Effectiveness of flossing loops in the control of the gingival health

J Clin Exp Den . 2017;9(6):e756-61. Flossing loops and o al heal h e756 Jou nal sec ion: Bioma e ials and Bioenginee ing in Den is y Publica ion Types: Resea ch E ec i eness o lossing loops in he con ol o he gingi al heal h F ancisco Azca a e-Velázquez 1, Robe o Ga ido-Se ano 1, Gab iel Cas illo-Dalí 1, Ma ía-Angeles Se e a- Figallo 1, Al onso Gañán-Cal o 2, Daniel To es-Laga es 1 1 Mas e in O al Su ge y. Depa men o Den is y. Facul y o Den is y. Uni e si y o Se ille, Spain 2 Depa men o Ae ospace Enginee ing and Fluid Mechanics. Uni e si y o Se ille, Spain Co espondence: Calle A icena s/n 41009 Se illa, Spain [email p o ec ed] Recei ed: 15/03/2017 Accep ed: 14/04/2017 Abs ac Backg ound: One o he key ac o in he good condi ion o pe iodon al issues is hei daily hygiene. O al hygiene echniques such b ushing and a good in e den al hygiene by co ec lossing a e e y impo an . The aim o his s udy is o compa e he use o den al loss in a loop s adi ional loss in he con ol o Loe-Silness Gingi al In- dex (IG), Tu esky´s Plaque Index (IPT), Gingi al Bleeding Index (IS) and he alues o in e leukin 6 (IL-6) and in e leukin 8 (IL-8). Ma e ial and Me hods: A compa a i e s udy o 40 pa ien s in which each pa ien was his own con ol, using du ing 45 days each one o he de ices (new loop loss and con en ional loss) o in e den al hygiene analysed. Da a o Loe-Silness Gingi al Index (IG), Tu esky´s Plaque Index (IPT), Gingi al Bleeding Index (IS) and he alues o in e leukin 6 (IL-6) and in e leukin 8 (IL-8)we e collec ed and measu ed in e e y isi o e e y ype o in e den al hygiene de ice . Resul s: Ou da a indica es ha he a e o Tu esky´s Plaque Index p esen ed s a is ically signi ican di e ences be ween g oups (loop: 1.66 ± 0.8; adi ional: 1.12 ± 0.8; p <0.0001). The es o he indices s udied showed no s a is ically signi ican di e ences. Conclusions: The c ea ion o new den al loss designs y o make hei use easie and mo e sensi i e, and plaque emo al mo e e ec i e. The loop design can acili a e in e den al hygiene, eaching simila e ec i eness han a- di ional loss, imp o ing some indica o s, such as Tu esky´s Plaque Index. Key wo ds: Den al loss, bac e ial plaque, loop loss, plaque index, pe iodon al diseases. doi:10.4317/jced.53858 h p://dx.doi.o g/10.4317/jced.53858 In oduc ion I is well known ha he p esence o bac e ial plaque is associa ed wi h he de elopmen o gingi al and pe io- don al disease (1). Good oo h b ushing (TB) p ocedu es a e essen ial o achie e adequa e esul s in plaque con- ol and emo al, and he use o den al loss in combina- ion wi h TB has shown some e idences o imp o emen o in e p oximal plaque emo al (2-5), in addi ion o he A icle Numbe : 53858 h p://www.medicinao al.com/odo/indice.h m © Medicina O al S. L. C.I.F. B 96689336 - eISSN: 1989-5488 eMail: [email p o ec ed] Indexed in: Pubmed Pubmed Cen al® (PMC) Scopus DOI® Sys em Azca a e-Velázquez F, Ga ido-Se ano R, Cas illo-Dalí G, Se e a-Figa- llo MA, Gañán-Cal o A, To es-Laga es D. E ec i eness o lossing loops in he con ol o he gingi al heal h. J Clin Exp Den . 2017;9(6):e756-61. h p://www.medicinao al.com/odo/ olumenes/ 9i6/jced 9i6p756.pd J Clin Exp Den . 