Patient-reported outcomes following guided bone regeneration: Correlation with clinical parameters

OBJECTIVES

Postoperative oral health-related quality of life is procedure-dependent and may vary during early healing. There is scarce evidence on patient-reported outcome measures (PROMs) after extraction and guided bone regeneration (GBR) or on the clinical parameters influencing PROMs. This prospective observational study aimed to evaluate PROMs during the first 2 weeks following extraction and GBR and correlate them with clinical parameters.

METHODS

Patients undergoing extraction and GBR (bone graft and resorbable membrane) at a single tooth-bound site were recruited. PROMs (pain, swelling, difficulty of mouth opening, and OHIP-14) were recorded immediately preoperatively, and at 2, 7, and 14 days postoperatively. Flap advancement, gingival and mucosal thickness, duration of surgery, and wound opening were the clinical parameters assessed.

RESULTS

Twenty-seven patients were included. All PROMs peaked on postoperative day 2, decreased subsequently and were significantly correlated with each other. Although 41-56% of patients reported moderate to severe pain, swelling, or mouth opening difficulty on day 2, most patients experienced mild or no symptoms throughout the postoperative period. Pain, swelling and difficulty of mouth opening were determinants of OHIP-14 and were correlated with all OHIP-14 domains during different time points. Wound opening peaked on day 7. Flap advancement, soft tissue thickness, wound opening, duration of surgery and preoperative PROMs affected postoperative PROMs.

CONCLUSIONS

Within the limitations of the present study, postoperative symptoms after guided bone regeneration are worst on day 2 and oral health-related quality of life is significantly impacted by pain, swelling, difficulty of mouth opening, surgery duration and flap advancement.

CLINICAL SIGNIFICANCE

This is the first study to report PROMs following extraction and GBR with particulate bone graft and resorbable membrane in preparation for implant placement. It will help guide both practitioners and patients on what should be the anticipated experiences following such a routinely performed surgery.

Iatrogenic acid-induced gingival recession during crown cementation: A case report

Accidental contact of various chemicals in dentistry may cause damage to the gingiva. A male patient presented for a full mouth rehabilitation with ceramic crowns. The patient underwent the steps of ceramic crown preparation uneventfully. At the time of crown delivery, cotton rolls were placed in several vestibular areas for isolation. They were regularly changed during different steps of etching and cementation process, which included the use of Multilink Primer B (Ivoclar Vivadent™). On removal of the cotton roll in the area of upper right canine, the gingival tissues appeared blanched and grayish white. The cotton roll was found to have absorbed some etching material in it. As the patient was asymptomatic, he was dismissed. Two weeks later, the patient presented with inflammation and gingival recession in the same area. Initially, he was treated palliatively, and subsequently, he received a connective tissue graft on the upper right canine. This case report showed that acid etching material used during the prosthodontic cementation may have caused a gingival recession, which was successfully treated with tunnel flap and connective tissue graft. Optimal isolation of the operative field should be performed to avoid this problem.

Sublingual emphysema following alveoloplasty: A case report

Various cases of introduction of air into soft tissues have been reported in the dental literature. Here, we report a rare case of localized sublingual emphysema after alveoloplasty. There was no facial involvement. The patient responded to treatment and recovered uneventfully.

Osteonecrosis and spontaneous exfoliation of dental implants associated with oral bisphosphonate therapy: a case report

Bisphosphonates (BPs) have long been used for the treatment of osteoporosis and diseases like bone malignancies, active Paget's disease of bone, severe osteogenesis imperfecta and fibrous dysplasia among others. They bond highly to the bone surface and inhibit bone resorption. As BPs have a long half-life in bone because of their irreversible binding to bone, patients retain their risk profile even after drug cessation. This property also explains the complications wherein the cessation of bone resorption leads to halt in bone turnover. Usually with alendronate the risk of bisphosphonate-related osteonecrosis of jaw (BRONJ) wears off after 12 months. Reporting of the development of BRONJ is commonly associated with the intravenous BPs. Invasive surgical procedure associated with the placement of implants has been shown to be a major reason for the occurrence or initiation of BRONJ in susceptible patients. The prognosis of implants placed in the jaws of patients under or past BP medication is still uncertain. The present case report describes a patient on long-term oral BP therapy with spontaneous exfoliation of implant supported bone due to osteonecrosis.

