perio tri 2

list some differences between a periodontal pocket and a sulcus in health

• plaque and biofilm more subgingival

• apical migration of junctional ep.

• sulcular epithelium turns to pocket epithelium (often ulcerated)

• lower collagen in region and higher inflamm cells

• apical movement of bone

what is biological width?

• the length of JE and connective tissue attachment

• aka the bare min length btwn bone and sulcus

• average is ~1mm

why do we have an average biological width?

• without this, it will move apically until it has enough room to attach.

• alv bone resorbs to give room for JE and connective tissue

• OR

• it wont’t resorb and has constant inflamm/irritation (local chronic gingivitis)

why is biological width important in respect to crowns?

• easy to just electrosurge gums (stops bleeding then crown prep)

• but, if width impeded, prep is done subging

• 2 outcomes

  1. inflamed, hypertrophic, irritated gums (ugly)

  2. recession unaccounted for as bio. width reestablished itself and crown and tooth margins can be seen

what are the histological features of periodontal pockets?

• epithelium has loads of immune cells and is degenerated/necrosed

• increase in blood vessel size and number

• apical movement of ep. into connective tissue

• degeneration of sulcus ep into pocket ep

• ulceration, bleeding, suppuration (histologically)

what are the histological contents of a periodontal pocket?

• debris

• bacteria

• bacterial products

• calculus

• food

• GCF products

• leukocytes

• pus

what are the five zones of the periodontal pocket?

1. cementum covered by calc (tissue changes occuring)

2. attached plaque (over calc, extends apically)

3. unattached plaque (surrounds att. plaque and extends apically)

4. JE reduced attachment in disease (autoimmune)

5. JE attached to tooth - reduced in disease

clinical features of periodontal pockets

• foul taste

• urge to dig

• hot and cold sensitivity

• localised pain/pressure

is pus related to peridontal disease severity? why/why not?

• not related to it

• reflects nature of inflammatory changes in pocket wall

• pockets can be firm and fibrotic w little BOP and still have inflamm changes occuring (eg smokers)

• doesnt necessarily mean pocket is getting worse

what are some factors affecting probing depth?

• operator (pressure, angle, mood, sensitive pt)

• instruments (shape/size, type)

• pt (inflamm, calc, touchy)

bone loss should be seen as a _____ of the balance of bone turnover

decoupling

why is decoupling important?

susceptible pts will have cytokines and prostoglandins which will affect OPG and RANKL ratio, (change in how stimulated osteoblasts and clasts are, causing resorption)

state the radius of action for plaque

• 1.5-2.5mm for plaque

• after 2.5mm - no effect on bone

why would you get supra and infrabony pockets in different regions?

• there is a limited distance of inflammatory diffusion

• eg if 1mm bone - all will go

• but if 5mm, infrabony will lose 1.5-3mm

list the different types of periodontal pockets

suprabony pocket

• base of pocket coronal to bone crest

• horizontal bone loss

• horizontal arrangement of transeptal fibres

infrabony

• base of pocket apical to bone crest

• vertical (angular) bone loss

• oblique arrangement of transeptal fibres

• angular pattern of bony architecture

• classified by walls remaining and angle of bone loss (in context of radiographs)

flip over for walls diagram

furcations are a local anatomical complication which can lead to…

excessive localised bone loss

furcation grade is related to increased prognosis. elaborate.

• grade 1) furcation plasty

• grade 2) may try to regenerate bone

• grade 3) root sectional tunnel prep

• all can be non surgical

bone loss vs age calculation

• % bone loss / age

• eg 20mm root with 10mm bone los is 50%. in 50 yr old would be BL/age = 1

• can also estimate from radiograph

explain about past bone loss being used as a prognostic indicator for a tooth

• used to be a prog. indicator ab whether the tooth can be saved but its not that accurate

• you can tell past damage and may show speed and risk the pt is at, but not entirely reliable