2017;9(6):e756-61. Flossing loops and o al heal h e757 ob ious help in in e den al deb is emo al. Howe e , cu en esea ches cas doub s on he bene i s o loss on plaque and clinical pa ame e s o gingi i is (6), poin- ing o a undamen al issue: he echnique-sensi i eness o den al loss. In his ega d, some indings poin o a de imen al e ec o he use o some kinds o loss unde ce ain pe iodon al condi ions (7). Cu en gene al public exposu e o in o ma ion on gene- al heal h guidelines allows pa adigm shi s ha , combi- ned wi h sel -ca e measu es, can p oduce e y signi ican posi i e global heal h impac . In he case o pe iodon al sel -ca e (8), pe sonal assessmen o compliance wi h den al lossing owa ds plaque emo al can be c i ical. To his end, nowadays he e is a g ea amoun o che- mical me hods in he ma ke such as plaque e y h osine, malachi e g een, basic uchsin, and o he ood dyes ha a e used o iden i ied he p esence o den al plaque. Too hb ushes could be conside ed one o he main ins- umen s o he emo al o den al plaque. Those can be manual o elec ic. Some o he mos well-known ma- nual b ushing echniques a e he Bass echnique o mo- di ied S illman echnique (9). In e ms o e ec i eness, elec ic oo hb ushes wi h oscilla o y / o a y head ha e a highe le el o scien i ic e idence han manual oo h- b ushes, ega ding o bo h plaque emo al and gingi i is con ol. This no only comes o be e plaque emo al, bu because he elec ic oo hb ush makes b ushing mo e com o able and longe las ing (9). As basic ools o emo ing in e p oximal plaque, den- al loss has gene ally been used in s ing o m, bu also has been ma ke ed in di e en o ms, as a ached o U- shaped suppo s, in o de o acili a e i s use. The e is a wide ange in he ma ke : waxed o unwaxed, s iplike o ound sec ion, igid o so and wi h di e en ac i e ing edien s such as luo ide, chlo hexidine o la o ing subs ances. I s inal aim is o acili a e i s mo emen o e he p oximal su aces and cleaning o he small su ace i egula i ies. A good quali y s ing should s e ch p o- pe ly wi hou aying. The use o in e p oximal b ushes o di e en sizes, s aigh o angled, make he plaque emo al easie (10,11), especially esidues in pos e io sec o s. Also o in e p oximal cleaning a e used in e den al s imula o s o cones (9). O he ins umen s used a e wooden wedges o oo h- picks. These can be made o wood o plas ic al hough i s e ec i eness is much discussed since hei use, in some cases as in heal hy pa ien s, can be mo e ha m ul han bene icial (10). De ices like o al i iga o s use he p essu e o he wa e agains issues and hey a e use ul o emo e ood pa i- cles bu no e ec i e o plaque emo al. They a e only use ul i used oge he wi h oo hb ush and loss. Use can be made o chemicals o con ol plaque, o exam- ple, chlo hexidine (6,11,12). Fo i s gene al accep ance, low p ice, simplici y and o- bus ness, den al loss has been conside ed a majo de i- ce ca ego y o inno a ion and imp o emen . Howe e , as no ed abo e, i s own simplici y, inhe en echnique- sensi i eness and consequen use low compliance lea e li le oom o inno a ion and pose ob ious clinical li- mi a ions. The only oom o ce ain inno a ion in den al loss o make i clinically a ac i e, while keeping he ex eme simplici y and low p ice o he o iginal de ice, would be in he di ec ion o he imp o emen o use compliance. A basic mechanical concep ual app oach in ha di ec- ion would be es ic ing he la ge numbe o deg ees o eedom allowed by he o iginal de ice. In his pape , he mos ob ious, simple, obus , and ye ne e clinically s udied inno a ion in his ega d is conside ed: ying up he ends o a con en ional loss o o m a ci cle o closed loop. Majo ad an ages o eseen o e he o iginal linea loss a e: (i) d as ic imp o emen o use compliance, (ii) easie handling, (iii) lowe aw ma e ial and s ing was e, (i ) d as ic imp o emen o s ing leng h use, ( ) imp o ed s ing hygiene, and ( i) imp o ed plaque e- mo al e icacy and pe iodon al condi ion. Thus, he de ice s udied in his a icle o in e den al cleaning echnique is a den al loss loop (Fig. 1). This loop is aken wi h se e al inge s o make i ense. Den al loss is passed h ough he in e p oximal spaces du ing usage, while i is o a ed o allow he use a clean piece o