#Oral Irrigator Previous Data

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[ad_1] Conventional farming data as soon as shaped the spine of agricultural communities, guiding every little thing from find out how to put together the soil to the very best instances of yr to prune orchard timber. At present, horticulture and agriculture are within the midst of profound change. Local weather fluctuations, the introduction of latest plant varieties, evolving shopper expectations, and technological instruments have all shifted the way in which fruit timber are grown, maintained, and distributed. But, woven by this altering panorama is a thread of older, time-honoured data. Whereas many fashionable growers now flip to superior irrigation methods or soil sensors, they nonetheless depend on concepts handed down by generations in relation to understanding how climate, soil composition, and biodiversity work together. This interaction of previous and current makes clear that though expertise has introduced nice advances, conventional strategies nonetheless have a important function to play. In line with one nursery specialist at CRJ FruitTrees, the retention of tried-and-tested orchard practices is way from being an outdated sentiment. They stress that heritage strategies can inform higher decision-making, particularly in unpredictable rising seasons. These long-standing strategies, they are saying, have proved repeatedly that understanding the plant’s pure rhythms, together with the encompassing surroundings, is commonly simpler than any synthetic shortcut. They counsel that whereas novices dashing to purchase fruit timber would possibly concentrate on essentially the most sturdy, fashionable cultivars, the astute grower nonetheless finds knowledge within the outdated methods. By embracing this steerage—one which has labored for hundreds of years—gardeners can guarantee their orchards are more healthy, extra resilient, and higher in a position to deal with quite a lot of stressors. They add that clients who search to harmonise newer horticultural improvements with established, earthy traditions usually tend to see balanced development and style the complete sweetness of their backyard’s potential. The Historic Foundations of Agricultural Knowledge Lengthy earlier than the onset of synthetic fertilisers, mechanised instruments, or international provide chains, agriculture depended largely on what may very well be found by shut statement and lived expertise. Historical orchardists and small-scale farmers invested immense time into understanding how native ecosystems labored. They recognised that every piece of land had its personal character, formed by microclimates, slope, soil sort, water sources, and native natural world. They mapped the altering seasons, famous the presence of useful bugs, studied patterns of pests, and catalogued which crops thrived in shade versus direct daylight. Over generations, this holistic strategy shaped a physique of sensible data that was examined consistently. If a selected pruning approach constantly led to more healthy apple yields, it was remembered. If making use of sure natural mulch or rotating sure cowl crops helped keep soil fertility, it too grew to become a part of the accrued knowledge handed down by oral custom and cautious demonstration. This sort of studying functioned as a dwelling library. A grandfather would possibly train his grandchild find out how to graft a department or choose essentially the most useful understock for grafting specific fruit timber, guaranteeing that the data survived. In rural communities, gatherings and harvest festivals weren't simply social occasions however alternatives to share, evaluate, and refine strategies. Every success or failure added a brand new chapter to an agricultural story that prolonged by time. This affected person accumulation of trial and error allowed orchard keepers and gardeners to grasp the fragile steadiness wanted to supply dependable yields whereas preserving the long-term well being of the land. Conventional Data in a Trendy Context

At present, fast globalisation and the tempo of change in horticulture would possibly counsel that older strategies are dropping relevance. But, when confronted with unpredictable local weather occasions—late frosts, summer time droughts, or uncommon pest invasions—fashionable orchardists more and more flip to those historic insights. In lots of circumstances, conventional data provides one thing extremely invaluable on this period of mechanisation: adaptability. Whereas equipment can carry out duties with nice effectivity, it can't modify instinctively to sudden shifts in climate or adjustments within the soil’s microbe inhabitants. Human instinct and reasoning, knowledgeable by time-honoured knowledge, can pivot plans immediately, planting at a unique time of yr or selecting totally different help vegetation to push back encroaching illnesses. Trendy gardeners, whether or not they handle giant orchards or have a tendency small dwelling gardens, usually discover that mixing custom with up to date science creates a a lot richer toolkit. Superior climate forecasts would possibly warn of a coming chilly snap, however it's the orchardist’s ingrained data that means wrapping younger trunks in hessian or spreading a protecting mulch on the proper second. Laboratory analyses would possibly point out a nutrient deficiency within the soil, however the orchardist’s eye, educated by ancestral strategies, can interpret delicate leaf color adjustments or patterns within the undergrowth that assist information the treatment. Strategies and Strategies Passing the Take a look at of Time The continuity of sure farming practices proves their enduring value. Strategies corresponding to crop rotation, cautious grafting of fruit tree varieties, and the usage of pure predators for pest management haven't grow to be out of date; somewhat, they've discovered a renewed objective. Conventional pruning strategies, as an example, stay integral to managing fruit timber’ form, publicity to daylight, and total vigour. Regardless of the provision of latest pruning instruments and mechanised shears, the ideas guiding how and when to prune stay comparatively in keeping with what orchardists did centuries in the past. The truth that fashionable textbooks and horticultural pointers echo these outdated approaches is testomony to their reliability. One other space during which older strategies persist is in water and soil administration. Natural mulches, composting, and inexperienced manures, all important strategies in conventional gardening, are actually embraced by fashionable advocates of sustainable agriculture. Pure mulches not solely add vitamins to the soil but in addition assist regulate moisture ranges, cut back competitors from weeds, and keep a secure root surroundings. These strategies are grounded in a holistic understanding that depends on nurturing dwelling soil ecosystems somewhat than merely feeding the vegetation. Whereas artificial fertilisers have their place, the deeper perception that more healthy soil results in more healthy timber finally originated within the custom of cautious statement and stewardship. Biodiversity and Soil Well being: Classes from the Previous One of the urgent fashionable issues in horticulture and agriculture is the lack of biodiversity and declining soil well being. Conventional data, which at all times seen the orchard or backyard as a part of a broader ecological tapestry, provides important classes right here. Older farming practices hardly ever operated in isolation from the encompassing surroundings. Companion planting, the encouragement of useful bugs, and the usage of sure herbs and flowers to repel pests or encourage pollinators all replicate an understanding that nature works finest in steadiness. Historical orchardists revered that fruit timber thrived in a system teeming with life—microorganisms, earthworms, beetles, bees, and birds—all contributing to a delicate equilibrium. On this period of chemical interventions, many growers have begun to return to those strategies.

