ppt 4 - management of pts with PD Disease

Evidence-based healthcare:

• The conscientious, explicit, and judicious use of current best evidence in care of patients

• Incorporates individual clinical experience, patient preferences, and best available evidence

Traditional Components of Periodontal Examination

• Description of Gingiva

• Periodontal Pocket Probing Depths

• Measurement of Recession

• Calculation of Attachment Loss

• BOP

• Explore Furcations

• Detect Mobility

• Radiographic Examination of Bone Level

• Assessment of Plaque and Calculus

• Complicating Factors

ADHA standards state the RDH

• is responsible and accountable for their dental hygiene practice, conduct, and decision-making

• need to access and utilize current literature

• need to be aware of changing trends

• need to participate in activities that maintain competence

Goal of Evidence-Based Care

• To assist healthcare professionals in applying the most current and best scientific evidence to patient care

• To improve health outcomes by closing the gap between what is known—research—versus what is practiced (the care that patients receive in medical and dental offices)

What Prompted the Best Practice Approach to Patient Care?

Direct access to clinical research information

Three Foundational Elements of Evidence-Based Care

• Incorporation of the best scientific evidence Scientific evidence

• The healthcare provider's clinical expertise

• The patient's preferences and values

Practicing hygienists must remain current with new techniques, devices, treatments, materials, and philosophies that will result in _______

improvements in delivering the best possible periodontal care

Dental hygiene is an evolving profession. What was appropriate treatment for optimum care 2 years ago may not reflect the highest standard of care today (T/F)

True

Patient Role in Decision Making

• Today's patients expect to be active participants concerning their care

• Patients may arrive with information obtained from the internet or from speaking with someone else

• Widespread health information from the internet is available to patients

Self-evaluation

Periodically, ask questions

For best treatment outcomes, pay attention to patient preferences and values, which can be:

• Cost

• Pain

• Time lost from work

• Impact on family

• Insurance benefits

Patient Management

• Get informed consent making sure to disclose risks and benefits of the proposed treatment, alternative treatments, and no treatment at all.

• Develop an individualized treatment plan for each patient

• Identify problems from the patient's history/assessments

• Interpretation and/or dental hygiene diagnosis will be made from each problem

• Evaluate Problem and determine a prognosis

Prognosis

the prediction of the future with or without treatment

Factors of prognosis

All aspects of patient's history, data gathered from clinical examination, and the patient's own healing capacity

Ideal goal of periodontal therapy

restore the periodontium to a functional state of health

Goals of Periodontal Therapy

• **Ideal goal is to restore the periodontium to a functional state of health

• Preserve health, comfort, and function of teeth

Arrestive therapy:

periodontal therapy aims to prevent the initiation, progression, or recurrence of periodontal disease

• Preventive measures included achieving a low level of plaque biofilm (we can't and don't want to eliminate ALL bacteria; it is impossible AND there are good bacteria in there).

• Patient education

Regenerative therapy:

reformation of periodontal tissue lost due to disease

Dental plaque induced gingivitis:

• plaque related or modified by systemic factors, medications, or malnutntion

• best treated with instrumentation and oral hygiene instructions

• Therapeutic goal is to establish gingival health by eliminating the etiological factors

• Prevent sites from progressing into periodontitis

Non-plaque induced gingival disease

• Plaque biofilm is a modifying factor

• May be of bacterial, viral, fungal, and genetic origin

• Manifestations of systemic conditions, traumatic lesions, and foreign body reactions

Drug induced gingival diseases

Gingival enlargement

Chronic periodontitis management

oral hygiene instructions, periodontal debridement, surgical therapy if needed

Aggressive periodontitis management

treatment is similar to chronic except that surgery is often done right away - refer promptly to periodontist

Refractory Periodontitis

patients who are already treated but the disease fails to respond to treatment and maintenance therapy

Due to:

Inadequate treatment, systemic disease, deficient immune response, persistent periodontal pathogens

Recurrent periodontitis

present in patients who initially responded well to therapy but later showed signs of disease reactivation

Per-implantitis treatment

• periodontal debridement

• oral hygiene instructions

• mouth rinses

• systemic antibiotics

• arrestive and regenerative periodontal surgery

• possibly implant removal.

• Refer to periodontist

Geriatric patients may be at an increased risk for periodontal disease or progression of disease, due to:

• Limited ability to remove plaque/manual dexterity - modifications can be made to equipment

• Medications

• Xerostomia

• Systemic disease

• May require cooperation from caregivers

Periodontal Therapy: Ongoing Care

• Different therapies for every patient

• Continued reassessments

• Continued periodontal maintenance care - prevent recurrence of perio

• Interval is for each individual but usually 3-4 months

• Patient compliance is key

• Home care

• Not failing appointments

Patient Problem List

• Take into consideration the patient's chief complaint, signs, and symptoms

• Identify the patient's problem

• A solution must be given for each problem - keep in mind that sometimes, the chief complaint can't be taken care of immediately (for example whitening in the presence of caries/perio), we must address it still.

