Smoking influences decision making in periodontal therapy: a retrospective clinical study.

BACKGROUND: Mechanical periodontal therapy consists of a non-surgical course, followed by surgical treatment to eliminate or reduce remaining pathological pockets. Only if diligent mechanical therapy fails are additional measures considered. It has been documented that smoking interferes with the host defense mechanisms. This study addresses the question is meticulous non-surgical periodontal therapy equally successful in smokers and non-smokers? If not, is a thorough and cumbersome non-surgical approach in smokers worth undertaking? METHODS: Thirty-five smokers and 35 non-smokers were selected retrospectively from a pool of 306 patients treated in a private practice over a 17-month period. All had at least 14 teeth present with 8 presenting with gingival pockets > or =6 mm. Non-surgical treatment was performed in 6 to 10 appointments and results were evaluated 6 to 12 weeks after therapy. Bleeding on probing sites with probing depths > or =5 mm were then considered for surgical treatment. RESULTS: Before treatment smokers had statistically significantly higher mean percent of pockets 4 to 5 mm and > or =6 mm (40.36+/-10.65 and 26.51+/-11.95, respectively, compared to 30.38+/-7.57 and 20.42+/-10.03 for non-smokers) and showed significantly lower proportional reduction of these parameters with treatment (50.80+/-33.76 and 81.36+/-19.82 for pocket 4 to 5 mm and 6 mm, compared to 68.43+/-21.23 and 91.7+/-8.92 for nonsmokers). A multivariate analysis gave smoking, plaque control, and initial percent of sites > or =6 mm to be significant predictors of the percent of teeth in need of further therapy. In non-smokers, treatment was apparently successful in all tooth types with the exception of upper first and second molars (28.5% failure) and lower second molar (20% failure). In smokers, rates of further treatment needs were particularly high in the premolar-molar area in both jaws, ranging from 31.4% to 48.5% for an individual tooth type; 42.8% of smokers and 11.5% of non-smokers needed further treatment in 16% of their teeth (pretest probability). A decision analysis showed that for smokers with at least 1 of 5 sites > or =6 mm, one should initiate surgical treatment, rather than first treat non-surgically. If the point of indifference that the decision is correctly set at 95%, the pretest probability should be >12%. There is a higher risk that non-surgical therapy will fail, for instance if we lower the point of indifference to 60%, the pretest probability should be >31%. CONCLUSIONS: It is concluded that smoking impairs healing after nonsurgical periodontal therapy. The decision analysis of this study questions the need for a thorough course of non-surgical treatment in smokers with advanced periodontal disease.     

Effect of periodontal therapy in smokers and non-smokers with advanced periodontal disease: results after maintenance therapy for a minimum of 5 years

BACKGROUND: Longitudinal clinical studies show smoking is a risk factor for periodontal disease progression. It has also been documented that smoking impairs healing after periodontal therapy. However, the longitudinal effect of smoking on treatment results in patients who undergo long-term maintenance therapy has not been extensively investigated. This study clinically and radiographically compared smoking and non-smoking patients who had been treated for advanced periodontal disease and who received maintenance therapy for a minimum of 5 years. METHODS: Twenty-nine patients were selected over a 6-month period when they presented for a regularly scheduled visit in a private office. Patients were selected on the basis of initially having lost 50% of bone support on 50% of their teeth; had received follow-up therapy for at least 5 years; were compliant at 75% of the appointments; and had plaque scores < 20% in 75% of the visits. All patients had received non-surgical and surgical therapy as required for pocket elimination. Fourteen were active smokers during the entire maintenance period. Clinical measurements of probing depths and presence of plaque and gingivitis and a new set of standardized radiographs were taken. RESULTS: Smokers had higher mean radiographic bone loss values prior to treatment (7.52 +/- 1.39 versus 6.65 +/- 1.39) and at the final examination (7.32 +/- 1.42 versus 6.29 +/- 1.29) mean radiographic bone loss as well as initial, immediate post-therapy, and final percent of pockets > or = 6 mm (1.42% +/- 1.87% versus 0.60% +/- 1.11%). Differences were not statistically significant. Over 5 to 8 years, seven sites in four non-smokers and 11 sites in six smokers exhibited radiographic bone loss > or = 2 mm. One tooth in a non-smoker and three teeth in two smokers were lost. In a logistic regression analysis, smoking increased the odds ratio 10.7 times of having > or = 1 site with bone loss > or = 2 mm. CONCLUSION: The present study on a small group of patients treated for advanced periodontal disease and well maintained over 5 to 8 years showed no statistically significant differences between smokers and non-smokers in clinical probing depth and radiographic bone loss measurements.     

