{"id":3716,"date":"2026-02-27T21:05:15","date_gmt":"2026-02-27T21:05:15","guid":{"rendered":"https:\/\/www.bestdentalhospitals.com\/blog\/bone-substitute-definition-uses-and-clinical-overview\/"},"modified":"2026-02-27T21:05:15","modified_gmt":"2026-02-27T21:05:15","slug":"bone-substitute-definition-uses-and-clinical-overview","status":"publish","type":"post","link":"https:\/\/www.bestdentalhospitals.com\/blog\/bone-substitute-definition-uses-and-clinical-overview\/","title":{"rendered":"bone substitute: Definition, Uses, and Clinical Overview"},"content":{"rendered":"\n<h2 class=\"wp-block-heading\">Overview of bone substitute(What it is)<\/h2>\n\n\n\n<p>A bone substitute is a material used to help fill or rebuild areas where natural bone is missing.<br\/>\nIt is commonly used in dental bone grafting before or during implant treatment.<br\/>\nIt can also be used to support healing around teeth affected by periodontal (gum) disease.<br\/>\nBone substitute materials may come from human, animal, or synthetic sources.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Why bone substitute used (Purpose \/ benefits)<\/h2>\n\n\n\n<p>In dentistry, bone is the foundation that supports teeth and dental implants. When bone volume is reduced\u2014after a tooth extraction, due to infection, trauma, or long-standing tooth loss\u2014there may not be enough healthy bone to support planned treatment or to maintain the desired contour of the jaw.<\/p>\n\n\n\n<p>A bone substitute is used to help address these situations by acting as a scaffold or filler in areas where bone has been lost. Depending on the material and the clinical goal, it may help:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Maintain space for new bone formation<\/strong> during healing, especially in an extraction socket.<\/li>\n<li><strong>Support implant planning<\/strong> by improving ridge shape, width, or height (how much bone is available in different dimensions).<\/li>\n<li><strong>Stabilize localized defects<\/strong> (small areas of bone loss) around teeth or implants.<\/li>\n<li><strong>Promote predictable healing conditions<\/strong> by helping the body \u201cbridge\u201d gaps that might otherwise collapse or fill with soft tissue instead of bone.<\/li>\n<li><strong>Reduce the need for harvesting bone from another site<\/strong> in some cases (varies by clinician and case).<\/li>\n<\/ul>\n\n\n\n<p>It is important to note that \u201cbone substitute\u201d does not mean the material instantly turns into your own bone. Instead, many products are designed to <strong>support<\/strong> the body\u2019s healing response over time. The degree to which a graft is replaced by new bone depends on multiple factors, including defect type, blood supply, stability, and the specific material used (varies by material and manufacturer).<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Indications (When dentists use it)<\/h2>\n\n\n\n<p>Dentists and oral surgeons may use bone substitute in situations such as:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Socket preservation<\/strong> after tooth extraction to help maintain ridge contour<\/li>\n<li><strong>Dental implant site development<\/strong>, when bone volume is limited for implant placement<\/li>\n<li><strong>Sinus augmentation (sinus lift)<\/strong> in the upper back jaw when vertical bone height is insufficient<\/li>\n<li><strong>Guided bone regeneration (GBR)<\/strong> around implants or in ridge defects<\/li>\n<li><strong>Periodontal (gum disease\u2013related) bone defects<\/strong> next to teeth, in selected cases<\/li>\n<li><strong>Peri-implant bone defects<\/strong> (bone loss around an implant), depending on cause and severity<\/li>\n<li><strong>Defects after cyst or lesion removal<\/strong>, when a bony void remains<\/li>\n<li><strong>Trauma-related defects<\/strong> in the jaw, when clinically appropriate<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\">Contraindications \/ when it\u2019s NOT ideal<\/h2>\n\n\n\n<p>A bone substitute is not suitable for every situation. Situations where it may be avoided or where alternative approaches may be considered include:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Uncontrolled infection at the graft site<\/strong>, where infection management may be prioritized first (varies by clinician and case)<\/li>\n<li><strong>Inadequate soft-tissue coverage<\/strong> or inability to achieve stable closure, which can increase the chance of exposure and compromised healing<\/li>\n<li><strong>Poor blood supply to the area<\/strong>, since blood supply supports healing and bone formation<\/li>\n<li><strong>Certain uncontrolled systemic conditions<\/strong> that can affect wound healing or bone metabolism (the specifics depend on medical history and clinician assessment)<\/li>\n<li><strong>Known sensitivity or preference-based avoidance<\/strong> of specific sources (for example, some patients decline animal-derived products)<\/li>\n<li><strong>Defects requiring structural support beyond the product\u2019s capacity<\/strong>, such as cases needing rigid fixation, block grafting, or staged reconstruction<\/li>\n<li><strong>Situations where primary stability cannot be achieved<\/strong>, meaning the graft cannot be kept still enough for predictable healing<\/li>\n<\/ul>\n\n\n\n<p>In clinical practice, the \u201cnot ideal\u201d category often reflects a <strong>planning issue<\/strong> rather than a single absolute rule: the defect shape, tissue quality, and treatment goals determine whether a bone substitute is appropriate and what type is selected.