Periodontology Posts

03/07/13
Minimally Invasive Surgical Technique (MIST) In Regenerative Periodontal Therapy
Pierpaolo Cortellini

04/06/09
Periodontal disease (parodontosis) as risk factor for cardiovascular diseases (heart attack, stroke)
Natascia Raciti Fabio Cozzolino


Minimally Invasive Surgical Technique (MIST) In Regenerative Periodontal Therapy

Minimally Invasive Surgical Technique (MIST) In Regenerative Periodontal Therapy

ITALIAN VERSION

 

Introduction

In the last decade, a growing interest for more friendly, patient oriented surgery have urged clinical investigators to focus their interest in the development of less invasive approaches. Surgical procedures in medicine and in dentistry have undergone radical changes to reduce invasivity; in parallel novel instruments and materials have been developed for the inevitable evolution of the surgical armamentarium (Cortellini 2012).

The field of periodontal surgery have been enriched with this peculiar and innovative approach rather recently (Harrel and Rees 1995). They proposed the “Minimally Invasive Surgery (MIS)” with the aim to produce minimal wounds, minimal flap reflection and gentle handling of the soft and hard tissues (Harrel and Nunn 2001, Harrel et al. 2005). Cortellini and Tonetti (2007a) proposed the Minimally Invasive Surgical Technique (MIST) to stress the aspects of wound and blood clot stability and primary wound closure for blood-clot protection. These concepts were further enforced with the Modified Minimally Invasive Surgical Technique (M-MIST, Cortellini & Tonetti 2009) that, additionally, incorporated the concept of space provision for regeneration. Minimally invasive surgery is a term that describes the application of very precise and delicate surgical procedures that require the use of magnifying devices, like operating microscopes or magnifying lenses, and microsurgical instruments and materials. Cortellini & Tonetti (2001, 2005) proposed the use of an operative microscope in periodontal regenerative surgery, reporting an increased capacity to manipulate the soft tissues that resulted in an improved potential for primary closure of the wound from an average 70% of the cases obtained with regular surgery to an excellent 92% obtained with microsurgery.

Minimally Invasive Surgical Techniques

Two different minimally invasive techniques have been proposed: 1) procedures that include the elevation of a tiny buccal flap as well as the elevation of the interdental papilla and of the palatal flap and 2) techniques that are limited to the elevation of the buccal flap.

These procedures can be applied for the treatment of shallow and deep intrabony defects (up to the apical third of the root surface).

Diagnosis of intrabony defects

The diagnosis of the intrabony defect is based on periodontal probing. The difference of attachment level between two interproximal surfaces represents the intrabony component of the defect. If the mesial surface of a tooth has an attachment level of 10 mm and the distal surface of the neighbouring tooth has an attachment level of 4 mm, the depth of the intrabony component is 6 mm.

Periodontal disease (parodontosis) as risk factor for cardiovascular diseases (heart attack, stroke)


Cardiovascular diseases include chronic pathologies having a multifactorial etiology that affect heart and blood vessels and are the first cause of death in the U.S.A, Europe and Asia. The most important of them affect the coronary arteries (coronary disease) which bring oxygenated blood to the heart. Because of their small diameter, in case of sustained obstruction of the blood flow (atherosclerosis) they are no more able to bring oxygen and nutrients to the myocardium. The narrowing of the vascular lumen due to atherosclerosis is determined by the buildup of cholesterol, cholesterol esters, calcium ions, fibroblasts and immune system cells deposits on the vessel walls. The resulting plaques can break down and produce clots which can migrate and occlude distally arteries having a narrower diameter: this will result in a necrosis of the affected area (heart attack or brain stroke).

Studying the known risk factors (hypertension, diabetes mellitus, age, high cholesterol and triglyceride plasmatic levels, smoke, stress, alcohol consumption, etc.) it is possible to ascribe them only the 2/3 of the new cases of cardiovascular diseases: for this reason the researchers have started to investigate new possible risk factors. From the studies conducted in the last decades it comes out that inflammation plays an important role in the pathogenesis of atherosclerosis and that the setting up of a chronic and systemic inflammatory reaction increases the risk of cardiovascular accidents.

Considering the existence of numerous common elements (age, diabetes mellitus, stress, smoke) as risk factors of cardiovascular diseases and periodontal disease, the multifactorial etiology chronic inflammation of the support tissues of the tooth, in the last decade the attention of the world medical and dental community has started to study possible correlations between the two pathologies.

