingival
recession with coronally advanced flap procedures: a
systematic review.
→ J Clin Periodontol.
2008 Sep;35(8 Suppl):136–62.
4. Geiger AM. Mucogingival problems and the movement of mandibular incisors: a clinical review.
→ Am J Orthod.
1980 Nov;78(5):511–27.
5. Gorman WJ. Prevalence and etiology of gingival
recession.
→ J Periodontol.
1967 Jul–Aug;38(4):316–22.
6. Haffajee AD, Socransky SS. Relationship of
cigarette smoking to attachment level profiles.
→ J Clin Periodontol.
2001 Apr;28(4):283–95.
7. Hägewald S, Spahr A, Rompola E, Haller B, Heijl L,
Bernimoulin JP. Comparative study of Emdogain and
coronally advanced flap technique in the treatment of
human gingival recessions. A prospective controlled
clinical study.
→ J Clin Periodontol.
2002 Jan;29(1):35–41.
8. Kassab MM, Cohen RE. The etiology and prevalence of gingival recession.
→ J Am Dent Assoc.
2003 Feb;134(2):220–5.
9. Löe H, Anerud A, Boysen H. The natural history of
periodontal disease in man: prevalence, severity, and
extent of gingival recession.
→ J Periodontol.
1992 Jun;63(6):489–95.
10. Marini MG, Greghi SL, Passanezi E, Sant’ana AC.
Gingival recession: prevalence, extension and severity
in adults.
→ J Appl Oral Sci.
2004 Sep;12(3):250–5.
11. Matas F, Sentis J, Mendieta C. Ten-year longitudinal study of gingival recession in dentists.
→ J Clin Periodontol.
2011 Dec;38(12):1091–8.
12. Papapanou PN, Sanz M, Buduneli N, Dietrich T,
Feres M, Fine DH, Flemmig TF, Garcia R, Giannobile WV,
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Graziani F, Greenwell H, Herrera D, Kao RT, Kebschull
M, Kinane DF, Kirkwood KL, Kocher T, Kornman KS,
Kumar PS, Loos BG, Machtei E, Meng H, Mombelli A,
Needleman I, Offenbacher S, Seymour GJ, Teles R,
Tonetti MS. Periodontitis: consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and
Conditions.
→ J Periodontol.
2018 Jun;89 Suppl 1:173–82.
13. Kayalvizhi G, Radha S, Prathima GS, Mohandoss S,
Ramesh V, Arumugam SB. Comparative evaluation of
plaque removal effectiveness of manual and chewable
toothbrushes in children: a randomized clinical trial.
→ Int J Clin Pediatr Dent.
2019 Mar–Apr;12(2):107–10.
19. Sarfati A, Bourgeois D, Katsahian S, Mora F,
Bouchard P. Risk assessment for buccal gingival recession defects in an adult population.
→ J Periodontol.
2010 Oct;81(10):1419–25.
20. Palkovics D, Gera I. [The significance of biotype
in the predictability of dental-periodontal treatment].
Hungarian.
→ Fogorv Sz.
2016 Jun;109(2):45–55.
21. Tugnait A, Clerehugh V. Gingival recession—its
significance and management.
→ J Dent.
2001 Aug;29(6):381–94.
14. Zweers J, Thomas RZ, Slot DE, Weisgold AS,
Van der Weijden FG. Characteristics of periodontal
biotype, its dimensions, associations and prevalence:
a systematic review.
→ J Clin Periodontol.
2014 Oct;41(10):958–71.
15. Rajapakse PS, McCracken GI, Gwynnett E,
Steen ND, Guentsch A, Heasman PA. Does tooth
brushing influence the development and progression
of non-inflammatory gingival recession? A systematic
review.
→ J Clin Periodontol.
2007 Dec;34(12):1046–61.
16. Bin Bahar BS, Alkhalidy SR, Kaklamanos EG,
Athanasiou AE. Do orthodontic patients develop more
gingival recession in anterior teeth compared to untreated individuals? A systematic review of controlled
studies.
