North Charlotte Dental Hygiene Study Club - North State Perio Panel... · Hand Instrument vs. Ultrasonic Disruption of ... Historically there has been two conflicting schools of thought:

North Charlotte Dental Hygiene Study Club

Periodontal Panel Discussion

4-24-12

General Information

• CE Certificate

• Periodontal Panel Discussion Handout

• Website

• Another Pathology question

#18 History

• “Gum irritation and pain”

• Hard to brush and floss area

• Localized site

• On-going over past year

• RCT then performed – no resolution of symptoms

Patient referred

• Gingival pain and irritation

• “ulcerated tissue”

• Traumatized with mirror led to subepithelial hematoma – developed over 2-3 minutes

Periodontal Panel

• Summary of Questions

– Scaling and Root Planning

– Periodontal Abscess

– Occlusion / Impact on Periodontal Disease

– Periodontal classification system

– Implants

– Recession

– Diagnosis

– Systemic Health

– Laser Assisted Periodontal Therapy

– Oral Pathology

– Chemotherapeutics

– 3-D imaging

– Cosmetic Periodontal Therapy

– Immediate Implants / Provisionalization

Latest Protocol; # of visits; ROT at 4-6 weeks

• Half-mouth vs full-mouth

– Equally effective

– No longer than 2 weeks apart – “reinfection”

• Review of Therapy

– 4-6 weeks later

– Optimal response to therapy

– Oral hygiene and plaque check

– Opportunity for behavior modification

Debridement then ScRP?

Influencing Factors

1. Amount of supra and subgingival

2. Pocket depths

3. Teeth impacted

Total Surface Area vs Time Available

Approximate Position Of Scaler Tip

Dry With Water

Hand Instrument vs. Ultrasonic

Disruption of Biofilm

WalmsleyAD J Periodontol. 15:9, p539-543, 1988

(Efficiency in Biofilm Disruption)

Primary Periodontal Instrumentation

Mechanical Debridement

PATIENTS WHO SHOULD BE TREATED BY A PERIODONTIST

Any patient with:

• Severe chronic periodontitis

• Furcation involvement

• Vertical/angular bony defect(s)

• Aggressive periodontitis (formerly known as juvenile, early-onset, or rapidly progressive periodontitis)

• Periodontal abscess and other acute periodontal conditions

• Significant root surface exposure and/or progressive gingival recession

• Peri-implant disease

• Any patient with periodontal diseases, regardless of severity, whom the referring dentist prefers not to treat.

PATIENTS WHOWOULD LIKELY BENEFIT FROM COMANAGEMENT BY THE REFERRING DENTIST AND THE PERIODONTIST

Periodontal Risk Factors/Indicators

• Early onset of periodontal diseases (prior to the age of 35 years)

• Unresolved inflammation at any site (e.g., bleeding upon probing, pus, and/or redness)

• Pocket depths ‡ 5 mm

• Vertical bone defects

• Radiographic evidence of progressive bone loss

• Progressive tooth mobility

• Progressive attachment loss

• Anatomic gingival deformities

• Exposed root surfaces

• A deteriorating risk profile

Medical or Behavioral Risk Factors/Indicators

• Smoking/tobacco use

• Diabetes

• Osteoporosis/osteopenia

• Drug-induced gingival conditions (e.g., phenytoins, calcium channel blockers, immunosuppressants, and long-term systemic steroids)

• Compromised immune system, either acquired or drug induced

• A deteriorating risk profile

PATIENTS WHO MAY BENEFIT FROM COMANAGEMENT BY THE REFERRING DENTIST AND THE PERIODONTIST

Any patient with periodontal inflammation/infection and the following systemic conditions:

• Diabetes

• Pregnancy

• Cardiovascular disease

• Chronic respiratory disease

Any patient who is a candidate for the following therapies who might be exposed to risk from periodontal infection, including but not limited to the following treatments:

• Cancer therapy

• Cardiovascular surgery

• Joint-replacement surgery

• Organ transplantation

Isolated areas that aren’t responding to treatment; why?

• Access

– Line Angles

– CEJ

– Furcations: Dome

– Concavities

– Grooves

– Pseudopocket?

Where is the pockets?

• Soft tissue only

– Inflammation can be resolved

– Pocket will not go away

• Hard Tissue

– Pocket reduction can be addressed depending on severity and type of bone loss

• Combination

– Pocket reduction can be addressed depending on severity and type of bone loss

Kornman, 1997.

