Hyaluronic acid as adjunctive to non-surgical and surgical periodontal therapy: a systematic review and meta-analysis

Effects of 0.2% Hyaluronic Acid Gel-Impregnated Dental Floss on Clinical Gingival Parameters: A Randomised Clinical Trial

OBJECTIVES

Gingivitis is a common inflammatory lesion caused by the build-up of oral biofilm and is an essential precursor to periodontitis. For its treatment, oral hygiene habits, such as dental flossing, must be improved, and adjunctive materials, such as hyaluronic acid, may be used to reduce plaque formation and gingival inflammation. This study aimed to assess the effects of 0.2% hyaluronic acid gel-impregnated dental floss on the clinical periodontal markers of patients with gingivitis.

MATERIAL AND METHODS

This clinical study adopted a split-mouth, randomised controlled trial design. After clinical data were assessed at baseline, and supragingival scaling was performed, bilateral gingivitis regions were randomly allocated to either the hyaluronic acid gel-impregnated floss group or just the floss group using a computer-generated randomisation table. Clinical parameters were recorded at 1, 2 and 4 weeks after treatment.

RESULTS

Over the 4-week trial period, all patients showed significant improvements in all clinical periodontal markers. The 1-week plaque index, 4-week gingival index and 4-week papillary bleeding index were significantly lower in the test group than in the control group (p < 0.05).

CONCLUSIONS

The use of hyaluronic acid-impregnated dental floss has resulted in more significant improvements in clinical periodontal parameters compared to dental floss alone. For ease of use, ready-made products with this innovative formulation may be produced.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT06307041.

Evaluation of the effects of using an interdental brush dipped in 0.2% hyaluronic acid gel on clinical periodontal parameters among patients with periodontitis: a randomized controlled trial

BACKGROUND

The additional use of agents with antibacterial and anti-inflammatory activities, such as hyaluronic acid in treating periodontal disease, has recently become popular. This study aimed to evaluate the effects of using an interdental brush dipped in 0.2% HA gel on clinical periodontal parameters.

METHODS

This randomized controlled trial was conducted among 60 patients with stages II/III grades A/B periodontitis. After full-mouth scaling root planning and oral hygiene training, the patients were divided into two groups; the test group was asked to use an interdental brush dipped in 0.2% HA, while the control group was asked to use a regular interdental brush. Clinical periodontal parameters [ gingival index (GI), plaque index (PI), papillary bleeding index (PBI), pocket depth (PD), and clinical attachment loss (CAL) ] were assessed at baseline and in the 1st and 3rd months after treatment.

RESULTS

Clinical periodontal parameters were improved in control and test groups at the 1 and 3-month compared to baseline (p < 0.05). The 1st- and 3rd-month PBIs were significantly lower in the test group (p < 0.05). There was no significant difference between the test and control groups regarding PI, PD, GI, and CAL between the follow-up times.

CONCLUSIONS

Although the clinical efficacy of the tested methods of interdental brush use was similar, it can be concluded that the use of an interdental brush dipped in HA may contribute to the reduction of gingival bleeding in the early period.

CLINICAL SIGNIFICANCE

Incorporating HA into the oral hygiene regime after periodontitis treatment using an interdental brush is a useful and practical method. NAME OF THE REGISTRY: https://clinicaltrials.gov/ TRIAL REGISTRATION NUMBER: NCT06309797.

DATE OF REGISTRATION

07/03/2024 "Retrospectively registered". URL: https://clinicaltrials.gov/study/NCT06309797.

The Use of Hyaluronic Acid in the Non-Surgical Treatment of Periodontitis-An Umbrella Review

Background: Periodontitis is a prevalent inflammatory condition that destroys periodontal tissues. Scaling and root planing (SRP) is the gold standard for non-surgical treatment; however, its efficacy may be limited in cases with complex dental issues. This umbrella review aims to evaluate the effectiveness of hyaluronic acid (HA) as an adjunct to scaling and root planing (SRP) in enhancing clinical outcomes for periodontitis management. Methods: A comprehensive review of five systematic reviews, including meta-analyses where available, was conducted to synthesize evidence on the adjunctive use of HA with SRP. The studies were evaluated using the AMSTAR-2 quality assessment tool to determine methodological rigor. Data on clinical parameters such as probing depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), gingival index (GI), and plaque index (PI) were extracted and analyzed. Results: The findings indicate that HA supplementation leads to moderate improvements in PD, CAL, BOP, GI, and PI compared to SRP alone. Notable reductions in PD and gains in CAL were observed, with some meta-analyses showing statistically significant benefits. However, the heterogeneity in HA concentrations (0.2-1.4%), application methods, treatment frequencies, and follow-up durations (1 week to 12 months) limits definitive conclusions. Additionally, HA did not significantly affect the reduction in P. gingivalis prevalence. Conclusions: The use of HA in conjunction with SRP shows promise in enhancing the efficacy of non-surgical periodontal therapy. However, the heterogeneity in the quality and methodologies of the studies indicates the necessity for high-quality, standardized randomized controlled trials to establish clear clinical guidelines for the application of HA in the treatment of periodontitis.

The Effectiveness of Hyaluronic Acid on Prefabricated CAD CAM Bone Blocks for Ridge Augmentation: A Split Mouth Study

INTRODUCTION

Alveolar ridge augmentation has been one of the most accepted treatments for restoring bone volume. Various products are available in particle forms, which have limitations, especially related to controlling the expected volume gain. A prefabricated computer-aided design and computer-aided manufacturing (CAD-CAM) allogenic bone block could provide a good alternative.

MATERIALS AND METHODS

A split-mouth randomized clinical trial included 10 patients with the bilateral posterior atrophic mandible (20 sides), who were randomly assigned to two groups with an allocation ratio of 1:1. Group I: the ridge was augmented using prefabricated CAD-CAM allogenic bone block hydrated using hyaluronic acid, and group II was hydrated using saline. Blinding was limited to the patients and the investigator responsible for data analysis (double blinding). Six months after grafting surgery, a core biopsy was taken for histological analysis, and implants were inserted into the augmented ridge. The amount of bone gain was evaluated radiographically using CBCT.

RESULTS

All ridges in both groups revealed a successful bone gain in CBCT. However, the mean bone gain in group I (3.975 ± 0.31) was significantly higher than in group II (2.497 ± 0.66). Histologically, both groups showed osteointegration and new bone formation, with group I being superior. VEGF, OPN, and Cox 2 expressions were more intense in group I than in group II. The histomorphometric analysis revealed that group I had a considerably higher surface area of new bone formation than group II (p-value < 0.001). Immunohistochemical staining for VEGF revealed a significant difference between groups I (15.04 ± 0.47) and II (11.41 ± 0.54).

CONCLUSION

Within the limitations of this study, the addition of HA to prefabricated CAD-CAM allogenic block enhanced its osteogenic properties and guaranteed adequate integration of the graft for implant insertion.

TRIAL REGISTRATION

This clinical trial was not registered before the participants' recruitment and randomization (https://clinicaltrials.gov/study/NCT06395818).

Adjunctive use of hyaluronic acid in non-surgical periodontal therapy: A systematic review and meta-analysis

INTRODUCTION AND OBJECTIVES

Clinical studies have shown that adjunctive use of hyaluronic acid (HA) as part of non-surgical periodontal treatment (NSPT) has led to favourable clinical outcomes. However, no systematic review and meta-analysis has been carried out recently and technical and patient factors have not been previously explored. Therefore, the aim of this systematic review and meta-analysis is to evaluate the clinical effects of topical- HA as an adjunct to NSPT on probing depth (PD), clinical attachment level (CAL), and bleeding on probing (BoP) in periodontitis patients.

STUDY SELECTION AND SOURCES

Systematic literature searches using the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) approach identified clinical studies involving randomized controlled trials (RCTs) and split-mouth designs involving adult periodontitis. The searches were performed across six databases (PubMed, Embase, Medline, Cochrane, Web of Science, Scopus, and Google Scholar).

DATA

Of the 1479 articles identified from the initial searches, a total of 23 were included in this systematic review, and 12 studies were included in the meta-analysis and sub-group analyses. Based on the included studies, HA adjunctive therapy showed improvements in PD reduction (WMD of -0.46, 95 % Confidence Interval CI:0.89 to -0.04, P = 0.04), CAL gain (WMD of -0.35, 95 % CI:0.61 to -0.09, P = 0.01), and BoP reduction (WMD of -0.38, 95 % CI:0.78 to 0.01, P = 0.06). However, due to the heterogeneity of the included studies, further evidence were needed to support the improvement of HA adjunctive therapy outcomes due to wider prediction intervals (PD reduction 95 % prediction interval, PI:1.95 to 1.03; CAL enhancement 95 % PI -1.11 to 0.42; BoP reduction 95 % PI -1.35 to 0.59)Higher HA concentrations (0.8 %)showed more pronounced PD reduction. The overall quality of the included studies were moderate using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment tool.

CONCLUSION

Although topical HA application may provide additional benefits when used with NSPT, the limited number of studies, risk of bias, heterogeneity and moderate quality of evidence indicate that further research is warranted to confirm these findings and establish more definitive clinical guidelines.

CLINICAL SIGNIFICANCE

HA showed promise as an adjunctive treatment in enhancing the clinical outcomes following NSPT.

Non-surgical management of gingival cleft

The aims of the present case report are to describe the non-surgical management in addition to hyaluronic acid application of two gingival recessions with cleft and to perform a narrative review on the newest evidence of non-surgical treatment of gingival recessions. A 47-year-old female patient with dentine hypersensitivity and pain during brushing has type 1 gingival recession with red Stillman's cleft on 1.4 and 1.5. The gingival defects have been treated with a Gracey curette n° 7/8 to cause bleeding. Sodium hyaluronate gel has been applied in the gingival sulcus of both elements affected. Three months after treatment the gingival tissue on 1.5 and 1.4 revealed complete healing of the Stillman's cleft and the mean value of REC depth reduced by 0.50 mm. Furthermore, four articles about this topic were selected for a narrative review. Based on the recent literature, the non-surgical treatment of Stillman's clefts and gingival recessions is not highly rated. The clinical result of this case report suggests a non-surgical method to treat Stillman's cleft. However, the evidence from a single case report is weak and more clinical trials are required to deepen the knowledge on the topic.