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">How it works (Material \/ properties)<\/h2>\n\n\n\n<p>Bone substitute materials are designed primarily for <strong>biologic compatibility and handling<\/strong>, not for the same properties used to describe tooth-colored filling materials. The concepts of \u201cetch\/bond,\u201d \u201clight curing,\u201d and \u201cpolishability\u201d (common in composites) generally do not apply to bone graft materials.<\/p>\n\n\n\n<p>That said, the prompt\u2019s property categories can be translated into the closest relevant concepts used for bone substitute selection:<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Flow and viscosity (handling)<\/h3>\n\n\n\n<p>Bone substitute may come as:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Particulates\/granules<\/strong> (grain-like particles) that pack into a defect<\/li>\n<li><strong>Putty or paste<\/strong> forms that are more cohesive and resist scattering<\/li>\n<li><strong>Gel-based or injectable<\/strong> forms that can be delivered through a syringe<\/li>\n<\/ul>\n\n\n\n<p>Here, \u201cflow\u201d and \u201cviscosity\u201d refer to <strong>how the material handles in a surgical site<\/strong>\u2014how easily it can be placed, whether it stays where it is put, and how it adapts to the shape of the defect. Handling is influenced by particle size, moisture content, and any carrier added by the manufacturer (varies by material and manufacturer).<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Filler content (closest relevant property)<\/h3>\n\n\n\n<p>\u201cFiller content\u201d is not a standard way to describe bone substitute. A closer equivalent is the material\u2019s:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Composition<\/strong> (for example, hydroxyapatite, beta-tricalcium phosphate, or mixed phases)<\/li>\n<li><strong>Porosity and surface structure<\/strong>, which can influence how fluids and cells interact with the graft<\/li>\n<li><strong>Particle size distribution<\/strong>, which affects packing and space maintenance<\/li>\n<\/ul>\n\n\n\n<p>Some products are designed to <strong>resorb (break down) faster<\/strong>, while others are <strong>more slowly resorbing<\/strong> and can maintain volume longer. The \u201cright\u201d balance depends on the case goals and clinician preference.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Strength and wear resistance (closest relevant property)<\/h3>\n\n\n\n<p>Wear resistance is generally not relevant, because bone substitute is not used on biting surfaces. The more relevant mechanical considerations are:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Space maintenance<\/strong>: the ability to resist collapse from surrounding soft tissue pressure<\/li>\n<li><strong>Dimensional stability<\/strong> over healing time<\/li>\n<li><strong>Cohesion<\/strong> (whether the material holds together when placed)<\/li>\n<\/ul>\n\n\n\n<p>For larger or more demanding defects, clinicians may use techniques that increase stability, such as combining a bone substitute with a <strong>barrier membrane<\/strong> (guided bone regeneration) or choosing a <strong>block-type graft<\/strong> where indicated.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">bone substitute Procedure overview (How it\u2019s applied)<\/h2>\n\n\n\n<p>The clinical steps for placing a bone substitute are <strong>surgical<\/strong> and differ from tooth filling procedures. The sequence listed below (Isolation \u2192 etch\/bond \u2192 place \u2192 cure \u2192 finish\/polish) is commonly used for resin restorations, so several steps do not directly apply to bone substitute. The closest conceptual \u201cworkflow\u201d is:<\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li>\n<p><strong>Isolation<\/strong><br\/>\n   In grafting, \u201cisolation\u201d generally means controlling the surgical field and minimizing contamination. This may involve suction, gauze control, and careful tissue handling to keep the site clean and stable.<\/p>\n<\/li>\n<li>\n<p><strong>Etch\/bond<\/strong><br\/>\n   Etching and bonding are <strong>not used<\/strong> for bone substitute placement. Instead, the clinician prepares the site by cleaning the defect and, when appropriate, encouraging bleeding from bone surfaces to support healing (details vary by clinician and case).<\/p>\n<\/li>\n<li>\n<p><strong>Place<\/strong><br\/>\n   The bone substitute is placed into the defect or socket. The clinician shapes and adapts it to the site, aiming for stable contact with surrounding bone and appropriate contour.