• Expected outcomes (result of taking care of the problem)

• Prognosis (predication of recovery)

• Patients should be given treatment options

Risk Assessment is essential for ________

treatment planning

Treatment plan can be completed once the examination and problem list is completed, always find:

The "best care" treatment plan and an alternative treatment plan

Refer to a periodontist any patient with:

• Moderate to severe periodontitis

• Furcation involvement

• Vertical/angular bony defects)

• Aggressive periodontitis

• Pediatric or young individuals

• Refractory cases — not responding to treatment

• Periodontal disease with systemic factors

• 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 preters not to treat

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 millimeter

• 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 (low bone density)

• Drug-induced gingival conditions (eg, phenytoin, calcium channel blockers, immunosuppressants, and long-term systemic steroids)

• Compromised immune system, either acquired or drug induced

• Deteriorating risk profile

Patients who may benefit from co-management:

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

• Diabetes

• Pregnancy

• Cardiovascular disease

• Chronic respiratory disease (perio can worsen these conditions such as COPD, emphysema, and increase risk for pneumonia)

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

Phase 1 (Non-surgical)

• Emergencies taken care of first (Pain, abscess, NUG, injury)

• Non-restorable teeth are identified and extracted

• Oral hygiene instruction

• Smoking cessation

• Nutritional counseling

• Correction of restorations

• Periodontal debridement/oral prophylaxis (multiple appointments)

• Tissue response: re-evaluation (4-8 weeks)

Phase II: Periodontal Surgery

• Reduction/ elimination of inflammation before surgical phase

• Access to deep periodontal pockets

• Various surgeries

• Arrestive or regenerative surgery

• Periodontal plastic surgery (gingival recession)

• Ridge augmentation

• Crown lengthening

Phase Ill: Restorative Care

• Final restorations are completed

• All dental health care professionals involved:

• Dental hygienist

• General dentist

• Periodontist

• Prosthodontist

Phase IV: Maintenance Care

• Periodontal maintenance

• important for monitoring the overall dental health of the patient and to recognize, identity, and manage other diseases or conditions found within or related to the oral cavity.

Periodontal maintenance Objectives

1. To prevent or minimize the recurrence of periodontal diseases in patients by controlling risk factors known to contribute to the disease process (biofilm, calculus, etc.)

   
   

2. To prevent or reduce the incidence of tooth or implant loss by monitoring the dentition and prosthetic replacements of natural teeth

3. To increase the probability of locating and treating other conditions or disease found in the mouth

   
   

4. To preserve the health, comfort, and function of the teeth

Periodontal Maintenance Is indicated for:

• Patients who respond favorably after periodontal therapy to prevent or minimize recurrence and progression

• Medically compromised patients or those with poor oral hygiene and aren't candidates for periodontal surgery

Periodontal Maintenance Code

D4910

Treatment of Patients with Aggressive Periodontitis

• Similar treatment as in chronic periodontitis

• Additionally, usually requires systemic antibiotics because bacteria invade connective tissue

• Referral to periodontist is necessary

Treatment of Patient with Necrotizing Ulcerative Gingivitis (NUG)

• Patient may be in severe pain

• Analgesics and antibiotics may be prescribed

• 24 hour re-appointment

• Periodontal debridement

• Patient scheduled for maintenance appointment

Treatment of Patient with Necrotizing Ulcerative Periodontitis (NUP)

• Tissue and bone necrosis

• Systemic involvement (immunosuppressed patients)

• Referral to periodontist is necessary

Treatment for Patients presenting with Peri-implantitis

• Mechanical debridement

• Oral hygiene instruction

• Mouthrinses (therapeutic) like Chlorhexidine Gluconate (**binds to salivary proteins and enters the bacterial cell wall to cause death

• Local chemotherapeutic agents

• Referral to periodontist is necessary

Antibacterial Periodontal Therapy

• Mechanical means (physical removal of bifilm)

• Chemical means (chlorhexidine, medications, etc.)