 

CORRELATION CARDIOVASCULAR DISEASES-PERIODONTAL DISEASE

An accurate revision of the literature suggests the existence of a link between the periodontal disease and cardiovascular problems which may show itself in two different ways. The direct mechanism consists in the hypothesis that periodontal pathogenic bacteria move from the oral tissues to the bloodstream (bacteremia) and from here to distant locations during causal therapy or during simple periodontal probing.

To support this hypothesis there is the ability showed by the P. gingivalis to invade, in cell cultures, the endothelial wall and the discovery of periodontal pathogens in atheromasic plaques in specimens obtained from carotid endarterectomy.

The indirect mechanism makes reference to local production of inflammatory mediators able to reach the bloodstream and cause vascular damages in distant areas. The release of interleukins and tumor necrosis factor-a by the monocytes and the endothelial cells would then trigger the hepatic release of acute phase proteins, reactive C protein and fibrinogen, haptoglobin, a-1, antitrypsin which have the ability of promoting the deposit of low density lipoproteins and cholesterol along the arteries vascular walls, platelets aggregation and the activation of the clotting cascade, thus increasing the genetic risk of blood clot.

This hypothesis becomes even stronger if scientific evidence which relates other inflammatory pathologies, such as SLE (Systemic Lupus Erythematosus) and reumathoid arthritis, with a growing cardiovascular risk is taken into account.

This indirect effect of periodontal disease is supported by the correlation found in different clinical and epidemiological studies between that disease and high plasmatic levels of reactive C protein and other inflammatory biomarkers. Cohort and case-control studies have further showed a correlation between endothelial dysfunction (endothelial dysfunction may influence the slow atherogenic process and, in the presence of acute inflammation may give rise to an acute cardiovascular event), atherosclerosis and growing risk of heart disease and heart attack.

 

M. TONETTI’S STUDY

Starting from the presupposition that a systemic inflammatory reaction can cause vascular damage, the work Maurizio Tonetti and his research group published in 2007 aimed at researching the possible link that would involve periodontal disease on the basis of the observation of the effects of mechanical causal therapy on the endothelial function assessed 6 months after the start of the treatment. In that research – carried out on 120 patients who had severe and widespread periodontal disease (probing depth >6 mm and loss of marginal alveolar bone >30% for 50% or more teeth present on the dental arches) – before the start of the therapy, they measured some parameters, such as endothelial function based on the variation in brachial artery diameter during the flow (expressed in percentage, from the reference level to the maximum diameter reached in the interval between 45 and 75 seconds after blood pressure release), inflammation biomarkers, clotting markers and endothelial activation. Subsequently they compared them 1, 7, 30, 60 and 180 days after the start of the therapy. From this study all the patients suffering from systemic diseases or who had already suffered from acute or chronic infectious diseases or who had taken antibiotics up to three months before being recruited for the experimentation were excluded. All the patients received appropriate instructions about dental hygiene and the patients in the control group had tartar mechanically removed by supragingival scaling and polishing. The patients in the intensive care group underwent a full-mouth disinfection and supragingival and subgingival tartar removal, root planning – after administration of local anesthetic – , polishing, extraction of non savable teeth and positioning of minocycline microspheres in periodontal pockets.

 

FINDINGS OF M. TONETTI’S RESEARCH

A marked reduction of flow mediated expansion and a significant increase in reactive C protein, Interleukin-6, E-Selectin soluble endothelial activation marker, von Willebrand factor were already recorded in the intensive therapy group (61 patients) after just 24 hours from the start of the treatment. After 60 days and 180 days time, the parameters under examination inverted in the intensive therapy group with respect to the control group. The flow mediated expansion had increased and plasmatic levels of E-Selctin had decreased. The improvement of endothelial function observed after 6 months from the periodontal therapy is associated to a reduction in periodontal lesions and sites that bleed when probed.

 

CONCLUSIONS

The conclusion of this research is that an intensive mechanical periodontal treatment, not combined with systemic drug administration, causes an acute systemic inflammatory reaction for a short time and a temporary worsening of endothelial function. On the contrary, about 6 months after the therapy, an increase in oral health (decrease of periodontal indicators) goes along a recovery in endothelial function with increased elasticity of the arteries.

It is thus possible to state that there is a direct correlation between untreated periodontal disease, endothelial dysfunction and atherosclerosis with subsequent increase in the risks of heart disease and heart attack in patients suffering from periodontal disease. For these reasons, it is important to make an interdisciplinary cooperation having preventive aims among the heart specialist, the dental surgeon and the internist in order to make the patients aware of the existence of this correlation with cardiovascular diseases and treat them with the necessary periodontal treatments.

 

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For information:

Dr. Natascia Raciti
natasciaraciti@gmail.com

Dr. Fabio Cozzolino