Subepithelial connective tissue graft for root coverage in smokers and non-smokers: a clinical and histologic controlled study in humans

BACKGROUND: The aim of this study was to evaluate root coverage of gingival recessions and to compare graft vascularization in smokers and non-smokers. METHODS: Thirty subjects, 15 smokers and 15 non-smokers, were selected. Each subject had one Miller Class I or II recession in a non-molar tooth. Clinical measurements of probing depth (PD), relative clinical attachment level (CAL), gingival recession (GR), and width of keratinized tissue (KT) were determined at baseline and 3 and 6 months after surgery. The recessions were treated surgically with a coronally positioned flap associated with a subepithelial connective tissue graft. A small portion of this graft was prepared for immunohistochemistry. Blood vessels were identified and counted by expression of factor VIII-related antigen-stained endothelial cells. RESULTS: Intragroup analysis showed that after 6 months there a was gain in CAL, a decrease in GR, and an increase in KT for both groups (P <0.05), whereas changes in PD were not statistically significant. Smokers had less root coverage than non-smokers (58.02% +/- 19.75% versus 83.35% +/- 18.53%; P <0.05). Furthermore, the smokers had more GR (1.48 +/- 0.79 mm versus 0.52 +/- 0.60 mm) than the non-smokers (P <0.05). Histomorphometry of the donor tissue revealed a blood vessel density of 49.01 +/- 11.91 vessels/200x field for non-smokers and 36.53 +/- 10.23 vessels/200x field for smokers (P <0.05). CONCLUSION: Root coverage with subepithelial connective tissue graft was negatively affected by smoking, which limited and jeopardized treatment results.     

Root coverage outcome may be affected by heavy smoking: a 2-year follow-up study

BACKGROUND: Although subepithelial connective tissue graft (CTG) has been reported to be a predictable procedure for root coverage, the impact of smoking on the long-term outcome of periodontal plastic surgery is unclear. Hence, the aim of this study was to evaluate the effect of smoking, on a long-term basis, on the stability of gingival tissue following CTG treatment of gingival recession. METHODS: Twenty-two defects were treated by CTG in canine and premolar Miller Class I and II gingival recessions (11 smokers and 11 non-smokers). The following clinical measurements were obtained at baseline and at 1, 2, 3, 4, 6, 12, 18, and 24 months after surgery: plaque and gingival indexes, extension of gingival recession (GR), probing depth (PD), clinical attachment level (CAL), and gingival thickness. Individuals smoking > or =20 cigarettes/day for > or =5 years were considered smokers. RESULTS: Data analysis demonstrated that both groups presented similar plaque and gingival indexes (P >0.05), and an intragroup analysis showed that CTG was able to promote root coverage and increase gingival thickness in both groups over time (P <0.05). However, at 24 months postoperatively, statistical analysis showed that smokers presented poorer outcomes with regard to PD, GR, and CAL (P <0.05); in addition, a more satisfactory stabilization of the gingival tissue was found in the non-smoker group. CONCLUSION: Smoking may represent a challenge to root coverage outcome for CTG because smoking significantly affected the stability of gingival tissue over time.     

Coronally positioned flap for root coverage: poorer outcomes in smokers

BACKGROUND: Gingival recession is significantly more common among smokers, while the relative outcome of various root coverage procedures in smokers, compared to non-smokers, is debatable. The objective of this study was to evaluate the influence of cigarette smoking on the outcome of coronally positioned flap (CPF) in the treatment of Miller Class I gingival recession defects. METHODS: Ten current smokers (> or = 10 cigarettes daily for at least 5 years) and 10 non-smokers (never smokers), each with one 2- to 3-mm Miller Class I recession defect in an upper canine or bicuspid, were treated with CPF. At baseline and 6 months, clinical parameters, probing depth (PD), clinical attachment level (CAL), recession depth (RD), and apico-coronal width of keratinized tissue (KT) were determined. RESULTS: Intragroup analysis showed that CPF was able to reduce RD and improve CAL in both groups (P <0.05). Intergroup analysis demonstrated that smokers presented greater residual RD at 6 months and lower percentage of root coverage (69.3% versus 91.3%; P <0.05). No smokers obtained complete root coverage compared to 50% of non-smokers (P <0.05). CONCLUSIONS: Within the limits of the present study, it can be concluded that CPF provides benefits for both smokers and non-smokers in terms of root coverage of shallow Miller Class I recession defects. However, cigarette smoking negatively impacts the clinical outcomes, specifically residual recession, percent root coverage, and frequency of complete root coverage.     