→ Int Orthod.
2019 Nov 1. pii: S1761-7227(19)30155-X. doi: 10.1016/
j.ortho.2019.08.025.
17. Matas F, Sentís J, Mendieta C. Ten-year longitudinal study of gingival recession in dentists.
→ J Clin Periodontol.
2011 Dec;38(12):1091–8.
18. Vehkalahti M. Occurrence of gingival recession in
adults.
→ J Periodontol.
1989 Nov;60(11):599–603.
36
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
[37] =>
Welcome to
MasterClass.Dental
Online classes taught by the world’s best doctors
directly from their practice
OBSERVE
DISCUSS
YOUR CASE
ON DEMAND
ALL DEVICES
GUARANTEED
www.MasterClass.Dental
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ADA CERP is a service of the American Dental Association to assist dental professionals in identifying
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courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.
Tribune Group GmbH designates this activity for 1 continuing education credits.
This continuing education activity has been planned and implemented in accordance with the
standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts
between Tribune Group GmbH and Dental Tribune Int. GmbH.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
37
[38] =>
Topical doxycycline in deep pockets
Topical doxycycline after nonsurgical
instrumentation of deep periodontal
pockets: Results from a prospective
case series with 12 months’ follow-up
Roberto Abundo,a
Giuseppe Corrente,a
Michele Perelli,a
Mara Briganti,a
Mauro Centracchioa &
Marta Zambellia
a
Private practice, Turin, Italy
Corresponding author:
Dr. Marta Zambelli
SICOR
Corso Sicilia 51
10122 Turin
Italy
martaz11@hotmail.com
How to cite this article: Abundo R, Corrente G, Perelli M,
Briganti M, Centracchio M, Zambelli M. Topical
doxycycline after nonsurgical instrumentation of deep
periodontal pockets: Results from a prospective case
series with 12 months’ follow-up. J Oral Science Rehabilitation. 2019 Dec;5(4):38–42.
Abstract
Objective
The objective of this paper was to evaluate the
clinical results at 12 months of a topical application
of doxycycline after nonsurgical instrumentation of
deep periodontal pockets.
Materials and methods
Forty healthy patients previously treated for periodontal disease, with 1 or more residual periodontal pockets
of at least 6 mm in depth around nonmolar teeth, were
enrolled. After registration of pocket depth (PD), clinical
38
attachment loss (CAL) and bleeding on probing (BOP),
the pockets were nonsurgically treated with hand and
ultrasonic instruments, then a single topical application
of 14% doxycycline hyclate gel was performed. At
12 months, measurement of PD, CAL and BOP was
repeated. The results underwent statistical analysis by
means of the Student t test for paired data (PD and
CAL) and the chi-square test (BOP).
Results
Of the 40 enrolled patients, 35 (14 males and 21
females; mean age: 59.94 years) attended the
12-month clinical reevaluation. The analysis was therefore based on the data from 87 pockets. The initial
values were: PD = 7.28 ± 1.69 mm, CAL = 9.00 ± 2.40 mm
and BOP = 78.16%. The 12-month values were:
PD = 4.62 ± 1.77 mm, CAL = 6.75 ± 2.54 mm and
BOP = 22.99%. The difference was of high statistical
significance (P < 0.001) for all clinical parameters.
Conclusion
Nonsurgical treatment by means of hand and ultrasonic instruments plus a single topical doxycycline
application showed high efficacy in deep periodontal
pockets (≥ 6 mm).
Keywords: Periodontal disease; nonsurgical periodontal therapy; periodontal pocket; topical doxycycline.
Introduction
The first goal of periodontal therapy is to remove the
biofilm on supra- and subgingival dental surfaces.
