Decontamination and Biomodification of Periodontally Affected Root Surface for Successful Regeneration

Periodontitis is a multifactorial inflammatory condition associated with an oral microbiome dysbiosis that results in gingival inflammation and clinical attachment loss. Periodontal therapies are based on scaling and root planing to disturb the bacterial biofilm mechanically and remove calculus and contaminated cementum. Research does not support the use of root modifiers for decontamination and biomodification of periodontally affected root surfaces. Standardized clinical trials in large populations, assessing biological and patient-reported outcome measures, are necessary to evaluate candidate biomaterials for decontamination and biomodification of periodontally affected root surfaces.

Key points

  • Root modifiers do not provide clinical benefits for decontamination and biomodification of periodontally affected root surfaces.

  • The use of enamel matrix derivative might improve clinical outcomes after the surgical treatment of deep intrabony defects.

  • Standardized clinical trials in large populations, assessing biological and patient-reported outcome measures are necessary, to evaluate candidate biomaterials for decontamination and biomodification of periodontally affected root surfaces.

Introduction

Periodontitis is a multifactorial inflammatory condition associated with an oral microbiome dysbiosis that results in clinical attachment loss. Nonsurgical and surgical therapies have been used to treat periodontitis, focusing on stopping further attachment loss and reestablish the clinical health condition. Scaling and root planing (SRP) is applied to all periodontitis cases to disturb the bacterial biofilm and remove calculus and any contaminated cementum. , Debridement of root surfaces using hand instruments or ultrasonic scalers results in a variated range of damage to the root surface. The root surface may also be exposed after debridement, and this factor may jeopardize future periodontal regeneration procedures.

The periodontal wound healing regeneration starts with the blood clot that functions as a matrix for the migration of inflammatory cells such as neutrophils and monocytes. This cascade of cellular events involves migration, adhesion, proliferation, and differentiation of several cell populations. Thus, the decontamination and biomodification of root surfaces in combination with mechanical debridement to benefit periodontal healing is still a matter of debate. In that sense, several studies have used strategies to modify or conditionate the periodontally affected root surface to increase tissue regeneration and root coverage success rates. Chemical, mechanical, and physical strategies have been evaluated for their potential to modulate the hypermineralized surface layer and to remove the endotoxins. In general, promising results have been demonstrated in in vitro studies, although clinical trials have shown contradictory results.

Therefore, this narrative review aimed to address whether different root decontamination and/or biomodification methods could improve the periodontal regeneration of infrabone defects and root coverage. A search strategy was conducted as presented in Box 1 . The related literature of clinical studies is discussed, and the future role of these strategies in periodontal regeneration is explored.

Box 1
Search strategy to root surface decontamination for tissue regeneration used in the PubMed database

  • Field 1: root surface, root surface modification, root surface biomodification, decontamination.

  • Field 2: tissue regeneration, intrabony defects, intrabony defects, infrabony defects, infrabony defects, intraosseous defects, intraosseous defects, vertical defects, furcation, furcation defects, furcation lesions, root coverage, periodontal defect.

  • Inclusion criteria: Surgical periodontal therapy, human study with periodontal clinical evaluation; sample size – 10 defects and/or teeth per group; present a negative control group (without root conditioner/root decontamination); 6-month follow-up

  • Exclusion criteria: in vitro studies; animal studies; case reports; histologic human reports; microbiological and immunologic studies without periodontal evaluation.

  • Biochemical agents:

    • Citric acid, EDTA, Tetracycline, aPDT.

  • Mechanical and Physical agents:

    • Polishing, Air polishing, Washing with saline solution, SRP, and Laser.

  • Possible antimicrobial effects:

    • Emdogain, PRP, PRF.

Root surface modifier strategies to treat periodontally affected teeth

SRP can decrease and disturb the organization of bacterial dental biofilm and the cytotoxic substances contained in the calculus and cementum on root surfaces of periodontally diseased teeth. However, these procedures inevitably leave a smear layer that, with the remaining contaminated cementum, may negatively influence the recruiting and adhesion of periodontal ligament cells and inhibit new attachment.

