Root Surface Demineralization in Periodontal Therapy:
Subject Review*
Scott H. Nightingale and Phillip J. Sheridan
Accepted for publication 2 June 1982
The literature of root surface demineralization in periodontal therapy is reviewed. Root
surface alterations in periodontal disease and root surface preparation are also discussed.
ROOT SURFACE ALTERATIONS IN PERIODONTAL
DISEASE
Selvig,1 in an ultrastructural study, observed changes
in the mineralization patterns and surface appearance of
cementum that corresponded to the degree of breakdown
of periodontal connective tissue attachment associated
with periodontal disease. Cementum, in areas where
disease activity had resulted in complete breakdown of
the connective tissue attachment and in areas where it
was lined by epithelium, was characterized ultrastruc-
turally by a reduction in the number and size of mineral
crystals, by loss of typical collagen structure, and by a
very irregular surface outline. These alterations extended
40 to 100 µ from the cementum border but did not
reach the cemento-dentinal junction.
Selvig and Zander2 found higher contents of calcium,
magnesium and phosphorus in the cervical cementum of
periodontally diseased roots than in corresponding areas
of healthy teeth. They also demonstrated the presence of
a highly mineralized zone in the superficial layer of the
root surface in periodontally diseased teeth. They related
these changes to penetration of minerals from the surface
while the tooth root was exposed to either the environ-
ment of the periodontal pocket or the oral cavity. Later
studies confirmed these findings and also identified high
levels of fluoride in the hypermineralized zone.3
Organic changes also take place in root surfaces ex-
posed to the periodontal pocket. In 1951, Bass4 described
refractile "pathologic granules" in exposed cementum
and underlying dentin. These granules were studied
further by Armitage and Christie,5 who observed them
in areas of incompletely mineralized collagen fibrils.
Bigarre and Yardin6 later determined that the granules
contained cholesterol or steroid. Although their signifi-
cance is not well understood, the granules may represent
foci of degradation of collagen. On the other hand, the
*
From the Department of Dentistry, Section of Periodontics,
Clinic and Mayo Foundation, Rochester, MN 55905.
granules may represent bacteria,4'7 or they may result
from penetration of exogenous bacterial or salivary sub-
stances.6
In 1971, Hatfield and Baumhammers8 exposed mono-
layers of gingival epithelial cells in tissue culture to
healthy and periodontally diseased roots of extracted
teeth. The monolayers exposed to the involved roots
showed irreversible morphologic changes, while those
exposed to healthy roots did not. They hypothesized that
toxic factors or endotoxins released by oral microorga-
nisms in the periodontal pocket had penetrated the root
surfaces to later leach out and produce cytotoxic effects.
The plaque flora in Periodontitis is predominantly
Gram-negative, and most Gram-negative bacteria con-
tain a complex lipopolysaccharide (endotoxin) in their
walls.9
Aleo et al.9 found endotoxin present in cementum of
untreated periodontally involved teeth. They too used
human gingival fibroblasts to study the in vitro attach-
ment of cells to the root surfaces of such teeth. They
found that root portions exposed to the disease process
had minimal cell attachment, while uninvolved root
areas had cell attachment that was normal.10
Everhart and Stahl11 found antigen in the cementum
of periodontally involved teeth which was not present in
the cementum of impacted teeth. They later extracted
this antigenic component from cementum. Using coun-
tercurrent immunoelectrophoresis to show the antibody-
antigen reaction, they demonstrated that a component
from pocket-exposed cementum will react with homol-
ogous serum and with heterologous sera from persons
with periodontal disease.12'13
Whether endotoxin is adsorbed to or trapped within
the irregularities in the exposed root surface has not been
established. However, by acting as a reservoir, the dis-
eased root surface may perpetuate the destructive effects
of endotoxin on the periodontium.
ROOT SURFACE PREPARATION
Mayo
Preparation of the root surface in periodontal therapy
611

612 Nightingale, Sheridan
usually includes scaling to remove plaque and calcified
deposits and root-planing to remove surface layers which
have been altered by disease. Jones and O'Leary14 found
that in vitro root-planing removes nearly all detectable
bacterial endotoxin from periodontally involved root
surfaces. This type of root preparation is a prerequisite
for new attachment and periodontal health.
DEMORALIZATION OF DENTIN
Recent evidence suggests that regeneration of the con-
nective tissue attachment to the root can be significantly
enhanced by demineralization of the exposed dentin.
