Imagine this! Instead of repairing damaged tissue after periodontal disease has ravaged a patient’s tooth-supporting bone, cementum, and periodontal ligament, periodontists can regrow a patient’s once-eroded tissue into natural, healthy, and functional structures.
We now have a wealth of evidence-based advancements coming to the forefront that are demonstrating regeneration and tissue engineering. These include the stimulation of regrowth of new blood vessels and formation of new bone resulting from osteoinduction and osteopromotion, which is accessible, predictable, and offers a chance to have an impact on preserving the dentition and improving patient-related outcomes.
PROBLEMS AND OPPORTUNITIES
With recent research findings indicating that nearly half of American adults (older than the age of 30) have some form of periodontal disease, increased prevalence has significantly driven the dental and periodontal communities’ focus of maintaining a patient’s function, aesthetics, and the health of his or her natural dentition. Of those patients who suffer from periodontal disease, approximately 38% have moderate to severe periodontitis. Additionally, 70% of patients age 65 and older are experiencing destructive periodontitis, which is often characterized by rapid attachment loss and the erosion of bone.
In a time when oral health can go beyond the mouth with a significant body of evidence linking periodontal disease to systemic conditions as diabetes and cardiovascular disease, the promise of regenerative therapy plays a role in more than a patient’s avoidance of dentures and other artificial replacements; this work has become about a patient’s overall health. Inflammation, the chief culprit in the onset of periodontal disease and a shared feature of many perio-systemic diseases, can also be reduced in the process of tissue regrowth. Research indicates that hard- and soft-tissue regeneration allows for tooth, gum, and bone retention and oral health maintenance.
During the past few decades, the advancements in the discovery, research, and daily practice of periodontal regeneration and tissue engineering have been staggering. Several polypeptide growth factors are now approved by the US FDA for clinical use, and considering biologic agents, biomaterials, and the advent of novel delivery systems, the regenerative technologies arena has grown worthy of more than just a cursory look. There is an opportunity for all dental practitioners to contemplate the future of the science, what it means for clinical innovation, and exactly what it means for patient care.
THE PERIODONTIST’S ROLE
As dedicated members of the dental team, periodontists are committed to saving patients’ teeth. Periodontists are well versed in the practice of hard- and soft-tissue regeneration in addition to the provision of periodontal therapy for patients presenting with all levels of disease. The establishment of regenerative therapy as a viable and predictable method of keeping the natural dentition (while managing and controlling infection) provides another therapeutic option to preserve the patient’s own teeth and possibly reshape the promise and quality of patient satisfaction and care for years to come. While implants provide the best tooth replacement available, they are not without problems and complications. Evidence suggests that anywhere from 11% to 47% of all implants suffer from peri-implantitis, which is much more difficult to manage than periodontitis. The incidence is even higher in patients who already have periodontitis. When considering a treatment approach for a patient at risk of loss of hard or soft tissue, consulting with a periodontist on regenerative therapies may help identify an opportunity to maintain both natural function and aesthetics.
A MEETING OF THE MINDS
In June 2014, more than 50 of the world’s key opinion leaders in periodontics, regeneration, and tissue engineering convened in Chicago for the American Academy of Periodontology’s (AAP’s) first workshop focusing solely on periodontal regeneration and tissue engineering. The multiday event provided clinicians and scientists from the United States and abroad a venue to evaluate the state of regenerative science as it pertains to available technologies and current clinical understandings. Participants drafted systematic review-based consensus reports, earmarking priorities and next steps for future research. Patient outcomes were a central principle of the workshop, and attendees assessed evidence-based findings to determine how to best manage a variety of clinical circumstances. As a result, the workshop proceedings provide all members of the dental team with real-world clinical translations of existing research.
Systematic reviews were published in the Journal of Periodontology1 and covered the following: periodontal soft-tissue root coverage procedures, gingival enhancement or replacement for non-root coverage procedures, regeneration of periodontal intrabony and furcation defects, and emerging technologies in regeneration. Corresponding consensus reports identified the use of minimally invasive surgical and diagnostic procedures and weighed the possible future consideration of patient-reported outcomes for periodontal reconstructive technologies. In addition, practical application reports based on real-life clinical cases were published in the AAP’s online journal, Clinical Advances in Periodontics.2-7
This meeting of the minds was the first step toward securing the place of periodontal regeneration and tissue engineering in dentistry’s future. There have been many notable advances in these areas in recent years. As researchers and clinicians continue to explore clinical applications of regenerative therapies, new possibilities for the way we care for our patients will emerge.
