45. Diagnosis /Indices – Radiographic Interpretation

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Are Radiographs an accurate method of diagnosing periodontal disease?

  1. HardekopfJ, et al. The “furcation arrow” – A reliable radiographic image? J Periodontol. 58:258 – 261, 1986.

  2. DeasDE, Moritz A., Mealey B et al: Clinical reliability of the furcation arrow as a diagnositc marker. J Periodontol 2006;77;1436-1441

  3. OrtmanL, McHenry K, Hausmann E: Relationship between alveolar bone measured by 1251 absorptiometry with abalsysis of standardized radiographs: 2. Bjorn technique: J Periodntol 1982;53:311-314

  4. BuchananSA, et al: Radiographic detection of dental calculus. J Periodontol. 58:747-751, 1987.

What alveolar crest level represents bone loss on a bitewing radiograph??

  1. HausmanE., Allen K., Clerehugh V. What alveolar crest level on a bite wing radiograph represents bone loss? J Periodontol 1991;62;570-572

Are digital radiographs equivalent to conventional radiographs in revealing bone loss?

  1. KhochtA, Janal M, Harasty L, Chang K: Comparison of direct digital and conventioanl intraoral radiographs in detecting alveolar bone loss. J Am Dent Assoc 2003;134;1468-1475

  2. BruderG, Casale J, Goren, A, Friedman S; Alteration of computer dental radiography images J Endod 1999;25;275-276

Are panoramic radiographs ever of value in periodontics?

  1. KasajA, Vasiliu Ch, Willershausen B. Assessment of alveolar bone loss and angular bony defects on panoramic radiographs. Eur J Med Res. 2008 Jan 23;13(1):26-30.

  2. PerssonRE, Tzannetou S, Feloutzis AG, Brägger U, Persson GR, Lang NP. Comparison between panoramic and intra-oral radiographs for the assessment of alveolar bone levels in a periodontal maintenance population. J Clin Periodontol. 2003 Sep;30(9):833-9.

When should cone beam computed tomography (CBCT) be used?

  1. The American Dental Association Council on Scientific Affairs. The use of cone beam computed tomography in dentistry: An advisory statement from the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2012;143;899-902

  2. MischKA, Yi ES, Sarment DP: Accuracy of cone beam computed tomography for periodontal defect measurements.. J Periodontol. 2006 Jul;77(7):1261-6.

  3. VandenbergheB, Jacobs R, Yang J. Detection of periodontal bone loss using digital intraoral and cone beam computed tomography images: an in vitro assessment of bony and/or infrabony defects. Dentomaxillofac Radiol. 2008 Jul;37(5):252-60.

What if the significance of the lamina dura?

  1. TibbettsJ, Allen K, Hausmann E: Effect of x-ray angulation on radiographic periodontal ligament space width. J Periodontol 63: 114-117, 1992

  2. GreensteinG, Polson A, et al: Associations between crestal lamina dura and periodontal status. J. Periodontol. 52:362-366, 1981.

Can radiographs be used to detect progression of periodontitis?

  1. SelikowitzH-S, et al: Retrospective longitudinal study of the rate of alveolar bone loss in humans using bite-wing radiographs. J. Clin. Periodontol. 8:431-438,1981.

Are radiographs an accurate way to assess healing after periodontal surgery?   Do newer radiographic techniques improve the usefulness of radiographs?

  1. TobackGA, Brunsvold MA, et al. The accuracy of radiographic methods in assessing the outcome of periodontal regenerative therapy. J Periodont 70:1479-1489,1999.

  2. ZybutzM, Rapoport D, Laurell L, Persson GR. Comparisons of clinical and radiographicmeasurements of inter-proximal vertical defects before and 1 year after surgical treatments. J Clin Periodontol 27:179-186, 2000.

  3. GrimardBA, Hoidal MJ, Mills MP, Mellonig JT, Nummikoski PV, Mealey BL. Comparison of clinical, periapical radiograph, and cone-beam volume tomography measurement techniques for assessing bone level changes following regenerative periodontal therapy. J Periodontol. 2009 Jan;80(1):48-55.

  4. GorenAD, Dunn SM, Wolff M, van der Stelt PF, Colosi DC, Golub LM. Pilot study: digital subtraction radiography as a tool to assess alveolar bone changes in periodontitis patients under treatment with subantimicrobial doses of doxycycline. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; Oct;106(4):e40-5. Epub 2008 Aug 20.

How do Radiographic Measurements Compare to Clinical Examination Measurements?

  1. PapapanouPN, Wennstrom JL: Radiographic and clinical assessments of destructive periodontal disease. J Clin Periodontol.16:609-612, 1989.

  2. MachteiEE, Hausmann E, Grossi SG, Dunford R, Genco RJ. The relationship and clinical changes in the periodontium. J Perio Res 32:661-666, 1997.

  3. EickholzP, Hausmann E. Accuracy of radiographic assessment of interproximal bone loss in intrabony defects using linear measurements. Euro J Oral Sci 108:70-73, 2000.

  4. PilgramTK, Hildebolt CF, et al. Relationships between radiographic alveolar bone height and probing attachment level: data from healthy post-menopausal women. J Clin Perio 27:341-346, 2000.

Comparison of Techniques

  1. ReedBE, Polson AM : Relationships between bitewing and periapical radiographs in assessing crestal alveolar bone levels. J. Periodontol. 55:22-27, 1984.

Reviews

  1. BennDK. A review of the reliability of radiographic measurements in estimating alveolar bone changes. J. Clin. Periodontol. 17:14-21, 1990. (Review)

  2. JeffcoatMK. Radiographic methods for the detection of progressive alveolar bone loss. J Periodontol 63: (Suppl 4) 367-372, 1992. (Review)

  3. TugnaitA, Clerehugh V, Hirschmann PN. The usefulness of radiographs in diagnosis and management of periodontal diseases: a review. J Dent 28:219-226, 2000. (Review)

  4. KimIH, Mupparapu M.Dental radiographic guidelines: a review.Quintessence Int. 2009 May;40(5):389-98. Review

Are Radiographs an accurate method of diagnosing periodontal disease?

Topic:Furcation Arrow

Authors:Hardekopf J, et al.                               ARTICLE

Title:The “furcation arrow” – A reliable radiographic image?

Source:J.Periodontol.58:258-261,1986.
Type: Clinical study

Rating: Good

Keywords:Furcation Arrow, Radiograph

Furcation Arrow:Small triangular shadow across the mesial or distal roots of maxillary molars. Indicates class II or class III involvement.

P: To determine whether there is a consistent relationship between furcation arrows on radiographs and proximal bony furcation involvement in maxillary molars.

M&M: 45 adult human skulls with proximal furcation involvement in maxillary 1st or 2nd molars were used. 66 Degree 1, 53 Degree 2, 43 Degree 3 proximal furcation involvements. An additional 120 proximal furcations without bony involvement served as controls. Furcation classifications were determined independently by two examiners. Each maxillary molar was radiographed radiographed. Film placement was standardized to minimize interproximal overlap and to position the film lingually/palatally on a plane that paralleled the buccal surfaces of the teeth radiographed. Evaluations for the presence of the furcation arrow were made independently by 6 dentists as the radiographs were projected onto a screen. Projected radiographs with identifiable “arrow” images were used.

R: Incidence of furcation arrow image over degree 2 and 3 involvements was significantly greater than that observed over the uninvolved controls. The incidence of the furcation arrow image over the 120 uninvolved proximal furcations was low (18% for mesial and 7% for distal furcations). There was NSD between degree 1 involvement and the controls in the incidence of the furcation arrow image. There was an equal number of furcation arrows observed over mesial and distal furcations. The existence of a buccal furcation involvement of any degree did not influence the appearance of the furcation arrow. The image was no more likely to be observed over Degree 3 involvement than over Degree 2 involvement.

D: As the extent of furcation involvement increased, so did furcation arrow image.  Degree 3 involvement reflected the radiographic image > 50% of the time. The furcation arrow seldom appears over uninvolved furcations, its appearance indicates that there is proximal bony furcation involvement. Absence of arrow does not indicate the absence of a bony furcation involvement.  Root morphology and horizontal angulation of the tube head may be factors in determining whether a given furcation defect will exhibit an arrow.    

BL: The radiographic presence of the furcation arrow appears to be a reliable diagnostic tool for the clinician when evaluating bony furcation involvement.

Topic:Furcations

Authors: Deas DE, Moritz A., Mealey B                               NO ARTICLE

Title:Clinical reliability of the furcation arrow as a diagnositc marker.

Source: J Periodontol 2006;77;1436-1441

Type:Clinical study

Rating: Good

Keywords:Furcation involvement, periapical, bitewings

B:Traditionally, radiographic assessment in conjunction with clinical probing using a curved explorer or furcation probe has been the chief diagnostic methods used for detecting and characterizing furcation involvement.

P:To evaluate the furcation arrow in a clinical setting, with emphasis on testing the assertion that the radiographic presence of a furcation arrow reliably identifies a furcation invasion.

Questions answered: 1. What is the prevalence of furcation arrow images in the radiographs of maxillary molars with periodontitis? 2. What is the interexaminer agreement on what constitutes a furcation arrow? 3. How does the presence or absence of a furcation arrow correlate with the true clinical status of the furcation? 4. What is the sensitivity and specificity of the furcation arrow as a diagnostic indicator?

M&M:89 patients were referred between February 2004-June 2005 for treatment of moderate to advanced periodontitis that required surgical access to at least one maxillary posterior sextant. Before surgery, one of five calibrated examiners viewed PA and BW radiographs of the surgical site and recorded the presence or absence of a furcation arrow at each proximal furcation. Before administering anesthesia, the same examiner recorded a Hamp index value of each proximal furcation. After flap reflection and debridement, the examiner recorded a second Hamp index at each proximal furcation. After surgery, each of the four remaining examiners independently reviewed the radiographs for furcation arrows. Descriptive statistical analysis was performed to correlate the appearance of the furcation arrow image to the actual degree of furcation invasion as determined by the intrasurgical Hamp index.

R:

  • 164 maxillary molars were examined, providing 328 interproximal furcations

  • 111/328 (33.8%) furcations were determined at surgical debridement to have a furcation invasion of Hamp degree of 1 or greater.

  • When comparing the appearance of the radiographic image to the extent of furcation invasion, 20/64 (31.3%) Hamp 1 furcation invasions and23/47 (48.9%) Hamp 2 and 3 furcation invasions were predicted by furcation arrows observed by at least three of five examiners.

  • The multirater k statistic for interexaminer agreement on the presence or absence of the image was 0.489 (low)

  • The sensitivity of the furcation arrow image as a diagnostic marker was 38.7%, and the specificity was 92.2%  Most actual furcation invasions were not associated with a furcation arrow: a high number of false negatives. The absence of a furcation arrow had a much higher likelihood of not having an accompanying furcation invasion present: a low number of false positives.

  • The positive predictive value of the image was 71.7%, and the negative predictive value was 74.6%.

  • Of the 324 furcations used to compare clinical indices, the agreement of pre-anesthesia and post-debridement Hamp indices was 0% for degree 3, 83.7% for degree 2, and 98.4% for degree 1 furcation lesions.

C:Clinical probing, post-anesthetic sounding and surgical access provide more diagnostic data about furcations than the radiographs to the clinicians. The image is difficult to interpret and highly subjective and can correctly predict furcation invasions only 70% of the time when present on the radiograph. In addition, when furcation invasions are truly present, the furcation arrow is seen in <40% of sites.

Topic:standardized radiographs

Authors: Ortman L, McHenry K, Hausmann E                              NO ARTICLE

Title:Relationship between alveolar bone measured by 1251 absorptiometry with analysis of standardized radiographs: 2. Bjorn technique

Source:J Periodntol 1982;53:311-314

Type:Skull study

Rating:Fair

Keywords:standardized radiographs, Bjorn technique

B:Bjorn developed a bone scoring technique using the projected 5x magnification of periapical radiographs on a scale which divides the tooth into 5% portions.

P:To compare the Bjorn and Henrikson (125I absorptiometry) techniques in their ability to detect small bone changes.

Omnell demonstrated that established principles of radiation absorptiometry permitted measurement of alveolar bone mineral mass. Henrikson applied these principles to development of an 125I absorptiometry technique capable of detecting alveolar bone mass changes on the order of 5%. The technique utilizes an essentially monoenergetic radiation beam, a collimating device and a scintillation counter for directly determining the amount of absorbed radiation.

M&M: 4 periodontal defects were created in dried human skulls between 1stand 2nd PM and 1st M of differing sizes, with incremental reduction of approximately 10%. The defects were made either by reducing the buccal wall or creating crater like defects and were measured using both of the techniques utilizing stents for standardization.

R:In initial bone loss, the Bjorn technique consistently underestimated the amount. 53% of the bone as measured by 125I absorptiometry needed to be reduced before the Bjorn technique could detect any loss. In advanced bone loss, the Bjorn technique was shown to overestimate the amount of loss in 2 of the sites and underestimate in the two other sites.

Conclusion:When bone loss is under 30%, the Bjorn technique tends to underestimate how much true loss has occurred and when over 60%, it is inconsistent.

Topic:Radiography

Authors: Buchanan SA, et al                               ARTICLE

Title:Radiographic detection of dental calculus.