Earlier studies performed in the 1980s and 1990s evaluated the smear layer removal etching the denude root dentin and some portions of cementum with tetracycline hydrochloride, citric and phosphoric acids as well texapon detergent ethylenediaminetetra-acetic acid (EDTA). These modifiers also exposed dentinal tubules and reduced the endotoxins into the cementum. However, acidic modifiers resulted in a necrotizing effect on the surrounding tissues compared with EDTA treatment with a neutral pH and calcium chelator. This chelating agent also preserved the integrity of exposed collagen fibers, early cell colonization, and vitality of adjacent tissues. In addition to etching chemical substances, some elegant reviews , showed that treated root surface by physical methods as laser and antimicrobial photodynamic therapy (aPDT) demonstrated better attachment of the regenerated periodontal tissues. erbium-doped yttrium-aluminium-garnet (Er:YAG) and erbium, chromium-doped yttrium-scandium-gallium-garnet (Er,Cr:YSGG) were used to improve the capability to remove and to conditioned the contaminated root surface for periodontal tissue regeneration.

Several attempts have been made to enhance regeneration outcomes by combining/adding root modifiers and membranes and/or barriers, as presented elsewhere in this article.

Root surface modifier strategies to improve clinical outcomes of periodontal surgeries

The multifactorial etiology of periodontitis and the several local and systemic risk factors associated with this disease makes periodontal tissue regeneration is a challenging task. Anti-infective and regenerative procedures have been evaluated in several investigations for their capacity to remove as much as possible the contaminated cement and endotoxins. The ultimate goal of these studies were to assess the potential of these procedures to modulate the regeneration of the lost periodontal tissues ( Table 1 ).

Table 1
Characteristics of studies that evaluated periodontal surgery and root surface decontamination
Study (Year)/Root Modifier Study Design Follow-up Period (mo) No of Treated Tooth/No. of Treated Participants Methodology Clinical Outcomes Conclusion
Parodi & Esper (1984)/citric acid Case control 6 20 lower molars with furcation involvement divided in test (topically applied citric acid) and control (saline solution)/there was no mention for number of patients After 30 d of non-surgical periodontal therapy, the molars were divided in test (citric acid) and control (saline solution) and surgical periodontal procedures were performed in both groups. Clinical parameters were taken at pre-baseline, baseline, 3, and 6-mo postoperatively. Reentry was performed at 6 mo to measure bone level.
  • At 6-mo period:

  • Proximal area:

    • Test control

      • ΔCAL 1.20 ± 0.65 1.06 ± 0.65

  • Furcation area:

    • ΔCAL 1.00 ± 0.45 1.44 ± 0.72

    • Non-significant difference between groups ( P >.05).

  • Proximal area:

    • Test control

      • ΔBL 1.00 ± 0.37 0.58 ± 0.63

  • Furcation area:

    • ΔBL 1.00 ± 0.45 0.92 ± 0.61

    • Nonsignificant difference between groups ( P >.05).

The use of citric acid presented a “weak” beneficial effect in the furcation-involved human molars.
Smith et al, 1986/citric acid Randomized 6 120 teeth/10 participants with severe periodontitis Teeth were divided in test (citric acid) and control (saline solution). Each are must present ≥2 teeth from second molar to cuspid, with PD ranged from 1 to 13 mm.
Surgical access using modified Widman flap to scaling and root planning. The participants were included in a maintenance control during 2-, 4-, and 6-wk postsurgical for professional control.
  • At 6 mo period:

  • All surfaces

    • Shallow pockets (1 to 3 mm)

      • Demonstrate clinical attachment loss for both groups ( P >.05).

  • Test control

    • ΔCAL -0.31 ± 0.37–0.25 ± 0.53

    • Pockets > 4 mm

      • Demonstrate clinical attachment gain for both groups ( P >.05).

