University of Southern California Dissertations and Theses

Patient reported outcomes measures (PROMs) and medication count of the three coronal advancement methods for the treatment of multiple gingival recession defects

(USC Thesis Other)

Patient reported outcomes measures (PROMs) and medication count of the three coronal advancement methods for the treatment of multiple gingival recession defects

PDF

Download

Open document

Flip pages

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content 1
Patient reported outcomes measures (PROMs) and medication count of the three
coronal advancement methods for the treatment of multiple gingival recession defects

A Thesis Presented to the
Faculty of the Ostrow School of Dentistry of University of Southern California
In Partial Fulfillment of the Requirements for
Master of Science in Craniofacial Biology

August 2019

Author
Julio Moreno-Alemán Sánchez DDS
Department of Advanced Periodontology; Herman Ostrow School of Dentistry of USC

2
Table of Contents

Title 1
Table and figure legends 3
Abstract 4
Introduction 5
Material and Methods 9
Results 13
Discussion 14
Conclusions 17
Figure and Tables 18
References 25

3
Table and Figure legends

Tables

Table 1: Clinical characteristics of participants.

Table 2: Adverse events and complications.

Table 3. VAS Questionnaire 3 days post-surgery.

Figures

Figure 1A: Participant recruitment and randomization

Figure 1B: Study flowchart

Figure 2: VAS pain measure reported by patients at day 3 post-operative

Figure 3: Analgesic medication consumed by participants until 3-week post-op

Figure 4: Scatter plot demonstrating the correlation between VAS and analgesic medication
consumption

4
Abstract

Aim: The aim of this randomized controlled clinical trial was to evaluate the patient
reported outcome measures (PROMs) of participants undergoing three different
interventions for the treatment of multiple gingival recession defects, and attempt to
compare post-operative pain of 3 modalities for coronal advancement of gingival margins
to achieve root coverage:

Material and methods: Participants with recession types (RT) I and II were recruited into
this study and randomly assigned into three intervention groups, namely, Coronally
Advanced Flap (CAF), Vestibular Incision Subperiosteal Tunnel Access (VISTA) and
Intrasulcular tunneling (IST). Three days after the intervention, a questionnaire using the
visual analog scale (VAS) was administered to the participants to assess PROMs, including
pain experience. Analgesic use was determined by counting the number of analgesic tablets
used by each patient during the 3 weeks following surgery.

Results: 23 patients (9 CAF, 9 VISTA, 5 IST) were included in the study. The IST group
showed a numerically higher total VAS score (18.6 + 9.44), compared to CAF (15.66 +
6.16) and VISTA (11.33 + 6.24). However, no statistically significant difference was found
among the groups. IST group showed statistically significantly more analgesic consumption
(7320 mg + 2451) than VISTA (1422 mg + 891) (p=0.009) and more than CAF group
(2733 mg + 3232) (p=0.045). There were no statistical differences between the analgesic
consumption between VISTA and CAF group.

Conclusions: IST was associated with greatest amount of analgesics consumed compared to
CAF and VISTA in early post-operative periods (3-week). However, VAS scores showed
no statistically significant differences among the 3 groups at the 3-day post-operative time
point.

5

6
Introduction

Gingival recession is defined as the apical migration of the gingival margin in relationship
to the cementoenamel junction in one or multiple teeth. This is one of the most common
periodontal findings, affecting more than 80% of the population (Chambrone et al., 2010).
Anatomic factors, trauma from brushing, periodontal disease and tooth malposition are the
main risk factors for the development of these periodontal defects. Gingival recession is
often associated with esthetic problems and dentinal hypersensitivity (Chambrone et al.,
2010). Irregularities of gingival margin contour may also pose difficulty for patients to
perform adequate oral hygiene, leading to accumulation of plaque and gingival
inflammation. Sites with gingival recession also have increased susceptibility to future
gingival recession (Serino et al., 1994). The negative consequences associated with gingival
recession provide a rationale for the treatment of certain gingival recession defects.

Recent systematic reviews have reported that coronally advanced flap (CAF) in
combination with a connective tissue graft (CTG) is the gold standard for soft tissue
augmentation and root coverage (Buti et al., 2013, Chambrone et al., 2015). Multiple
randomized controlled clinical trials (RCTs) have demonstrated successful recession
reduction, clinical attachment level gain and increased zone of keratinized tissue. (Aroca et
al., 2013, Zucchelli et al., 2009).