Source:J Periodontol. 58:747-751, 1987

Type:Clinical

Rating: Good

Keywords:calculus, radiographs, sensitivity, specificity.

P:To quantify the sensitivity, specificity and observer error associated with radiographic detection of dental calculus on proximal surfaces of teeth in patients with severe periodontitis.

M&M:18 patients that required extraction of at least 3 teeth because of severe periodontitis participated in the study. Excessively rotated or malpositioned teeth were not included in the study. Radiographic presence of calculus was determined by two examiners. After tooth extractions teeth were prepared and examined microscopically for calculus.

R:275 proximal tooth surfaces and the corresponding radiographs were available for evaluation. Mean AL was 5.8mm.

Of the 153 surfaces with calculus noted visually, radiographically calculus was detected 43.8% (false negative 56.2%), (low sensitivity).

Of the 73 surfaces with calculus present radiographically, 91.8% were determined calculus present clinically.

Of the 160 surfaces assessed radiographically as calculus absent, 46.3% were verified by visual examination to have no calculus.

Radiographic evaluation of calculus was not an effective diagnostic method in most surfaces with thin or moderate deposits.

C:Conventional radiographs are a poor diagnostic method for detection of calculus. Radiographic analysis predicted calculus on less than half of the proximal surfaces where deposits were present visually.

Whatalveolar crest level represents bone loss on a bitewing radiograph??

Topic:Radiographic measurement of bone

Author: Hausman E., Allen K., Clerehugh V.                                ARTICLE

Title: What alveolar crest level on a bite wing radiograph represents bone loss?

Source: J Periodontol 1991;62;570-572

Type:RCT

Rating:Good

Keywords:bone level, radiographic interpretation

P: Compute the distance from the CEJ to the alveolar crest on radiographs at sites where there was no clinical loss of attachment.

M&M:

  • Bitewing radiographs were taken on 68 pts (13-14 years old). A second set of radiographs were taken 18 months later.

  • The radiographs were taken using a routine unstandardized clinical technique and were processed under standardized conditions using a Refrema processing machine.

  • At each radiographic examination probing attachment level measurements were made at the mesio-buccal surfaces of the first molar teeth. Only the sites with zero attachment loss (attachment at the level of the CEJ) at both baseline and at 18 months were included in this study. A total of 134 sites included in the study.

  • A computer program was developed to measure the CEJ-crest distance (mm) in a line parallel to the long axis of the tooth.

R: The mean radiographic CEJ- alveolar crest distance (mm) for the 134 sites with zero loss of clinical attachment was 1.11 ±0.37 mm. at the initial examination and 1.19 ±0.34 mm at the same sites examined 18 months later . The 95% confidence limits were 0.4 mm to 1.9 mm.

BL: No crestal bone loss is consistent with a range of CEJ- alveolar bone crest distance between 0.4 and 1.9 mm as evidenced on bitewing radiographs.

Are digital radiographs equivalent to conventional radiographs in revealing bone loss?

Topic:Radiographic Interpretation

Authors: Khocht A, Janal M, Harasty L, Chang K:                               ARTICLE

Title: Comparison of direct digital and conventioanl intraoral radiographs in detecting alveolar bone loss.

Source: J Am Dent Assoc 2003;134;1468-1475

Type:Clinical Study

Rating: Good

Keywords:conventional radiographs, digital radiographs

P: To compare direct digital (D) and conventional (C) radiographic estimates of alveolar bone under normal clinical use.

M&M:25 subjects with perio with age range b/w 18-65 years and had full set of PAs and BW for diagnostic purpose and tx planning. All subject had min of 15 teeth without any intraoral pathology or systemic dz. A long cone parallel technique was used to take PAs and a paper sleeve with biting tab was used for BW. Within 4 weeks, a second set PAs and BW was taken with digital system (Shick). The distance from the CEJ (surfaces with non-identifiable CEJs due to restorations or overlapping were excluded) to the interproximal alveolar crest (where the PDL space ends on the root surface) was measured. 3rd molars were excluded. One examiner measured with a plastic ruler on the C x-rays while another examiner measured the D x-rays. Overall % agreement of first and second readings in C x-rays was 99 and it was 92 for the D images. The examiners performed their measurements independently from each other. Each examiner measured the conventional or digital radiographs twice and took two sets of measurements for each subject. The examiners took the second set of measurements without having access to the initial set.

R: Examiner measured 857 PAs and 315 BW image sites match on both radiographic systems.

  • Measurements in the D images for BW averaged about 0.3mm greater bone loss than did C x-rays.

  • For BW, the difference between C x-rays and D was not found in all mouth sextants.

  • Rather,more bone loss was indicated by D x-rays only in the posterior mand region (BW); measures in the posterior maxillary region were similar between the two methods.

  • Measurements from C PA images showed more bone loss in all max sextants.

  • Categorical bone levels (normal<3 mm, early-to-moderate loss 4-6mm and advanced loss>7mm) were assigned to evaluate how each rx method revealed bone level and loss. Agreement between D and C x-rays in revealing bone levels as normal or having early-to-moderate loss was low (D x-rays revealed more early-to-moderate sites).

It seems that digital radiographs impart a constant addition of millimeters to measures taken in the posterior mandibular.

C:  Under normal clinical use and without standardized film positioning, the average bone level measurements varied SS between C and D radiographs in certain regions of the mouth and that the disagreement between these two systems is influenced by the type of image PA or BW as well.

Cr: It is very difficult to take x-rays at the exact same angle with the sensor/film in the exact same place to compare measurements. Also, there may be error in calculating exactly where the CEJ is on the x-ray. The digital sensor is a different size, not flexible, and can be more difficult to position than conventional films. Having the USB cord attached to the digital sensor may interfere with subjects biting down on the BW tabs.

Topic:radiographic alterations

Authors: BruderG, Casale J, Goren, A, Friedman S                               NO ARTICLE

Title:Alteration of computer dental radiography images

Source:J Endod ;25;275-276 DOI: 10.1016/S0099-2399(99)80159-9

Rating: good

Keywords:radiography, distortion, digital images, alterations

P:to determine if digital images could be exported, altered, and then restored without visible signs of alteration

M&M:Images were exported from the computer radiography program, files were altered, then files were restored to the Schick format and printed

D:Digital images are relatively easy to export and alter with the use of a photo editing program. The need to implement technologies to safeguard digital radiography must be addressed to prevent potential abuses.

Are panoramic radiographs ever of value in periodontics?

Topic:Radiographs

Author: Kasaj A., Vasiliu Ch, et al.                               ARTICLE

Title:Assessment of alveolar bone loss and angular bony defects on panoramic radiographs

Source:Eur J Med Res. 2008 Jan 23;13(1):26-30

Type:Prospective study

Rating: Good

Keywords:Panoramic radiographs, angular bony defects, periodontal disease, bone loss

P: To investigate the prevalence and severity of alveolar bone loss and angular bony defects in randomly selected panoramic radiographs.

M&M: 500 panoramic radiographs of adult patients were studied. The mean age of the subjects was 51 years (range 20-80). Panoramic radiographs were placed on an x-ray viewer and evaluated by the same examiner. A calibrated periodontal probe was used to assess horizontal and vertical defects. If the interproximal projection of the CEJ was not identifiable, the apical termination of the restoration or crown margin was used for the measurements. A site was considered as having an angular bony defect if the bottom of the oblique radiolucency was located at least 2mm apical to the most coronal level of the interproximal alveolar bone.

R:

-In majority of subjects (86.7%) had some form of bone loss (horizontal and vertical).

–Angular bony defects were found in 49.8 % of the patients.

-Angular defects were more present in the mandible than in the maxilla, most frequently in the mandibular posterior, and least frequently in the mandibular anterior.

-The mean depth of the angular bony defects was 6.0 mm with the greatest mean depth in the maxillary anterior area (6.8 mm).

-The mean M-D width of the intrabony defects was 2.44 mm, and was most pronounced in maxillary molars (3.1 mm).

-Female subjects exhibited a gradual increase of vertical defect with age whereas in male subjects vertical bone loss was most prevalent in the age group 40-60 years and decreased in the older age group (60% vs. 40%).

-Interradicular molar radiolucencies demonstrated 38.3 % of the subjects and were more frequent in the md (first molar) than mx.

C: This study demonstrated a high prevalence of angular bony defects found on panoramic radiographs suitable for regenerative periodontal treatment.

Topic:Radiography

Authors: Persson RE, Tzannetou S, Feloutzis AG, Brägger U, Persson GR, Lang NP                               NO ARTICLE

Title:Comparison between panoramic and intra-oral radiographs for the assessment of alveolar bone levels in a periodontal maintenance population

Source:J Clin Periodontol. 2003. 30(9):833-9

Type:Clinical study

Rating: Good

Keywords:orthopantomogram; radiographs; alveolar bone level; diagnosis; periodontitis; maintenance population; agreement

P:To assess the level of agreement between intraoral and panoramic radiograph for direct measurements of the distance between the CEJ and the alveolar bone level (BL) as well as the proportional relationship (CEJ-BL/root length) and to explore the symmetry between left and right sided measurements.

M&M: Intraoral (IO) and panoramic (OPG) images were obtained from 292 patients on maintenance therapy. Two examiners performed measurements on digitally processed images. The distance between the CEJ and marginal BL was measured at the mesial and distal aspects of each tooth. The distance between the CEJ and apex of the tooth was also measured. The proportional distance between CEJ and BL relative to the length of the root was calculated.

R:All measurements between the two examiners showed no statistically significant differences. The largest mean proportional difference between CEJ and BL was seen in the maxillary right posterior segment, suggesting advanced periodontal disease in these sites. The largest difference between IO and OPG reading was observed between measurements for the maxillary anterior sextant, while the smallest difference was seen in the mandibular anterior sextant.

C: The study suggests that BL measurements between IO and OPG radiographs are highly comparable. The mean differences observed for the distance CEJ-BL in proportion to root length were neither statistically nor clinically different. A significant degree of symmetry of alveolar bone loss between the left and right side of the dentition was also found.

When should cone beam computed tomography (CBCT) be used?

Topic:CBCT in dentistry

Authors: The American Dental Association Council on Scientific Affairs.                               NO ARTICLE

Title:The use of cone beam computed tomography in dentistry: An advisory statement from the American Dental Association Council on

Scientific Affairs.

Source:J Am Dent Assoc 2012;143;899-902
Type:Discussion

Rating: Good

Keywords:CBCT, ALARA

ADA Council on scientific affairs 2012: The use of CBCT in dentistry

CBCT imaging provides three-dimensional volumetric data construction of dental and associated maxillofacial structures with isotropic resolution and high dimensional accuracy.

A CBCT scanner uses a collimated x-ray source that produces a cone- or pyramid-shaped beam of x- radiation, which makes a single full or partial circular revolution around the patient, producing a sequence of discrete planar projection images using a digital detector. These two-dimensional images are reconstructed into a three-dimensional volume that can be viewed in a variety of ways, including cross-sectional images and volume renderings of the oral anatomy.

Although CBCT units produce a higher radiation dose than one would receive from a single traditional dental radiograph, the radiation dose delivered typically is less than that produced during a medical multichannel computed tomographic scan. CBCT radiation doses also vary widely according to the device used, x-ray energy and filtration, tolerance for image noise and motion artifacts and the size of the imaging area that is used to acquire volumetric data.

Principles for the safe use of dental and maxillofacial CBCT

– Should be used only after review of pt’s health, and imaging history and thorough clinical examination

– Should be used only after professional justification that the potential clinical benefits will outweigh the risks associated with exposure to ionizing radiation

-The clinician should prescribe traditional dental radiographs and CBCT scans only when he or she expects that the diagnostic yield will benefit patient care, enhance patient safety, sig- nificantly improve clinical outcomes or all of these.

-Should be considered as an adjunct to standard oral imaging modalities

– ALARA(As-low-as-reasonably-achievable) principle

– Should take every precaution to reduce radiation dose and ensure the patient’s safety. The use of thyroid collars and lead aprons is recommended when they do not interfere with the examination.

– Regardless of the primary purpose for the selection of CBCT, the complete image data set must be interpreted by a qualified health care provider. The prescribing clinician should receive a thorough radiological report

– Dental practitioners who use CBCT devices must receive appropriate training and education in the safe use of CBCT imaging systems

– Facilities using CBCT systems should consult a health physicist to perform equipment performance and compliance evaluations initially at installation and then follow a schedule in compliance with local, state and federal requirements

– Staffs of facilities using CBCT should establish a quality control program. This program can be based on the manufacturer’s recommendations

Topic:Radiograph

Authors: Misch KA, Yi ES, Sarment DP:.                                ARTICLE

Title: Accuracy of cone beam computed tomography for periodontal defect measurements.

Source: J Periodontol. 2006 Jul;77(7):1261-6.

Type: Clinical study

Rating: Good

Keywords:Periodontal defect, CBCT

P:To compare linear measurements of periodontal defects using CBCT to traditional methods.

M&M: 2 human dry cadaver skulls with existing horizontal bone loss up to 20% were examined. Infrabony buccal, lingual, and interproximal defects with varying width and height were created with a bur in mandibular molar and premolar regions. Grooves were also placed vertically into the roots from the CEJ to the depth of defect. Gutta percha cones were superglued into the grooves. CBCT (i-cat) and PA radiographs were taken.