Host Pathway to Periodontal Disease

Genetic Risk Factors

Host Immuno-

inflammatory

Response

Microbial

Challenge

Bio-film /

Plaque /

Calculus

Connective

Tissue

Metabolism

Clinical Signs

Disease

Antigens

Virulence

Factors

Environmental

& Acquired

Risk Factors

Tissue Breakdown Products & Ecological Factors

Antibody

Prostanoids

Cytokines

What is The Extent of Subgingival

Scaling and Root Planing?

Limitations of Nonsurgical Therapy

• Pocket Depth • 1-3mm 89% clean, 3-5mm 39% clean, >5mm 11% clean (Waerhaug 1978)

• 3.7 mm- Average PD that can be efficiently cleaned with Sc/RP

(6.2mm- average limit)

• Root Anatomy • CEPs, CEJ, Furcation, root flutes, line angles

• Access

• Long-term maintenance • Sc/RP teeth require retreatment twice as often compared to surgical

treatment (Ramfjord 1987)

• Patient compliance (OH, systemic health)

Is it realistic to perform ScRP in GD office? Does it benefit patient?

• Minimal osseous involvement?

• Biotype: thick vs thin

• Radiographic bone loss – infrabony defects

– Severity of bone loss; depth of pocket

• Understanding type of pockets vs Expected Response

– Soft tissue pocket

– Hard tissue pocket

– Combination

Severe Bone Loss

Pre-op and 1 year Post-op

Do you prefer that we do ScRP prior to referring?

• “Refer” - Goals of therapy

• Understanding type of pockets vs Expected Response

– Soft tissue pocket

– Hard tissue pocket

– Combination

“How do we get a patient to see you if we can’t care for patient adequately?”

• Pt has to “own” their problem

• If patient does not see the urgency in getting their own disease treated, then no amount of effort will work

• Time, Trust, Consistency, Urgency, Confidence

Periodontal Panel

– Implants

– Recession

– Diagnosis

– Systemic Health

– Oral Pathology

– 3-D imaging

How to treat?

• What is the cause?

– Etiology

– Food Impaction

– Diabetes

– Poor wound healing: systemic health

– Recent ScRP

– Severe probing depth areas

• Removal of etiology; antibiotics

Abscess

Abscess etiology: periodontal infection / food

impaction / root canal failure

TX: Flap; Penrose Drain; Antibiotics; ScRP; I&D;

Extraction

Periodontal Endodontic

Periodontal Panel

– Implants

– Recession

– Diagnosis

– Systemic Health

– Oral Pathology

– 3-D imaging

What is the impact of occlusion on periodontal disease?

• Health

– Increase PD

– No Bone Loss

– Mobility

• Elimination of occlusal issue resolves periodontal issues

• Disease

– Increase PD

– Bone loss: Progressive

– Mobility

– Pathologic Migration

• Elimination of occlusal issue leave persistent periodontal issues

Occlusal Trauma and Periodontitis

Historically there has been two conflicting schools of thought:

Grinders Grind free

Pathologic force (excessive or off axis) results/contributes to alterations in the inflammatory front around teeth.

This in turn results in bone loss and attachment as collagenase and osteoclastic activity increases.

Occlusal Trauma and Periodontitis

• Intrabony defects associated with occlusal trauma assume many forms.

• The most commonly seen defect in “My Chair” seems to be the circumferential.

• What tooth is most commonly affected by occlusion??

WHAT DO WE CALL IT?

• Non-Carious Cervical Lesion

• Cervical Erosion

• Cervical Abrasion

• Abfraction

• Dental Compression

Syndrome

• Stress Corrosion Lesion

• Biodental Engineering

Factorial Lesion

Occlusal Therapy

• Occlusal equilibration

– Fremitus

– Prematurities and Interferences

• Parafunctional habits

– Occlusal guards

Periodontal Panel

– Implants

– Recession

– Diagnosis

– Systemic Health

– Oral Pathology

– 3-D imaging

ALWAYS REMEMBER

Your initial diagnosis is a presumptive diagnosis

You must re-evaluate your diagnosis during treatment and after treatment to prevent missing the true diagnosis / etiology

What is the prognosis of your treatment? What length of treatment benefit do you expect?

How often should you perio chart an adult patient?

• Periodontal Disease pt

– Changes charted every periodontal maintenance visit

– Annual full mouth charting

• Healthy

– Annually full mouth charting

How young should you begin perio charting?