  • Test control

    • ΔCAL 0.93 ± 0.80 0.30 ± 0.64

  • Interproximal surfaces

    • Shallow pockets (1–3 mm)

      • Demonstrate clinical attachment loss for both groups ( P >.05).

  • Test control

    • ΔCAL -0.39 ± 0.54–0.34 ± 0.73

    • Pockets >4 mm

    • Demonstrate clinical attachment gain for both groups ( P >.05).

  • Test control

    • ΔCAL 0.12 ± 0.77 0.20 ± 0.73

      • Furcation defects: both groups showed decrease in the PD, although there was no difference statistical significance between groups ( P >.05).

The citric acid did not clinical evidence of improve or accelerate periodontal healing during modified Widman flap surgery. CAL demonstrated similar patters for the groups in both shallow and moderate/deeper pockets.
Moore et al, 1987/citric acid Double-blind, controlled clinical trial on a split-mouth design 9 There was no mention for number of teeth/12 12 participants received initial periodontal therapy including oral hygiene instruction, SRP, and after a minimum period of 8 wk. Follow the initial therapy, 10 participants were included: present at least a pair of sites (except molars) with PD > 5 mm receive periodontal surgery with adjunctive procedures: Test (citric acid with pH = 0.6) and control (saline solution). The participants also received penicillin and chlorhexidine 0.2%.
  • At baseline

    • Test. Control

      • CAL 7.58 + 1.10 7.38 ± 1.15

  • At 3 mo

    • Test Control

      • CAL 1.00 ± 1.15 1.17 ± 1.07

  • At 9 mo

    • Test Control

      • CAL 1.05 ± 1.60 0.90 ± 0.34

  • The test group presented gain of CAL in both 3 and 9m; control group did not ( P <.05)

  • PD and recession were improved at 3 and 9 mo for both groups, without difference between them ( P >.05).

This study showed that 75% and 60% of experimental sites gain attachment at 3 and 9 mo irrespective of the treatment group. In addition, there was no statistical difference in all clinical parameters in the group of root surface etching with or without citric acid during flap surgery.
Kersten et al, 1992/citric acid Randomized clinical study 12 26 intrabony defects/23 Defects with proximal residual PD ≥ 6 mm and intrabony defects ≥4 mm; the defects were surgically treated with test – citric acid and ePTFE and control – ePTFE without acid etching
  • At 12 mo period both groups showed similar clinical improvements ( P >.05).

  • Control test

    • ΔCAL 1.0 ± 1.1 0.7 ± 1.5

    • ΔPD 1.8 ± 1.2 1.8 ± 1.2

The ePTFE barrier was effective to treat the defects irrespective the use of citric acid.
Fuentes et al, 1993/citric acid Clinical study 12 27 furcation defects/16 Patients with ≥1 mandibular molar with buccal class II furcation defect with horizontal PD >3 mm; Surgical treatment included coronal flap positioning with citric acid (test) or without (control).
  • At 12 mo period both groups showed similar clinical improvements ( P >.05).

  • Control test

    • ΔCAL 0.4 ± 1.0 0.7 ± 1.1

    • Vertical and horizontal reentry bone fill ranged between 0.4 ± 1.0 and 1.8 ± 0.4 mm

Although a slight clinical improvement was associated with citric acid group without statistical significance, etching root surfaces may be not be “necessary part” of this procedure.
Machtei et al, 1993/tetracycline HCl RCT 12 36 furcation defects/18 Class II furcation involvement of the mandibular first or second molars were surgically treated with ePTFE; defects were treated with tetracycline HCl (test) or saline solution (control). All clinical parameters were improved after treatment in both groups ( P >.05).
Tetracycline saline ΔPD 3.12 ± 1.5 3.16 ± 1.6
Microbiological differences were not detected between groups; however, Actinobacillus actinomycetemcomitans was detected in 5 sites during the monitoring phase and was associated with less favorable clinical results.
Anti-infective therapy and monitoring for A actinomycetemcomitans and/or other periodontal pathogens might be useful in guided tissue regeneration; tetracycline HCl did not improved the periodontal parameters.
Mayfield et al, 1998/EDTA CCS 6 36 interproximal intraosseous defects/36 3 mo after of hygienic treatment phase:
Test group: access flap procedure + root conditioning with EDTA gel for 3 min followed by copious irrigation with sterile saline.
Control group: access flap procedure
  • Test (mean ± SD)

