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Indian Journal
of Comprehensive
TITLE: - ENHANCED REPAIR AND REGENERATION Dental Care
OF PERIODONTAL LESIONS IN TETRACYCLINE ROOT 1. Khan R ABSTRACT
Background: The guided tissue regeneration with bioresorbable membrane is
a predictable technique for infra-bony defects, and the addition of the
tetracycline root conditioning provides an added advantage to the results.
Objective: 1.To assess the change in the depth of the base of the defect after
1. Assistant Professor, Department of Community Medicine, Jawaharlal Nehru Medical College (JNMC), Aligarh Muslim the periodontal treatment. 2. Assessment of the change in the overall area of the infra-bony defect after the periodontal surgical treatment. Study design:
2. Professor, Department of Community Medicine, Jawaharlal Nehru Medical College (JNMC), Aligarh Muslim University An intervention study. Setting: Department of Periodontics, Subharti Dental
College, Meerut, Uttar Pradesh, India. Participants: Ten systemically healthy
3. Professor, Department of Community Medicine, Jawaharlal Nehru Medical College (JNMC), Aligarh Muslim University patients, (age of 20-46 years) Sampling: Purposive sampling method.
Statistical Analysis: Data entry and statistical analysis was carried out using
4. Senior Resident. Department of Periodontics & Community Dentistry, Dr. Z. A. Dental College, A.M.U, Aligarh (UP), India.
SPSS 10. Significant difference was determined using the paired student “t”
statistics. The result was assessed using Mean ± Standard Deviation and
difference was accepted significant at more than 95% (p value <0.05). Results:
The application of the paired student “t” statistics to Infra I and osseous fill
Corresponding author:
values at six months revealed the effect of TTC-HCl root conditioning along with Name : Dr. Ruby Khan
E-5 Abdullah Apartment, Girls College road
GTR membrane on the patients as significant i.e. p < 0.05 and p < 0.001 for the Phone 09236005373(M)Email: drrubykhan@yahoo.co.in Conclusion: It was concluded that the G.T.R. procedures using bioresorbable
membranes along with TTC-HCl root conditioning offer an easy and
dependable treatment alternative in cases of intra-bony defects.
Keywords: infra-bony defects, guided tissue regeneration, tetracycline root
conditioning, collagen membrane.
Introduction:
is chemotactic for fibroblasts, acts as a barrier for migrating epithelial cells in vitro and is a weak immunogen. Collagen The aim of treating destructive periodontal disease is the when used as a barrier is pliable when moist, conforms well regeneration of the lost attachment apparatus; i.e., the to the surgical area and provides a thrombogenic surface formation of new cementum, a new periodontal ligament that is sealed coronally to the root surface by a fibrin clot. (PDL), and new alveolar bone. Literature has demonstrated the possibility of favoring the regeneration of a new The effect of acid conditioning on healing after surgical connective tissue attachment to denuded root surfaces by debridement has been extensively reported. Tetracycline allowing the selective coronal regrowth of the PDL cells hydrochloride (TTC-HCl) solution treatment of the root while excluding the gingival tissues from reaching contact surface has been demonstrated to dissolve the smear layer with the root during wound healing by means of a barrier produced by instrumentation and enhance the binding of membrane, a process known as Guided Tissue Regeneration fibronectin to dentin, thus stimulating fibroblast growth and GTR procedures use type I collagen as membrane attachment. Previous studies have indicated that barrier due to it's following properties: it is absorbable, no
reattachment and new cementum formation can be surgical procedure is required for it's removal, is the major achieved with root demineralization with TTC-HCl in extracellular macromolecule of the periodontal connective tissue and is physiologically metabolized by these tissues, it Indian Journal of Comprehensive Dental Care
There is ample evidence to suggest that present regenerative clinically after flap reflection and recorded. The same was techniques lead to significant amounts of regeneration at measured radiographically and all further radiographic localized sites on specific teeth. However, if complete measurements were calibrated according to this scale. regeneration is to become a reality, additional stimuli like The infra-bony component was assessed on the following root conditioning, bone morphogenetic proteins, growth factors and enamel matrix derivatives etc. are needed to Infra I: Difference of the distance CEJ to BD minus enhance the regenerative process. Thus, the present study was designed to evaluate the effect of GTR with TTC root conditioning in the treatment of infra-bony defects using a Infra II: An auxillary line (AUX I) was drawn in the barrier membrane with the following objectives: 1. To assess direction of the tooth axis, another line (Aux II) the change in the depth of the base of the defect after the perpendicular to the tooth axis was drawn through periodontal treatment. 2. Assessment of the change in the the most coronal extension of the lateral wall of the overall area of the infra-bony defect after the periodontal infra-bony defect. Infra II was measured from the point where AUX II crossed the contour of the root to BD. Materials and method: The present study entitled
“Enhanced Repair and Regeneration of Periodontal Lesions
BDW: i.e. the width of bony defect was measured in Tetracycline Root Conditioning -Treated Patients” was from the lateral margin of the infra-bony defect to conducted in the Department of Periodontics, Subharti the point where AUX II crossed root surface. Dental College, Meerut, Uttar Pradesh, India. Ten Infra III: The third side of the defect triangle was systemically healthy patients, (age of 20-46 years) were measured as Infra III i.e. the distance from BD to AC recruited for treatment after informed consent from the undergraduate clinic, Periodontics of the Subharti Dental Defect area: calculated as Infra II X Infra III X BDW.