• Look at clinical parameters: radiographs and clinical presentation

• Deciduous and Mixed Dentition

– Aggressive Periodontal Disease: Early onset, localized juvenile periodontitis

• Adult

– Previously addressed

Peridontal Disease Classification

• Gingival Diseases

• Chronic Periodontitis

• Aggressive Periodontitis

• Periodontitis as a Manifestation of Systemic Dz

• Necrotizing Periodontal Diseases

• Abscesses of the Periodontium

• Periodontitis Associated with Endodontic Lesions

• Developmental or Acquired Deformities and Conditions

Plaque Associated Gingivitis

Inflammation confined to the gingiva

Rateitschak 1989

Non-Plaque Associated Gingivitis

Chronic Periodontitis Case

Aggressive Periodontitis

Localized Aggressive Periodontitis

Necrotizing Ulcerative Periodontitis

NUG NUP

Oral Manifestation of a Systemic Dz

Periodontal Abscesses

Recession

Gingivitis: Are 3-4mm PD’s acceptable to ID gingivitis

• Healthy Periodontium

– Inflammation

• Reduced Periodontium

– Even with recession; a 1-4mm probing depth will still be considered healthy or gingivitis given inflammation

Prognosis

• Short Term (3-5 years)

• Long Term (7-10 years)

• Define: Periodontal and Restorative – Excellent: No issues

– Good: Slight issues but managable

– Fair: Compromised but with treatment can do well

– Poor: 3-5 years

– Guarded: Reevaluate after initial therapy

– Hopeless: No amount of treatment will work

Periodontal Panel

– Implants

– Recession

– Diagnosis

– Systemic Health

– Oral Pathology

– 3-D imaging

Discuss causes of inflamed tissue around implants

• Cement

• Plaque

• Tissue quality: lack of attached tissue

What’s wrong with this x-ray?

Earliest age for implant placement? Congenitally missing teeth

• Growth

– Boy : 20-21

– Girls: 18-20

• Mini-implants

• Conventional implants

Time period b/w implant placement and crown What if you had to wait a long time to restore

• Implant stability

• Type of bone

• Amount of bone

– Grafting needed

• Risks

– Still get bone remodeling as if nothing is there. Loading important in maintaining bone

– Super-eruption of opposing teeth

– Tilt of adjacent teeth over the implant

Can you place an immediate implant on a posterior tooth

Immediate implants; success rates

• Patient Selection very important

• Success vs Survival rates

• Stability - Key

• Restorability - Critical

• Equal success rates dependent on patient selection

Periodontal Panel

– Implants

– Recession

– Diagnosis

– Systemic Health

– Oral Pathology

– 3-D imaging

Loss of IP papillae (w or w/o bone loss)

• Bone Loss

• Restorative Contact point

The Effect of the Distance From the Contact Point to the Crest of Bone on the Presence or Absence of the

Interproximal Dental Papilla

The Effect of the Distance From the Contact Point to the

Crest of Bone on the Presence or Absence of the

Interproximal Dental PapillaTarnow DP, Magner AW, Fletcher P J Periodontol 1992; 63:995-996.

Contact point of natural

tooth to crest of ridge:

≤ 5 mm papilla present

almost 100% of time

6 mm present 56% of

7 mm present 17% of

> 8 mm present 10% of

• Contact point of natural tooth to crest of ridge

– ≤ 5mm - papilla present almost 100% of time

– 6mm - present 56% of time

– 7mm – present 17% of time

– > 8 mm – present 10% of time

At what point do you get best root coverage

• IP bone #1 factor

• Root prominence –

– Before or after ortho

Recession classification

III IV

When is the best time to refer for TG referral? How much recession should a patient have to consider a TG?

• Progressive

• Inflammation

• Cold sensitivity

• Esthetics – patient driven

• Lack of facial attached/keratinized tissue

Definitions

• Gingival Recession

• Hidden Recession

• Mucogingival Junction

• Keratinized Gingiva

• Attached Gingiva

• Alveolar Mucosa

Tongue piercing: what damage are you seeing?

• Lingual recession

What else can we do for recession besides hard nightguards?

• Occlusion important but only a contributing

factor

• Diagnosis of tissue quality and quantity

• Other important contributing factors to recession

Esthetic Periodontal Procedures

• Principles

• CEJ / Bone level / Soft Tissue level

Esthetic Periodontal Therapy

• Location

– ST

– Bone

– CEJ

• Why does tissue rebound?