Antibiotic Therapy

• Target specific bacteria in pocket, concentrates in GCF, multiple drugs can be used (doxycycline and minocycline are great choices)

• Adverse side effects, dilution of drug, patient non-compliance, reinfection or bacterial resistance

• Use for refractory, aggressive, medically compromised patient, NUP, regenerative procedures, implants

Locally applied

• Topical: oral rinses and oral irrigation

Locally Applied Antibiotics Indications for use:

• Non-responding periodontal sites

• 5mmt sites with BOP

• Controlled-release/ sustained-release: powder, gels, chips

Drug delivery systems

• Place subgingival into the pocket

• Active ingredient will slowly release within 24 hours (sustained release) or greater than 24 hours (controlled release)

• Used in conjunction with scaling and root planing

• Best time is after initial debridement when patient returns for a re-evaluation and localized sites are noted as nonresponding

Periochip

• gelatin matrix from bovine -may not be accepted by vegans

• 2.5mg of chlorhexidine gluconate

• absorbed

Atridox

• powder or liquid that are mixed together in a syringe and injected into pocket

• contains doxycycline hyclate gel

• gel solidifies once it contacts the GCF

• absorbed

Arestin

• cartridge - chalky formed substance

• made of minocycline HCI microspheres

• device is placed into depth of sulcus and released into pocket

• absorbed

Bacteria are the culprits in initiating periodontal disease, however, host inflammatory mediators that are produced in response to the bacterial antigens are also partially responsible for periodontal tissue breakdown (T/F)

True

Polymorphonuclear leukocytes (PMNs=white blood cells) synthesize and release _______\

Collagenase

Collagenase is an enzyme that breaks down collagen (connective tissue) and is part of the family of matrix ________

metalloproteinases (MMPs)

sub-antimicrobial doses of ________ inhibit collagenase activity

tetracycline (doxycycline)

Doxycycline

• 20 mg tablets

• Taken twice a day for 90 days

Enzyme suppression therapy

To be used in conjunction with scaling and root planing

• Reduction in probing depths

• Gain in clinical attachment levels

• Prevents disease progression

Useful as adjuncts to conventional periodontal therapy in certain patients

• Aggressive periodontitis patients

• Refractory patients

• No use in chronic periodontitis patients

The selection of an effective antibiotic for systemic use depends on

knowledge of the bacteria likely to be present and their susceptibilities.

Subantimicrobial doses of doxycycline hyclate (generic) is indicated for

chronic periodontitis patients

Dentifrices

• Fluoride dentifrice- most widely used form of self-applied fluoride (recommended for children and adults)

• Stannous fluoride

• Triclosan

• Sodium bicarbonate/hydrogen peroxide

• Tartar control

• Zinc citrate

• Herbal and natural

Currently, evaluating attachment loss of gain is one of the most valid measurements of the status of periodontal disease (T/F)

True

Gingival Crevicular Fluid Assays Test for:

• Host derived enzymes

• Test detects risk up to 6 months prior to occurrence

• Indicators for Attachment loss and bone loss

• Collagenase (Periocheck) & Elastase among others

• Inflammatory mediators

• Associated with bone loss and inflammation

• Prostaglandin E2 (PGE2)

• Cytokines

• Tissue-break-down products

Culturing Bacteria

• Method

• Paper points

• sterile curet

• Gold standard

• Advantages

• Disadvantages

Phase Contrast Microscope notes

• Age of plaque

• Morphology

• Motility

• Does not Identify specific species of bacteria

Nucleic acid probes (DNA probes)

• Identify the DNA sequence for specific periodontal pathogens.

• Very reliable

• Micro-Ident- Plus

• tests for up to eleven pathogens

• Reserved for refractory patients

Immunoassays

* detect specific antigen-antibody reactions

1. Immunofluorescent microscopy

2. Enzyme immunoassay

3. Latex agglutinations or clumping

Genetic Assays

• The most recent technical advance

• Measures individual's genetic tendency to periodontal disease

• Does not diagnose disease but, it identifies individuals who have increased susceptibility

• It uses a finger-stick blood sample

Interleukin-1 (IL-1)

•A cytokine produced and secreted by macrophages

• Responsible for inflammation and bone loss

• Severe periodontal disease has been demonstrated

• some individuals produce too much

Advanced Diagnostic Techniques Are indicated for:

• Advanced diagnosis

• Treatment planning

• Rapidly progressive perio

• Non-responsive

• Medically compromised

• More frequent visits

• Use of antibiotics

• Assess Treatment Success

Salivary Diagnostic Assays

• Oral DNA Labs:

• Identifies the type and concentration of specific perio-patogenic bateria that are known to cause periodontal disease.

• MyPerioPath® helps support the clinician with better risk assessment and personalized treatment options for more predictable

patient outcomes.

68

PST™ (Periodontal Susceptibility Testing)

• Blood test

• Determines IL-1 genotypes

• An IL-1 gene-positive patient is more susceptible to periodontal diseases

• Severe periodontal disease has been demonstrated

• some individuals produce too much IL-1