Clinical and microbiological effect of scaling and root planing in smoker and non-smoker chronic and aggressive periodontitis patients

OBJECTIVES: To compare the effects of scaling and root planing (SRP) on clinical and microbiological parameters at selected sites in smoker and non-smoker chronic and generalized aggressive periodontitis patients. MATERIALS AND METHODS: Clinical parameters including probing depth (PD), relative attachment level (RAL), and bleeding upon probing (BOP), and subgingival plaque samples were taken from four sites in 28 chronic periodontitis (CP) and 17 generalized aggressive periodontitis (GAgP) patients before and after SRP. Polymerase chain reaction assays were used to determine the presence of A. actinomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythensis, Prevotella intermedia and Treponema denticola. RESULTS: Both CP and GAgP non-smokers had significantly greater reduction in pocket depth (1.0+/-1.3 mm in CP smokers versus 1.7+/-1.4 mm in non-smokers, p=0.007 and 1.3+/-1.0 in GAgP smokers versus 2.4+/-1.2 mm in GAgP non-smokers, p<0.001) than respective non-smokers, with a significant decrease in Tannerella forsythensis in CP sites (smokers 25% increase and non-smokers 36.3% decrease, p<0.001) and Prevotella intermedia at GAgP sites (smokers 25% reduction versus 46.9% in non-smokers, p=0.028). CONCLUSION: SRP was effective in reducing clinical parameters in both groups. The inferior improvement in PD following therapy for smokers may reflect the systemic effects of smoking on the host response and the healing process. The lesser reduction in microflora and greater post-therapy prevalence of organisms may reflect the deeper pockets seen in smokers and poorer clearance of the organisms. These detrimental consequences for smokers appear consistent in both aggressive and CP.     

Smoking may affect root coverage outcome: a prospective clinical study in humans

BACKGROUND: Cigarette smoking has been shown to negatively influence healing following periodontal therapeutic procedures. Therefore, the aim of this study was to evaluate the impact of smoking on clinical outcome of root coverage following subepithelial connective tissue graft (CTG) surgery. METHODS: Eighteen defects were treated in 15 patients (seven smokers and eight non-smokers) who presented canine and pre-molar Miller Class I and II recessions. CTG was performed and clinical measurements were obtained at baseline, and 30, 60, 90, and 120 days after surgery. Clinical measurements included plaque and gingival indexes, gingival recession, probing depth, clinical attachment level, gingival thickness, and keratinized tissue width. RESULTS: Intragroup analysis showed that CTG was able to promote root coverage, increase gingival thickness, and improve clinical attachment level in both groups (P < 0.05). On the other hand, intergroup analysis demonstrated that smokers presented with a lower percentage of root coverage (58.84% +/- 13.68% versus 74.73% +/- 14.72%), less clinical attachment level gain (2.54 +/- 0.79 mm versus 2.00 +/- 1.04 mm), and deeper probing depths (1.56 +/- 0.53 mm versus 2.35 +/- 0.67 mm) than non-smokers (P < 0.05). Moreover, 4 months after CTG, smokers presented more keratinized tissue compared to non-smokers (3.30 +/- 0.86 mm versus 4.50 +/- 1.16 mm) (P < 0.05). CONCLUSION: Within the limits of the present study, it can be concluded that cigarette consumption may present a negative impact on root coverage outcome by CTG and, therefore, may represent one more challenge for periodontal plastic therapy.     

Noxious effect of cigarette smoking on periodontal health

Periodontal probing depth, furcation involvement and tooth mobility were compared in smokers and non-smokers. The study covered 242 subjects aged 21–60 yr, 76 of whom were smokers. Oral hygiene status and dental care habits were above average and of similar standard in both groups (Pll = 0.9). Probing depth was measured at 6 sites around all teeth and sites with a depth of 4 mm or more were regarded as diseased. Both number and probing depth of pockets were significantly greater in smokers than in non-smokers. On average, smokers exhibited 36.0 sites with a probing depth of 4 mm or more, in contrast to 21.8 sites in non-smokers. Probing depth was 2.59 ± 0.06 (mean ± SEM) and 2.36 ± 0.03 in smokers and non-smokers, respectively. The relatively greater occurrence of pockets in smokers remained even when allowance was made for age and oral hygiene. There were also significantly increased numbers of teeth with furcation involvement, pocket involvement and hypermobility in smokers. It is concluded that smoking is associated with a deterioration in periodontal health and that the influence of smoking may be independent of plaque exposure.     