• so, dont just extract it if its poor prog, may still have 50% chance lol

• prog also tends to improve as its treated

• infrabony pockets has been used in the past but not commonly used to determine prog, instead to dictate different tx plans

tx options for horizontal bone loss/shallow bone loss

• non surgical debridement, open flap debridement with or without minor osseous ressective surgeries

tx options for vertical bone loss/shallow bone loss

non surgical debridement (finer tips required)

open flap debridement w regen technqieu like GTR

ressective (drill away bone loss to remove pocket) would result in massssive recession and loss of perio tissues

what is NSPT

• part of perio tx that consists of:

  • plaque removal

  • plaque control

  • supra and sub and root debridement

  • adjunctive use of chemical agents

difference between historical and contemporary concepts in NST

• historically, root planing removed the diseased cementum and dentin to restore biocompatibility of perio diseased root (i/e get a smooth root)

• nowadays perio debridement gives minimal iatrogenic damage to the soft tissues and cementum

• its instrumentation to disrupt and remove biofilm

• no intentional cementum removal as LPS don’t adhere to cementum

• surface irregularities should be removed if possible but not aggressively

rationale of NST

• perio associated w biofilm on root. to control need to disrupt subging biofilm so the immune response can overcome the bacterial challenge/invasion

• even with meticulous scaling you cant remove all deposits from pockets/roots

• individual threshold of bacterial load. if below, host can cope

• goal is to disrupt and modify subging biofilm to reach below threshold load for all tooth sites

• must address host related and mod factors (eg diabetes, stress, smoking)

aims of perio therapy

• control bacterial infection

• arrest/slow perio disease prog

• return tissue to non inflamed state thats manageable by pt

• changing disease prognosis

• decreasing signs/symptoms of disease

what happens if the working end angle is too obtuse/acute in subging scaling?

OBTUSE

• cratering/consequent roughening of the root

ACUTE

• ineffective removal and burnishing of subging calc

give details about ablative laser devices

• bactericidal detoxification effects

• can remove biofilm and calc with really low mechanical stress and no formation of a smear layer on root

• can remove epithelium lining and inflamed tissue within perio pocket

• common type) Er:YAG

pros and cons of mechanical instrumentation

PROS

• easy to use/less learning curve

• reduced instrumentation time

• acoustic turbulence/cavitation

• fluid lavage

• access to deep sites

• preferred by some

CONS

• communicable disease can be disseminated by aerosols (hep, flu, resp infections)

• resp dise pts with difficulty breathing

• types of cardiac arrest

• young growing tissues, wide plural chamber

• high suscep to opportunistic infections that may be transmitted by contaminated dental unit water/aerosols

anatomical and host response factors that can limit the effectiveness of debridement

ANATOMICAL

• deep probing depths

• root concav

• furcation

HOST

• diabetes

• pregnancy

• stress

• immunodeficiency

• blood dyscrasias

3 approaches to subgingival debridement

1. full mouth instrumentation - two sessions of SRP within 24 hours, each covering ½ dentition.

2. full mouth disinfection - full mouth SRP and extensive microbial regimen with CHX. rinse mouth and spray tonsils 2/xday with this after SRP

3. conventional staged quadrant-wise SRP in weekly intervals (one week inbetween appts. one Q at a time)

chemical plaque control agents mechanism of action

• prevent bacterial adhesion

• avoiding bacterial growth and/or co-aggregation

• eliminating an already established biofilm

• altering pathogenicity of biofilm

goals of NST

• full mouth BOP score and PI <25%

• PD <4mm

• furc involv <grade 2

• pink and firm gingival tissue

• decreased mobility of teeth

• pt satisfaction

outcomes of NST (clinical)

inc recession

reduction of PD

less BOP

full mouth plaque score reduced

outcomes of NST (general)

• molars generally less improvement than single rooted teeth

• smoking can -vely affect outcome of all modalities of perio therapy

• around 50% pockets with initial probing depth of >=7mm will remain as non successful sites

• after re-tx, probability of pocket closure is around 45%

• <6mm PPD, ~12% will be unsuccessful

• poor response after repeated re-eval may need other tx like antimicrobials, open flap and surgical pocket reduction

what is in cigarette smoke?