College, Meerut. Approval for study was passed from the institutional board of study meeting. Purposive sampling i.e. Osseous fill was calculated by subtracting the preoperative nonrandom sampling to include subjects that serve the and postoperative defect areas where Bony defect (BD) specific purpose was used. The patients had received oral was the most coronal point where the periodontal hygiene instructions and root planing before surgical ligament space showed a continuous width and Alveolar procedure. Each patient displayed an interproximal infra- crest (AC) was the crossing of the silhouette of the bony defect in a posterior tooth which was evident alveolar crest with the root surface. (Illustration 1.) radiographically and which manually probed 6mm.
Statistical Analysis: Data entry and statistical analysis was
Tr e a t m e n t P r o c e d u r e s : Fo l l o w i n g a n e s t h e s i a ,
carried out using SPSS 10. Significant difference was mucoperiosteal flaps were reflected using sulcular incisions, determined using the paired student “t” statistics. The result granulation tissue removed, and the teeth were root planed was assessed using Mean ± Standard Deviation and with currettes and sonic scalers. Root surfaces were difference was accepted significant at more than 95% (p conditioned with TTC-HCl solution applied by cotton pellets, burnishing the exposed root for 3 minutes and then rinsed Result: On comparing the values of infra 1 and osseous fill at
extensively. Membranes were fitted to cover the defects and baseline and at six month time period, it was seen that there sutured with 5-0 resorbable sutures. In cases where was an increase in the level of bone height of the patients adequate adaptation was possible due to the defect after the treatment. Also, there was a decrease in the defect anatomy, the membrane was adapted without the use of area after the treatment, thus favouring the use of sutures using the pouch technique as advocated by Mattson tetracycline root conditioning with bioresorbable membrane et al. The flap was repositioned to cover the membrane
in the treatment of these defects. The application of the and sutured with 3-0 silk suture. (Figure no. 1). Patients were paired student “t” statistics to Infra I and osseous fill values at prescribed antibiotics and instructed to rinse twice daily with six months revealed the effect of TTC-HCl root conditioning a 0.12% chlorhexidine solution for 6 to 8 weeks. Sutures were along with GTR membrane on the patients as significant i.e. P removed after one week and follow up was done at 1, 3 and 6 < 0.05 and P < 0.001 for the decrease in these values. (Tables months. Radiographs were taken at baseline and six month time, using images obtained in a digitized format. In order to Discussion: Therapeutic procedures such as bone grafting
calibrate measurement digitally the distance from the cusp and GTR are in common usage throughout the world, yet the tip to the cementoenamel junction (CEJ) was measured ability to reconstruct all components of the periodontium in Indian Journal of Comprehensive Dental Care
Table 1: Infra I & Osseous fill pre operative at Table 2.Statistical test application on Infra1 & Osseous fills baseline & post operative at interval of 6 months OSSEOUS FILL
OSSEOUS FILL
SD=Standard Deviation, * P < 0.05= statistically significant , *P < 0.001= statistically significant prevent colonization of the exposed root surface by gingival cells; second, to allow selective repopulation of this surface by periodontal ligament cells. Given the extensive microbiologic research suggesting that specific bacteria can be associated with different clinical forms of periodontitis, it seems rational that antibiotics directed against these organisms would be a useful adjunct to other treatment modalities used in treating periodontal disease. Accordingly, drugs such as tetracycline and metronidazole, which are effective against Gram-negative anaerobic infection, have been useful in cases which are unresponsive to conventional The idea that microorganisms have their major effect locally within the pockets and that the destructive aspects of the disease are seen in the periodontal tissues which are areas where the roots have been denuded as a result of adjacent to the sulcular area is a concept that has not been inflammatory periodontal disease and have been exposed to challenged in modern times. It has been reported that, when the oral environment still remains an unrealized and TTC-HCl therapy was employed in such cases along with unpredictable goal. The results of this study have conventional periodontal therapy (i.e., scaling, root planing demonstrated that it is possible to favor the regeneration of a surgery) exemplary results were observed in the arrest of new connective tissue attachment to denuded root surfaces by a surgical procedure based on the principle of GTR, thus, The present study was designed to evaluate the healing response following the use of combined procedures of that progenitor cells arising from the periodontal ligament, epithelium and gingival flap exclusion via collagen and possibly from bone, have the capacity to form new membranes coupled with TTC-HCl application which could attachment. Results of all of these studies indicated that the afford significant advantage over either procedure alone. formation of new attachment is related to the problem of Results of the study demonstrated that: 1) periodontal guiding the growth of granulation tissue in such a way that healing following the use of the GTR procedure resulted in an the root surface becomes repopulated by those specific cells increase in connective tissue and alveolar bone which possess the biological capacity of regenerating the regeneration; and 2) adjunctive TTC-HCl root conditioning attachment apparatus. Partial regeneration of periodontal tissues was obtained when a "barrier" made of collagen was In the present study, the linear and surface area interposed between the gingival tissue on one side and the measurements obtained showed more positive values when exposed root surfaces and the supporting alveolar bone on the combined approach was utilized. In essence, this may the other. The role of the barrier was two-fold: first, to mean that some benefit may arise from supplementing GTR Indian Journal of Comprehensive Dental Care
with adjunctive therapy. The cases described in this report regeneration. J Clin Periodontol 1986; 13:604-616. represent only several out of an accumulating cadre of Hyder PR, Dowell P, Singh G, Dolby AE. Freeze-dried, patients in which TTC-HCl has been used as an adjunctive cross linked bovine type I collagen: Analysis of form of treatment and led us to suspect that the antibacterial properties. J Periodontol 1992; 63:182-186.