Angioleiomyoma (Vascular Leiomyoma) of the Oral Cavity

A 70-year-old male presented with a slow growing, dome shaped and painless mass of the hard palate. The mass was excised. Histopathological examination confirmed the diagnosis of a angioleiomyoma (vascular leiomyoma). A leiomyoma is an uncommon benign tumor of smooth muscle differentiation. True leiomyomas of the oral cavity are rare and most oral tumors are derived from the smooth muscle of walls of blood vessels. Therefore, they are called vascular leiomyomas or angioleiomyomas. Clinically, they may resemble a myriad other conditions both benign and malignant. A definitive diagnosis depends upon histopathological examination of the biopsied tissue in correlation with the tumor cell immunohistochemistry. Tumors are excised and recurrence is rare. The histopathological findings and differential diagnosis of a case of a palatal angioleiomyoma are discussed.

Periodontal and oral manifestations of marijuana use

Marijuana, prepared from the plant Cannabis sativa, is the most widely used illicit drug in the United States. Marijuana use has been associated with adverse psychosocial and health effects, including effects on oral tissues. Periodontal literature has limited references to the periodontal effects of cannabis use. In this report, we present two cases of marijuana-associated gingival enlargement and review the literature on oral complications of marijuana use.

METHODS

Two asymptomatic males, aged 23 and 42 years, presented independently for oral prophylaxis. Both had an unremarkable medical history and related a history of significant marijuana use of 2-16 years duration. Common findings following oral and periodontal examination were nicotinic stomatitis-like lesions, uvulitis and gingival enlargement. Marginal and papillary gingiva of the anterior dentition were the areas primarily affected by gingival enlargement, while some of these areas exhibited a nodular or "pebbly" appearance.

RESULTS

Marijuana-associated gingival enlargement was diagnosed in the reported cases. A review of the literature revealed two other reports of marijuana-associated gingival enlargement, all in young adult males with chronic (2 or more years) cannabis use. These authors reported a resemblance to phenytoin-induced enlargement. Biochemical similarities between phenytoin and cannabis active compounds suggest possible common pathogenetic mechanisms. Uvulitis and nicotinic stomatitis appear to be the two most common of the several oral manifestations of marijuana use.

CONCLUSIONS

Chronic marijuana use may result in gingival enlargement with clinical characteristics similar to phenytoin-induced enlargement.

Mandibular abnormalities in a patient with neurofibromatosis type 1

Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder characterized by the presence of cutaneous neurofibromas, multiple cafd-au-lait spots and pigmented nodules of the iris known as Lisch nodules. In some cases, the diagnosis can be made at birth while in others the diagnosis is made later in life based on the appearance of additional criteria. We describe radiographic abnormalities of the mandible in a young adult male with NF1.

Effect of cannabidiol on human gingival fibroblast extracellular matrix metabolism: MMP production and activity, and production of fibronectin and transforming growth factor β

BACKGROUND AND OBJECTIVE

Marijuana (Cannabis sativa) use may be associated with gingival enlargement, resembling that caused by phenytoin. Cannabidiol (CBD), a nonpsychotropic Cannabis derivative, is structurally similar to phenytoin. While there are many reports on effects of phenytoin on human gingival fibroblasts, there is no information on effects of Cannabis components on these cells. The objective of this study was to determine effects of CBD on human gingival fibroblast fibrogenic and matrix-degrading activities.

