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UNIVERSITATEA DE MEDICINA SI FARMACIE

Gr.T.Popa IASI
FACULTATEA DE MEDICINA DENTARA

REZUMATUL TEZEI DE DOCTORAT

CERCETARI CLINICE SI DE LABORATOR


PRIVIND EFICIENTA UNOR METODE SI
TEHNICI DE STIMULARE PARODONTALA

Coordonator tiinific
Prof. dr. VATAMAN RADU
DOCTORAND
LCTU (PDURARIU) ALEXANDRA

- 2011-

CUPRINS
Partea generala.
INTRODUCERE.....................................................................1
CAP.I.
BOALA
PARODONTALA
ASPECTE
GENERALE ............................................................................2
I.1. Definiie. Clasificarea bolilor parodontale..........................2
I.2. Aspecte microbiologice.......................................................4
I.3.Aspecte privind reaciile inflamatorii locale........................8
I.4. Aspecte privind rspunsul imun local...............................11
I.5. Aspecte privind rolul factorilor genetici........................ ..12
CAP.II. ASPECTE GENERALE PRIVIND TEHNICI SI
MIJLOACE
DE
DIAGNOSTIC
AL
BOLII
PARODONTALE..................................................................15
II.1. Metode de diagnostic convenionale................................15
II.2.Teste n diagnosticul activitii bolii parodontale ............18
II.3.Teste biochimice i imunologice utilizate n diagnosticarea
i monitorizarea evoluiei bolii parodontale ...........................21
CAP.III.
PROCEDURI
TERAPEUTICE
PARODONTALE
CU
ROL
ANTIBACTERIAN,
ANTIINFLAMATOR SI TROFIC.....................................25
III.1. Terapia parodontal clasic non-chirurgical................25
III.2. Ageni medicamentoi cu rol antibacterian i
antiinflamator...........................................................................29
III.3. Laseroterapia...................................................................35
III.4. Ozonoterapia...................................................................37
III.5. Terapia de biostimulare prin infiltraii cu Gerovital.......42
CAP.IV.BIOMARKERI
BIOCHIMICI
SI
IMUNOLOGICI
CU
ROL
IN
MODULAREA
PROCESELOR DE DISTRUCTIE SI REPARATIE LA
NIVEL PARODONTAL.......................................................43

CAP.V. MOTIVAIA STUDIULUI. SCOPURILE STUDIULUI.


OBIECTIVE GENERALE. CULEGEREA SI PRELUCRAREA
DATELOR.......................................................................................52
CAP.VI.
STUDIU
EPIDEMIOLOGIC
PRIVIND
PREVALENA,
DISTRIBUIA
I
SEVERITATEA
AFECIUNILOR PARODONTALE IN CADRUL UNUI LOT
DE PACIENI CU VRSTA 15-65 ANI..................................... 55
VI.1.Introducere................................................................................55
VI.2.Scopul studiului........................................................................55
VI.3.Material i metod....................................................................55
VI.4.Rezultate i discuii...................................................................58
VI.5.Concluzii...................................................................................86
CAP.VII. STUDIU CLINIC SI PARACLINIC PRIVIND
ROLUL ANTIBIOTERAPIEI LOCALE IN POTENTAREA
EFECTELOR ANTIBACTERIENE SI ANTIINFLAMATORII
ALE TERAPIEI PARODONTALE CONVENTIONALE.........87
VII.1.Introducere..............................................................................87
VII.2.Scopul studiului......................................................................87
VII.3.Material i metod..................................................................87
VII.4.Rezultate i discuii................................................................89
VII.5.Concluzii..............................................................................113
CAP.VIII. STUDIU CLINIC SI PARACLINIC PRIVIND
POSIBILITATILE DE STIMULARE A PROCESELOR DE
REPARATIE SI VINDECARE PARODONTALA CU
AJUTORUL LASEROTERAPIEI..............................................115
VIII.1.Introducere...........................................................................115
VIII.2.Scopul studiului....................................................................115
VIII.3.Material i metod................................................................115
VIII.4.Rezultate i discuii..............................................................120
VIII.5.Concluzii..............................................................................144

CAP.IX. STUDIU CLINIC SI PARACLINIC PRIVIND


POSIBILITATILE DE STIMULARE A PROCESELOR DE
REPARATIE SI VINDECARE PARODONTALA CU
AJUTORUL OZONOTERAPIEI...............................................145
IX.1.Introducere............................................................................ 145
IX.2.Scopul studiului......................................................................145
IX.3.Material i metod..................................................................145
IX.4.Rezultate i discuii................................................................148
IX.5.Concluzii................................................................................173
CAP.X. STUDIU CLINIC, BIOCHIMIC SI IMUNOLOGIC
PRIVIND ROLUL INFILTRATIILOR LOCALE CU
GEROVITAL IN TERAPIA PARODONTITELOR CRONICE
MARGINALE...............................................................................171
X.1.Introducere...............................................................................171
X.2.Scopul studiului........................................................................171
X.3.Material i metod....................................................................171
X.4.Rezultate i discuii..................................................................173
X.5.Concluzii..................................................................................292
CONCLUZII FINALE.................................................................193
ORIFINALITATE.CONTRIBUTII PERSONALE.................194
BIBLIOGRAFIE..........................................................................195

INTRODUCERE
In Europa exist puine studii cuprinztoare care s
conduc la date naionale representative asupra prevalenei i
gradului de extindere a bolilor parodontale. Evaluarea
prevalenei i severitii bolilor parodontale este ngreunat de
discuiile nesfarite la nivel global asupra unei definiii comune
i asupra unor sisteme de indici comune care s evite
interpretarea diferit a datelor clinice i epidemiologice i s
permit o evaluare obiectiv a necesitilor de tratament
parodontal (237). Studiile longitudinale constat c la
majoritatea situsurilor i la majoritatea subiecilor rata de
progresie a leziunilor parodontale este foarte redus n
condiiile meninerii unei bune igiene orale . In acest context,
procesele de iniiere i progresie a bolii parodontale sunt
deosebit de complexe, pentru nelegerea acestora fiind
necesare cercetri clinice i paraclinice aprofundate. O atenie
deosebit este generat de apariia unor teste de diagnostic care
pot oferi informaii asupra procesului propriu-zis de distrucie,
starea de activitate de boal, rata de progresie a bolii, tipare de
distrucie, extensia i severitatea distruciei, rspunsul la
tratament. Examenele paraclinice includ metode biochimice i
imunologice care permit determinarea nivelului unor anticorpi,
citokine, colagenaze, care fac parte din rspunsul individual la
infecia parodontal. Rspunsul gazdei n boala parodontal
implic aspecte ale inflamaiei acute i cronice, rspunsuri
imune umorale i celulare. Msurarea nivelelor acestor
mediatori implic recoltarea de eantioane (saliv, fluidul
crevicular, serul sangvin, urina) prin tehnici neinvazive sau
tehnici minim invazive. Utilizarea acestor teste paraclinice
asigur succesul tratamentului prin depistarea afeciunii n
stare incipient. Totui, n prezent metodele curente de
diagnostic se bazeaz nc pe examen clinic i radiologic.

CAP.V.
MOTIVAIA STUDIULUI.
SCOPURILE
STUDIULUI. OBIECTIVE GENERALE. CULEGEREA
SI PRELUCRAREA DATELOR.
V.1. Motivaia studiului
Motivaia alegerii acestui subiect pentru teza de
doctorat a fost determinat de posibilitatea de a aprofunda o
serie de aspecte clinice i paraclinice (teste biochimice,
imunologice) privind eficiena unor terapii parodontale bazate
pe asocierea dintre terapia convenional etiologic i o serie
de proceduri terapeutice alternative (adjuvante). In acest scop
am solicitat i primit suport teoretic i practic n cadrul
Disciplinelor de Parodontologie, Biochimie i Imunologie,
ceea ce a permis realizarea unor studii complexe de ordin clinic
i paraclinic.
V.2.Scopurile, obiectivele si metodologia cercetarii.
In cursul pregtirii doctoratului mi-am propus:
- selectarea datelor din literatura de specialitate privind
aspectele etiopatogenice, clinice, paraclinice ale
diversele categorii de afeciuni parodontale, aspecte
privind markeri biochimici i imunologici, terapii nonchirurgicale convenionale i adjuvante;
- efectuarea unui studiu epidemiologic clinicoradiografic i statistic pe un lot de pacieni personal
privind prevalena diverselor afeciuni parodontale,
severitatea i distribuia i stabilirea unor corelaii
statistice n raport cu factori precum varsta, sexul,
grupul dentar, tipul de afeciune parodontal;
- monitorizarea dinamicii unor parametri clinici,
biochimici i imunologici n cursul unor terapii
parodontale convenionale (detartraj subgingival,
detartraj subgingival asociat cu surfasaj radicular);

determinarea eficienei n iniierea proceselor de


reparare/vindecare parodontal a unor proceduri
terapeutice adjuvante asociate cu terapie nonchirurgical convenional (detartraj subgingival).
- Pentru realizarea scopurilor propuse am stabilit
urmtoarele obiective:
- evaluarea clinico-radiografic a unui lot de pacieni
personal;
- crearea unei baze de date pentru prelucrare statistic;
- determinarea n stadiul pretratment a parametrilor
clinici i paraclinici (MMP8, Il1);
- stabilirea protocolului de tratament pentru fiecare lot
investigat;
- evaluarea rspunsului la tratament pe termen scurt
(30 zile) prin monitorizarea modificrilor parametrilor clinici,
biochimici (MMP8) i imunologici (Il1);
- compararea i interpretarea rezultatelor privind
eficiena terapiei convenionale non-chirurgicale
(detartraj subgingival) asociat cu proceduri terapeutice
cu
rol
antibacterian,
antiinflamator,
trofic
(antibioterapie local, laseroterapie, ozonoterapie,
infiltraii locale cu Gerovital).
Baza de date privind selecionarea i examinarea
cazurilor incluse n studiul epidemiologic clinico-radiografic a
fost realizat ntr-un interval de 2 ani n cabinetul de practic
privat i n cadrul Bazei de Invatamant StomatologicFacultatea Medicin Dentar, UMF Gr.T.Popa Iasi. Baza de
date privind determinarea eficienei unor terapii parodontale cu
rol de stimulare a proceselor de reparaie i regenerare
parodontal a fost realizat n intervalul august-decembrie
2010 n cadrul cabinetului de practic privat. Realizarea
studiilor biochimice i imunologice a fost efectuat n
colaborare cu disciplinele de Biochimie a Facultii de
Medicin Dentar i Laboratorul de Genetic i Imunologie,
-

Facultatea Medicin General, U.M.F.Gr.T.Popa Iasi.


