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Preservation of root cementum: A comparative evaluation of power-driven versus hand instruments

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Objectives: The purpose of this study was to evaluate the effects of three distinct periodontal treatment methods in comparison with hand instrumentation on residual cementum of periodontal diseased teeth. Cementum can influence the activities of periodontal cells and may play an important regulatory role in periodontal treatment. The ideal method for periodontal therapy involves removal of biofilm, calculus and endotoxin while preserving root cementum. Material and methods: Forty-eight caries free, single-rooted teeth in patients diagnosed with severe chronic periodontitis were treated using four different methods prior to extraction. The teeth were instrumented subgingivally at one approximal site either by hand curettes (HC), piezoelectric ultrasonic scalers (U), piezoelectric ultrasonic scalers following air polishing (U + AP) or air polishing (AP) alone. Following extraction of teeth, instrumented and non-instrumented sites were analysed with a dissecting microscope and SEM for measurement of the amount of and surface characteristics of residual cementum. Results: The percentage of coronal cementum remaining following subgingival instrumentation was 84% for U, 80% for U + AP, 94% for AP and 65% for HC. Although subgingival instrumentation of apical portions of the cementum demonstrated 6% less retained cementum in comparison with coronal portions, the amount of retained cementum with AP was still significantly greater than with HC. SEM results found the smoothest root surfaces were produced by the HC followed by the AP, while root surfaces instrumented by U or U + AP presented grooves and scratches. Conclusions: This study demonstrated that AP was superior to U devices in preserving cementum, whereas HC were the most effective instruments in removing cementum.
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ORIGINAL ARTICLE
E Bozbay
F Dominici
AY Gokbuget
S Cintan
L Guida
MS Aydin
A Mariotti
A Pilloni
Authorsafliations:
E Bozbay, F Dominici, A Pilloni, Section of
Periodontics, Department of Dentistry and
Maxillofacial Surgery, School of Dentistry,
Sapienza University of Rome, Rome, Italy
AY Gokbuget, S Cintan, Department of Peri-
odontology, Faculty of Dentistry, Istanbul
University, Istanbul, Turkey
LGuida, Department of Odontostomatological,
Orthodontic and Surgical Disciplines,
Second University of Naples, Naples, Italy
MS Aydin, Department of Histology and
Embryology, Faculty of Medicine, Bezmi-
alem Vakif University, Istanbul, Turkey
A Mariotti, A Pilloni, Division of Periodon-
tology, College of Dentistry, The Ohio
State University, Columbus, OH, USA
Correspondence to:
Prof A. Pilloni
Section of Periodontics
School of Dentistry
Sapienza University of Rome
Via Caserta 6, 00161 Rome, Italy
Tel.: 0649918152, 0649976635
Fax: 0649976635
E-mail: andrea.pilloni@uniroma1.it
This is an open access article under the
terms of the Creative Commons Attribu-
tion-NonCommercial-NoDerivs License,
which permits use and distribution in any
medium, provided the original work is prop-
erly cited, the use is non-commercial and no
modifications or adaptations are made.
Dates:
Accepted 8 September 2016
To cite this article:
Int J Dent Hygiene
DOI: 10.1111/idh.12249
Bozbay E, Dominici F, Gokbuget AY, Cintan S,
Guida L, Aydin MS, Mariotti A, Pilloni A.
Preservation of root cementum: a comparative
evaluation of power-driven versus hand instruments.
©2016 The Authors. International Journal of
Dental Hygiene Published by John Wiley & Sons
Ltd.
Preservation of root cementum:
a comparative evaluation of
power-driven versus hand instruments
Abstract: Objectives: The purpose of this study was to evaluate the
effects of three distinct periodontal treatment methods in comparison
with hand instrumentation on residual cementum of periodontal
diseased teeth. Cementum can influence the activities of periodontal
cells and may play an important regulatory role in periodontal
treatment. The ideal method for periodontal therapy involves removal
of biofilm, calculus and endotoxin while preserving root cementum.
Material and methods: Forty-eight caries free, single-rooted teeth in
patients diagnosed with severe chronic periodontitis were treated
using four different methods prior to extraction. The teeth were
instrumented subgingivally at one approximal site either by hand
curettes (HC), piezoelectric ultrasonic scalers (U), piezoelectric
ultrasonic scalers following air polishing (U +AP) or air polishing (AP)
alone. Following extraction of teeth, instrumented and non-
instrumented sites were analysed with a dissecting microscope and
SEM for measurement of the amount of and surface characteristics of
residual cementum. Results: The percentage of coronal cementum
remaining following subgingival instrumentation was 84% for U, 80%
for U +AP, 94% for AP and 65% for HC. Although subgingival
instrumentation of apical portions of the cementum demonstrated 6%
less retained cementum in comparison with coronal portions, the
amount of retained cementum with AP was still significantly greater
than with HC. SEM results found the smoothest root surfaces were
produced by the HC followed by the AP, while root surfaces
instrumented by U or U +AP presented grooves and scratches.
Conclusions: This study demonstrated that AP was superior to U
devices in preserving cementum, whereas HC were the most effective
instruments in removing cementum.
Key words: air polishing with glycine; cementum removal; hand
instrumentation; residual cementum; root surface instrumentation;
ultrasonic scaling
Introduction
The major role of cementum is to serve as the site of attachment for
principal collagen fibres (Sharpey’s fibres). In particular, cementum, by
virtue of its structural and dynamic qualities, provides tooth attachment
and maintenance of occlusal relationships between the jaws. These multi-
ple functions are fulfilled by the biological activity and reactivity of
cementoblasts, which deposit two collagen-containing varieties of cemen-
tum with completely different properties (1). Periodontal disease may
Int J Dent Hygiene || 1
alter cementum resulting in the loss of connective tissue
attachment to cementum. As the relationship between local
bacteria and periodontal disease is widely recognized (2, 3), it
is generally accepted that removal of pathogenic micro-organ-
isms that form plaque and calculus on cementum is the major
goal of periodontal treatment. This therapy currently consists
of scaling and root planing, using mechanical instrumentation
(4, 5).
Previously it was accepted that bacterial endotoxins or bac-
teria penetrate the cementum of periodontally diseased root
surfaces. This concept resulted in the removal of the subgingi-
val plaque and calculus deposits, and the removal of all or
most of the cementum as a primary endpoint of periodontal
healing (6, 7). More specifically, the goal of periodontal ther-
apy was to obtain a treated root surface with smooth and hard
surface characteristics that was free of endotoxins (6, 8).
In contrast, recent studies have reported that endotoxins
were not located within cementum (9, 10) and removal of
‘diseased’ cementum was not necessary for a successful peri-
odontal treatment (11). The preservation of cementum on the
root surface was further supported by Saygin et al. (12) who
reported that cementum was necessary for new attachment
and as a source of growth factors (12,13). Furthermore, Grzesik
et al. suggested that cementum plays an important regulatory
role in periodontal regeneration (14). From these studies, it
can be concluded that non-aggressive removal of cementum is
necessary for optimal periodontal health as well as for peri-
odontal regeneration.