Measurements were taken from A) CEJ-depth of pocket, B) CEJ to alveolar crest, C) width of the defect. Impressions of the defects were taken, and all measurements were compared to electronic caliper measurements. The accuracy of impression and caliper measurements were verified using another set of defects with known height and width prepared in cast acrylic blocks. Statistical analysis was done.

R:

All infrabony defects were detected using CBCT and the probe.

Average correlation was 0.4 for direct, 0.53 for PA, 0.62 for CBCT and 0.95 for impressions.

Correlation varied b/w 0.09 and 0.99 within examiners.

NSSD between all the methods for CEJ-depth of pocket, detection of isolated IP defects, and for buccal and lingual defects.

C: CBCT measurements compared well to traditional methods, with the advantage of allowing observation of defects in all directions. Further investigation is needed.

Topic:CBCT vs intraoral radiographs

Authors:Vandenberghe B, Jacobs R, Yang J.                               ARTICLE

Title:Detection of periodontal bone loss using digital intraoral and cone beam computed tomography images: an in vitro assessment of bony and/or infrabony defects.

Source:Dentomaxillofac Radiol. 2008 Jul;37(5):252-60.

Type:Skull study

Rating:Good

Keywords:periodontium, crater, furcation involvement, intraoral radiography, cone beam computed tomography

P: To determine the diagnostic values of digital intraoral radiographs and cone beam CT (CBCT) in the determining bone loss, infrabony defects, and furcation involvement.
M&M: A cadaver head with upper and lower jaws fixed with 10% formalin and a dry skull covered with a soft tissue substitute were used to measure 71 selected periodontal defects. To assess bone levels, the CEJ was used as a reference point for the fixed jaws, and gutta-percha fixated onto the buccal and lingual of teeth for the dry skulls. Intraoral radiographs were obtained with standardized bite blocks. CBCT was obtained with I-CAT. For the CBCT the observation were made on a 5.2 mm panoramic reconstruction view and on .4mm thick cross-sectional slices. First part of the study: 43 randomly selected sites with linear or vertical defects were chosen for radiographic and CBCT assessment of the bone loss and compared to the actual measurements. Second part of the study, 11 teeth containing vertical defects or furcation involvement was compared to actual measurements. The defects were categorized by 1, 2, 3 and 4 walls and the furcations by class 1, 2,3. Readings were performed by 3 examiners a medical imaging master and PhD student, and two radiology faculty members.

R: No intra- or interobserver effect was found. No significant differences were found when comparing the radiographs with those on the panoramic reconstruction image of the CBCT. The mean error for bone level measurements was 0.56 mm for radiographs, 0.47 mm for the CBCT panoramic view and 0.29 mm for the .4mm thick cross-sectional slices.SSD between the cross sectional slices and the radiographs. The detection of crater and furcation failed 29% and 44% with radiographs, and 0% with CBCT.

C: CBCT allowed more accurate assessment of periodontal bone loss.

What if the significance of the lamina dura?

Topic:Lamina Dura

Authors: Tibbetts J, Allen K, Hausmann E                               ARTICLE

Title:Effect of x-ray angulation on radiographic periodontal ligament space width

Source:J Periodontol 63: 114-117, 1992

Type:Clinical

Rating: Good

Keywords:Periodontal ligament/anatomy and histology; periodontal ligament/radiography.

P:To determine the influence of known changes in x-ray beam angulation anticipated under clinical conditions on the change in radiographic ligament space width. Radiographs of molars and incisors were studied to determine the influence of anatomical factors on changes associated with alteration in x-ray beam angulation

M&M:Pairs of radiographs were taken of incisor and molar locations in whole dried human skulls with known differences in x-ray beam angulation. To be acceptable, radiographs had to meet the following requirements: 1) no overlaps of contact areas of adjacent teeth, 2) visible interdental alveolar bone, 3) no cone-cut in the radiograph, 4) sufficient contrast to read any anatomic structures present. Baseline for vertical angulation was set perpendicular of the long axis of the tooth. For each tooth site, radiographs were taken at 2 vertical angulations: 1) perpendicular to tooth’s buccal surface 0° and 2) 10° off the perpendicular. 5 different horizontal angulations at each of the 2 indicated vertical angulations 1) baseline 0°, 2) -3° and -6° from the perpendicular, 3) +3° and +6° from the perpendicular. Replicate radiographs were taken at 0° and at each of the 2 vertical angulations. The radiographs were converted to digitized images and PDL width measurements were made utilizing a computer program. Data were analyzed separately for the incisor and molar sites.

R:The variation between the mean difference of baseline measurements was compared with that of discrepant-angle combinations, 10/20 pairs of radiographs which differed in horizontal angle only were significantly different from results of baseline replicates. 2/5 groups of pairs of radiographs which differed in vertical angle only were significantly different from results of baseline replicates. 11/20 groups of pairs of radiographs which differed in both vertical and horizontal angulation were significantly different from results of baseline replicates. Mean PDL width differences for incisor locations were SS from the mean baseline PDL width difference, posterior PDL width difference showed no statistical variation from the mean baseline width difference

C:Changes in x-ray angulation resulted in a SS change in radiographic PDL width at incisor locations, no such significant effect was found at molar locations. At molar area, thick bone overlying PDL will tend to reduce the difference in density seen on the radiograph of the ligament space and adjacent interproximal bone. It is suggested the radiographs should be taken with controlled projection geometry when clinical interpretation of change in PDL width is desired.

Topic:Lamina dura

Author:Greenstein G, Polson A, et al                              ARTICLE

Title:Associations between crestal lamina dura and periodontal status.

Source: J. Periodontol. 52:362-366, 1981.

Type:RCT

Rating:Good

Keywords:lamina dura, radiographic diagnosis, bitewing radiographs

P:To investigate the association between the radiographic presence of crestal lamina dura and the clinical periodontal status of the corresponding interdental area.

M&M:

  • 90 pts (53F, 37M; 21-45 years old) had 4 interproximal locations evaluated.

  • Sites were scored for visual inflammation, BOP, presence of PD> 3mm, and loss of attachment.

  • Bitewings and full mouthseries radiographs taken.

  • The radiographs were examined and scored for the presence or absence on an intact crestal lamina dura.

R:  NSSD correlations were obtained between PA radiographs, presence of lamina dura and inflammation, PD, or attachment loss. On bitewings, there was a SSD between presence of crestal lamina dura and inflammation (81.9%) versus absence of crestal lamina dura and inflammation (72.5%).No SSD with the other parameters and bitewings. However, there were significant discrepancies on whether the crestal lamina dura was present (agreed 24% of the time) and agreed 89% of the time when absent.

BL: Radiographically, the crestal lamina dura did not appear to be related to the presence or absence of clinical inflammation, BOP, presence of pockets, or loss of attachment.

Can radiographs be used to detect

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42. Diagnosis / Indices-Gingival Fluid & Saliva

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Gingival Crevicular Fluid – Overview

Is the measurement of gingival fluid easy, repeatable, and dependable?

1. Griffiths, G. Formation, collection and significance of gingival crevice fluid. Periodontl 2000. 2003; 31: 32-42

2. Goodson, J. Gingival crevice fluid flow. Periodontol 2000. 2003; 31:43-54

3. Delima, A, Van Dyke, T. Origin and function of the cellualr componenents in gingival crevice fluid. Peridontol 2000. 2003; 31: 55-76

4. Uitto V., Overall, C, McCulloch, C. Proteolytic host cell enzymes in gingvial crevice fluid. Periodontol 2000. 2003; 31:77-104

5. Eley, G., Cox, S. Proteolytic an hydrolytic enzymes from putative periodotal pathogens: characterization, molecular genetics, effects on host defecses and tissues and detection in gingival crevice fluid. Periodotol 2000. 2003; 31:105-24

Gingival Crevicular Fluid

Discuss the composition of gingival fluid.   What is the diagnostic significance of increased amounts of gingival fluid?

6. Orban, J, Stallard, R: Gingival crevicular fluid: A reliable predictor of gingvial health: J Periododontol 40:231-235, 1969

7. Hancock, E et al: The relationship between gingival crevicular fluid and gingival inflammation. A Clinical and histologic study. J Periodontol 50: 13-19, 1979

8. Offenbacher, S et al: The use of crevicular fluid prostaglandidn E2 levels as a predictor of periodontal attachment loss. J Periodont Res 21:101, 1986

9. Lamster, I et al: Development of a risk profile for periodontal disease: Microbial and host response factors. J Periodontol 65:511-520, 1994

10. Giannopoulou, C., Kamma J., Mombelli, A. Effect of inflammation, smoking and stress on gingival crevicular fluid cytokine level. J Clinical Periodontol 2003; 30: 145-153

11. Safkan-Sppparla, B., Sorsa, T et al: Collagenases in gingival crevicular fluid in type I diabetes mellitus. J Clin Periodontol 2006; 77:189-194

12. Bostanci N. et al. Ginvial crevicular fluidlevels of RANKL and OPG in periodontal diseases: Implications of the relative ratio. J Clin Periodontol 2007; 34:370-376

Passage of Antibiotics

Which antibiotics are concentrated in the gingival crevicular fluid?

13. Gordon JM, Walker CB, Murphy JC, Goodson JM, Socransky SS. Concentration of tetracycline in human gingival fluid after single doses. J Clin Periodontol8:117-121,1981.

14. Gordon JM, et al. Tetracycline: Levels achievable and in vitro effect on subgingival organisms. Part I. Concentrations in crevicular fluid after repeated doses. J. Periodontol. 52:609, 1981.

15. Pascale D, et al: Concentration of doxycycline in human gingival fluid. J. Clin. Periodontol. 13: 841- , 1986

16. Ciancio S, Mather M, McCullen J : An evaluation of minocycline in patients with periodontal disease. J. Periodontol. 51:530, 1980.

17. Britt MR, Pohlod DJ. Serum and crevicular fluid concentrations after a single dose of metronidazole. J. Periodontol. 57:104-107, 1986.

18. Conway TB, Beck FM, Walters JD. Gingival fluid ciprofloxacin levels at healthy and inflammed human periodontal sites. J Periodontol71:1448-1452, 2000.

Indicators of Disease Activity

Can gingival fluid contents be used to determine severity of periodontal conditions or disease activity?

19. Leibur E, Tuhkanen A, Pintson U, Soder P-O. Prostaglandin E2 levels in blood plasma and in crevicular fluid of advanced periodontitis patients before and after surgical therapy. Oral Diseases5:223-228, 1999.

20. Lamster IB, Oshrain RL, Harper DS, et al : Enzyme activity in crevicular fluid for detection and prediction of clinical attachment loss in patients with chronic adult periodontitis. Six month results. J. Periodontol. 59: 516-523, 1988.

21. Bader HI, Boyd RL. Long-term monitoring of adult periodontitis patients in supportive therapy: Correlation of gingival crevicular fluid proteases with probing attachment loss. J Clin Perio26:99-105,1999.

22. Lamster IB, Ahlo JK. Analysis of gingival crevicular fluid as applied to the diagnosis of oral and systemic diseases. Ann N Y Acad Sci. 1098:216-29, 2007. Review

Saliva

How does saliva play a role in a patient’s susceptibility or resistance to periodontal disease ?

23. Giannobile WV. Salivary diagnostics for periodontal diseases.J Am Dent Assoc. 2012 Oct;143(10 Suppl):6S-11S. Review.

25. Guentsch A, Preshaw PM, Bremer-Streck S, Klinger G, Glockmann E, Sigusch BW. Lipid peroxidation and antioxidant activity in saliva of periodontitis patients: effect of smoking and periodontal treatment. Clin Oral Investig. 12(4):345-52, 2008. Epub 2008 May 29.

26. Reher VG, Zenóbio EG, Costa FO, Reher P, Soares RV. Nitric oxide levels in saliva increase with severity of chronic periodontitis. J Oral Sci. 49(4):271-6. 2007

27. Frodge BD, Ebersole JL, Kryscio RJ, Thomas MV, Miller CS. Bone remodeling biomarkers of periodontal disease in saliva. J Periodontol. 79(10):1913-9, 2008.

28. Tobón-Arroyave SI, Jaramillo-González PE, Isaza-Guzmán DM. Correlation between salivary IL-1beta levels and periodontal clinical status. Arch Oral Biol. 53(4):346-52, 2008.

29. Rai B, Kharb S, Jain R, Anand SC. Biomarkers of periodontitis in oral fluids. J Oral Sci. 50(1):53-6, 2008

30. Miller CS, King CP Jr, Langub MC, Kryscio RJ, Thomas MV. Salivary biomarkers of existing periodontal disease: a cross-sectional study. J Am Dent Assoc. 137(3):322-9, 2006.

Gingival Crevicular Fluid – Overview

Is the measurement of gingival fluid easy, repeatable, and dependable?

Topic:Gingival crevicular fluid (GCF)

Authors:Griffiths, G.                                                           ARTICLE

Title: collection and significance of gingival crevice fluid.

Source: Periodontl 2000. 2003; 31: 32-42
Type:Discussion

Rating: Good

Keywords:gingival crevice fluid

Background:  The exact nature of GCF, its origins and composition has been subject of controversy.  The principle questions that remain unanswered are whether GCF is a transudate or an exudate, and whether GCF can form in a clinically healthy site.  The answers to these questions could yield therapeutic approaches.  An increase in GCF flow may have physical protective effects through flushing the pocket, as well as facilitating the passage of immunoglobulins.