<\/p>\n<\/li>\n<li>\n<p><strong>Cure<\/strong><br\/>\n   Light curing is <strong>not applicable<\/strong> to most bone substitute materials. Stability is achieved through packing, containment by bony walls, use of membranes, and soft-tissue closure. Some products use carriers that set or thicken, but this depends on the product design (varies by material and manufacturer).<\/p>\n<\/li>\n<li>\n<p><strong>Finish\/polish<\/strong><br\/>\n   Finishing and polishing are <strong>not part<\/strong> of graft placement. Instead, the procedural endpoint is typically <strong>membrane placement (if used), flap repositioning, and suturing<\/strong> to protect the graft during early healing.<\/p>\n<\/li>\n<\/ol>\n\n\n\n<p>This overview is intentionally general. In real clinical care, the approach may differ between socket preservation, sinus augmentation, and ridge augmentation, and may involve staged treatment planning.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Types \/ variations of bone substitute<\/h2>\n\n\n\n<p>Bone substitute is often categorized by <strong>source<\/strong> and by <strong>form\/handling<\/strong>. These categories help clinicians match a material to the defect type, healing goals, and patient preferences.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">By source (what it\u2019s made from)<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>\n<p><strong>Autograft (patient\u2019s own bone)<\/strong><br\/>\n  Often considered the reference standard biologically because it contains living cells and natural bone components. It requires a donor site, which can increase procedure complexity (varies by clinician and case).<\/p>\n<\/li>\n<li>\n<p><strong>Allograft (human donor bone, processed)<\/strong><br\/>\n  Typically provided through tissue banks and processed for safety and consistency. Some forms are primarily osteoconductive (scaffold-like), and some processing methods aim to preserve signaling proteins to varying degrees (varies by material and manufacturer).<\/p>\n<\/li>\n<li>\n<p><strong>Xenograft (animal-derived, processed)<\/strong><br\/>\n  Often derived from bovine or porcine sources and processed to remove organic components. Many xenografts are relatively slow to resorb and may help maintain volume over time (varies by material and manufacturer).<\/p>\n<\/li>\n<li>\n<p><strong>Alloplast (synthetic materials)<\/strong><br\/>\n  Common examples include calcium phosphate ceramics such as hydroxyapatite (HA) and beta-tricalcium phosphate (\u03b2-TCP), or combinations. Resorption and remodeling behavior varies widely by formulation.<\/p>\n<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">By form (how it\u2019s delivered)<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Particulate\/granular<\/strong>: versatile and commonly used for sockets and contained defects  <\/li>\n<li><strong>Putty\/paste<\/strong>: cohesive handling, often used where particle migration is a concern  <\/li>\n<li><strong>Injectable formats<\/strong>: delivered via syringe for access and handling control  <\/li>\n<li><strong>Blocks or molded forms<\/strong>: used when space maintenance and shape are major goals (case-dependent)<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">By biologic behavior (high-level)<\/h3>\n\n\n\n<p>These terms may be used in education and product descriptions:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Osteoconductive<\/strong>: provides a scaffold for bone growth along its surface  <\/li>\n<li><strong>Osteoinductive<\/strong>: may stimulate precursor cells to form bone (not universal; varies by material and processing)  <\/li>\n<li><strong>Osteogenic<\/strong>: contains living bone-forming cells (mainly relevant to autograft)<\/li>\n<\/ul>\n\n\n\n<p>Clinicians may also use <strong>combinations<\/strong> (for example, mixing autograft with a bone substitute) to balance handling and biologic goals.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Pros and cons<\/h2>\n\n\n\n<p>Pros:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Can help <strong>preserve or rebuild bone volume<\/strong> in selected dental procedures<\/li>\n<li>Offers <strong>multiple source options<\/strong> (human, animal, synthetic) to fit preferences and indications<\/li>\n<li>Many products have <strong>convenient handling forms<\/strong> (granules, putty, injectable)<\/li>\n<li>May reduce the need for <strong>secondary donor-site surgery<\/strong> in some cases<\/li>\n<li>Can be combined with membranes or biologics as part of <strong>guided bone regeneration<\/strong> (case-dependent)<\/li>\n<li>Useful across several specialties: implant dentistry, periodontics, and oral surgery<\/li>\n<\/ul>\n\n\n\n<p>Cons:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Healing outcomes can be <strong>variable<\/strong> and depend on defect type, stability, and patient factors<\/li>\n<li>Some materials may <strong>resorb slowly<\/strong> or