Management of a carcinoma in situ of the tongue margin, using a Nd:YAG laser, cross-linked hyaluronic acid (xHyA) gel and a porcine pericardium resorbable membrane: a case report

BACKGROUND

Oral tongue squamous cell carcinoma is the most prevalent cancer of the oral cavity. To date, the mainstay management for carcinoma in situ of the oral cavity is the surgical radical removal of the neoplastic tis-sue. This paper describes a new approach in the management of an in situ carcinoma of the tongue margin, treated surgically by the use of Nd:YAG laser, the application of cross-liked hyaluronic acid (xHyA) gel and the placement of a resorbable porcine pericardium membrane (PPM).

CASE PRESENTATION

The case involves a 49-years old male patient with no history of smoking and alcohol use, who presented a non-homogeneous leukoplakia of the right tongue border. The biopsy revealed high-grade lichenoid dysplasia, corresponding to severe epithelial dysplasia or carcinoma in situ (Tis), characterized by full-thickness dysplasia without stromal invasion.

CONCLUSIONS

The case shows that the combined use of Neodimium laser surgery, xHyA gel and PPM is a viable option for promoting soft tissue regeneration in the oral cavity, enabling excellent clinical results in terms of healing medium-sized surgical defects. In addition, compared with other options for the reconstruction of surgical defects of the tongue, the clinical use of the association between these two materials has several biological advantages due to the absence of donor sites and high patient tolerability.

Local application of 0.8% hyaluronic acid gel as an adjunct to minimally invasive nonsurgical treatment of periodontal intrabony defects-A randomized clinical trial

AIM

The aim of this study was to evaluate the clinical and radiographic effects of hyaluronic acid (HA) gel application as an adjunct to minimally invasive nonsurgical treatment (MINST) in intrabony defects ≥3 mm.

METHODS

A total of 36 patients were included and randomly assigned to two groups: (a) MINST + HA (test; n = 17) and (b) MINST (control, n = 19). Subgingival 0.8% HA gel was applied in intrabony defects of test group and repeated 4 weeks following MINST protocol. Clinical measurements including probing depth (PD), clinical attachment level (CAL), and gingival recession (GR) were recorded at baseline and repeated at 3 and 6 months. Radiographic evaluation was performed at baseline and 6 months.

RESULTS

Test group showed significantly greater reduction in PD and gain in CAL at 3 months compared to baseline than that of controls (p < .05), but the changes (Δ) at 6 months compared to baseline did not differ between the groups (p > .05). Although, both groups showed statistically significant GR in all evaluated time periods (p < .05), control group showed higher ΔGR than that of test group (p < .05). There was no significant difference between the groups in terms of radiographic defect fill/bone gain (p > .05).

CONCLUSIONS

The additional use of 0.8% HA gel in the treatment of periodontal intrabony defects did not provide additional benefits in clinical and radiographic parameters. On the other hand, GR measurements showed favorable results in the test group.

Enhancing wound healing with synthetic hyaluronic acid injection in sutured incisions on BALB/c mice

INTRODUCTION

Hyaluronic acid has been shown to possess notable properties in wound healing, skin regeneration, and anti-inflammatory effects. The formation of scar tissue is a common and unintended phenomenon during the wound-healing process, potentially leading to diverse consequences for individuals.

Hyaluronic acid-based minocycline-loaded dissolving microneedle: Innovation in local minocycline delivery for periodontitis

Periodontitis is a prevalent inflammatory disease that affects tooth-supporting tissues and is induced by complex polymicrobial dental plaques. Prior treatments, including topical antibiotic ointments, have faced difficulties in tissue permeability issues. Although dissolving microneedle (DMN) has been proposed as a painless and highly efficient transdermal drug delivery system to resolve this challenge, minocycline, widely used for the treatment of periodontitis, is light-sensitive, making it challenging to maintain its stability using conventional fabrication methods. Our hyaluronic acid-based minocycline-loaded dissolving microneedle (HAM-DMN) was designed utilizing an innovative light-blocking strategy, preserving 94.4 % of minocycline's stability, as confirmed by liquid chromatography-tandem mass spectrometry (LC-MS/MS) analysis. HAM-DMNs demonstrated antimicrobial efficacy in in vitro zone of inhibition tests with Streptococcus mutans strains and provided enhanced local delivery of minocycline to porcine oral gingival mucosa at concentrations 6.1 times higher than those of commercial ointments. In vivo studies in periodontitis-induced rat models showed that HAM-DMNs reduced levels of junctional epithelium more effectively than control and blank DMN groups, indicating enhanced treatment efficacy. HAM-DMN is a novel local delivery system developed to overcome the limitations of systemic delivery and conventional topical treatment. We suggest that HAM-DMNs can replace injections for the treatment of intraoral mucosal and systemic diseases.

Effects of Hyaluronic Acid on Three Different Cell Types of the Periodontium in a Novel Multi-Culture Cell Plate: An Exploratory Study

Hyaluronic acid (HA) has received considerable attention in the reconstruction of lost periodontal tissues. HA has been proposed to play a role in cell proliferation, differentiation, migration, and cell-matrix as well as cell-cell interactions. Although various studies have been conducted, further research is needed to expand our knowledge based on HA such as its effects on cell proliferation and osteogenic differentiation. The aim of this study is to assess, in single- and multi-culture plate models, the effect of HA on the proliferation, viability, and function of periodontal ligament fibroblasts, osteoblasts, and gingival epithelial cells. A novel multi-culture cell plate was chosen to simulate a cell-cell communication as close as possible to a real clinical condition in an in vitro setting. We found that HA exclusively enhanced epithelial cell proliferation, while intercellular communication stimulated the proliferation and osteogenic potential of the osteoblasts, independently from HA use. The proliferation and function of the periodontal ligament fibroblasts were not changed by HA or the cellular interplay. The use of multi-culture plates could represent a promising method to investigate and compare dental biomaterials in experiments mimicking an in vivo environment.

Sequential Bone Repair in Rabbit Sinus Lifts Using Bio-Oss and Hyaluronic Acid-Polynucleotide Gel (Regenfast)

BACKGROUND

A comprehensive investigation to associate the use of polynucleotides and hyaluronic acid with bovine bone in maxillary sinus lift procedures in rabbits has not been performed yet. The aim was to evaluate the influence of this novel association on the processes of bone regeneration in maxillary sinus augmentation.

METHODS

In this prospective, randomized, within-animal model, maxillary sinus augmentation was performed bilaterally in 12 rabbits. Deproteinized bovine bone material (DBBM) was used as filler material. A hyaluronic acid-polynucleotide gel was aggregated at the test site. Histological evaluations were performed after 2 and 10 weeks of healing.

RESULTS

After 2 weeks of healing, similar amounts of new bone were observed at both the control (7.7 ± 4.3%) and test sites (8.1 ± 3.8%; p = 0.697). Bone formation was observed predominantly along the osteotomy margins and adjacent sinus walls. After 10 weeks of healing, the total new bone fraction reached 28.0 ± 10.1% at the control sites and 27.3 ± 10.5% at the test sites (p = 0.563). Multiple perforations of the sinus mucosa were observed in both groups when in contact with the biomaterial granules.

CONCLUSION

The present study failed to demonstrate a positive effect on bone formation when incorporating hyaluronic acid-polynucleotide gel (Regenfast) into a xenograft for maxillary sinus augmentation. Additionally, the use of this gel did not mitigate the occurrence of thinned mucosa or reduce the risk of subsequent sinus mucosa perforation.

Non-surgical treatment of peri-implantitis

Treatment of peri-implantitis follows similar steps as the therapy of periodontitis. Non-surgical interventions, however, show limited success and in many cases, don't lead to a complete resolution of the local inflammation. The scientific literature was evaluated and based on the European Federation of Periodontology's S3-level guideline, recommendations for clinical practice are presented. Despite limitations in the success of this type of treatment, it is an important first step before surgical interventions and as such may help to improve overall treatment outcomes.

The Chick Embryo Chorioallantoic Membrane (CAM) Assay: A Novel Experimental Model in Dental Research

Animal experimental models are ruled out by respecting the 3Rs (Replacement, Reduction, Refinement) rules which governed the experimental research for decades with an increased tendency to minimize as much as it is possible any pain suffering or distress that the animals might feel. The chick embryo chorioallantoic membrane (CAM) model is an alternative to other experimental models due to its superior properties compared to other animal models. The CAM is painless by itself due to the lack of innervation and has no immune cells till the 11th day of incubation. Thus, it is extensively used for implanting malignant tumors and assessing them in relation to their metastatic and angiogenic potential. Also, various biomaterials from collagen to hard scaffolds can be implanted on the CAM surface and analyzed mainly related to their property of inducing inflammation. Dental research often uses mouse or rabbit models for experimental purposes. Different surgical techniques from experimentally induced periodontal disease to experimental dental implants may cause pain and suffering to animals. Due to all these arguments, the CAM model is a quick, cheap, and reliable alternative to other animal experimental models used in dental research. Despite its usefulness as an experimental model for different applications, ranging from inflammation studies to cancer research, the CAM model is insufficiently used in dental research. Currently, about 135 studies pertaining to this issue are available in PubMed, the majority of which focus on the reactivity of CAM vessels to various materials employed in dentistry. Limited data exist about the capacity of the CAM to promote osteogenic differentiation of dental stem cells or to enhance biomaterial integration into novel tissue architectures. The present review critically analyzed the use of the CAM model as an experimental tool in dental research. We selected from PubMed all the papers having as topic the CAM in dentistry by searching based on the following keywords: " chorioallantoic membrane, dentistry" or "chorioallantoic membrane, dental ". We focused on discussing the benefits and limitations of the CAM model in dental studies and its prospective role as a preclinical instrument for the assessment of dental tissues, biomaterials, or different dentistry-related substances prior to their use for various purposes in dental clinical practice. ​​​​​​The impact of the CAM model-derived preclinical findings on clinical practice will be also stated by mentioning "pros and cons" arguments. The last part of the present paper reviewed the perspective of CAM assay used in combination with other experimental techniques such as tooth organoids and also the strengths and weaknesses of other species CAM assays recently developed in ostrich and Nile crocodile CAMs.