Purpose:  To discuss the formation, collection, and significance of GCF.

Discussion: How is GCF formed?

  • GCF is a result of an increase in the permeability of the vessels underlying junctional and sulcular epithelium.  Some irritation (chemical or mechanical) is necessary to induce production of GCF, and should therefore be considered a pathological phenomenon, but this stimulation is important for the maintenance of gingival health (e.g. transporting antibiotics, flushing effect). 

  • GCF is an important component of the protective mechanisms of the crevicular regions due to its flushing effect which is capable of removing carbon particles and bacteria introduced into the gingival crevice.

  • GCF may have an important role in transporting antibacterial substances to the gingival crevice.

Is GCF a transudate of interstitial fluid?

Controversy exists whereas GCF is a transudate or inflammatory exudate.

  • Studies by Brill and Egelbergsupport that production of GCF was primarily a result of an increase in the permeability of the vessels underlying junctional and sulcular epithelium.

  • An alternative theory arose from Alfano and Pashleysupporting that the initial fluid produced could simply represent interstitial fluid which appears in the crevice as a result of an osmotic gradient. This initial, pre-inflammatory fluid was considered to be atransudate, and, on stimulation, this changed to become an inflammatory exudate.

Collection Methods:

Several techniques have been employed and the technique chosen will depend upon the objectives of the study as each technique has advantages and disadvantages. Three basic categories:

  1. Gingival washing: the gingival crevice is perfused by isotonic solution. The fluid collected represents a dilution of crevicular fluid and contain both cells and soluble constituents such as plasma proteins. This technique is valuable for harvesting cells from the gingival crevice region. Major disadvantage is that all fluid may not be recovered and accurate quantification of GCF volume or composition is not possible.

  2. Capillary tubing and micropipettes: following isolation and drying of the site capillary tubes are inserted into the entrance of the gingival crevice. GCF from the crevice migrates into the tube and because the internal diameter is known the volume of the fluid collected can be accurately determined by measuring the distance which the GCF has migrated. However, it is difficult to collect an adequate volume of GCF in a short period unless the sites are inflamed and contain large quantities of GCF. It is difficult to conceive that holding a capillary tube at the entrance to the gingival crevice for long time ensures an atraumatic collection. Also, it is difficult to remove the complete sample from the tubing.

  3. Absorbent filter paper strips: quick and easy to use. Can be applied to individual sites and is possibly the least traumatic.

Methods of collection can be broadly divided into intracrevicular and extracrevicular techniques. The former depends on the strip being inserted into the gingival crevice, whereas in the latter the strips are overlaid on the gingival crevice region in an attempt to minimize trauma. The intracrevicular methodis the method used most frequently and can be further subdivided depending upon whether the strip is inserted just at the entrance of the crevice or periodontal pocket or whether the strip is inserted to the base of the pocket or until minimum resistance is felt.

(a) extracrevicular method; (b) intracrevicular method ‘superficial’ (c) intracrevicular method ‘deep’

  • Collection and quantification of GCF is a very sensitive procedure and all techniques have limitations and flaws (contamination, inconsistent sampling times, volume determination, recovery from strips). 

  • The method of collecting GCF may have a significant effect upon the nature collected and will therefore prejudice results assessing diagnostic markers

Association of GCF with health or disease: The association of an increased volume of GCF with an increase in the severity of inflammation is well supported by evidence from literature.

Topic:Gingival crevicular fluid

Authors:Goodson, J                                                          ARTICLE

Title:Gingival crevice fluid flow

Source:J. Periodontol 2000. 2003; 31:43-54

Type:Discussion article

Rating: Good

Keywords:Gingival fluid

Purpose: To focus attention on the importance of GCF flow and the effect that small streams of fluid flowing out of the periodontal pocket have on the periodontal environment.

Discussion:

GCF flow(or flow rate): is the process of fluid moving into and out of the gingival crevice or pocket.

Fluid flow:is a rate measure of the volume that crosses a defined boundary over a given time.

Resting volumeis the amount of fluid within a given space.

3 Methods of Measurementare available to differentiate fluid flow from the resting GCF volume.

Method 1: Samples are collected(w/ filter paper strips) rapidlyunder strict timing protocol so that the resting volume is removed by the first sampleand the volume of the newly formed GCF can be measured in subsequent samples. The key to this measurement is to select a sampling time that is small enough so that the resting volume of the pocket is not allowed to re-establish. Ideally, one would remove the entire contents of the pocket with the first sample so that all subsequent samples would be repetitive estimates of the GCF volume flow over the sampling time.

Method 2: Collect samples(w/ filter paper strips) after equilibrium has been re-established in the pocket over several different time intervals. In this case, each GCF sample includes both the resting volume (Vr) and the volume of GCF that entered the pocket over the sampling period lends itself directly to linear regression analysis in which the volume and time of each sample contribute to the analysis to determine the slope which is the GCF influx (fi) and the intercept which is the resting volume of the pocket (Vr).

Method 3: Measure the equilibrium concentration of a marker substance pumped into a pocket at a constant rate. By pumping a marker substance (ie Tetracycline) into a periodontal pocket at a constant rate, an equilibrium concentration will be established which is the result of the fluid flow rate and the pump delivery rate. To date, no published study has been conducted to evaluate GCF flow in this manner.

Lamster et al:

Described changes in GCF sample volumes taken during experimental gingivitis that are directly amenable to analysis by method 1. In the GCF sampling protocol of this study, a filter paper strip was placed in the sulcus for 30s and removed for volume determination (V1). Thirty seconds was allowed to elapse and the GCF volume was determined by introducing a second filter paper strip into the site for 3s (V2). The results of this study clearly indicated that the two sample volumes collected increased linearly over the period of development of experimental gingivitis. The GCF flow increases as inflammation becomes more severe and vascular permeability increases.

  • Studies showthat GCF flow as an outcome variable for therapy studies does not have the statistical power of either pocket depth reduction or attachment level gain.

One site from each of 56 systemically healthy subjects with periodontal disease was assigned to each clinical category (Health, gingivitis, mod Periodontitis and advanced periodontitis). The data indicate that broadly defined categories of health and disease can be distinguished by differences in GCF flow.

  • By this analysis, the GCF flow at healthy sites was significantly less than all other categories.

  • The GCF flow at sites with gingivitis was significantly less than the GCFflow at advanced periodontitis sites.

  • Thedifference between the GCF flow at gingivitis sites and sites with moderate periodontitis was not statistically significant.

Conclusion:Given the evidence that change in GCF flow may be a sensitive measure of local inflammation, this type of evaluation could increase the diagnostic potential of this measure being used chair-side. GCF flow measurement could provide added benefit in establishing a diagnosis and monitoring the response to therapy.

Topic:Gingival crevicular fluid

Authors:Delima, A, Van Dyke, T.                                                          ARTICLE

Title:Origin and function of the cellualr componenents in gingival crevice fluid.

Source:Peridontol 2000. 2003; 31: 55-76

Type:Discussion/Review

Rating:Good

Keywords:gingival crevicular fluid

Purpose:To review the origin and function of the cellular components in gingival crevicular fluid

Discussion:Periodontitis is initiated by bacterial colonization, followed by proliferation, and extension of the plaque into the subgingival environment. While diseases of the periodontium are bacterial in origin, the extent and severity of the disease depend upon the interaction between pathologic microbes and host response. The outflow of GCF helps to cleanse the dentogingival space of non-adherent microbes and to reduce the concentrations of toxins and byproducts. GCF contains microbes and antimicrobial compounds and enzymes directed at them. We often think about the flushing mechanism of GCF, but it also serves as an entry point to bacteria. One of the initial responses of the host to bacterial plaque is an increase in the vascular permeability of the subepithelial blood vessels. This leads to edema in the gingival crevice (via the JE) and results in increased crevicular fluid flow. Since this exudate is essentially a growth medium that supports host cells and tissues, the GCF can also act as an excellent source of nutrients for subgingival microbes and may actually contain factors that are necessary for the proliferation of some pathologic bacterial species.

The GCF is rich in cellular elements and also delivers antibodies and the complement system to fight the plaque front. The epithelia of the sulcus are constantly renewing and this rapid turnover appears to aid in the clearance of bacteria that adhere to these cells. One major set of cells found here are the PMN’s – these are the major cellular defense system in the gingival crevice. These cells leave the connective tissue and migrate through the JE into the crevicular space where they accumulate at the interface of the subgingival plaque. PMN’s compromise about 90% of the cells in the GCF, and their defense mechanism includes phagocytosis and release of bactericidal enzymes. It also has been shown that the release of granules from PMN’s that are capable of disengaging bacterial plaque adherence to the tooth. Other cells present in the GCF include monocytes and macrophages. These are usually seen against the oral epithelium, and they function in the cellular defense and acquired immunity of the periodontal tissues.

Conclusion:The nature and extent of bacterial challenge is modulated and attenuated by the host immune response. Inflammatory and immune responses can also contribute to the destruction of host tissues. The narrow balance between periodontal homeostasis and disease depends upon a qualitatively and quantitatively appropriate response of the host defense mechanism to infection of the periodontal tissue. The outflow of GCF helps to cleanse the dentogingival space of non-adherent microbes and to reduce the concentrations of toxins and metabolic byproducts. Constant cellular turnover and the presence of PMNs help to aid in the clearance and protection of the sulcus. Understanding the components of GCF will help to clarify the initial events in the pathogenesis of periodontal disease and aid in the monitoring of the disease process.

Cell Type

Source

Function

Bacteria

Adjacent plaque mass

Etiologic factors of periodontal disease. Initiates the host immune response.

Epithelial cells

Oral sulcular and junctional epithelium

Represents the high turnover rate of the epithelium that comprise the gingival sulcus.

Leukocytes

Gingival plexus of blood vessels

Effector cells of host response. PMNs play a role in innate immunity. Monocytes/macrophages and lymphocytes play roles in cell-mediated immunity.

Erythrocytes

Blood vessels

Incidental finding. Results from damage to the small blood vessels and capillaries of gingival connective tissue.

Topic:GCF

Authors: Uitto V., Overall, C, McCulloch, C                                                          ARTICLE

Title:Proteolytic host cell enzymes in gingvial crevice fluid.

Source:Periodontol 2000. 2003; 31:77-104

Type:Discussion

Rating: Good

Keywords:GCF

Purpose: This is a review of literature on findings on host cell-derived enzymes that relate to periodontal disease processes. Special emphasis is placed on MMPs. The potential use of tissue-derived GCF in enzymes in clinical periodontology is also discussed.

Discussion: Neutrophils form the first line of defense and are attracted to infected tissues by chemoattractants released from bacteria, host cells or degraded tissue. Over 90% of leukocytes in GCF are neutrophils.

They contain vesicles where molecules used for host defense are stored. These granules are generally classified into azurophilic (primary), specific (secondary) and gelatinase (tertiary) types. Gelatinase granules are released first, then specific and lastly the azurophilic. The major MMPs in neutrophils are MMP-8 and -9.

The serine proteinases (neutrophil elastase, cathepsin G and proteinase 3) are secreted from the azurophilic granules during phagocytosis, stimulation and cell lysis. Stimulation by LPS, TNF-and IL-8 results in increased (20-fold) binding of these proteinases with cell membranes. Their actions is inhibited by the serpins. When there is increased population of neutrophils there is increased concentration of active forms of the enzymes in the tissues, causing degradations of extracellular matrix. Elastase and cathepsin G are capable of activating epithelial cells to produce IL-8, IL-6 and prostaglandin E2, which further increase chemotaxis, immune cell proliferation, and tissue degradation in inflamed tissues.

Epithelial cell proteinases: Although epithelial cells were considered as relatively passive cells whose function was to protect body surfaces, it now clear that they strongly respond to exogenous factors and therefore exhibit different morphotypes. When activated they behave aggressively by migrating, proliferating and producing various cytokines and proteolytic enzymes. They were found to produce collagenases (MMP-13, produced by the basal cells of pocket epithelium) when stimulated in vitro by TNF-TGF-or keratinocyte growth factor. MMPs -2, -9, -7 have also been found to being produced by epithelial cells.

Fibroblast proteinases: Fibroblasts are responsible for the turnover of connective tissue in normally functioning tissues and they have therefore the capacity to degrade all the components of CT. The major MMPs produced are 1, 2, 13, 3, 14. It appears that MMP- 1 is secreted in the crevicular fluid of patients with localized juvenile periodontitis, while neutrophil type collagenase MMP-8 is prevalent in adult periodontitis. Expression of MMPs can be regulated by the protein composition of the extracellular matrix and following ligation of integrin receptors.

Matrix metalloproteinases: MMPs form the most important family of proteinases that participate in the normal turnover of periodontal tissues as well as their degradative aspects during periodontal diseases. As MMPs can potentially destroy tissues, their activity is strictly controlled at different levels. First, specific inhibition of MMPs can be mediated by the four members of the tissue inhibitor of metalloproteinase (TIMP) family, proteins that regulate the extracellular activity of MMPs. Second, MMPs are synthesized as latent zymogens. Activation of MMP zymogens is a critical step for regulating MMP activity and hence the composition, structure, and function of periodontal connective tissue matrices. Third, most MMPs are secreted from cells as a soluble proform. For some soluble MMPs, activation occurs at the cell surface following proteolytic cleavage by MT-MMPs, often in a TIMP dependent pathway. For other MMPs, activation occurs in the extracellular environment in an activation cascade initiated by tissue proteinases, such as plasmin, kallikrein, and tryptase, a process that is often amplified by the activated MMPs functioning as pro-MMP activators.