The tunneling procedure for root coverage was introduced in 1994 (Allen et al., 1994) and
defined as supraperiosteal envelope technique, and was first applied for multiple gingival
recessions in 1999 (Zabalegui et al., 1999). Some of the characteristic of this mucogingival
procedure is that the interdental papillae are left intact, being one of the advantages of the
technique the minimally invasive nature of the surgery, which results in minimal
postoperative discomfort at the recipient site (Papageorgakopoulos, Georgios et al., 2008).

The Vestibular Incision Subperiosteal Tunnel Access (VISTA) technique has been
developed in an attempt to address the limitations of current techniques. VISTA consists of
a vertical incision placed in the vestibule, remote from the treatment area. Through this
7
incision, a subperiosteal tunnel is created using a series of specially designed elevators,
extending toward the vestibular depth as well as the ridge crest. This method of tunneling
provides an opportunity for tension-free mobilization of the mucoperiosteal complex,
which can be relocated and fixated in a coronal direction in order to achieve soft tissue
augmentation and coverage of exposed root surface.

In a retrospective study (Gil, et al., 2018) multiple gingival recessions were treated by
VISTA, and demonstrated a mean percentage of linear root coverage of 96.2% and 84.3%
for Miller Class I/II and Class III recessions, respectively.

The techniques mentioned above have shown positive outcomes, especially in cases when
there is no loss of the interproximal bone: recession defects class I and II, according to the
Miller Classification (Miller et al., 1985). These type of recession defects present with more
remaining blood supply adjacent to the defect site when there is intact interproximal bone
and periodontal attachment. Subsequently there is a better chance of obtaining complete
root coverage, regardless of the technique used. Conversely, in sites with loss of interdental
bone and attachment (Miller class III and IV), or RT2 and RT3 defects (Cairo et al. 2011)
root coverage procedures have reduced efficacy and less predictability (Chambrone et al.,
2015, Cortellini & Pini Prato 2012). The limitation of root coverage correlates to the level
of interproximal bone that will provide blood supply during healing process.

The outcome of root coverage procedures is usually measured by the position of the
gingival margin with respect to the cemento-enamel junction (CEJ). In this sense, complete
root coverage is achieved when the gingival margin is located at the CEJ level.

However, the position of the gingival margin may not be adequate for assessing the overall
outcome of the surgical treatment of gingival recessions. Irregularities of the marginal
gingiva, poor color match, and presence of scar tissue are some of the common
consequences after these types of mucogingival procedures. Therefore, a complete
coverage of the root surface cannot be considered the only factor for determining success in
the treatment of gingival recessions.
8

In clinical research, patient reported outcome measures (PROMs) are becoming the
parameters that will also help to determine the success of the therapy. PROMs can be
defined as “any report of the status of a patient’s health condition that comes directly from
the patient, without interpretation of the patient’s response by a clinician or anyone else”
(FDA 2009). These reports can be about specific symptoms, such as pain in certain oral
sites, or less specific, as in satisfaction with the therapy or the outcome, as well as function,
such as talking or eating. Since these reports include patient opinions to questions and
parameters that are difficult to measure or quantify, PROMs are often subjective.

Clinicians use objective parameters to assess the efficacy of a therapy. However, unless
these therapeutic approaches are accepted by patients, they cannot be considered
successful. A person’s well-being, including aspects concerning oral health and other
physical and mental status are factors that need to be considered, when performing any type
of surgical treatment. Therefore, it is important to determine the patients’ perspective as a
significant parameter to judge the utility of various clinical approaches.
Currently, there is paucity of data on PROMs related to the treatment of gingival recession.
In a study by Curtis et al. (1985) it was reported that mucogingival surgery resulted in more
postoperative pain compared to osseous surgery and periodontal flap surgery. Wessel et al.
(2008) reported more pain, when patients were treated with a free gingival graft (FGG)
compared to CTG at the early postoperative period. Gobbato et al. (2016) evaluated the
differences in PROMs between coronally advanced flap (CAF) + CTG and intra sulcular
tunneling (IST) + CTG for the treatment of gingival recessions and concluded that the
tunneling group was associated with more pain in early postoperative periods (3 days).
However, there were no differences in the clinical outcomes of the two therapeutic
modalities.