properties of the drug were not solely responsible for the Pitaru S, Tal H, Soldinger M, Grosskopf A, Noff M. Partial unanticipated results. It is known that tetracycline binds to regeneration of periodontal tissues using collagen bone and it is apparently the non-antibacterial portion of the barriers. Initial observations in the canine. J Periodontol tetracycline molecule which is involved and which conceivably remains active for a prolonged period of time, possibly suggesting that the anticollagenolytic component of Blumenthal NM. A clinical comparison of collagen the drug may encourage and enhance the repair and membranes with ePTFE membranes in the treatment of regeneration of periodontal tissues destroyed as a result of human mandibular buccal Class II furcation defects. J The effect of acid conditioning on healing after surgical Wikesjö U, Claffey N, Christersson LA, et al. Repair of debridement has been extensively evaluated in experimental periodontal furcation defects in beagle dogs following and clinical studies. Tetracycline solution treatment of the reconstructive surgery including root surface root surface has been demonstrated to dissolve the smear demineralization with tetracycline hydrochloride and layer produced by instrumentation and enhance the binding topical fibronectin application. J Clin Periodontol of fibronectin to dentin, thus stimulating fibroblast growth Terranova VP, Franzetti LC, Hic S, et al. A biochemical subsequently desorbed from dentin maintaining its approach to periodontal regeneration: Tetracycline antimicrobial activity for at least 48 hours. Previous studies treatment of dentin promotes fibroblast adhesion and have indicated that reattachment and new cementum growth. J Periodont Res 1986; 21: 330-337. formation can be achieved with root demineralization with Alger FA, Salt CW, Vuddhakanok S, Miles K. The histologic evaluation of new attachment in periodontally-diseased It may be speculated, however, that the biochemical human roots treated with tetracycline-hydrochloride modification of the root surface may have exerted beneficial and fibronectin. J Periodontol 1990; 61:447-455. effects on the healing dynamics of formation and maturation Mattson JS, Lanny LM, Mansoor HJ: Treatment of of the new growth tissue under the membrane. The exposure Intrabony Defects with Collagen Membrane Barriers. of the collagenous matrix of the dentin by tetracycline HCl Case Reports. J Periodontol 1995;66:635-645 treatment may have favored the stabilization of the fibrin clot 10. Eickholz P, Horr T, Klein F, Hassfeld S and Kim TS: to the root surface and, therefore, its subsequent Radiographic parameters for prognosis of periodontal maturation. The authors emphasize that the material healing of 9 infrabony defects: two different definitions presented in this report is not to be construed as a controlled of defect depth. J Periodontol 2004; 75: 399-407.
clinical study, but an increasing series of interesting clinical observations demonstrating enhanced healing following the 11. Genco RJ. Antibiotics in treatment of human periodontal use of tetracycline in combination with other forms of diseases. J Periodontol 1981; 52:545-558.
periodontal therapy. In order to further validate the 12. Golub LM, Ciancio S, Ramamurthy NS, et al. Low-dose observations made in this report and acquire supportive doxycycline therapy: Effect on gingival & crevicular fluid quantitative data, further research is needed.
collagenase activity in humans. J Periodont Res 1990; Acknowledgments: I would like to express my profound
gratitude to all the participants for their co-operation and for 13. Polson AM, Proye MP. Fibrin linkage: A precursor for new attachment. J Periodontol 1983; 54:141-145. References:
Nyman S, Lindhe J, Karring T, Rylander H. New attachment following surgical treatment of human periodontal disease. J Clin Periodontol 1982; 9:290-296.
Gottlow J, Nyman S, Karring T, Lindhe J. New attachment formation in the human periodontium by guided tissue Indian Journal of Comprehensive Dental Care

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