Evaluation of the efficacy of microneedling alone and in combination with injectable hyaluronic acid in augmentation of peri-implant soft tissues: A randomized controlled trial

Objectives

The objective of this study was to evaluate the efficacy of injectable hyaluronic acid (HA) combined with microneedling (MN) in augmenting peri-implant soft tissue.

Materials and Methods

Sixty-five patients were enrolled and divided into two groups. Group 1 received MN alone, while Group 2 received HA following MN on the peri-implant mucosa. Various parameters - including the plaque index (PI), gingival index (GI), peri-implant probing depth, clinical attachment levels, Sulcus Bleeding Index, mucosal thickness (MT), keratinized tissue width (KTW), interproximal width (IPW), and papillary recession height (PRH) - were evaluated at baseline, 3 months, and 6 months postoperatively. Patient-reported outcome measures were assessed to gauge treatment effectiveness and patient satisfaction.

Results

Group 2 patients exhibited reduced PI, GI, SBI, PIPD, and CAL compared to Group 1. Both groups showed a significant increase in MT and KTW after 6 months; MT increased to 1.03 ± 0.11 mm in Group 1 and 2.48 ± 0.45 mm in Group 2, while KTW increased to 2.44 ± 0.84 mm in Group 1 and 4.34 ± 1.02 mm in Group 2. In addition, the mean PRH was 1.67 ± 0.32 mm in Group 1 and 0.88 ± 0.25 mm in Group 2, with a mean IPW of 2.19 ± 0.52 mm in Group 1 and 0.90 ± 0.16 mm in Group 2.

Conclusion

HA combined with MN leads to increased MT and KTW, reduced inflammation, and improved papillary fill. Thus, HA with MN may serve as an effective short-term implant maintenance modality, assisting clinicians in achieving peri-implant soft tissue regeneration.

Enhanced alveolar ridge preservation with hyaluronic acid-enriched allografts: a comparative study of granular allografts with and without hyaluronic acid addition

PURPOSE

Ridge preservation is essential to restore alveolar ridge volume and to enhance esthetic and functional outcomes for dental implants. The addition of hyaluronic acid to allogeneic bone substitute materials might enhance these outcomes. This clinical study evaluated the efficacy of ridge preservation after tooth extraction using granular allografts with and without hyaluronic acid addition.

METHODS

In this retrospective study, 40 patients with compromised extraction sockets were enrolled. Among them, 19 received particulate allogeneic bone substitutes (Allo), 21 received allogeneic bone substitutes with hyaluronic acid (AlloHya). Vertical and horizontal graft stability, graft shrinkage rate, and bone mineral density were assessed using radiographic measurements on CBCT scans conducted before tooth extraction, directly after ridge preservation and after four months. Patients were followed up 12 months post-implantation.

RESULTS

Vertical height loss after 4 months was significantly greater in the Allo group (-0.82 ± 0.95 mm) compared to the AlloHya group (-0.19 ± 0.51 mm; p = 0.011). Graft shrinkage rate was 16.9 ± 11.5% (Allo) and 10.3 ± 7.7% (AlloHya) (p = 0.038). After four months, average bone density was significantly higher in the AlloHya compared to the Allo group (p = 0.004). Nearly all implants (39 out of 40) were classified as "Success" according to the ICOI scheme, with no differences in implant quality between the two study groups.

CONCLUSIONS

Improved graft stability, reduced resorption, and increased bone density were observed in hyaluronic acid-enriched allografts compared to pure allografts. Adding hyaluronic acid to allogeneic bone grafts significantly enhanced outcomes in ridge preservation.

Effect of hyaluronic acid on palatal wound healing: A systematic review

OBJECTIVES

To evaluate the efficacy of topically applied hyaluronic acid on wound healing (patient-reported outcomes and clinical healing) after a palatal autogenous gingival graft is harvested.

MATERIALS AND METHODS

A systematic search was performed in April 2024 in eleven electronic databases. Two investigators independently screened the references for inclusion. Outcomes of interest included postoperative pain, analgesic consumption, complete epithelialization, and color match, which were synthesized using narrative synthesis.

RESULTS

A total of 535 results were identified and eight articles were included in the systematic review. Hyaluronic acid use on the palatal donor site had a better response to healing and wound size compared to the control sites with no agent applied. Hyaluronic acid demonstrated a positive effect in the form of complete epithelialization, and color match, with improved patient-reported outcomes such as post-operative pain.

CONCLUSION

Within the limitations of this systematic review, it can be concluded that hyaluronic acid shows a strong potential to improve patient-reported outcomes and clinical wound healing at the graft donor site on the palate. Future studies are required to clarify the optimal concentration, frequency of application, and synergistic effect when HA is combined with other interventions.

CLINICAL RELEVANCE

Within the limitations of this systematic review, it can be concluded that hyaluronic acid shows a strong potential to improve patient-reported outcomes and clinical wound healing at the graft donor site on the palate. Future studies are required to clarify the optimal concentration, frequency of application, and synergistic effect when HA is combined with other interventions.

Effectiveness of 0.2% Hyaluronic Acid on Clinical, Biomolecular and Microbiological Parameters in Type 2 Diabetes Mellitus Patients with Periodontitis

OBJECTIVE

 This double-blind randomized clinical trial assessed the effectiveness of 0.2% hyaluronic acid (HA) gel as an adjunct to scaling and root planning (SRP) in patients with periodontitis and type 2 diabetes mellitus (DM), focusing on changes in clinical periodontal parameters, the expression of inflammatory mediators, and oral pathogens.

MATERIALS AND METHODS

 The randomized clinical trial involved 36 participants, 18 DM patients, and 18 healthy patients. The participants in each group were randomly assigned to receive placebo or HA gel after SRP. Gingival crevicular fluid and subgingival plaque samples were taken before treatment and at 4-week follow-up. Clinical parameters, interleukin-1β (IL-1β) and IL-10 levels, and proportions of Porphyromonas gingivalis (Pg) and Fusobacterium nucleatum (Fn) were evaluated at baseline and follow-up.

STATISTICAL ANALYSIS

 Paired t-test (parametric data) or Wilcoxon signed-rank test (nonparametric data) was used for intragroup comparison between baseline and follow-up, and comparisons between groups one-way analysis of variance test (parametric data) or Kruskal-Wallis test (nonparametric data).

RESULTS

 At 4 weeks, most of the groups showed statistically significant decreases (p ≤ 0.05) in various clinical and biomolecular parameters. However, there were exceptions: the pocket probing depth (PPD) and clinical attachment loss (CAL) parameter did not significantly decrease for the placebo (p > 0.05) non-DM group, and the IL-10 parameter in the DM HA gel group (p = 0.108). Regarding bacterial proportions, the non-DM and DM placebo group exhibited significant test results for Pg after 4 weeks (p ≤ 0.05). In the case of Fn bacteria proportions, they decreased in all groups, but these results were not statistically significant (p ≥ 0.05). An intergroup analysis revealed no significant differences (p ≤ 0.05) for bleeding on probing (BOP), PPD, and both proinflammatory and anti-inflammatory cytokines. Only clinical attachment loss (CAL) exhibited a statistically significant intergroup difference 0.042.

CONCLUSION

 The use of 0.2% HA gel into periodontal pockets alongside SRP, for both diabetic and healthy individuals, showed no statistically significant variances in clinical, biomolecular, and microbiological measures.

In-vitro effects of different hyaluronic acids on periodontal biofilm-immune cell interaction

Introduction

Recent studies have demonstrated a positive role of hyaluronic acid (HA) on periodontal clinical outcomes. This in-vitro study aimed to investigate the impact of four different HAs on interactions between periodontal biofilm and immune cells.

Methods

The four HAs included: high-molecular-weight HA (HHA, non-cross-linked), low-molecular-weight HA (LHA), oligomers HA (OHA), and cross-linked high-molecular-weight HA (CHA). Serial experiments were conducted to verify the influence of HAs on: (i) 12-species periodontal biofilm (formation and pre-existing); (ii) expression of inflammatory cytokines and HA receptors in monocytic (MONO-MAC-6) cells and periodontal ligament fibroblasts (PDLF) with or without exposure to periodontal biofilms; (iii) generation of reactive oxygen species (ROS) in MONO-MAC-6 cells and PDLF with presence of biofilm and HA.

Results

The results indicated that HHA and CHA reduced the bacterial counts in a newly formed (4-h) biofilm and in a pre-existing five-day-old biofilm. Without biofilm challenge, OHA triggered inflammatory reaction by increasing IL-1β and IL-10 levels in MONO-MAC cells and IL-8 in PDLF in a time-dependent manner, whereas CHA suppressed this response by inhibiting the expression of IL-10 in MONO-MAC cells and IL-8 in PDLF. Under biofilm challenge, HA decreased the expression of IL-1β (most decreasing HHA) and increased IL-10 levels in MONO-MAC-6 cells in a molecular weight dependent manner (most increasing CHA). The interaction between HA and both cells may occur via ICAM-1 receptor. Biofilm stimulus increased ROS levels in MONO-MAC-6 cells and PDLF, but only HHA slightly suppressed the high generation of ROS induced by biofilm stimulation in both cells.

Conclusion

Overall, these results indicate that OHA induces inflammation, while HHA and CHA exhibit anti-biofilm, primarily anti-inflammatory, and antioxidant properties in the periodontal environment.