Since many of the periodontal plastic surgical procedures involve both donor, as well as
recipient sites, when assessing post-operative pain experience, it is difficult to ascertain
how much of the pain experience can be attributed to each component. Therefore, the
present study aimed to evaluate PROMs of patients undergoing three different interventions
9
for the treatment of multiple gingival recession defects. This study sought to compare post-
operative pain of CAF, VISTA, and IST. Since these surgical procedures were performed
without additional graft, this provided for a unique opportunity to assess the pain
experience, solely at gingival recession treatment sites.

Objectives

To assess PROMs related to pain experience following the treatment of patients with
multiple recession defects with 3 different root coverage procedures for 3 weeks following
surgery.

Hypothesis

The present study sought to test the null hypothesis that there is no difference in PROMs
related to pain experience among the three root coverage procedures.

10
Material and Methods

Study population:

The study protocol was approved by the Institutional Review Board of the University of
Southern California (Approval number HS-16-00885). The study protocol was registered
with clinicaltrial.org registry.
The study design was randomized controlled clinical trial (RCT) and followed the Consort
Guidelines. Participants were selected among the patients who reported to the Advanced
Periodontology Clinic of the University of Southern California, if they met the following
inclusion and exclusion criteria.

The inclusion criteria were set as:
- Two or more adjacent teeth exhibiting facial gingival recession defects with at least
one tooth having 3 mm or more of recession.
- No prior surgical treatment in the site
- Absence of cervical restorations extending to the CEJ.
- Detectable CEJ
- Willingness to participate in the study with one-year follow-up

The following exclusion criteria were applied:
- Gingival recessions affecting molars
- RT 3 defects
- Smoking
- Uncontrolled local or systemic diseases that affect wound healing
- Students and staff from University of Southern California School of Dentistry.

Included participants were randomly assigned to three different treatment groups: IST, CAF
or VISTA according to a computer-generated randomization list (Random Allocation
Software, http://mahmoodsaghaei.tripod.com/Softwares/randalloc.html).

11
Surgical intervention:
All included patients underwent clinical examination and initial periodontal therapy to
control inflammation. Oral hygiene instructions were given to reduce the risk of aggressive
tooth brushing. Antibiotic premedication was taken by each patient one hour prior to the
initiation of surgical procedure (Amoxicillin 2g or Clindamycin 600mg).

All surgical procedures were performed by residents of the Advanced Education in
Periodontology of USC, under the supervision of attending faculty, who were periodontists
with experience in all three surgical intervention techniques.

IST: The surgical procedure was performed in accordance with the description on
microsurgical tunneling technique (Allen et al. 1994). Intrasulcular incisions were
performed with a microsurgical blade (MB69 mini blade, Hu-Friedy, Chicago, IL) in order
to create a split thickness tunnel up to the mucogingival junction. The dissection was
extended under the papilla in order to mobilize the papilla. Beyond the mucogingival
junction, split thickness tunnel was created with the aid of tunneling instruments (Hu-
Friedy, Chicago, IL). Sharp dissection was performed at the base of the tunnel in order to
achieve flap mobility with reduced tension. Sling sutures were placed (6.0 polypropylene
with C3 needle; Hu-Friedy, Chicago, IL) in order coronally position the gingival margins
and stabilize in that position.

CAF: The incision design based on Zuchelli et al (2000). Oblique marginal incisions were
done in the interdental areas using a 15c blade (Hu-Friedy, Chicago, IL), followed by
intrasulcular incisions at the recession defects. The flap consisted of a split-full-split
thickness dissection; i.e, split thickness in the attached gingiva, full thickness at the
mucogingival junction and split thickness at the base of the flap. Root surfaces were
debrided with curettes (4R4L Hu-Friedy, Chicago,IL) and odontoplasty was performed
with rotatory instruments in cases with root prominence. Continuous sling sutures (6.0
polypropylene with C3 needle; Hu-Friedy, Chicago, IL) were used to coronally advance the
flap.

12
VISTA: A vertical vestibular incision was placed in the alveolar mucosa using a 15 blade
(Hu-Friedy, Chicago, IL). Care was taken to ensure that the coronal position of the incision
was at least 5mm apical to the closest gingival margin. Subperiosteal tunnel was created
through this incision, using elevators, extending at least one or two teeth beyond the teeth
being treated. The subperiosteal tunnel was extended interproximally, under each papilla in
order to mobilize the tunnel with low tension. The mucogingival complex was advanced
coronally and stabilized at least 2mm coronal to the CEJ. Double mattress sutures (6.0
polypropylene with C3 needle; Hu-Friedy, Chicago, IL) were placed at 3-4 mm apical to
the gingival margin and the knots were placed 2-3mm coronal to the gingival margin. The
facial surfaces of the teeth were etched with phosphoric acid (35% phosphoric acid gel
Ultra-Etch, Ultradent Products, UT) for 5-10 seconds. The coronally advanced sutures were
bonded to the facial aspects of each tooth with flowable composite resin.