MATERIAL AND METHODS

Fibroblasts were incubated with CBD in serum-free medium for 1-6 d. The effect of CBD on cell viability was determined by measuring activity of a mitochondrial enzyme. The fibrogenic molecule transforming growth factor β and the extracellular matrix molecule fibronectin were measured by ELISA. Pro-MMP-1 and total MMP-2 were measured by ELISA. Activity of MMP-2 was determined via a colorimetric assay in which a detection enzyme is activated by active MMP-2. Data were analysed using ANOVA and Scheffe's F procedure for post hoc comparisons.

RESULTS

Cannabidiol had little or no significant effect on cell viability. Low CBD concentrations increased transforming growth factor β production by as much as 40% (p < 0.001), while higher concentrations decreased it by as much as 40% (p < 0.0001). Cannabidiol increased fibronectin production by as much as approximately 100% (p < 0.001). Lower CBD concentrations increased MMP production, but the highest concentrations decreased production of both MMPs (p < 0.05) and decreased MMP-2 activity (p < 0.02).

CONCLUSION

The data suggest that the CBD may promote fibrotic gingival enlargement by increasing gingival fibroblast production of transforming growth factor β and fibronectin, while decreasing MMP production and activity.

The epithelioid blue nevus: A rare intraoral nevomelanocytic tumor

The epithelioid blue nevus (EBN) is considered a cutaneous marker of the Carney complex. Sporadic EBN has been reported in patients not exhibiting the Carney complex. The EBN does not exhibit unique clinical features that help to differentiate it from other lesions and is often provisionally diagnosed as an acquired melanocytic nevus, or a malignant melanoma. A 52-year-old African-American female had a 3-4 mm bluish macule of the left anterior hard palate. An excisional biopsy was performed to rule out an incipient melanoma. Formalin-fixed, hematoxylin and eosin-stained sections were examined microscopically. On the basis of histopathological features, a diagnosis of EBN was rendered. We document a case of the rare EBN affecting the oral mucosa. The patient did not exhibit any features associated with the Carney complex. Two years post-operatively, there is no evidence of a recurrent tumor.

Cancellous osteoma of the maxillary tuberosity: case report

The osteoma is a benign, bone-forming lesion that is not considered a true neoplasm. It almost exclusively affects the flat bones of the skull and face. Jaw lesions may cause facial deformity and impair oral function. Multiple osteomas may be associated with Gardner's syndrome. Clinically and radiographically, osteomas may need to be differentiated from other bone-forming lesions. This article describes a cancellous osteoma of the left maxillary molar and tuberosity area and differentiates it from other benign and malignant lesions, including the parosteal osteosarcoma.

Severe periodontal damage by an ultrasonic endodontic device: a case report

Heat produced within a root canal during use of an ultrasonic instrument can be conducted through the dentin into periodontal ligament, bone and soft tissue. If severe in intensity or long in duration, it can induce damage to these tissues. This report describes a case in which an ultrasonic endodontic instrument apparently induced severe damage to alveolar bone, gingiva and nasal mucosa in a 42-year-old female. Overheating of a maxillary central incisor caused necrosis of soft tissue and bone on the facial and mesial aspects and triggered a protracted inflammatory response in the adjacent nasal cavity. To relieve the severe discomfort associated with this damage, the patient chose to have her maxillary incisors extracted and replaced by a removable partial denture. A defect in the soft tissue and bone was present at a follow-up visit 10 months after the extractions. While morbidity of this nature is rare, this case reinforces the need to maintain adequate cooling of ultrasonic instruments.

Verruciform xanthoma: immunohistochemical characterization of xanthoma cell phenotypes

BACKGROUND

Verruciform xanthoma (VX) is a benign lesion that primarily affects the oral cavity, most frequently the gingiva. VX lesions are characterized by xanthoma cells (lipid-laden macrophages or foam cells) found in the superficial connective tissue. To characterize these foam cells further, immunohistochemical techniques were used to investigate the presence of macrophage subpopulations in oral lesions of VX.