Criteriile de includere a subiecilor n loturile de studiu au fost
urmtoarele:
Parodontit cronic marginal moderat sau sever;
Minim 2 situsuri interproximale cu liza vertical i
profunzime 4-6 mm;
Absena tratamentului parodontal n ultimele 12 luni;
Absena antibioterapiei sistemice n ultimele 6 luni;
Absena afeciunilor sistemice care pot influena
rezultatul terapiei parodontale (afeciuni hepatice,
diabet zaharat, afeciuni imunologice, tulburri de
metabolism fosfo-calcic);
Absena tratamentelor cronice cu orice tip de
medicament care poate influena statusul parodontal
(ex. antagoniti de calciu, fenitoina, ciclosporina,
anticoagulante, medicamente antiinflamatoare nonsteroidale, aspirina).
Criteriile de includere a situsurilor parodontale n
loturile de studiu au fost urmtoarele:
Situsuri active (indici PBI 3-4; GI 2-3);
Profunzime pungi parodontale 4-6 mm.
Pacienii au fost informai de scopul studiului i i-au
dat consimmant scris.
Pentru fiecare pacient a fost ntocmit foaia de observaie
clinic cu specific parodontal, completat cu examene
paraclinice:
- examen radiografic (ortopantomografie);
- msurarea nivelelor concentraiei MMP8 (iniial, final);
- msurarea nivelelor concentraiei IL-1 (iniial, final).
Inregistrarea parametrilor clinici de diagnostic ai bolii
parodontale a fost efectuat pretratament i posttratament de
ctre un singur examinator (doctorandul) i a inclus:
- indicele de sngerare (PBI);
- indicele gingival (GI);

- pierderea de ataament (CAL);


- adncimea pungilor parodontale (PD).
Examenul ortopantomografic a permis completarea
diagnosticului de boala parodontal moderat/sever i
selectarea situsurilor parodontale n raport cu nivelul de
afectare a osului alveolar, tipul de alveoliz, relaia lizei osoase
cu factori locali.
Determinarea modificrilor de concentraie a MMP8
(colagenaza) a fost efectuat cu scopul de a verifica obiectiv
iniierea proceselor de vindecare parodontal posttratament.
Determinarea modificrilor de concentraie a IL-1 a fost
efectuat cu scopul de a evalua obiectiv influena terapiei
parodontale studiate asupra modificrilor dinamicii proceselor
inflamatorii la nivelul suportului parodontal. Examinrile
clinice au inclus msurarea adancimii pungilor parodontale
(PD), pierderea de ataament (CAL). Evalurile au fost
repetate de 3 ori pentru fiecare situs, valoarea final fiind
media celor trei msurtori. Pentru profunzimea pungilor
parodontale (PD) valoarea final a fost rotunjit la intervale de
0,5 mm, fiind introdus n baza de date valoarea cea mai
apropiat. Nivelul de ataament clinic (CAL) a fost calculat ca
suma PD (profunzime pungi parodontale)+ RG (recesiune
gingival).
Fluidul crevicular gingival (GCF) a fost colectat cu
conuri de hartie aplicate pan la o limit maxim de 2-3 mm n
situsul parodontal, pentru un interval de 30 secunde. Anterior
aplicarii s-a procedat la indeprtarea plcii bacteriene
supragingivale. Pentru a evita contaminarea cu saliv sau
sange, s-a realizat izolarea cu comprese si aspirator chirurgical
i nlocuirea conului n cazul contaminrii cu sange. Conurile
de hartie au fost introduse n eprubete Eppendorf, n mediu cu
soluie tampon cu pH 7,4. Eprubetele Ependorf au fost
introduse n congelator (-20 grd. Celsius) pan n momentul
procesrii n laborator, n scopul dozrii IL-1 i MMP8. In

laborator GCF a fost separat din soluie prin metoda dublei


centrifugri.
Dozarea interleukinei 1 n fluidul crevicular s-a
realizat cu kituri comerciale furnizate de firma Diamedix SRL,
prin metoda ELISA (Enzime Linked Immunosorbent Assey).
Nivelul de IL-1 s-a msurat prin compararea concentratiilor
de IL-beta1 din solutiile standard cu solutiile prob, prin
intermediul unor indicatori de culoare. Nivelele de MMP8 au
fost determinate cu ajutorul kitului Quantikinine (Human
MMP-8 Immunoassay,R&D System,USA) care utilizeaz
anticorpi anti-protein MMP-8 i tehnica quantitative
sandwich enzyme immunoassay. Aceast metod const ntr-o
reacie ce are loc n microplci furnizate de kit, tapetate cu
anticorpi antiIL1. n aceste microplci se pipeteaz produsul
patologic de cercetat (lichidul gingival). Peste complexul AgAnticorp format, se adaug un al doilea anticorp marcat n
domeniul Fc cu o enzim (n general peroxidaz). n funcie de
cantitatea de IL existent are loc formarea proporional de
complexe sandwich. Peste aceste complexe se pipeteaz
substratul specific enzimei. Intensitatea culorii va fi direct
proporional cu concentraia IL. Valorile obinute se compar
cu o curb standard realizat n 6 puncte.
Nivelul de MMP-8 a fost msurat prin intermediul
spectrofotometriei, adsorbia luminii depinznd direct de
nivelul de MMP-8. Toate valorile au fost corectate pentru
volumul de diluie i volumul GCF pentru a fi prezentate ca i
concentraii GCF (ng/l).
Modificrile de la stadiul iniial la stadiul final ale
indicilor GI (indice gingival), PBI (indicele de sangerare), PD
(profunzimea pungilor), CAL (nivelul de ataament) au fost
comparate prin teste statistice bazate pe modele lineare cu
matrici structurate de covarian. Valorile medii n GCF ale
mediatorilor studiai (MMP8, IL1) au fost deasemenea
analizate prin modele lineare generale care au comparat stadiul

iniial (pretratament) cu stadiul final (posttratament). Analiza


statistic descriptiv a fost realizat cu ajutorul programului
Microsoft Excel iar analiza statistic analitic a fost realizat
cu ajutorul programului SPSS 16.0 (SPSS, Inc., SUA) cu
aplicaie n statistica medical.
Studiul a fost efectuat pe urmtoarele direcii:
- Studiu epidemiologic clinico-radiografic i statistic;
- Studiu clinic, biochimic i imunologic privind
efectele antiinflamatoare ale terapiei parodontale prin detartraj
US subgingival;
- Studiu clinic, biochimic i imunologic privind
efectele antiinflamatoare ale terapiei parodontale prin detartraj
US asociat cu chiuretaj parodontal n cmp nchis;
- Studiu clinic, biochimic i imunologic privind
efectele antiinflamatoare i regeneratorii ale terapiei
parodontale prin detartraj US asociat cu antibioterapie local
(metronidazol);
- Studiu clinic, biochimic i imunologic privind
efectele antiinflamatoare i de iniiere a proceselor de reparaie
ale terapiei parodontale prin detartraj US asociat cu
laseroterapie;
- Studiu clinic, biochimic i imunologic privind
efectele antiinflamatoare i regeneratorii ale terapiei
parodontale prin detartraj US asociat cu ozonoterapie;
- Studiu clinic, biochimic i imunologic privind
efectele antiinflamatoare i regeneratorii ale terapiei
parodontale prin detartraj US asociat cu infiltraii locale cu
Gerovital.
Parametrii clinici evaluai au fost urmtorii:
-indicele de sngerare (PBI);
-indicele gingival (GI);
-pierderea de ataament (CAL);
-adncimea pungilor parodontale (PD)

