NONSURGICAL ATTACHMENT GAIN
ever, EMD did reduce postsurgical
recession24 and gene expression of inflammatory markers when occlusal
forces were not excessive,
25 and it enhanced effectiveness of nanohydroxyapatite as an adjunct to periodontal
Evidence that nonsurgical application of EMD promotes periodontal
regeneration has been equivocal. In
one clinical study, EMD as an adjunct
to SRP increased attachment primarily
by long junctional epithelium rather
than bone growth.
27 In another study,
researchers using EMD found no significant difference in pocket depth or
gain of attachment compared with
controls receiving only SRP.
28 On the
other hand, a nonsurgical approach on
four single-rooted teeth generated
histological and clinical evidence of
periodontal regeneration, although the
amount of regeneration was not sufficient to save those teeth.
Periodontal endoscopy might play
a role in the success of this protocol to
demonstrated that tetracycline ana-
logues reduce collagen destruction
associated with MMP function.
antimicrobial doses of doxycycline
inhibit the destructive mechanisms of
11, 13-15 thereby making it effective
as an adjunct to SRP.
Inflammation inhibits extracellular
matrix formation and decreases the
ability of stem cells from the periodontal ligament and dental follicle to differentiate into cementoblasts, osteoblasts, and fibroblasts.
16 EMD is a
biologic agent composed of proteins,
primarily amelogenins, derived from
pig tooth germs.
17, 18 EMD promotes
stem cell differentiation and blast cell
18, 19 thereby speeding bone
The effectiveness of EMD is unclear.
Use of EMD as an adjunct to flap de-
bridement did not improve radiograph-
ic bone growth compared with flap
debridement alone22 or compared to
the use of nanohydroxyapatite as an
adjunct to periodontal surgery.
gain was clinically evident as well (see
Table 2). Pocket depths had marked
improvement with elimination of fur-
cation involvement on both teeth,
decreased mobility of tooth No. 18, and
no increase in recession. The patient
also submitted three-year post-treat-
ment radiographs taken by the dental
hygienist of record (see Figure 3) with
evidence of bone stability.
Bacteria in plaque, particularly
Porphyromonas gingivalis, Tannerella
forsythia, and Treponema denticola,
initiate a host immune response and
promote a plaque biofilm resistant to
8 The host’s response to bacterial pathogens associated with periodontitis can destroy
8-10 This host response includes matrix metalloproteinases (MMPs) that destroy collagen,
allowing leukocytes to enter the area
and fight infection.
11 Golub et al.
surfaces. Tooth No. 18 had 11. 8 mm
bone loss on the distal surface, a Class
II buccal furcation with a 10 mm pocket, and a Class I lingual furcation with
a 5 mm pocket. Tooth No. 31 had 8. 4
mm bone loss on the distal surface and
a Class II furcation with an 8 mm pocket on the buccal surface (see Table 1).
The dental hygiene diagnosis was
localized, severe chronic periodontitis.
Occlusal trauma was a contributing
factor to the initiation of periodontitis;
occlusal trauma and mucogingival
deformity were contributing factors to
Protocol—The patient took 20
mg doxycycline twice a day for 180 days
beginning two weeks prior to clinical
treatment. Dental hygiene care comprised SRP on teeth Nos. 18 and 31,
with adjunctive therapy of enamel
matrix derivative (EMD) under local
anesthetic. A periodontal endoscope
enhanced treatment site visualization
during SRP, removal of granulomatous
tissue, preparation of the root surfaces
with ethylenediaminetetraacetic acid
(EDTA), and application of EMD. The
patient returned to his dental hygienist
of record for periodontal
Evaluation—A six-month evaluation demonstrated reattachment (see
Figure 2). The radiograph of tooth No.
18 exhibited 7. 4 mm bone loss on the
distal surface, reflecting an increased
bone height of 4. 4 mm. For tooth No.
31, the radiograph exhibited 6. 2 mm
bone loss, reflecting an increased bone
height of 2. 2 mm. Epithelial attachment
PRETREATMENT PERIODONTAL CHART
TOOTH NO. 31 18
Depth/mm 7 8 4 4 10 9
Bleeding + + - + + +
Furcation II II
Depth/mm 8 3 5 5 5 10
Bleeding + - - + + +
Furcation 0 1
Mobility 0 1
POST-TREATMENT PERIODONTAL CHART
TOOTH NO. 31 18
Depth/mm 3 3 3 3 4 3
Reattachment 4 5 1 1 6 7
Bleeding - - - - - -
Furcation 0 0 - + + +
Depth/mm 4 2 3 3 3
Reattachment 4 1 2 2 2 7
Bleeding - - - - - -
Furcation 0 0
Mobility 0 0