This decontamination, which is the result of correct
at-home plaque control and of sound professional instrumentation of root surfaces, is able to eliminate the
bacterial infection which is the cause of periodontitis, reducing inflammation and pocket probing depth
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
[39] =>
Topical doxycycline in deep pockets
Fig. 1
and allowing regaining of the clinical attachment of
affected and treated teeth.1 Nonsurgical debridement
is not always able to achieve the ideal results just
mentioned, especially when deep pockets require
treatment.2 When nonsurgical therapy is not appropriate, surgical procedures are indicated.3
In serious cases of generalized aggressive periodontitis, the association of systemic antibiotics has
proved to be very effective after nonsurgical pocket
instrumentation.4, 6 In order to improve the results
of nonsurgical therapy, the topical application of
antibiotics in addition to conventional instrumentation has also been proposed,7–13 in particular for the
treatment of isolated sites with severe periodontitis, as can often be found during maintenance
therapy11 in subjects also previously successfully
treated.
Specifically, slow-release 14% doxycycline hyclate
gel was able to release therapeutically effective
doses for more than 10 days even after a single local
administration.11 The aim of this study was to evaluate the clinical outcome of nonsurgical periodontal
instrumentation associated with a single topical application of doxycycline in deep pockets.
Materials and methods
This prospective case series was conducted according
to the guidelines of the STROBE statement for observational studies.14 All procedures followed in this study
were in accordance with the ethical standards of the
Declaration of Helsinki of 1975 as revised in 2013.
From the same private practice for the treatment
of periodontal disease, 40 patients (18 males and 22
females) were selected from Jan. 2 to Feb. 28, 2017,
using the following inclusion criteria: age between 35
and 75 years, absence of systemic diseases, previously diagnosed and treated periodontal disease (through
oral hygiene motivation and instruction, professional
nonsurgical periodontal debridement and, eventually,
surgical therapy), nonsmoker or smoking less than
10 cigarettes/day, plaque index of lower than 25%, enrollment in a regular periodontal maintenance therapy
program, and 1 or more residual periodontal pockets
of at least 6 mm around nonmolar teeth, which were
the subject of this study. In the sites to be treated, the
clinical parameters of pocket depth (PD),clinical attachment loss (CAL) and bleeding on probing (BOP)
were registered by calibrated clinicians (2 dentists and
2 dental hygienists; Fig. 1).
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
39
[40] =>
Topical doxycycline in deep pockets
Fig. 2
Fig. 3
After local anesthesia with articaine plus 1:100,000
epinephrine, the selected pockets underwent a single
nonsurgical periodontal debridement using hand (curettes) and ultrasonic (XO Odontogain, XO CARE) instruments. For each tooth, every root aspect (mesial,
distal, buccal and lingual) included in the study was
instrumented for 3–5 min, according to the operator’s assessment during the instrumentation and a
single topical application of a 14% doxycycline hyclate
gel (Ligosan, Heraeus Kulzer) was then performed
(Fig. 2).
In the postoperative period, the patients were to
avoid at-home oral hygiene for 1 day, replacing it with
40
chlorhexidine spray applications (Corsodyl Spray,
GlaxoSmithKline) after meals, and to avoid chewing at
the sites being treated. The patients followed a regular
personalized program of professional oral hygiene
sessions every 3 or 4 months, but no subgingival
instrumentation of the treated sites was performed
during such recalls. Twelve months after treatment,
the previously recorded clinical parameters (PD, CAL
and BOP) were reregistered (Fig. 3).
The results underwent statistical analysis by means
of the Student t test for paired data (PD and CAL) and
the chi-square test (BOP). P values of < 0.005 were
considered statistically significant.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
[41] =>
Topical doxycycline in deep pockets
PD (mm)
CAL (mm)
BOP (%)
Baseline
7.28 ± 1.69
9.00 ± 2.40
78.16
12 months
4.62 ± 1.77
6.75 ± 2.54
22.99
Table 1: Initial and final values for pocket depth (PD), clinical attachment loss (CAL) and bleeding on probing (BOP).