10

- Testele biochimice privind modificrile nivelelor de


MMP8 (colagenaza) au fost efectuat cu rolul de a evalua rolul
terapiilor parodontale adjuvante n inhibarea proceselor de liz
colagenic, efectele antiinflamatorii i de stimulare a
proceselor de reparaie;
- Testele imunologice privind modificrile nivelelor de
IL-1 au fost efectuate cu scopul de a evalua rolul terapiilor
parodontale studiate n reducerea proceselor inflamatorii la
nivelul suportului parodontal;
- Compararea i interpretarea rezultatelor privind
eficiena terapiei convenionale non-chirurgicale
(detartraj subgingival) asociat cu proceduri terapeutice
cu
rol
antibacterian,
antiinflamator,
trofic
(antibioterapie local, laseroterapie, ozonoterapie,
infiltraii locale cu Gerovital).
Studiile
privind
iniierea
proceselor
de
reparaie/vindecare dup aplicarea unor terapii parodontale
bazate pe asocierea terapiei non-chirurgicale etiologice cu
terapii alternative cu rol antibacterian, antiinflamator, trofic, au
fost efectuate pe un numr total de 65 subieci, cu varste
cuprinse ntre 25 i 50 ani, mprii n urmtoarele loturi:
- lot martor (5 subieci/10 situsuri parodontale)- subieci
sntoi parodontal (determinarea nivelelor de
mediatori MMP8 i IL1 la situsuri neafectate
parodontal);
- Lotul S (scaling) (10 subieci/ 20 situsuri, parodontit
cronic marginal, parodontit rapid progresiv)detartraj subgingival;
- Lotul SRP (scaling/root planing) (10 subieci/20
situsuri, parodontit cronic marginal, parodontit
rapid progresiv)- detartraj subgingival asociat cu
surfasaj radicular;
- Lotul S/MZ (scaling/metronidasol, parodontit
cronic marginal, parodontit rapid progresiv) (10

11

subieci/ 20 situsuri)- detartraj subgingival asociat cu 4


edine aplicaii locale de gel metronidazol (Metrogyl
Denta);
- Lotul S/L (scaling/laser) (10 subieci/ 20 situsuri,
parodontit cronic marginal, parodontit rapid
progresiv)- detartraj subgingival asociat cu 9 sedine
laseroterapie;
- Lotul S/OZ (scaling/osone) (10 subieci/ 20
situsuri, parodontit cronic marginal, parodontit
rapid progresiv)- detartraj subgingival asociat cu 4
edine ozonoterapie;
- Lotul S/G (scaling/Gerovital) (10 subieci/ 20
situsuri, parodontit cronic marginal, parodontit
rapid progresiv)- detartraj subgingival asociat cu 9
edine de infiltraii aplicaii locale Gerovital H3.
Consimmnt informat. Pentru toi subiecii inclui n
studiu a fost obinut consimmntul informat.
V.3. Culegerea i prelucrarea datelor
n cadrul studiului i pentru finalizarea rezultatelor s-au
utilizat programele:
MS Office (prezentarea datelor sub form de
grafice);
programele SPSS 16 i STATISTICA 6 pentru
prelucrarea statistic a datelor.
n lucrarea de fa am folosit urmtoarele teste de
verificare a ipotezelor statistice: t Test, test KolmogorovSmirnov, test Pearson, test Wilcoxon. Analiza statistic
descriptiv a fost realizat cu ajutorul programului Microsoft
Excel iar analiza statistic analitic a fost realizat cu ajutorul
programulu SPSS (SPSS, Inc., SUA) cu aplicaie n statistica
medical.

12

CAP.VI.
STUDIU
EPIDEMIOLOGIC
PRIVIND
PREVALENA, DISTRIBUIA I SEVERITATEA
AFECIUNILOR PARODONTALE IN CADRUL UNUI
LOT DE PACIENI CU VRSTA 15-65 ANI
VI.1. Introducere.
Epidemiologia reprezint un domeniu central al
sntii orale i trebuie s fie considerat un instrument de
analiz major pentru planificarea programelor i procedurilor
terapeutice precum i pentru evaluarea i controlul eficienei
terapiilor aplicate. In acest context, n Europa exist puine
studii cuprinztoare care s conduc la date naionale
reprezentative asupra prevalenei i gradului de extindere a
bolilor parodontale.
VI.2. Scopul studiului.
Studiul i-a propus s evalueze prevalena i severitatea
bolii parodontale precum i existena unor corelaii ntre aceti
parametri i sexul, grupa de vrst, grupul dentar n cadrul unui
lot de pacieni cu vrste cuprinse ntre 15 i 65 ani.
VI.3. Material si metoda.
Studiul epidemiologic a fost efectuat pe un numr de
143 pacieni de sex masculin (n=58) i sex feminin (n=85), cu
vrste cuprinse ntre 15 i 65 ani (fig.1,2). Pacienii s-au
prezentat n cabinetul de practic privat n perioada martie
2009-decembrie 2010. Pacienii au fost mprii n urmtoarele
grupe de vrst: 15-24 ani (n=46); 25-34 ani (n=38); 35-44 ani
(n=27); 45-54 ani (n=12); 55-64 ani (n=20). Distribuia
leziunilor parodontale a fost urmrit prin corelarea prezenei
acestora cu sexul subiecilor (masculin, feminin), grupa de

13

vrst (15-24; 25-34; 35-44; 45-54; 55-65) i grupul dentar


(molar, premolar, frontal).
Valori privind distribuia lotului de pacieni sunt
prezentate n figurile 1-2..
Fig.1. Distribuia lotului de pacieni (sex)

58
M
F
85

Fig.2. Distribuia lotului de pacieni (grupe de varst)


20
46

12

15-24
25-34
35-44
45-54

27

55-64
38

Fiecare pacient a fost examinat prin anamnez, examen


clinic i examen radiografic.
Prin intermediul examenului clinic au fost nregistrai
urmtorii parametri : pierderea de ataament, profunzimea
pungilor parodontale (<5mm, >5mm), indicii de plac (PI),
indicii gingivali (GI-Silness-Loe), indicii de sangerare, indicii
CPITN.
Au fost examinate ortopantomografiile pacienior pentru a
aprecia gradul de distrucie a osului alveolar. Severitatea bolii
parodontale a fost evaluat prin evaluarea gradului de resorbie

14

a osului alveolar, pe ortopantomografii, utiliznd clasificarea


Rateitschak:
P.uoar (resorbie osoas maxim 1/3 din lungimea
rdcinii);
P.medie (resorbie osoas localizat ntre 1/3 i din
lungimea rdcinii);
P.avansat (resorbie osoas extins la nivelul 1/3
apicale).
Prin intermediul examenului clinic i radiografic a fost
nregistrat statusul parodontal, pacienii fiind clasificai n 4
categorii : 1- status sntos (S); 2- gingivita (G); 3- parodontita
marginala cronic (PMC), 4-parodontita rapid progresiva
(localizat, generalizat) (PRP).
Datele au fost introduse n tabele realizate n Microsoft
Excel i au fost prelucrate statistic prin intermediul
programului STATISTICA SPSS 6.0
VI.4. Rezultate si discutii.
In figurile 3-4 sunt prezentate aspecte radiografice
privind resorbia alveolar n cadrul lotului investigat.
Fig.3. I.O., 51 ani. Parodontita lent progresiv (resorbie
alveolar medie i sever)

Fig.4. C.M., 37 ani. Parodontit rapid progresiv localizat


(resorbie sever 1.3.-1.1.)

15

In graficul urmtor este prezentat statusul parodontal la


nivelul ntregului lot investigat (distribuia procentual a
subiecilor sntoi, cu gingivita, cu parodontite cronice
marginale (PMC), cu parodontite rapid progresive (PRP).
Conform clasificrii AAP (1999) n cadrul lotului investigat
am constatat un procent de 6% subieci sntoi parodontal,
30% subieci cu inflamaie gingival prezent, 59,8% subieci
cu parodontit lent progresiv i un procent de 4,2% subieci
cu parodontit rapid progresiv (fig. 5).
Fig. 5. Status parodontal n lotul investigat

4%

6%
30%

Sanatos
Gingivita
PMC
PRP

60%

Rezultatele privind distribuia indicilor CPITN n lotul


investigat (fig.6) au fost urmtoarele : CPITN 0- 6%, CPITN 18%, CPITN 2- 22%, CPITN 3- 47%, CPITN 4- 17%.
Rezultatele privind gradul de resorbie alveolar n
lotul investigat au fost urmtoarele : resorbie alveolar
absent- 37 %, uoar- 28%, medie- 24%, sever- 11% (fig. 7).
Fig.6. Distribuia indicilor CPITN n lotul investigat
17%

6%

8%

0
1
2
22%

3
4

47%

16

Fig.7. Gradul resorbiei alveolare n lotul investigat


11%
37%

24%

absenta
redusa
medie
severa

28%

In figurile urmtoare (fig.8-9) sunt prezentate corelaii privind


statusul parodontal, indicii CPITN, resorbia alveolar n raport
cu sexul pacienilor. In cazul pacienilor de sex masculin am
constatat urmtoarele rezultate privind statusul parodontal :
status sntos- 5% ; gingivita- 29% ; parodontit cronic- 64%,
PRP-2%. In cazul pacienilor de sex masculin am constatat
urmtoarele rezultate privind indicii CPITN : 0- 5%; 1- 10%;
2- 21%; 3- 43%; 4- 21%. In cazul pacienilor de sex masculin
am constatat urmtoarele rezultate privind resorbia alveolar :
absent- 36%; redus- 26%; medie- 26%; sever- 12%. In
cazul pacienilor de sex feminin am constatat urmtoarele
rezultate privind statusul parodontal : status sntos- 8% ;
gingivita- 31% ; parodontit lent progresiv (cronic)- 54% ;
parodontit rapid progresiv 7%. In cazul pacienilor de sex
feminin am constatat urmtoarele rezultate privind indicii
CPITN : 0- 7%; 1- 7%; 2- 24%; 3- 48%; 4- 14%. In cazul
pacienilor de sex feminin am constatat urmtoarele rezultate
privind resorbia alveolar : absent- 38%; redus- 29%;
medie- 22%; sever- 11%.