Post-operative instructions: Patients were instructed to only use ultra-soft tooth brush with
very gentle pressure to avoid mechanical trauma in the surgical site. Patients were
instructed to rinse with 0.12% chlorhexidine gluconate twice a day for 3 weeks. Analgesic
medication (Ibuprofen 600mg) was prescribed and patients were instructed to take as
needed for pain. Sutures were removed after 21 days.
Participants were recalled at 3, 6, 12, 24, 36 and 52 weeks. At each of the visits, oral
hygiene was reinforced and light tooth debridement and polishing with prophy paste was
performed.

Patient Reported Outcome Measures (PROMs)
Three days after the intervention, patients were asked to answer a visual analogue scale
(VAS) questionnaire to assess PROMs.

The questionnaire (Gobbato et al., 2016) included seven questions that patients had to
answer with values from 0 (no pain) to 10 (maximum pain). The questions were:

1. Pain experience within the whole mouth
2. Pain experienced while drinking beverages
13
3. Pain experienced while chewing
4. Pain experienced in the morning
5. Pain experienced throughout the day
6. Pain experienced at night
7. Edema experienced after the surgery

During the follow-up period, the operators recorded the occurrence of postsurgical
complications (Table 2).

Analgesic usage. Participants were asked to bring their analgesic medication jar with them
to their suture removal appointment at three weeks, so that the number of tablets remaining
can be counted to determine analgesic usage.

Statistical analysis:
Continues variables were described in means and standard deviations. VAS scores were
compared among the three groups using one-way ANOVA. However, the amount of
analgesics consumption was compared using the Kruskal-Wallis non-parametric test due to
the non-homogeneity observed among the variances. If cases that statistically significant
differences were observed among the groups, pair-wise comparisons were performed using
post-hoc tests (Tukey’s for VAS and Wilcoxon rank sum test for analgesics). P value of
less than 0.05 was used to identify statistically significant difference.

14
Results:

Clinical characteristics of participants and treated sites are reported in Table 1. The study
sample consisted of 23 patients (14 females and 9 males), with a total of 63 sites treated (10
incisors, 14 canines, 13 premolars in the maxilla, and 9 incisors, 7 canines, and 10
premolars in the mandible). A mean of 3 recession defects were treated per subject, with a
mean follow up of 7.6 months. Out of the 23 subjects, 9 were treated with CAF, 5 with IST
and 9 with VISTA. (See Fig. 1 for the flowchart of the study).

A total of 1 adverse event occurred (Table 2). In the CAF group, one subject experienced a
periodontal abscess 3 months after the surgical procedure. No adverse events occurred in
subjects treated with VISTA and IST.

Mean VAS scores: The lowest score was reported by patients treated with VISTA (11.33 +
6.2). Mean VAS score was 15.6 + 6.1 in CAF group, while the group with the highest score
was IST (18.6 + 9.44). No statistical significant difference was demonstrated among the
groups in any of the VAS-related parameters: pain experienced within the mouth as a whole
(p = 0.35), pain expressed while drinking (p= 0.70), pain expressed while chewing
(p=0.39), pain experienced in the morning (p=0.41), pain experienced during the day
(p=0.40), pain experienced at night (p=0.31) or edema experienced after the surgery
(p=0.76).

Analgesic use: (Figure 3). Participants from the IST group used significantly more
analgesics than the ones from VISTA and CAF groups. Statistically significant differences
related to the Ibuprofen dosage were observed among the three groups (p=0.009). Pair-wise
comparisons showed statistically significant differences between the groups: VISTA vs IST
(p=0.009), CAF vs IST (p=0.045). However, there was no significant differences between
VISTA and CAF groups (p=0.51).

15
Positive linear correlations were observed between the amount of pain medication
consumed and VAS questionnaire (r
2
= 0.46, p=0.025) (Figure 4). This constitutes a
moderate correlation, indicating substantial relationship between the 2 parameters analyzed.