Root coverage of advanced gingival recession: a comparative study between acellular dermal matrix allograft and subepithelial connective tissue grafts

BACKGROUND: Acellular dermal matrix allograft (ADMA) has successfully been applied as a substitute for free connective tissue grafts (CTG) in various periodontal procedures, including root coverage. The purpose of this study was to clinically compare the efficiency of ADMA and CTG in the treatment of gingival recessions > or = 4 mm. METHODS: Seven patients with bilateral recession lesions participated. Fourteen teeth presenting gingival recessions > or = 4 mm were randomly treated with ADMA or CTG covered by coronally advanced flaps. Recession, probing depth, and width of keratinized tissue were measured preoperatively and 12 months postoperatively. Changes in these clinical parameters were calculated within and compared between groups and analyzed statistically. RESULTS: Baseline recession, probing depth, and keratinized tissue width were similar for both groups. At 12 months, root coverage gain was 4.57 mm (89.1%) versus 4.29 mm (88.7%) (P = NS), and keratinized tissue gain was 0.86 mm (36%) versus 2.14 mm (107%) (P < 0.05) for ADMA and CTG, respectively. Probing depth remained unchanged (0.22 mm/0 mm), with no difference between the groups. CONCLUSIONS: Recession defects may be covered using ADMA or CTG, with no practical difference. However, CTG results in significantly greater gain of keratinized gingiva.     

Coronally positioned flap for root coverage in smokers and non-smokers: stability of outcomes between 6 months and 2 years

BACKGROUND: Smoking adversely affects the short-term outcomes of coronally positioned flap (CPF) root coverage procedures, but the long-term stability of this procedure in smokers has not been studied. The objective of this study was to evaluate the effect of smoking on the long-term outcomes of CPF in recession treatment. METHODS: CPF was used to treat a Miller Class I defect in a maxillary canine or premolar in 10 current smokers (> or =10 cigarettes daily for > or =5 years) and 10 non-smokers (never smokers). At baseline and 6, 12, and 24 months, clinical parameters, including probing depth (PD), clinical attachment level (CAL), recession depth (RD), and width of keratinized tissue (KT), were determined. RESULTS: Intragroup analysis showed that CPF failed to maintain the gingival margin at the initially achieved position. RD significantly increased in smokers (from 0.84 +/- 0.49 to 1.28 +/- 0.58 mm) and in non-smokers (from 0.22 +/- 0.29 to 0.50 +/- 0.41 mm) between 6 and 24 months. Further analysis showed that 50% of smokers and 10% of non-smokers lost between 0.5 and 1.0 mm of root coverage in the same period. Intergroup analysis showed that smokers had significantly greater residual recession (P = 0.001) at 24 months. Both smokers and non-smokers lost CAL and experienced decreases in KT. CONCLUSIONS: The long-term stability of CPF outcomes is less than desirable, particularly in smokers. Two years after a CPF procedure, smokers have significantly greater residual recession compared to non-smokers both statistically and clinically.     

A 2-year follow-up of root coverage using sub-pedicle acellular dermal matrix allografts and subepithelial connective tissue autografts