loss in each in e p oximal space (Fig. 2). In his way, he e iciency o he use o loss ma e ial is maximum. Fig. 1: Looped den al loss. Design. The cu en use o adi ional den al loss demands a ic ion o ce wi h he skin o he inge s o keep i me- chanically esis i e o pe pendicula o ces associa ed o in e p oximal space inse ion. No e ha e en i he use employs a gene ous ex a loss leng h o make some loose loops a ound each inge , ic ion o ce is always p esen as he majo mechanical componen o he esis- i e o ces. Such a esul is highly a iable depending on he na u e o he skin, i s mois u e con en , e c. In con as , he looped den al loss con igu a ion allows a J Clin Exp Den . 2017;9(6):e756-61. Flossing loops and o al heal h e758 Fig. 2: Biomechanics o looped den al loss. ension in excess o he one o adi ional loss wi hou eso ing o ic ion a all: e en i he inge s a e we , ac ing like mechanical pulleys, he wi e is kep unde a ension o ce ha is en i ely imposed by he di ec o ce ha he use pu s h ough his/he hands o a ms. This es ic s e y signi ican ly he a iabili y el by he use and p o ides a comple e con ol on he loop. In addi ion, he loop p o ides he possibili y o using i s en i e leng h in cleaning, only by u ning he used loss p og essi ely, ensu ing a high alue o e ec i eness o he loss. Besides, in e leukin-6 is a mul i unc ional cy okine wi h biological ac i i ies such as B lymphocy e di e en ia- ion, T cells p oli e a ion and s imula ing he sec e ion o immunoglobulins (Ig) by B lymphocy es, s imula ion o p o ein syn hesis in acu e phase and ac i a ion o he complemen cascade (13). Pa icula impo ance is he abili y o IL-6 o induce bone eso p ion, bo h by i sel and in combina ion wi h o he agen s o bone eso p ion (14). These e ec s a e de eloped especially in cases o bac e ial in ec ion and a e he e o e also o c ucial im- po ance in in lamma o y pe iodon al diseases (15). Au- ho s like Mo elli e al. in 2014 concluded ha sali a y le els o IL-1 a and IL-6 could be po en ial indica o s o changes in p obing dep h and gingi al in lamma ion- inducing (16). IL-8 is a po en chemokine wi h unc ion in he e- c ui men and ac i a ion o human g anulocy es and media ion o in lamma o y p ocesses (17). I can be eleased om a ious cells, including monocy es / ma- c ophages, lymphocy es, ib oblas s, endo helial cells, and epi helial cells (17,18). IL-8 plays an impo an ole in he egula ion o neu ophil unc ion (19). Lü ioglu e al. in 2015 linked he inc ease in IL-8 in he p esence o pe iodon al disease, his being highe in ch onic agg es- si e pe iodon i is and gingi i is (20). In ou s udy, he bene i o using looped den al loss was s udied in con olling den al plaque and gingi i is h ough he analysis o a ious clinical indica o s and measu ing he concen a ion o IL-6 and IL 8 in c e i- cula luid. Ma e ial and Me hods Ou clinical s udy was conduc ed a he clinic o he Fa- cul y o Den is y a he Uni e si y o Se ille a e being app o ed by he E hics Commi ee Resea ch a Vi gen del Rocio Teaching Hospi als in Se ille, Spain. Resea ch has been conduc ed in ull acco dance wi h he Wo ld Medical Associa ion Decla a ion o Helsinki. We ha e ob ained w i ed consen om all pa icipan s in ol ed in you s udy (consen p ocedu e was app o ed by he e hics commi ee). The s udy began wi h he s uc u ing o he s udy g oups wi h a o al o 40 andomized pa ien s which should mee he ollowing inclusion c i e ia: pa ien s aged be - ween 18 and 30 yea s wi hou unde lying pa hology as- socia ed (hype ension, diabe es, endoc ine pa hology, among o he s), p esence in he mou h o mo e han 20 ee h (excluding hi d mola s) and absence o in ec ious disease o den al decay. Simila ly, pa ien s should no submi any o he exclusion c