    • ΔPPD: 2.9 ± 1.3

    • ΔPAL: 1.8 ± 1.5

    • ΔGL: 1.1 ± 0.8

    • ΔPBL: 1.0 ± 1.3

    • % of defect remaining: 65% ± 30%

  • Control (mean ± SD)

    • ΔPPD: 2.6 ± 1.5

    • ΔPAL: 1.0 ± 1.7

    • ΔGL: 1.8 ± 0.7

    • ΔPBL: 0.4 ± 1.2

    • % of defect remaining: 73% ± 32%

EDTA gel did not provide additional benefits to flap surgery in the treatment of periodontal intraosseous defects.
Issa et al, 2019/PBM-SMV-EDTA RCT 9 40 periodontal defects/40 4 wk after of hygienic treatment phase:
Group 1: OFD, 1.2% SMV gel followed by defect coverage with OM.
Group 2: OFD, 1.2% SMV gel, and defect coverage with PBM.
Group 3: OFD, 24% EDTA root surface etching, 1.2% SMV gel, and coverage of the defect with OM.
Group 4: OFD, 24% EDTA root surface etching, 1.2% SMV gel, and defect coverage with PBM.
  • Group 1

    • PPD BL: 6.2 ± 0.4

    • PPD 9M: 2.8 ± 0.4

    • CAL BL: 6.3 ± 0.6

    • CAL 9M: 3.0 ± 0.4

    • DBL BL: 6.5 ± 1.7

    • DBL 9M: 4.7 ± 1.0

    • CBL BL: 3.1 ± 1.1

    • CBL 9M: 3.2 ± 1.0

    • BD BL: 77.0 ± 9.0

    • BD 9M: 92.3 ± 6.8

  • Group 2

    • PPD BL: 6.2 ± 0.4

    • PPD 9M: 2.5 ± 0.5

    • CAL BL: 6.5 ± 0.7

    • CAL 9M: 3.2 ± 0.7

    • DBL BL: 6.3 ± 1.0

    • DBL 9M: 2.9 ± 1.0

    • CBL BL: 2.6 ± 0.6

    • CBL 9M: 2.2 ± 0.6

    • BD BL: 76.6 ± 12.7

    • BD 9M: 96.0 ± 11.9

  • Group 3

    • PPD BL: 6.3 ± 0.6

    • PPD 9M: 1.6 ± 0.5

    • CAL BL: 6.3 ± 0.6

    • CAL 9M: 1.8 ± 0.4

    • DBL BL: 6.1 ± 0.9

    • DBL 9M: 3.6 ± 0.7

    • CBL BL: 2.5 ± 0.5

    • CBL 9M: 1.8 ± 0.6

    • BD BL: 78.8 ± 12.4

    • BD 9M: 96.8 ± 11.1

  • Group 4

    • PPD BL: 6.3 ± 0.6

    • PPD 9M: 1.6 ± 0.7

    • CAL BL: 6.4 ± 0.7

    • CAL 9M: 2.0 ± 0.6

    • DBL BL: 6.5 ± 0.9

    • DBL 9M: 2.2 ± 0.8

    • CBL BL: 3.0 ± 0.7

    • CBL 9M: 2.2 ± 0.6

    • BD BL: 81.6 ± 9.3

    • BD 9M: 101.1 ± 6.9

PBM-SMV-EDTA combination therapy seemed to be a promising regimen in treating periodontal defects. SMV availability seemed to be enhanced after the use of EDTA root surface etching.
Cortellini et al, 2007/EMD COS 12 13 intrabony defects/13 3 mo after of hygienic treatment phase: MIST + EMD PPD BL: 7.7 ± 1.8
PPD 12M: 2.9 ± 0.8
REC BL: 1.0 ± 1.5
REC 12M: 0.9 ± 2.1
CAL BL: 8.7 ± 2.7
CAL 12M: 3.8 ± 2.2
MIST associated with EMD is effective in the treatment of isolated deep intrabony defects.
Aslan et al, 2017/EMD COS 12 12 deep intrabony defects/12 3 mo after of hygienic treatment phase: EPP technique + 24% EDTA gel for 2 min + EMD PPD BL: 9.7 ± 3.0
PPD 12M: 2.7 ± 0.7
REC BL: 2.5 ± 1.3
REC 12M: 2.66 ± 1.5
CAL BL: 12.2 ± 3.6
CAL 12M: 5.4 ± 2.0
EPP technique and 24% EDTA and EMD resulted in enhanced clinical outcomes in deep intrabony defects without any soft tissue complication