BACKGROUND: Coverage of roots exposed by gingival recession is one of the main objectives of periodontal reconstructive surgery. A large variety of mucogingival grafting procedures are available. However, the long-term effectiveness of this procedure is still not clear. This study compared the effectiveness of sub-pedicle acellular dermal matrix allografts with subepithelial connective tissue autografts in achieving root coverage 2 years postoperatively. METHODs: One hundred one (101) patients were treated with dermal matrix allografts (mean age, 28.4+/- 0.7 years; mean recession, 4.2 mm) and 65 patients treated with connective tissue graft (mean age, 30.1+/- 1.4 years; mean recession, 4.9 mm). All patients underwent full periodontal evaluation and presurgical preparation, including oral hygiene instruction and scaling and root planing. The exposed roots were thoroughly planed and covered by a graft without any further root treatment or conditioning. There were no differences in the average age, time of follow-up, or gender between the two groups. Patients were evaluated periodically between 1 and 2 years. Residual recession and defect coverage were assessed. RESULTS: Mean residual root recession after root coverage with acellular dermal matrix allograft was 0.2 +/- 0.04 mm, with defect coverage of 95.9% +/- 0.9%. Frequency of defect coverage was 82.2%. Root coverage was 98.8% +/- 0.2%, resulting in a frequency of root coverage of 100%. Gain in keratinized gingiva was 2.2+/- 0.04 mm and attachment gain was 4.5+/- 0.1 mm per patient. Connective tissue autografts resulted in mean residual root recession of 0.1+/- 0.04 mm, with percent defect coverage of 97.8%+/- 0.6% and frequency of defect coverage of 95.4%. Root coverage was 99.1%+/- 0.2%, and frequency of root coverage was 100%. Gain in keratinized gingiva was 3.0+/- 0.1 mm and attachment gain was 5.3+/- 0.2 mm per patient. No significant differences in final recession and root coverage between the two treatment methods were found. However, autografts resulted in significant increases in defect coverage, keratinized gingival gain, attachment gain, and residual probing depth. The clinical results were stable for the 2-year follow-up period. CONCLUSIONS: These results indicate that coverage of root by sub-pedicle acellular dermal matrix allografts or subepithelial connective tissue autografts is a very predictable procedure which is stable for 2 years postoperatively. However, subepithelial connective tissue autografts resulted in significant increases in defect coverage, keratinized gingival gain, attachment gain, and residual probing depth.     

Root coverage with a coronally positioned flap used in combination with enamel matrix derivative: 18-month clinical evaluation

BACKGROUND: Ginigival recession can be successfully treated with coronally positioned flaps. Twelve-month data failed to demonstrate that topical application of enamel matrix derivative (EMD) used in combination with the coronally positioned flap enhances clinical outcomes of the surgical technique used alone. This study was designed to examine the effects of EMD combined with the coronally positioned flap over an 18-month postoperative period. METHODS: Thirty patients presenting with Miller Class I or II gingival recessions on single-rooted teeth participated in this parallel-design clinical study. Six weeks after phase I therapy, recession areas were surgically treated with a coronally positioned flap for root coverage. Teeth in the experimental group received EMD treatment of the exposed root, whereas control teeth did not. Clinical parameters evaluated at baseline and 18 months postoperatively included gingival recession, clinical attachment level, probing depth, and the apico-coronal dimension of the keratinized tissue. RESULTS: Compared to baseline, 18-month measurements showed a significant reduction in probing depth, gain in attachment level, and decrease in gingival recession for control and experimental groups. When the results of the two treatment groups were compared, the experimental group presented with significantly greater root coverage than the control group (2.66 +/- 0.61 mm versus 1.73 +/- 0.70 mm, respectively), more gain in clinical attachment than the control group (2.80 +/- 0.76 mm versus 2.06 +/- 0.70 mm, respectively), and a greater gain in the apico-coronal dimension of the keratinized tissue than the control group (0.13 +/- 0.06 mm versus -0.06 +/- 0.01 mm, respectively). CONCLUSION: The results of this study indicate that topical application of EMD is beneficial in augmenting the effects of the coronally positioned flap in terms of amount of root coverage, gain in clinical attachment, and in increasing the apico-coronal dimension of the keratinized tissue.     

Harvesting technique using a mucotome and modified surgical procedure for root coverage with enamel matrix derivatives with and without a connective tissue graft