Long-term effects of supportive therapy in periodontal patients treated with fibre retention osseous resective surgery. I: recurrence of pockets, bleeding on probing and tooth loss

BACKGROUND: Periodontal surgery is indicated in the treatment of persistent pockets following cause-related therapy. The aim of this study was to evaluate the long-term effect of supportive therapy in periodontal patients treated with fibre retention osseous resective surgery. METHODS: Three-hundred and four consecutive patients were identified and retrospectively examined while presenting for a supportive periodontal care (SPC) appointment (T2). All had received non-surgical periodontal treatment and osseous resective surgery as needed, to obtain no sites with probing depth (PD) >3 mm before being enrolled in the SPC programme. The mean SPC duration for the patients was 7.8+/-3.2 years while the mean interval of SPC was 3.4+/-0.8 months. RESULTS: During SPC, a total of 67 teeth had been removed (0.9%). At T2, mean full-mouth plaque scores (FMPS) was 13+/-11.3% and full-mouth bleeding scores (FMBS) was 2+/-3%. In 98.5% of the sites, PD was minimal (or=6 mm was 68 and limited to 41 patients (13.8% of sample). Initial periodontal diagnosis of severe periodontitis, smoking habits, FMBS, number of teeth at completion of active periodontal therapy (T1), number of surgically treated teeth, number of teeth with furcation involvement and number of multi-rooted teeth were associated with the number of pockets at T2. A total of 598 sites (2.1%) displayed bleeding on probing (BOP) at T2. The odds ratio of sites 4 mm or deeper to be BOP positive was 32.9 compared with sites of <3 mm depth. Gender, FMBS, FMPS, furcation involvements and overall number of pockets were associated with the number of bleeding pockets at T2. CONCLUSION: Shallow PDs achieved by treatment of the persistent pockets by fibre retention osseous resective surgery can be maintained over time. These patients displayed minimal gingival inflammation and tooth loss during SPC.     

Use of Emdogain in the treatment of deep intrabony defects: 12-month clinical results. Histologic and radiographic evaluation

The objective of this study was to evaluate the application of an enamel matrix derivative (Emdogain) in deep periodontal pocket therapy. Twenty-one patients presenting intrabony and interproximal defects that could be treated with guided tissue regeneration were selected. The intrabony defects were divided into deep (< 9 mm) and very deep (> or = 9 mm) defects. Bleeding on probing, Plaque Index, probing pocket depth, mobility index, gingival recession, probing attachment level, and surgical bone level were measured at baseline. At 12 months, cases were reexamined and indices recorded again. The mean probing depth decreased from 8.1 +/- 2.1 mm to 3.2 +/- 1.5 mm; attachment level decreased from 10.4 +/- 2.4 mm to 7.0 +/- 1.8 mm; recession increased from 2.3 +/- 1.4 mm to 3.8 +/- 1.8 mm; and surgical bone level decreased from 9.6 +/- 1.9 mm to 7.1 +/- 1.5 mm. No significant difference wa noted between bone defects with one or 2 walls, between local and generalized periodontitis, or between smokers and nonsmokers. Significant statistical difference was found, however, between deep intrabony defects and very deep defects when attachment gain was considered. No adverse reaction to the substance was noted. The good clinical results obtained were not confirmed by radiologic results; standardized and computerized radiographs at 12 months did not reveal significant improvement. The histologic examination carried out on 2 samples did not show evidence of new attachment. Further studies are necessary to clarify the action mechanism and to evaluate the long-term results of this method.     