Periodontal Panel

– Implants

– Recession

– Diagnosis

– Systemic Health

– Oral Pathology

– 3-D imaging

Kornman, 1997

Host Pathway to Periodontal Disease

Genetic Risk Factors

Host Immuno- inflammatory

Response

Microbial Challenge

Bio-film / Plaque / Calculus

Connective Tissue

and Bone

Metabolism

Clinical Signs of

Disease

Antigens

Other Virulence

Factors

Environmental & Acquired Risk Factors

Tissue Breakdown Products & Ecological Factors

Antibody

Prostanoids

Cytokines

Women’s Health

• Adolescence

• Smoking

• Stress

• Pregnancy

• Diabetes

• Menopause

• Osteoporosis/Osteopenia

• Cardiovascular Disease

• Stroke

• Sjogren’s Syndrome

• Medications

• Autoimmune Dz

• Immune Deficiency

Periodontal Disease

• Inflammation

• Attachment lost

• Susceptibility

– Aggressive

– Chronic

– NUG / NUP

– Systemic Health

Osteoporosis / Osteopenia • Bone remodeling equilibrium dysfunction

– Decreased bone mass

– Fragility, deformity, and fracture

• Diagnosis:

– Dexa scan:

• > -1: Normal bone density

• -1 to -2.5: Osteopenia

• < -2.5: Osteoporosis

Correlation between osteoporosis and bone loss?

Impact on Periodontal Health

• Oral bone density decreases

• Increased ridge resorption after extraction

• Increased risk of tooth loss?

– 1% density loss -- 4x risk for tooth loss

• Increased risk for periodontal disease?

– Greater progressive loss of attachment

Bisphosphonates: options for implants and bone grafts

• Oral vs IV drugs

• Total cumulative dose

• Rules of thumb

– Cumulative dose > 7 years

Bisphosphonate Related OsteoNecrosis of the Jaw (BRONJ)

What do you do with periodontally involved teeth?

Periodontal Panel

– Implants

– Recession

– Diagnosis

– Systemic Health

– Oral Pathology

– 3-D imaging

“Are you using a laser for tissue reduction?”

• Lasers available: Nd:Yag; Diode; CO2; Er:Yag; Argon

• Nd:Yag

– Readily absorbed in pigments (dark pathogens, blood)

– No readily absorbed by water and HA

– Standard protocol and training

– Research and Results

Clinical effects of Nd: Yag laser

• Removes the pocket epithelium

• Kills pathogens

• Neutralizes endotoxin

• Reduces inflammation and inflammatory products (PGE, IL, MMP, TNF)

• Biostimulation (increased growth factors and cell activity)

Why we use a Nd:Yag laser

• Hybrid between surgery and Sc/Rp

• Avoids Sc/Rp charge so increases treatment acceptance and decreases time for case completion

• Do not have to take patient off of anticoagulant therapy

• Less invasive for older patients and patients with poor systemic health

• Prevents significant recession unless you purposely create it

• No sutures to create tension or irritation

• No coronal creep of papilla over the mesial concavities of premolars

• Most likely prevents the 0.5 - 1mm of crestal resorption associated with flap reflection

• Patients love it and tell their friends! (Polar opposite of traditional surgery)

• Will we be able to use it as a future definitive therapy in patients on IV bisphosphonates?

Is it effective in PD reduction?

Failed GTR LAPT

Laser Presentation

• 4th study club meeting

• More in-depth information

• Review of research

• Clinical results

Periodontal Panel

– Implants

– Recession

– Diagnosis

– Systemic Health

– Oral Pathology

– 3-D imaging

Oral Pathology The following are questions to think about when evaluating oral lesions:

1. Review medical history: smoking, diabetes, medications, radiation therapy, cancer history

2. Review dental history: look for causes of tissue trauma

3. Extraoral and Intraoral Exams (palpation of lymph nodes, lesions): size, soft, firm, fixed

4. Etiology: calculus, plaque, habits, appliances

5. Pain: If no pain and it looks like it should hurt, this can be a red flag.

6. Duration: new; present longer than 2 weeks

7. Frequency: new or recurring

8. Pattern: localized or generalized; unilateral

9. Location: attached gingiva, mucosal tissue, tongue, FOM, retromolar pad

10. Palpation: does surface wipe off, bleeding, soft, firm, fixed

11. Radiographic findings: crestal bone loss, -luscency, -opacity, calculus present

Take Home Message

1. Duration: If a lesion is present longer than 2 weeks — biopsy warranted! Do not wait until next cleaning to check lesion. Bring back in 2 weeks if necessary.