Subgingival instrumentation during periodontal therapy
results in the removal of root cementum, which can eventually
lead to exposure of dentinal tubules, pulp injury and dentin
hypersensitivity (15). The in vitro studies, including establish-
ing in vitro experimental models under standardized experi-
mental conditions, evaluated the amount of cementum with
various instruments or force combinations (1625). Several
studies that have shown the effects of different instruments on
root surfaces emphasized that periodontal treatment can be
performed less aggressively with respect to the removal of
cementum (16, 17, 2228).
There has been a previous report that the teeth treated by
hand curettes (HC) and piezoelectric ultrasonic scalers (U) can
produce a root surface without cementum and with open
dentinal tubules (26). More specifically, root surfaces treated
by U exhibited a scaly and rough topography, whereas the
teeth treated with HC presented smooth surfaces. Kawashima
et al. compared two different U (Vector
TM
and Enac
R
scaler)
with HC and found that both U groups had significantly more
remaining cementum than the HC group (27). In addition,
they observed some areas with thin or absent cementum in
the HC group. Ruhling et al. compared the effects of various
ultrasonic scalers, sonic scalers (SS) and HC and found that
HC and SS groups caused greater removal of cementum (28).
In fact, nearly all cementum was removed in 25% of the sam-
ples treated with HC.
Tomasi et al. reported that biofilm and calculus certainly
should be removed, but also they questioned the requirement
for removal of ‘contaminated’ root cementum by root planning
(29). U with new shaped tips and subgingival air polishing
(AP) devices have been developed for removal of root accre-
tions with minimal root damage. In recent years, newly devel-
oped instruments have provided clinically positive results in
the treatment of chronic periodontitis with minimal cementum
removal. As AP has been suggested as a treatment modality
for root debridement (30), recent studies (31, 32) using this
technique have revealed probing depth reductions and
removal of subgingival biofilm. Currently, there is no scientific
evidence showing the loss of root substance or surface rough-
ness by AP or U instrumentation with AP (33).
The aim of the present clinical study was to evaluate how
much cementum could be retained as well as the surface char-
acteristics of the retained cementum following in vivo root
instrumentation. More specifically, a new U instrument with or
without AP with glycine powder was compared to HC on
cementum removal on diseased root surfaces that had never
been periodontally treated.
Materials and methods
Selection criteria
Twenty-seven patients (aged >18) with teeth diagnosed with
severe chronic periodontitis and scheduled for extraction were
included in this study. The inclusion criteria included partici-
pants who were systemically healthy, were non-smokers, had
single-rooted teeth or molars with fused roots and had bleed-
ing on probing. The patients participated on the basis of a
periodontal probing depth (PPD) 5 mm in at least two sites
per tooth with radiographical bone loss for more than two-
thirds of root length and having hopeless single-rooted teeth
for periodontal treatment. Exclusion criteria for subjects
included subjects who were pregnant, breastfeeding, had been
treated for periodontal disease (either non-surgical or surgical),
had dental caries or restorations on the mesial or distal tooth
surfaces or had class III dental mobility. The study protocol
was approved by the Sapienza, University of Rome Ethical
Committee (Resolution 2821 from the National Health Coun-
cil, Health Ministry, Italy, 26/09/2013; ClinicalTrials.gov Iden-
tifier: NCT02205619 with the Protocol Record ABT-1233-RV),
the participants volunteered for the study after receiving ver-
bal and written information and a signed informed consent
approved by the Sapienza, University of Rome Ethical Com-
mittee in accordance with the Declaration of Helsinki. The
patients selected had periodontal pocketing with radiographic
bone loss of more than two-thirds of the root length with a
hopeless tooth prognosis.
Clinical procedures
All the subjects of the study received a supragingival tooth
cleaning 1 week prior to the measurements with the use of
ultrasonic scaler (Air-Flow Master Piezon
â
, Instrument Tip A;
EMS SA, Nyon, Swiss) and glycine-based air polishing
2|| Int J Dent Hygiene
Bozbay et al. Cementum amounts after variety of debridements
(Air-Flow
â
Powder SOFT; EMS SA). Probing depths (PD)
and clinical attachment levels (CAL) were measured by a cali-
brated investigator (DDS) prior to instrumentation. The mea-
surements were carried out on all teeth, at six locations per
tooth to nearest 1 mm using a standardized periodontal probe
(PCPUNC 15, University of North Carolina, Hu-Friedy,
Chicago, IL, USA).
Prior to extraction, the teeth (n=48) were randomly divided
into these four treatment groups: (i) piezoelectric ultrasonic sca-
ler (U) (Air-Flow Master Piezon
â
, Instrument Tip PS; EMS SA);
(ii) U (Air-Flow Master Piezon
â
; EMS SA) followed by air pol-
ishing with the glycine powder (Air-Flow
â
Powder Perio, Perio-
Flow Nozzles; EMS SA) (U +AP); (iii) air polishing with the
glycine powder (Air-Flow
â
Powder Perio, Perio-Flow Nozzles;
EMS SA) (AP); and (iv) hand instruments (HC) (Gracey curettes
5/6, 11/12, 13/14 American Eagle, Missoula, MT, USA). Treat-
ment options were randomly assigned to the operator immedi-
ately prior to treatment. Instrumentations with air polishing and
U devices were performed with medium power settings and with
the use of water cooling (as instructed by the manufacturer).
One approximal root surface (distal or mesial) of each tooth was
randomly subjected to debridement, and the other approximal
surface was used as control. All the measurements and instru-
mentations of teeth were performed by a single operator (DDS).
The criteria for adequate treatment were smooth, hard root sur-
faces, with no clinical evidence of calculus. The cleanliness and
smoothness of the root surface were checked using a fine dental
explorer (Hu-Friedy 3A Explorer, Chicago, IL, USA). The
instrumentations were carried out under local anaesthesia. The
length of time required for scaling, air polishing and root planing
with each instrument was recorded in seconds (s). The mesial
and distal locations of the gingival margin that were marked on
the root surface were determined and marked with shallow
‘V’-shaped notches by a diamond flame bur. Following instru-
mentation, the teeth were immediately extracted atraumatically
and wiped with wet gauze to remove debris. The teeth were
stored in numbered and labelled jars in a solution of 0.9% w/v of
NaCl (about 300 mOsm/l) for a maximum 30 days.
SEM procedures
Before sectioning, the root surface characteristics of 20 ran-
domly selected teeth were analysed using a scanning electron
microscopy (LEO, EO 435 VP, Marvell Nanofabrication,
Berkeley, CA, USA). The roots were gold-sputtered with a
sputtering device (Agar Sputter Coater, 108 Supply 230, Fre-
quency 50, Essex, UK). Micrographs were taken at magnifica-
tions from 948 to 9210. Remaining Calculus Index (RCI) and
Roughness Loss of Tooth Substance Index (RLTSI) were cal-
culated to determine remaining calculus, root surface rough-
ness and loss of root substance. However, calculus appearance
was provided with qualitative information on the mineral and
organic composition of the root surface. Additionally, scratches,
gouges, cracks, cementum presence and any other changes in
the cementum were noted.