Using the PerioChip in treating adult periodontitis: an interim report

Multicenter clinical trials have established that the adjunctive use of the subgingival controlled release of chlorhexidine, in the form of the PerioChip, significantly reduces pocket probing depth, improves probing attachment levels, and reduces bleeding on probing compared to scaling and root planing alone, for periods up to 9 months. The purpose of the present study was to report on the adjunctive use of the PerioChip for the long-term management of adult periodontitis for 2 years. A total of 836 patients with adult periodontitis from private dental offices were recruited into the trial. This interim report is on the first 72 patients to have completed the 2-year study. Treatments included initial definitive therapy followed by PerioChip placement in pocket sites with a pocket probing depth of > or = 5 mm after 1 month. Subsequently, the patients received routine periodontal maintenance therapy together with the placement of a PerioChip in pockets with pocket probing depths > or = 5 mm every 3 months. Results indicated that there was a continuous decrease in pocket probing depth over the 2 years (1.26 +/- 0.77 mm). This decrease in pocket probing depth was marked over the first 9 to 12 months, and then appeared to be less marked over the next 12 months. At 2 years, 60% of the patients had at least 2 pockets showing a reduction of 2 mm or more, and only 10% of the patients showed no change or increased pocket probing depth. The results indicate that adjunctive PerioChip use is a clinically effective treatment option for dental professionals and their patients for the long-term management of adult periodontitis.     

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.     

Clinical evaluation of partial- and full-mouth scaling in the treatment of chronic periodontitis

BACKGROUND: Full-mouth scaling (FMS) is claimed by some researchers to be superior to standard scaling and root planing (SRP). The aim of the present study was to evaluate clinical outcomes of two modalities of non-surgical periodontal therapy for patients with chronic periodontitis. METHODS: In a prospective, randomized, controlled clinical study, 37 subjects with chronic periodontitis were treated by SRP in two quadrants at 4-week intervals (N=20) or by FMS (N=17). Clinical attachment level (CAL), probing depth (PD), and bleeding on probing (BOP) were recorded at premolar and molar teeth at baseline and after 6 and 12 months. RESULTS: Both therapies resulted in significant improvements of all clinical variables. After 12 months, CAL at pockets with PDs of 4 to 6 mm was reduced significantly from 4.5+/-0.8 mm to 3.4+/-1.0 mm with SRP and from 4.7+/-0.9 mm to 3.8+/-1.1 mm with FMS (P<0.001). PD decreased from 4.4+/-0.6 mm to 3.3+/-0.9 mm in the SRP group and from 4.5+/-0.7 mm to 3.5+/-1.0 mm in the FMS group (P<0.001). BOP was reduced from 63.6%+/-45.3% to 29.0%+/-42.6% in the SRP group and from 59.6%+/-43.8% to 28.6%+/-38.3% in the FMS group (P<0.001 and P=0.001, respectively). There were no significant differences between the groups with respect to CAL gain, PD, and BOP reduction. CONCLUSION: Both therapy modalities have the same positive influence on clinical outcome at premolar and molar teeth with PDs of 4 to 6 mm.     

Tetracycline fibers as an adjunct in the treatment of nifedipine-induced gingival enlargement

BACKGROUND: The hypothesis that nifedipine-induced gingival enlargement in periodontitis patients can be treated with the adjunctive use of tetracycline (TCN) fibers was tested in this study. METHODS: Ten patients (mean age 66 +/- 4 years) with chronic periodontitis combined with nifedipine-induced gingival enlargement participated. Full mouth recordings of clinical parameters (probing depth, clinical attachment level, bleeding on probing, presence or absence of plaque) were assessed at baseline and gingival enlargement was estimated from casts. Participants were instructed in proper oral hygiene and received supragingival scaling before being reassessed 1 month later. They subsequently received full-mouth scaling and root planing followed by the immediate placement of TCN fibers in all pockets >5 mm. Clinical parameters were reassessed at 3, 6, and 12 months after completion of treatment. RESULTS: TCN fiber placement was well tolerated by patients. All clinical parameters recorded displayed significant improvements after treatment, and they were preserved for the 12-month experimental period. A significant reduction of the percentage of pockets >5 mm was noticed after treatment. The reduction of enlargement was still observed at 12 months despite patients not achieving optimal oral hygiene. CONCLUSION: Placement of tetracycline fibers as an adjunct to mechanical treatment is an option for the non-invasive therapy of nifedipine-induced gingival enlargement in periodontitis patients whose general medical condition and concomitant ailments do not favor a surgical approach.     