Though fashionable science explains why these approaches work when it comes to chemistry, biology, and ecology, the precept stays the identical: once you respect the surroundings’s pure cycles, you harness a pressure of resilience. Sustaining numerous groundcover vegetation might help cut back erosion, enhance water infiltration, and keep soil construction. Together with wildflower strips can help useful predators that handle insect pests with out chemical sprays. These concepts are usually not new however somewhat a reaffirmation of historic instincts that a wholesome orchard is greater than only a assortment of timber. It's an interdependent group. Preservation of Heritage Varieties in Trendy Nurseries Regardless of market tendencies to streamline fruit manufacturing right into a handful of extremely productive, disease-resistant varieties, there's a rising curiosity in preserving and cultivating heritage fruit tree varieties. Nurseries that concentrate on these older cultivars present a hyperlink to the previous, guaranteeing that particular flavours, distinctive resistances, and long-standing traits are usually not misplaced in a rush towards uniformity. A youthful orchardist deciding to purchase fruit timber at present is perhaps shocked to seek out that these heritage alternatives convey richer tastes, delicate textures, and aromas which were loved for hundreds of years. The selection to maintain these older varieties alive is greater than a nod to nostalgia. It acknowledges that resilience is commonly present in genetic range. A fruit tree from a neighborhood heritage selection could also be higher tailored to the area’s particular local weather, extra tolerant of sure illnesses, or extra environment friendly at utilising the native soil’s vitamins. Trendy strategies permit for the propagation and distribution of those varieties extra effectively than up to now. But their worth rests on the time-honoured data that fastidiously chosen genetics, handed down by orchardist lineages, have real ecological and gastronomic value. By looking for out nurseries that curate such collections, these trying to purchase fruit timber can contribute to preserving agricultural traditions whereas including depth and character to their orchards. Embracing Trendy Sources Whereas Honouring Custom At present, orchardists and gardeners profit from an unprecedented availability of data. Web sites, books, cellular apps, and on-line boards provide fast insights on planting distances, really useful cultivars, pruning schedules, and extra. Laboratories can analyse soil in methods unimaginable in earlier centuries, recommending exact nutrient amendments to realize optimum plant well being. Precision irrigation methods present water in actual quantities on the proper instances. Greenhouses and polytunnels lengthen seasons and shield susceptible varieties. These improvements have elevated effectivity, predictability, and yield for a lot of growers. Nonetheless, integrating these instruments successfully usually requires the tempering affect of conventional data. Strategies which have guided orchard administration for generations be sure that expertise shouldn't be misapplied. Soil evaluation would possibly inform a grower that the bottom is low in phosphorus, however an skilled orchardist additionally is aware of from custom find out how to enrich the soil organically and progressively, guaranteeing that the treatment suits into the orchard’s long-term well being plan. Equally, whereas expertise can detect moisture ranges in real-time, it might nonetheless be the orchardist’s seasoned instinct that recognises a deeper signal of plant stress, prompting adjustments in care that no algorithm may counsel. The important thing lies to find a steadiness. Trendy orchardists can honour centuries of accrued data by combining it with up to date understanding. The place superior pruning saws facilitate cleaner cuts, making use of them in step with outdated pruning