The aim of this clinical study was to evaluate the coverage of gingival recession defects with enamel matrix derivatives (EMD) with or without a connective tissue graft (CTG). Twenty-five patients (16 female, 9 male) from 16 to 58 years of age (mean: 32.2; SD: 11.2) with 92 gingival recessions (Miller Class I and II) and with at least 4.0 mm of clinical attachment loss were treated with a modified surgical technique for root coverage by CTG with EMD (45 recession defects) or EMD only (47 recession defects). Vertical recession depth, probing depth, clinical attachment level, dehiscence depth, width of keratinized gingiva (vertical), and recession coverage were recorded before surgery (baseline) and at 12 and 24 months. The average presurgical recession depth was 4.4 mm (SD: 1.3) with EMD and CTG versus 3.2 mm (SD: 1.1) with EMD only. Both treatment modalities led to a significant decrease in recession and a gain in attachment. Mean root coverage 12 months postoperatively was 92.7% (SD: 13.5) (EMD and CTG) versus 96.3% (SD: 11.5) (EMD only). Compared to the mean root coverage of recession after 24 months, the change was not significant. The results confirmed that the applied modified surgical techniques are safe and predictable, with better clinical outcomes at the donor and recipient sites.     

Tobacco smoking and periodontal health in a Saudi Arabian population

BACKGROUND: The objective of this study was to examine the association between tobacco smoking, in particular water pipe smoking, and periodontal health. METHODS: A total of 262 citizens of Jeddah, Saudi Arabia in the age range from 17 to 60 years volunteered to participate in the study. The clinical examinations were carried out at King Faisal Specialty Hospital and Research Center in Jeddah and included assessments of oral hygiene, gingival inflammation, and probing depth. Smoking behavior was registered through a questionnaire and confirmed by an interview. Participants were stratified into water pipe smokers (31%), cigarette smokers (19%), mixed smokers (20%), and non-smokers (30%). RESULTS: The mean probing depth per person was 3.1 mm for water pipe smokers, 3.0 mm for cigarette smokers, 2.8 mm for mixed smokers, and 2.3 mm for non-smokers. The association between smoking and probing depth was statistically significant controlling for age (P <0.001). The association between lifetime smoking exposure and mean probing depth was statistically significant in water pipe as well as cigarette smokers controlling for age (P <0.001). Using multivariate analysis, besides smoking, the gingival and plaque indexes were associated with increased probing depth. The prevalence of periodontal disease defined as a minimum of 10 sites with a probing depth > or =5 mm was 19.5% in the total population, 30% in water pipe smokers, 24% in cigarette smokers, and 8% in non-smokers. The prevalence was significantly greater in water pipe and cigarette smokers compared to non-smokers (P <0.001). The relative risk for periodontal disease increased by 5.1- and 3.8-fold in water pipe and cigarette smokers, respectively, compared to non-smokers (P <0.001 and P <0.05, respectively). CONCLUSIONS: An association was observed between water pipe smoking and periodontal disease manifestations in terms of probing depth measurements. The impact of water pipe smoking was of largely the same magnitude as that of cigarette smoking.     

A multicenter comparative study of two root coverage procedures: coronally advanced flap with addition of enamel matrix proteins and subpedicle connective tissue graft

BACKGROUND: Free grafts, pedicle flaps, and barrier membranes have been used to cover exposed root surfaces. The aim of the present study was to evaluate the clinical efficacy of a coronally advanced flap procedure with the additional use of enamel matrix protein derivative (EMD) to treat gingival recession and to compare it to the subpedicle connective tissue graft procedure (CTG). METHODS: The study was conducted in six different periodontal clinics. Miller Class I or II buccal recession type defects in the anterior or premolar teeth were treated in 70 consecutive patients, 30 with EMD and 40 with CTG. At baseline and 6 and 12 months post-surgical treatment, vertical recession defect, defined as the distance from cemento-enamel junction to gingival margin; width of keratinized tissue; and probing depth were recorded and the percentage of coverage of the original defect was calculated. Statistical analyses consisted of t-test, analysis of variance, and analysis of covariance. RESULTS: At 6 months, percent of root coverage was 77.4% +/- 11.92% in EMD and 84.1% +/- 11.97% in CTG (statistically significant at P = 0.024). At 12 months, percent of root coverage in EMD was 71.7% +/- 16.14% and 87.0% +/- 12.22% in CTG; again, differences between groups were statistically significant (P < 0.001). Differences between the 6- and 12-month vertical recession defect and percent of root coverage recordings within each group were also statistically significant. CONCLUSIONS: The connective tissue graft procedure was superior to the coronally positioned flap with the addition of enamel matrix proteins derivative in percentage of coverage and increase in width of keratinized tissue. The EMD procedure is a predictable treatment for root coverage that is relatively easy to perform and presents low patient morbidity, and is appropriate especially where a substantial increase in the width of keratinized tissue is not of prime importance.     