Early periodontal wound healing after chlorhexidine rinsing: a randomized clinical trial

OBJECTIVES

This single-center randomized, parallel design, clinical trial with a 2-week follow-up involved patients affected by periodontitis undergoing periodontal surgery. The aim was to evaluate periodontal surgical wound healing with the use of chlorhexidine-based mouth rinses versus an untreated control group.

MATERIALS AND METHODS

Periodontal surgery was performed following a standardized protocol. Patients were randomly prescribed i) chlorhexidine (CHX) + anti-discoloration system (ADS) + hyaluronic acid (HA), ii) CHX + ADS or iii) no treatment (control group). Plaque score, gingival inflammation, and Early Healing Index (EHI), assessing the degree of wound closure and the presence of fibrin and necrosis, were evaluated at 3, 7 and 14 days after surgery.

RESULTS

In total, 33 patients were enrolled. Patients were comparable at baseline for all measured clinical parameters. At 3-days wound healing was significantly improved in all patients treated with CHX + ADS-based mouth rinses with a lower EHI score at the interdental papillae compared with control group (p < 0.01). CHX + ADS + HA group presented improved healing across all time points in terms of EHI, plaque containment, and gingival inflammation when compared to control group (p < 0.01).

CONCLUSIONS

The usage of CHX-ADS following periodontal surgery improved early wound healing, reduced plaque accumulation and gingival inflammation. During the early post-operative period the adjunct of HA further improved soft tissue closure.

CLINICAL RELEVANCE

This study aims at evaluating the response of gingival tissues to mouth rinsing with chlorhexidine and anti-discoloration system (CHX + ADS) or CHX + ADS + hyaluronic acid (CHX + ADS + HA) versus no rinse in terms of healing of the periodontal surgical wound. CHX + ADS mouth rinses enhanced early soft tissue closure after periodontal surgery and contributed to the reduction in plaque accumulation and gingival inflammation. The adjunct of HA may be beneficial especially in the early post-operative period. CHX + ADS administration following periodontal surgery may improve soft tissue healing in the first two post-operative weeks.

Adjunctive use of hyaluronic acid in the treatment of gingival recessions: a systematic review and meta-analysis

OBJECTIVES

To explore the efficacy of Hyaluronic acid as an adjunctive in treatment of gingival recessions (GR).

MATERIALS AND METHODS

A systematic literature search was performed in several electronic databases, including Medline/ PubMed, Embase, CENTRAL and LILACS. Recession improvement was evaluated through multiple outcome variables. The Cochrane Risk of Bias tool and the ROBINS-I tool were used to assess the quality of the included trials. Weighted Mean Differences (WMDs) and 95% confidence intervals (CIs) between test and control sites were estimated through meta-analysis using a random-effect model for the amount of Relative Root Coverage (RRC).

RESULTS

A total of 3 randomised studies were deemed as eligible for inclusion. Their data were also used for pooling the effect estimates. Overall analysis of RRC (3 studies) presented a WMD of 7.49% (p = 0.42; 95% CIs -10.88, 25.86) in favour of adjunctive use of hyaluronic acid during Coronally Advanced Flap (CAF) technique, although statistical significance was not reached. Statistical heterogeneity was found to be high (I2 = 80%).

CONCLUSIONS

Within their limitations, the present data indicate that the local application of Hyaluronic acid does not lead to additional clinical benefits when used as an adjunctive to the treatment of GR with CAF. However, due to the high heterogeneity among the studies, additional well-designed RCTs are needed to provide further evidence on this clinical indication for the use of Hyaluronic acid.

CLINICAL RELEVANCE

In the frame of the current review, the adjunctive use of Hyaluronic acid does not additionally improve the clinical outcomes obtained during treatment of GR with CAF.

Healing of Periodontal Suprabony Defects following Treatment with Open Flap Debridement with or without Hyaluronic Acid (HA) Application

Background and Objectives: This randomized, double-arm, multicentric clinical trial aims to compare the clinical outcomes following the treatment of suprabony periodontal defects using open flap debridement (OFD) with or without the application of hyaluronic acid (HA). Materials and Methods: Sixty systemically healthy patients with at least two teeth presenting suprabony periodontal defects were randomly assigned with a 1:1 allocation ratio using computer-generated tables into a test (OFD + HA) or control group (OFD). The main outcome variable was clinical attachment level (CAL). The secondary outcome variables were changes in mean probing pocket depth (PPD), gingival recession (GR), full-mouth plaque score (FMPS), and full-mouth bleeding score (FMBS). All clinical measurements were carried out at baseline and 12 months. Results: Sixty patients, thirty in each group, were available for statistical analysis. The mean CAL gain was statistically significantly different (p < 0.001) in the test group compared with the control group (3.06 ± 1.13 mm vs. 1.44 ± 1.07 mm). PPD reduction of test group measurements (3.28 ± 1.14 mm) versus the control group measurements (2.61 ± 1.22 mm) were statistically significant (p = 0.032). GR changes were statistically significant only in the test group 0.74 ± 1.03 mm (p < 0.001). FMBS and FMPS revealed a statistically significant improvement mostly in the test group. Conclusions: Suprabony periodontal defects could benefit from the additional application of HA in conjunction with OFD in terms of improvement of the clinical parameters compared with OFD alone.

From Basic Science to Clinical Practice: A Review of Current Periodontal/Mucogingival Regenerative Biomaterials

Periodontitis is a dysbiosis-driven inflammatory disease affecting the tooth-supporting tissues, characterized by their progressive resorption, which can ultimately lead to tooth loss. A step-wise therapeutic approach is employed for periodontitis. After an initial behavioral and non-surgical phase, intra-bony or furcation defects may be amenable to regenerative procedures. This review discusses the regenerative technologies employed for periodontal regeneration, highlighting the current limitations and future research areas. The search, performed on the MEDLINE database, has identified the available biomaterials, including biologicals (autologous platelet concentrates, hydrogels), bone grafts (pure or putty), and membranes. Biologicals and bone grafts have been critically analyzed in terms of composition, mechanism of action, and clinical applications. Although a certain degree of periodontal regeneration is predictable in intra-bony and class II furcation defects, complete defect closure is hardly achieved. Moreover, treating class III furcation defects remains challenging. The key properties required for functional regeneration are discussed, and none of the commercially available biomaterials possess all the ideal characteristics. Therefore, research is needed to promote the advancement of more effective and targeted regenerative therapies for periodontitis. Lastly, improving the design and reporting of clinical studies is suggested by strictly adhering to the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement.

Histological evaluation of nonsurgical periodontal treatment with and without the use of sodium hypochlorite / amino acids and cross-linked hyaluronic acid gels in dogs

OBJECTIVES

To evaluate periodontal wound healing following scaling and root planing (SRP) in conjunction with the application of sodium hypochlorite/amino acids and cross-linked hyaluronic acid (xHyA) gels in dogs.

MATERIALS AND METHODS

In four beagle dogs, 2-wall intrabony defects were created and metal strips were placed around the teeth. Clinical parameters were measured 4 weeks after plaque accumulation. The experimental root surfaces were subjected to SRP with either the subgingival application of a sodium hypochlorite/amino acid gel and a xHyA gel (test group) or SRP alone (control group) using a split-mouth design. Clinical parameters were re-evaluated at 6 weeks. The animals were sacrificed at 8 weeks for histological analysis.

RESULTS

The test group showed significant improvements in all clinical parameters compared to the control group. Histologically, the test group exhibited statistically significantly greater new bone formation [i.e., length of newly formed bone, new bone area] compared with the control group (p < 0.05). Furthermore, statistically significantly greater formation of new attachment [i.e., linear length of new cementum adjacently to newly formed bone with inserting collagen fibers] and new cementum was detected in the test group compared with the control group at 8 weeks (p < 0.05 and p < 0.01, respectively).

CONCLUSION

The adjunctive subgingival application of sodium hypochlorite/amino acid and xHyA gels to SRP offers an innovative novel approach to enhance periodontal wound healing/regeneration.

CLINICAL RELEVANCE

The present findings have for the first-time shown histologic evidence for periodontal regeneration in support of this novel treatment modality.

Topical Agents in Biofilm Disaggregation: A Systematic Review and Meta-Analysis

Background: to evaluate the effectiveness of different topical agents in biofilm disaggregation during non-surgical periodontal therapy. Methods: the search strategy was conducted according to the PRISMA 2020 on Pubmed, Cochrane Library, Scopus, and Web of Science, and it was registered in PROSPERO, ID: CRD42023474232. It included studies comparing non-surgical periodontal therapy (NSPT) with and without the application of topical agents for biofilm disruption. A risk of bias analysis, a qualitative analysis, and a quantitative analysis were performed. Results: out of 1583 records, 11 articles were included: 10 randomized clinical trials and one retrospective analysis. The total number of participants considered in the 11 articles included in the study was 386. The primary outcomes were probing pocket depth (PPD), clinical attachment level (CAL), and bleeding indices. The secondary outcomes were plaque indices, gingival recessions, and microbiological parameters. The meta-analysis revealed the following: [Weighted mean difference (WMD): -0.37; 95% confidence interval (CI) (-0.62, -0.12), heterogeneity I2: 79%, statistical significance p = 0.004]. Conclusions: the meta-analysis of probing pocket depth reduction (PPD) between baseline and follow-up at 3-6 months showed a statistically significant result in favor of sulfonated phenolics gel. The scientific evidence is still limited and heterogeneous; further randomized clinical trials are required.