strategies ensures that the tree is formed respectfully, following its pure development patterns. The selection to combine each paths not solely enhances plant well being but in addition creates a extra fulfilling expertise for growers. Those that recognize the historical past and craft behind their work are sometimes higher stewards of their land and happier of their pursuits. Sustainable Practices and Moral Sourcing Sustainability has grow to be a central concern, and older traditions have a fantastic deal to show fashionable growers about find out how to keep agricultural methods with out exhausting sources. Earlier than international provide chains and mass manufacturing, farmers needed to keep the long-term viability of their soils and guarantee ongoing fertility. This was achieved by strategies corresponding to utilizing compost, rotating crops, sustaining hedgerows, and inspiring useful organisms within the soil. None of those insights originated in a scientific laboratory; they emerged from necessity, affected person statement, and a profound respect for the pure world. As shoppers grow to be extra conscious of the origins of their meals, nurseries and orchardists who nonetheless respect these ideas might discover themselves . Consumers usually search for fruit that has been grown ethically, with a low environmental footprint. They might additionally search alternatives to purchase fruit timber themselves from sources dedicated to sustainable strategies, together with heritage varieties that help better biodiversity. In each circumstances, conventional data informs the way in which these timber are propagated, raised, and delivered to the patron. Moral sourcing additionally consists of recognising that older data can come from many alternative cultures and communities. Farmers from varied areas have tailored orchard strategies to their particular climates and terrains. Amassing, sharing, and respecting this data can result in improvements that serve fashionable wants whereas preserving a worldwide heritage of concepts. As local weather change threatens to change rising situations drastically, the orchard traditions of areas which have discovered to deal with harsh or unpredictable climate will grow to be ever extra invaluable. Navigating Cultural Shifts and Shopper Calls for Shopper demand adjustments quickly, formed by well being developments, aesthetic preferences, and shifting culinary pursuits. But the orchard stays ruled by elementary ideas that don't change practically as quick. The natural processes of development, blossoming, pollination, and fruiting nonetheless comply with patterns established lengthy earlier than fashionable shopper markets existed. Conventional data reminds orchardists that no advertising innovation or fashionable new cultivar can override the essential wants of vegetation and soil. This isn't to say that custom stifles innovation. Quite, it offers a measure of stability and continuity. As orchardists reply to new calls for for distinctive fruit flavours, improved vitamin, or uncommon varieties, they'll depend on acquainted strategies to make sure their experiments align with pure rhythms. The orchard has at all times been an area of experimentation, however it's the underlying framework of inherited knowledge that retains these experiments grounded in actuality. Growers who know their land intimately—as a result of they've noticed it intently for years and have constructed upon ancestral insights—usually tend to produce constant high quality, whilst they adapt to shoppers’ evolving tastes. Neighborhood Involvement and the Passing On of Data The continued relevance of conventional farming data additionally depends on how nicely it's handed on to the following era. Whereas formal training in horticulture or agriculture might help be sure that novices study the fundamentals, really mastering the orchard usually requires interpersonal mentorship. Elders can reveal delicate strategies, corresponding

to find out how to prune to realize the precise cover form for solar penetration, or find out how to detect the presence of illness earlier than it turns into apparent. The apprentice advantages not solely from technical talent but in addition from the ethos of stewardship and respect that underpins these strategies. In communities the place this passing of information continues to be practised, youthful growers develop a wealthy understanding that goes past manuals and information sheets. They kind a respect for the orchard as a dwelling system, one which exists each within the second and as a part of a convention that connects the previous to the longer term. This sense of continuity is invaluable, particularly in a world the place so many elements of life really feel in flux. The orchard turns into a repository of identification and tradition, a spot the place the outdated methods and new strategies meet, guaranteeing that future generations will nonetheless know find out how to have a tendency the land responsibly and productively. Trendy communication instruments can truly improve this custom. Digital conferences, movies, and on-line tutorials imply that older orchardists can share insights with learners far past their native area. This broad dissemination of information would possibly result in surprising collaborations and hybrids of custom, the place somebody discovering find out how to purchase fruit timber in a single a part of the nation can apply pruning ideas gleaned from the expertise of orchard keepers in one other. Over time, this international data trade would possibly spawn new traditions, mixing native knowledge with strategies borrowed from distant lands. Dealing with Environmental Challenges As climates shift and environmental pressures intensify, farmers face an unsure future. Floods, droughts, and heatwaves take a look at even essentially the most resilient orchards. Right here, conventional data performs an more and more very important function. Historical strategies of water conservation, shade administration, and pollinator help grow to be greater than quaint customs; they're important instruments for sustaining productiveness in a altering surroundings. The orchardist who respects these outdated methods shouldn't be clinging to nostalgia however somewhat arming themselves with confirmed options. Many of those strategies have been developed exactly as a result of growers up to now confronted their very own challenges—typically harsher or much less understood than these of at present. They discovered find out how to create windbreaks, enhance drainage, or encourage pure insect predators not only for aesthetics however to make sure survival. Their successes and failures present a historic blueprint that helps fashionable orchardists reply extra successfully. Pairing this inherited knowledge with at present’s scientific developments and local weather modelling permits a extra nuanced strategy to threat administration, guaranteeing that orchards stand a greater probability of remaining productive and sustainable within the many years to return. The Timeless Attraction of the Orchard A part of the enchantment of orchard traditions is that they join folks to an easier, extra secure previous. Even those that stay in city environments or depend on grocery store cabinets for his or her fruit nonetheless recognize the notion of a well-tended orchard, brimming with blossoms in spring and laden with fruit in summer time and autumn. Gardens and orchards remind folks of seasonal rhythms and pure cycles that city life usually obscures. There's a psychological consolation in figuring out that sure issues—corresponding to the very best instances to plant sure varieties, or the cycles of fertility within the soil—don't change merely as a result of human life do. When people select to purchase fruit timber, they usually achieve this for causes past productiveness. They need to reconnect with nature, style fruit that they've