TIMPs:Inhibition of MMPs by TIMPs is largely interchangeable, except for the MT-MMPs, which are not inhibited by TIMP-1. TIMP-2 also plays a paradoxical role in mediating MMP-2 activation.

Detection methods for GCF MMPs: collagenases (MMP-1, -8, 13), gelatinases (MMP-2, -9), and stromelysin (MMP-3) have all been measured in GCF. Immunological assays, including ELISA and immunoblots, offer highly sensitive and specific testing methods. Immunoblots are time consuming, ELISA using antibodies is accurate and significant numbers of anti-MMPs exist on the market. Although these methods of detection are highly specific, they might not be able to distinguish between active and inactive MMPs, since MMPs can still bind the substrate without cleavage. Immunohistochemical examinations can help identify MMPs but without actually quantifying them. Another possible but untried method would be neo-epitope antibodies that can detect degradation fragments from matrix proteins or MMPs, thus help identify, quantify, and determine activity.

Substrate degradation: measure primarily the ability of MMPs to degrade the substrate, estimating enzyme activity depending on the relative abundance of the substrate degradation products by dot assays.sodium dodecyl sulfate–polyacrylamide gel electrophoresis, radioactivity, zymography, or fluorescence. The rationale for examining enzyme activity compared to the presence or abundance of MMPs (measured typically by immunochemical methods) is that in periodontitis the temporal progression of lesions is more strongly associated with the presence of active MMPs than with the total amount of enzyme. Collagen degradation products: measuring collagen metabolites in GCF can help and more directly quantify MMPs activity

GCF enzymes as indicators of periodontal health:it has been shown that PMNs enzymes detected in the GCF reflect the number of leukocytes rather than tissue destructions, so directing our attention to MMP-13 for example rather than MMP-8 (collagenase-2) appears more rational, since MMP-13 (collagenase-3) can also be produced by fibroblasts and pocket epithelial cells during tissue destruction. Neutrophil elastase, and B-Glucuronidase have been extensively studied as well, both are involved in tissue destruction. A simple mouth rinse assay has determined that total crevicular fluid elastase levels were indicated that there was a good correlation between the oral elastase activity and the number of deep pockets and the average CPITN scores. Longitudinal studies have shown the risk ratio of clinical attachment loss in patients with high B-glucuronidase activity in GCF is about 10-fold, this relation is also high when considering progressive sites vs. non progressive. Another test that has been developed is detection of aspartate aminotransferase activity GCF, this test yielded an OR of 12 for attachment loss.

Topic:Host defense

Author:Eley, G., Cox, S.                                                           ARTICLE

Title:Proteolytic and hydrolytic enzymes from putative periodontal pathogens: characterization, molecular genetics, effects on host defenses and tissues and detection in gingival crevice fluid.

Source:Periodontology 2000. 2003; 31:105-24

Type:Discussion article

Rating:Good

Keywords:proteolytic, hydrolytic, enzymatic reactions, host defense, pathogenicity

Purpose:Discussion article that describes the characteristics of proteolytic and hydrolytic enzymes produced by various bacteria, (Pg, Pi, Aa, Fn, Treponema, Eikenella corrodens, and capnocytophaga).

Discussion:

  • All of the bacteria discussed produce both proteolytic and hydrolytic enzymes (degrade non-proteinaceous components of connective tissue). Proteases are more critical to bacterial survival since most of their nutrition is obtained from protein sources. P. gingivalisproduces and releases a greater number of proteases with more protease activity than any other bacteria.

  • The genes encoding for bacterial proteases have been identified for arg-gingipain A and B, lys-gingipain, collagenolytic proteases tripsine and chymotripsine-like protease from T. denticola. These proteases are able to degrade immunoglobulins, clotting factors, proteinase inhibitor and components of host CT. All of these enzymes are released in the GCF.

  • P. gingivalis appears to produce two cysteine proteinases with trypsin-like activity (cleaves BANA). One of these is arginine specific (arg-gingipains A and B) and the other is lysine specific (lys-gingipain), deriving from rgpA, rgpB and kgp genes respectively.

  • These enzymes have collagenolytic activities (Type I and IV) increasing host tissue destruction. RgpA degrades IgA1, IgA2 and IgG, reducing the host response. It also degrades complement component C3 reducing opsonization. RgpA and kgp degrade C5 and release C5a, stimulating inflammation. P.g. inhibits PMN migration and diapedesis by degrading Il-8 and intracellular adhesion molecule 1 (ICAM-1).

  • Furthermore, P.g. cysteine proteinases can degrade the lysozyme that is found in the GCF and saliva.

  • Gingipains activate pre-kallikrein system, leading to bradykinin formation and subsequent vasodilation. This process increase GCF flow, thus increasing the nutrients in the crevice. P.g. also degrades fibrinogen which increases the local clotting time and as a result leads to gingival bleeding. This provides a rich source of haem and iron required by the bacterium for its survival.

  • P.g. also releases hydrolytic enzymes, (hyalouronidase and chondroitinase) which hydrolyze the glycozaminoglycan components of proteoglycans.

  • P.intermedia and P.nigresens, Treponema species, Capnocytophaga species, A.a., F. nucleatum, C. rectus and E.corrodenshave been also shown to have trypsin-like activity, but all is very weak compared to P.g.

  • They have proteolytic activity for various components of the ECM (laminin, gelatin and fibronectin). Their proteases are able to degrade IgG and fibrinogen. F. nucleatum and E.corrodens are the weakest species. Bacterial proteases are released in the GCF and can be detected on filter paper strips. Selective biochemical assays have been developed to detect and distinguish between those proteases. Cross sectional study showed 93.81% positive prediction and 100% negative prediction for arg-gingipains, and 100% negative prediction for dipeptidylpeptidases for all incidence of rapid episodic CAL loss in a 3-month period. All comparisons of mean patient values in patients with or without CAL loss were SS.

BL:GCF arg-gingipain appears to be an excellent predictor and GCF dipeptidylpeptidase is a moderately good predictor of future progressive CAL loss. A chair-side system has been developed to detect these bacterial proteases.

Gingival Crevicular Fluid

Discuss the composition of gingival fluid.

What is the diagnostic significance of increased amounts of gingival fluid?

Topic:Gingival crevicular fluid

Authors:Orban, J, Stallard, R                                                           ARTICLE

Title: Gingival crevicular fluid: A reliable predictor of gingvial health

Source:J Periododontol 40:231-235, 1969

Type:Clinical study

Rating: Good

Keywords: gingival crevicular fluid, hyaluronidase, biopsy

Purpose:  To evaluate the accuracy of GCF as an indicator of gingival inflammation.

Method: Dental school patients were chosen at random and evaluated by using Ramfjord’s criteria for Perio Dx Index (PDI) & Greene & Vermillion’s Oral Hygiene Index-Simplified (OHI-S).  GCF measurements were made using filter strips 1mm wide and several mm long, placed intracrevicularly for 3 minutes, removed and allowed to dry. The area that absorbed crevicular fluid was stained by 2% ninhydrin solution. The area stained was then measured and mean scores were calculated.  Calculus was scored for OHI-S and plaque for Ramfjord’s Index using disclosing tablets.  Biopsies taken from distal half of each area evaluated. Each biopsy was evaluated according to amount and extent of inflammatory infiltrate and scored on a 0-10 scale.

Results:  From the data obtained it was apparent that GCF scores were not directly related to biopsy scores. Thus, crevicular fluid did not prove to be an accurate predictor of gingival inflammation. Plaque scores revealed a high degree of correlation on both an individual and overall evaluation when compared to biopsy scores of inflamed gingiva.

Discussion:Enzymes commonly found in plaque, primarily hyaluronidase, cause an increase in crevicular fluid flow without altering the inflammatory condition of the gingiva. Apparently, the intercellular cementing substance is modified, resulting in an increased permeability of the crevicular epithelium. Other factors including chewing, brushing, gingival massage, circadian rhythm and hormones all affect crevicular fluid flow without necessarily altering the inflammatory condition of the gingival tissues. However, it is a measure of the intactness and permeability of the gingival tissuesdue to previously mentioned factors. Further, as a single measurement on a patient, crevicular fluid recordings may have little significant value. Consecutive measurements, however, are of value in relating the response of the gingival tissues to environmental, physiologic and pathologic conditions and changes.

Conclusion: Dental plaque is a better indicator of the inflammatory status of the gingival tissues than GCF levels.

Topic:gingival fluid

Authors: Hancock EB, Cray RJ, O’Leary TJ.                                                          ARTICLE

Title:The relationship between gingival crevicular fluid and gingival inflammation. A clinical and histologic study.

Source:J Periodontol. 1979Jan;50(1):13-9. DOI: 10.1902/jop.1979.50.1.13

Type:clinical

Rating: good

Keywords:GCF, gingival crevicular fluid, gingival inflammation,

Background:Past research reported that the flow of GCF begins a few days before other clinical signs of inflammation are apparent. Therefore, it is suggested that its flow might be measured to evaluate gingival inflammation.

Purpose: To evaluate the relationship between GI, GCF flow, and histology in order to see if GCF could be an indicator of disease severity in form of gingival inflammation.

Methods: 60 patients (26M, 34F, 18-72 years old); considered themselves in good health without known systemic diseases. No periodontal therapy within the last 90 days. Teeth #5-#12 were examined in each patient and evaluated for selection by the following criteria:

1) Presence of an adequate zone of gingiva, 2) No cervical or interproximal carious lesions. 3) No defective interproximal restorations. 4) No facial cervical restorations. 5) No acute gingivitis or periodontitis condition.

Data was collected on 57 sites; amount of GCF flow, gingival health status, GI, histologic evaluation, and histologic evaluation. After isolation with cotton rolls, GCF collected from mid-facial with filter paper in the opening of the gingival crevice for 3 min. A second sample was taken to verify fluid flow rate. Gingiva at these areas was evaluated for inflammation. GI assessed using modified GI by Löe. One tooth from each patient had gingival biopsy, trying to take equal numbers of healthy and inflamed tissues. Histology looked for inflammatory cell density. Histologic analysis looked at extent of inflammatory infiltrate using a gravimetric method

Results: results show that GCF flow tended to increase as the degree of inflammation became more severe. The quantity of GCF, by itself, was a poor indicator of the severity of gingival inflammation.The highest correlation was seen between GI and the gingival status (mainly BOP based). A high correlation was seen between clinical and histologic scores, but a very weak correlation was seen between GCF and either of these factors.

Conclusion: GCF was weakly correlated with GI and histologic evidence of inflammation; it did, however, tend to increase when inflammation increased.

Topic:Indices

Author: Offenbacher S.                                                          ARTICLE

Title:The use of Crevicular fluid prostaglandin E2 levels as a predictor of periodontal attachment loss

Source:J Periodont Res 21:101, 1986

Type:Longitudinal study

Rating: Good

Keywords:Indices; prostaglandin E2; periodontal disease

Purpose:To report results of a three-year longitudinal study, which demonstrate that crevicular fluid PGE levels can be used to reliably indicate ongoing tissue destruction, and may also be used to predict future acute periodontal attachment loss.

Methods:7 healthy patients, 41 adult periodontitis patients and 12 juvenile periodontitis patients were assessed. All patients had a negative history of major systemic illness. All patients had at least 20 remaining teeth. Data was obtained over a period of 18 months up to 3 years for analysis. CF fluid was collected and clinical measurements (redness, edema, suppuration, BOP, pain on probing, Attach loss) were obtained at baseline and repeated one week later. SRP was performed on all diseased patients. CF collection and clinical measurements were repeated one month following initial therapy. Patients were placed on a three-month recall and CF collection was repeated at each maintenance. When a site demonstrated a statistically significant loss of periodontal attachment, after the data collection (CF and clinical parameters), local curettage and root planning was performed. One month after therapy data was again collected, and then patients were exited from the study and referred to periodontist for additional therapy. During the visit at which AL was identified, 6 consecutive CF samples were obtained at attachment loss site and 6 CF samples at the contralateral control site. Mean CF-PGE level was determined.

Results:The mean CF-PGE2 of the healthy individuals(26.9 ng/mL) was significantly lower than the one of the adult periodontitis patients (56.6± 5.4 ng/mL) and the juvenile periodontitis patients(139.4±15.3 ng/mL). The CF- PGE2 was also elevated at the time of detectable ALcomparing to the cross-sectional adult periodontitis MCF-PGE.

It was observed that CF-PGE levels were increased prior to the development of the acute lesion (immediately preceding the AL episode). There was a high degree of overall and specific agreement between high CF-PGE2 levels and attachment loss. The elevated levels of CF-PGE are highly specific (0.94) and sensitive (0.76) of ongoing AL.

Conclusion: PGE levels in GCF reliably indicate ongoing disease activity and could predict upcoming attachment loss.