Enamel matrix derivative and coronal flaps to cover marginal tissue recessions

BACKGROUND: Correcting recession defects is one of the goals of periodontal therapy, and the efficacy and predictability of the various techniques are important considerations for both patients and clinicians. Several reports have examined the outcome of gingival recession treatment by means of coronally positioned flaps (CPF) and enamel matrix derivative (EMD). The purpose of this study was to clinically evaluate the use of EMD in association with CPF to cover localized gingival recessions compared to CPF alone. METHODS: Twenty-two patients with Miller Class I or II gingival recessions >2 mm were included. One recession from each patient was treated in the study. Two treatments were randomly assigned: coronally positioned flap with EMD (test) and coronally positioned flap alone (control). Clinical parameters measured at baseline and 1, 6, and 12 months included gingival index, plaque index, probing depth, clinical attachment level, vertical and horizontal recession, and width of keratinized gingiva. RESULTS: At 12 months, both treatment modalities showed significant root coverage, gain in clinical attachment, and gain in width of keratinized gingiva (P <0.05). Vertical recessions were reduced from 2.68 +/- 1.63 mm to 0.36 +/- 0.60 mm in the test group and from 2.31 +/- 1.52 mm to 0.90 +/- 0.95 mm in the control group. Horizontal recessions decreased from 4.27 +/- 2.06 mm to 0.77 +/- 0.87 mm in the test group and from 3.68 +/- 1.91 mm to 1.72 +/- 1.31 mm in the control group. Changes in keratinized gingiva went from 3.81 +/- 1.95 mm to 4.63 +/- 2.15 mm in the test group and from 3.31 +/- 1.81 mm to 3.27 +/- 1.80 mm in the control group. When both treatments were compared at 12 months, there was a significant difference in vertical tooth coverage and gain in keratinized gingiva in favor of the experimental group (P <0.05). The average percentage of root coverage for test and control groups was 88.6% and 62.2%, respectively. CONCLUSIONS: The coronally positioned flap alone or with EMD is an effective procedure to cover localized gingival recessions. The addition of EMD significantly improves the amount of root coverage.     

Locally delivered doxycycline as an adjunctive therapy to scaling and root planing in the treatment of smokers: a clinical study

BACKGROUND: The aim of this clinical study was to evaluate the association of locally delivered doxycycline (10%) with scaling and root planing in the periodontal treatment of smokers. METHODS: Forty-three patients with chronic periodontitis and a minimum of four pockets (> or = 5 mm) on anterior teeth that bled on probing were selected. Patients were randomly assigned to scaling and root planing (SRP) or scaling and root planing followed by local application of doxycycline (SRP-D). Plaque, bleeding on probing, gingival recession, relative attachment level (RAL), and probing depth (PD) were recorded at baseline, 45 days, and 3 and 6 months. Differences between baseline and each period were considered for analysis. RESULTS: At 6 months, no difference was found between groups regarding plaque, bleeding reduction, gingival recession or PD (P > 0.05). However, RAL gain was greater for SRP-D (1.63 +/- 0.93 mm) than for SRP (1.04 +/- 0.71 mm) (P = 0.025). In addition, deep pockets (> or = 7 mm) showed a significant reduction (3.78 +/- 1.41 versus 2.60 +/- 1.28 mm, P = 0.039) and RAL gain (2.54 +/- 1.27 mm versus 1.29 +/- 0.95 mm, P = 0.01) when doxycycline was applied. The proportion of sites showing RAL gain of 1 to 2 mm was 36.8% versus 21.7% for SRP-D and SRP, respectively (P = 0.01). CONCLUSION: The use of locally delivered doxycycline may constitute an important adjunct for the treatment of severe periodontal disease in smokers.     