grown themselves, and play an element in sustaining conventional strategies that maintain the earth wholesome. By doing so, they grow to be a part of a lineage of orchardists who've, over numerous generations, discovered to learn the delicate clues nature offers and reply accordingly. This timeless enchantment ensures that, irrespective of how superior horticultural science turns into, there'll at all times be a spot for conventional farming data in shaping how fruit timber are grown. Conclusion: A Timeless Useful resource for Future Generations The function of conventional farming data in fashionable orchard administration is each enduring and evolving. As local weather challenges mount, shopper tastes shift, and expertise turns into ever extra subtle, it may appear as if the orchardist’s reliance on older knowledge would fade. As a substitute, the alternative is true. Conventional strategies present a stabilising affect, a repository of examined insights that no quantity of recent gadgetry can absolutely substitute. From guiding sustainable soil administration to influencing the choice of heritage varieties, from providing resilient methods to dealing with environmental stresses to nurturing a respectful strategy to biodiversity, conventional farming data is woven into each side of the orchard. Trendy growers and their clients profit from this mix of outdated and new, experiencing richer tastes, more healthy ecosystems, and a stronger connection to the land and its historical past. So long as folks proceed to have a tendency fruit timber, recognize the subtleties of their development and flavour, and try to work in concord with nature’s rhythms, conventional data will stay a significant a part of the method. When fashionable orchardists search steerage, they discover knowledge cast by centuries of statement. Whether or not they put money into cutting-edge irrigation methods or just comply with ancestral recommendation to prune at a selected time of yr, they're collaborating in a dynamic custom. A lot has modified in agriculture, but the orchard endures as a spot the place outdated data nonetheless guides new fingers. By means of all of it, growers who select to purchase fruit timber and combine conventional farming data into their follow will proceed to reap the rewards—plentiful harvests, sustainable strategies, and a dwelling reference to a wealthy agricultural heritage. [ad_2] Supply hyperlink

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Oral Irrigator Market size to maintain the average annual growth rate of 0.0388047212443 from 186.0 million $ in 2014 to 225.0 million $ in 2019, BisReport analysts believe that the market size of the Oral Irrigator will reach 334.0 million $ by 2024.

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Guided Tissue Regeneration using an Equine Bio-absorbable Collagen Membrane with or without Equine Bone Graft in the Treatment of Intrabony Defects in Patients with Aggressive Periodontitis Results of 18 month- Juniper Publishers

Authored by Mahmoud Helmy Belal

Abstract

Background:Successful periodontal regeneration is considered a gold standard for periodontists. Several GTR materials and bone grafts have been attempted but showed variable success rates.

Objective:The present randomized clinical and radiographic study was undertaken to compare the effectiveness of guided tissue regeneration (GTR) by using equine bioabsorbable collagen membrane with or without equine bone graft in the treatment of periodontal intrabony defects affected by aggressive periodontitis.

Materials and Methods: Ten systemically healthy patients with 20 periodontal intrabony defects were enrolled as a split mouth design. These defects were affected with aggressive periodontitis. The recorded measurements included plaque index, gingival bleeding index, gingival recession, PPD, clinical attachment level, radiographic defect depth and radiographic density. The defects were randomly distributed either as a control group (equine bioabsorbable collagen membrane alone) or a test group (equine bioabsorbable collagen membrane combined with equine bone graft).

Results: The inter- & intra-group comparison showed no significant differences between studied groups nor within each group for these clinical parameters (PI, BI & GR), except only gingival recession within group 1. On contrary, the inter- & intra-group comparison showed significant differences between studied groups and within each one for these parameters (PPD, CAL, RDD & RD).

At 18-month examination, PPD reduction was significantly greater in GTR + bone graft group (3.80±1.33 mm) compared with GTR group (2.60±1.57 mm), and clinical attachment level gain were 3.60±1.15 and 2.20±1.26 respectively. Radiographic DD reduction was similarly greater in GTR + bone graft group (3.30 ± 0.84 mm) compared with GTR group (2.40±1.09 mm). Also, the change in the radiographic density indicated a significant greater gain of mean gray level as (19.90 ± 16.00) in group 2 whereas 7.10±10.65 in group 1.