Discussion:

There is a great deal of recent interest in PROMs which is an indicator of patient
satisfaction. However, data on PROMs, specifically for the treatment of gingival recession
defects is scarce. A randomized controlled clinical trial evaluating patient reported
outcomes following CAF compared to tunneling technique reported that IST with the use of
a connective tissue graft was associated with greater pain and discomfort in early
postoperative periods (Gobbato et al. 2016). These findings are in contrast with other
human studies, where it was concluded that microsurgical tunneling flap procedures are
associated with more favorable postoperative patient-reported outcomes (Zuhr et al. 2013
Aroca et al. 2010).

However, most of the previous studies that report on pain assessment after mucogingival
procedures combine the use of a connective tissue graft from the palatal or tuberosity area.
This can be misleading when patients are reporting their pain experience, since there are
two different surgical sites which can be contributing to the pain experience. Hence, more
focus is needed on specific sites, mostly the recipient. Therefore, this study compared the
PROMs without the use of autogenous connective tissue graft.

There is scarcity of information concerning the postoperative pain experience by patients
when performing different mucogingival procedures. The use of a sub-epithelial connective
tissue graft is generally associated with significant donor site morbidity. A study by Sanz et
al. (2008) compared the use of CTG with a xenogenic native collagen matrix (Mucograft,
Geistlich, Switzerland), reported that the use of the collagen matrix was associated with
significantly lower patient morbidity, evaluated by the subjective patient’s pain perception
16
and the amount of pain and inflammatory medication needed. However, in terms of clinical
outcomes, it is evident that the addition of a connective tissue graft to CAF resulted in long-
term stability and an increase in KT. A clinical study by Rasperini et al. (2018) reported on
the 9-year result of the treatment of single recessions defects with CAF with or without
CTG. It was reported that the use of CTG resulted in a coronal displacement of the gingival
margin, while an apical relapse of the gingival margin was observed in those cases without
the use of CTG.

In this study, the pain experience of the participants treated by three different techniques for
coronal advancement without donor harvesting was assessed. A VAS scale was utilized in
order to measure patients’ pain perception and experiences during early postoperative
phase. According to Wessel et al. (2014), most of the pain and postoperative symptoms
including bleeding or swelling occur during the first 3 days.
The results of this study failed to find any statistical differences in the VAS scores of
participants among the three different groups. The lack of statistical significance in the
VAS scores may be due to the low sample size, especially in the IST group.
Nonetheless, the analgesic medication consumption was significantly different among the
three different modalities. IST group reported the highest consumption of analgesics
followed by CAF and VISTA. This was surprising, because it is generally accepted that a
procedure without surface or vertical incisions would result in less post-operative pain
experience.

Differences in analgesic consumption may be due to sharp dissection of split thickness flap
elevation used in IST technique. VISTA did not entail any split thickness flap elevation,
while both IST and CAF had some degree of split thickness dissection. Clementini et al.
(2018) conducted a randomized controlled clinical trial comparing full versus split
thickness flap when performing root coverage procedures. The pain experience and
discomfort experienced during the first week postoperatively was two times more in the
partial thickness group. The results of this investigation are in agreement with the
previously mentioned study.

17
To our knowledge, the study by Gobbato et al. (2016) is the only study available where
they have compared patient morbidity between two different mucogingival surgical
procedures focusing only in the recipient site. However, they included the use of a
connective tissue graft from the palate which may induce some alteration in patient
perception and interpretation of the symptoms.

The present study has a number of limitations, including 1) small sample size, 2) limited
number of time points for the analysis of pain experience and analgesic consumption and 3)
the procedures were carried out by periodontology residents with limited clinical
experience.

Conclusions:
This prospective randomized controlled clinical trial showed no statistically significant
differences among the 3 treatment modalities (VISTA, CAF, IST) in terms of patient
reported VAS scores at 3-day follow up. However, the results showed a statistically
significant difference in the amount of analgesic consumed within the first 3 weeks post-
operative. IST showed the highest amount of analgesics followed by CAF and VISTA.
While CAF patients reported numerically higher amount of analgesics compared to VISTA,
this difference was not statistically significant.

18
Figures and Tables:

Figure. 1A: Participant recruitment and randomization

Fig. 1B: Study flowchart

19

Figure 2. VAS pain measure reported by patients at day 3 post-operative. The lowest score
was reported by participants treated with VISTA (11.33 + 6.2), but no statistically
significant difference was found among the groups. Mean VAS score was 15.6 +6.1 in CAF
group, while the group with the numerically highest score was IST (18.6 + 9.44).