Specimen preparation
The teeth were rinsed in NaOCl for 2 min to remove deposits
and periodontal fibres before sectioning. The gingival margin
on the mesial and distal root surfaces were identified from pre-
vious markings (while teeth were in situ), and a line was drawn
at the level of the marked area with a permanent marker (ed-
ding, 780 gloss paint marker 0.8 mm, Ahrensburg, Germany)
to ensure evaluation of subgingival root surfaces. Subsequent
to the identification of the subgingival root surface, crowns
were removed, teeth were cut into mesial and distal sections
and the roots were stored in a decalcification solution
(Osteomoll
â
rapid decalcifier, Merck Millipore, Darmstadt,
Germany) for 24 h. After decalcification, the roots were
immersed in a tissue processor (Leica ASP300S, Wetzlar, Ger-
many) for approximately 24 h and embedded into paraffin
blocks. The teeth were sectioned perpendicularly to the root
axis with a microtome (Leica, RM2245, Wetzlar, Germany)
between 10 and 15 lm thickness and stained with haema-
toxylin and eosin. Two horizontal root sections of each tooth
were taken from the coronal and apical portion of the instru-
mented root for a total 96 histologic specimens. Coronal sec-
tions were taken 1 mm apically from the gingival margin,
whereas apical sections were taken 1 mm coronally from the
notched root surface (i.e. endpoint of periodontal pocket).
Measurement process
Both histologic and SEM measurements were carried out by
blinded examiners. The teeth were examined by an optic
microscope (Nikon Eclipse i5, Tokyo, Japan) connected to a
camera (Nikon, DS-Filc, Tokyo, Japan) and a dedicated com-
puter. The thickness of the cementum was measured by speci-
fic software (Nikon, NIS Elements 4.0, Tokyo, Japan). As
shown in Fig. 1, six components, including the mesial and dis-
tal areas of each tooth, were analysed and each measure was
reported as a mean value of five quantifications (Fig. 3a).
Statistical analysis
Statistical analyses were performed with SPSS software (SPSS
21.0, IBM
â
Corp, Armonk, New York, USA). Paired t-tests
were used to evaluate the differences between the thickness
of instrumented and non-instrumented surfaces for each group.
The amount of cementum in instrumented and non-instru-
mented surfaces was calculated, and one-way analysis of vari-
ance (ANOVA) test was used for comparisons between the
differences of four instrumentation groups. Tukey’s HSD and
Bonferroni tests were performed to compare multiple compar-
isons between instrumentation groups. Pvalues <0.05 were
considered as statistically significant.
Results
Ninety-six sections of 48 teeth were processed for histologic
examination. The mean age of patients (14 females and 13
Int J Dent Hygiene || 3
Bozbay et al. Cementum amounts after variety of debridements
males) was 42.5 years. The mean values of PD and CAL for all
teeth were 5.08 1.64 mm and 7.77 2.10 mm, respectively.
Regardless of the type of subgingival instrumentation, a sta-
tistically significant amount of cementum was removed in both
coronal and apical surfaces of the root (Table 1). Despite the
consistent removal of cementum, there were differences
between the treatment modalities in regard to the amounts of
cementum retained following the subgingival instrumentation.
The percentages of coronal cementum retained were 84% with
U, 80% with U +AP and 94% with AP, whereas HC only
retained 65% of the cementum. In the apical sections, cemen-
tum loss was 84% with U, 83% with U +AP, 88% with AP
and 70% with HC. When comparing the cementum retention
for coronal and apical sections, only AP had a statistically sig-
nificant effect on reducing the amount of remaining cementum
in apical sites when compared to coronal sites (P=0.027).
Overall, power-driven instruments were statistically more
efficient at retaining cementum when compared to hand
instruments. More specifically, HC and U +AP produced sig-
nificantly greater cementum removal than AP in coronal sec-
tions (P=0.002, P=0.004, respectively); HC caused
significantly greater removal of cementum than AP in apical
sections (P=0.016). It should be noted that in both the coro-
nal and apical sections, AP produced the least amount of
cementum loss and therefore the greatest retention of residual
cementum.
Fig. 1. Schematic drawing of the measurement method.
Table 1. AB: Mean cementum thickness and standard deviation (SD), in micrometres, for each coronal and apical cut section. C:
Mean loss of cementum thicknesses and standard deviation (SD), in micrometres, for each coronal and apical cut section,
*: considered as statistically signicant (P<0.05)
(A)
Coronal sections
Non-instrumented Instrumented
Paired t-test
Instrumentation Mean SD Mean SD
Piezoelectric (U) 77.11 32.65 64.04 33.84 P<0.001
U+AP (Piezo +air polish) 103.37 49.70 82.57 44.19 P<0.001
AP (air polishing) 70.53 46.13 65.60 45.48 P=0.008
Hand curettes (HC) 62.77 21.64 40.49 12.39 P<0.001
(B)
Apical sections
Non-instrumented Instrumented
Paired t-test
Instrumentation Mean SD Mean SD
Piezoelectric (U) 89.23 47.93 74.73 43.65 P<0.001
U+AP (Piezo +air polish) 100.49 40.38 82.93 35.92 P=0.001
AP (air polishing) 74.28 29.12 64.81 30.46 P=0.003
Hand curettes (HC) 76.74 18.00 53.07 13.03 P<0.001
(C)
Coronal sections Apical sections
Paired t-test
Instrumentation Mean SD Mean SD
Piezoelectric (U) 13.08 7.59 14.50 79.479 P=0.734
U+AP (Piezo +air polish) 20.80 12.10 17.56 13.6348 P=0.571
AP (air polishing) 4.93 5.24 9.47 8.5204 P=0.027
Hand curettes (HC) 22.28 15.22 23.67 13.1199 P=0.762
One-way ANOVA (P=0.001) (P=0.025)
4|| Int J Dent Hygiene
Bozbay et al. Cementum amounts after variety of debridements
In regard to mean time to complete root instrumentation,
the shortest mean time was using AP and the longest mean
time was U +AP. In comparison with HC, AP required 31%
less time for root preparation, whereas U +AP required 30%
more time (Table 2).
SEM results
The teeth instrumented with HC exhibited smooth surfaces,
while the cementum appeared completely removed in one
micrograph (as showed in the Fig. 2b); whereas in other micro-
graphs, a few areas without cementum could be noticed. Root
surfaces instrumented with U (Fig. 2a) presented with grooves
and scratches as did roots instrumented with U +AP (Fig. 2c).
Large areas without remaining calculus and with a relatively
smooth and intact surface occurred following the use of all the
instruments tested, although the use of AP (Fig. 2d) left the
surface more intact and inadequate on removal of calculus
than the other groups.
Discussion
This study was initiated to assess the in vivo removal of root
cementum following different traditional periodontal treatment
methods. Once these different clinical instrumentation tech-
niques were applied, in vitro histologic measurements were
used to evaluate cementum removal following teeth extractions.
There are few in vivo studies that have compared root surface
characteristics following periodontal instrumentation (2628, 34,
35), and this study investigates the effects of various types of
in situ instrumentation on cementum removal in periodontal
patients. More specifically, this is the first study to histologically
determine, using multiple replicate measures, the effects of a
clinician in achieving both debridement and preservation of a
diseased root surface on never-instrumented teeth.
The in vitro evaluation of substance loss of dental tissue has
been described by various investigators using different
periodontal treatment methods (1625, 3638). All of the peri-
odontal treatment methods used in this study have demon-
strated the removal of cementum, although AP alone
eliminated less cementum than HC or U. The histologic sec-
tions of the present study indicated that cementum was gener-
ally present on the root surfaces after experimental
instrumentation; only in the three sections of the HC group
was the cementum totally absent and the dentin layer exposed
(Fig. 3b) and was thinner on the instrumented areas (Fig. 3c).