Topic:risk factors

Authors: Lamster I, et al                                                          ARTICLE

Title:Development of a risk profile for periodontal disease: Microbial and host response factors

Source:J Periodontol 65:511-520, 1994

Type:report

Rating: Good

Keywords:periodontitis/microbiology; periodontal diseases/microbiology; risk factors, host response, gingival crevicular fluid, glucuronidase

Purpose:To list risk factors associated with the host-microbial interaction in periodontal disease

Conclusion:4 factors and their association with active chronic periodontal disease were explored in this review: Elevated GCF levels of β-glucuronidase (a lysosomal hydrolase that can serve as a marker for primary granule release from PMNs), elevated levels of periodontal pathogens, reduced levels of IgA in GCF, and reduced levels of serum IgG antibody to putative periodontal pathogens. These pathogen associated risk factors, as well as patient- associated risk factors (DM, smoking), can provide diagnostic information to aid in the treatment of patients with periodontal disease.

Saliva

How does saliva play a role in a patient’s susceptibility or resistance to periodontal disease ?

Topic:Smoking on gingival crevicular fluid

Authors:Giannopoulou, C., Kamma J., Mombelli                                                          ARTICLE

Title: A. Effect of inflammation, smoking and stress on gingival crevicular fluid cytokine level.

Source: J Clinical Periodontol 2003; 30: 145-153
Type:Clinical study

Rating: Good

Keywords:smoking, interleukins, gingival crevicular fluid

Purpose:To determine the levels of interleukin (IL)-1β, IL-4, IL-6 and IL-8 in gingival crevicular fluid of periodontally healthy and diseased individuals and to study their association to environmental factors such as smoking and stress.

Material and method:

  • A total of 80 patients from a private periodontal practice were included in the study:

  • 20 patients per disease category: aggressive periodontitis (EOP), chronic adult periodontitis (AP), gingivitis (G) healthy periodontium (H).

  • PD, AL, Pl, BOP, suppuration, and smoking and stress information were recorded at initial visit and after GCF sampling. Full mouth standardized periapical radiographs were taken and bone loss was assessed.

  • GCF was collected from four sites per patient, randomly selected in each quadrant by means of durapore filter membranes. After isolation of the test sites from saliva, a first Durapore strip was inserted 1mm into the sulcus or pocket and left in place for 15s. Three minutes after removal of the first strip, a second Durapore strip was similarly inserted in the same site for 15s. The two strips were then placed into a microcentrifuge tube and immediately frozen until the day of the analysis. In case of visible contamination with blood, the strips were discarded.

  • The contents of IL- 1β, IL-4, IL-6 and IL-8 were measured in 320 samples by use of commercially available sandwich enzyme-linked immune adsorbent assays.

Results:In subjects with periodontitis, the total amounts of IL-1β, IL-6 and IL-8were significantly elevated compared to healthy subjects.  IL-4showed an inverse relationship to periodontal status and higher amounts were found in the healthy group. The amounts of all four cytokines were positively correlated with probing depths. IL-4, IL-6 and IL-8 were significantly correlated to smoking while stress was associated withIL-1β, IL-6 and IL-8levels.

Conclusion:IL-1β, IL-6 and IL-8 reflect the activity of periodontal destruction, whereas IL-4 shows an inverse correlation to it.

Topic: Gingival Crevicular Fluid

Authors:Safkan-Sppparla, B., Sorsa, T                                                           ARTICLE

Title:Collagenases in gingival crevicular fluid in type I diabetes mellitus.

Source:Implant Dent. 2008 Mar;17(1):16-23

Type:Clinical study

Reviewer:Laura Porras

Rating: Good

Keywords:

Purpose: To analyze GCF collagenases of poorly and well-controlled type 1 DM and chronic periodontitis subjects compared to non-

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Advanced surgery II- Biological aspects, including materials. Histological results. Success/Survival rate of implants in grafted maxilla. Short Implants and Tilted Implants, Implant survival.

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Advanced surgery II

Biological aspects, including materials. Histological results.

Success/Survival rate of implants in grafted maxilla.

Short Implants and Tilted Implants, Implant survival

  1. Tarnow DP, Wallace SS, Froum SJ, Rohrer MD, Cho SC. Histologic and clinical comparison of bilateral sinus floor elevations with and without barrier membrane placement in 12 patients: Part 3 of an ongoing prospective study. Int J Periodontics Restorative Dent. 2000 Apr;20(2):117-25.

  2. Corbella S, Taschieri S, Del Fabbro M. Long-Term Outcomes for the Treatment of Atrophic Posterior Maxilla: A Systematic Review of Literature. Clin Implant Dent Relat Res. 2013 May 8.

  3. Schmitt C, Karasholi T, Lutz R, et al. Long-term changes in graft height after maxillary sinus augmentation, onlay bone grafting, and combination of both techniques: a long-term retrospective cohort study. Clin Oral Implants Res. 2012 Oct 17. doi: 10.1111/clr.12045. [Epub ahead of print]

  4. Del Fabbro M, Corbella S, Ceresoli V, Ceci C, Taschieri S. Plasma Rich in Growth Factors Improves Patients’ Postoperative Quality of Life in Maxillary Sinus Floor Augmentation: Preliminary Results of a Randomized Clinical Study. Clin Implant Dent Relat Res. 2013 Nov 12. doi: 10.1111/cid.12171. [Epub ahead of print]

  5. Boyne PJ, Lilly LC, Marx RE, Moy PK, Nevins M, Spagnoli DB, Triplett RG.  De novo bone induction by recombinant human bone morphogenetic protein-2 (rhBMP-2) in maxillary sinus floor augmentation. J Oral Maxillofacial Surg 2005; 63(12):1693-1707.

  6. Maiorana C, Sommariva L, Brivio P, Sigurta D, Santoro F. Maxillary sinus augmentation with anorganic bovine bone (Bio-Oss) and autologous platelet-rich plasma: preliminary clinical and histologic evaluations. Int J Periodontics Restorative Dent 2003; 23:227-235.

  7. Schmitt CM, Doering H, et al. Histological results after maxillary sinus augmentation with Straumann® BoneCeramic, Bio-Oss®, Puros®, and autologous bone. A randomized controlled clinical trial. Clin Oral Implants Res. 2013 May;24(5):576-85.

  8. Mardinger O, Chaushu G, et al. Factors affecting changes in sinus graft height between and above the placed implants. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011 Jan;111(1):e6-11.

  9. Cha HS, Kim A, Nowzari H, Chang HS, Ahn KM. Simultaneous Sinus Lift and Implant Installation: Prospective Study of Consecutive Two Hundred Seventeen Sinus Lift and Four Hundred Sixty-Two Implants. Clin Implant Dent Relat Res. 2012 Nov 15. [Epub ahead of print]

  10. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review. Ann Periodontol 2003; 8:328-343.

  11. Del Fabbro M, etc. Systematic review of survival for implants placed in the grafted maxillary sinus. Int J Periodont Restorative Dent 2004; 24:565-77.

  12. Del Fabbro M, Wallace SS, Testori T. Long-term implant survival in the grafted maxillary sinus: a systematic review. Int J Periodontics Restorative Dent. 2013 Nov-Dec;33(6):773-83.

  13. Felice P, Pistilli R, Piattelli M, Soardi E, Pellegrino G, Corvino V, Esposito M. 1-stage versus 2-stage lateral maxillary sinus lift procedures: 4-month post-loading results of a multicenter randomised controlled trial. Eur J Oral Implantol. 2013 Summer;6(2):153-65.

  14. Nooh N. Effect of Schneiderian Membrane Perforation on Posterior Maxillary Implant Survival. J Int Oral Health 2013; 5(3):28-34 

  15. Najm SA, Malis D, Hage ME, Rahban S, Carrel JP, Bernard JP. Potential adverse events of endosseous dental implants penetrating the maxillary sinus: Long-term clinical evaluation. Laryngoscope. 2013 Dec;123(12):2958-61. doi: 10.1002/lary.24189. Epub 2013 Oct 2.

  16. Fugazzotto PA. Shorter implants in clinical practice: rationale and treatment results. Int J Oral Maxillofac Implants. 2008 May-Jun;23(3):487-96.

  17. Pommer B, Frantal S, Willer J, Posch M, Watzek G, Tepper G. Impact of dental implant length on early failure rates: a meta-analysis of observational studies. J Clin Periodontol. 2011 Sep;38(9):856-63.

  18. Maló P, Nobre Md, Lopes A. Immediate loading of ‘All-on-4’ maxillary prostheses using trans-sinus tilted implants without sinus bone grafting: a retrospective study reporting the 3-year outcome. Eur J Oral Implantol. 2013 Autumn;6(3):273-83.

  19. Esposito M, Felice P, Worthington HV. Interventions for replacing missing teeth: augmentation procedures of the maxillary sinus. Cochrane Database Syst Rev. 2014 May 13;5:CD008397.

Topic:sinus floor elevation with/without barrier membrane    maxillary sinus augmentation

Authors:Tarnow DP, Wallace SS, Froum SJ, Rohrer MD, Cho SC.

Title:Histologic and clinical comparison of bilateral sinus floor elevations with and without barrier membrane placement in 12 patients: Part 3 of an ongoing prospective study

Source:Int J Periodontics Restorative Dent. 2000 Apr;20(2):117-25.

Type:Prospective study (Abstract ONLY)

Rating: Good

Keywords:Sinus elevation, barrier membrane

Purpose:To evaluatethe effect of barrier membrane placement on the creation of vital bone in the grafted sinus cavity.

Materials and methods:

  • In 1993 the Department of Implant Dentistry at New York University College of Dentistry began a long-term clinical, histologic, histomorphometric, and radiographic study of the sinus elevation procedure

  • 12 patients who underwent bilateral sinus elevation surgery. In each of these 12 patients the same grafting material was used in both sinuses, making the presence or absence of an expanded polytetrafluoroethylene (e-PTFE) barrier membrane the only controlled variable.

  • A histologic and histomorphometric evaluation of healing with and without the placement of an e-PTFE barrier membrane over the lateral window at the time of sinus grafting.

Results:

(1) Placement of the barrier membrane tends to increase vital bone formation

(2) Placement of a barrier membrane has a positive effect on implant survival

(3) Membrane placement should be considered for all sinus elevation procedures.

Topic: Posterior maxilla

Authors:Corbella S, Taschieri S, Del Fabbro M.

Tittle: Long-Term Outcomes for the Treatment of Atrophic Posterior Maxilla: A Systematic Review of Literature.

Source:Clin Implant Dent Relat Res. 2013 May 8.

Type: Systematic review

Rating: Good

Keywords:maxilla, implants

Purpose:to estimate the implant survival rate in different types of techniques for the rehabilitation of posterior atrophic maxilla, after at least 3 years of follow-up.

Methods:MEDLINE database and hand searching of the relevant journals was searched using a combination of specific terms. All retrospective and prospective studies evaluating short implants in posterior maxilla, osteotome sinus floor elevation and lateral approach sinus floor elevation, and having a follow-up of at least 3 years, were included.

Results:Forty-four articles were included in the review. In four studies reporting on a total of 901 short implants (less than 10mm long, mean length around 8mm), the implant survival rate varied from 86.5% to 98.2% with up to 5 years follow-up. For the osteotome technique, 1,208 implants in eight studies were considered, showing a survival rate varying from95.4% to 100%after 3-year follow-up. Twenty-nine studies, accounting for 6,940 implants placed in 2,707 sinuses augmented through lateral techniquewere considered. Implant survival rate varied from 75.57% to 100%. Only three comparative studies were found that showed no significant difference in clinical outcomes between lateral approach and osteotome technique.

Conclusions:Sinus floor elevation with the lateral approach and with the osteotome technique is an effective and well- documented therapeutic option for the rehabilitation of atrophic posterior maxilla. The use of short implants is promising but needs further investigation to be considered as effective as the other techniques in the long term. However, the indication for the three different techniques is not perfectly equivalent and the treatment choice should be based on a careful evaluation of the individual case, in particular on the available residual bone.

Topic:Maxillary sinus augmentation                               need for KG around implants

Authors: Schmitt C, Karasholi T, Lutz R, Wiltfang J, Neukam F-W, Schlegel KA

Title: Long-term changes in graft height after maxillary sinus augmentation, onlay bone grafting, and combination of both techniques: a long-term retrospective cohort study.

Source: Clin Oral Implants Res. 2012 Oct 17. doi: 10.1111/clr.12045.

Type:Long-term retrospective cohort study

Reviewer:Evan Santiago

Rating:Fair

Keywords:autologous bone, bone augmentation, bone resorption, dental implant, keratinized gingiva, onlay bone grafting, sinus lift

Purpose:To examine long-term changes in graft height, implant survival rate, and peri-implant tissue conditions of dental implants place din alveolar ridges after augmentation procedures with a follow-up of 10 years

Method:25 patients with edentulous severe atrophic maxillary situations who received vertical augmentation procedures with autologous bone prior to implant placement. Patients were divided into groups (sinus elevation, onlay grafting, or a combination of both techniques). Patients were allowed to heal for 4 months and 127 implants were placed and allowed to heal for 6 months before loading. These patients were followed up clinically and radiographically followed up 1, 5, and 10 years later.