persist longer than expected (varies by material and manufacturer)<\/li>\n<li>Not all sites are ideal candidates, especially when <strong>soft-tissue closure is difficult<\/strong><\/li>\n<li>Source-related concerns may matter to patients (ethical, religious, or allergy\/sensitivity considerations)<\/li>\n<li>Additional materials (like membranes) and surgical steps can <strong>increase complexity and cost<\/strong><\/li>\n<li>Infection, exposure, or graft loss are recognized clinical risks in grafting procedures (risk level varies by clinician and case)<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\">Aftercare &amp; longevity<\/h2>\n\n\n\n<p>Bone substitute placement is typically part of a <strong>healing-based process<\/strong>, meaning the \u201cresult\u201d depends on how well the site heals over time. Longevity and stability are influenced by:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Bite forces and loading timing<\/strong>: early or excessive mechanical forces can compromise stability (varies by clinician and case)<\/li>\n<li><strong>Oral hygiene and plaque control<\/strong>: cleaner conditions generally support healthier gum healing<\/li>\n<li><strong>Smoking status and overall health<\/strong>: factors that affect wound healing can affect graft outcomes as well<\/li>\n<li><strong>Bruxism (clenching\/grinding)<\/strong>: can increase forces on implants and surrounding bone after restoration<\/li>\n<li><strong>Regular dental follow-up<\/strong>: monitoring helps detect inflammation or bone changes earlier<\/li>\n<li><strong>Material choice<\/strong>: resorption rate, space maintenance, and handling can influence outcomes (varies by material and manufacturer)<\/li>\n<li><strong>Defect anatomy<\/strong>: contained defects (with bony walls) often behave differently from non-contained defects<\/li>\n<\/ul>\n\n\n\n<p>\u201cLongevity\u201d can mean different things depending on the goal. In some cases, the goal is temporary scaffolding that is gradually replaced by new bone; in others, a portion of the graft may remain longer term while still supporting volume. How much remains and for how long varies by case and material.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Alternatives \/ comparisons<\/h2>\n\n\n\n<p>Bone substitute is one option within a broader set of strategies for managing missing or reduced bone. Comparisons are most useful when framed around <strong>clinical goals<\/strong>: space maintenance, biologic stimulation, handling, and patient preference.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Bone substitute vs autograft (patient\u2019s own bone)<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Autograft<\/strong> may offer strong biologic potential because it is living bone.  <\/li>\n<li><strong>bone substitute<\/strong> may be easier to obtain and avoids a donor site, but biologic behavior depends on the product.  <\/li>\n<li>Clinicians may combine them to balance biologic activity and volume stability (varies by clinician and case).<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">Bone substitute with membrane (GBR) vs without membrane<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>A <strong>barrier membrane<\/strong> can help keep soft tissue from growing into the grafted space and can improve space maintenance in certain defects.  <\/li>\n<li>Not every site needs a membrane, and membrane choice adds variables (resorbable vs non-resorbable), which can affect planning and follow-up (varies by clinician and case).<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">Bone substitute vs \u201cno graft\u201d (natural healing)<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Some extraction sites heal acceptably without grafting, particularly when future implant placement is not planned or when anatomy is favorable.  <\/li>\n<li>Grafting is more often considered when preserving ridge contour or preparing for implants is a priority (varies by clinician and case).<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">Clarifying a common confusion: bone substitute vs tooth filling materials<\/h3>\n\n\n\n<p>Patients sometimes encounter terms like <strong>flowable composite<\/strong>, <strong>packable composite<\/strong>, <strong>glass ionomer<\/strong>, or <strong>compomer<\/strong> when researching dental materials. These are <strong>tooth restorative materials<\/strong> for cavities and repairs, not bone grafting. They are placed in teeth using etch\/bond and often light-cured, whereas bone substitute is placed in bone defects and relies on biologic healing rather than polishing and wear resistance.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Common questions (FAQ) of bone substitute<\/h2>\n\n\n\n<p><strong>Q: Is bone substitute the same as a \u201cbone graft\u201d?<\/strong><br\/>\nA: \u201cBone graft\u201d is a broad term for the procedure and\/or the material used to fill a bone defect. A bone substitute is one type of grafting material used in that procedure. Some grafts use the patient\u2019s own bone, while others use donor, animal-derived, or synthetic materials.