17

Fig.8. Distribuia indicilor investigai la pacienii de sex


masculin
Fig.8.a. Status parodontal
2%

5%
29%

Sanatos
Gingivita
PMC
PRP

64%

Fig.8.b. Indici CPITN


CPITN

5%

21%

10%

0
1
2
21%

3
4

43%

Fig.8.c. Gradul resorbiei alveolare


GR A D D E R ES OR B TI E OS OA S A

12%
36%

absenta
R.r edusa
medie

26%

sever a
26%

18

Fig.9. Distribuia indicilor investigai la pacienii de sex


feminin
Fig.9.a. Status parodontal

7%

8%
Sanatos

31%

Gingivita
PMC
PRP

54%

Fig.9.b. Indici CPITN


CPITN

7%

14%

7%
0
1
2
24%

3
4

48%

Fig.9.c. Grad de resorbie osoas


GRAD DE RESORBTIE OSOASA

11%
38%

22%

absenta
R.r edusa
medi e
sever a

29%

19

In figurile 10.a-c.
sunt prezentate rezultatele privind
distribuia resorbiei alveolare pe grupe de dini (grup molar,
grup premolar, grup frontal).
Fig.10.a. Relaia alveoliza-grup dentar molar
M O LA R I

4%
16%
37%

43%

absenta

redusa

medie

severa

Fig.10.b. Relaia alveoliza-grup dentar premolar


PR EM O LA R I

3%

13%

37%

47%

absenta

redusa

medie

severa

Fig.10.c. Relaia alveoliza-grup dentar frontal


F R ON T A LI

9%
17%

38%

36%

absenta

redusa

medie

20

severa

In graficele urmtoare este prezentat distribuia


statusului parodontal n raport cu grupele de varst n cadrul
lotului investigat. Se observ urmtoarele : grupa de varst 1524 ani prezint 13% subieci sntoi parodontal, 83% subieci
cu gingivit, 4% subieci cu parodontit marginal cronic;
grupa de varst 25-34 ani prezint 8% subieci sntoi
parodontal, 16% subieci cu gingivit, 8% subieci cu
parodontit rapid progresiv, 68% subieci cu parodontit
marginal cronic; grupa de varst 35-44 ani prezint 3,7%
subieci cu parodontit rapid progresiv, 96,3% subieci cu
parodontit marginal cronic; grupa de varst 45-65 ani
prezint 100% subieci cu parodontit cronic marginal.
Fig.11.a. Status parodontal- grupa de varst 15-24 ani
0% 4%

13%
Sanatos
Gingivita
PMC
PRP

83%

Fig.11.b. Status parodontal- grupa de varst 25-34 ani

8%

8%
16%
Sanatos
Gingivita
PMC
PRP

68%

21

Fig.11.c. Status parodontal- grupa de varst 35-44 ani

4% 0%
Sanatos
Gingivita
PMC
PRP
96%

In tabelele urmtoare

sunt prezentate o serie de

corelaii ntre statusul parodontal, indicii CPITN i gradul


resorbiei alveolare n raport cu sexul i grupa de varst.
Tabel 1. Status parodontal n raport cu parametrii sex, grupa de
vrst
Sex

Status
(diagnostic)

sanatos
gingivita
PLP
PRP

Masculin
Col %
5.2%
31.0%
63.8%
.0%

Varsta
Feminin
Col %
7.1%
30.6%
55.3%
7.1%

15- 24 ani
Col %
13.0%
82.6%
.0%
4.3%

25-34 ani
Col %
7.9%
15.8%
68.4%
7.9%

35-44 ani
Col %
.0%
.0%
96.3%
3.7%

45-54 ani
Col %
.0%
.0%
100.0%
.0%

55-64 ani
Col %
.0%
.0%
100.0%
.0%

Tabel 2. Corelaii ntre gradul de resorbie alveolar i


parametrii sex i varsta

Grad de
resorbtie
osoasa

absenta
redusa
medie
severa

Sex
Masculin
Feminin
Column N % Column N %
36,2%
37,6%
27,6%
28,2%
24,1%
23,5%
12,1%
10,6%

15- 24 ani
Column N %
95,7%
2,2%
,0%
2,2%

25-34 ani
Column N %
23,7%
55,3%
18,4%
2,6%

22

Varsta
35-44 ani
Column N %
,0%
59,3%
33,3%
7,4%

45-54 ani
Column N %
,0%
8,3%
75,0%
16,7%

55-64 ani
Column N %
,0%
5,0%
45,0%
50,0%

Datele nregistrate n cadrul lotului investigat au fost


prelucrate prin intermediul unor teste statistice (KruskalWallis, Kolmogorov-Smirnov, Pearson) pentru a determina
existena unor diferene semnificative statistic ntre diferitele
categorii de variabile investigate i existena unor corelaii ntre
acestea i unii parametrii caracteristici subiecilor investigai.
Studiul nostru se nscrie n cadrul studiilor
epidemiologice de tip cross-sectional care msoar prevalena,
extinderea i severitatea afeciunilor parodontale. Studiul
prezentat n acest capitol poate fi util pentru a compara
caracteristicile persoanelor de sex masculin/feminin, diverse
grupe de varst, sau pentru a compara nivelul de afectare pe
grupe dentare. Fiind un studiu cross-sectional este considerat
un studiu descriptiv. Repetat la intervale regulate de timp poate
furniza o imagine asupra evoluiei n timp a nivelului de
afectare parodontal sau asupra rezultatelor interveniilor
preventive sau terapeutice.
VI.5. CONCLUZII

Lotul investigat a prezentat procente de 6% subieci


sntoi parodontal, 30% subieci cu inflamaie gingival
prezent, 59,8% subieci cu parodontit lent progresiv i
un procent de 4,2% subieci cu parodontit rapid
progresiv;
Gingivita este asociat semnificativ statistic cu grupa de
varst 15-25 ani;
Parodontita rapid progresiv este asociat cu grupa de
varst 25-35 ani;
Parodontita marginal cronic prezint o prevalen de
96,3%, respectiv 100% la grupele de varst 35-44 ani,
respectiv peste 45 ani;
Prevalena parodontitei marginale cronice pare a fi strns
corelat cu grupa de varst i grupul dentar molar.

23

CAP. VII. STUDIU CLINIC SI PARACLINIC PRIVIND


ROLUL
ANTIBIOTERAPIEI
LOCALE
IN
POTENTAREA EFECTELOR ANTIBACTERIENE SI
ANTIINFLAMATORII
ALE
TERAPIEI
PARODONTALE CONVENTIONALE
VII.1. Introducere.
Dei aplicaiile locale de antibiotice nu pot nlocui
terapia bazat pe detartraj i surfasaj radicular (considerat
standard-gold standard), acestea pot fi utilizate ca tratament
adjuvant n cazul situsurilor cu pungi parodontale adanci sau n
cazurile n care infecia parodontal nu rspunde la terapia
convenional (105).
VII.2. Scopul studiului.
Studiul prezentat n acest capitol are rolul de a
determina posibilitile de accelerare a proceselor de vindecare,
prin potenarea efectelor antibacteriene i antiinflamatorii, prin
utilizarea unui gel cu metronidazol cu eliberare prelungit n
timp (24 ore), ca adjuvant al terapiei parodontale clasice.
VII.3. Material si metod.
Studiul a fost efectuat pe un lot de 30 subieci cu
parodontit cronic marginal moderat sau sever, care s-au
prezentat n cabinetul de practic privat n perioada august
2010- decembrie 2010. Varsta pacienilor a fost cuprins ntre
35 i 50 ani. Subiecii au fost mprii n trei loturi, n raport
cu tipul terapiei parodontale, rezultatele fiind evaluate la un
interval de 30 zile:
Lotul S (scaling)/MZ (metronidazol) (10 subieci/
20 situsuri)- detartraj subgingival asociat cu aplicaii
locale de gel metronidazol (Metrogyl Denta);
Lotul S (scaling) (10 subieci/ 20 situsuri)- detartraj
subgingival;
Lotul SRP (scaling/rootplaning) (10 subieci/20
situsuri)- detartraj subgingival asociat cu surfasaj
radicular.

24

Rolul antibioterapiei locale n accelerarea proceselor de


vindecare parodontal a fost determinat prin evaluarea la un
interval de 30 zile posttratament, a modificrilor parametrilor
clinici (profunzime pungi parodontale, castig de ataament
parodontal, indici GI, indici PBI) i a nivelelor de MMP8 ,
respectiv Il1 n fluidul crevicular gingival (GCF).
Fig.12. Gel METROGYL DENTA

VII.4. Rezultate i discuii


In figurile urmtoare sunt prezentate aspecte clinice
pretratament i posttratament pentru situsuri parodontale tratate
prin detartraj subgingival asociat cu metronidazol (lot S/MZ).
Fig.13.a. I.E., 37 ani, Parodontita cronic marginal. Aspect
radiografic.
Fig.13.b. I.E., 37 ani. Situs parodontal 1.2.(MV).

Fig.13.c. I.E., 37 ani. Situs parodontal 3.2. (MV).