i e ia: inju y o inabili y o pe o m b ushing / use o loop, lack o mou h opening (<30 mm), p esence o o hodon ic appliances ixed, p egnancy, smoking o ha ing pe iodon al disease. All pa ien s s udied we e s uden s o he Deg ee in Den- is y a he Uni e si y o Se ille. They we e andomized in a g oup (n = 40) ha began wi h he use o con en- ional loss. This g oup unde wen ou ine scaling and polish a baseline (T0), a 15 (T15) and 45 days (T45) days measu emen s and IL samples aken. A e aking he samples T45 p oceeded o make a new ou ine sca- ling all pa ien s, and began using he me hod o looped den al loss. A 15 days (T60) and 45 (T90) he same ope a ion akes da a (Fig. 3) we e epea ed. Clinical gingi al index, Tu esky´s plaque index, blee- ding on p obing index and he concen a ion o in lam- ma o y ma ke s in e leukin 6 and 8, bo h p esen in he c e icula luid we e eco ded and analyzed. C e icula luid samples we e collec ed om he in- e den al a eas in he lowe la e al inciso s wi h ou wo-cen ime e s long pape poin s p e iously s e ilized. The soaking ime o each pa ien was i e seconds and immedia ely inse ed in o 0.5ml Eppendo mic o ubes wi h 50 μl o saline a 4° C o p ese a ion. T anspo a ion o samples o he biological labo a o y was conduc ed in a co k e ige a o wi h he mal ice shee s, and ozen a -80° C on a i al o lab. Then we p oceeded o analyze he concen a ion o in e leukins (IL-6 and IL-8) de ec ed in each sample by panels bio- plex ma k Luminex, which a e based on binding be ween he di ec immuno luo escence echnique (DIF) and low cy ome y (FCM), h ough magne ized sphe es labeled J Clin Exp Den . 2017;9(6):e756-61. Flossing loops and o al heal h e759 Fig. 3: Ch onology o he esea ch. enzyma ically wi h s ep a idin, (which upon addi ion o i s subs a e subsequen ly gene a es a de ec able and measu able colou ed p oduc ), and ma ked wi h wo speci ic an ibodies (one o each In e leukin o s udy). The labo a o y p o ocol began wi h a desc ip ion o he de ec ion me hod Bio-Plex P o Assay. Reac i e subs an- ces, calib a ion o “Luminex” eade and so wa e we e se up o p oceed wi h he p ocedu e unning he assay (poin s 1-16). A e his p ocedu e, he p o eins desig- na ed we e analyzed o he p pa a ion o he s anda s BioRAD - Bio-Plex Human Cance Bioma ke s Panel 2, 18 plex s anda s cu es. This cu e is used o in e pola e he esul s o he cuan i ia i e measu emen . Thus, he p esence o bo h hese wo in e leukins a e de- ec ed only and speci ically o bo h hei quan i y and hei concen a ion (pg / ml), simul aneously o bo h analy es. The da a we e included in a da a base SPP 15.0 o Win- dows, compa ing da a om bo h es sys ems using he U Mann-Whi ney, wi h a le el o s a is ical signi icance o p <0.05, using he so wa e men ioned abo e. Resul s F om an ini ial sample o 40 indi iduals who me he in- clusion c i e ia only 35 indi iduals comple ed he s udy. These i e indi iduals who we e los du ing he s udy we e disca ded due o wo causes: hey ook an i-in la- mma o y ea men o 90 days ( wo o hem) o missed any o he isi s ( h ee o hem). Among he 35 indi i- duals who comple ed he s udy, he e we e i e men and 30 women. In e e ence o he Gingi al Index (GI), he e is a dec ea- se be ween Visi 2 (0.95 ± 0.3) and isi 3 (0.87 ± 0.4) in con ol g oup as occu s be ween isi 2 g oup (1.00 ± 0.4) and isi 3 (0.98 ± 0.4) in he s udy g oup, he di e- ence is no s a is ically signi ican (p = 0.69) (Table 1). When we analyze Tu esky´s Plaque Index, we ind ha he e is an inc ease in alues be ween isi 2 (1.49 ± 0.8) and isi 3 (1.66 ± 0.8) in he con ol g oup, bu he s udy g oup ound a dec ease be ween isi 2 (1.70 ± 0.7) and isi 3 (1.12 ± 0.8), he di e ence is s a is ically signi i- can (p <0.05) (Table 1). Rega