The effects of cigarette smoking on the periodontal condition of young Jordanian adults

BACKGROUND: Several studies have reported an association between smoking and periodontal destruction in young adults. AIMS: To investigate the effects of cigarette smoking on the periodontal condition of young Jordanian adults. METHODS: A case-control study of young adults between the ages of 20 and 35 years who were attending a dental hospital in Jordan for routine dental treatment. A group of 100 subjects who had smoked for at least 2 years were compared with 100 age- and sex-matched never smokers. Clinical measurements of plaque, bleeding on probing and probing depth were recorded and interproximal bone levels related to molar teeth were assessed from bitewing radiographs. RESULTS: The smokers had higher levels of plaque, more sites which bled in response to probing and a greater mean probing depth than never smokers. The unadjusted odds ratio for smoking to be associated with the presence of more than 10 pockets which were > or =4 mm was 3.08 (95% confidence interval 1.58-6.03). The proportion of measurable surfaces in smokers (22.7%) which had bone levels > or =3 mm below the cementoenamel junction was significantly higher (P<0.0001) than in never smokers (7.4%). Independent predictors of reduced bone levels in multivariate analysis were infrequent interdental cleaning (P=0.03), age of 30 or older (P=0.03) and smoking (P<0.0001). Within the multivariate analysis the adjusted odds ratio for smoking to be associated with reduced molar bone levels was 4.95 (confidence interval 2.48-9.88). CONCLUSIONS: It is concluded that cigarette smoking was a major environmental factor associated with accelerated periodontal destruction in the young adult Jordanians investigated.     

The role of periodontal probing depth in clinical decision-making

This retrospective study examines the role of periodontal probing depth in clinical decision-making. The expected values of no treatment and surgical and non-surgical therapies were obtained by combining the probability of each treatment outcome and utility values denoting the preference for each outcome. The expected value for non-surgical therapy was higher for sextants exhibiting a positive response to initial therapy than sextants which did not respond to initial therapy (0.735 versus 0.706). This trend was not observed for sextants treated surgically. Surgical therapy was effective over all levels of disease severity and was the preferred form of therapy with respect to reduction of probing depth except for sextants exhibiting 4 to 5 mm pockets. In this latter situation, the expected value at 3 years for non-surgical and surgical therapy was 0.795 and 0.792, respectively. Neither form of therapy could consistently achieve periodontal probing depths equal to or less than 3 mm throughout a given sextant. This study facilitates the selection of an optimal therapeutic strategy with respect to periodontal probing depth.     

Smoking affects the outcome of guided tissue regeneration with bioresorbable membranes: a retrospective analysis of intrabony defects

OBJECTIVES: To disclose factors that may influence the results of guided tissue regeneration (GTR) treatment in intrabony defects with bioresorbable membranes. METHODS: Forty-seven intrabony defects in 32 patients were treated by means of polylactic acid/citric acid ester copolymer bioresorbable membranes. At baseline and after 1 year, the following parameters were recorded: (1) probing pocket depth (PPD), (2) gingival recession (REC), (3) probing attachment level (PAL)=PPD+REC, (4) presence/absence of plaque (PI), (5) presence/absence of bleeding on probing (BOP) and (6) intrabony component (IC) configuration (i.e. primarily presence of one, two, or three bone walls). Occurrence of membrane exposure and smoking habits were also recorded. Significance of differences between categorical variables was evaluated with McNemar's test, and between numerical variables with the t-test for paired observations. Generalized linear models were constructed to evaluate the influence of various factors on PAL gain and PPD after 1 year, including in the analysis only one defect per patient (i.e. 32 defects) chosen at random. Odds ratios were calculated using the Mantel-Haenszel method. Differences between smokers and non-smokers were evaluated by means of Pearson's chi2 and Student's t-test for non-paired observations. RESULTS: At baseline, a mean PPD of 8.6+/-1.1 mm and a mean PAL of 9.8+/-1.6 mm was recorded. Statistically significant clinical improvements were observed 1 year after GTR treatment. An average residual PPD of 3.7+/-1.1 mm and a mean PAL gain of 3.8+/-1.5 mm were recorded. IC configuration and exposure of the membrane did not seem to influence the results, while a negative effect of smoking on the clinical parameters was observed. Smokers gained approximately 1 mm less in PAL than non-smokers (3.2+/-1.4 versus 4.3+/-1.3, respectively; p=0.03) and had approximately seven times less chances to gain 4 mm in PAL as compared with patients who did not smoke (odds ratio: 0.15). PPD reduction was less pronounced in smokers than in non-smokers (4.5+/-0.7 versus 5.5+/-0.7, respectively; p<0.01), resulting in somewhat deeper residual PPD in smokers than in non-smokers (3.6+/-1.0 versus 3.4+/-1.1; p>0.05). CONCLUSION: Smoking impairs the healing outcome of GTR treatment of intrabony defects with bioresorbable membranes.     