Conclusion: Use of GTR bioresorbable membrane with bone graft showed significant improved outcomes when compared to use of bioresorbable membrane in treating aggressive periodontitis. However, the studied groups showed significant improvement within each group when baseline & 18 month data were compared.

Keywords: Aggressive Periodontitis; Bone Graft; Guided Tissue Regeneration; Intrabony Defect

Abbreviations: AP: Aggressive Periodontitis; GTR: Guided Tissue Regeneration; CAL: Clinical Attachment Level; PPD: Probing Pocket Depth; GR: Gingival Recession; BI: Bleeding Index; PI: Plaque Index; RD: Radiographic Density; RDD: Radiographic Defect Depth; CBR: Crestal Bone Resorption; AC: Alveolar Crest; CEJ: Cementoenamel Junction; BD: Base of the Defect

Introduction

The aim of successful periodontal therapy is a trial to arrest inflammatory process, suppress microbial growth, control infection and attempt to restore the tissues destroyed due to periodontal disease. Different regenerative techniques may be used for such purposes, but the treatment or elimination of the infection should be the most important goal especially in patients having aggressive periodontitis [1,2].

Aggressive periodontitis (AP) is characterized by severe periodontal destruction within a relatively short period of time. It has some etiologic agents capable of causing clinically detectable diseased levels that may negatively hazard oral healthy condition and alter daily life style of such patients. AP has less occurrence among periodontitis patients and few studies have evaluated some treatment protocols [3].

The predictable complete periodontal regeneration remains a major goal in the planned therapy. Despite several procedures such as usage of guided tissue regeneration (GTR), grafting materials, growth factors and/or host modulating agents have been attempted, the outcomes are not always predictable [4-6]. However, there is a great variation caused by many factors, for example; type of periodontitis, patient characteristics, anatomy of defect site and the surgical intervention [7]. The treatment of aggressive type of periodontitis has a great challenge to many clinicians.

In general, the most successful documentation of periodontal regeneration is GTR since it acts as an effective principal therapy for the treatment of different anatomic defects associated with periodontitis [5]. Some earlier animal [8,9] and human studies [10,11] indicated a predictable reconstruction of the periodontium by using either non-bioabsorbable or bioabsorbable membranes [12]. However, bioabsorbable GTR membranes were developed to avoid the second surgery needed to retrieve the non-resorbable barrier [13-16]. These bioabsorbable devices have two main products, natural (collagen membrane) and synthetic (copolymers) like Guidor, Vicryl periodontal mesh, Resolut and Atrisorb GTR barriers.

Use of GTR through the use of equine barrier and equine bone graft material showed a favorable clinical outcome and an effective periodontal therapy in the regenerative treatment of intrabony defects [17]. Also, these equine collagen membranes and equine bone acts as an effective therapy for guided bone regeneration in the treatment of bone defect consequent to removal of periapical cyst in clinical & histological report [18].

Some previous literature reports [13-16] were found, in which the efficacy of bioabsorbable membranes alone or combined with graft materials were evaluated and compared for regenerative purposes. However, to our knowledge, there are no available studies comparing the efficacy of using an equine bioabsorbable collagen barrier (Biocollagen®) alone or combined with equine graft (Bio-Gen®), in treating intrabony defects of aggressive periodontitis.

Subjects and Methods

Inclusion criteria

Aggressive periodontitis.

Intrabony periodontal defect sites with probing pocket depth > 5mm, as assessed by clinical and radiographic evaluation.

Radiographic evidence of vertical/angular bone loss.

Age ranged from 17 to 37 years.

Good general health.

Exclusion criteria

Periodontal treatment received during the last 6 months at least.

Hopeless teeth or evident grade-III mobile teeth.

Any relevant systemic diseases.

    Smokers and/or alcoholics.

Pregnancy and/or lactation for female patients.

Hypersensitivity to any of the tested research materials.

Study Design

Ten patients (seven males & three females) were selected to be enrolled in this study and gathered from the out-patient clinic of the Department of Oral Medicine, Periodontology, Oral Diagnosis & Radiology. Verbal and written informed consent forms were obtained from all subjects and an ethical clearance was also get from the institution.

Ten patients with bilateral intrabony periodontal defects were selected. Thus, a total of twenty affected sites were chosen as noticed primarily on the radiographs and confirmed clinically as well as within the reconstructive surgical intervention. These defects were distributed into two groups as follows:-

   Group 1 (the control group): Ten sites received flap debridement followed by the application of bioabsorbable equine collagen membrane* (Biocollagen®).

        Group 2 (the test group): Ten sites received flap debridement followed by the application of the same bioabsorbable collagen membrane but combined with equine bone graft material as xenograft† (Bio-Gen®).

Primary Assessment and Patient’s Preparation

Patients were subjected to pre-surgical, clinical and radiographic interpretation. The patients completed a thorough plaque control regimen and a strict oral hygiene instruction. Full-mouth phase I therapy was done using periodontal Gracey curettes# and an ultrasonic apparatus$. The reevaluation period was determined according to each individual response, with an average period of about 6 weeks. Thereafter, a treatment plan was defined and an additional non-surgical therapy and/or dental extractions were done whenever needed. However, the surgical intervention were started when the subject’s plaque and gingival index had achieved at least 20% levels, according to instructions of some previous reports [19-21].