This information has important implications regarding
new attachment procedures, since an early and durable
attachment of gingival connective tissue to tooth during
healing could significantly reduce apical epithelial mi-
gration along the root surface and under the healing flap;
such migration can impede regeneration of bone, cemen-
tum and periodontal ligament.15 Furthermore, the loss of
such tissues would deprive the periodontium of a pre-
dominantly connective tissue attachment which might
be better able to resist further pathologic change than
would a long junctional epithelium.
USE OF ACIDS
The use of acids in the treatment of Periodontitis dates
to the last century. In 1899, Stewart16 described an
operation that included elevation of the gingiva from the
teeth, scraping of tooth root surfaces to remove cemen-
tum, and application of "pure sulfuric or hydrochloric
acid to decalcify the surface." He reported consider-
...
able success.
Research in bone induction has suggested a new ra-
tionale for the demineralization of dentin as an adjunct
to regenerative periodontal technique.17"23 A number of
investigators have demonstrated reproducible Osteogen-
esis within and about dentin fragments demineralized by
acid in vitro and implanted into the muscle, oral or
subcutaneous tissue of both animal18'20,22 and human.17
These authors observed differentiation into osteoblasts
of the mesenchymal cells adjacent to the implants and
observed evidence of Osteogenesis as early as 10 days
after implantation. Lamellar bone and bone marrow
formation were subsequently observed. The bone-induc-
tive effect of demineralized dentin was lost if the dentin
was exposed to chemical solvents that denature or de-
range the fibrous protein matrix.18 In addition, the in-
duction of bone appeared to be more active on the
surface areas of the substrates that had been in direct
contact with the acid.17'19 These findings suggested to
investigators that demineralizing the dentinal wall of a
periodontal pocket may induce the formation of new
bone and cementum, resulting in repair of the osseous
defect.
Register,24 in a pilot study of 21 teeth in monkeys,
dogs and a cat, determined that dentin wounds demin-
J. Periodontol.
October, 1982
eralized in situ by contact with acid before flap closure
showed better histologie attachment of the healing flaps
and more new cementum and bone formation 6 weeks
to 3 months after the procedure than did contralateral
controls. Ten per cent of the demineralized teeth showed
prolonged résorption of dentin during healing, with no
pulpal reactions noted. In a subsequent histologie study
of more than 1,000 teeth in 50 dogs and 5 cats, Register
and Burdick25 duplicated these results. Additionally, they
determined the optimal demineralization that produced
histologie attachment of flaps with new cementum, using
HCl at various pH and application times. They then
duplicated the degree of demineralization, using lactic,
citric, phosphoric, trichloroacetic and formic acids and
RDO (a proprietary demineralizer) in various combina-
tions of pH and application times. In all, 250 different
combinations were studied. At comparable deminerali-
zation rates, all acids produced identical results. Roots
that were "underdemineralized" exhibited a detachment
artifact on processing. "Overdemineralized" roots dem-
onstrated attachment with no detachment artifact on
processing but without cementogenesis. Optimal demin-
eralization produced new attachment with cemento-
genesis and no detachment on processing. Undeminer-
alized controls showed only partial attachment, with
epithelium frequently migrating under the flap through
the entire length of the wound. The attachment that
occurred consistently separated on processing. This re-
search utilized experimentally induced defects in dogs
and cats, and the results are not necessarily applicable to
chronic, naturally occurring defects in humans. Never-
theless, it was concluded that citric acid, pH 1, applied
for 2 to 3 minutes was the most desirable combination to
produce optimal demineralization for new attachment in
human trials.