Green tea and hyaluronic acid gel enhance fibroblast activation and improves the gingival healing post-third molar extraction

This study evaluates the effects of a green tea (Camellia sinensis) and hyaluronic acid gel on fibroblast activity and alveolar bone repair following third molar extractions. By examining the gene expression related to cell survival, proliferation, and angiogenesis, the study bridges in vitro findings with clinical outcomes in a split-mouth randomized trial. Human fibroblasts were exposed to the treatment gel, analysing gene expression through RT-qPCR. Twenty participants undergoing bilateral third molar extractions received the test gel on one side and a placebo on the other. Assessments included patient-reported outcomes, professional evaluations, and radiographic analyses at multiple postoperative intervals. The test gel significantly enhanced AKT, CDKs, and VEGF gene expressions, indicating a positive effect on angiogenesis and cell proliferation. Clinically, it resulted in reduced exudate, swelling, and secondary interventions, with radiographs showing improved alveolar bone density after 90 days. The green tea and hyaluronic acid gel significantly improves soft tissue and bone healing post-extraction, offering a promising adjunctive therapy for enhancing postoperative recovery. This gel represents a novel adjuvant treatment option for facilitating improved healing outcomes after third molar extractions, highlighting its potential utility in clinical dental practice.

Effect of sodium hypochlorite gel on bacteria associated with periodontal disease

OBJECTIVES

An adjunct in non-surgical periodontal therapy might be sodium hypochlorite (NaOCl)-based agents. The purpose of the present in vitro study was to get deeper knowledge on the influence of different parameters as time after mixing, pH, and chemical composition of an amino acid 0.475% NaOCl (AA-NaOCl) gel consisting of two components on its anti-biofilm activity.

MATERIALS AND METHODS

Six-species biofilms were cultured for 5 days, before AA-NaOCl gel was applied. In the different series, the influence of the time after mixing of the two components before application, of the concentration of NaOCl in the gel mixture, of the pH of the gel mixture, and of an exchange of the amino acid component by hyaluronic acid (HA), was analyzed.

RESULTS

Mixing time point experiments showed that the AA-NaOCl gel is capable of statistically significantly reducing colony-forming unit (cfu) counts up to 30 min after mixing, but only up to 20 min after mixing the reduction was more than 2 log10 cfu. The pH experiments indicate that a reduced pH results in a reduced activity of the NaOCl formulation. NaOCl concentrations in the formulation in the range from 0.475 to 0.2% provide adequate activity on biofilms. A HA/NaOCl gel was equally active against the biofilm as the AA-NaOCl gel.

CONCLUSION

Mixing of the components should be made in a timeframe of 20 min before applications. An optimization of the composition of the NaOCl formulation might be possible and should be a topic in further in vitro studies.

CLINICAL RELEVANCE

The AA-NaOCl gel formulation can be mixed up to 20 min before application. Further, the study indicates that the composition of the NaOCl gel formulation can be optimized.

Repeated local delivery of hyaluronic acid gel as adjunctive treatment of residual pockets in periodontitis patients undergoing supportive periodontal care. A randomized controlled clinical trial

OBJECTIVES

To assess the effect of hyaluronic acid (HyA) application as adjunct to re-instrumentation of residual pockets in patients undergoing regular supportive periodontal care (SPC).

METHODS

Chronic periodontitis patients (stage III and IV, grade B and C) with 4 interproximal residual pockets were randomly assigned to the test (HyA gel) or control (saline) group. After subgingival instrumentation, test or control substance was applied subgingivally, then daily supragingivally for 3 months, and if required a second time after subgingival re-instrumentation after 3 months. Clinical and patient reported outcome parameters were recorded every 3 months for 12 months. Pocket closure [probing pocket depth (PPD) ≤ 4mm with absence of bleeding on probing (BoP) at PPD = 4mm] was the main outcome parameter.

RESULTS

Fifty-six patients (221 experimental sites) were analysed. Pocket closure was achieved in 56.8 and 46.6% of the experimental sites in the test and control group, respectively (p > 0.05), while median PPD and PPD distribution (< 5mm/5mm/ > 5mm) differed significantly between groups in favour of the test group, at 12 months. Further, significantly fewer sites in the HyA group required re-instrumentation at 3 months, and sites in the HyA group showed a tendency for lower odds to remain diseased compared to the control group (OR 0.48, 95%CI 0.22-1.06). The odds for a site to remain diseased after 12 months increased significantly in the presence of plaque (OR 7.94, 95%CI 4.12-15.28), but in general, decreased significantly over time (OR 0.48, 95%CI 0.28-0.81).

CONCLUSION

Re-instrumentation of residual pockets in SPC patients, per se, leads to a significant increase in pocket closure over time; this was impeded by poor plaque control. Repeated local application of HyA results in fewer sites requiring re-instrumentation and might slightly improve the rate of pocket closure. (clinicaltrials.gov registration nr. NCT04792541).

CLINICAL RELEVANCE

HyA gel is easy to apply, well accepted by patients, and may have some positive effect in terms of fewer sites requiring re-instrumentation at 3 months and higher pocket closure rate at 12 months.

Control of tissue homeostasis by the extracellular matrix: Synthetic heparan sulfate as a promising therapeutic for periodontal health and bone regeneration

Proteoglycans are core proteins associated with carbohydrate/sugar moieties that are highly variable in disaccharide composition, which dictates their function. These carbohydrates are named glycosaminoglycans, and they can be attached to proteoglycans or found free in tissues or on cell surfaces. Glycosaminoglycans such as hyaluronan, chondroitin sulfate, dermatan sulfate, keratan sulfate, and heparin/heparan sulfate have multiple functions including involvement in inflammation, immunity and connective tissue structure, and integrity. Heparan sulfate is a highly sulfated polysaccharide that is abundant in the periodontium including alveolar bone. Recent evidence supports the contention that heparan sulfate is an important player in modulating interactions between damage associated molecular patterns and inflammatory receptors expressed by various cell types. The structure of heparan sulfate is reported to dictate its function, thus, the utilization of a homogenous and structurally defined heparan sulfate polysaccharide for modulation of cell function offers therapeutic potential. Recently, a chemoenzymatic approach was developed to allow production of many structurally defined heparan sulfate carbohydrates. These oligosaccharides have been studied in various pathological inflammatory conditions to better understand their function and their potential application in promoting tissue homeostasis. We have observed that specific size and sulfation patterns can modulate inflammation and promote tissue maintenance including an anabolic effect in alveolar bone. Thus, new evidence provides a strong impetus to explore heparan sulfate as a potential novel therapeutic agent to treat periodontitis, support alveolar bone maintenance, and promote bone formation.

Hyaluronic acid enhances cell migration, viability, and mineralized tissue-specific genes in cementoblasts

BACKGROUND/OBJECTIVES

It has been repeatedly demonstrated that cementum formation is a crucial step in periodontal regeneration. Hyaluronic acid (HA) is an important component of the extracellular matrix which regulates cells functions and cell-cell communication. Hyaluronic acid/derivatives have been used in regenerative periodontal therapy, but the cellular effects of HA are still unknown. To investigate the effects of HA on cementoblast functions, cell viability, migration, mineralization, differentiation, and mineralized tissue-associated genes and cementoblast-specific markers of the cementoblasts were tested.

MATERIALS AND METHODS

Cementoblasts (OCCM-30) were treated with various dilutions (0, 1:2, 1:4, 1:8, 1:16, 1:32, 1:64, 1:128) of HA and examined for cell viability, migration, mineralization, and gene expressions. The mRNA expressions of osteocalcin (OCN), runt-related transcription factor 2 (Runx2), bone sialoprotein (BSP), collagen type I (COL-I), alkaline phosphatase (ALP), cementum protein-1 (CEMP-1), cementum attachment protein (CAP), and small mothers against decapentaplegic (Smad) -1, 2, 3, 6, 7, β-catenin (Ctnnb1) were performed with real-time polymerase chain reaction (RT-PCR). Total RNA was isolated on days 3 and 8, and cell viability was determined using MTT assay on days 1 and 3. The cell mineralization was evaluated by von Kossa staining on day 8. Cell migration was assessed 2, 4, 6, and 24 hours following exposure to HA dilutions using an in vitro wound healing assay (0, 1:2, 1:4, 1:8).

RESULTS

At dilution of 1:2 to 1:128, HA importantly increased cell viability (p < .01). HA at a dilution of 1/2 increased wound healing rates after 4 h compared to the other dilutions and the untreated control group. Increased numbers of mineralized nodules were determined at dilutions of 1:2, 1:4, and 1:8 compared with control group. mRNA expressions of mineralized tissue marker including COL-I, BSP, RunX2, ALP, and OCN significantly improved by HA treatments compared with control group both on 3 days and on 8 days (p < .01). Smad 2, Smad 3, Smad 7, and β-catenin (Ctnnb1) mRNAs were up-regulated, while Smad1 and Smad 6 were not affected by HA administration. Additionally, HA at dilutions of 1:2, 1:4, and 1:8 remarkably enhanced CEMP-1 and CAP expressions in a dilution- and time-dependent manner (p < .01).

CONCLUSIONS

The present results have demonstrated that HA affected the expression of both mineralized tissue markers and cementoblast-specific genes. Positive effects of HA on the cementoblast functions demonstrated that HA application may play a key role in cementum regeneration.

Effects of topically administered 0.6% hyaluronic acid on the healing of labial frenectomy in conventional and 940-nm indium gallium arsenide phosphide (InGaAsP) diode laser techniques in pediatric patients: a randomized, placebo-controlled clinical study

This study aimed to investigate the effects of 0.6% hyaluronic acid (HA) gel on the healing process and postoperative pain levels after diode laser-assisted labial frenectomy in pediatric patients. Ninety-six pediatric patients (females, 50 and males, 46) aged 8-14 years were randomly divided into four groups as follows: (1) conventional frenectomy with 0.6% topically administered HA (CFH, n = 24); (2) conventional frenectomy with placebo gel (CFP, n = 24); (3) frenectomy performed by diode laser with 0.6% topically administered HA (DLH, n = 24); and (4) frenectomy performed by diode laser with placebo gel (DLP, n = 24). HA application was continued for 1 week thrice daily after the frenectomy. Visual analog scale forms were collected from patients 1 week after the operation. In addition, the plaque index, gingival index, periodontal probing depth, and keratinized tissue width and thickness were recorded. This process was repeated 1 and 3 months after the first visit. The DLH group revealed significant differences in the probing depth, bleeding on probing, keratinized gingiva width, and attached gingiva width according to dual comparisons of the initial, first, and third-month values (p = 0.010, p = 0.007, p<0.001, and p = 0.001, respectively). Significant differences were observed between the CFP and CFH groups according to the initial and initial third-month values with regard to the bleeding on probing (p=0.019 and p = 0.019, respectively). The attached gingival thickness revealed significant differences between the CFP and CFH groups for the initial and initial-third-month comparisons (p = 0.005 and p = 0.007, respectively). The mean values of the initial and initial-third-month differences were significantly higher in the CFH group than those in the CFP group. HA- and laser-assisted labial frenectomies revealed better outcomes in terms of the probing depth, attached gingiva width, keratinized gingiva width, healing process, and postoperative comfort.