25

In figurile 14-17 sunt prezentate valorile medii iniiale i finale


pentru parametrii clinici investigai. In stadiul iniial (T1)
valorile medii ale parametrilor clinici pentru lotul S/MZ
(detartraj subgingival asociat cu aplicaii locale metronidazol)
au fost urmtoarele: GI- 2,75; PBI- 3,4; PD- 5,075mm, CAL6mm. In stadiul iniial valorile medii ale parametrilor clinici
pentru lotul SRP (detartraj subgingival asociat cu surfasaj
radicular) au fost urmtoarele: GI- 2,8; PBI- 3,45; PD5,175mm, CAL-5,975mm. In stadiul iniial valorile medii ale
parametrilor clinici pentru lotul S (detartraj subgingival) au
fost urmtoarele: GI- 2,6; PBI- 3,25; PD- 4,95mm, CAL5,75mm. In stadiul final (T2) valorile medii ale parametrilor
clinici pentru lotul S/MZ (detartraj subgingival asociat cu
aplicaii locale metronidazol) au fost urmtoarele: GI- 1,1;
PBI- 1,4; PD- 4,725mm, CAL-5,225mm. In stadiul iniial
valorile medii ale parametrilor clinici pentru lotul SRP
(detartraj subgingival asociat cu surfasaj radicular) au fost
urmtoarele: GI- 0,9; PBI- 1,3; PD- 4,65mm, CAL-5,45mm. In
stadiul iniial valorile medii ale parametrilor clinici pentru lotul
S (detartraj subgingival) au fost urmtoarele: GI- 1,6; PBI- 2,1;
PD- 4,8mm, CAL-5,6mm.
Fig.14. Profunzime pungi parodontale (pretratament;
postttratament)
0.6

0.52

0.5
0.35

0.4

SRP
S

0.3

S/MZ
0.15

0.2
0.1
0
SRP

S/MZ

26

Fig.15. Pierderea de ataament (pretratament; posttratament)


6.675

7
5.97

5.75

6.325

5.6

4.65

5
4

Series1

Series2

2
1
0
SRP

S/MZ

Fig.16. Indici PBI (pretratament; posttratament)


3.45

3.4

3.25

3.5
3
2.5

1.9

Series1
1.4

1.3

1.5

Series2

1
0.5
0
SRP

S/MZ

Fig.17. Indici GI (pretratament; posttratament)


3

2.8

2.75

2.6

2.5
2

1.6
Series1

1.5
1.1

Series2

0.9

1
0.5
0
SRP

S/MZ

Modificri ale parametrilor biochimici (MMP8) i


imunologici (Il1)
Lot martor:
MMP8- V.M. 25 ng/l (+/-20)
IL1- V.M. 15 ng/l (+/-15)
In stadiul iniial (T1) valorile medii indicate de testele
paraclinice au fost urmtoarele:

27

- lot S/MZ: MMP8 105,5ng/l; Il1 264,25pg/l ;


- lot SRP: MMP8 107ng/l; Il1 267,25 pg/l;
- lot S:
MMP8 96ng/l; Il1 260,25pg/l
In stadiul final (T2) valorile medii indicate de testele
paraclinice au fost urmtoarele:
- lot S/MZ: MMP8 25,75ng/l; Il1 40,25pg/l ;
- lot SRP: MMP8 20,5ng/l; Il1 32,5pg/l;
- lot S:
MMP8 41,5ng/l; Il1 58,75pg/l
Valori minime, medii, maxime pentru mediatorii MMP8 i
Il1 (pretratament, posttratament) pentru cele 3 loturi studiate
sunt prezentate n tabel 3..
Tabel. 3. Indicatori paraclinici pentru loturile S/MZ, SRP, S
(pretratament, posttratament):
S/MZ
SRP
S
MMP8
105,5ng/l
107ng/l
96ng/l
(T1)
MMP8
25,75ng/l
20,5ng/l
41,5ng/l
(T2)
Il1 (T1)
264,25pg/l
267,25 pg/l 260,25pg/l
Il1 (T2)
40,25pg/l
32,5pg/l
58,75pg/l
Constatm absena proceselor inflamatorii la nivelul
situsurilor parodontale studiate n cazul a 75% din situsuri
pentru lotul S/MZ, comparativ cu 80% pentru lotul SRP,
respectiv 60% pentru lotul S.
Fig.18. Situsuri parodontale inactive (posttratament)
80%
70%
60%
50%
40%

S/MZ
75%

80%

SRP
60%

30%
20%
10%
0%
S/MZ

SRP

28

Analiza statistic demonstreaz existena unor


diferene semnificative statistic privind modificrile
parametrilor clinici (profunzimea pungilor parodontale-PD;
catig de ataament-CAL; indici gingivali-GI; indici de
sangerare papilar- PBI) i paraclinici (MMP8, Il1) de la T1
la T2 (30 zile).
VII.5.CONCLUZII

Aplicaile locale de metronidazol permit mbuntirea


indicilor clinici (GI, PBI, PD, CAL), manifestate prin
reducerea i dispariia sngerrii, normalizarea tabloului
clinic i reducerea pierderilor de ataament parodontal;
Testele
paraclinice
demonstreaz
rolul
metronidazolului asupra reducerii nivelelor de MMP8
i Il1 la nivelul sulcusului gingival (GCF);
Asocierea terapiei parodontale convenionale (detartraj
subgingival) cu antibioterapie local conduce la
creterea efectelor antibacteriene, antiinflamatorii i la
accelerarea proceselor de reparaie tisular;
Rezultatele clinice i paraclinice demonstreaz c
aplicaiile locale de metronidazol nu pot nlocui terapia
convenional bazat pe detartraj i surfasaj radicular
(standardul de aur), dar acestea pot fi utilizate ca
tratament adjuvant al detartrajului subgingival n cazul
situsurilor cu pungi parodontale adanci sau n cazurile
n care infecia parodontal nu rspunde la terapia
convenional.

29

CAP. VIII. STUDIU CLINIC SI PARACLINIC PRIVIND


POSIBILITATILE DE STIMULARE A PROCESELOR
DE REPARATIE SI VINDECARE PARODONTALA CU
AJUTORUL LASEROTERAPIEI
VIII.1. Introducere.
Eficiena terapiei non-chirurgicale convenionale scade
n cazul unor situaii clinice de tipul furcaiilor, concavitilor
radiculare sau invaginaiilor (360). Deasemenea creterea
rezistenei microbiene la antibioterapie reduce eficiena terapiei
convenionale, n condiiile n care terapia convenional este
asociat frecvent cu aplicaii locale de antibiotice
(metronidazol, tetraciclin) sau administrare sistemic (302,
358). In acest context, utilizarea unor terapii alternative, de
tipul terapiei cu laser, este necesar. Raportul prezentat n
cadrul <Sixth European Workshop on Periodontology> (275)
constat c exist o heterogenitate a studiilor privind
laseroterapia n parodontologie, heterogenitate care mpiedic
realizarea unei meta-analize i tragerea unor concluzii
definitive privind utilitatea i protocolul optim de utilizare a
laserelor n terapia parodontal.
VIII.2. Scopul studiului.
Studiul prezentat n acest capitol are rolul de a determina
influena laseroterapiei asupra unor parametri clinici,
biochimici, imunologici cu rol de indicatori ai proceselor de
vindecare parodontal.
VIII.3. Material si metod.
Studiul a fost efectuat pe un lot de 30 subieci cu
parodontit cronic marginal moderat sau sever, care s-au
prezentat n cabinetul de practic privat n perioada august

30

2010- decembrie 2010. Varsta pacienilor a fost cuprins ntre


35 i 50 ani. Subiecii au fost mprii n trei loturi, n raport
cu tipul terapiei parodontale, rezultatele fiind evaluate la un
interval de 30 zile:
Lotul S/L (scaling/laseroterapie) (10 subieci/ 20
situsuri)- detartraj subgingival asociat cu laseroterapie
(laser dioda 650nm); au fost efectuate un numr de 9
edine, 3 sptmanal, timp de 3 sptmani.
Lotul S (scaling) (10 subieci/ 20 situsuri)- detartraj
subgingival;
Lotul SRP (scaling/root planing) (10 subieci/20
situsuri)- detartraj subgingival asociat cu surfasaj
radicular.
Rolul laseroterapei n accelerarea proceselor de vindecare
parodontal a fost determinat prin evaluarea la un interval de
30 zile posttratament, a modificrilor parametrilor clinici
(profunzime pungi parodontale, catig de ataament
parodontal, indici GI, indici PBI) i a nivelelor de MMP8,
respectiv Il1 n fluidul crevicular gingival (GCF).
Fig.19. Laser dioda DMC (880 nm).

VIII.4. Rezultate i discuii.


In figurile urmtoare sunt prezentate aspecte clinice
pretratament i posttratament pentru situsuri parodontale tratate
prin detartraj subgingival asociat cu laseroterapie (lot S/L).

31

Fig.20. B.G., 36 ani., PMC. Situs parodontal 2.4. (MV).


Situs parodontal 4.1.(DV).
Fig.20.a. Parametri laser diod

Fig.20.b. Sedin de laseroterapie situsus parodontal


2.4.(MV)

Fig.20.c. 2.4. (MV). Status parodontal.