USE OF CITRIC ACID
Advantages of the use of citric acid, pH 1, for 2 to 3
minutes include: less résorption of dentin before cemen-
togenesis, less coagulation of tissue and blood than with
other agents, and ease of clinical use. No pronounced
root résorption or pulpal response was noted with any of
the agents tested. Slight contact of the acid with the
surrounding periodontal tissues slowed bone repair
somewhat, but had no effect on new attachment. Other
advantages of citric acid for use in humans include the
facts that citrates are used as anticoagulants in transfused
blood and that citric acid is essential to human metabo-
lism and is found in many foods. These facts make it an
unlikely allergen.26 Endogenous citric acid from the met-
abolic citric acid cycle has been associated with solubil-
ization of bone mineral during bone résorption.27'28
Citric acid may act on dentinal hydroxyapatite in three
ways. First, it releases hydrogen ions, which demineralize
the crystalline structure. Second, it contains two or more
groups in its molecule which can combine with calcium
Volume 53
Number 10
and act as a chelating agent. Third, it can participate in
surface exchange, with citrate ions replacing phosphate
ions in the hydroxyapatite structure.28,29
SIMULATED PERIODONTAL DEFECTS IN
ANIMALS
In a later study of simulated periodontal defects in
dogs, Register and Burdick30 reviewed histologie sections
of controls and of defects treated with citric acid at 1,2,
3, 4, 5, and 6 weeks, 6 months, and 1 year after surgical
treatment of the defects. The results were substantially
similar to those reported previously.24'25 The authors
described seeing under the light microscope "cementum
pins" that extended into dentinal tubules widened by
demineralization. They hypothesized that this enhanced
mechanical fixation, together with the bone-inductive
effect of demineralized dentin on adjacent mesenchymal
cells, represented the mechanism for the accelerated
reattachment observed in experimental animals. They
proposed that this response be categorized as "a cellular
phenomenon with mechanical assistance."30 Others have
suggested that irregularities in the dentin surface may
aid in the attachment of new connective tissue.31'32 Scan-
ning electron microscopic studies have demonstrated that
dentin treated with 50% citric acid becomes considerably
roughened owing to preferential demineralization of the
peritubular dentin.33
Crigger et al.34 studied the effect of saturated citric
acid (pH 1) applied topically for 3 minutes in the treat-
ment of experimental furcation defects in dogs. Thirteen
of 23 acid-treated furcations showed complete formation
of new attachment, while all of the contralateral control
teeth showed epithelium-lined defects on histologie eval-
uation 6 weeks post-treatment. The authors suggested
cautious interpretation of their results because of the
artificial nature and lack of chronicity in the experimen-
tal defects and because the anatomy of the canine pre-
molar teeth studied provided unusually favorable con-
ditions for tight flap adaptation and protection of the
surgical site. Simulated periodontal pockets and the ca-
nine healing response do not adequately represent the
chronic destructive periodontal lesions seen in humans.
Dogs have more dentinal tubules than adult humans,
especially in the cervical area of the root.35 If the mech-
anism of enhanced new attachment, due to deminerali-
zation, involves mechanical fixation of "cementum pins"
into dentinal tubules, then a better response would be
expected in dogs. In spite of these drawbacks, however,
dogs and other experimental animals have provided a
convenient model for histologie studies of new attach-
ment. Nyman et al.36 created periodontal defects in
monkeys. They applied saturated citric acid to planed
root surfaces for 3 minutes during flap surgery. They
observed no new connective tissue attachment in either
the demineralized teeth or the undemineralized controls.
Nilvéus et al.37 created furcation defects in the man-
Root Surface Demineralization 613
dibular premolars of six Beagle dogs. The defects were
treated using citric acid and flap surgery. Six weeks after
the initial surgical procedure, one side of each dog was
re-treated in exactly the same manner. Histologie eval-
uation showed closure of the furcations and new connec-
tive tissue attachment, including deposition of new ce-
mentum in 77% of the treated teeth. The authors con-
cluded that the repeated surgical curettage and acid
application did not improve the overall results. Nilvéus
and Egelberg38 created through-and-through furcation
pockets in the mandibular premolars of Beagle dogs.
They applied citric acid to instrumented root surfaces
during flap surgery and assessed three adjunctive thera-
peutic measures: (1) the effect of systemic antibiotics, (2)
the use of Gelfoam® within the defects, and (3) coronal
repositioning of the mucoperiosteal flaps. They observed
regeneration and new attachment histologically, regard-
less of the use of antibiotics or Gelfoam or flap position.
EXAMINATION OF EXTRACTED TEETH
Garrett et al.39 studied the effect of topically applied
citric acid on periodontally diseased human tooth roots,
using scanning and transmission electron microscopy.
Sixteen extracted teeth were studied. Teeth were treated
with saturated citric acid (pH 1) for 3 minutes. Results
indicated that the acid had no effect on surfaces that had
not been root-planed. After application of the acid to
root-planed surfaces, however, a 4 µ wide zone of
demineralization, not seen in control teeth, was observed.