<\/p>\n\n\n\n<p><strong>Q: Does a bone substitute become real bone?<\/strong><br\/>\nA: Many bone substitute materials are designed to support new bone growth by acting as a scaffold. Over time, some materials resorb and may be replaced by the body\u2019s bone, while others resorb more slowly and may remain partially present. The extent and timing vary by material and manufacturer, and by the clinical situation.<\/p>\n\n\n\n<p><strong>Q: Is the procedure painful?<\/strong><br\/>\nA: Discomfort levels vary by person and by the extent of the procedure. Bone grafting is commonly performed with local anesthesia, and patients may experience soreness during early healing. Expectations and pain control approaches vary by clinician and case.<\/p>\n\n\n\n<p><strong>Q: How long does it take to heal after bone substitute placement?<\/strong><br\/>\nA: Healing occurs in phases, with early gum healing typically happening before deeper bone remodeling. The time needed before the area is ready for the next step (such as implant placement) varies widely based on the site, graft type, and treatment plan. Your clinician generally frames timing around the specific goal of the graft.<\/p>\n\n\n\n<p><strong>Q: How long does bone substitute last?<\/strong><br\/>\nA: \u201cLast\u201d can mean either how long the material remains or how long the reconstructed bone supports teeth or implants. Some products are designed to resorb faster, and others more slowly. Long-term stability depends on hygiene, inflammation control, bite forces, and overall treatment design (varies by clinician and case).<\/p>\n\n\n\n<p><strong>Q: Is bone substitute safe?<\/strong><br\/>\nA: Bone substitute materials used in dentistry are typically manufactured and processed to be biocompatible and suitable for clinical use. Safety considerations can differ by source type (human, animal, synthetic) and by processing methods. Specific risks and product selection vary by clinician and case.<\/p>\n\n\n\n<p><strong>Q: Will my body reject a bone substitute?<\/strong><br\/>\nA: Classic \u201crejection\u201d like with organ transplants is not how dental graft materials are usually discussed. However, complications can occur, including inflammation, infection, or graft exposure, and these risks vary with surgical conditions and patient factors. Material selection and handling protocols are chosen to reduce these risks.<\/p>\n\n\n\n<p><strong>Q: Why would a dentist choose animal-derived vs synthetic bone substitute?<\/strong><br\/>\nA: The choice often relates to desired resorption rate, space maintenance, handling, and clinical evidence for a particular indication. Patient preferences and values can also play a role. There is no single material that fits every case.<\/p>\n\n\n\n<p><strong>Q: Is bone substitute used at the same time as a dental implant?<\/strong><br\/>\nA: Sometimes grafting is done at the same appointment as implant placement, and other times it is staged before the implant is placed. The decision depends on how much bone is missing, whether the implant can be stabilized, and the treatment plan goals. Timing varies by clinician and case.<\/p>\n\n\n\n<p><strong>Q: Does bone substitute affect the cost of treatment?<\/strong><br\/>\nA: It can, because grafting may involve additional materials (graft, membrane) and surgical steps. Costs vary by region, clinician, complexity, and the specific products selected. Many practices provide itemized estimates as part of planning.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>A bone substitute is a material used to help fill or rebuild areas where natural bone is missing. It is commonly used in dental bone grafting before or during implant treatment. It can also be used to support healing around teeth affected by periodontal (gum) disease. Bone substitute materials may come from human, animal, or synthetic sources.<\/p>\n","protected":false},"author":10,"featured_media":0,"comment_status":"open","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[],"tags":[],"class_list":["post-3716","post","type-post","status-publish","format-standard","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.7 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>bone substitute: Definition, Uses, and Clinical Overview - Best Dental Hospitals<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.bestdentalhospitals.com\/blog\/bone-substitute-definition-uses-and-clinical-overview\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"bone substitute: Definition, Uses, and Clinical Overview - Best Dental Hospitals\" \/>\n<meta property=\"og:description\" content=\"A bone substitute is a material used to help fill or rebuild areas where natural bone is missing. It is commonly used in dental bone grafting before or during implant treatment. It can also be used to support healing around teeth affected by periodontal (gum) disease. 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