Clinical Measurements

Plaque index (PI), gingival bleeding index (BI), gingival recession (GR); probing pocket depth (PPD) and clinical attachment level (CAL) were recorded. An acrylic stent with reference points was used to localize the measurement sites at baseline and 18 months postoperatively. The periodontal measurements were recorded using a graduated William’s periodontal probe‡. Tooth mobility was also graded [22], scored and evaluated.

Surgical Procedures

Access to the defects were done using full-thickness flaps and sulcular incisions through the bottom of the crevice, extending mesial and distal to the adjacent teeth and including the flap papillae. No releasing incisions needed on either sides of the flap. Granulomatous tissues were curetted and thorough root planning was performed. EDTA with a concentration of 24%, at neutral pH, was used then washed with saline irrigation.

Randomly, using a coin, one defect treated with equine bioabsorbable collagen membrane as a control group whereas the other defect was treated with the same collagen membrane but combined with equine bone graft (the test group). Graft material was soaked with sterile saline and condensed gently in the defects to the adjacent crestal walls. The collagen membrane was adapted to obtain precise application to the interproximal area of the affected site. The membrane was then adjusted to completely cover the defect, overlapping at least 2-3 mm of the residual bone and sutured adequately with bioabsorbable sutures. Flaps were repositioned coronally during wound suturing, if required. The surgical site was covered with a noneugenol periodontal dressing% on the buccal and lingual aspects.

Post Operative Care

Chlorhexidine digluconate mouth rinse (0.12%) was used as two times daily for one month postoperatively. Amoxicillin trihydrate 875 mg/clavulanic acid as potassium salt 125 mg (Hibiotic 1gm film coated tablets, Amoun Pharmaceutical Co. SAE., El-Obour city, Cairo, Egypt), was prescribed as two times daily for 10 days. Also, a non-steroidal anti-inflammatory drug (Ibuprofen 600 mg, “Brufen granules”, effervescent sachets, Kahira Pharm. & Chem. Ind. Co. under license of Abbott Laboratories-USA) was also prescribed twice per day, for 7 days. In addition, antiprotozoal drug (Secnidazole 1gm, Nitroimidazole derivative, Cipazole forte, SIGMA Pharmaceutical Industries-Egypt, with cooperation of Queen Pharm international) was prescribed two tablets (each tablet contains Secnidazole 1gm) as a single dose (one day treatment) during meal.

Postoperative care was performed weekly in the first month, monthly up to six months and then every 3 months. In cases of membrane exposure, Doxycycline 100 mg was prescribed 2 times per one day then once for 5-7 days, and the surgical sites were carefully cleaned with a cotton swab soaked with 0.12% chlorhexidine digluconate two times daily.

Assessment of radiographic parameters and radiographic interpretation

Standardized intra-oral periapical radiographs (Kodak X-ray film, USA) were obtained at baseline and 18 months postoperatively. These radiographs were taken using long cone/ extension cone paralleling technique with a positioning device mounted on a roentgen machine, operating at 70 Kilo Voltage Power.

Radiographs were scanned using a digital scanner at an input of 300 dpi and 100% scale, then they were analyzed using a software@. The images had 768 × 512 pixels and 256 gray scale level. The alignment of images, in the pairs of radiographs, was applied to correct small geometric misalignments. Gray level was then calibrated to indicate changes in the radiographic density (RD).

In addition, the following measurements were obtained in millimeters: distance from cementoenamel junction (CEJ) to base of the defect (BD) and from CEJ to alveolar crest (AC). The differences between baseline and 18-month postoperative values for CEJ–BD indicated the change in the radiographic defect depth (RDD), whereas the differences for CEJ–AC suggested the possible occurrence of crestal bone resorption (CBR).

Statistical Analysis

The present study had parametric variables. Thus, student’s paired t-test was used to compare the changes in the data from baseline up to 18 months postoperatively within each treatment group. On the other hand, the intergroup comparison was accomplished by independent sample t-test. A ‘P’ value of 0.05 or less was considered statistically significant.

Results

Using student’s paired t-test, the intra-group comparison showed comparable outcomes in the experimental groups regarding plaque index, gingival bleeding index as well as gingival recession, when comparing baseline scores to 18 months postoperative data. This is because there were no statistically significant differences noticed for these parameters, except only gingival recession within group 1 where P value recorded as 0.04. In addition, using independent sample t-test for intergroup comparison there were no statistically significant differences found between the two groups for these clinical parameters (PI, BI & GR). (Table 1).