This zone was characterized by exposed collagen fibrils,
identified by their banding pattern, that were continuous
between the mineralized and the demineralized zones of
the root. The authors speculated that the ineffectiveness
of the acid on the unplaned root surfaces was due to the
hypermineralization of the root surface previously re-
ported in Periodontitis.2
These authors39 proposed some new theories regarding
the mechanism of enhanced new attachment using citric
acid. They cited evidence that cementogenesis is en-
hanced by prior surface résorption or demineraliza-
tion31' 32,40-44 and suggested that acid demineralization of
the root surface during therapy might aid new attach-
ment by reducing or eliminating the need for cell-medi-
ated root résorption, which normally precedes cemento-
genesis. They also believed that the exposed dentinal
collagen fibers observed on root-planed demineralized
roots could provide a nidus for direct splicing with new
collagen fibrils of the healing flap. This direct collage-
nous type of attachment could occur much sooner after
surgery than new attachment mediated by new cemen-
tum. Seven days after surgery, new connective tissue
formation is well under way, while cementum formation
requires several weeks and is not predictable.45 This
initial attachment of connective tissue could prevent the
establishment of a long junctional epithelium, thereby

614 Nightingale, Sheridan
improving the chance for regeneration of cementum,
periodontal ligament and alveolar bone. There is consid-
erable evidence to support the concept of predictable
new attachment between collagen fibers retained on the
tooth and the detached fibers of a periodontal flap.46"49
Boyko et al.,50 in an electron microscopic study of
porcine molars demineralized by citric acid, confirmed
the presence of formerly mineralized dentinal collagen
fibers on the root surface. They also performed studies
of cell attachment using fibroblast-like cells of the peri-
odontal ligament of the monkey. They found that more
cells attached to demineralized roots than to undeminer-
alized roots, in vitro. These authors hypothesized that the
relatively greater attractiveness of demineralized roots to
cultured cells may have been due to the exposed collagen
on the root surface, since many cultured cell lines grow
well on collagen substrate.51 They suggested that the
attractiveness of the collagen substrate covering the de-
mineralized root surfaces could represent the true mech-
anism of enhanced new attachment.
SURGERY AND CITRIC ACID
Ririe et al.52'53 studied healing of periodontal connec-
tive tissue after surgical wounding and application of
citric acid in dogs. Root surfaces were exposed surgically,
root-planed and etched with citric acid, pH 1, for 3 faces were treated with citric acid, pH 1, for 2 minutes
minutes. Control teeth were not etched. Flaps were
repositioned at their original level. Block sections were
obtained at 7, 14, 21, and 42 days and examined with
light and electron microscopy. Compared with the con-
trols, the demineralized sites in the same animals showed
enhanced connective tissue healing with rapid and con-
sistent establishment of connective tissue attachment
devoid of initial embedding of collagen fibers in newly
formed cementum. These authors confirmed the findings
of Garrett et al.39 of a 3- to 5-µ wide zone of deminer-
alization and observed interdigitation of new and previ-
ously mineralized collagen fibrils as early as 7 days after
surgery. The authors likened this mode of connective
tissue attachment to dentin to the interdigitation of con-
nective tissue fibers that occurs in the healing of a soft-
tissue incisional wound. They also observed microscopic
widening of the dentinal tubules in the demineralized
specimens, with collagen fibrils projecting into the tu-
bules. No significant effects on the dental pulp or the
adjacent soft tissues were encountered. Noteworthy, the
undemineralized controls also healed, but not as rapidly
or with the same sequence of events as did the acid-
treated sites.
HUMAN STUDIES
of newly formed flap collagen with
Interdigitation
previously mineralized dentinal collagen has not been
demonstrated in human material. In addition, reports of
adequately controlled, statistically valid studies of in situ
demineralization used in treatment of human periodon-
J. Periodontol.
October, 1982
tal defects are rare or lacking. In 1975, Register54 pub-
lished an abstract of a project claiming an average of 7
mm of reattachment with bone repair 4 months after
flap surgery with adjunctive citric acid treatment in
human periodontal defects. A complete published report
of this work has not yet followed.
There are several reports of human case histories.