Because diseased root cementum is thinner than healthy
cementum (39, 40), one can hypothesize that during
Table 2. Mean instrumentation time and standard deviation
(SD), in seconds, for each treatment group, *: considered as
statistically signicant (P<0.05)
Instrumentation Mean SD Tukey’ s HSD test
Piezoelectric (U) 103.50 43.83 P>0.05
U+AP (Piezo +air polish) 149.42 52.94 P>0.05
AP (air polishing)*70.75 30.37 P<0.05*
Hand curettes (HC) 139.00 54.23 P>0.05
(a) (b)
(c) (d)
Fig. 2. Representative 489photomicrographs of the four instrumentation groups. (a) Instrumented root with U. Cementum is absent coronally.
Cementum has irregularities, scratches and gouges. (b) Instrumented root with HC. There is no cementum in the instrumentation area, surface
clean and smooth. (c) Instrumented root with U +AP. Most of the cementum is intact, groove present with irregularities and debris. (d) Instru-
mented root with AP: cementum is present.
Int J Dent Hygiene || 5
Bozbay et al. Cementum amounts after variety of debridements
instrumentation of the diseased root, a portion of the dentin
structure may also be removed with the cementum.
An in vitro study (34) comparing the depth of root surface
removal by hand curettes with different stroke numbers has
shown that hand curettes removed cementum completely with
a minimum of 20 strokes. However, they used periodontally
healthy teeth including impacted third molars and bicuspids.
To replicate routine clinical treatment procedures, only peri-
odontally diseased teeth were selected for the present study.
Ritz et al. (36) reported that the debridement of the root sur-
face should preserve the root material. This being the case,
this study demonstrates how much root cementum can be
retained after power-driven or hand instrumentation of root
surfaces.
Regardless of the amount of cementum removed, patches of
dental calculus could be observed, from SEM micrographs, on
the root surfaces in U or AP instrumentation groups. These
findings are consistent with those of Crespi et al. (26) who
found both ultrasonic devices and hand curettes were not cap-
able of removing all residual plaque and calculus deposits pre-
sent on root surfaces. Although single instrumentation
procedures were not able to remove all calculus, this study
found that a combination of instrumentation (e.g. U +AP)
was able to remove all residual calculus deposits present on
root surfaces. Therefore, U devices in conjunction with AP
seem to be more efficient for the removal of hard or soft
deposits.
In regard to root roughness, the present findings seem to be
consistent with Schimidlin and co-workers who found that
roots instrumented with hand curettes produced the smoothest
surfaces if compared to the surfaces instrumented with the
ultrasonic or sonic scalers (19). Similarly, Bless et al. (25) found
that rougher surfaces occurred after treatment with ultrasonic
scalers when compared to treatment with hand curettes. The
SEM results of this study have shown that smoother root sur-
faces can be obtained with HC when compared to U.
The time necessary to complete a procedure can also play
an important role in what type of instrumentation a dentist
will use. The time required to complete root surface prepara-
tion in this study varied depending on the type of subgingival
instrumentation. The average time for HC was 115.33 s per
site. Although the time of use of U (107.83 s) was similar to
HC, the use of U +AP was significantly longer than HC
(34.75 s) and U was significantly shorter (36.5 s) than HC.
The thickness of cementum can be affected by various fac-
tors (41), and a limitation of this study was the assumption
that the thickness of the cementum on the mesial and distal
surfaces was similar. Bellucci and Perrini (41) measured the
thickness of radicular dentine and cementum of 220 single-
rooted incisors, canines and premolars from adult subjects aged
between 35 and 55 years and revealed differences between
mesial and distal thicknesses were not statistically significant.
In contrast, Dastmalchi et al. (42) reported markedly thicker
cementum on the distal root surfaces of eight human premo-
lars and three molars and speculated that this was due to ten-
sile forces after mesial drift. Furthermore, Stamfelj et al. (43)
have shown that distal and oral root surfaces exhibit thicker
cementum than corresponding mesial and vestibular surfaces
of multirooted teeth. Although similarity between mesial and
distal cementum thickness may be controversial, data from the
above-mentioned studies do not confirm differences in cemen-
tum thicknesses between mesial and distal sides of the tooth.
From a biological perspective, the periodontium has been
shown to contain biologically active mediators (12, 4446) and
these molecules are elevated in alveolar bone and cementum
(4750). Periodic professional cleaning may lead to major
losses of root cementum, leading to a loss of growth factor
reservoirs in the cementum. For this reason, it is strongly sug-
gested that the root surface debridement should aim on
preserving root substance to improve healing following non-
surgical or surgical therapy. The study design of this
work seems to help in showing how the efforts of a clinician,
in achieving both debridement and preservation of a diseased
root, can be measured, the former using never-instrumented-
diseased root surfaces and the latter by obtaining replicable
thicknesses of cementum with the use of averages of the
entire perimeter of the tested root in one specific site.
Clinical relevance
Scientic rationale for the study
Cementum is a key component of periodontal tissues, and its
preservation is of paramount importance for the quality of
(a) (b) (c)
Fig. 3. Haematoxylin and eosin histologic root sections (magnification 9400). (a) Instrumentation of root surface: evaluation of cementum thickness
is a mean value of five measurements at each point. (b) Instrumentation of root surface with HC. The surface is without cementum, exposed den-
tin present. (c) Instrumentation of root surface with HC. The cementum thickness is thinner on the middle of the approximal surface.
6|| Int J Dent Hygiene
Bozbay et al. Cementum amounts after variety of debridements
healing at completion of periodontal both non-surgical and
surgical treatment modalities. Periodontal reattachment or
new attachment as end result of therapy strongly relies on
the presence of cementum after root instrumentation. Impro-
per or aggressive mechanical instrumentation may reduce the
thickness or eventually remove all the cementum over the
root surface. This study investigates the effects of various
types of in situ instrumentation on cementum removal in
periodontal patients. More specifically, this is the first study
to histologically determine, using multiple replicate measures,
the effects of a clinician in achieving both debridement and
preservation of a diseased root surface on never-instrumented
teeth.
Principle ndings
AP was significantly more effective on preserving cementum.
Use of HC resulted more removal of cementum than those of
US and AP.
Practical implications
Clinicians seek for more conservative or minimally aggressive
means for root debridement as it may offer better chance for
cementum preservation. Clinical methods aiming at the regen-
eration of inserted and functionally oriented new fibres may
benefit from this type of approach for proper preparation of
the previously diseased root surfaces.
Acknowledgements
The authors thank Professor Antonella Polimeni from Sapien-
za, University of Rome, Italy, for the knowledgeable contribu-
tion to the protocol of this study. The authors wish to thank
Dr. Sevda Ozel from Istanbul University for the statistical
analyses.
Source of support
Research Fund of Istanbul University.
Conflict of Interest
None.
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8|| Int J Dent Hygiene
Bozbay et al. Cementum amounts after variety of debridements
... Still, the surface of the root becomes rough [8,9]. Therefore, using hand instruments and ultrasonic instrumentation has been recommended in treating root surfaces affected by the disease [10][11][12]. ...