• over 4000 chemicals

• gases (carbon monoxide, nitrogen oxides)

• liquid vapours (formaldehyde, methane)

• tiny solid particles (phenols, nicotine)

• metals and radioactive compounds

which substances in cigarettes contribute to causing disease the most?

• tar

• nicotine

• carbon monoxide

give details about tar (cigarettes)

• solid particles inhaled

• large variety of organic and inorganic chemicals and carcinogens

• can vary in ratio of carcinogens and other substances

• stains lung tissue

• average 15-20 a day smoker has a full mug of tar in their lungs every year

give details about nicotine (cigarettes)

• drug that causes addiction

• affects body quickly once inhaled. once it reaches the brain, releases dopamine

• changes brain structure and working - leading and maintaining addiction

• raises heart rate, bp, hormones affected CNS, constricts blood vessels

• highly toxic and manufacture, use and sale is under control of State Poisons Acts, except when in tobacco

give details about carbon monoxide (cigarettes)

• competes with oxygen in blood

• affinity for CO is approx 210x stronger than O on hemoglobin

• large quantities is fatal rapidly

• smokers can have 10x the amount of CO in bloodstream compared to nonsmokers

give details about smoking related deaths

• 2/3 lifetime smokers will die from smoking caused disease

• remains leading cause of death in aus

• 1/6 men and 1/8 women still smoke

• sequelae of tobacco caused death and disease will remain for decades to come

list some diseases and/or health problems caused by smoking

CANCERS

• lung, throat, mouth, oesophagus, pancreas, stomach, liver, kidney

• smoking related cancers was 20-30% of all cancer deaths in 2010

HEART DISEASE

• 1/3rd of all cases under 65 are due to smoking

COPD

• includes emphysema and small airways disease

• emphysema rare in non-smokers

CHRONIC BRONCHITIS

• occurs in ½ of heavy smokers

• recurring cough and increased phlegm

STROKE

• under 65 yrs 3x more likely to have one

PERIPHERAL VASCULAR DISEASE

• narrowing of leg arteries that can lead to blockage and in some cases amputation

• smoking is main risk factor

oral problems caused by smoking

• cancers

• periodontal diseases

• periodontitis

• necrotising gingivitis/periodontitis

• impaired surgical wound healing

give details about the link between smoking and oral cancer

• more than 80% of oral cancer occur in people who smoke

• longer and more you smoke, greater the risk

• someone who has ever smoked up to 9x more likely than non smoker to develop oral cancer

• 1 pack a day smokers 16x more likely than non smokers to develop larynx cancer

smoking and periodontal disease

• analysis of epidemiologic studies implicating smokign as a risk factor for perio disease is supported by:

• consistency of results across many studies

• dose-response of association

• temporal sequence (happenings in a space of time)

• biologic plausibility (method of reasoning - cause and effect relationship btwn biologic factor and disease/adverse event)

smoking and perio disease

• major risk factor

• severity directly related to…

• clinical presentation

• current/former smoking

• both no. cigarettes smoked/day and no. years pt has smoked

• ging bleeding and inflamm. more pockets in maxillary quadrants

• impairment of local neutrophil function

• affects healing ability

• smokers lose more perio bone than non

smoking and necrotising gingivitis/periodontitis

• involves bacteria (treponema, fusobacteria, gram - anaerobes)

• almost all pts smoke even though stress, fatigue, lack of sleep, poor OH are all factors

effect of smoking on periodontal tissues

• reduction of blood flow and vascularity 9reduced ging bleeding)

• more perio pathogens

• -ve effects on cytokine and growth factor production

• inc. expression of cytokines involved in perio destruction

• acrolein and acetaldehyde inhibit gingival fibroblasts

• -ve effects on polymorphonuclear leukocytes causing abnormal phagocytosis

impact of smoking on therapeutic outcomes

• scaling/debridement (50-75% improvement)

• antimicrobial therapy (adjunctive)

• antimicrobial doxycycline therapy (brings response to that of non smokers)

• site development and implants (2x failure rate)

role of dental professionals in smoking cessation

• key to prevention and control of perio disease (bc it affects bacterial and host etiological components in disease process)

• need to increase involvement of dental professionals in management of pts who smoke