The difference was of high statistical significance (P < 0.001) for all clinical parameters.
Results
Of the 40 patients enrolled in the study, 35 (14 males
and 21 females; mean age: 59.94 ± 9.34 years) attended the 12-month clinical reevaluation. The 5 dropouts
were due to missing a periodontal recall scheduled for
maintenance therapy (3 patients), to a periapical lesion
needing endodontic therapy of the tooth involved in the
study (1 patient) and to moving abroad (1 patient). The
analysis was therefore based on data from 87 pockets.
The mean initial and final values are reported in
Table 1. A mean PD reduction of 2.66 ± 1.52 mm, a
mean CAL gain of 2.25 ± 1.45 mm and a mean BOP reduction of 55.16% were recorded. The difference was
of high statistical significance (P < 0.001) for all clinical
parameters.
Discussion
The results of the study showed a significant improvement in all periodontal parameters (PD, CAL and BOP)
after nonsurgical treatment and a single topical doxycycline application in deep pockets of ≥ 6 mm around
nonmolar teeth, confirming what has already been reported in literature9 for clinical parameters. Also in this
case, it is emphasized that the long time dedicated to
root debridement, with manual and ultrasonic instruments, may have contributed to the good results, as
well as in previous works,1,9 compared with those reported for studies in which less time was devoted to
this important step of the therapy.12
Very interesting in the results was the minimum
amount of postoperative recession (PD reduction—
CAL gain) reported in the present study. The same
treatment modality investigated in this study had
already been described to provide a high possibility of
reducing pocket depth from ≥ 6 mm to ≤ 5 mm than
subgingival instrumentation alone, without the application of topical doxycycline.11
The data presented in this study can therefore orient
toward a possible association between nonsurgical
periodontal therapy and a single topical application of
doxycycline as an alternative to surgical procedures,
thus providing a valid therapeutic option in all those situations in which clinicians and patients prefer or have
to limit the invasiveness of the treatment. Caution is
recommended in the use of antibiotics owing to possible development of resistance to antimicrobial agents;15
however, in a previous study, application of 14% doxycycline gel demonstrated high efficacy toward periodontal pathogens without any induced resistance.16
The stability of the results after the treatment needs to
be evaluated in studies with longer follow-up and with
a control group.
Conclusion
In patients that follow a regular periodontal maintenance therapy program, nonsurgical treatment by
means of hand and ultrasonic debridement plus a
single topical doxycycline application showed high efficacy in deep periodontal pockets (≤ 6 mm) around
nonmolar teeth.
Competing interests
The authors declare that they have no competing interests.
Acknowledgments
The authors wish to thank dental hygienists Sabrina
Camiolo, Eliana Orlando and Patrizia Rosa for their
valuable contribution in different stages of the study.
Legends
Fig. 1 – Recording of the initial values of pocket depth,
clinical attachment loss and bleeding on probing.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
41
[42] =>
Topical doxycycline in deep pockets
Fig. 2 – Single
application of locally delivered controlled-release 14% doxycycline gel after nonsurgical
instrumentation.
Fig. 3 – Recording of the values of pocket depth, clini-
cal attachment loss and bleeding on probing at the 12month reevaluation.
References
1. Badersten A, Nilvéus R, Egelberg J. Effect of nonsurgical periodontal therapy. I. Moderately advanced
periodontitis.
→ J Clin Periodontol.
1981 Feb;8(1):57–72.
2. Badersten A, Nilvéus R, Egelberg J. Effect of nonsurgical periodontal therapy. II. Severely advanced
periodontitis.
→ J Clin Periodontol.
1984 Jan;11(1):63–76.
3. Rabbani GM, Ash MM Jr, Caffesse RG. The effectiveness of subgingival scaling and root planing in calculus removal.
→ J Periodontol.