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The present study aimed to evaluate the root surface topography and cutting-edge retention after mechanical root planing using five different types of curettes. Sixty premolars were divided among stainless steel curette (SS), titanium-coated curette (SC), titanium curette (Ti), EverEdge curette (EE), and XP curette (XP) groups. Mean tooth surface roughness (Ra) and the mean roughness depth (Rz) values were determined. The SEM and EDX values were checked after 40, 500, 1,000, and 2500 strokes. At 40 strokes, the mean Ra value of 2.33 ± 0.88 and mean Rz value of 18.5 ± 5.70 was the lowest recorded for titanium coated instrument. After 500 strokes, XP curettes presented with the lowest Ra and Rz values of 1.39 ± 0.25 and 12.32 ± 1.76, respectively. After 1000 and 2500 strokes, the XP curettes had Ra (1.02 ± 0.07; 0.71 ± 0.12) and Rz (9.63 ± 0.50; 7.20 ± 0.96), respectively. The 2-way ANOVA of Ra and Rz values and the post hoc showed a statistically significant difference with p < 0.05. The SEM analysis showed the surface of the roots to be smoother in XP, and the cutting was retained in XP and the EE curettes. In the EDX analysis, there was corrosion on the lateral surface of the Ti and the SC. XP curettes showed to be better statistically than other curettes, and both XP and EE retained the cutting edges longer. Hence, curettes with edge retention technology are long-lasting and effective for root surface instrumentation in periodontal practice.
... Another material frequently used for oral biofilm assays is hydroxyapatite (HA) [49], mimicking dental enamel surfaces. In vivo, periodontal biofilms predominantly adhere to enamel, dentine [50] and cementum [51]. In future studies, utilising dental tissue substrates such as dentine slices or other relevant surfaces such as titanium used in dental implant manufacturing, in combination with inverted CLSM [52] or atomic force microscopy [53,54] could provide more detailed information on bacterial adhesion and biofilm architecture. ...
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Development of dysbiosis in complex multispecies bacterial biofilms forming on teeth, known as dental plaque, is one of the factors causing periodontitis. Fusobacterium nucleatum ( F. nucleatum ) is recognised as a key microorganism in subgingival dental plaque, and is linked to periodontitis as well as colorectal cancer and systemic diseases. Five subspecies of F. nucleatum have been identified: animalis, fusiforme, nucleatum, polymorphum , and vincentii . Differential integration of subspecies into multispecies biofilm models has been reported, however, biofilm forming ability of individual F. nucleatum subspecies is largely unknown. The aim of this study was to determine the single-subspecies biofilm forming abilities of F. nucleatum ATCC type strains. Static single subspecies F. nucleatum biofilms were grown anaerobically for 3 days on untreated or surface-modified (sandblasting, artificial saliva, fibronectin, gelatin, or poly-L-lysine coating) plastic and glass coverslips. Biofilm mass was quantified using crystal violet (CV) staining. Biofilm architecture and thickness were analysed by scanning electron microscopy and confocal laser scanning microscopy. Bioinformatic analysis was performed to identify orthologues of known adhesion proteins in F. nucleatum subspecies. Surface type and treatment significantly influenced single-subspecies biofilm formation. Biofilm formation was overall highest on poly-L-lysine coated surfaces and sandblasted glass surfaces. Biofilm thickness and stability, as well as architecture, varied amongst the subspecies. Interestingly, F. nucleatum ssp. polymorphum did not form a detectable, continuous layer of biofilm on any of the tested substrates. Consistent with limited biofilm forming ability in vitro, F. nucleatum ssp. polymorphum showed the least conservation of the adhesion proteins CmpA and Fap2 in silico . Here, we show that biofilm formation by F. nucleatum in vitro is subspecies- and substrate-specific. Additionally, F. nucleatum ssp. polymorphum does not appear to form stable single-subspecies continuous layers of biofilm in vitro . Understanding the differences in F. nucleatum single-subspecies biofilm formation may shed light on multi-species biofilm formation mechanisms and may reveal new virulence factors as novel therapeutic targets for prevention and treatment of F. nucleatum -mediated infections and diseases.
... µm. 9 When calculating the thickness of cementum loss with the thickness of total cementum, it appears that there should be a thin layer of cementum left after scaling and root planing. If root sensitivity occurs according to the hydrodynamic theory, the minimal thickness of cementum that can protect the movement of dentinal fluid is another point of concern. ...
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Root sensitivity is a common complication that occurs after periodontal therapy. The etiology is multifactorial, which causes the exposure of dentin. The hydrodynamic theory is the underlying mechanism that describes dentin sensitivity. However, the exact mechanism of how root sensitivity occur is still unknown. This review comprises the prevalence, etiology and managements of root sensitivity. The effect of mechanical debridement on the structure of root is also included. Due to the increasing attention in nanotechnology and nanomaterials, the use of nanomaterials in the management of dentin hypersensitivity are reviewed as a part of the management improvement. Finally, the understanding of root sensitivity and the possible applications of nanomaterials in the treatment together with some research questions that may lead to more understanding and more satisfying managements for root sensitivity are discussed.
... Результати дослідження показали, що робота магнітострикційним ультразвуковим скалером усувала менше цементу порівняно з зоноспецифічними кюретами Грейсі. Ці дані узгоджуються з дослідженнями, проведеними Bozbay et al. та Ritz et al. [6,7]. У пацієнтів із генералізованим пародонтитом цемент кореня зубів тонший, тому під час інструментальної обробки поверхні коренів зубів можна видалити цемент разом із нижчеприлеглим дентином, що призведе до оголення дентинних трубочок. ...
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Актуальність. Важливу роль у процесах регенерації пародонтального комплексу у хворих на генералізований пародонтит відіграє цемент кореня зуба. Мета дослідження: вивчити вплив механічної обробки поверхні коренів зубів на товщину цементу при проведенні пародонтологічного лікування у пацієнтів із генералізованим пародонтитом. Матеріали та методи. У дослідження включено 14 пацієнтів із генералізованим пародонтитом, яким було проведено пародонтологічне обстеження. Матеріалом дослідження стали 24 зуби з генералізованим пародонтитом II–III ступеня тяжкості, видалених за ортопедичними і пародонтологічними показаннями. Результати. Товщина цементу коренів зубів (на поздовжніх шліфах), що оброблялися зоноспецифічними кюретами Грейсі, була найнижчою, її середні показники становили 5,47 ± 3,35 мкм, тоді як товщина цементу верхньої третини коренів зубів, що не підлягали інструментальному впливу, була 44,09 ± 15,32 мкм. За результатами морфометрії цементу поздовжніх шліфів зубів встановлено значний вплив зоноспецифічних кюрет Грейсі на товщину цементу кореня порівняно з магнітострикційним ультразвуковим скалером (p = 0,020). Висновки. На товщину цементу коренів зубів впливають зміни pH ротової рідини, мікробний біофільм, інфекційно-запальні процеси в тканинах пародонта та інструментальна обробка коренів зубів. У пацієнтів із пародонтитом зменшення товщини цементу коренів зубів разом із підвищеним жувальним навантаженням у результаті травматичної оклюзії та низькими регенеративними властивостями цементу пришийкової частини кореня зуба є чинниками розвитку гіперестезії та цервікальних уражень.