ding o he Gingi al Bleeding Index (ISG), he e is a dec ease be ween Visi 2 (1.09 ± 0.4) and isi 3 (0.88 ± 0.6) in he con ol g oup as occu s be ween isi 2 (1.11 ± 0.6) and isi 3 (1.05 ± 0.5) in he s udy g oup, he di e ence is no s a is ically signi ican (p = 0.089) (Table 1). Resul s o biochemical pa ame e s like In e leukin 6 (IL-6) showed ha he e is a le elling-o be ween di- e en alues be ween isi 2 (0.32 ± 0.9) and Visi 3 (0.46 ± 1.5) in con ol g oup as occu s be ween isi 2 (1.35 ± 2.3) and isi 3 (1.55 ± 5.0) in he s udy g oup, he di e ence is no s a is ically signi ican (p = 0.658) (Table 1). In espec o In e leukin 8 (IL-8), he e is a le elling- o be ween di e en alues be ween isi 2 (139.9 ± 208.25) and Visi 3 (237.89 ± 268.2) in con ol g oup as occu s be ween isi 2 (241.72 ± 177.0) and isi 3 (235.93 ± 225.2) in he s udy g oup, he di e ence is no s a is ically signi ican (p = 0.984) (Table 1). Discussion Th oughou his o y, many me hods ha e been used o he p e en ion and ea men o pe iodon al disease. Ty- pically, den al loss is used as a con ol me hod o in e - den al plaque. I s use equi es a lea ning pe iod which depends on a ious ac o s such as pa ien ’s abili y o pa ien ´s o al heal h mo i a ion. In o de o ob ain he maximum le els in e den al plaque emo al, den al loss should be combined wi h a good b ushing echnique. Tha is why ou s udy combines he use o b ushing wi h den al loss (21,22). Two echniques lossing we e compa ed in his s udy, con en ional loss and looped den al loss, analyzing hei e ec i eness in emo ing plaque. Sys ema ic e iew conduc ed by Chapple e al. in 2015 (23) suppo s he need o con ol den al plaque o main- ain gingi al heal h h ough elec ic oo hb ushes. The use o loss is only ecommended o hose loca ions J Clin Exp Den . 2017;9(6):e756-61. Flossing loops and o al heal h e760 NT adi ional Looped p IG Visi 2 35 0,95 ± 0,3 1,00 ± 0,4 0,195 Visi 3 35 0,87 ± 0,4 0,89 ± 0,4 0,648 Di . Vis. 3 – Vis. 2 35 -0,08 ± 0,5 -0,11 ± 0,6 0,690 TPI Visi 2 35 1,49 ± 0,8 1,70 ± 0,7 0,008 Visi 3 35 1,66 ± 0,8 1,12 ± 0,8 0,0001 Di . Vis. 3 – Vis. 2 35 0,17 ± 1,18 -0,58 ± 1,0 0,0001 GBI Visi 2 35 1,09 ± 0,4 1,11 ± 0,6 0,658 Visi 3 35 0,88 ± 0,6 1,05 ± 0,5 0,006 Di . Vis. 3 – Vis. 2 35 -0,20 ± 0,7 -0,06 ± 0,8 0,089 IL6 (pg/ml) Visi 2 35 0,32 ± 0,9 1,35 ± 2,3 0,02 Visi 3 35 0,46 ± 1,5 1,55 ± 5,0 0,104 Di . Vis. 3 – Vis. 2 35 -0,08 ± 1,2 0,24 ± 5,6 0,658 IL8 (pg/ml) Visi 2 35 208,25 ± 139,9 241,72 ± 177,0 0,267 Visi 3 35 237,89 ± 268,2 235,93 ± 225,2 0,967 Di . Vis. 3 – Vis. 2 35 1,95 ± 211 3,00 ± 285 0,984  Table 1: Resul s o IL6, IL8 Tu esky´s Plaque Index, Gingi al Bleeding Index. whe e you canno use in e den al oo hb ushes wi hou auma. The e o e, acco ding o his au o , he in e poxi- mal oo hb ushes would be he ins umen o choice o main ain gingi al heal h. Salze e al. in 2015 (24) e alua ed he e ec i eness o di e en ins umen s o con ol in e den al plaque h ough a sys ema ic e iew. They concluded ha in e - p oximal b ushes we e he mos e ec i e me hod and mos o he s udies did no demons a e ha he use o loss was e ec i e. All de ices help o con ol gingi i is. Ou s udy e alua es he echnique o using den al loss. Mo e con empo a y s udies such as C onin e al. com- pa ed elec ic in e den al cleaning de ices, losse , oo hpick, and adi ional den al loss wi h wax. They cncluded ha he oo hpick g oup had a highe plaque index compa ed o he o he s (25). These s udies show ha den al loss gene ally educes he p esence o plaque in a sa is ac o y manne wi hou encoun e ing di e ence be ween he di e en ypes. Va ious s udies show ha he addi ion o excipien s such as e asodium py ophospha e podwe , due o i s an i-plaque ac ion, only las s wo hou s a e applica ion (26). In ou s udy we ha e e alua ed he echnique i sel o he emo al o plaque. Te ezhalmy e al. in 2008 compa ed he e ec i eness in emo ing plaque om ou di e en ypes o den al loss in hei mic os uc u e ( h ee con en ional silks: unwaxed, in e wined and esis an o b eakage and loss in s ick) concluding ha he e was no di e ence s a is- ically signi ican be ween hem al hough loss in s ick emo ed mo e plaque (27). I showed ha he e was only s a is ically signi ican di e ence compa ed wi h b ushing alone. In ou s udy he ype o loss ma e ial was no e alua ed, only i s p esen a ion and minimal di- e ences we e ound, hence bo h sys ems ha e a simila e iciency. Shibly e al. in 2001 compa ed di e en p esen a ions o den al loss. In his case hey we e compa ed con en- ional loss o “au oma ic powe losse ”. No di e ences be ween he gingi al index and plaque index we e ound (28). Ciancio e al. compa ed wo ypes o den al loss (waxed and expanded poly e a luo oe hylene) concluding ha lossing gene ally imp o es plaque emo al, i does no ma e i s p esen a ion (29). Mizu ani e al. e alua ed he o al heal h acco ding bleeding, a ques ionnai e o al hygiene habi s and sel - e icacy scale hygiene. They concluded ha he e was co ela ion be ween good hygiene, e ec i eness and co- llege s uden s (30). Indi iduals used in ou s udy may be hype mo i a ed in hei o al hygiene habi s. Some s udies show ha he e is an inc ease in he con- cen a ion o IL-6 when we a e aced wi h an episode o ch onic (31) pe iodon i is o agg essi e. In ou s udy we do no ha e any o hese case and o hem he alues o IL-6 we e s able du ing he s udy. Mo elli e al. in 2014 J Clin Exp Den . 2017;9(6):e756-61. Flossing loops and o al heal h e761 concluded ha sali a y le els o IL-1 and IL-6 could be po en ial indica o s o changes in p obing dep h when gingi al in lamma ion (16) is induced. Compa ed wi h ou s udy, we ound no inc ease in p obing dep h o le- els o IL-6. O he s udies show ha only he alues o p os aglandin E2 and mac ophage in lamma o y p o ein (MIP) -1a a e he only ones ha inc eases and allow us o disce n be ween heal h and gingi i is (32). Some s udies show signi ican changes in alues in c e- icula luid when pe iodon al disease is in an ad an- ced s age and / o agg essi e (20) and e en in cases o pe i-implan pa hology as pe implan i is (33), showing a posi i e co ela ion be ween p obing dep h and he p esence o IL-8 (34). In conclusion, he esul s o ou s udy indica e ha he use o looped den al loss is use ul in emo ing den al plaque and gingi i is con ol. While mos clinical indica o s and IL6 and IL8 we e le elled o be ween he wo g oups, a signi ican imp o emen in he a e o Tu esky´s Plaque Index in he looped den al loss g oup was iden i ied. Re e ences 1. B own LJ, Löe H. P e alence, ex en , se e i y and p og ession o pe iodon al disease. Pe iodon ol 2000. 1993;2:57-71. 2. Biesb ock A, Co by PM a, Ba izek R, Co by AL, Coelho M, Cos a S, e al. Assessmen o ea men esponses o den al lossing in wins. J Pe iodon ol. 2006;77:1386-91. 3. Kige RD, Nylund K, Felle RP. 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Synde gaa d B, Al-Sabbagh M, K yscio RJ, Xi J, Ding X, Ebe sole JL, e al. Sali a y bioma ke s associa ed wi h gingi i is and esponse o he apy. J Pe iodon ol. 2014;85:e295-303. 33. Schminke B, om O de F, G ube R, Schliephake H, Bu ge s R, Miosge N. The Pa hology o Bone Tissue du ing Pe i-Implan i is. J Den Res. 2014;94:354-61. 34. Recke EN, A ila-O iz G, Fische CL, Pagan-Ri e a K, B ogden KA, Dawson D V, e al. A c oss-sec ional assessmen o bioma ke le els a ound implan s e sus na u al ee h in pe iodon al main enance pa ien s. J Pe iodon ol. 2015;86:264-72. Acknowledgemen s None. Con lic o In e es None.