METHODS

Sixteen biopsy samples of VX lesions from the oral cavity (six from gingiva, three from palate, and seven from other mucosa) were studied. Immunohistochemical analysis was performed using antibody probes to macrophage subpopulations, including RM3/1 (reparative), 25F9 (resident), and 27E10 (inflammatory). The percentage of antibody-labeled foam cells was determined by visual counts of selected fields within lesional connective tissue.

RESULTS

The proportion of VX lesions that demonstrated positive xanthoma cell reactivity with antibodies RM3/1, 25F9, and 27E10 was 100%, 88%, and 50%, respectively. Foam cells that stained positively with RM3/1, 25F9, and 27E10 represented 61.5% +/- 19.6%, 51.8% +/- 29.4%, and 10.9% +/- 14.7% of the counted cells, respectively. When results were analyzed based on anatomic location (gingiva, palate, and other mucosa), there was no difference in the percentage of positively stained cells by anatomic site for any of the three antibodies (P >0.05). Similarly, there were no differences between masticatory (gingiva and palate) and other mucosa (P >0.05).

CONCLUSIONS

VX lesions contain primarily reparative and resident foam cells, with limited numbers of inflammatory macrophages, consistent with a chronic reactive process. These findings were independent of the anatomic site.

Diffuse Pigmentation of Maxillary Attached Gingiva: Four Cases of the Cultural Practice of Gingival Tattoo

BACKGROUND

Gingival pigmentation is a common finding, may be of endogenous or exogenous origin, and can have diagnostic significance. Diffuse gingival pigmentation may be physiologic in nature or can be due to environmental factors, drugs, endocrine disorders, or genetic conditions. We present four cases of diffuse gingival pigmentation due to traditional gingival tattooing and review the literature on this practice.

METHODS

Four black females (aged 19 to 56 years) of West African origin (Mauritania and Senegal), representing three different ethnic groups (Fulani, Mandinka, and Soninke) presented with various chief complaints. All exhibited diffuse pigmentation of the maxillary vestibular gingiva extending to the second premolar areas, without any associated radiographic abnormalities. The color ranged from intense blue gray to light gray or grayish pink. One case was biopsied for histopathologic evaluation.

RESULTS

Questioning revealed that the women had had one or more sessions of traditional gingival tattooing. In one case, the procedure was performed in a dental office. The color range appeared to depend on the time that elapsed since the last procedure. The biopsy exhibited dense fibrous connective tissue containing aggregates of foreign material consistent with a foreign body tattoo.

CONCLUSIONS

Gingival tattooing, a cultural practice prevalent in certain African ethnic groups, results in diffuse pigmentation. Outside of Africa, it may be misinterpreted as racial pigmentation or pose a diagnostic puzzle. The color and distribution pattern of diffuse gingival pigmentation often are quite suggestive, and the clinical diagnosis should be confirmed by patient history. In selected cases, biopsy may be necessary to exclude other diagnostic considerations.

Effect of biologic mediators on ciprofloxacin accumulation by gingival fibroblasts

BACKGROUND

Human gingival fibroblasts actively accumulate fluoroquinolone antimicrobials. Because fibroblasts are prevalent in gingiva, they may help sustain therapeutic fluoroquinolone levels at that site. The purpose of this study was to determine whether mediators associated with infection or injury can enhance ciprofloxacin accumulation by gingival fibroblasts.

METHODS

Quiescent fibroblast monolayers were treated for 1, 6, or 24 hours with several concentrations of tumor necrosis factor (TNF)-alpha, transforming growth factor (TGF)-beta1, platelet-derived growth factor (PDGF)-BB, fibroblast growth factor (FGF)-2, or insulin-like growth factor (IGF)-1. Transport was assayed by measuring cell-associated fluoroquinolone fluorescence.