... Each treatment causes loss of dental material, sometimes inducing endodontic problems. This will reduce the regeneration possibilities by removing the Enamel Remnants of Malassez, remnants of the root formation, capable of producing Enamel Matrix Proteins(EMP), signaling molecules for regeneration [14]. ...
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Abstract: One-stage, Full-mouth Sulcular Debridement with FRP 1064 Nd:YAG as Adjunctive to a Full Mouth Initial Periodontal Therapy: A Clinical Case Series Retrospective Study Objective: Since the high prevalence, worldwide, of periodontitis and periimplantitis, both proven to contribute and/or exacerbate systemic diseases by their inflammatory response, they are becoming a major concern in general health care. The search for finding a cost-effective and repeatable treatment for the majority of the population, without causing detrimental side effects, are a necessity and has been a question mark for many years. Since traditional treatment protocols cannot meet to all our expectations and have some contraindications, the rational of One Stage Full Mouth Disinfection (OFMD) has been the new paradigm in treatment strategy. However, several important details can be optimized. Lasers have taken an eminent place in periodontal care the last two decades. Straggly, they still didn’t find their way in mainstream dentistry. The use of Free Running Pulsed (FRP) Lasers in particular, might solve some shortcomings in the traditional approach. The reason behind this, is the way FRP lasers, by their very short bursts of energy, cannot only take care of bacterial and viral components of the periodontal infection, in hard as well as in soft tissue, but also by dissipation of that energy, have the capability to repair and at a certain level, stimulates regeneration. This can contribute to preservation of soft and hard tissue, in a cost-effective way. Materials and Methods: This retrospective cohort study collected data of 53 patients in private practice, having dpsi3+ or 4, undergoing all the same protocol of a true OFMD of scaling with adjunct of FRP laser treatment, with or without antibacterial support as indicated along microbiological assessment. Periodontal parameters were compared to baseline, at 2, 8 up to 14 months, without retreatment. Results: Clinical outcome of the parameters for all cases were statistically significant improved to baseline. Age, gender or classification of the periodontal condition didn’t affect the results of the procedure. Conclusions: One -Stage, Full-Mouth disinfection by scaling, in combination with laser attachment procedure for debridement of the pocket, disinfection of dentine and if necessary specific indicated antibiotics, provides a predictable outcome of statistically gain of attachment level in a cost effective way for every patient. Key words: Periodontitis, peri-implantitis, OFMD, Free Running Pulsed lasers, repair, regeneration, cost- effective treatments. Introduction: In physiological conditions, we live in balance with a microbiome and/or virome, mainly governed by our immune system. Existence would be impossible without this equilibrium, providing essential nutrients, contributing to general health(1). This ecosystem, called symbiosis can be disturbed and is called dysbiosis, which is the major cause of degenerative disease amongst periodontitis and periimplantitis, by an abundance of Reactive Oxygen Species (ROS/) and exacerbating systemic disease by the inflammatory response (2-5).Classification of both, periodontitis and periimplantitis have been documented in the EUROPERIO IX report(6). Periodontitis is also host dependant and listed as one of the factors contributing to periimplantitis. A lifelong maintenance program is required without detrimental side effects like hypersensitivity, recessions and in a cost effected way(7, 8). Lasers, being used in dentistry for over 30 years, have in spite of the significant advantages, still not found their way in mainstream dentistry. The scientific questions being asked is: Why is peak power, created by Free Running Pulsed Lasers(FRP) giving much advantages over other pulsed lasers or traditional standard operational procedures(SOP) of scaling and rootplaning (SRP), or ultimately, flap surgery? To address these questions, some understanding of periodontal structures and disease, aim of the treatment and some understanding of laser physics is required. Periodontology & Periodontitis. Periodontitis, also known as gum disease is defined as the inflammatory process of the deeper structures of supportive dental structures in response to bacterial or other detrimental processes, which can lead to dysfunction and ultimately to the loss off teeth. To stop this process, managing the cause of destruction, is our prime goal. Next to systemic conditions and malocclusion, the main cause is imbalance in the microbiome and virome. Traditional approach of SRP and flap surgery is removing soft and hard dental plaque. Disinfection of the root surface by rootplaning to disinfect dentine tubules, acting as reservoirs for reinfection is removing too much cementum from which regeneration might occur(9-11). 1. Shkoporov AN, Clooney AG, Sutton TDS, Ryan FJ, Daly KM, Nolan JA, et al. The Human Gut Virome Is Highly Diverse, Stable, and Individual Specific. Cell Host Microbe. 2019;26(4):527-41 e5. 2. Liguori I, Russo G, Curcio F, Bulli G, Aran L, Della-Morte D, et al. Oxidative stress, aging, and diseases. Clin Interv Aging. 2018;13:757-72. 3. Deng ZL, Szafranski SP, Jarek M, Bhuju S, Wagner-Dobler I. Dysbiosis in chronic periodontitis: Key microbial players and interactions with the human host. Scientific reports. 2017;7(1):3703. 4. Sanz M, Marco Del Castillo A, Jepsen S, Gonzalez-Juanatey JR, D'Aiuto F, Bouchard P, et al. Periodontitis and cardiovascular diseases: Consensus report. J Clin Periodontol. 2020;47(3):268-88. 5. Singhrao SK, Harding A, Poole S, Kesavalu L, Crean S. Porphyromonas gingivalis Periodontal Infection and Its Putative Links with Alzheimer's Disease. Mediators Inflamm. 2015;2015:137357. 6. Caton JG, Armitage G, Berglundh T, Chapple ILC, Jepsen S, Kornman KS, et al. A new classification scheme for periodontal and peri-implant diseases and conditions - Introduction and key changes from the 1999 classification. J Clin Periodontol. 2018;45 Suppl 20:S1-S8. 7. Berglundh T, Armitage G, Araujo MG, Avila-Ortiz G, Blanco J, Camargo PM, et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018;89 Suppl 1:S313-S8. 8. Axelsson P, Nystrom B, Lindhe J. The long-term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults. Results after 30 years of maintenance. J Clin Periodontol. 2004;31(9):749-57. 9. Kina JR, Kina J, Kina EF, Kina M, Soubhia AM. Presence of bacteria in dentinal tubules. J Appl Oral Sci. 2008;16(3):205-8. 10. Bozbay E, Dominici F, Gokbuget AY, Cintan S, Guida L, Aydin MS, et al. Preservation of root cementum: a comparative evaluation of power-driven versus hand instruments. Int J Dent Hyg. 2018;16(2):202-9. 11. Sculean A, Gruber R, Bosshardt DD. Soft tissue wound healing around teeth and dental implants. J Clin Periodontol. 2014;41 Suppl 15:S6-22.
... In the periodontal healing response, fibroblasts in gingival tissue synthesize collagen fibers connecting the gingiva and cementum, which play a key role in new tissue formation [26]. At present, fibroblast attachment is the main index to evaluate the biocompatibility of the tooth root surface [27]. ...