Results:Seven implants lost during observation period (94.48% 10 year survival rate). Significant bone loss occurred in the first 12 months and slowed afterwards and stabilized. After 10 years the total vertical bone loss was 27.51% after onlay grafting, 28.14% after sinus elevation, and 30.24% in the combination group (NSSD between groups). Signification positive correlations between PD and the degree of peri-implant inflammation. KG showed a statistically negative correlation to the degree of peri-implant inflammation.

Conclusion:Treatment does not impact vertical bone loss following augmentation using autologous grafts. This approach results in long term stability of dental implants. A sufficient width of keratinized peri-implant mucosa is important to prevent peri-implant bone loss and inflammation.

Topic:Growth Factors                         PRGF

Authors: Del FabbroM, Corbella S, Ceresoli V, Ceci C, Taschieri S

Title:Plasma Rich in Growth Factors Improves Patients’ Postoperative Quality of Life in Maxillary Sinus Floor Augmentation: Preliminary Results of a Randomized Clinical Study.

Source:Clin Implant Dent Relat Res. 2013 Nov 12. doi: 10.1111/cid.12171

Type:Clinical

Rating: Good

Keywords:growth factors, maxillary sinus augmentation, platelet concentrate, quality of life, sinus grafting

Purpose:The purpose of the present preliminary report was to assess if the use of autologous platelet concentrate during maxillary sinus augmentation may have a favorable impact on pain and other factors related to patient’s quality of life in the first week after surgery.

Method:This is an interim report of a randomized single-blind study. Fifteen patients with atrophic edentulous posterior maxilla underwent maxillary sinus augmentation using deproteinized bovine bone matrix (DBBM) as the grafting material (control group). In other 15 patients (test group), autologous plasma rich in growth factors (P-PRP) was added to DBBM, then a P-PRP clot was applied to covering the graft before suturing and finally P-PRP was placed over the suture in liquid form. During the first week postsurgery, all patients filled in a questionnaire for evaluation of main symptoms and daily activities. The outcomes of the questionnaires of the two groups were statistically compared.

Results:In the first days postsurgery, the group using P-PRP reported significantly less pain, swelling, and hematoma, and improved functional activities with respect to the control group.

Conclusion:The adjunct of P-PRP to the maxillary sinus augmentation procedure produced a beneficial effect to patients’ quality of life in the early postsurgical phase.

Topic:Sinus floor augmentation

Title: De novo bone induction by recombinant human bone morphogenetic protein-2 (rhBMP-2) in maxillary sinus floor augmentation.

Author: Boyne PJ, Lilly LC, Marx RE, Moy PK, Nevins M, Spagnoli DB, Triplett RG. 

Source: J Oral Maxillofacial Surg 2005; 63(12):1693-1707.

Type:Clinical trial

Rating:Good

Keywords:sinus lift, bone graft, BMP

Purpose:This phase II study was designed to evaluate 2 concentrations of recombinant human bone morphogenetic protein-2 (rhBMP-2) for safety and efficacy in inducing adequate bone for endosseous dental implant in patients requiring staged maxillary sinus floor augmentation.

Materials and Methods:Patients were treated with rhBMP-2 (via an absorbable collagen sponge [ACS]), at concentrations of 0.75 mg/mL (n = 18), 1.50 mg/mL (n = 17), or with bone graft (n = 13). Bone induction was assessed by alveolar ridge height, width, and density measurements from computed tomography scans obtained before and 4 months after treatment and 6 months post-functional loading of dental implants (density only).

Results:Mean increases in alveolar ridge height at 4 months after treatment were similar among the groups; 11.3 mm, 9.5 mm, and 10.2 mm, respectively, in the bone graft, 0.75 mg/mL, and 1.50 mg/mL rhBMP-2/ACS treatment groups. Mean increases in alveolar ridge width (buccal to lingual) at the crest of the ridge were statistically different among the treatment groups; 4.7 mm, 2.0 mm, and 2.0 mm, respectively, in the bone graft, 0.75 mg/mL, and 1.50 mg/mL treatment groups (P <or= .01 vs 0.75 mg/mL; P < .01 vs 1.50 mg/mL). At 4 months postoperative new bone density was statistically different among the treatment groups; 350 mg/cc, 84 mg/cc, and 134 mg/cc for the bone graft, 0.75 mg/mL, and 1.50 mg/mL rhBMP-2/ACS treatment groups, respectively (P = .003 vs 0.75 mg/mL, P = .0137 vs 1.50 mg/mL, P = .0188; 1.50 mg/mL vs 0.75 mg/mL). Core bone biopsies obtained at the time of dental implant placement confirmed normal bone formation. The proportion of patients who received dental implants that were functionally loaded and remained functional at 36 months post-functional loading was 62%, 67%, and 76% in the bone graft, 0.75 mg/mL, and 1.50 mg/mL rhBMP-2/ACS treatment groups, respectively.

Conclusion:This study is the first randomized controlled trial demonstrating de novo organ tissue growth in humans from a recombinant human protein. rhBMP-2/ACS safely induced adequate bone for the placement and functional loading of endosseous dental implants in patients requiring staged maxillary sinus floor augmentation.

Topic:Maxillary sinus

Title: Maxillary sinus augmentation with anorganic bovine bone (Bio-Oss) and autologous platelet-rich plasma: preliminary clinical and histologic evaluations

Author: Maiorana C et al

Source:Int J Periodontics Restorative Dent 2003; 23:227-235.

Type:Clinical Study

Rating:Good

Keywords:PRP, BioOss, maxillary sinus augmentation

P:To describe clinical and histological evidence derived from the use of bovine bone and autologous PRP in a two stage surgical technique for maxillary sinus augmentation to avoid the use of autologous bone grafting technique.

M&M: 10 pts with posterior max atrophy recruited for bone augmentation. Eleven sinus elevation procedures were procedure according to 2 stage technique. Whole blood drawn and two centrifugation was performed and kept in continuous motion at 20 degrees Celsius until the time of surgery. BioOss and PRP gel mixed together and grafted into the sinus.

R:In all 11 cases, continuity of maxillary lateral wall was restored with tissue macroscopically similar to cortical bone in which some superficial particles of BioOss were identifiable. 3 months later CT scans showed presence and volume of graft. 6 months later, the scan showed graft to be more homogenous with reduce/resolved mucosal hypertrophy. Histomorphometric examination in 2 samples showed 40 % of the specimen composed of BioOss and newly formed bone and ratio between newly formed bone and total bone was in favor of bone regeneration. This results demonstrate osteoconductive properties of BioOss and suggest effective amplification of the bone regeneration and maturation processes evident only at 6 months after grafting procedures. Fibrin network present within PRP provides BioOss with scaffold for osteoblastic migration and platelet GF enhance the regenerative potential.

Topic:sinus lift

Authors: Schmitt CM, Doering H,

Title:Histological results after maxillary sinus augmentation with Straumann® BoneCeramic, Bio-Oss®, Puros®, and autologous bone. A randomized controlled clinical trial.

Source:Clin Oral Implants Res. 2013 May;24(5):576-85. doi: 10.1111/j.1600-0501.2012.02431.

Type:randomized clinical trial

Rating: good

Keywords:biomaterials, bone regeneration, bone substitutes, clinical research, clinical trials, guided tissue regeneration, sinus floor elevation

Purpose:To compare the clinical and histological characteristics of the tissue after sinus floor augmentation with:

  • biphasic calcium phosphate (BCP, Straumann BoneCeramic®)

  • anorganic bovine bone (ABB, Geistlich Bio-Oss®)

  • mineralized cancellous bone allograft (MCBA Zimmer Puros®)

  • autologous bone (AB)

Methods: Thirty patients with a posterior edentulous maxilla and a vertical bone height of ≤4 mm participated (45 sinuses and 94 implants in posterior maxilla). A two-stage procedure was carried out. Mucoperiosteal incision was made and Schneiderian membrane was elevated through lateral bone window. After augmentation of the maxillary sinus with ABB, BCP, MCBA, or AB followed by a healing period of 5 months, biopsies were taken from the future implant sites. Drilling with the trephine bur was performed as apically as possible. Thus, oral mucosa, residual maxillary bone, augmented sinus, and Schneiderian membrane were included in the biopsies. The trephine sites were used for implant placement after definitive treatment of the implant site. All patients received postoperative nose drops for 10 days (Otriven® nose drops 1-1-1; Novartis®) The samples were analyzed microradiographically and histologically.

Results: Course was uneventful. Although patients undergoing retromandibular bone harvesting demonstrated more swelling. Exposition of alveolar nerve occurred in 2 cases of harvesting bone block from mandible. No membrane perforations. Placement of implants was uneventful as well. 53 bone biopsies were generated from the later implant site; 41 samples were lost during removal or implant was peripheral to the augmented sinus. In total there were: 15 ABB, 14 BCP, 12 MCBA, and 12 AB samples.

Microradiography and histomorphometric analysis were carried out. Parameters for the residual bone(ROI1) and augmented sinus (ROI2) for each group were measured. (table 1)

Conclusion:Autologous bone provides the highest rate of de novo bone formation and can be considered to remain the gold standard in sinus floor augmentation. All tested control materials showed comparable results and are suitable for maxillary sinus augmentation.

Topic:Sinus Lift

Author:Mardinger O, Chaushu G.

Title:Factors affecting changes in sinus graft height between and above the placed implants

Source:Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011 Jan;111(1):e6-11

Type:Longitudinal Study

Rating: Good

Keywords:Sinus lift; bone grafting; dental implants

Purpose: The aim of this study was to compare the radiographic dimensional changes of sinus graft height above and between placed implants, and to evaluate the factors effecting these changes with 2 different grafting materials and a combination of both.

Methods: The study group included 42 patients (27 F, 15M) who underwent 50 sinus augmentation procedures, with a total of 154 implants placed. Three different grafting materials were used: 1-intraoral autogenous bone alone; 2-anorganic bovine bone (Bio-oss) alone; 3-mixtures of both (20% autogenous, 80% Bio-oss). Lateral wall technique was used for all sinus lifts. Four panoramic radiographs were evaluated: Before surgery (T0); 1 year (T1); 1-5 years (T2); 5-10 years (T3) after implant placement. The following measurements were performed for analysis: 1-Vertical new bone height at the center b/t the 2 most distal implants

2-Vertical height of the grafted bone above implant

3-Residual alveolar ridge height at the center b/t the 2 most distal implants

4-Implant length

Results:The mean percentage of autogenous bone height reduction was 23% between implants and 13% above the implants. Bovine xenograft showed a mean of 6.5% graft height reduction between implants and 0% above implants. The only two parameters that correlated with reduction of graft height above and between the implants were time elapsed from surgery and the type of bone graft. Autogenous bone graft presented significantly more reduction, whereas anorganic bovine graft only had minor or no changes in height.

Discussion: The most dominant factor influencing long-term vertical stability of the grafted bone after sinus augmentation is the grafting material. Sinus grafting with bovine xenograft yields the best results regarding long-term stability of the graft height and implant survival rates. The second factor those influences stability is the presence of a functional implant. Grafted bone height maintenance was superior above the implant compared with bone height between the implants.

Conclusion:The most important factor influencing reduction in vertical bone height on the time axis, following sinus augmentation is the grafting material, followed by the presence of a functional implant. Anorganic bovine bone was found superior in graft height maintenance in an up to 10 years of follow-up.

Topic:Sinus lifts

Authors: Cha H, et al.

Title:: Prospective study of consecutive two hundred seventeen sinus lift and four hundred sixty-two implants.

Source:Clin Implant Dent Relat Res. 2012 Nov 15

Type:

Rating: Good

Keywords:Dental implants, perforation, residual alveolar bone, Schneiderian membrane, sinus lifting, smoking, xenogenic bone

Purpose:To evaluate the survival and success rates of implants simultaneously placed into grafted sinus and evaluate whether there are any differences in survival and success rates regarding residual alveolar bone height, smoking status, and membrane perforation.

Method:217 lateral window sinus lifts and 462 implants were performed by the same oral surgeon. Medical and dental histories including smoking habits were reviewed for each patient. Tapered implants (10-12 mm long) with microthreads in the coronal part with sand blasting, large grit, and acid etched surface were used. Grafting was completed with xenogenic bone (Bio-Oss) soaked in gentamycin for 5 minutes. Implants were placed initially with automated handpiece and finalized with hand wrench. Perforated membranes were repaired with porcine membrane and fibrin glue. Implants were divided into 2 groups: Group 1- implants installed in posterior maxilla with <5 mm residual bone height and Group 2- ≥ 5 mm alveolar bone height. Survival rate of each group was evaluated, as well as smoking status and membrane perforation. Uncovery was at 6 months and implants were further evaluated every 6 months for the next three years. Success was defined as absence of pain (1), infection (2), mobility (3), PA radiolucency (4), and <1.5 mm of bone resorption in the first year as well as < 0.2 mm in years following (5). Survival was indicated by the first 4 parameters only.

Results:Cumulative survival rate was 98.91%, and survival was slightly higher in group 2, though not significantly different. Cumulative success rate was 96.54% and slightly (but not significantly) higher in group 1. There was no significant difference in implant survival in perforated membranes versus non perforated membranes. There was a significant difference in smokers versus not smokers in regard to implant failure.