Register26 reported three successfully treated cases of
deep periodontal defects associated with nonvital, en-
dodontically treated teeth using citric acid, pH 1, applied
for 2 to 3 minutes, both in conjunction with flap surgery
and introduced directly into the periodontal pocket in
conjunction with soft-tissue curettage. Passanezi et al.55
reported two cases of successful new attachment, in
which dentin had been etched in situ using 37% phos-
phoric acid with laterally sliding flap procedures in
humans. Shiloah56 reported two cases of successful new
attachment after laterally sliding flap procedures and
demineralization of root-planed dentin with citric acid,
pH 1, for 3 minutes. Otomo and Sims,57 in a controlled
study of coronally repositioned flaps to cover denuded
roots, found that mean postoperative attachment levels
remained constant with preoperative levels in controls
and in groups in which demineralization was achieved
by citric acid. Liu and Solt,58 however, found a significant
gain in attachment when root-planed, denuded root sur-
before coronal repositioning of a flap subsequent to a
free gingival graft.
Two studies have considered block sections of human
teeth and periodontium after flap surgery and root-sur-
face demineralization with citric acid. Stahl and Froum09
studied seven periodontally involved anterior and pos-
terior teeth in two patients. After initial procedures that
included root-planing and curettage, flap surgery was
accomplished with further root-planing and application
of citric acid, pH 1, for 2 minutes. The control was
treated with saline. Sixteen weeks after surgery, block
sections were removed and examined under the light
microscope. Neither accelerated cementogenesis nor new
or accelerated attachment of collagen fibers to the for-
merly exposed areas of the root surfaces was observed.
The authors noted that the exposure to citric acid had
no apparent effect on supra-alveolar collagen fibers,
which were left intact on the root surfaces. They also
noted that complete removal of cementum from the root
surfaces was difficult and was not always accomplished.
More extensive clinical trials were suggested to determine
the usefulness of root demineralization in periodontal
therapy.
Cole et al.60 conducted a similar study of ten surfaces
of nine incisor teeth in six patients with chronic Peri-
odontitis. The experimental teeth were not scaled or
root-planed prior to the study. Full-thickness mucoper-
iosteal flaps were elevated. A notch was cut in the root
surface through the most apically positioned existing
calculus deposit. The teeth were root-planed in an at-
Volume 53
Number 10
tempt to remove all cementum, and saturated citric acid
was applied for 5 minutes. The flaps were replaced,
sutured and allowed to heal. The patients received tet-
racycline, 250 mg, four times a day for 7 days. They were
seen at least once a week in professional hygiene main-
tenance for 4 months after surgery, at which time block
sections of tooth and periodontium were removed. Light
microscopy revealed regeneration of soft tissue ranging
from 1.2 to 2.6 mm coronal to the apical border of the
notch. Cementogenesis was observed within the notch in
all ten specimens. Bone was noted coronal to the apical
border of the notch in four of the ten specimens. The
authors also noted incomplete removal of cementum by
root-planing. Ankylosis or root résorption was not ob-
served. Because of no controls in the study, the authors
were unable to establish whether or not the acid condi-
tioning is a prerequisite for new attachment.
SUMMARY AND CONCLUSIONS
In Periodontitis, root surface alterations have been
noted extending 40 to 100 µ deep to the cementum
surface.1 The diseased root surfaces have been demon-
strated to be hypermineralized,2 and "granules" have
been described in exposed cementum.4"7
In tissue culture, epithelial cells8 and fibroblasts9 fail
to attach normally to diseased roots of extracted teeth.
This failure indicates the presence of a toxic substance,
perhaps endotoxin, within the cementum. An antigenic
component has been extracted from diseased cemen-
tum.11 Elimination or extraction of endotoxin from dis-
eased root surfaces seems to be essential for new attach-
ment procedures. Root-planing removes nearly all de-
tectable endotoxin from periodontally involved sur-
faces.14
Application of acid to root surfaces results in demin-
eralization. Recent evidence suggests that demineraliza-
tion of exposed dentin may significantly enhance regen-
eration of connective tissue attachment to the root. De-
mineralized dentin has been demonstrated to have a
bone-inductive effect.17"22
Register and Burdick25 used a number of acids and
various combinations of pH and application times in
animals to determine the optimal combination that
would yield demineralization and produce new attach-
ment with cementogenesis. Their studies concluded that
citric acid, pH 1, applied for 2 to 3 minutes was the most
desirable combination for producing optimal deminer-
alization and new attachment. This combination pro-
duced no untoward side effects. No root résorption or
pulpal response was observed.