Locally delivered doxycycline improves the healing following non-surgical periodontal therapy in smokers

OBJECTIVE: The outcome of non-surgical periodontal therapy is known to be inferior in smokers compared to non-smokers. In the present study, the question was asked whether such a difference in healing response may be less evident following adjunctive use of locally delivered controlled-release doxycycline. METHODS: One hundred and three patients (42 smokers, 61 non-smokers), each having at least eight periodontal sites with PPD (probing pocket depth) > or =5 mm, were following stratification for smoking randomly assigned to two different treatment protocols; non-surgical scaling/root planing (Control) or ultrasonic instrumentation+application of a 8.5% w/w doxycycline gel (Atridox trade mark ) (Test). Instructions in oral hygiene were given to all patients. Clinical examinations of plaque, PPD, clinical attachment level (CAL) and bleeding following pocket probing were performed at baseline and after 3 months. Primary efficacy endpoints were changes in PPD and CAL. Patient mean values were calculated as basis for statistical analysis (multiple regression analyses). RESULTS: The baseline examination revealed no significant difference in mean PPD between treatment groups or between smokers and non-smokers (mean PPD 5.7-5.9 mm). The mean PPD reduction in the control group at 3-month was 1.1 mm (SD=0.45) for smokers and 1.5 mm (0.67) for non-smokers. In the test group the PPD reduction was 1.4 mm (0.60) and 1.6 mm (0.45) for smokers and non-smokers, respectively. The mean CAL gain for smokers and non-smokers amounted to 0.5 mm (0.56) and 0.8 mm (0.71), respectively, in the control group, and to 0.8 mm (0.72) and 0.9 mm (0.82), respectively, in the test group. Multiple regression analysis revealed that smoking and initial PPD negatively influenced the treatment outcome in terms of PPD reduction and CAL gain, while the use of doxycycline had a significant positive effect. CONCLUSION: Locally applied controlled-release doxycycline gel may partly counteract the negative effect of smoking on periodontal healing following non-surgical therapy.     

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.     

Initial outcome and long-term effect of surgical and non-surgical treatment of advanced periodontal disease

AIM: A clinical trial was performed to determine (i) the initial outcome of non-surgical and surgical access treatment in subjects with advanced periodontal disease and (ii) the incidence of recurrent disease during 12 years of maintenance following active therapy. MATERIAL AND METHODS: Each of the 64 subjects included in the trial showed signs of (i) generalized gingival inflammation, (ii) had a minimum of 12 non-molar teeth with deep pockets (> or =6 mm) and with > or =6 mm alveolar bone loss. They were randomly assigned to 2 treatment groups; one surgical (SU) and one non-surgical (SRP). Following a baseline examination, all patients were given a detailed case presentation which included oral hygiene instruction. The subjects in SU received surgical access therapy, while in SRP non-surgical treatment was provided. After this basic therapy, all subjects were enrolled in a maintenance care program and were provided with meticulous supportive periodontal therapy (SPT) 3-4 times per year. Sites that at a recall appointment bled on gentle probing and had a PPD value of > or =5 mm were exposed to renewed subgingival instrumentation. Comprehensive re-examinations were performed after 1, 3, 5 and 13 years of SPT. If a subject between annual examinations exhibited marked disease progression (i.e., additional PAL loss of > or =2 mm at > or =4 teeth), he/she was exited from the study and given additional treatment. RESULTS: It was observed that (i) surgical therapy (SU) was more effective than non-surgical scaling and root planing (SRP) in reducing the overall mean probing pocket depth and in eliminating deep pockets, (ii) more SRP-treated subjects exhibited signs of advanced disease progression in the 1-3 year period following active therapy than SU-treated subjects. CONCLUSION: In subjects with advanced periodontal disease, surgical therapy provides better short and long-term periodontal pocket reduction and may lead to fewer subjects requiring additional adjunctive therapy.     