1981 Mar;52(3):119–23.
4. Sigurdsson TJ, Holbrook WP, Karadottir H,
Magnusdottir MO, Wikesjo UM. Evaluating surgical, nonsurgical therapy in periodontic patients.
→ J Am Dent Assoc.
1994 Aug;125(8):1080–7.
5. Van Winkelhoff AJ, Rodenburg JP, Goené RJ,
Abbas F, Winkel EG, de Graaff J. Metronidazole plus
amoxycillin in the treatment of Actinobacillus actinomycetemcomitans associated periodontitis.
→ J Clin Periodontol.
1989 Feb;16(2):128–31.
6. Guerrero A, Griffiths GS, Nibali L, Suvan J, Moles DR,
Laurell L, Tonetti MS. Adjunctive benefits of systemic
amoxicillin and metronidazole in non-surgical treatment of generalized aggressive periodontitis: a randomized placebo-controlled clinical trial.
→ J Clin Periodontol.
2005 Oct;32(10):1096–107.
7. Pedrazzoli V, Kilian M, Karring T. Comparative clinical and microbiological effects of topical subgingival application of metronidazole 25% dental gel and
scaling in the treatment of adult periodontitis.
→ J Clin Periodontol.
1992 Oct;19(9 Pt 2):715–22.
9. Tomasi C, Koutouzis T, Wennström JL. Locally
delivered doxycycline as an adjunct to mechanical
debridement at retreatment of periodontal pockets.
→ J Periodontol.
2008 Mar;79(3):431–9.
10. Eickholz P, Kim TS, Bürklin T, Schacher B,
Renggli HH, Schaecken MT, Holle R, Kübler A,
Ratka-Krüger P. Non-surgical periodontal therapy
with adjunctive topical doxycycline: a double-blind
randomized controlled multicenter study.
→ J Clin Periodontol.
2002 Feb;29(2):108–17.
11. Tonetti MS, Lang NP, Cortellini P, Suvan JE,
Eickholz P, Fourmousis I, Topoll H, Vangsted T,
Wallkamm B. Effects of a single topical doxycycline
administration adjunctive to mechanical debridement
in patients with persistent/recurrent periodontitis but
acceptable oral hygiene during supportive periodontal
therapy.
→ J Clin Periodontol.
2012 May;39(5):475–82.
12. Kim TS, Klimpel H, Fiehn W, Eickholz P. Comparison of the pharmacokinetic profiles of two locally
administered doxycycline gels in crevicular fluid and
saliva.
→ J Clin Periodontol.
2004 Apr;31(4):286–92.
13. Van Steenberghe D, Bercy P, Kohl J, De Boever J,
Adriaens P, Vanderfaeillie A, Adriaenssen C, Rompen E,
De Vree H, McCarthy EF, Vandenhoven G. Subgingival minocycline hydrochloride ointment in moderate
to severe chronic adult periodontitis: a randomized,
double-blind, vehicle-controlled, multicenter study.
→ J Periodontol.
1993 Jul;64(7):637–44.
14. Jepsen K, Jepsen S. Antibiotics/antimicrobials:
systemic and local administration in the therapy of mild
to moderately advanced periodontitis.
→ Periodontol 2000.
2016 Jun;71(1):82–112.
15. Ratka-Krüger P, Schacher B, Bürklin T,
Böddinghaus B, Holle R, Renggli H, Eickholz P,
Kim TS. Non-surgical periodontal therapy with adjunctive topical doxycycline: a double-masked, randomized, controlled multicenter study. II. Microbiological
results.
→ J Periodontol.
2005 Jan;76(1):66–74.
8. Tomasi C, Wennström JL. Locally delivered doxycycline improves the healing following non-surgical periodontal therapy in smokers.
→ J Clin Periodontol.
2004 Aug;31(8):589–95.
42
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
[43] =>
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
43
[44] =>
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[45] =>
Guidelines for authors
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[46] =>
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Journal of Oral Science & Rehabilitation | Volume 5 – Issue 4/2019
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