Cosgarea et al, 2021/air polishing RCT 12 A total of 27 teeth (n = 14 test and n = 13 control)/30 patients with periodontitis stages III and IV were included at baseline; 27 participants were evaluated at 12 mo: n = 14 test and n = 13 control groups
Smokers were also included
Single-center, examiner-masked, 2-arm parallel design
RCT pilot study to compare clinical outcomes and side effects of root surface decontamination during periodontal surgery
Test group: erythritol powder and air-polishing device (mid water and power settings for 10 s; Air-Flow Master with Perio-Flow System, EMS, Nyon, Switzerland)
Control group: flap debridement using conventional hand and ultrasonic instruments
Primary outcome variable was CAL gain, with the patient as unit. Secondary endpoints were
mean changes in FMPS, bleeding on probing, GBI, PD, decrease in the PD, CAL-, BS- (ΔBS) and BL-gain (ΔRBL) at 12 mo.
All parameters decrease at 6 and 12 mo after therapy for both groups ( P >.05);
Reductions after 12 mo

  • Test control

    • ΔPD 3.00 ± 0.96 3.38 ± 1.12

    • ΔCAL 2.50 ± 1.60 2.85 ± 1.21

    • Nonsignificant difference between groups ( P >.05).

Air polishing with an erythritol powder during periodontal surgery may represent a valuable minimally invasive adjunct following calculus removal by means of hand and ultrasonic instruments or a valuable alternative to these, for root surfaces without calculus.
Clem et al, 2020/Er, Cr:YSGG RCT 6 79 intrabony defects/53 Multicenter, blinded study; patients with generalized periodontitis stage III, grade B; ≥1, but up to 2, nonadjacent teeth PD ≥6 mm and an intrabony defect with vertical dimension ≥3 mm; the defects were treated according to the group – Er,Cr:YSGG or MIST; PROs for pain, bleeding, swelling, ice pack use, anxiety, and satisfaction were also recorded. After 6 mo period, both treatments presented similar results ( P >.05)
Er,Cr:YSGG MIST
ΔCAL 1.26 ± 1.20 1.22 ± 1.32
ΔPPD 1.71 ± 1.18 1.63 ± 1.22
ΔGL – 0.41 ± 0.65–0.35 ± 0.66
Er,Cr:YSGG group presented less bruising, facial swelling, and use of ice pack
Both treatments presented similar clinical outcomes, however superior effect in PROs for the surgical treatment of intrabony defects.
Karthikeyan et al, 2019/diode RCT 6 40 quadrants/20 patients Patients with generalized chronic periodontitis PD ≥ 5 mm; 30% of sites with 3 ≤ CAL ≤ 5 mm;
6 teeth per quadrant
Treatment groups: Kirkland flap surgery and DL-assisted open flap debridement (test) and Kirkland flap surgery (control). Microbiological test for the pathogens from red complex were also evaluated.
  • Test group presented better outcomes when compared with control group at 6 mo ( P <.001)

  • Test control

    • ΔCAL 4.68 ± 1.02 3.14 ± 0.86

    • ΔPPD 4.72 ± 0.93 3.11 ± 0.90

    • The microbial reduction was statistically higher in the test group ( P <.05).