20
Figure 3. Analgesic medication consumed by participants until 3-week post-op. Bar chart
representing the amount of analgesic medication used (mg) during the first 3 weeks
following the procedure. Statistically significant differences were observed among the
groups (P=0.009).

21
Figure 4. Scatter plot demonstrating the correlation between VAS and analgesic medication
consumption. Positive linear relations were observed between the mean pain measured in
the VAS questionnaire and the analgesic medication consumption (mg) (r
2
= 0.46, p=0.025).
This constitutes a moderate correlation, indicating substantial relationship between the 2
parameters analyzed.

22
Table 1. Clinical characteristics of participants.

Parameter Quantity
Subjects N=23 (9 males, 14 females)
Sites Total N=63
Maxillary Incisors. (N=10)
Maxillary Canines (N=14)
Maxillary Premolars (N=13)
Mandibular Incisors. (N=9)
Mandibular Canines (N=7)
Mandibular Premolars (N=10)
Age (years) 47 + 15
Mean follow-up (months) 7.6 months
Sites treated per patient 3
Treatment Group CAF (N=9)
IST (N=5)
VISTA (N=9)

Table 2. Adverse events and complications.

Adverse Event CAF VISTA IST
Periodontal abscess 1

23
Table 3. VAS Questionnaire 3 days post-surgery.

Pain/discomfort Group N Mean SD P value
VAS pain mouth as a
whole
CAF 9 2.66 1.65 CAF vs
VISTA
0.79
VISTA 9 2.11 1.45 VISTA vs
IST
0.32
IST 5 3.6 2.6 IST vs CAF 0.63
VAS pain while
drinking beverages
CAF 9 0.66 0.86 CAF vs
VISTA
0.73
VISTA 9 0.33 1 VISTA vs
IST
0.59
IST 5 1.6 0.89 IST vs CAF 0.19
VAS pain while
chewing
CAF 9 2.44 1.92 CAF vs
VISTA
0.78
VISTA 9 1.55 2 VISTA vs
IST
0.35
IST 5 3.2 2.58 IST vs CAF 0.68
VAS pain in the
morning
CAF 9 1.66 1.66 CAF vs
VISTA
0.63
VISTA 9 0.88 1.45 VISTA vs
IST
0.85
IST 5 2 1.41 IST vs CAF 0.86
VAS pain during the
day
CAF 9 2.66 1.5 CAF vs
VISTA
0.37
VISTA 9 1.66 1.41 VISTA vs
IST
0.92
IST 5 2.2 1.87 IST vs CAF 0.72
VAS pain at night CAF 9 2.11 1.45 CAF vs
VISTA
0.32
24
VISTA 9 1.11 1.16 VISTA vs
IST
0.52
IST 5 2 1.87 IST vs CAF 0.99
Edema after surgery CAF 9 3.11 1.83 CAF vs
VISTA
0.95
VISTA 9 2.88 1.69 VISTA vs
IST
0.74
IST 5 3.6 1.51 IST vs CAF 0.86
25
References:

1) Allen, A L. “Use of the Supraperiosteal Envelope in Soft Tissue Grafting for Root
Coverage. II. Clinical Results.” The International Journal of Periodontics &
Restorative Dentistry, U.S. National Library of Medicine, Aug. 1994,
www.ncbi.nlm.nih.gov/pubmed/7814223.
2) Aroca, Sofia, et al. “Treatment of Class III Multiple Gingival Recessions: a
Randomized-Clinical Trial.” Journal of Clinical Periodontology, vol. 37, no. 1,
2010, pp. 88–97., doi:10.1111/j.1600-051x.2009.01492.x.
3) Cairo, Francesco, et al. “The Interproximal Clinical Attachment Level to Classify
Gingival Recessions and Predict Root Coverage Outcomes: an Explorative and
Reliability Study.” Journal of Clinical Periodontology, John Wiley & Sons, Ltd
(10.1111), 20 Apr. 2011, onlinelibrary.wiley.com/doi/full/10.1111/j.1600-
051X.2011.01732.x.
4) Clementini, Marco, et al. “Biologically Guided Flap Stability: The Role of Flap
Thickness Including Periosteum Retention on the Performance of the Coronally
Advanced Flap-A Double-Blind Randomized Clinical Trial.” Journal of Clinical
Periodontology, vol. 45, no. 10, 2018, pp. 1238–1246., doi:10.1111/jcpe.12998.
5) Curtis, James W., et al. “The Incidence and Severity of Complications and Pain
Following Periodontal Surgery.” Journal of Periodontology, vol. 56, no. 10, 1985,
pp. 597–601., doi:10.1902/jop.1985.56.10.597.
6) Gil, Alfonso, et al. “Treatment of Multiple Recession Defects with Vestibular
Incision Subperiosteal Tunnel Access (VISTA): A Retrospective Pilot Study
Utilizing Digital Analysis.” Journal of Esthetic and Restorative Dentistry, John
Wiley & Sons, Ltd (10.1111), 27 Oct. 2018.
7) Gobbato, Luca, et al. “Patient Morbidity and Root Coverage Outcomes after the
Application of a Subepithelial Connective Tissue Graft in Combination with a
Coronally Advanced Flap or via a Tunneling Technique: a Randomized Controlled
Clinical Trial.” Clinical Oral Investigations, vol. 20, no. 8, 2016, pp. 2191–2202.,
doi:10.1007/s00784-016-1721-7.
26
8) Griffin, Terrence J., et al. “Postoperative Complications Following Gingival
Augmentation Procedures.” Journal of Periodontology, vol. 77, no. 12, 2006, pp.
2070–2079., doi:10.1902/jop.2006.050296.
9) “Guidance for Industry by U.S. Department of Health and Human Services—Food
and Drug Administration—Center for Biologics Evaluation and Research
(CBER)—February 1999.” Biotechnology, 2009, pp. 657–721.,
doi:10.1201/9781420084498-32.
10) Langer, Burton, and Laureen Langer. “Subepithelial Connective Tissue Graft
Technique for Root Coverage.” Journal of Periodontology, vol. 56, no. 12, 1985,
pp. 715–720., doi:10.1902/jop.1985.56.12.715.
11) Matthews, Debora C., and Christopher A. G. Mcculloch. “Evaluating Patient
Perceptions as Short-Term Outcomes of Periodontal Treatment: A Comparison of
Surgical and Non-Surgical Therapy.” Journal of Periodontology, vol. 64, no. 10,
1993, pp. 990–997., doi:10.1902/jop.1993.64.10.990.
12) Moher, D., et al. “CONSORT 2010 Explanation and Elaboration: Updated
Guidelines for Reporting Parallel Group Randomised Trials.” Bmj, vol. 340, no.
mar23 1, 2010, pp. c869–c869., doi:10.1136/bmj.c869.
13) Papageorgakopoulos, Georgios, et al. “Root Coverage Using Acellular Dermal
Matrix and Comparing a Coronally Positioned Tunnel to a Coronally Positioned
Flap Approach.” Journal of Periodontology, John Wiley & Sons, Ltd, 1 June 2008,
onlinelibrary.wiley.com/doi/full/10.1902/jop.2008.070546.
14) Sanz, Mariano, et al. “Clinical Evaluation of a Newcollagen
Matrix(Mucograft®Prototype) to Enhance the Width of Keratinized Tissue in
Patients with Fixed Prosthetic Restorations: a Randomized Prospective Clinical
Trial.” Journal of Clinical Periodontology, vol. 36, no. 10, 2009, pp. 868–876.,
doi:10.1111/j.1600-051x.2009.01460.x.
15) Schulz, Kenneth F, et al. “CONSORT 2010 Statement: Updated Guidelines for
Reporting Parallel Group Randomised Trials.” Trials, vol. 11, no. 1, 2010,
doi:10.1186/1745-6215-11-32.
27
16) Zucchelli, G., and M. De Sanctis. “Treatment of Multiple Recession-Type Defects
in Patients With Esthetic Demands.” Journal of Periodontology, vol. 71, no. 9,
2000, pp. 1506–1514., doi:10.1902/jop.2000.71.9.1506.
17) Zucchelli, G., et al. “Coronally Advanced Flap With and Without Vertical
Releasing Incisions for the Treatment of Multiple Gingival Recessions: A
Comparative Controlled Randomized Clinical Trial.” Journal of Periodontology,
vol. 80, no. 7, 2009, pp. 1083–1094., doi:10.1902/jop.2009.090041.
18) Zuhr, Otto, et al. “Tunnel Technique with Connective Tissue Graftversuscoronally
Advanced Flap with Enamel Matrix Derivative for Root Coverage: a RCT Using 3D
Digital Measuring Methods. Part I. Clinical and Patient-Centred Outcomes.”
Journal of Clinical Periodontology, vol. 41, no. 6, 2013, pp. 582–592.,
doi:10.1111/jcpe.12178.