A PRIORITY FOR RESEARCH
As promising as regenerative therapy posits itself to be in the treatment of periodontal disease, it is not a cure-all. However, it is instead a worthy advancement that expands possibilities for practitioners and their patients. It is an area of much-needed continued investigation that can allow periodontists to adhere to the specialty’s emphasis on tooth retention and promotion of oral health. Periodontal disease is a complex condition, one that wreaks havoc on the multilayered architecture of a person’s mouth. Additionally, each patient has a unique set of immune system reactions, personal habits, risk factors, and other medical or dental conditions. These factors are compounded by a multidimensional combination of biological, pathological, and interactive factors. As such, future research requires the collaboration of those in various disciplines with insight from such fields as biology, chemistry, clinical research, infectious diseases, and biomedical engineering.
The findings that result from future studies could not only influence clinical practice, but could provide for the development of substantive metrics that allow practitioners to deliver better treatment for patients with more promising and predictable clinical outcomes.
References
- Giannobile WV, McClain PK. Enhancing periodontal health through regenerative approaches. J Periodontol. 2015;86(2 Suppl):S1-S3.
- Richardson CR, Allen EP, Chambrone L. Periodontal soft tissue root coverage procedures: practical applications from the AAP regeneration workshop. Clinical Advances in Periodontics. 2015;5(1):2-10. joponline.org/toc/cap/5/1. Accessed on February 20, 2015.
- John V, Langer L, Rasperini G, et al. Periodontal soft tissue non–root coverage procedures: practical applications from the AAP regeneration workshop. Clinical Advances in Periodontics. 2015;5(1):11-20. joponline.org/toc/cap/5/1. Accessed on February 20, 2015.
- Reynolds MA, Kao RT, Nares S, et al. Periodontal regeneration—intrabony defects: practical applications from the AAP regeneration workshop. Clinical Advances in Periodontics. 2015;5(1):21-29. joponline.org/toc/cap/5/1. Accessed on February 20, 2015.
- Aichelmann-Reidy ME, Avila-Ortiz G, Klokkevold PR, et al. Periodontal regeneration—furcation defects: practical applications from the AAP regeneration workshop. Clinical Advances in Periodontics. 2015;5(1):30-39. joponline.org/toc/cap/5/1. Accessed on February 20, 2015.
- Rios HF, Bashutski JD, McAllister BS, et al. Emerging regenerative approaches for periodontal reconstruction: practical applications from the AAP regeneration workshop. Clinical Advances in Periodontics. 2015;5(1):2-10. joponline.org/toc/cap/5/1. Accessed on February 20, 2015.
- Participants: 2014 AAP regeneration workshop. Clinical Advances in Periodontics. 2015;5(1):47-48. joponline.org/toc/cap/5/1. Accessed on February 20, 2015.
Dr. Giannobile is a graduate of the University of Missouri, and earned his certificate in periodontology and doctorate in oral biology from Harvard University. He is a practicing periodontist and the Najjar Endowed Professor of Dentistry and Biomedical Engineering at the University of Michigan School of Dentistry. He also serves as the editor-in-chief for the Journal of Dental Research, the official journal of the International Association for Dental Research. He has served as a participant in a number of international consensus workshops, including the American Academy of Periodontology’s landmark Workshop on Regeneration, which he co-chaired in June 2014. He can be reached via email at wgiannob@umich.edu.
Disclosure: Dr. Giannobile reports no disclosures.
Dr. McClain is an associate clinical professor in the department of surgical dentistry at the University of Colorado School of Dentistry, where she earned her dental degree. She is past president of the American Academy of Periodontology (AAP) and maintains a full-time private practice with an emphasis on regeneration and clinical research. She co-chaired the AAP’s Workshop on Regeneration in June 2014. She can be reached via email at periopam@aol.com.
Disclosure: Dr. McClain reports no disclosures.