Effect of smoking and periodontal treatment on the subgingival microflora

BACKGROUND: The effect of smoking on the prevalence of periodontal pathogens after periodontal treatment is still not clear. Some studies found no effect of the smoking status on the prevalence of periodontal pathogens after therapy, whereas others did. The aim of this retrospective study was to investigate the influence of smoking on the treatment of periodontitis and the composition of the subgingival microflora. METHOD: The study included 59 periodontitis patients (mean age 41.5 years): 30 smokers and 29 nonsmokers. The treatment consisted of initial periodontal therapy and, if necessary, surgery and/or antibiotics. Clinical and microbiological data were obtained before and after treatment at the deepest site in each quadrant. A pooled sample was analysed for the presence of Actinobacillus actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), Prevotalla intermedia (Pi), Bacteroides forsythus (Bf), Fusobacterium nucleatum (Fn) and Peptostreptococcus micros (Pm). RESULTS: For smokers and nonsmokers a significant improvement of the clinical condition was found after treatment. A decrease could be assessed for bleeding on probing (smokers: 0.46; nonsmokers: 0.52) and probing pocket depth (PPD) (smokers: 1.64 mm; nonsmokers: 2.09 mm). Furthermore, both groups showed gain of attachment (smokers: 0.68 mm; nonsmokers: 1.46 mm). No significant difference in bleeding on probing and PPD reduction was found between smokers and nonsmokers. In contrast, nonsmokers showed significantly more gain of attachment than smokers. The microbiological results revealed no differences in the prevalence of the various bacteria between smokers and nonsmokers before treatment. After treatment in nonsmokers, a significant decrease was found in the prevalence of Aa (11-3), Pg (17-7), Pi (27-11), Bf (27-11), Fn (28-20) and Pm (27-17). In smokers, a significant decrease could be shown only for the prevalence of Pg (15-5). CONCLUSIONS: Nonsmokers showed more gain of attachment and a greater decrease in the prevalence of periodontal bacteria as compared to smokers. The phenomenon that among smokers, more patients remain culture positive for periodontal pathogens after therapy, may contribute to the often observed unfavourable treatment results in smoker periodontitis patients.     

Cigarette smoking negatively affects healing response following flap debridement surgery

BACKGROUND: The purpose of the present parallel design, controlled clinical trial was to evaluate the treatment outcome following flap debridement surgery (FDS) in cigarette smokers compared to non-smokers. METHODS: After initial therapy, 57 systemically healthy subjects with moderate to advanced periodontitis who presented with one area (at least 3 teeth) where surgery was required were selected. Twenty-eight patients (mean age: 39.6 years, 20 males) were smokers (> or = 10 cigarettes/day); 29 patients (mean age: 43.9 years, 7 males) were non-smokers. Full-mouth plaque (FMP) and bleeding on probing (BOP) scores, probing depth (PD), clinical attachment level (CAL), and recession depth (RD) were assessed immediately before and 6 months following surgery. Only sites with presurgery PD > or = 4 mm were used for statistical analysis. RESULTS: Presurgery FMP and BOP were similar in smokers and non-smokers and significantly decreased postsurgery in both groups. Overall, PD reduction and CAL gain were greater, although not significantly, in non-smokers (2.4 +/- 0.9 mm and 1.6 +/- 0.7 mm, respectively) than in smokers (1.9 +/- 0.7 mm and 1.2 +/- 0.7 mm, respectively). For moderate sites (PD 4 to 6 mm), no significant differences in PD and CAL changes were found between groups. For deep sites (PD > or = 7 mm), PD reduction was 3.0 +/- 1.0 mm in smokers and 4.0 +/- 0.8 mm in non-smokers, and CAL gain amounted to 1.8 +/- 1.1 mm in smokers and 2.8 +/- 1.0 mm in non-smokers (P = 0.0477). In smokers, 16% of deep sites healed to postsurgery PD values < or = 3 mm as compared to 47% in non-smokers (P = 0.0000); 58% of deep sites in smokers showed a CAL gain > or = 2 mm, as compared to 82% in non-smokers (P = 0.0000). CONCLUSIONS: Results of the study indicated that: 1) FDS determined a statistically significant PD reduction and CAL gain in patients with moderate to advanced periodontitis; 2) smokers exhibited a trend towards less favorable healing response following FDS compared to non-smokers, both in terms of PD reduction and CAL gain; and 3) this trend reached clinical and statistical significance at sites with initial deep PD.     

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.