Light microscopy of demineralized root surfaces re-
veals "cementum pins" that extend into widened dentinal
tubules. It has been hypothesized that this enhanced
mechanical fixation, together with the bone-inductive
effect of demineralized dentin, represents the mechanism
for new attachment observed in experimental animals.30
Some authors postulate that irregularities in the demin-
Root Surface Demineralization 615
eralized dentin may aid in the attachment of new con-
nective tissue.81,32 Complete formation of new attach-
ment has been described in acid-treated furcations in
dogs.34
Demineralization did not occur when saturated citric
acid was applied to untreated diseased and hyperminer-
alized extracted human tooth roots; however, application
of acid to root-planed surfaces resulted in a zone of
demineralization 4 µ wide.39 These studies indicated
that root-planing of hypermineralized root surfaces is
necessary before citric acid application if demineraliza-
tion is to be achieved. The use of citric acid deminerali-
zation in conjunction with surgical treatment of artifi-
cially created periodontal defects in dogs has resulted
in enhanced new attachment, including cementogene-
sis.52, 53
Encouraging results associated with demineralization
of root surfaces in periodontal therapy in humans have
been reported. However, there are no well-controlled
human studies documenting the efficacy of root surface
deminerahzation in the treatment of Periodontitis. Ad-
ditional clinical investigations are indicated to determine
the place of root surface demineralization in periodontal
therapy.
REFERENCES
1. Selvig, . .: Ultrastructural changes in cementum and adjacent
connective tissue in periodontal disease. Acta Odontol Scand 24: 459,
1966.
2. Selvig, . ., and Zander, . .: Chemical analysis and micro-
radiography of cementum and dentin from periodontally diseased
human teeth. J Periodontol 33: 303, 1962.
3. Selvig, . ., and Hals, E.: Periodontally diseased cementum
studied by correlated microradiography, electron probe analysis and
electron microscopy. J Periodont Res 12: 419, 1977.
4. Bass, C. C: A previously undescribed demonstrable pathologic
condition in exposed cementum and the underlying dentine. Oral Surg
4:641, 1951.
5. Armitage, G. C, and Christie, T. M.: Structural changes in
exposed human cementum. I. Light microscopic observations. II. Elec-
tron microscopic observations. J Periodont Res 8: 343, 356, 1973.
6. Bigarre, G, and Yardin, M.: Demonstration of lipids in the
pathologic granules in cementum and dentin in periodontal disease. J
Clin Periodontol 4: 210, 1977.
7. Benson, L. .: A study of a pathologic condition in exposed
cementum. Oral Surg 16: 1137, 1963.
8. Hatfield, C. G., and Baumhammers, .: Cytotoxic effects of
periodontally involved surfaces of human teeth. Arch Oral Biol 16:465,
1971.
9. Aleo, J. J., De Renzis, F. ., Farber, P. ., and Varboncoeur,
A. P.: The presence and biologic activity of cementum-bound endo-
toxin. J Periodontol 45: 672, 1974.
10. Aleo, J. J., De Renzis, F. ., and Färber, P. .: In vitro
attachment of human gingival fibroblasts to root surfaces. J Periodontol
46: 639, 1975.
11. Everhart, D. L., and Stahl, S. S.: A possible source of antigen(s)
in periodontal disease (abstract). J Dent Res 55 (Special Issue A-B):
B222, 1976.
12. Everhart, D. L., and Stahl, S. S.: Reaction of component re-
covered from cementum exposed to periodontal pocket with human
serum. J Dent Res 56: 538, 1977.
13. Bravman, R. J., Everhart, D. L., and Stahl, S. S.: A cementum-
bound antigen: Its reaction with serum antibody and localization, in
situ. J Periodontol 50: 656, 1979.

616 Nightingale, Sheridan
14. Jones, W. ., and O'Leary, T. J.: The effectiveness of in vivo
root planing in removing bacterial endotoxin from the roots of peri-
odontally involved teeth. J Periodontol 49: 337, 1978.
15. Ellegaard, B., Karring, T., and Löe, H.: New periodontal at-
tachment procedure based on retardation of epithelial migration. J
Clin Periodontol 1: 75, 1974.
16. Stewart, H. T.: Partial removal of cementum and décalcification
of tooth in the treatment of pyorrhea alveolaris. Dent Cosmos 41: 617,
1899.