Gingival recession treatment: guided tissue regeneration with bioabsorbable membrane versus connective tissue graft

BACKGROUND: Gingival recession represents a significant concern for patients and a therapeutic problem for clinicians. Several techniques have been proposed to achieve root coverage. The purpose of this randomized clinical trial was to evaluate the effect of a guided tissue regeneration (GTR) procedure in comparison to connective tissue graft (CTG) in the treatment of gingival recession defects. METHODS: Twelve patients, each contributing a pair of Miller Class I or II buccal gingival recessions, were treated. In each patient one randomly chosen defect received a poly(lactic acid)-based bioabsorbable membrane, while the paired defect received a CTG. Clinical recordings included oral hygiene standards and gingival health, recession depth (RD), recession width (RW), probing depth (PD), clinical attachment level (CAL), and keratinized tissue width (KT). RESULTS: Mean RD statistically significantly decreased from 2.5 mm presurgery to 0.5 mm with GTR (81% root coverage), and from 2.5 mm to 0.1 mm with CTG (96% root coverage), at 6 months postsurgery. Prevalence of complete root coverage was 58% for the GTR group and 83% for the CTG group. Mean CAL gain was 2.0 mm for the GTR group and 2.2 mm for the CTG group. No statistically significant differences between treatment groups were observed for changes in RD, RW, PD, CAL, and KT. CONCLUSIONS: Treatment of human gingival recession defects by means of either GTR or CTG results in clinically and statistically significant improvement of the soft tissue conditions of the defect when pre- and post-treatment measurements were compared. Although differences between CTG and GTR in mean root coverage and prevalence of complete coverage consistently favored the CTG procedure, the differences in measurements were not statistically significant.     

Subepithelial connective tissue graft for treatment of gingival recessions with and without enamel matrix derivative: a multicenter, randomized controlled clinical trial

The aim of this multicenter, randomized controlled trial was to compare the clinical outcomes of a connective tissue graft (CTG) alone or in combination with enamel matrix derivative (CTG + EMD) in the treatment of Miller Class I and II gingival recessions. The 56 selected defects were evaluated for probing depth, recession depth, keratinized tissue width, and probing attachment level, and were measured at baseline and 12 months after treatment. The mean recession reduction was 3.9 ± 0.8 mm for EMD-treated sites (test) and 3.6 ± 1.5 mm for the control group (P = .22), corresponding to a mean root coverage of 90% and 80% for test and control groups, respectively (P = .05). Complete root coverage was obtained in 62% of test sites compared to 47% in the control group (P = .27). Both procedures provided good soft tissue coverage. The better results of the test group did not achieve a statistically significant level.     

Comparison of the validity of periodontal probing measurements in smokers and non-smokers

AIM: To determine whether the reduced inflammation and bleeding and increased fibrosis reported in tobacco smokers affect the validity of clinical probing measurements by altering probe tip penetration. METHOD: A constant force probe was used to measure probing depths and sound bone levels at six sites on 64 molar teeth (384 sites) in 20 smoking and 20 non-smoking patients from grooves made with a bur at the gingival margin prior to extraction. Connective tissue attachment levels were measured from the grooves with a dissecting microscope following extraction. Data were analysed using robust regression with sites clustered within subjects. RESULTS: Sites in smokers showed more calculus but less bleeding than sites in non-smokers (p<0.05). The mean clinical probing depth was not significantly different (smokers: 5.54 mm, confidence intervals=4.81 to 6.28; non-smokers: 6.05 mm, ci=5.38 to 6.72). The corresponding post-extraction pocket depth measurements (smokers: 4.95 mm, ci=4.30 to 5.61; non-smokers: 5.23 mm, ci=4.49 to 5.96) were less than clinical probing depth in sites from both smokers and non-smokers (p<0.01). However, the proportional difference was less in smokers (p<0.05), particularly in deeper pockets, indicating that clinical probe tip penetration of tissue was greater in non-smokers. Regression analysis indicated that the presence of calculus and bleeding also influenced the difference in clinical probe penetration (p<0.05). CONCLUSION: Clinical probing depth at molar sites exaggerates pocket depth, but the probe tip may be closer to the actual attachment level in smokers due to less penetration of tissue. This may be partly explained by the reduced inflammation and width of supra-bony connective tissue in smokers. These findings have clinical relevance to the successful management of periodontal patients who smoke.     