32

In figurile 23-26 sunt prezentate valorile medii iniiale


i finale pentru parametrii clinici investigai In stadiul iniial
(T1) valorile medii ale parametrilor clinici pentru lotul S/L
(detartraj subgingival asociat cu laseroterapie) au fost
urmtoarele: GI- 2,7; PBI- 3,35; PD- 5,075mm, CAL-6mm. In
stadiul iniial valorile medii ale parametrilor clinici pentru lotul
SRP (detartraj subgingival asociat cu surfasaj radicular) au fost
urmtoarele: GI- 2,8; PBI- 3,45; PD- 5,175mm, CAL5,975mm. In stadiul iniial valorile medii ale parametrilor
clinici pentru lotul S (detartraj subgingival) au fost urmtorii:
GI- 2,6; PBI- 3,25; PD- 4,95mm, CAL-5,75mm. In stadiul
final (T2) valorile medii ale parametrilor clinici pentru lotul
S/L (detartraj subgingival asociat cu laseroterapie) au fost
urmtoarele: GI- 1,25; PBI- 1,6; PD- 4,675mm, CAL-5,65mm.
Valorile medii ale parametrilor clinici pentru lotul SRP
(detartraj subgingival asociat cu surfasaj radicular) au fost
urmtoarele: GI- 0,9; PBI- 1,3; PD- 4,65mm, CAL-5,45mm.
Valorile medii ale parametrilor clinici pentru lotul S (detartraj
subgingival) au fost urmtoarele: GI- 1,6; PBI- 2,1; PD4,8mm, CAL-5,6mm.
Fig.21. Profunzime pungi parodontale (pretratament;
posttratament)
0.6

0.52

0.5
0.375
0.4

SRP
S

0.3

S/L
0.15

0.2
0.1
0
SRP

S/L

Fig.22. Pierderea de ataament (pretratament; posttratament)

33

5.97

5.75

5.95
5.6

5.575

4.65

5
4

Series1

Series2

2
1
0
SRP

S/L

Fig.23. Indici PBI (pretratament; posttratament)


3.45

3.35

3.25

3.5
3
2.5

1.9

1.6
1.3

1.5

Series1
Series2

1
0.5
0
SRP

S/L

Fig.24. Indici GI (pretratament; posttratament)


3

2.8

2.7

2.6

2.5
2

1.6

1.5

1.25

Series1
Series2

0.9

1
0.5
0
SRP

S/L

Modificri ale parametrilor biochimici (MMP8) i


imunologici (Il1)
Lot martor:
MMP8- V.M. 25 ng/l (+/-20)
IL1- V.M. 15 pg/l (+/-15)
In stadiul iniial (T1) valorile medii indicate de testele
paraclinice au fost urmtoarele:
- lot S/L: MMP8 100,75ng/l; Il1 261,75pg/l ;
- lot SRP: MMP8 107ng/l;
Il1 267,25 pg/l;
- lot S:
MMP8 96ng/l;
Il1 260,25pg/l
In stadiul final (T2) valorile medii indicate de testele
paraclinice au fost urmtoarele:

34

- lot S/L: MMP8 27,5ng/l; Il1 42,5pg/l ;


- lot SRP: MMP8 20,5ng/l; Il1 32,5pg/l;
- lot S:
MMP8 41,5ng/l; Il1 58,75pg/l
Valori minime, medii, maxime pentru mediatorii
MMP8 i Il1 (pretratament, posttratament) pentru cele 3 loturi
studiate sunt prezentate n tabel 4.
Tabel 4. Indicatori paraclinici pentru loturile S/L, SRP, S
(pretratament, posttratament):
S/L
SRP
MMP8 (T1)
100,75ng/l
107ng/l
MMP8 (T2)
27,5ng/l
20,5ng/l
Il1 (T1)
261,75pg/l
267,25 pg/l
Il1 (T2)
42,5pg/l
32,5pg/l
In graficul urmtor sunt prezentate rezultatele privind
modificarea activitii situsurilor parodontale posttratament.
Constatm sau absena proceselor inflamatorii la nivelul
situsurilor parodontale studiate n cazul a 70% din situsuri
pentru lotul S/L, comparativ cu 80% pentru lotul SRP,
respectiv 60% pentru lotul S.
Fig.25.Situsuri parodontale inactive
80%
70%
60%
50%
40%

S/L
80%

SRP

70%
60%

30%

20%
10%
0%
S/L

SRP

Analiza statistic demonstreaz existena unor


diferene semnificative statistic privind modificrile
parametrilor clinici (profunzimea pungilor parodontale-PD;
catig de ataament-CAL; indici gingivali-GI; indici de
sangerare papilar- PBI) i paraclinici (MMP8, Il1) de la T1
la T2 (30 zile).

35

O problem important a studiilor axate pe terapia


parodontal cu laser este data de numrul redus de studii
longitudinale pe perioade de 3-12 luni. O trecere n revist a
278 articole axate pe utilizarea laserului n parodontologie,
realizat de Academia American de Parodontologie, arta c
doar 20 de cercetri erau longitudinale (55). Deasemenea
numrul redus de subieci inclui n studii, varietatea grupelor
de varst i statusul sistemic pot influena rezultatele i
concluziile acestor studii. Datele arat c utilizarea adiional a
terapiei laser conduce la mbuntirea performanelor clinice
pe termen scurt (1-3 luni), dar nu reduce recolonizarea
bacterian pe termen lung (3-6 luni), la interval de 6 luni.
VIII.5. CONCLUZII
Radiaia laser, utilizat ca adjuvant al terapiei
convenionale parodontale de rutin (detartraj
subgingival), permite mbuntirea indicilor clinici
(GI, PBI, PD, CAL), manifestate prin reducerea i
dispariia sngerrii, normalizarea tabloului clinic i
reducerea pierderilor de ataament parodontal;
Testele paraclinice demonstreaz influena benefic a
edinelor de laseroterapie asupra reducerii nivelelor de
MMP8 i Il1 la nivelul sulcusului gingival (GCF);
Asocierea terapiei parodontale convenionale (detartraj
subgingival) cu laseroterapie conduce la creterea
efectelor antiinflamatorii, accelerarea proceselor de
reparaie tisular i creterea troficitii esuturilor
parodontale;
Utilizarea laseroterapiei ca procedur adjuvant a
detartrajului subgingival prezint rezultate clinice i
paraclinice inferioare n raport cu cele obinute prin
terapia
parodontal
de
tip
SRP
(detartraj
subgingival/surfasaj radicular), considerat standard de
aur.

36

CAP.IX. STUDIU CLINIC SI PARACLINIC PRIVIND


POSIBILITATILE DE STIMULARE A PROCESELOR
DE REPARATIE SI VINDECARE PARODONTALA CU
AJUTORUL OZONOTERAPIEI
IX.1. Introducere.
Folosirea agenilor antiinflamatori i/sau antiinfecioi
n tratamentul parodontitei a fost fcut frecvent n mod
empiric. Exist dovezi care arat c adugarea unei terapii
antiinfecioase corecte la tratamentul tradiional poate
mbunti n mod substanial rezultatele clinice i poate reduce
nevoia unor proceduri chirurgicale costisitoare.
IX.2. Scopul studiului.
Studiul prezentat n acest capitol are rolul de a
determina influena ozonoterapiei asupra unor parametri
clinici, biochimici, imunologici cu rol de indicatori ai
proceselor de vindecare parodontal.
IX.3. Material si metod.
Studiul a fost efectuat pe un lot de 30 subieci cu
parodontit cronic marginal moderat sau sever, care s-au
prezentat n cabinetul de practic privat n perioada august
2010- decembrie 2010. Varsta pacienilor a fost cuprins ntre
35 i 50 ani. Subiecii au fost mprii n trei loturi, n raport
cu tipul terapiei parodontale, rezultatele fiind evaluate la un
interval de 30 zile:
Lotul S/OZ (scaling/ozonoterapie) (10 subieci/ 20
situsuri)- detartraj subgingival asociat cu ozonoterapie
(OZONYMED); expunerea la ozon a pungilor
parodontale s-a efectuat n patru edine, 2 edine
/sptman, la interval de 3 zile; timp de expunere 60
secunde;
Lotul S (scaling) (10 subieci/ 20 situsuri)- detartraj
subgingival;

37

Lotul SRP (scaling/root planing) (10 subieci/20


situsuri)- detartraj subgingival asociat cu surfasaj
radicular.
Rolul ozonoterapei n accelerarea proceselor de vindecare
parodontal a fost determinat prin evaluarea la un interval de
30 zile posttratament, a modificrilor parametrilor clinici
(profunzime pungi parodontale, castig de ataament
parodontal, indici GI, indici PBI) i a nivelelor de MMP8,
respectiv Il1 n fluidul crevicular gingival (GCF).
Fig.26. Dispozitivul OZONYMED

IX.4.Rezultate i discuii
In figurile urmtoare sunt prezentate aspecte clinice
pretratament i posttratament pentru situsuri parodontale tratate
prin detartraj subgingival asociat cu ozonoterapie (lot S/OZ).
Fig.27.a. T.R., 50 ani, PMC. Aspect clinic (arcada
maxilar)

38

Fig.27.b-c.
Sedina
1.3.(DV), 2.3.(DV)

ozonoterapie-situsuri

parodontale

In figurile 28-31 sunt prezentate valorile medii iniiale


i finale pentru parametrii clinici investigai. In stadiul iniial
valorile medii ale parametrilor clinici pentru lotul S/OZ
(detartraj subgingival asociat cu ozonoterapie) au fost
urmtoarele: GI- 2,65; PBI- 3,3; PD- 5,075mm, CAL5,875mm. In stadiul iniial valorile medii ale parametrilor
clinici pentru lotul SRP (detartraj subgingival asociat cu
surfasaj radicular) au fost urmtoarele: GI- 2,8; PBI- 3,45; PD5,175mm, CAL-5,975mm. In stadiul iniial valorile medii ale
parametrilor clinici pentru lotul S (detartraj subgingival) au
fost urmtoarele: GI- 2,6; PBI- 3,25; PD- 4,95mm, CAL5,75mm. In stadiul final (T2) valorile medii ale parametrilor
clinici pentru lotul S/OZ au fost urmtoarele: GI- 1,25; PBI1,6; PD- 4,675mm, CAL-5,65mm. Valorile medii ale
parametrilor clinici pentru lotul SRP au fost urmtoarele: GI0,9; PBI- 1,3; PD- 4,65mm, CAL-5,45mm. Valorile medii ale
parametrilor clinici pentru lotul S au fost urmtoarele: GI- 1,6;
PBI- 2,1; PD- 4,8mm, CAL-5,6mm.