On the other hand, by using student’s paired t-test, statistically significant differences were found when comparison was done from baseline up to 18 month postoperatively within both groups (1 & 2) regarding PPD, CAL, RDD & RD. Furthermore, using independent sample t-test for intergroup comparison there were also statistically significant differences found between the two groups for these clinical and radiographic parameters (PPD,CAL, RDD & RD) (Table 1).

The probing depth is reduced from (7.80±1.75 mm) at baseline to (5.20±1.40 mm) at 18 month with a mean difference of (2.60±1.57 mm) in group 1, whereas from (7.90±1.66 mm) to (4.10±.99 mm) with a mean difference of (3.80±1.33 mm) in group 2. This was statistically significant (P = 0.000). The intergroup comparison indicated that the difference was statistically significant with a P value of 0.05 (Table 1).

The clinical attachment level is changed from (8.60±1.26 mm) at baseline to (6.40±1.26 mm) at 18 month postoperative with a mean CAL gain of (2.20±1.26 mm) in group 1, whereas from (8.60±1.35 mm) to (5.00±.94 mm) with a mean CAL gain of (3.60±1.15 mm) in group 2. This was statistically significant (P = 0.000). The intergroup comparison indicated that the difference was statistically significant with a P value of 0.01 (Table 1).

The radiographic defect depth was reduced from (5.90±1.10 mm) at baseline to (3.50±1.08 mm) at 18 month postoperative with a mean difference of (2.40±1.09 mm) in group 1, whereas from (5.90±.99 mm) to (2.60±.70 mm) with a mean difference of (3.30±0.84 mm) in group 2. This was statistically significant (P = 0.000).

The radiographic density was changed from (92.40±12.38) at baseline to (99.50±10.91) at 18 month postoperative with a mean difference of (7.10±10.65) in group 1, whereas from (94.10±14.32) to (114±17.68) with a mean gain of (19.90±16.00) in group 2. This was statistically significant (P = 0.000 & 0.03 respectively). In addition, the intergroup comparison regarding both RDD and RD showed that the difference between the studied groups was statistically significant with a P value of 0.04 (Table 1).

Two cases are presented in figures from 2 to 5 with clinical photographs during surgical intervention and pre-& postoperative radiographic images. Case 1 is presented in figures ( 1 & 3) and was treated by using bio absorbable equine collagen membrane, for covering and treatment of selected intrabony defect site between teeth No. 26 & 27 as mainly distal to tooth No. 26. Case 2 is presented in ( figures 4 & 5 ) and was treated by the application of the same bio absorbable collagen membrane but in combination with equine bone as xenograft material, for covering and treatment of selected intrabony defect site between teeth No. 35 & 36 as mainly mesial to tooth No. 36.

Discussion

It has been established in the previous literature [10,23] that the exclusion of epithelial and gingival connective tissue cells by using GTR barriers is important for periodontal wound healing, in order to achieve regeneration of the attachment apparatus. However, the non-restorable barriers have some disadvantages, such as higher cost, membrane exposure, need of a second intervention for their retrieval, complexity and bacterial accumulation [24,25]. Several restorable barriers are therefore developed to decrease such drawbacks. These are preferable and widely used for guided tissue and/or bone regeneration [26,27].

Collagen membranes are selected frequently as restorable barriers, especially they possess some advantageous properties. These are a low toxicity due to a low immune response, the ability of collagen to reconstitute into the natural tissues and to enhance cell growth and attachment [28,29]. In addition, collagen membranes are absorbed quickly to provide the needed integrity during regenerative process.

Bone grafts are used to treat different types of alveolar bone defects. They have a function to act with osteoconductive or osteoinductive properties. They can maintain a space and play an evident role by preventing membrane from collapse in the bone defect [30,31]. They can also support the flap, facilitate the wound stability process and enhance the regenerative procedure [32]. Equine bone graft showed a favorable clinical and histological outcomes and an effective therapy for periodontal guided tissue and bone regeneration of intrabony defects, especially when combined with equine resorbable membranes [17,18].

Regeneration of aggressive periodontal defects is considered as a real challenge. Some earlier studies [33-36,13] used different graft materials and barrier membranes, either alone or in combination, to achieve periodontal regeneration. However, the treatment outcome showed the combination therapy (GTR membrane + bone graft) as more effective than using GTR membrane or graft alone. Most of these studies showed a combination of GTR membrane with either allograft (DFDBA), xenograft (Bio-Oss), hydroxyapatite, or enamel matrix proteins. However, in recent years, some evidence [17,18] suggested that equine bone graft and equine membrane are also capable of supporting the periodontal regenerative healing capacity. The present study was therefore planned to evaluate and compare the efficacy of using equine bio absorbable barrier, either alone or combined with equine graft, in treating intrabony defects of aggressive periodontitis.