In vitro activity of hyaluronic acid and human serum on periodontal biofilm and periodontal ligament fibroblasts

OBJECTIVES

A beneficial effect of cross-linked hyaluronic acid (cHA) on periodontal wound healing and regeneration has recently been demonstrated. The present in vitro study was designed to obtain deeper knowledge on the effect of cHA when applied in the gingival sulcus (serum-rich environment) during non-surgical periodontal therapy.

MATERIALS AND METHODS

The influence of cHA, human serum (HS), and cHA/HS on (i) a 12-species biofilm formation, (ii) the adhesion of periodontal ligament fibroblasts (PDLF) to dentine surface, (iii) the expression and secretion of interleukin-8, and (iv) the expression of receptors of HA in PDLF and gingival fibroblasts (GF) were evaluated.

RESULTS

At 4 h of biofilm formation, cHA and HS in combination (cHA/HS) slightly decreased the colony-forming unit counts in biofilm whereas the metabolic activity of biofilm was reduced in all test groups (cHA, HS, cHA/HS) vs. control. At 24 h, the quantity of biofilm was reduced in all test groups vs. untreated control. The test substances did not affect adhesion of PDLF to dentin. HS increased the expression of IL-8 by PDLF and GF which was partially downregulated by cHA. HS and/or cHA promoted the expression of the HA receptor RHAMM in GF but not in PDLF.

CONCLUSIONS

In summary, the present data indicate that serum neither negatively affect the activity of cHA against periodontal biofilm nor had any unwanted influence on the activity of PDLF.

CLINICAL RELEVANCE

These findings lend additional support for the positive effects of cHA on cells involved in periodontal wound healing, thus pointing to its potential use in non-surgical periodontal therapy.

Osteogenic stimulation of osteoprogenitors by putamen ovi peptides and hyaluronic acid

Eggshell peptides (EP) majorly contribute to rapid bone building in chicks, wherefore this paper investigated their potential for stimulating osteogenesis in vitro. In this study, the effects of EP, also called putamen ovi peptides and a combination of hyaluronic acid with EP in cell culture medium were tested towards proliferation, differentiation, gene expression and mineralization of bovine osteoprogenitors and primary human osteoblasts. The influence of EP at concentrations of 0.005 g/L, 0.5 g/L and 0.5 g/L with 0.25% hyaluronic acid was analyzed using immunocytochemical staining of bone-specific matrix proteins, namely collagen type I, osteonectin, osteopontin and osteocalcin, to prove osteoblastic differentiation. Additionally, Richardson-staining was performed. All tests revealed a superior osteoblastic differentiation with EP at 0.5 g/L after 5 days of cultivation. Hyaluronic acid alone showed controversial results and partially constrained osteoblastic differentiation in combination with EP to a level as low as for pure EP at 0.005 g/L. Of particular interest is the osteoblast-typical mineralization, as an important indicator of bone formation, which was measured indirectly via the calcium concentration after cultivation over 4 weeks. The mineralization showed an increase by a factor of 286 during the cultivation of primary human osteoblasts with hyaluronic acid and EP. Meanwhile, cell cultures treated with EP (0.5 g/L) only showed an 80-fold increase in calcium concentration.The influence of EP (0.5 g/L) on primary human osteoblasts was investigated by gene expression after 2 weeks of cultivation. Microarray and qRT-PCR analysis showed a strongly increased expression of main important genes in bone formation, bone regeneration and the physiological bone remodelling processes. Namely, BMP 2, osteopontin and the matrix metalloproteinases 1 and 9, were present during in vitro osteoprogenitor culture with EP. By explicitly underlining the potential of eggshell peptides for stimulating osteogenesis, as well as emphasizing complex and controversial interaction with hyaluronan, this manuscript is relevant for developing new functionalized biomaterials for bone regeneration.

The Effect of Adjunctive Use of Hyaluronic Acid on Prevalence of Porphyromonas gingivalis in Subgingival Biofilm in Patients with Chronic Periodontitis: A Systematic Review

Porphyromonas gingivalis (P. gingivalis) is a Gram-negative anaerobic bacterium that plays an important role in the development and progression of periodontitis. Hyaluronic acid (HA) is a naturally occurring glycosaminoglycan that has previously demonstrated antibacterial potential in vitro against multiple bacterial species, including P. gingivalis. The purpose of this systematic review is to evaluate the effectiveness of HA as an adjunctive topical antibacterial agent to non-surgical mechanical therapy of periodontitis in reducing the prevalence of P. gingivalis in subgingival biofilms. Five clinical studies were identified that satisfied the eligibility criteria. Only three trials were suitable for the meta-analysis as they provided data at three and six months. Data on the prevalence of P. gingivalis in each study were collected. The odds ratio (OR) for measuring the effect size with a 95% confidence interval (CI) was applied to the available data. The results did not favor the use of HA during non-surgical mechanical therapy to reduce the prevalence of P. gingivalis in subgingival biofilm (odd ratio = 0.95 and 1.11 at three and six months, consecutively). Within their limitations, the current data do not indicate an advantage for using HA during mechanical periodontal therapy to reduce the prevalence of P. gingivalis.

Reconstructive Peri-Implantitis Therapy by Using Bovine Bone Substitute with or without Hyaluronic Acid: A Randomized Clinical Controlled Pilot Study

BACKGROUND

The present pilot study aimed to assess clinical and radiographic efficiencies of bovine bone substitute (BBS) merged with hyaluronic acid (HA) in peri-implantits reconstructive surgery.

METHODS

Peri-implantitis (diagnosed 6.03 ± 1.61 years of implant loading) bone defects were randomly treated either with BBS plus HA (test group) or BBS alone (control group). Clinical parameters including peri-implant probing depth (PPD), bleeding on probing (BOP), implant stability (ISQ), and radiographic changes in vertical and horizontal marginal bone (MB) levels were assessed at six months postoperatively. New temporary and permanent screw-retained crowns were made at two weeks and three months postoperatively. Data were analyzed using parametric and non-parametric tests.

RESULTS

In both groups, 75% of patients and 83% of implants achieved treatment success after six months (no BOP, PPD <5 mm, and no further MB loss). Clinical outcomes improved over time within groups; however, without significant difference between them. ISQ value obtained significant increases in the test compared to the control group at six months postoperatively (p < 0.05). The vertical MB gain was significantly greater in the test group compared to the control (p < 0.05).

CONCLUSIONS

Short-term outcomes suggested that BBS merged with HA could improve clinical and radiographic outcomes in peri-implantitis reconstructive therapy.

3D-Printed Soft Membrane for Periodontal Guided Tissue Regeneration

OBJECTIVES

The current study aimed to perform an in vivo examination using a critical-size periodontal canine model to investigate the capability of a 3D-printed soft membrane for guided tissue regeneration (GTR). This membrane is made of a specific composition of gelatin, elastin, and sodium hyaluronate that was fine-tuned and fully characterized in vitro in our previous study. The value of this composition is its potential to be employed as a suitable replacement for collagen, which is the main component of conventional GTR membranes, to overcome the cost issue with collagen.

METHODS

Critical-size dehiscence defects were surgically created on the buccal surface of the roots of canine bilateral mandibular teeth. GTR treatment was performed with the 3D-printed membrane and two commercially available collagen membranes (Botiss Jason® and Smartbrane-Regedent membranes) and a group without any membrane placement was considered as the control group. The defects were submerged with tension-free closure of the gingival flaps. Histologic and histometric analyses were employed to assess the periodontal healing over an 8-week experimental period.

RESULTS

Histometric evaluations confirmed higher levels of new bone formation in the 3D-printed membrane group. Moreover, in all defects treated with the membranes, the formation of periodontal tissues, bone, periodontal ligaments, and cementum was observed after 8 weeks, while in the control group, only connective tissue was found in the defect sites. There was no clinical sign of inflammation or recession of gingiva in any of the groups.

SIGNIFICANCE

The 3D-printed gelatin/elastin/sodium hyaluronate membrane can be safe and effective for use in GTR for periodontal tissue regeneration therapies, with better or comparable results to the commercial collagen membranes.

Immunomodulatory fibrous hyaluronic acid-Fmoc-diphenylalanine-based hydrogel induces bone regeneration

AIM

To investigate the potential of an ultrashort aromatic peptide hydrogelator integrated with hyaluronic acid (HA) to serve as a scaffold for bone regeneration.

MATERIALS AND METHODS

Fluorenylmethyloxycarbonyl-diphenylalanine (FmocFF)/HA hydrogel was prepared and characterized using microscopy and rheology. Osteogenic differentiation of MC3T3-E1 preosteoblasts was investigated using Alizarin red, alkaline phosphatase and calcium deposition assays. In vivo, 5-mm-diameter calvarial critical-sized defects were prepared in 20 Sprague-Dawley rats and filled with either FmocFF/HA hydrogel, deproteinized bovine bone mineral, FmocFF/Alginate hydrogel or left unfilled. Eight weeks after implantation, histology and micro-computed tomography analyses were performed. Immunohistochemistry was performed in six rats to assess the hydrogel's immunomodulatory effect.

RESULTS

A nanofibrous FmocFF/HA hydrogel with a high storage modulus of 46 KPa was prepared. It supported osteogenic differentiation of MC3T3-E1 preosteoblasts and facilitated calcium deposition. In vivo, the hydrogel implantation resulted in approximately 93% bone restoration. It induced bone deposition not only around the margins, but also generated bony islets along the defect. Elongated M2 macrophages lining at the periosteum-hydrogel interface were observed 1 week after implantation. After 3 weeks, these macrophages were dispersed through the regenerating tissue surrounding the newly formed bone.

CONCLUSIONS

FmocFF/HA hydrogel can serve as a cell-free, biomimetic, immunomodulatory scaffold for bone regeneration.

Clinical efficacy of hyaluronic acid in the treatment of periodontal intrabony defect: a systematic review and meta-analysis

OBJECTIVE

This systematic review aimed to evaluate the effects of hyaluronic acid (HA) alone or in combination with any bone substitute for the treatment of intrabony defects (IBDs).

MATERIAL AND METHODS

Six databases were searched up to April 2022 to find randomized clinical trials comparing the clinical effects of open flap debridement (OFD) + HA versus OFD alone (first group) or OFD + HA + bone substitutes versus OFD + bone substitutes (second group) in the treatment of IBDs with a follow-up of at least 3 months. Random effects models of mean differences were used to determine the clinical attachment level (CAL) gain, probing depth (PD) reduction, and radiographic bone fill (RBF).

RESULTS

Of the 276 studies identified, 6 were included in the qualitative synthesis, and 5 in the meta-analyses. The meta-analyses in the first group showed a statistically significant differences for CAL gain (mean difference [MD]:1.00; 95% confidence interval [CI]:0.65 - 1.35; n = 2) and PD reduction (MD: 0.76; 95%CI: 0.34 - 1.17; n = 2) favoring HA + OFD at 6 months. However, in the second group, the meta-analyses did no show additional effect of HA in association with bone substitute was demonstrated for either CAL gain (MD: 0.57; 95%CI: - 0.30 - 1.43; n = 2) or PD reduction (MD: 1.05; 95%CI: - 0.38 - 2.47; n = 2) but did show significant differences for RBF (MD: 0.57; 95%CI: 0.15 - 0.99; n = 2) at 12 months.

CONCLUSION

Compared with OFD alone, local application of HA in the treatment of IBDs provided a significant CAL gain and PD reduction at 6 months. However, its combination with bone substitutes showed no statistically significant differences at 12 months.

CLINICAL RELEVANCE

The use of OFD + HA improves the CAL and PD in the treatment of IBDs compared to OFD only after 6 months of follow-up. These results are not maintained after 12 months.

Drug Release and Cytotoxicity of Hyaluronic Acid and Zinc Oxide Gels, An In-Vitro Study

Hyaluronic acid (HA) is a naturally occurring biopolymer, with a remarkable wound healing property. Zinc-oxide non-eugenol is a material widely used for periodontal dressing in dentistry. However, it has been reported that zinc oxide non-eugenol is toxic to osteoblasts and fibroblasts. Hence, the present study aimed to evaluate the drug release and cytotoxicity of HA and zinc-oxide gels. Hydrogels of HA and zinc oxide were formulated with carbopol as a carrier. In vitro drug release was performed by UV spectrophotometry, dialysis, and vial bag methods. Cytotoxicity assessment of HA and zinc-oxide gels was performed in human periodontal ligament fibroblasts (HPdLF) and human gingival fibroblasts (hGFs). An inverted phase-contrast microscope was used to assess the morphological changes. At 24 and 48 hr, HPdLF cells showed the highest viability in 0.1% low molecular weight-HA (LMW-HA) with a median value of 131.9, and hGFs showed the highest viability in 5% LMW-HA with a median of 129.56. The highest viability of HPdLF cells was observed in 5% high molecular weight-HA (HMW-HA), with a median value of 127.11. hGFs showed the highest viability in 1% HMW-HA with a median value of 97.99. Within the limitations of the present study, we concluded that LMW-HA is more efficient than HMW-HA. Both HPdLF and hGF cells showed complete cell morbidity with zinc-oxide hydrogels. Therefore, zinc oxide-based gels in concentrations as low as 9% could be toxic intraorally to soft tissues that harbor gingival and periodontal ligament fibroblasts.

Cross-linked hyaluronic acid gel with or without a collagen matrix in the treatment of class III furcation defects: A histologic and histomorphometric study in dogs

AIM

To histologically evaluate the effects of cross-linked hyaluronic acid (xHyA) with or without a collagen matrix (CM) on periodontal wound healing/regeneration in class III furcation defects in dogs.

MATERIALS AND METHODS

Class III furcation defects were surgically created in the mandibular premolars in six beagle dogs. The defects were randomly treated as follows: open flap debridement (OFD) + CM (CM), OFD + xHyA (xHyA), OFD + xHyA + CM (xHyA/CM) and OFD alone (OFD). At 10 weeks, the animals were euthanized for histological evaluation.

RESULTS

The newly formed bone areas in the xHyA (4.04 ± 1.51 mm² ) and xHyA/CM (4.32 ± 1.14 mm² ) groups were larger than those in the OFD (3.25 ± 0.81 mm² ) and CM (3.31 ± 2.26 mm² ) groups. The xHyA (6.25 ± 1.45 mm) and xHyA/CM (6.40 ± 1.35 mm) groups yielded statistically significantly (p < .05) greater formation of new connective tissue attachment (i.e., new cementum, with inserting connective tissue fibres) compared with the OFD (1.47 ± 0.85 mm) group. No significant differences were observed in any of the histomorphometric parameters between the xHyA and xHyA/CM groups. Complete furcation closure was not observed in any of the four treatment modalities.

CONCLUSIONS

Within their limits, the present results suggest that the use of xHyA with or without CM positively influences periodontal wound healing in surgically created, acute-type class III furcation defects.

Adjunctive Application of Hyaluronic Acid in Combination with a Sodium Hypochlorite Gel for Non-Surgical Treatment of Residual Pockets Reduces the Need for Periodontal Surgery-Retrospective Analysis of a Clinical Case Series

The comprehensive treatment of periodontitis stage 2 to 4 aims at the resolution of periodontal inflammation and “pocket closure”, which implies a residual probing depth of ≤4 mm and a negative BoP. However, supportive periodontal therapy (SPT) regularly leaves behind persistent periodontal pockets with 5 or more mm in residual PPD and sites that often re-colonize and re-infect. Various adjunctive options for subgingival instrumentation have been proposed to enhance the antimicrobial effects to better control the re-infection of these residual sites. The locally applied adjuncts, based on their anti-inflammatory effect, are sodium hypochlorite antiseptic cleaning gel and cross-linked hyaluronic acid (xHyA). Both recently moved into the focus of clinical research on non-surgical and surgical therapy for periodontitis. The surgical use of xHyA indicates regenerative potential, supporting periodontal regeneration. This case series retrospectively analyzes the clinical benefits of the consecutive flapless application of sodium-hypochlorite-based cleaning gel and xHyA at the SPT to achieve pocket closure, thereby reducing the need for periodontal surgery. In 29 patients, 111 sites received the treatment sequence. At 6-month re-evaluation, an overall PPD reduction exceeding 2 mm was achieved, associated with a similar CAL gain (2.02 mm); the bleeding tendency (BoP) was reduced by >60%. Pocket closure occurred in almost 25% of all the sites. Within their limits, the present data suggest that the proposed combined adjunctive treatment of residual active periodontal sites yielded significant improvement in the clinical parameters. Further studies in RCT format are required to confirm these observations.

THE EFFECT OF COENZYME Q10 ON PERIODONTITIS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF CLINICAL TRIALS

OBJECTIVE

Coenzyme Q10 gel might be beneficial for periodontitis. However, the results have been controversial. We designed a systematic review and meta-analysis to explore the efficacy of coenzyme Q10 in periodontitis patients.

MATERIALS AND METHODS

A systematic review of controlled trials (PROSPERO: CRD42020212424) was performed from 1980 to August 2020 by 2 separate investigators through the following databases: Embase, CENTRAL, PubMed/MEDLINE, Scopus, Web of Science, Google Scholar, and ProQuest. Hand search of reference lists of the included studies was also performed. Of 269 records, eleven trials were included in the meta-analysis using a random-effect model.

RESULTS

Coenzyme Q10 could significantly reduce Plaque Index (SMD, -0.64; CI, -1.03 to -0.26, P = .002; I2 = 85.7%), Bleeding Index (SMD, -1.05; CI, -1.70 to -0.41, P = .001; I2 = 89.5%), Pocket Depth (SMD, -0.96; CI, -1.35 to -0.58, P ˂ .001, I2 = 84.7%), clinical attachment level (SMD, -0.73; CI, -1.23 to -0.22, P = .005; I2 = 87.8%), and gingival index (SMD, -0.63; CI, -0.97 to -0.28, P = .001; I2 = 72.8%) in periodontitis. Subgroup analysis showed that coenzyme Q10 had a stronger reduction effect if administered intra-pocket rather than topical. Studies with high risk of bias reported a greater positive effect of coenzyme Q10 compared to studies with unclear risk.

CONCLUSIONS

Our findings encourage administration of coenzyme Q10 gel in periodontitis based on its meaningful effect on Plaque Index, Bleeding Index, gingival index, clinical attachment level and Pocket Depth. Future studies with better qualities are required for a better conclusion.

Efficiency of Hyaluronic Acid in Infrabony Defects: A Systematic Review of Human Clinical Trials

Background and objectives: The aim of this systematic review was to assess the electronic literature about the benefits of using hyaluronic acid (HA) in the surgical periodontal treatment of infrabony defects. Materials and methods: This review was conducted under the PRISMA guidelines. The electronic search was conducted on PubMed, Scopus, Web of Science, and Cochrane databases until February 2022. The inclusion criteria consisted of human clinical trials that reported the use of HA in open-flap debridement (OFD) for infrabony defects. The assessment of risk of bias was performed using the Cochrane risk of bias tool. Statistical analysis was performed using Review Manager. Results: Overall, three RCTs were found eligible for the statistical analysis. Probing depth (PD) reduction and clinical attachment level (CAL) gain in the HA test group presented WMs of −1.11 mm (95% CI −2.38 to 0.16 mm; p = 0.09) and −1.38 mm (95% CI −2.26 to −0.49 mm; p = 0.002), respectively. However, the heterogeneity of the RCTs was high, and the risk of bias, in general, was low. Conclusions: The use of hyaluronic acid seems to have beneficial effects in periodontal surgery using OFD, in terms of PD and CAL. To draw a clear conclusion, more adapted and well-designed clinical trials are needed to assess the advantage of this product in comparison with other products.