Diode laser associated with Kirkland flap showed better clinical improvements than control group.
Martins et al, 2017/aPDT RCT 5 20 patients (unit of analysis) Patients with interproximal attachment loss involving ≥2 contralateral teeth with PD ≥5 mm, CAL ≥5 mm and bleeding on probing.
The defects were treated with flap debridement and aPDT (test) and flap debridement (control).
Microbiological evaluation using DNA–DNA checkerboard hybridization.
  • aPDT improved statistically the periodontal parameters after 5 mo ( P <.001)

  • Test Control

    • CAL 3.70 ± 0.80 4.18 ± 0.66

    • PPD 3.40 ± 0.50 2.70 ± 0.30

    • Beneficial microbial changes were positively associated with flap debridement + aPDT

Flap debridement associated with a single episode of aPDT presented beneficial results for the periodontal treatment.
Dilsiz et al, 2010/Nd:YAG + EMD RCT/split mouth design 12 41 intrabony defects/21 Intrabony defects without furcation involvement in each of 2 contralateral quadrants; PD ≥ 6 mm and depth of the defect component >3 mm.
Defects were divided in test (Nd:YAG and EMD) and control (EMD) groups
  • At 12 mo follow-up, there was no statistical difference for periodontal parameters between groups ( P >.05).

  • Test control

    • CAL 2.6 ± 1.2 3.0 ± 1.1

    • PPD 4.0 ± 0.8 4.4 ± 0.9

Nd:YAG laser root conditioning did not improve the outcome of EMD
Sculean et al, 2004/Er:YAG RCT 6 23 defects (Test n = 12; Control n = 11)/23 Intrabony defect with a PD ≥ 6 mm at interproximal sites; intrabony component of ≥3 mm as detected on radiographs.
Defects were divided in Test (Er:YAG) and Control (flap debridement)
  • Test group

    • Baseline 6 mo

      • PD 7.8 ± 1.3 4.1 ± 1.3 ( P <.05)

      • CAL 9.8 ± 2.9 7.2 ± 2.5 ( P <.05)

  • Control group

    • Baseline 6 mo

      • PD 7.8 ± 0.8 4.6 ± 1.6 ( P <.05)

      • CAL 9.1 ± 1.2 7.7 ± 1.6 ( P <.05)

      • Test and control groups present no statistical differences at 6 mo period.

Er:YAG laser did not improve the clinical outcomes.
Schwarz et al, 2003/Er:YAG and EMD RCT 6 42 intrabony defects/22 Intrabony defect with a PD ≥ 6 mm at interproximal sites; intrabony component of ≥3 mm as detected on radiographs.
Defects were treated with EMD associated (test) or not (control) with Er:YAG
  • The association of EMD and Er:YAG laser did not improve the clinical outcomes ( P >.05).

  • Test group

    • Baseline 6 mo

      • PD 8.1 ± 0.8 4.0 ± 0.5 ( P <.001)

      • CAL 10.4 ± 1.1 7.1 ± 1.2 ( P <.001)

  • Control group

    • Baseline 6 mo

      • PD 8.6 ± 1.2 4.6 ± 0.8 ( P <.001)

      • CAL 10.7 ± 1.3 7.5 ± 1.4 ( P <.001)

Both therapies led to short-term improvements of clinical parameters, however, Er:YAG laser did not add additional benefit to the treatment.
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Feb 19, 2022 | Posted by in General Dentistry | Comments Off on Decontamination and Biomodification of Periodontally Affected Root Surface for Successful Regeneration
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