Abstract (if available)

Abstract Aim: The aim of this randomized controlled clinical trial was to evaluate the patient reported outcome measures (PROMs) of participants undergoing three different interventions for the treatment of multiple gingival recession defects, and attempt to compare post-operative pain of 3 modalities for coronal advancement of gingival margins to achieve root coverage. ❧ Material and methods: Participants with recession types (RT) I and II were recruited into this study and randomly assigned into three intervention groups, namely, Coronally Advanced Flap (CAF), Vestibular Incision Subperiosteal Tunnel Access (VISTA) and Intrasulcular tunneling (IST). Three days after the intervention, a questionnaire using the visual analog scale (VAS) was administered to the participants to assess PROMs, including pain experience. Analgesic use was determined by counting the number of analgesic tablets used by each patient during the 3 weeks following surgery. ❧ Results: 23 patients (9 CAF, 9 VISTA, 5 IST) were included in the study. The IST group showed a numerically higher total VAS score (18.6 ± 9.44), compared to CAF (15.66 ± 6.16) and VISTA (11.33 ± 6.24). However, no statistically significant difference was found among the groups. IST group showed statistically significantly more analgesic consumption (7320 mg ± 2451) than VISTA (1422 mg ± 891) (p=0.009) and more than CAF group (2733 mg ± 3232) (p=0.045). There were no statistical differences between the analgesic consumption between VISTA and CAF group. ❧ Conclusions: IST was associated with greatest amount of analgesics consumed compared to CAF and VISTA in early post-operative periods (3-week). However, VAS scores showed no statistically significant differences among the 3 groups at the 3-day post-operative time point.

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

A retrospective analysis of the outcome of three methods used for the treatment of multiple gingival recession defects

PDF

Treatment of multiple gingival recession defects with VISTA: 2D-analysis

PDF

Efficacy of fibrin-assisted soft-tissue promotion (FASTP) in treatment of multiple gingival recession defects: a retrospective 3-D volumetric analysis

PDF

Three-dimensional volumetric analysis of gingival augmentation for the treatment of multiple recession defects by vestibular incision subperiosteal tunnel acces (VISTA)

PDF

Reproducibility of digital and analogue assessment methods used for quantitative measurements of periodontal soft tissues dimensions

PDF

Predictibility of fibrin-assisted soft tissue promotion (FASTP) in treatment of multiple gingival recession defects: a retrospective 2-D analysis

PDF

The reliability of simultaneous quantitative 3D analysis of bone and soft tissue volumes

PDF

A randomized controlled clinical trial evaluating the efficacy of grafting the facial gap at immediately placed implants in the anterior maxilla: 3D analysis of bone and soft tissue changes

PDF

The effect of vertical level discrepancy of adjacent dental implants on crestal bone resorption: a retrospective radiographic analysis

PDF

3D assessment of virtual bracket removal for modern orthodontic retainers: a prospective clinical study

PDF

Effect of 0.25% sodium hypochlorite oral rinse and subgingival irrigation on periodontal clinical parameters

PDF

Reprogramming the NiTi expander: an alternative to conventional rapid and slow maxillary expansion modalities for the treatment of patients with cleft lip and palate

PDF

Detrimental effects of dental encroachment on secondary alveolar bone graft outcomes in the treatment of patients with cleft lip and palate: a cone-beam computed tomography study

PDF

The utility of bleeding on probing and 0.25% sodium hypochlorite rinse in the treatment of periodontal disease

Asset Metadata

Creator Moreno-Alemán Sánchez, Julio (author)

Core Title Patient reported outcomes measures (PROMs) and medication count of the three coronal advancement methods for the treatment of multiple gingival recession defects

School School of Dentistry

Degree Master of Science

Degree Program Craniofacial Biology

Publication Date 07/31/2019

Defense Date 05/20/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag gingival recessions,OAI-PMH Harvest,pain perception,root coverage

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Bakhshalian, Neema (committee chair), Chen, Casey (committee member), Kar, Kian (committee member)

Creator Email jmorenoa@usc.edu,jmorenoaleman807@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-201685

Unique identifier UC11663301

Identifier etd-MorenoAlem-7704.pdf (filename),usctheses-c89-201685 (legacy record id)

Legacy Identifier etd-MorenoAlem-7704.pdf

Dmrecord 201685

Document Type Thesis

Format application/pdf (imt)

Rights Moreno-Alemán Sánchez, Julio

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA