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Open Collection of Student Writing (OCSW)

Periodontal Observation and Evidence Based Research

INTRODUCTION

This semester dental hygiene students from Salt Lake Community College had the opportunity to observe any periodontal procedure that interested them. These procedures carry great significance because they are common practice today and use scientific evidence to show their usefulness. Bone grafts are an example of a scientifically based practices that have become very common for periodontists to perform. Bone grafts are indicated in severe bone loss related to periodontal disease, surgical extraction of teeth, and any cyst or tumors destroying bone.

PROCEDURE OBSERVATION

Indication for this procedure was #20 needed to be extracted because of severe bone loss and infection. A bone graft is also indicated because after the tooth, diseased tissue, and bone are removed, the bone will need to be replaced in order to have an implant positioned. The clinical findings were the same found radiographically, because both showed a severe infection surrounding #20 and bone loss. The patient’s oral health goals included an implant to restore the patient’s occlusion. His health history had no red flags for the procedure being performed. They did discuss how the patient’s genetics did play a factor in the history of periodontal disease and caries that contributed to the severe bone loss.

Before the procedure started the patient was brought back and given information about the procedure and was asked to sign consent forms. Then impressions were taken for the patient to have a flipper while the bone and tissue was healing in preparation for an implant. When Dr. S came in she talked to the patient about the procedure and made sure the patient understood what was about to take place and asked if he had any questions. Local anesthesia was given at the very beginning of the procedure, she performed an inferior alveolar nerve block, long buccal, and infiltration injection. Dr. S made sure to allow enough time to pass before beginning the procedure, she also touched around the tooth with a probe to see if it was numb. The patient could still feel the buccal tissue of tooth, so Dr. S performed a periodontal ligament (PDL) injection.

The crown of #20 was completely broken off and the infected root tip needed to be surgically removed. Dr. S made 3 incisions to make a flap which allowed visual accesses to the area. The tissue had an abscess as well that needed debridement. The bone was also debrided to access the underlying healthy bone to increase the success rate of the bone graft and future implant. The debridement also removed tissue tags, or granulation tissue, that have inflammatory cells causing continuous destruction unless removed. Once the whole area extending towards #21 was clean, the assistant mixed the bovine bone material. It was then packed around the tooth socket and debrided area. After the bone graft was successfully placed, a continuous interlocking suture was placed to close the flap.

To perform the inferior alveolar nerve block, Dr. S used 1.8ml of lidocaine. For the long buccal injection she used 0.4ml of articaine, and for each infiltration 0.2ml of articaine. She also performed 3 PDL injections of 0.2ml articaine when the patient could still feel the area. Dr. S also had a range of instruments to be used during each procedure. For the extraction; forceps, scalpel, spoon, cotton pliers, evacuator, bur, and hemostats. The scalpel was used first to cut a flap around the tooth to gain access. Then she switched back and forth between the forceps and evacuator to lift the tooth from the socket and disconnect all the periodontal ligaments still attached. She used the cotton pliers to remove small portions of the tooth being removed. The spoon and bur were used once the tooth was completely extracted to debride the area of disease granulation tissue and bone. After the area was completely debrided and bled without disease tissue, Dr. S used a spoon to place the bone graft material in the site of #20 extending to the distal aspect of #21. The hemostats were used at the end of the procedure to help with the placement of the suture.

At the end of the procedure, Dr. S discussed home care, to be mindful of the sutures. The patient was instructed not to brush or floss near the area and perform salt rinses. Dr. S then discussed the prescription she had written for pain, and that the patient should only use them if in severe discomfort. They also discussed the treatment plan and what needs to happen next to eventually achieve a successful implant. Dr. S continuously talked with her patient and he never showed any signs of nervousness or being uncomfortable throughout the whole procedure.

SCIENTIFIC EVIDENCE

Title

Alveolar Socket Preservation with Demineralised Bovine Bone Mineral and a Collagen Matrix

Authors

[redacted]

Purpose

The purpose of this research is to show that using demineralized bovine bone material (DBBM) and collagen matrix (CM) will improve the bone and tissue levels after an extraction. The research is showing how maintaining healthy bone and applying new DBBM and CM will help support a future implant.

“Hence, the purpose of the present pilot study was threefold: 1) to clinically and radiographically assess the magnitude of socket dimensional changes in both width and height, 2) to clinically evaluate soft tissue healing, and 3) to analyze the histologic and histomorphometric aspects of the grafted sockets filled with DBBM covered with a porcine-derived CM (pg. 196).”

Methods

This research used three different dental clinics from three different cities between January 2014- January 2015. The seven patients selected were all over the age of 18 with no systemic conditions, and all requiring an extraction of a tooth on the upper jaw between the premolars. To preserve the tooth socket, bovine xenografts with collagen (Bio-oss) were used to fill areas of diseased bone or bone loss. For soft tissue, porcine-derived non-crosslinked bioabsorbable CM (Mucograft) was placed to help with bone regeneration (pg. 196).

“Once the extraction socket was grafted, the bone graft was covered with a porcine CM that was trimmed and contoured according to the shape and dimension of the alveolar socket. The post-extraction socket was sealed with non-resorbable 6-0 simple interrupted suturing (Figure 1C). A peri-apical radiograph was conducted with the individualised film holder, serving as a post-operative radiological control (pg. 198).”

Each patient returns for a one, two, four, and eight week re-evaluation. If the patient had not fully recovered, a 10 week re-evaluation was required. Also “Six months after extraction, the re-entry procedure was performed in order to repeat the baseline radiological and clinical measurements, to collect hard and soft tissue biopsies, and to place implants (pg. 200).”