39

Fig.28. Profunzime pungi parodontale (pretratament;


posttratament)
0.6

0.52

0.5

0.4

0.4

SRP
S

0.3

S/OZ
0.15

0.2
0.1
0
SRP

S/OZ

Fig.29. Pierderea de ataament (pretratament;


posttratament)
5.97

5.75

5.9

5.6

5.55

4.65

5
4

Series1

Series2

2
1
0
SRP

S/OZ

Fig.30. Indici PBI (pretratament; posttratament)


3.45

3.3

3.25

3.5
3
2.5

1.9

1.65
1.3

1.5

Series1
Series2

1
0.5
0
SRP

S/OZ

Fig.31. Indici GI (pretratament; posttratament)


3

2.8
2.6

2.5
2

1.65

1.6

1.3

1.5

Series1
Series2

0.9

1
0.5
0
SRP

S/OZ

40

Modificri ale parametrilor biochimici (MMP8) i


imunologici (Il1)
Lot martor:
MMP8- V.M. 25 ng/l (+/-20)
IL1- V.M. 15 ng/l (+/-15)
In stadiul iniial (T1) valorile medii indicate de testele
paraclinice au fost urmtoarele:
- lot S/OZ: MMP8 103,5ng/l; Il1 264,5pg/l ;
- lot SRP: MMP8 107ng/l; Il1 267,25 pg/l;
- lot S:
MMP8 96ng/l; Il1 260,25pg/l
In stadiul final (T2) valorile medii indicate de testele
paraclinice au fost urmtoarele:
- lot S/OZ: MMP8 33,0ng/l; Il1 50,5pg/l ;
- lot SRP: MMP8 20,5ng/l; Il1 32,5pg/l;
- lot S:
MMP8 41,5ng/l; Il1 58,75pg/l
Valori minime, medii, maxime pentru mediatorii MMP8 i
Il1 (pretratament, posttratament) pentru cele 3 loturi studiate
sunt prezentate n tabel 5.
Tabel 5. Indicatori paraclinici pentru loturile S/OZ, SRP, S
(pretratament, posttratament):
S/OZ
SRP
S
MMP8
103,5ng/l
107ng/l
96ng/l
(T1)
MMP8
33ng/l
20,5ng/l
41,5ng/l
(T2)
Il1 (T1)
264,5pg/l
267,25 pg/l 260,25pg/l
Il1 (T2)
50,5pg/l
32,5pg/l
58,75pg/l
Constatm sau absena proceselor inflamatorii la
nivelul situsurilor parodontale studiate n cazul a 75% din
situsuri pentru lotul S/OZ, comparativ cu 80% pentru lotul
SRP, respectiv 60% pentru lotul S.

41

Fig. 32. Situsuri parodontale inactive (posttratament)


80%
70%
60%
50%
40%

S/OZ
75%

80%

SRP
60%

30%

20%
10%
0%
S/OZ

SRP

Analiza statistic demonstreaz existena unor


diferene semnificative statistic privind modificrile
parametrilor clinici (profunzimea pungilor parodontale-PD;
catig de ataament-CAL; indici gingivali-GI; indici de
sangerare papilar- PBI) i paraclinici (MMP8, Il1) de la T1
la T2 (30 zile).
IX.5. CONCLUZII
Ozonul, utilizat ca adjuvant al terapiei convenionale
parodontale de rutin (detartraj subgingival) permite
mbuntirea indicilor clinici (GI, PBI, PD, CAL);
Testele paraclinice demonstreaz influena benefic a
edinelor de ozonoterapie asupra reducerii nivelelor de
MMP8 i Il1 la nivelul sulcusului gingival (GCF);
Asocierea terapiei parodontale convenionale (detartraj
subgingival) cu ozonoterapie conduce la creterea
efectelor antiinflamatorii, accelerarea proceselor de
reparaie tisular i creterea troficitii esuturilor
parodontale;
Utilizarea ozonoterapiei ca procedur adjuvant a
detartrajului subgingival prezint rezultate clinice i
paraclinice similare cu cele obinute prin terapia
parodontal de tip SRP (detartraj subgingival/surfasaj
radicular), considerat standard de aur.

42

CAP.
X.
STUDIU
CLINIC,
BIOCHIMIC
SI
IMUNOLOGIC PRIVIND ROLUL INFILTRATIILOR
LOCALE
CU
GEROVITAL
IN
TERAPIA
PARODONTITELOR CRONICE MARGINALE
X.1.Introducere.
Un tratament al parodontopatiei prin mijloace care s
fie eficiente din punct de vedere al costului poate oferi
populaiei, care nu are acces la servicii medicale
ultraspecializate datorit lipsei de resurse financiare, un mijloc
eficient de a menine o dentiie funcional pentru o perioad
lung de timp. Procaina, componenta principal a produsului
Gerovital H3, a fost utilizat pentru prima dat, n terapia
parodontal cu rol de stimulare parodontal, n Germania n
1967 (310). Totui absena unor studii longitudinale nu a
permis impunerea n practica de rutin a infiltraiilor locale cu
produse de stimulare parodontal de tipul procainei sau
Gerovitalului ca o component a terapiei parodontale de
meninere.
X.2.Scopul studiului.
Studiul prezentat n acest capitol are rolul de a evalua
posibilitile de accelerare a proceselor de vindecare
parodontal (efectele antiinflamatorii, trofice, de stimulare
parodontal) n urma asocierii terapiei etiologice convenionale
cu infiltraii cu Gerovital.
X.3.Material si metod.
Studiul a fost efectuat pe un lot de 30 subieci cu
parodontit cronic marginal moderat sau sever, care s-au
prezentat n cabinetul de practic privat n perioada august
2010- decembrie 2010. Varsta pacienilor a fost cuprins ntre
35 i 50 ani. Subiecii au fost mprii n trei loturi, n raport
cu tipul terapiei parodontale, rezultatele fiind evaluate la un
interval de 30 zile:

43

Lotul S (scaling)/G (Gerovital) (10 subieci/ 20


situsuri)- detartraj subgingival asociat cu infiltraii cu
Gerovital (Gerovital H3);
Lotul S (scaling) (10 subieci/ 20 situsuri)- detartraj
subgingival;
Lotul SRP (scaling/root planing) (10 subieci/20
situsuri)- detartraj subgingival asociat cu surfasaj
radicular.
Fig.33.a-b. Gerovital H3

X.4.Rezultate i discuii
In figurile urmtoare sunt prezentate aspecte clinice i
radiografice caracteristice unor situsuri cu boala parodontal
tratate prin detartraj subgingival asociat cu infiltraii cu
Gerovital.

44

Fig.34.a-b. Aspect clinic status T1 (4.6.-DV; 3.6.-MV)

In fig.35-38 sunt prezentate valorile medii iniiale i


finale pentru parametrii clinici investigai. In stadiul iniial
(T1) valorile medii ale parametrilor clinici pentru lotul S/G
(detartraj subgingival asociat cu infiltraii locale cu Gerovital)
au fost urmtoarele: GI- 2,6; PBI- 3,25; PD- 4,975mm, CAL5,775mm. Valorile medii ale parametrilor clinici pentru lotul
SRP (detartraj subgingival asociat cu surfasaj radicular) au fost
urmtoarele: GI- 2,8; PBI- 3,45; PD- 5,175mm, CAL5,975mm. Valorile medii ale parametrilor clinici pentru lotul S
(detartraj subgingival) au fost urmtoarele: GI- 2,6; PBI- 3,25;
PD- 4,95mm, CAL-5,75mm. In stadiul final (T2) valorile
medii ale parametrilor clinici pentru lotul S/G au fost
urmtoarele: GI- 1,4; PBI- 1,75; PD- 4,675mm, CAL5,525mm. Valorile medii ale parametrilor clinici pentru lotul
SRP au fost urmtoarele: GI- 0,9; PBI- 1,3; PD- 4,65mm,
CAL-5,45mm. Valorile medii ale parametrilor clinici pentru
lotul S au fost urmtoarele: GI- 1,6; PBI- 2,1; PD- 4,8mm,
CAL-5,6mm.