RESULTS

All mediators significantly enhanced ciprofloxacin transport in a dose dependent manner (P < 0.05; ANOVA). Except for TNF, this enhancement was associated with a decrease in the Km of ciprofloxacin transport. Maximal enhancement was observed with 10 ng/ml PDGF or FGF and 30 ng/ml TNF, TGF, or IGF. Brief (1 hour) treatment with TNF or FGF upregulated ciprofloxacin accumulation by a maximum of 13% to 14%, whereas TGF, PDGF, and IGF enhanced this process by 19% to 24%. All of the mediators enhanced ciprofloxacin accumulation by a maximum of 19% to 24% after 6 hours and 30% to 38% after 24 hours. The accumulation of other fluoroquinolones (e.g., gatifloxacin) was also slightly enhanced.

CONCLUSIONS

Gingival fibroblasts treated with cytokines or growth factors accumulate significantly more ciprofloxacin than untreated controls. This provides a mechanism by which ciprofloxacin could be preferentially distributed to gingival wound or inflammatory sites, yielding local therapeutic levels that are more sustained than in serum.

Traumatic Lesions of the Gingiva: A Case Series

BACKGROUND

The most recent classification of periodontal diseases includes a new section on traumatic gingival lesions. Traumatic lesions of the gingiva are thought to be highly prevalent, yet the periodontal literature contains few references on the topic. The purpose of this article is to present a broad spectrum of traumatic gingival lesions of iatrogenic, accidental, and factitious origin.

METHODS

Twelve clinical cases were selected to document chemical (due to aspirin, snuff, and peroxide), physical (due to malocclusion, flossing, removable partial denture, oral piercing, and self-inflicted trauma), and thermal (due to overheated ultrasonic scaler, hot food, and ice) injury to the gingiva.

RESULTS

Chemical, physical, and thermal gingival injuries of iatrogenic, accidental, or factitious origin can have a variety of presentations with overlapping clinical features. Although the appearance and associated symptoms of a gingival lesion may be suggestive of a particular traumatic etiology, useful or confirmatory diagnostic information is often discovered through careful history-taking. The management of gingival injuries typically requires elimination of the insult and symptomatic therapy. If permanent gingival defects resulted from the injury, periodontal plastic surgery may be necessary.

CONCLUSIONS

A variety of chemical, physical, and thermal injuries may involve the gingiva. Accidental and iatrogenic injuries are often acute and self-limiting, while factitious injuries tend to be more chronic in nature.

Non-antimicrobial properties of tetracyclines--dental and medical implications

The tetracyclines are a group of broad-spectrum antimicrobial agents. The first of these compounds, chlortetracycline was isolated from Streptomyces aureofaciens by Benjamin Duggar and introduced into the market in 1948. In 1952, tetracycline was derived semisynthetically from chlortetracycline by removal of its chlorine atom by catalytic hydrogenation. Methacycline, doxycycline and minocycline are all semi-synthetic derivatives. The tetracyclines are closely congeneric derivatives of the polycyclic napthacenecarboxamide. The tetracyclines possess a wide range of antimicrobial activity against gram-positive and gram-negative bacteria. In vitro, these drugs are primarily bacteriostatic. Tetracyclines have been used extensively as antimicrobial agents for the treatment of various types of periodontal diseases until light was shed on their equally important non-antimicrobial properties by Golub. The tetracyclines and their non-antimicrobial, chemically modified analogues have properties that appear to modulate host response by inhibiting the activity of the matrix metalloproteinases that cause collagen destruction. They also inhibit osteoclast function, stimulate osteoblastic bone formation, and regulate angiogenesis.

Intraoral botryomycosis masquerading as a pyogenic granuloma

Bacterial pseudomycosis also known as Botryomycosis is a rare, indolent infection that has been described in patients with immunodeficiency and tissue with decreased healing ability. It affects the visceral organs and infection in the head and neck has been described as affecting the tongue and jaw bones. Histologically, the disease is characterized by the presence of 'Bollinger granules', surrounded by neutrophils in a fibrocellular stroma. A case of gingival Botryomycosis is presented which was diagnosed as a routine pyogenic granuloma in a healthy male.