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BACKGROUND This study aimed to compare the effectiveness of subgingival scaling and root planing with the Twinlight laser, Er: YAG laser, and hand instrumentation on the removal of endotoxin and attachment of human gingival fibroblasts (HGFs) to cementum surfaces in vitro. MATERIAL AND METHODS Single-rooted teeth extracted for periodontal disease were collected and divided into 3 groups: group A, root planing with Gracey curet no. 5/6; group B, irradiation with Er: YAG laser; group C, irradiation with Er: YAG laser and Nd: YAG laser. Endotoxins were determined by the limulus amebocyte lysate test. Cell attachment and proliferation of HGFs on root specimens were evaluated by cell counting kit-8 assay. The root surface and cell morphology were observed by scanning electron microscope. RESULTS A flat root surface with scratches was found in group A, Group B had a homogeneous rough morphology without carbonization, and group C had a non-homogeneous rough morphology with ablation. The endotoxin concentration was highest in group A (P<0.05) and lowest in group C (P>0.05). HGFs cultured in group B showed significantly increased adhesion and proliferation compared with groups A and C (P<0.05). HGFs in group B were well attached, covered densely by pseudopodia. HGFs in group A were round with poor extension and short pseudopodia, while the cells in the group C were in narrow, triangular, or polygonal shapes. CONCLUSIONS Twinlight laser-assisted periodontal treatment effectively improved the biocompatibility of root surface and promoted the attachment and proliferation of fibroblasts by removing calculus and reducing the concentration of endotoxins.
Article
Objectives To assess the differential early wear susceptibility of cementum, enamel and dentine at a micron level. Methods Whole human molar buccal surfaces incorporating natural enamel and cementum (n = 20) confirmed by imaging (digital microscopy: Keyence, VHX-7000 Milton Keynes, UK), were mounted, scanned (profilometry: XYRIS 4000, Taicaan, Southampton, UK), and allocated to receive erosion (citric acid, pH 2.7, 30 min (n = 10)) or erosion/abrasion challenges (3 cycles of (citric acid, pH 2.7, 10 min, 60 300 g linear abrasion strokes), n=10). Samples were polished and the experiment repeated on polished enamel, and polished coronal and radicular dentine within the same tooth. Profilometric wear data were obtained using superimposition: GeoMagic (3Dsystems, Darmstadt, Germany) and subtraction: MountainsMap (DigitalSurf, Besancon, France). Data were normal. A general linear model was used to assess differences between groups and substrates. Results The mean step height (SD) for natural enamel was 8.82 μm (2.53) for erosion and 11.48 μm (2.95) for erosion/abrasion. For natural cementum, the mean step height was 6.00 μm (2.29) for erosion and 4.67 μm (1.58) for erosion/abrasion. Dentine step heights ranged from 7.20 μm (1.53) for erosion and 9.79 μm (1.01) for erosion/abrasion with no statistical differences in dentine wear. Natural cementum surfaces had the lowest wear (p<0.001). Dentine had significantly less wear than natural enamel (p<0.02). Conclusions Cementum surfaces demonstrated the most wear resistance, followed by dentine under erosion dominant conditions in this in vitro study. Further in-vivo investigations are needed to confirm the intraoral stability of cementum. Clinical Significance Cementum may be the least susceptible of dental substrates to wear and dentine does not wear at a faster rate than enamel under erosive conditions. This adds to our knowledge on the development of non-carious cervical lesions and questions whether wear rates will accelerate once dentine is exposed.
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Objectives Evaluating the efficiency of combined air polishing and Nd:YAG laser application in addition to scaling and root planning (SRP) in treatment of periodontal pockets of stage III grade C periodontitis patients was the aim of this clinical trial. Materials and methods Twenty-four systemically healthy, stage III grade C periodontitis patients were recruited for this clinical trial. In this split-mouth study, the quadrants were randomly allocated to either SRP with combined air polishing (erythritol/chlorhexidine powder) and Nd:YAG laser (2 W, 200 mJ/pulse, 10 Hz) therapy (test group) or SRP alone (control group). A masked examiner recorded clinical parameters such as plaque index (PI), gingival index (GI), bleeding on probing (%) (BOP %), probing depth (PD), and clinical attachment level (CAL) on periodontal charts at baseline, 1 month and 3 months after treatment. Results The clinical parameters had significantly reduced 1 and 3 months after treatment compared to baseline for both study groups (p < 0.05). Considering PI, GI, and BOP (%) parameters, there were no significant differences between the study groups at any time points (p > 0.05). While PD and CAL reductions were similar in study groups for moderately deep pockets (5 to 6 mm) (p > 0.05), PD and CAL reductions were significantly greater in test group compared to control group for deep pockets (PD ≥ 7 mm) (p < 0.05). Conclusions The present clinical trial demonstrated that SRP with combined application of air polishing and Nd:YAG laser may be advantageous in sites where mechanical debridement alone cannot access, such as deep pockets in the short term. Long-term, well-designed future studies including clinical, biochemical, and microbiological analyses are needed to determine the effectiveness of this procedure. Clinical relevance SRP with combined application of air polishing and Nd:YAG laser provided more reductions in probing depth and clinical attachment level parameters in deep pockets compared to SRP alone.
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Oral health maintains in good condition by the saliva that is an aqueous fluid in the oral cavity and constantly covers the teeth and oral mucosa. Saliva is secreted by the three major salivary glands: the parotid, submandibular and sublingual glands, and numerous minor salivary glands. The three major salivary glands generate about 90% of the fluid secretion and minor salivary glands less than 10%. The average daily flow of the whole saliva has been reported to vary in health between 1 and 1.5 L. In unstimulated conditions, the average range of flow rate is 0.3–0.4 mL/min with an osmolality ranging from 50 to 70 mOsmol/kg. However, the volume, flow, and composition of saliva can be altered under the influence of various factors and stimuli. Stimulation like masticatory or gustatory enhances flow rate up to 7 mL/min and changes the percentage contributions from each gland. The parotid is contributing more than 20% of total salivary secretions under unstimulated conditions; however, 50% of secretions are under stimulation.
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Supragingivally applied glycine powder air polishing (SupraGPAP) has been shown to remove biofilms in shallow periodontal pockets. This study assesses efficacy and safety of subgingivally applied glycine powder air polishing (SubGPAP) in moderate-to-deep periodontal pockets. Patients with chronic periodontitis and intraoral Porphyromonas gingivalis (P. gingivalis) and Tannerella forsythia who completed initial therapy were randomly assigned to receive SubGPAP in periodontal pockets with probing depths of 4 to 9 mm, SupraGPAP in all other shallow periodontal sites, and at mucous membranes followed by removal of calculus using curets (full-mouth GPAP) or scaling and root planing followed by coronal polishing (SRP). Patients rinsed with 0.12% chlorhexidine gluconate after debridement, and twice daily, for 2 weeks. All 30 patients enrolled completed the baseline, day 10, and day 90 visits. SubGPAP resulted in significantly lower total viable bacterial counts in moderate-to-deep pockets when compared to SRP immediately after debridement and at day 10 (P <0.05). Total P. gingivalis counts in the oral cavity were significantly reduced after full-mouth GPAP compared to SRP at day 90 (P <0.05). Patients' comfort levels were high for both treatments. There were no adverse events related to full-mouth GPAP. The results indicate that SubGPAP is more efficacious in removing subgingival biofilm in moderate-to-deep periodontal pockets than SRP. Furthermore, full-mouth GPAP may result in a beneficial shift of the oral microbiota and appears to be well tolerated.