Conclusion: Residual alveolar bone had no significant effect on survival and success rates of implants. Sinus lifting with simultaneous implant placement reduces treatment time and number of surgeries required. Selecting and implant with characteristics that enhance initial stability is crucial for success. Membrane perforation at the time of surgery did not have an impact on implant success/survival however smoking is a possible factor for implant failure.

Topic:Advanced Surgery 2                   survival rates for implants placed in the grafted maxillary sinus

Authors: Wallace SS, Froum SJ

Title:Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review

Source:Annals of Periodontology, December 2003, Vol. 8, No. 1, Pages 328-343

Type:Systematic Review

Rating: Poor

KeywordsN/A

Purpose:To determine the efficacy of the sinus augmentation procedure and compare the results achieved with various surgical techniques, grafting materials and implants.

Methods:MEDLINE, the Cochrane Oral Health Group Specialized Trials Register, and the Database of Abstracts and Reviews of Effectiveness were searched for articles published through April 2003. Hand searches were conducted on Clinical Oral Implants Research, International Journal of Oral and Maxillofacial Implants, and the International Journal of Periodontics and Restorative Dentistry and the bibliographies of all relevant papers and review articles. Also, researchers, journal editors and industry sources were contacted to see if pertinent unpublished data that had been accepted for publication were available. Inclusion Criteria were: Human studies with a minimum of 20 interventions, a minimum follow-up period of1-year loading, an outcome measurement of implant survival, and published in English, regardless of the evidence level, were considered.

Results:43 studies, 3 randomized controlled clinical trials (RCTs), 5 controlled trials (CTs), 12 case series (CS), and 23 retrospective analyses (RA) were identified. 34 were lateral window interventions, 5 were osteotome interventions, 2 were localized management of the sinus floor, and 2 involved the crestal core technique.

Conclusion:

  1. Survival rate of implants placed in sinuses augmented with lateral window technique averaged 91.8% (range 61.7% and 100%)

  2. Implant survival rates compare favorably to survival rates of implants placed in non-grafted posterior maxilla.

  3. Survival rate of rough-surfaced implants is higher than machined-surfaced implants when placed in grafter sinuses.

  4. Higher survival rates of implants placed in particulate graft augmented sinuses than those placed in sinuses augmented with block grafts.

  5. Higher survival rates when a membrane was placed over the lateral window.

  6. 100% autogenous bone grafts or the inclusion of autogenous bone as a component of a composite grafe did not affect implant survival.

  7. No statistical difference between the covariates of simultaneous versus delayed implant placement, type of rough-surfaced implants, length of follow-up, year of publication and the evidence level of the study.

  8. Insufficient data were present to statistically evaluate the effects of smoking, residual crestal bone height, screw versus press-fit implant design or the effect of implant surface micromorphology other than machined versus rough surfaces.

  9. Insufficient evidence exists to recommended the utilization of platelet-rich plasma in sinus graft surgery.

Topic:Grafted maxillary sinus

Authors: Del Fabro M, Testori T, Francetti L, Weinstein R.

Title:Systematic review of survival rates for implants placed in the grafted maxillary sinus.

Source:International Journal of Periodontics and Restorative Dentistry 2004; 24: 565-577.

Type:Systematic Review

Rating:Good

Keywords:maxillary sinus, sinus lift, sinus augmentation, sinus elevation, sinus graft, bone grafting, dental implants, endosseous implants

Purpose:To determine the survival rate of root-form dental implants placed in the grafted maxillary sinus. Determine effects of graft material, implant surface characteristics and simultaneous versus delayed placement on survival rate.

Materials and methods: Computer search of electronic databases from 1986 to 2002. The search was limited to human studies. Additionally a hand search was performed. Inclusion criteria: 1) at least 20 sinus elevations performed 2) mean follow up no less than 12 months of implant loading 3) fewer than 5% of patients lost to follow up 4) multiple interventions (likesimultaneous ridge augmentation) were not performed 5) access to the antrum occurred by lateral window procedure 6) grafting material and implant placement timing were clearly reported 7) type of implants used was indicated.

Results:The search yielded 252 articles. Of these, 39 met the criteria.

Within autogenous graft subgroup, the influence of using graft in a block or particulate form was examined. Survival rates of block grafts 82.9%, block plus particulate grafts 89.4%, particulate grafts alone 92.5%. This suggests that the addition of particulate grafts or use of them alone, would improve survival rates.

Conclusion:Sinus grafting is considered a safe and well-documented procedure to prepare an environment in which dental implants may have an excellent prognosis. The choice of the type of graft material and the implant micromorphology may significantly influence the outcome. The performance of rough surface implants is superior to that of smooth surface. Grafts using bone substitutes are as effective as autogenous bone.

Topic: Sinus grafting, long-term survival

Authors:Del Fabbro, Wallace, Testori

Title: Long-term implant survival in the grafted maxillary sinus: a Systematic Review

Source:Int J Perio Rest Dent. 2013 Nov-Dec;33(6):773-86

Type:systematic review

Rating:

Keywords:

Background:Maxillary sinus augmentation has been shown to be the most predictable of the preprosthetic surgical techniques used to enhance bone volume for the placement of dental implants in previously compromised sites.

Purpose:The primary purpose of this systematic review was to investigate implant survival rates based on clinical studies with a follow-up of a minimum 3 years. A further aim was to assess whether implant survival was affected by several of- ten confounding variables. Specifically researched were: type of graft material, implant surface texture, simultaneous or staged implant insertion, residual crestal bone height, use of a biologic barrier membrane, timing of implant failure, duration of follow-up, publication date, and level of evidence (study design) of included studies

Materials and Methods:The inclusion criteria of this review extended the minimum postloading evaluation to 3 years to determine if the previously reported short-term survival rates are maintained. An electronic search of the literature was performed and retrieved articles were screened using specific inclusion criteria, paramount of which was a minimum of 3 years of follow-up. The search revealed 18 articles for the lateral window approach (6,500 implants in 2,149 patients) and 7 for the transalveolar approach (1,257 implants in 704 patients).In summary, 1 RCT (4%), 3 con- trolled trials (12%), 5 case series reports (20%), and 15 retrospective studies (64%) were included.

Results:Overall, implant survival after a minimum of 3 years loading was 93.7% and 97.2% for the lateral window and transalveolar approaches, respectively. Of importance is the fact that 80% of failures occurred within the first year and 93.1% of the failures occurred within 3 years. The risk of implant failure after 3 years can now be directly calculated as the overall risk of failure after 3 years (6.3%)×the incidence of late failures (6.9%), thus equaling 0.43%.The overall implant survival using 100% autogenous bone was significantly lower than that using 100% bone substitute (P< .001; OR, 4.42; 95% CI, 3.78 to 5.06)

Conclusions:This review discredits the theory that studies of a lower level of evidence report inflated results when compared with prospective randomized controlled clinical trials.

Critique: Distinguished authors (+); confounding variables make it hard to compare (-)

One of the major problems encountered in reviews of this type is the presence of confounding variables, ie, situations in which more than one variable may affect the outcome of a procedure. It is sometimes difficult to surmount this problem because of factors such as inadequate data reporting, changes in surgical techniques over time, lack of prospective trials with only one variable, or the reality that eliminating studies with only one variable would result in a very small database.

It is quite likely that failures occurring after 3 years are the result of factors unrelated to the placement of implants into grafted sinuses. Certainly one can speculate on the possibility of implant fracture in the heavy load-bearing area of the posterior maxilla and failures resulting from peri-implantitis.

Topic:Lateral maxillary sinus lift

Authors:Felice P, Pistilli R, Piattelli M, Soardi E, Pellegrino G, Corvino V, Esposito M

Title:1-stage versus 2-stage lateral maxillary sinus lift procedures: 4-month post-loading results of a multicenter randomised controlled trial.

Source:Eur J Oral Implantol. 2013 Summer;6(2):153-65.

Type:Prospective study

Rating: Good

Keywords:anorganic bovine bone, dental implant, sinus lift, surgical procedure

Purpose: To compare the efficacy of 1-stage versus 2-stage lateral maxillary sinus lift procedures.

Materials and methods:

  • 60 partially edentulous patients requiring 1 to 3 implants and having 1 to 3mm of residual bone height and at least 5mm of bone width below the maxillary sinus, as measured on CT scans, were randomized into two equal groups to receive:

    • 1-stage lateral window sinus lift with simultaneous implant placement

    • 2-stage procedure with implant placement delayed by 4 months using a bone substitute in 3 different centers.

  • Implants were submerged for 4 months and loaded with reinforced provisional prostheses, which were replaced, after 4 months, by definitive prostheses.

  • Outcome measures were augmentation procedure failures, prosthesis failures, implant failures, complications and marginal peri-implant bone loss assessed by a blinded outcome assessor.

  • Patients were followed up to 4 months after loading. Only data of implants placed in 1 to 3mm of bone height were reported.


Results: 2 patients dropped out from the 1-stage group and none from the 2-stage group.

1 stage (n=30)

2 stage (n=30)

P value

Sinus lift procedure failures

NSSD (P = 1.00)

Prosthesis failure

NSSD (P = 0.51).

Implant failure

NSSD (P = 0.28).

Complications

NSSD (P = 0.61).

Peri-implant bone loss

0.56 mm (SD: 0.36; 95% CI: -0.70 to -0.42

0.61mm (SD: 0.34; 95% CI: -0.74 to -0.48

P< 0.001

There is NSSD in bone loss between groups at loading (0.05mm).

Conclusions: NSSD were observed between implants placed according to 1- or 2-stage sinus lift procedures. However, this study may suggest that in patients having a residual bone height between 1 and 3 mm below the maxillary sinus there might be a slightly higher risk for implant failures when performing a 1-stage lateral sinus lift procedure.

Topic: Maxillary sinus

Authors:Nooh N.

Tittle:Effect of Schneiderian Membrane Perforation on Posterior Maxillary Implant Survival.

Source:J Int Oral Health 2013; 5(3):28-34 

Type: Clinical study

Rating: Good

Keywords:Schneiderian membrane, implant, sinus floor, perforated membrane

Background: To assess the survival rate of implants placed in the posterior maxilla by intentionally perforating the Schneiderian membrane and protruding the implant up to 3mm beyond the sinus floor in cases of reduced crestal bone height (CBH).

Methods: 56 patients with reduced CBH received 63 implants in the posterior maxilla. All implants intentionally penetrated the Schneiderian membrane and engaged the sinus floor cortical bone. All patients were followed up and implant survival was assessed at the end of one year post implant restoration.

Results: Out of 63 implants, there was only one failure (98.4% Survival rate) after a follow up period of one year. 7 patients experienced mild epistaxis during the immediate post-operative period with no associated implant loss. One patient developed sinusitis secondary to the surgical procedure, which was treated by antibiotic therapy and the patient improved clinically with no associated implant loss.

Conclusion: An intentional perforation of the Schneiderian membrane using a 2mm twist drill at the time of implant placement and protrusion of the implant up to 3mm beyond the sinus floor does not alter the stability and outcome of dental implants, one year post-restoration. This could be associated with minor complications ranging from epistaxis to sinusitis, which are manageable.

Topic:Dental implants in maxillary sinus

Authors: Najm SA, Malis D, Hage ME, Rahban S, Carrel JP, Bernard JP

Title: Potential adverse events of endosseous dental implants penetrating the maxillary sinus: Long-term clinical evaluation.

Source: Laryngoscope. 2013 Dec;123(12):2958-61. doi: 10.1002/lary.24189

Type:Retrospective cohort study

Rating:

Keywords:Dental implant, sinus membrane perforation, maxillary sinusitis

Purpose:To evaluate the nature and incidence of long-term maxillary sinus adverse events related to endosseous implant placement with protrusion into the maxillary sinus

Method:Patients with dental implant penetrating into the maxillary sinus were included. Minimum 5 year follow-up after implant placement. Sinus assessment was both clinical and radiographic.

Results:70 patients with 83 sinus implants with sinus perforation. Mean age 65.96. 12 patients had multiple implants penetrating the sinus and another 7 had bilateral sinus perforation. Estimated penetration was under 3 mm in all cases. The average follow up was 9.98 years. During follow up there were no signs of sinusitis clinically or radiographically in any patients.

Conclusion:No sinus complications are observed when implants penetrate into the maxillary sinus. This can be attributed to maintenance of successful osseointegraiton. In the presence of an acute or chronic maxillary sinusitis the differential diagnosis must always consider other potential odontogenic and nonodontogenic etiologies.

Topic: Short Implants

Authors:Fugazzotto PA

Title:Shorter implants in clinical practice: rationale and treatment results

Source:Int J Oral Maxillofac Implants. 2008 May-Jun;23(3):487-96.

Type:Retrospective Study

Rating: Good

Keywords:osseointegrated implants, short implants, treatment planning

Purpose:The purpose of this retrospective study was to assess the survival of short implants in various clinical situations in function over time.

Method:A retrospective study was conducted of all patients treated between May 2000 and May 2007 who received endosseous implants that were less than 10 mm in length. Patient age, gender, location of implants, type of prosthesis, time in function, and stability of peri-implant crestal bone were assessed.

Results:The retrospective analysis identified 2,073 implants of 6 mm, 7 mm, 8 mm, or 9 mm in length placed in a variety of clinical situations in 1,774 patients. Cumulative implant survival rates for implants in function in various areas of the mouth supporting single crowns or short-span fixed prosthese

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