Relationship between smoking and folic acid, vitamin B12 and some haematological variables in patients with chronic periodontal disease

AIM: The purpose of this study was to investigate the relationship between cigarette smoking and the serum levels of folic acid, vitamin B(12) and some haematological variables in patients with periodontal disease. PATIENTS AND METHODS: The study base consisted of 88 volunteer patients with periodontal disease, including 45 current smokers in the age range 31-68 years and 43 non-smokers in the range 32-66 years. The clinical parameters included plaque index (PI), gingival index (GI), bleeding on probing (BOP), probing depth (PD) and clinical attachment loss (CAL). Folic acid, vitamin B(12) and haematological variables were determined from peripheral blood samples. RESULTS: PI, PD and CAL means were significantly higher in smokers than non-smokers (p<0.05). The serum folic acid concentration of smokers was lower than that of non-smokers (p<0.05), whereas the white blood cell count was higher in smokers than in non-smokers (p<0.05). CONCLUSION: The results of this study suggest that among patients with periodontal disease the serum folic acid concentration is lower in smokers compared with non-smokers.     

Periodontal microsurgery: report of 16 cases consecutively treated by the free rotated papilla autograft technique combined with the coronally advanced flap

The coronally advanced flap combined with a free connective tissue graft is a predictable method for achieving root coverage in buccal gingival recession. Nevertheless, this procedure conventionally requires involvement of a second surgical site; the latter is avoided by the proposed technique. Sixteen isolated gingival recessions (2.5 to 4.0 mm deep) were surgically treated with a coronally advanced flap associated with a connective tissue graft harvested from one adjacent papilla whose dimensions matched those of the exposed root area. Procedures were performed with the aid of a surgical microscope. Recession depth, probing depth, periodontal attachment level, and keratinized tissue width were recorded at baseline and 12 months after surgery. Mean recession moved from 3.38 +/- 0.72 mm at baseline to 0.13 +/- 0.29 mm at 12 months, a gain of 97.03%. In 13 of the 16 cases 12 months after surgery, the gingival margin was located at the CEJ or coronal to it, while in two cases the residual recession was less than 1.0 mm and in another case it was 1.0 mm. Mean periodontal attachment level was 4.72 +/- 1.00 mm at baseline and 1.03 +/- 0.59 mm at follow-up. Mean keratinized tissue increased from 1.25 +/- 0.75 mm to 3.47 +/- 0.87 mm. All differences between 12 months and baseline were statistically significant. No pockets were present at baseline, and this situation remained stable during the observation period. All 16 isolated recessions treated showed an excellent gain in root coverage without requiring a second surgical site and thus reducing patient morbidity.     

The effect of smoking and periodontal treatment on salivary composition in patients with established periodontitis.

BACKGROUND: The purpose of this study was to evaluate the effect of smoking on the periodontal status and the salivary composition in subjects with established periodontitis before and after periodontal therapy. METHODS: Our study group included 26 healthy subjects, 12 smokers and 14 non-smokers with established periodontitis. Clinical measurements and non-stimulated whole saliva were obtained and analyzed at baseline and after scaling and root planing. Smokers presented at baseline with significantly greater probing depth (4.16+/-0.26) compared to non-smokers (3.52+/-0.32) which was statistically significant (P = 0.0268); likewise, baseline clinical attachment level was greater in smokers (4.49+/-0.31 compared to non-smokers 3.87+/-0.13; P = 0.0620). Mean plaque index was also greater in smokers compared to non-smokers (0.86 and 0.65, respectively; P = 0.0834). Baseline pretreatment sodium values were significantly greater in non-smokers (14.36 mEq/l compared to 9.31 mEq/l in smokers; P = 0.0662); likewise non-smokers exhibited 50% greater salivary calcium levels (6.04 mg/100 ml compared to 4.32 mg/100 ml in smokers; P = 0.0133). RESULTS: Post-treatment probing depth and clinical attachment level were not different between smokers and non-smokers; this in spite of significant difference in plaque index in smokers (0.35 compared to 0.13 in non-smokers; P = 0.0135). Post-treatment, smokers had reduced calcium concentration (3.58 mg/100 ml compared to 5.11 mg/100 ml in non-smokers; P = 0.0438). Treatment affected albumin level in smokers only, consequently non-smokers had significantly greater salivary albumin concentration (1.1 mg/100 ml compared to 0.38 mg/100 ml in smokers; P = 0.0274). CONCLUSIONS: Subjects with established periodontitis exhibited elevated concentrations of salivary electrolytes and proteins. Within this study group, smokers exhibited greater disease level but reduced sodium, calcium, and magnesium concentrations. Smokers responded favorably to treatment. The clinical improvement eliminated the differences in salivary composition.     