2. If you have no idea, ask your dentist to evaluate. May need to refer to a Periodontist or OMS

3. If you are not looking, you may not notice a lesion until it has progressed too far.

What do we see?

• Oral Manifestations of Systemic Disease

– Pemphigus / Pemphigoid

– Lichen Planus

– Mucocele

– Fibroma: Irritation

– POF, PG, PGCG

Periodontal Panel

– Implants

– Recession

– Diagnosis

– Systemic Health

– Oral Pathology

– 3-D imaging

Why don’t perio offices employ Arestin Tx for non-sx pockets?

• Goal of Therapy

• Radiographic defect present?

• Residual calculus present?

• Clinical vs statistical significance?

• Long term results vs other treatment modalities

Efficacy of Antibiotic Therapy

• Depends on:

– Anti-microbial spectrum and drug characteristics

– Drug binding to tissues

– Protection of pathogens by non-target organisms

– Biofilm phenomena

– Total bacterial load vs. max antibiotic concentration

– Effectiveness of host defenses

– Pathogens in sites not affected by therapy

Do you think Arestin helps much in reducing PD’s?

• What do you find is the typical result / application?

• What is the frequency of application?

• What is the value of the therapy?

What criteria for Arestin use?

• Soft tissue refractory cases

– Inflammation

• Localized deepening pockets

Chemotherapeutics

• All local delivery antibiotics must be combined with Scaling and Root planing!

• Do not use them as a stand alone therapy

• Residual calculus is an issue. Even sterilized calculus acts as a chronic irritant

• Local antibiotics are beneficial in certain situations but should not be used in 50 sites at every maintenance appointment

If you were bleeding to death would you keep putting new band-aids/Neosporin on the wound every 2 minutes or would you go the hospital to fix the problem?

Chemotherapeutics Obstacles

• Residual calculus • Inflammation causes outflow of GCF at a rate of

44ul/min. The flow/pressure is out of the sulcus! • Deep intrabony defects have tissue bridging the defect.

This will not miraculously close. • Allergy • Costly • Over medicated culture • Patients are referred to us after several rounds of Sc/Rp

and Arestin and still need surgery…are enraged unless the dentist communicated adequately.

• Meta analysis only shows modest short term gains in attachment

Periostat use?

• No longer on the market

• Concept: Low Dose Doxycycline

• $$, 3 x 3 months

• Statistical vs Clinical significance

Low Dose Doxycycline

• PERIOSTAT® (doxycycline hyclate 20 mg capsules)

No longer available

• Periostat™ acts as an Enzyme Suppressor

– Studies show that doxycycline hyclate 20 mg bid has no antimicrobial action

– No change in bacterial flora after 18 months

– No induction of resistance after 18 months

Low Dose Doxycycline (LDD)

How long can a patient stay of Peridex?

• Concentration: full strength vs diluted

• Alternating days

• Stain effects

• Calculus formation

• Why is being used?

Anything new on subgingival therapy?

• Traditional

– GTR

– Pocket Reduction Surgery

– Flap Currettage

• Latest Treatment Protocol

– Laser Assisted Periodontal Therapy / LANAP

Periodontal Panel • Summary of Questions

– Implants

– Recession

– Diagnosis

– Systemic Health

– Oral Pathology

– 3-D imaging

PA vs 3-D imaging

CT Scan

Fenestrations

Lingual Undercuts and/or Tori

Thin Ridges

F.J. Implant Planning

Periodontal Panel

– Implants

– Recession

– Diagnosis

– Systemic Health

– Oral Pathology

– 3-D imaging

• Extraction

– Fractured crown, non-restorable

– Failed/Re-infected RCT

– Vertical Root Fracture

– Root perforations

– Caries

– Combination of Factors

– Immediate Implant Contraindication?

Immediate Implant Placement

“Ideal” Immediate Placement Concerns

• Surface area engaged by internal walls / Tooth morphology

– Bio-Type: Thick or Thin

– Beyond apex of tooth

• Maxillary sinus proximity

• PARL - infection

– Bone quality/density

• Stability

• Restorability

What is a good immediate implant site?

Temporary Provisionalization

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