• less than 20% clinicians felt confident in ability to provide cessation counselling

• comprehensive intervention programs

health belief model application to smoking cessation

• perceived susceptibility) personalise risk based on person’s features or behaviour

• perceived severity) specify consequences of risk and condition

• perceived benefits) identify and reduce barriers through reassurance, incentives, assistance

• cues to action) how to info, awareness, reminders

• self-efficacy) training, guidance in performing action

stages of change model application to smoking cessation

• pre-contemplation) increase awareness of need for change, personalise info on risk and benefits

• contemplation) motivate, encourage

• prep) assist in making concrete plans, gradual goals

• action) feedback, problem solving, social support

• maintenance) assist in coping, finding alternatives, avoiding relapse if possible

5 A’s of smoking cessation

• ask

  • ab smoking in each appt

  • system for recording can help them stop bc it implies its important

• assess

  • the pt’s willingness to quit

  • asking ‘how do you feel ab smoking atm’ is enough

  • also assess level of nicotine dependence

• advise

  • and educate pt on quitting benefits

  • should be done in supportive, unambiguous, clear way

  • can link to pt’s health concerns

• assist

  • pt with developing quit plan

  • eg concrete help from GP, other staff or referral to quitline

• arrange follow up visits

  • helps keep them on track

  • phone call/appt after 1 week and 1 month can help encourage, give advice etc

  • at future consults, should congratulate quitted pts and encourage pts who relapsed with the 5 A’s

RULE and smoking cessation

• Resist righting reflex

• Understand pt’s own motivations

• Listen with empathy

• Empower the pt

5 R’s and smoking cessation

• Relevance: help pt identify why quitting is relevant

• Risk: encourage pt to verbalise negative outcomes of tobacco use

• Rewards: help pt identify benefits of quitting

• Roadblocks: help pt identify possible roadblocks, incl from past quit attempts

• Repetition: might take more than one brief intervention

____ ____ is an important determinant of disease susceptibility

host response

what does the variability in periodontal disease expression derive from?

• the variations in the host response to subgingival microbiota

4 parts of host modulation

1. anti-inflammatory drugs

2. anti-cytokine and biological therapies

3. matrix metalloproteinase inhibitors (MMP in)

4. lipid mediators

non steroidal anti-inflammatory drugs and host response

• selective cyclo oxygenase-2 inhibitors modifies prostaglandin production in perio tissues and potentially enhanced clinical tx outcomes

• NSAID’s have been extremely investigated for adjunct anti-inflammatory treatments for periodontitis

do NSAID’s have any clinical benefits?

• limited benefits

• this with a real risk of serious unwanted effects, precludes their use as drug tx for perio

what is anticytokine/biological therapy?

• range of drugs that are used particularly in tx of rheumatoid arthritis

• some also used in other chronic inflamm/autoimmune diseases like crohn’s disease (IBD), psoriasis and ulcerative colitis

anticytokine/biological therapy and perio

• no studies have evaluated its effects for perio specific tx

• but perio status has been evaluated in pts before and 6months after commencing therapy for management of rheumatoid arthritis

• in this study, perio paramters (plaque, bleeding, depths, AL) didnt vary that much from before to 6 months later with the anticytokine drugs

matrix metalloproteinase inhibitors (MMI’s)

• doxycycline, inhibits MMPs

• MMPs = zinc dependent enzymes that degrade a variety of extracellular matrix proteins, incl collagens

• MMPS fundamental in perio tissue breakdown

• MMP secreted by resident and infiltrating cell types in periodontium (incl neutrophils, macrophages, keratinocytes, fibroblasts, osteoclasts, endothelial cells)

what is the predominant MMP associated with periodontitis collagen breakdown? (+doxycycline effect)

• MMP-8 and MMP-9

• secreted by high no’s of infiltrating neutrophils that are recruited to inflamed perio tissue

• doxycycline identified to be more effective inhibitor of MMP-8 than MMP-1

doxycycline could be useful for…

• reducing pathologically elevated MMP levels without interfering w normal connective tissue turnover

• so these findings led to intro of low dose of doxy (20mg 2x/day) - first host response modulation drug licensed for perio treatment (called ‘submicrobial’)