45

Fig.35. Profunzime
postttratament)
0.6

pungi

parodontale

(pretratament;

0.52

0.5
0.35

0.4

SRP
S

0.3

S/MZ
0.15

0.2
0.1
0
SRP

S/MZ

Fig.36. Pierderea de ataament (pretratament; posttratament)


5.97

5.75

5.775

5.6

5.575

4.65

5
4

Series1

Series2

2
1
0
SRP

S/G

Fig.37. Indici PBI (pretratament; posttratament)


3.45

3.4

3.25

3.5
3
2.5

1.9

Series1
1.4

1.3

1.5

Series2

1
0.5
0
SRP

S/MZ

Fig.38. Indici GI (pretratament; posttratament)


3

2.8
2.6

2.6

2.5
2

1.6
1.4

1.5

Series1
Series2

0.9

1
0.5
0
SRP

S/G

46

Modificri ale parametrilor biochimici (MMP8) i


imunologici (Il1)
Lot martor:
MMP8- V.M. 25 ng/l (+/-20)
IL1- V.M. 15 pg/l (+/-15)
In stadiul iniial (T1) valorile medii indicate de testele
paraclinice au fost urmtoarele:
- lot S/G: MMP8 102,25ng/l; Il1 259,0pg/l ;
- lot SRP: MMP8 107ng/l;
Il1 267,25 pg/l;
- lot S:
MMP8 96ng/l;
Il1 260,25pg/l
In stadiul final (T2) valorile medii indicate de testele
paraclinice au fost urmtoarele:
- lot S/G: MMP8 36,75ng/l; Il1 52,5pg/l ;
- lot SRP: MMP8 20,5ng/l; Il1 32,5pg/l;
- lot S:
MMP8 41,5ng/l; Il1 58,75pg/l
Valori minime, medii, maxime pentru mediatorii MMP8 i
Il1 (pretratament, posttratament) pentru cele 3 loturi studiate
sunt prezentate n tabel 6.
Tabel 6. Indicatori paraclinici pentru loturile S/G, SRP, S
(pretratament, posttratament):
S/G
SRP
S
MMP8
102,25ng/l
107ng/l
96ng/l
(T1)
MMP8
36,75ng/l
20,5ng/l
41,5ng/l
(T2)
Il1 (T1) 259pg/l
267,25 pg/l 260,25pg/l
Il1 (T2) 52,5pg/l
32,5pg/l
58,75pg/l
Constatm sau absena proceselor inflamatorii la nivelul
situsurilor parodontale studiate n cazul a 65% din situsuri
pentru lotul S/G, comparativ cu 80% pentru lotul SRP,
respectiv 60% pentru lotul S.

47

Fig.39. Situsuri parodontale inactive (posttratament)


90%
80%
70%
60%

S/G

50%
40%

90%

SRP

65%

60%

30%

20%
10%
0%
S/G

SRP

Aplicarea Gerovital H3 n diverse forme clinice de boal


parodontal este oportun ntruct procesele degenerative sunt
prezente i la nivelul esuturilor parodontale (Vataman R.1988)
(352). Efectele benefice se datoreaz stimulrii troficitii
esuturilor
parodontale,
ameliorrii
circulaiei
i
metabolismului local, echilibrrii tonusului neuro-vegetativ
tisular, efecte care conduc la refacerea parial a zonelor
tisulare afectate.
X.5.CONCLUZII
Produsul Gerovital H3, utilizat ca adjuvant al terapiei
convenionale parodontale de rutin (detartraj
subgingival) permite mbuntirea indicilor clinici
(GI, PBI, PD, CAL);
Testele paraclinice demonstreaz influena benefic a
infiltraiilor cu Gerovital asupra reducerii nivelelor de
MMP8 i Il1 la nivelul sulcusului gingival (GCF);
Asocierea terapiei parodontale convenionale (detartraj
subgingival) cu infiltraii cu Gerovital H3 conduce la
accelerarea proceselor de reparaie tisular i la
creterea troficitii esuturilor parodontale;
Utilizarea infiltraiilor cu Gerovital H3 ca procedur
adjuvant a detartrajului subgingival prezint rezultate
clinice i paraclinice inferioare n raport cu standardul
de aur, reprezentat de terapia parodontal de tip SRP
(detartraj subgingival/surfasaj radicular).

48

CONCLUZII FINALE

Procedurile de terapie parodontal adjuvante


(antibioterapia local, laseroterapia, ozonoterapia,
infiltraiile locale cu Gerovital) stimuleaz accelerarea
proceselor de reparaie i vindecare parodontal,
manifestate prin reducerea indicilor clinici de
inflamaie i reducerea nivelelor de mediatori
biochimici (MMP8) i imunologici (Il1) la nivelul
GCF;
Aplicarea unor proceduri adjuvante detartrajului
subgingival poate crete eficiena terapiei parodontale,
efectele clinice fiind vizibile la un interval redus de
timp (30 zile);
Utilizarea antibioterapiei locale (gel metronidazol) ca
procedur adjuvant a detartrajului subgingival prezint
rezultate clinice i paraclinice inferioare n raport cu
standardul de aur, reprezentat de terapia parodontal de
tip SRP (detartraj subgingival/surfasaj radicular).
Utilizarea laseroterapei ca procedur adjuvant a
detartrajului subgingival prezint rezultate clinice i
paraclinice inferioare n raport cu standardul de aur,
reprezentat de terapia parodontal de tip SRP (detartraj
subgingival/surfasaj radicular).
Utilizarea ozonoterapiei ca procedur adjuvant a
detartrajului subgingival prezint rezultate clinice i
paraclinice similare terapiei parodontale de tip SRP
(detartraj subgingival/surfasaj radicular).
Utilizarea infiltraiilor cu Gerovital H3 ca procedur
adjuvant a detartrajului subgingival prezint rezultate
clinice i paraclinice inferioare n raport cu standardul
de aur, reprezentat de terapia parodontal de tip SRP
(detartraj subgingival/surfasaj radicular).

49

ORIGINALITATE. CONTRIBUTII PERSONALE.

Cercetrile prezentate n partea personal s-au


concentrat pe un domeniu major al stomatologiei
parodontologia. Dei parodontologia a prezentat un interes
major pentru cercettori, studiile prezentate n aceast tez de
doctorat se ocup de proceduri terapeutice mai puin
investigate i anume procedurile
adjuvante terapiei
parodontale etiologice clasice.
Studiul epidemiologic se ocup de un domeniu central
al sntii orale i poate fi utilizat ca instrument de analiz
pentru planificarea programelor i procedurilor terapeutice
precum i pentru evaluarea i controlul eficienei terapiilor
aplicate. Originalitatea studiului const n corelarea unor
parametri specifici lotului investigat cu o serie de indici mai
puin utilizai n studiile epidemiologice (indicii Rateitschack).
Testele statistice utilizate n corelarea diverselor variabile aduc
deasemenea o contribuie important la nelegerea
etiopatogeniei i factorilor favorizani n gradul de extindere i
severitate al bolii parodontale.
Studiul prezentat n capitolul doi al prii personale a
urmrit posibilitile de accelerare a proceselor de vindecare,
prin utilizarea unui gel cu metronidazol cu efect antibacterian
prelungit n timp (24 ore). Dei exist numeroase studii axate
pe rolul metronidazolului n terapia etiologic parodontal,
doar cateva studii au urmrit produse comerciale cu eliberare
lent. Contribuia major a acestui studiu este dat de corelarea
rezultatelor clinice cu rezultatele testelor biochimice
(metaloproteinaza 8) i imunologice (interleukina 1).
Studiul care a evaluat influena laseroterapiei asupra
unor parametri clinici, biochimici, imunologici cu rol de
indicatori ai proceselor de vindecare parodontal, se nscrie n
categoria de studii care ncearc s stabileasc o concluzie
final cu privire la oportunitatea utilizrii laserului n terapia

50

etiologic parodontal. Trebuie specificat c majoritatea


acestor studii se axeaz n special pe efectele clinice, puine
studii coreland parametrii clinici cu nivelele de mediatori la
nivel GCF..
Studiul care evalueaz rolul ozonoterapiei n
accelerarea proceselor de vindecare parodontal aduce o
contribuie personal important, n contextul n care exist
extrem de puine studii axate pe infiltraiile cu ozon n pungile
parodontale. In plus nici unul din aceste studii nu evalueaz
influena ozonului prin teste paraclinice care s evalueze
nivelele de enzime (colagenaze) sau interleukine la nivel GCF.
Tocmai de aceea corelarea parametrilor clinici cu nivelele de
MMP8 i Il1 trebuie considerat o contribuie personal
important n recomandarea utilizrii ozonoterapiei pe scar
larg n practica stomatologic.
Studiul axat pe evaluarea rolului antiinflamator, trofic
i de stimulare parodontal al infiltraiilor locale cu Gerovital
H3 poate fi considerat un studiu original, n contextul n care
ipotezele privind rolul procainei n procesele de reparaie
parodontal sunt susinute de efectele acesteia la nivel sistemic,
fr ca literatura de specialitate s prezinte date paraclinice
obinute n urma unor studii longitudinale. Dei efectele la
nivel biochimic i imunologic sunt evaluate pe termen scurt,
rezultatele sunt concludente n ceea ce privete capacitatea
produsului Gerovital H3 de a accelera iniierea proceselor de
vindecare parodontal.
Bazele de date obinute au permis reprezentri grafice
clare i sugestive precum i susinerea rezultatelor prin analize
statistice complexe.

51

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