17. Register, . ., Scopp, I. W., Kassouny, D. Y., Pfau, F. R., and
Peskin, D.: Human bone induction by allogeneic dentin matrix. J
Periodontol 43: 459, 1972.
18. Urist, M. R.: Bone histogenesis and morphogenesis in implants
of demineralized enamel and dentin. J Oral Surg 29: 88, 1971.
19. Urist, M. R.: Surface-decalcified allogeneic bone (SDAB) im-
plants: A preliminary report of 10 cases and 25 comparable operations
with undecalcified lyophilized bone implants. Clin Orthop 56: 37, 1968.
20. Yeomans, J. D., and Urist, M. R.: Bone induction by decalcified
dentine implanted into oral, osseous and muscle tissues. Arch Oral Biol
12: 999, 1967.
21. Dubuc, F. L., and Urist, M. R.: The accessibility of the bone
induction principle in surface-decalcified bone implants. Clin Orthop
55: 217, 1967.
22. Bang, G., and Urist, M. R.: Bone induction in excavation
chambers in matrix of decalcified dentin. Arch Surg 94: 781, 1967.
23. Urist, M. R., and Mikulski, A. J.: A soluble bone morphogenetic
protein extracted from bone matrix with a mixed aqueous and non-
aqueous solvent. Proc Soc Exp Biol Med 162: 48, 1979.
24. Register, . .: Bone and cementum induction by dentin,
demineralized in situ. J Periodontol 44: 49, 1973.
25. Register, . ., and Burdick, F. .: Accelerated reattachment
with cementogenesis to dentin, demineralized in situ. I. Optimum
range. J Periodontol 46: 646, 1975.
26. Register, . .: Induced reattachment in periodontic-endodon-
tic lesions by root demineralization in situ. Oral Surg 45: 774, 1978.
27. Reynolds, J. J.: Skeletal tissue in culture. G. H. Bourne (ed),
The Biochemistry and Physiology of Bone, vol. 1, ed 2, 91, New York,
Academic Press, 1972.
28. McLean, F. C, and Urist, M. R.: Bone: Fundamentals of the
Physiology of Skeletal Tissue, ed 3, pp 99-100, Chicago, University of
Chicago Press, 1968.
29. Neuman, W. F., and Neuman, M. W.: The Chemical Dynamics
of Bone Mineral, pp 141-142, Chicago, University of Chicago Press,
1958.
30. Register, . ., and Burdick, F. .: Accelerated reattachment
with cementogenesis to dentin, demineralized in situ. II. Defect repair.
J Periodontol 47: 497, 1976.
31. Persson, P.-A.: The regeneration of the marginal periodontium
after flap operation: An experimental study on dogs. Acta Odontol
Scand 20: 43, 1962.
32. Hiatt, W. H., Stallard, R. E., Butler, E. D., and Badgett, B.:
Repair following mucoperiosteal flap surgery with full gingival reten-
tion. J Periodontol 39: 11, 1968.
33. Lee, H. L., Jr., Orlowski, J. ., Scheidt, G. C, and Lee, J. R.:
Effects of acid etchants on dentin. / Dent Res 52: 1228, 1973.
34. Crigger, M., Bogle, G., Nilvéus, R., Egelberg, J., and Selvig, K.
.: The effect of topical citric acid application on the healing of
experimental furcation defects in dogs. / Periodont Res 13: 538, 1978.
35. Forssell-Ahlberg, K., Brännström, M., and Edwall, L.: The
diameter and number of dentinal tubules in rat, cat, dog and monkey:
A comparative scanning electron microscopic study. Acta Odontol
Scand 33: 243, 1975.
36. Nyman, S., Lindhe, J., and Karring, T.: Healing following
surgical treatment and root demineralization in monkeys with peri-
odontal disease. J Clin Periodontol 8: 249, 1981.
37. Nilvéus, R., Bogle, G., Crigger, M., Egelberg, J., and Selvig, K.
.: The effect of topical citric acid application on the healing of
experimental furcation defects in dogs. II. Healing after repeated
surgery. / Periodont Res 15: 544, 1980.
J. Periodontol.
October, 1982
38. Nilvéus, R., and Egelberg, J.: The effect of topical citric acid
application on the healing of experimental furcation defects in dogs.
III. The relative importance of coagulum support, flap design and
systemic antibiotics. J Periodont Res 15: 551, 1980.