Coronally positioned flap plus resin-modified glass ionomer restoration for the treatment of gingival recession associated with non-carious cervical lesions: a randomized controlled clinical trial

BACKGROUND: The aim of this randomized clinical trial was to evaluate the treatment of gingival recession associated with non-carious cervical lesions by a coronally advanced flap alone (CAF) or in combination with a resin-modified glass ionomer restoration (CAF+R). METHODS: Nineteen subjects with bilateral Miller Class I buccal gingival recessions associated with non-carious cervical lesions were selected. The recessions were assigned randomly to receive CAF or CAF+R. Bleeding on probing (BOP), probing depth (PD), relative gingival recession (RGR), clinical attachment level (CAL), non-carious cervical lesion height (CLH), and dentin sensitivity (DS) were measured at baseline; 45 days; and 2, 3, and 6 months postoperatively. Keratinized tissue width (KTW) and keratinized tissue thickness (KTT) were measured at baseline and 6 months. The height of the non-carious cervical lesion located on the root and crown were estimated, allowing calculation of root coverage. RESULTS: Both groups showed statistically significant gains in CAL and soft tissue coverage. The differences between groups were not statistically significant for BOP, PD, RGR, CAL, KTW, and KTT after 6 months. The percentages of CLH covered were 56.14% +/- 11.74% for CAF+R and 59.78% +/- 11.11% for CAF (P >0.05). The root and crown surfaces affected by the non-carious cervical lesion were 1.67 +/- 0.31 mm and 0.96 +/- 0.29 mm, respectively, for CAF+R and 1.59 +/- 0.37 mm and 1.01 +/- 0.33 mm, respectively, for CAF. The estimated root coverage was 88.02% +/- 19.45% for CAF+R and 97.48% +/- 15.36% for CAF (P >0.05). CAF+R reduced DS significantly compared to CAF (P <0.05). CONCLUSIONS: Both procedures provided similar soft tissue coverage after 6 months. Despite the fact that a greater reduction in DS was observed after CAF+R, longitudinal observations are necessary to confirm these results.     

Root coverage: comparison of coronally positioned flap with and without titanium-reinforced barrier membrane

BACKGROUND: Various surgical procedures have been proposed as effective treatment methods for recession defects. The purpose of this study was to evaluate the clinical outcome of root coverage comparing the coronally positioned flap (CPF) with and without guided tissue regeneration (GTR) using a titanium-reinforced expanded polytetrafluoroethylene barrier in paired gingival recession defects. METHODS: Procedures were performed in 10 patients having bilateral buccal recession defects > or = 2.0 mm on maxillary canines and first premolars. Mucoperiosteal flaps were raised and root surfaces were scaled, planed, and conditioned. Randomly assigned sites received either GTR + CPF or CPF treatment. Clinical parameters measured at baseline and at 6 months after the procedure included gingival recession depth (GRD), clinical attachment level (CAL), probing depth (PD), keratinized gingival width (KGW), and alveolar crest level (ACL). RESULTS: GRD decreased from 3.4 +/- 0.6 mm to 1.9 +/- 1.2 mm with GTR (45% root coverage) and from 3.3 +/- 0.4 mm to 1.3 +/- 0.7 mm with CPF (60% root coverage). The difference in GRD decrease between procedures was significant. CAL, KGW, and PD differences between procedures were not significant. ACL mean gain was significant (1.0 +/- 0.6 mm in the GTR group and 0.2 +/- 0.3 mm in the CPF group; P < 0.05). CONCLUSIONS: Both GTR and CPF procedures result in root coverage. The amount of root coverage obtained with CPF was greater than that observed with GTR, although GTR resulted in significantly greater ACL gain.