Enamel matrix derivative as adjunctive to non-surgical periodontal therapy: a systematic review and meta-analysis of randomized controlled trials

Objectives

To assess the potential additional benefit of the local application of enamel matrix derivative (EMD) on the clinical outcomes following non-surgical periodontal therapy (NSPT) (steps 1 and 2 periodontal therapy).

Materials and Methods

A systematic literature search was performed in several electronic databases, including Medline/PubMed, Embase, The Cochrane Register of Central Trials (CENTRAL), LILACS, and grey literature. Only randomized controlled clinical trials (RCTs) were eligible for inclusion. Clinical attachment level (CAL) change (primary outcome), probing pocket depth (PPD), and bleeding on probing (BoP) reductions (secondary outcomes) were evaluated. The Cochrane Risk of Bias tool (RoB 2.0) was used to assess the quality of the included trials. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) between test and control sites were estimated using a random-effect model for amount of mean CAL and PPD change.

Results

Six RCTs were included for the qualitative analysis, while data from 4 studies were used for meta-analysis. Overall analysis of CAL gain (3 studies) and PPD reduction (4 studies) presented WMD of 0.14 mm (p = 0.74; CI 95% − 0.66; 0.94) and 0.46 mm (p = 0.25; CI 95% − 0.33; 1.26) in favor of NSPT + EMD compared to NSPT alone respectively. Statistical heterogeneity was found to be high in both cases (I² = 79% and 87%, respectively).

Conclusions

Within their limitations, the present data indicate that the local application of EMD does not lead to additional clinical benefits after 3 to 12 months when used as an adjunctive to NSPT. However, due to the high heterogeneity among the studies, additional well-designed RCTs are needed to provide further evidence on this clinical indication for the use of EMD.

Clinical relevance

The adjunctive use of EMD to NSPT does not seem to additionally improve the clinical outcomes obtained with NSPT alone.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00784-022-04474-1.

Evaluation of the effectiveness of a novel mouth rinse containing hyaluronic acid and hydrogen peroxide on gingivitis: A randomized pilot controlled trial

Objective

To evaluate and compare the effectiveness of a mouth rinse with hydrogen peroxide (H₂O₂) and hyaluronic acid (HA) versus a placebo mouth rinse on gingivitis.

Material and methods

This was a 21‐day, double blind, randomized, two‐arm parallel allocation placebo‐controlled trial of 50 study participants with a diagnosis of plaque‐induced gingivitis. Patients were randomly allocated to the test group or the placebo group and were assessed at three time points over the course of the study by the same operator, at baseline (T0), 7 days (T1), and 21 days follow‐up (T2). Primary outcomes of the trial were improvement in gingivitis and plaque accumulation.

Results

In both groups there was a decrease in gingival and plaque indices but the combination of the two actives (H₂O₂/HA) proved to be more effective against gingivitis (p = 0.001). Regarding plaque index, the differences between the test product and placebo were not statistically significant (p = 0.084). Besides, the new mouthwash was considered palatable, no adverse events were registered over the 21‐day period.

Conclusions

The H₂O₂ + HA product was more effective in reducing gingivitis when compared to a placebo while no differences were observed for plaque accumulation.

Flapless application of enamel matrix derivative in non-surgical periodontal treatment: A systematic review

BACKGROUND AND OBJECTIVE

To assess the effects of the flapless application of enamel matrix derivative (EMD) in combination with non-surgical periodontal treatment (NSPT) when compared to non-surgical periodontal treatment alone in adult patients.

MATERIAL AND METHODS

An electronic literature search was conducted in MEDLINE, Scopus and Cochrane Library up to March 2021 complemented by a manual search. Human longitudinal studies of >5 participants and at least 3 months follow-up were eligible for inclusion in the review. Clinical outcomes were extracted and pooled. Meta-analysis of the included studies was not possible due to methodological differences.

RESULTS

A total of 1199 publications were identified and reviewed for eligibility. Nine of them fulfilled the inclusion criteria. Eight studies were randomized clinical trials. The clinical findings of the majority of the included studies demonstrated that the adjunctive use of EMD with NSPT could lead to significantly improved treatment outcomes including higher PPD reduction, more CAL gain, more robust BOP reduction, higher number of sites with PPD < 5 mm and more frequent pocket closure which reduces the need for further periodontal surgical treatment. Limited biological, microbiological and histological findings were reported. Minimal adverse events were observed.

CONCLUSION

The flapless application of EMD during NSPT leads to an improved clinical outcome in regards to CAL gain and PPD reduction when compared to conventional treatment alone. The potential effect on the biological and microbiological outcome is unclear.

A thermosensitive gel with an active hyaluronic acid ingredient that contains an octenidine preservation system as an adjunct to scaling and root planning: a randomized prospective clinical study

OBJECTIVES

To evaluate the adjunctive effect of a thermosensitive gel formulation that contains 0.8% oligo hyaluronic acid (HA) combined with a preservation system of octenidine HCl 0.625% and phenoxyethanol to scaling and root planing (SRP) as compared with SRP alone in the treatment of residual pockets of patients with stage 3 periodontitis.

MATERIALS AND METHODS

Thirty-four patients (21 males and 13 females) aged 29-78 years (51.3 ± 13.1) with stage 3 periodontitis were recruited to participate in the present split-mouth study. None of the patients has been previously treated for periodontitis. Plaque index (PI), probing depth (PD), clinical attachment level (CAL), and bleeding on probing (BOP) were evaluated at baseline and at 3 and 6 months post treatment. Full-mouth SRP was performed in all residual pockets ≥ 5 mm. Treatment was performed by means of ultrasonic and hand instruments and lasted 45-60 min. The gel was applied subgingivally in the test sites immediately after SRP (baseline) and 1 month later. The paired t-test for two means was applied to test the statistical significance of the change from baseline within each arm and determine the difference between groups. The level of significance was set at 0.05 for all tests.

RESULTS

Mean PD reductions between baseline and 3 and 6 months were 1.98 mm and 2.79 mm for the test and 1.22 mm and 1.50 mm for the control group, respectively. Comparisons between the test and control groups revealed that SRP + gel yielded statistically significantly higher PD reductions compared to SRP alone (p < 0.0001). Compared to baseline, CAL and BOP values improved statistically significantly in both groups, although the test group presented statistically significantly higher CAL gains and BOP reductions than the control group (P < 0.0001).

CONCLUSION

In residual pockets of stage 3 periodontitis patients, the local application of a thermosensitive gel with an active HA ingredient and a preservation system of octenidine HCl 0.625% in conjunction with SRP may additionally improve the clinical outcomes obtained with SRP alone.

CLINICAL RELEVANCE

A novel HA and octenidine containing thermosensitive gel effectively improved the clinical parameters in stage 3 periodontitis patients over a 6-month period.

The Influence of Hyaluronic Acid Adjunctive Therapy of Periodontitis on Salivary Markers of Oxidative Stress: Randomized, Controlled Clinical Trial

Periodontitis is a common oral disease affecting the tooth-supporting tissues. Bacteria have been long viewed as the main causative factor in its development; however, many investigations have proved that aberrant immune and inflammatory response and the resulting misbalance between the damage caused by reactive oxygen species and the antioxidant capacity of tissues may be an underlying factor in disease progression that reduces healing potential. The objective of the current trial is to assess the outcomes of the addition of hyaluronic acid (HA) to standard non-surgical periodontal therapy (NST) on some major oxidative stress markers in saliva. HA-based gel designed for dental application was used and the measurements were taken after 3 months. HA adjunctive therapy had a significantly greater increase in markers with antioxidant properties as well as total antioxidant capacity compared to standard NST alone. Furthermore, clinically measured levels of gingival inflammation (bleeding on probing-BOP) and periodontal destruction (clinical attachment loss-CAL) were significantly correlated with these markers, and the correlation was negative. This investigation demonstrates that HA may indeed express antioxidant properties and improve the antioxidant capacity of periodontal tissues, thus improving the prognosis for the teeth and the results of periodontal therapy. Further investigations will be necessary to determine the duration of these effects over time.

Coronally advanced flap with and without hyaluronic acid (HYALOSS) for the treatment of gingival recession – a randomized clinical trial

Objectives: To compare and evaluate the surgical outcome of gingival recession treatment using CAF alone or in conjunction with hyaluronic acid (HA) on Miller's Class I and class II gingival recession defects. Materials and methods: After randomisation, the control group (15 patients) received CAF alone and the test group (15 patients) received HA as an adjunct to CAF technique for an isolated gingival recession accompanied by an adequate width of keratinized gingiva on maxillary canines and premolars. All patients were evaluated at 7, 15, 30, 60 and 90 days interval post-operatively. Data obtained was subjected to statistical analysis and p value <0.05 was considered as statistically significant. Results: At 90 days interval statistically highly significant root coverage was obtained with mean gain of 66.1% in control group and 86.6% in test group. Statistically significant reduction in depth of gingival recession and gain in clinical attachment level was found for control and the test groups, and intergroup comparison showed statistically significant differences for root coverage and clinical attachment level between the groups (p = 0.000), however no significant differences were found for width of attached gingiva, keratinized gingiva and gingival thickness between the groups at 90 days (p > 005). Conclusion: HA has proven to be beneficial in the field of regenerative therapy. Our analysis suggested that HA can be used as a promising adjunct with CAF for root coverage, however further studies are required to imply the results on larger population.