39. Garrett, J. S., Crigger, M., and Egelberg, J.: Effects of citric acid
on diseased root surfaces. / Periodont Res 13: 155, 1978.
40. Linghorne, W. J.: Studies in the reattachment and regeneration
ofthe supporting structures ofthe teeth. IV. Regeneration in epithelized
pockets following the organization of a blood clot. J Dent Res 36: 4,
1957.
41. Wilderman, M. N., and Wentz, F. M.: Repair of a dentogingival
defect with a pedicle flap. J Periodontol 36: 218, 1965.
42. Patterson, R. L., Jr., Collings, C. K., and Zimmermann, E. R.:
Autogenous implants in the alveolar process of the dog with induced
Periodontitis. Periodontics 5: 19, 1967.
43. Dragoo, M. R., and Sullivan, H. C: A clinical and histological
evaluation of autogenous iliac bone grafts in humans. I. Wound healing
2 to 8 months. J Periodontol 44: 599, 1973.
44. Adell, R.: Regeneration of the periodontium: An experimental
study in dogs. Scand J Plast Recensir Surg Suppl 11: 1, 1974.
45. Ruben, M. P., Smukler, H., Schulman, S. M., Kon, S., and
Bloom, . .: Healing of periodontal surgical wounds. . M. Goldman
and D. W. Cohen (eds), Periodontal Therapy, ed 6, pp 692-693, St.
Louis, C. V. Mosby Company, 1980.
46. Levine, H. L., and Stahl, S. S.: Repair following periodontal
flap surgery with the retention of gingival fibers. J Periodontol 43: 99,
1972.
47. Kohler, C. ., and Ramfjord, S. P.: Healing of gingival muco-
periosteal flaps. Oral Surg 13: 89, 1960.
48. Löe, H., and Waerhaug, J.: Experimental replantation of teeth
in dogs and monkeys. Arch Oral Biol 3: 176, 1961.
49. Nasjleti, C. E., Caffesse, R. G., Castelli, W. ., and Hoke, J. .:
Healing after tooth reimplantation in monkeys: A radioautographic
study. Oral Surg 39: 361, 1975.
50. Boyko, G. ., Brunette, D. M., and Melcher, A. H.: Cell
attachment to demineralized root surfaces in vitro. J Periodont Res 15:
297, 1980.
51. Leighton, J.: Collagen-coated cellulose sponge. P. F. Kruse, Jr.
and M. K. Patterson, Jr. (eds), Tissue Culture: Methods and Applications,
pp 367-371, New York, Academic Press, 1973.
52. Ririe, C. M., Crigger, M., and Selvig, . .: Ultrastructural
study of wound healing on a root planed and citric acid treated root
surface (abstract). J Dent Res 57: (Special Issue A) 99, 1978.
53. Ririe, C. M., Crigger, M., and Selvig, . .: Healing of peri-
odontal connective tissues following surgical wounding and application
of citric acid in dogs J Periodont Res 15: 314, 1980.
54. Register, . .: Human pocket reattachment in root dentin,
demineralized in situ (abstract). J Dent Res 54: 64, 1975.
55. Passanezi, E., Alves, M. E. A. F., Janson, W. ., and Ruben, M.
P.: Periosteal activation and root demineralization associated with the
horizontal sliding flap. J Periodontol 50: 384, 1979.
56. Shiloah, J.: The clinical effects of citric acid and laterally
positioned pedicle grafts in the treatment of denuded root surfaces: A
pilot study. J Periodontol 51: 652, 1980.
57. Otomo, J. ., and Sims, T. N.: Effects of citric acid demineral-
ization on coronally repositioned flaps (abstract). J Dent Res 58:
(Special Issue A) 347, 1979.
58. Liu, W. J.-L., and Soit, C. W.: A surgical procedure for the
treatment of localized gingival recession in conjunction with root
surface citric acid conditioning. J Periodontol 51: 505, 1980.
59. Stahl, S. S., and Froum, S. J.: Human clinical and histologie
repair responses following the use of citric acid in periodontal therapy.
/ Periodontol 48: 261, 1977.
60. Cole, R. T., Crigger, M., Bogle, G., Egelberg, J., and Selvig, K.
.: Connective tissue regeneration to periodontally diseased teeth: A
histological study. J Periodont Res 15: 1, 1980.
Send reprint requests to: Dr. S. H. Nightingale, c/o Section of
Publications, Mayo Clinic, Rochester, MN 55905.