• shown to be safe and result in ++ clinical outcomes when used as adjunct to NSPT in controlled clinical trials

• called Periostat

lipid mediators (PUFAS)

• fatty acids naturally occuring dietary constituents that have extensive metabolic, structural and functional roles in the body

• important for energy and present in cell membranes

• few studies done to investigate impact on perio, so its a developing area of research

two main PUFAs: omega-6 and omega-3

• cant be made in the body and have to be taken thru diet (fish, nuts etc)

• most important long chain (LC) PUFAs are d-3 derivatives - DHA, EPA and DPA and n-6 derivative AA

• d-3 main one, AA less important

clinical fish oil studies (lipid mediators)

• used diet supplements (w fish oil and low dose aspirin) as adjunct to conventional NSPT

• greater probing depth reduction and greater reductions in salivary RANKL levels and MMP-* were noted in pts receiving the adjunct compared to controls (who just had NSPT)

• RANKL - osteoclast generation

why don’t we use NSAID’s as drug therapy? what is the only drug therapy for perio disease licensed for use?

• risks far outweigh benefits in terms of reduction of alveolar bone resorption

• 20mg doxycycline 2x/day for 3 months only available host mod agent available for perio tx

_________________ appear to offer the best potential for the development of a new class of drug therapies that could be used as adjunctive host mod therapies in perio

• pro-resolving lipid mediators

• main benefit: physiological resolution agonists that are produced exogenously as part of normal response to inflammation, as opposed to being inflamm. inhibitors that could compromise host defences

what is the main goals of periodontal therapy?

• prevention of tooth loss

• no BOP (resolution of lesion)

• pocket closure (<4mm)

• NSPT is effective in lowering BOP and PD mostly. but sometimes it can be persistent

can you treat 6-8mm pockets with NSPT?

• traditionally thought >6mm could only be surgical

• but studies say that good OH, good debridement and maintenance, NSPT can be successful

• furcations, premolar grooves, and inaccessible anterior sites may not respond well to just scaling tho

• these places should be re-evaluated at review and surgery considered for non-responding sites

surgery vs non surgery outcomes

• surgery = ++ short term PD reduction than non. but adv is lost over time

• shallow pockets) surg = greater AL than non

• no long term differences in mean AL change between surg and non-surg

why don’t we do surgical tx right after the periodontal examination?

• don’t know pt compliance

• don’t know pts subjective needs for corrective phase

• inflamed tissues are challenging to manage surgically

• NST gives opportunity to eval tissue response and reinforce home care

when should surgery be considered/is appropriate?

• on the bases on its ability to facilitate subging plaque removal and enhance long term preservation on perio tissues

• 2 purposes: control of disease, perio plastic surgery

main objective of surg therapy

• improve prognosis of the tooth by one or more of the following:

  • allow access for effective root surface debridement

  • improve gingival or tooth morphology to facilitate pts self care

  • regenerate lost periodontal attachment

examples of when surgical treatment is appropriate

• when intraosseous defects limit access for root surface debridement

• correction of gingiva-alveolar mucosal problem

• aesthetic improvement

• perio plastic surgery - eg crown lengthening

case selection of perio surgery

• subject, tooth and site specific factors have to be considered, pts may need to be referred to specialist

• compliance, pts with poor plaque control, poor commitment to tx, poor response to initial therapy = NOT GOOD CANDIDATES LOL - surg without maintenance may inc risk of progression

• uncontrolled diabetes, smoking/stress may affect tx response

• furcation + location, malposition/root proximity, occlusal factors - tooth factors

• site factors - root morphology, pocket depth, bone/soft tissue anatomy may also influence healing potential

• medical contraindication

medical contraindications and surgical therapy

• blood disorders like haemophilia

• anticoagulant where INR is high

• uncontrolled diabetes

• uncontrolled hypertension

• immunocompromised pts (blood disorder, immunosuppressive drugs)

surgical approaches

• types of approach) conserative to preserve tissues, resective to remove tissues, or reconstructive to regenerate tissue

• choice will vary according to factors)