It has been noticed that the clinical measurements have a critical role in evaluating regenerative process since they can provide reliable information regarding probing depth reduction and clinical attachment level gain. The studied groups of the present study showed significant improvement of PPD & CAL parameters when comparing baseline with 18 month post-operative data (Table 1) & (Figure 6), thus signifying the regenerative role of GTR materials. In this context, Garrett in (1996) [37] stated that use of GTR membrane enhanced successfully re-growth of the destroyed periodontium; however, there are some variations in the clinical predictability, degree of efficacy, and even the histological outcomes as postulated by Bartold et al. [38]. In addition, the intergroup comparison showed more probing depth reduction and greater attachment level gain in group 2 (the combined therapy) over group 1 (GTR alone) (Table 1) & (Figure 6), since statistically significant differences were found at 18 months post-operatively. This means that the attachment gain complied with the findings obtained in the previous studies [33-36,12-14]. However, there was a statistically significant difference found within group 1 when comparing gingival recession parameter from baseline up to 18 month denoting some gingival recession increase occurred in this group, whereas no significant difference noticed within group 2. On the other hand, the comparison between the two groups did not notice significant difference for gingival recession (Table 1). In addition, the membrane exposure was occurred in only one defect site per each group, but controlled with a careful post-operative care without complication.

The radiographic analysis is one of the valid methods to demonstrate the effectiveness of regenerative therapies, since it plays a certain role in determining treatment outcome through offering a non-invasive method of evaluating the hard tissue response to therapy. The radiographic analysis of the present study included linear measurements and bone density assessment using gray level. The results showed significant defect resolutions through an evident improvement in defect depth as well as a gain in bone density in both studied groups, when comparing baseline data with results of 18 month. Also, the intergroup comparison showed statistically significant differences favoring the results of the combined therapy (GTR + graft) over using GTR alone (Table 1) & (Figure 6). On the other hand, the changes in alveolar crest height were comparable in both groups. These results are consistent with the obtained findings of some previous reports [34-36,13-16,39].

The significant improvement of the combined therapy in the present study may be explained by the use of bone graft as defect filler. In this context, some studies [14,40] suggested that treatment of periodontal intrabony defects with graft materials lead to significantly greater gain in clinical attachment level and better defect fill, by promoting osteogenesis and allowing rapid and quick formation of new bone. Also, it appears that the graft material has a critical role in preventing collapse of the membrane and/or flap during initial healing periods, thus can potentiate regeneration [32].

Regarding the positive findings obtained in the present study and as a significant point of view, it has been noticed that the ten involved cases were selected carefully with a complete patient desire to treat the affected defects, to strictly follow instructions to maintain oral hygiene and to attend needed follow up visits in due times with almost a complete compliance. The subjects had comparable bilateral intrabony defects. Their ages were below thirty in seven subjects and above thirty in only three patients. Mobility did not has any worsening in their grades throughout the whole study interval. Regarding pocket depth reduction, the number of defects that showed a successful resolution were four in Group 1 (GTR alone) and seven in group 2 (combined therapy), whereas the remaining defects (six in group 1 and three in group 2) still had a severe probing periodontal pocket depths. These remaining defects ranged in their depths from 5 to 8 mm in group 1 but from 5 to 6 mm in group 2. Regarding radiographic defect depth resolution and radiographic density gain, group 2 showed favored significant results, but no defects showed complete fill radiographically.

Conclusion

In final conclusion, although the present split-mouth clinical study had some given constraints, the combined therapy of using graft material (equine bone, Bio-Gen®) with GTR bio absorbable membrane (equine collagen, Biocollagen®) showed enhanced and significant clinical outcomes (PPD & CAL) over using GTR alone. Also, the radiographic assessment that evaluated defect fill (RDD) and bone density (RD) showed significantly greater results of the combined therapy. However, the studied groups showed significant improvement of these parameters when comparing baseline data with results of 18 month postoperatively within each group.

Meanwhile, we are planning to make further future long-term follow up (3 & 5 years) of results of the present study. However, further studies with larger sample size and different evaluation methods such as histological assessment may be recommended.

Acknowledgement

The author would like to thank Mss. Afaf El-Ewaidy for her helpful assistance during the preparation of this manuscript. The author would also like to forward sincere regards & gratefulness for the kind great efforts that is done in the radiographic analysis needed for this research by Dr. Hisashi Watanabe, Associate Professor, Section of Periodontology, Department of Hard Tissue Engineering, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan.

Foot Notes

   *Biocollagen®, the product support bone remodelling phase, Lyophilized Equine bioabsorbable collagen membrane, 25 x 25 x 0.2 mm, Bioteck, Torino, Italy.

        †Bio-Gen®, bone tissue of animal Equine origin “xenograft”, deantigenized for total reabsorption, Bio-Gen Mix, Cortical-Spongy, GR. 0.5 size 0.5 – 1 mm, Bioteck, Torino, Italy.

#Hu-Friedy, Chicago, IL, USA.

$Cavitron, Dentsply, NY, USA.

‡Florida probe, Florida Probe Corporation, Gaineswille, FL, USA.

%Coe-pak, GC America.

@Emago Dental Software, Oral Diagnostics Dental Systems, Amsterdam, The Netherlands.

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