Reliability

This research is reliable because the patients had to be above the age of 18, and required an extraction on the upper jaw between the premolars. Also, the same three doctors traveled to 3 separate worldwide locations and achieved similar results.

Validity

This research was performed outside of any funded group, and the only conflict of interest was that “Geistlich Pharma AG (Wolhusen, Switzerland) supplied the biomaterials (collagen matrix and demineralised bovine bone mineral) used in this research (pg. 195).” This research also looked at all the levels and healing through a 6 month period, which showed current responses to the treatment performed. It also observed potentially negative outcomes that could have occured.

Results

To study the results, all seven patients provided a healing spot to be analyzed. These healing spots showed that horizontal changes were significant with a trend towards a reduced horizontal socket width, which was observed from the baseline appointment to the final examination. “At baseline, the [alveolar socket preservation] sites had a mean initial bucco-palatal width of 9.35 mm, which decreased to 8.14 mm after 6 months of healing (pg. 202).” Vertical ridge changes were also found significant with the initial depth at 13.46mm decreasing to 13.00mm at the 6 month evaluation (pg. 202). Every patient showed the most healing improvement at the 10 week evaluation. Each patient had a tissue biopsy performed at their 6 month evaluation, all showing a significant level of new bone with collagen rich tissue, active osteoblasts, proper osseointegration, and osteo matrix. This demonstrated that each area was successfully and properly healing.

Discussion

Bone levels after extraction go through vertical and horizontal bone loss. Bone loss is inevitable, so bone grafts are essential in replacing enough bone for a future implant. This research shows

“…socket intervention therapies might reduce post-extraction dimensional changes of the alveolus, but are unable to prevent resorption [24]. The present study investigated the dimensional changes and the histological healing of augmented extraction sockets within 6 months after tooth extraction. The sockets were grafted with DBBM and covered with a bioabsorbable porcine-derived CM. From the clinical and radiographic point of view, the residual ridge dimensions remained nearly stable, as highlighted by the mean height and width of bone resorption of 0.46 mm and 1.21 mm, respectively (pg. 204).”

According to this study, besides the unpreventable resorption all extraction sites go through, sockets with DBBM and the collagen through bioabsorbable porcine-derived CM showed significant changes to bone level and healing. “In conclusion, the application of DBBM particles covered with a CM to fresh extraction sockets allowed the preservation of an adequate hard and soft tissue volume to place implants, without the need for further augmentation procedures 6 months after tooth extraction (pg. 207).”

Significance

This research demonstrates that the use of demineralized bovine bone material for xenograft combined with the placement of a collagen matrix shows great success. This shows significant improvement to the levels and healing of horizontal and vertical bone loss cause from the extraction of a tooth from its socket. Without having this success, a proper implant placement would be very difficult and would most likely require more invasive procedures to achieve success. Therefore, the practical use of bone grafts is considered a quality evidence based practice.

PATIENT PREFERENCES/VALUES

Dr. S’s patient received an extraction because of the severe bone loss and infection surrounding the tooth. This patient wanted to be able to have a good smile and still be able to chew on his back teeth. For these reasons, the patient, his dentist, and Dr. S decided that an extraction, bone graft, and an implant would be a proper course of action. That implant would become a posterior abutment for a future bridge, which would fulfill the desires of the patient, as well as completing sound oral care. The patient was grateful and excited to have more teeth and be able to chew on that side again.

CLINICAL/PATIENT CIRCUMSTANCES

The patient’s circumstances affected the professional evidence-based clinical decision.

His dentist and Dr. S would normally recommend two implants instead of using number #21 as an abutment tooth. Tooth #21 has no need for a crown and will do better left alone. However, the patient could not afford the cost of an extraction, two bone grafts, and two implants. As a result, they came to the conclusion of a bridge with the posterior abutment based off of the newly placed implant.

CLINICIANS EXPERIENCES/JUDGEMENT

Dr. S has performed many procedures similar to the one observed. She discussed how each patient provides something different she needs to be aware of, but she uses her knowledge and past experience to continue with proper treatment. Dr. S continually learns what she can from scientific evidence and experience to stay aware of any changes in her practice, and to find better treatment plans.

CONCLUSION

In conclusion, Dr. S’s procedure was based on sound scientific based evidence. The patient losing bone from an extraction, both horizontal and vertical, is inevitable. However, Dr. S is aware of two problems related to the bone levels. First, that there is no way to prevent bone loss from an extracted tooth site, and secondly, that the diseased bone needs to be cleaned and remove to promote new bone attachment. Since Dr. S is aware of both of these complications, she performs demineralized bovine bone xenografts. The bone graft provides and promotes new osseous growth to the area experiencing bone loss. This graft and new bone growth with help heal the diseased socket and create an environment where a future implant will have success. However, she did not place any kind of collagen matrix to encourage collagen regrowth. Although the scientific evidence does not show large margins of difference in horizontal and vertical bone levels with the use of collagen matrix, there is enough to consider it significant. There needs to be more research performed on the collagen matrix to know if it should be used as a common practice. However, demineralized bovine bone xenografts are scientifically sound and have been proven very successful. Therefore, the procedure is an example of the importance of scientific evidence in evidence based practices

Sources

Maiorana, C., Poli, P. P., Deflorian, M., Testori, T., Mandelli, F., Nagursky, H., & Vinci, (2017). Alveolar socket preservation with demineralised bovine bone mineral and a collagen matrix. Journal of Periodontal & Implant Science, 47(4), 194. doi:10.5051/jpis.2017.47.4.194

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