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Some laboratory studies have evaluated the oscillation mode of ultrasonic scalers. None of them recorded its influence on calculus removal and quantified dental hard tissue loss. This study aimed to compare the performance of a magnetostrictive ultrasonic instrument at different power settings in vitro in relation to the tip oscillation activity. The oscillation activity of the straight Slimline® insert in the Cavitron® ultrasonic scaling device was analyzed at five different power settings with the help of two laser vibrometers. The performance of this instrument was tested on 60 roots of human single-rooted teeth. Twelve roots each were randomly assigned to be instrumented at a given power setting. Every root was instrumented for 120 s at a standardized instrumentation force of 0.1 ± 0.05 N. In addition, another 30 periodontally involved roots with subgingival calculus were instrumented accordingly to assess the calculus removal potential. The surface characteristics after instrumentation were analyzed under scanning electron microscope. The instrumentation at minimum power setting resulted in an mean increase of the root surface roughness of 0.18 ± 0.28 compared to 0.51 ± 0.48 at maximum power setting (P = 0.0327). The loss of dental hard tissue amounted to 11.37 ± 3.64 at minimum compared to 23.37 ± 15.76 at maximum power (P = 0.0010). The higher the power setting, the more calculus was removed. The values of the latter ranged between 4.04 ± 1.87 and 11.26 ± 4.66 mm² of cleaned dentin surface area (P = 0.0065). At lower power settings, a more favorable relation between cleaning ability, loss of dentine, and surface roughness was found.
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Objectives Air-polishing devices are used for the instrumentation of the root surface. Their potential of harm to the hard and/or soft tissues needs to be considered during periodontal treatment. The objective of this systematic review was to analyse the effects of air polishing devices on oral tissues.Methods The electronic databases MEDLINE, EMBASE and the Cochrane Library were screened for studies published through 18 November 2013. The surface modifications on human cementum, dentine or gingiva after the instrumentation were considered as outcomes.ResultsOf the 1266 abstracts screened, 17 studies were included in the analysis. Different air polishing powders consisting of sodium bicarbonate, calcium carbonate, pumice or glycine were used in different ex vivo or in vitro settings. Thirteen publications reported data on the effects of air polishing devices on cementum and dentine. Hard tissue modifications, including defect depths and volume, caused by sodium bicarbonate or calcium carbonate powders were significantly greater compared to powders consisting of glycine. The soft tissue modifications using different modes of instrumentation were assessed in four publications. The data demonstrate less potential of harm to the gingiva after spraying with glycine powder compared to sodium bicarbonate powder or instrumentation with curettes.Conclusion Glycine powder air polishing may be safely applied to human root surfaces and gingivae.
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Abstract Cementum thickness increases uniformly with age, and questionably from functional stimulation due to tensional forces. Mesial drift of teeth results in tensional forces on distal root surfaces. This study evaluated whether there was any discernible effect on cementum thickness related to mesial drift in humans. The material consisted of maxillary and mandibular bicuspids and molars with their surrounding periodontia from 5 humans (mean age at death, 48.6 years). The teeth and tissues had been sectioned histologically in a mesio-distal plane, and the analysis for each tooth was done using 3 step-serial sections from the mid-buccolingual region. On the mesial and distal surface of each tooth, cementum thickness was measured in μm at 3 defined locations at a level representing the mid-point of root length for bicuspids and molars. Means from the measurements on mesial and distal surfaces were compared using descriptive and inferential statistical methods. For each individual tooth analyzed, the cementum was thicker on the distal surface (range greater, 32–107%; mean, 69%). The statistical comparisons showed that cementum thickness on the distal surface was significantly greater for bicuspids (mesial, 135 μm: distal, 216 μm), molars (mesial, 154 μm : distal, 284 μm), and all teeth combined (mesial, 154 μm: distal, 284 μm). The magnitude of this difference became greater with increasing age. It was concluded that cementum thickness was markedly greater on the distal surfaces of teeth from adult humans, and that this may be due to functional stimulation from mesial drift over time.
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Abstract Flat root surface areas of formalin-stored mandibular incisors with plaque and calculus were scaled by sonic (PHATELUS® SONIC SCALER, SONIC FLEX 2000®, TITAN-S® SONIC SCALER) or ultrasonic instruments (HY-GIENIST® ULTRASONIC SCALER, CAVITRON®) or by a new reciprocating scaling insert for the EVA/PROFIN® system. The test areas were photographed by SEM and coded micrographs were independently graded by three examiners using the RCI (Remaining Calculus Index) and the RLTSI (Roughness Loss of Tooth Substance Index). The findings revealed that the sonic sealers as a group removed calculus more completely but also left significantly more roughness and loss of tooth substance than the other instruments tested. No difference was seen between the two ultrasonic sealers. The reciprocating insert gave results similar to those of the ultrasonic except for the scaling time which was significantly longer for the new “cleansing principle”.
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The objective was to determine clinical and microbiological effects and perceived treatment discomfort of root debridement by subgingival air polishing compared with ultrasonic instrumentation during supportive periodontal therapy (SPT). The trial was conducted as a split-mouth designed study of 2-month duration including 20 recall patients previously treated for chronic periodontitis. Sites with probing pocket depth (PPD) of 5-8 mm and bleeding on probing (BoP+) in two quadrants were randomly assigned to subgingival debridement by (i) glycine powder/air polishing applied with a specially designed nozzle or (ii) ultrasonic instrumentation. Clinical variables were recorded at baseline, 14 and 60 days post-treatment. Primary clinical efficacy variable was PPD reduction. Microbiological analysis of subgingival samples was performed immediately before and after debridement, 2 and 14 days post-treatment. Both treatment procedures resulted in significant reductions of periodontitis-associated bacterial species immediately and 2 days after treatment, and in significant reduction in BoP, PPD and relative attachment level at 2 months. There were no statistically significant differences between the treatment procedures at any of the examinations intervals. Perceived treatment discomfort was lower for air polishing than ultrasonic debridement. This short-term study revealed no pertinent differences in clinical or microbiological outcomes between subgingival air polishing and ultrasonic debridement of moderate deep pockets in SPT patients.
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This study assessed defect depth and volume resulting from root instrumentation using a KaVo Sonic-flex Lux 2000 L sonic scaler with a slim scaling tip (Perio-Tip no. 8) in vitro. Combinations of the following working parameters were analyzed: lateral forces of 0.5 N, 1 N, and 2 N; tip angulations of 0 degree, 45 degrees, and 90 degrees; and instrumentation time of 10 s, 20 s, 40 s, and 80 s. Defects were quantified using a three-dimensional optical laser scanner. Instrumentation time had an almost linear impact on defect depth and volume. Although lateral force (beta-weight 0.55 +/- 0.062) had a greater influence on defect volume than tip angulation (beta-weight 0.29 +/- 0.062), their effects on defect depth were similar (beta-weight 0.43 +/- 0.052 and 0.50 +/- 0.052, respectively). The combination of force and angulation showed synergistic effects resulting in a wide range of defect depths (21.9 +/- 0.96 microns to 174 +/- 28.8 microns, at 40 s) and volumes (0.056 +/- 0.019 mm3 to 0.68 +/- 0.10 mm3 at 40 s). Severe root damage (> 50 microns/40 s) did not occur at any combination of 0.5 N lateral force and/or 0 degree tip angulation. By adjusting lateral force and tip angulation, the efficacy of the assessed sonic scaler may be adapted to various clinical needs.