  • anatomy of residual pocket

  • anatomy of tooth

  • position of tooth in dental arch

  • complexity and predictability of the technique in different case scenarios (eg pt and operator factors)

type of surgical techniques

pocket reduction procedures

• open flap debridement

• modified widman flap

pocket elimination procedures

• soft tissue

  • gingivectomy

  • apically reposition flap

hard tissue

• osseous surgery

• resective procedures of furcation involved teeth

regenerative procedures

• guided tissue regeneration (GTR)

• root surface modification

open flap debridement

• reduced flap/access flap aka

• main goal to improve visibility + access for subging instrumentation of both soft + hard root surface deposits which couldnt be removed by non-surgical methods

open flap debridement techniques

• intra-sulcular incisions and full thickness mucoperiosteal flaps

• removal of granulation tissue

• thorough root surface debridement

• replacement of flap margins to og position and held w sutures

outcomes of open flap

• not intended but some pocket reduction can happen, depending on soft tissue phenotype (thin/thick) and morphology of underying bone lesions (supra/infra bony)

• gingival recession can be minimised by microsurgical techniques and minimally invasive surgical approach

modified widman flap objective

• historically designed as an access flap with removal of the inflamed pocket epithelium

• aim to remove marginal tissue cuff to achieve direct post op pocket depth reduction

mod widman flap technique

• initial scalloped inversed bevel incision 1mm from gingival margin and parallel to long axis of tooth

• mucoperiosteal flaps within within attached gingiva

• second incision to bone crest to separate tissue collar from root surface

• remove soft tissue collar

• removal of granulation tissue, mechanical instrumentation of the root surface and replacement of the flap

outcomes of mod widman flap

• greater pocket depth reduction than open flap bc of ++ potential for post op gingival recession

• more technically demanding than open flap tho

gingivectomy objective

• remove soft tissue wall of perio pocket to achieve pocket elimination

• surgically manage gingival overgrowth (hyperplasia) where its larger without apical migration of junctional epithelium (pseudopocketing)

• causative factors should be controlled before surgical tx

gingivectomy technique

• identify base of pocket w probe

• mark outer aspect of gingiva with bleeding point

• first incision is scalloped external bevel incision 45 deg to long axis of roots apical to bleeding points so incision is at level slightly apical to pocket base

• removal of detached gingiva

• gingivoplasty to create better aesthetic contour

gingivectomy outcomes

• exposed tissue will heal by secondary intention

• perio dressing can be used to cover exposed area to reduce post op discomfort and bleeding

• when limited attach gingiva, mod widman flap might be better

apically repositioned flap objective

• reduce pocket, maintain adequate zone of attached gingiva by displacing flap of gingiva and mucosa in apical direction

• palatal surface of upper jaw - lack of mucosa to allow apical displacement of flap, or when sufficient attached gingiva, purely resective technique (inverse bevel incision) can be used

apically repositioned flap outcomes

• pocket reduction should be achieved in areas where soft tissue has apically displaced, however may be residual pocketing in areas of greater bone loss

osseous surgery objectives

• final position of ging margin following any periodontal surgical technique determined by anatomy of underlying bone

• aim = establish physiological anatomy of the alveolar bone at more apical level

• removal of tooth supported bone to be avoided

• osseous surgery commonly used in conjunction with apically repositioned flap and resective surgery but also can be used with pocket reduction flap techniques

osseous surgery techniques

osteoplasty

• removal of non supporting bone to facilitate flap adaptation

• often used in

  • elimination/reduction of shallow intrabony defects

  • reduction of thickness of buccal/lingual bone at interdental areas

ostectomy

• intentional removal of supporting bone to correct osseous defects when significant discrepancies in bone height remain following osteoplasty around teeth with sufficient perio support

• commonly used in

  • elimination of small peaks of bone that often remain in the line angles

  • correction of reversed osseous architecture

surgical treatment of furcation-involved multi-rooted teeth

• molars that exposed furcation area due to perio breakdown respond less favourably to non-surgical perio therapy

• earlier studies suggest that molars may have reduced prognosis, but more recent studies suggest that when managed properly and maintained, molars my survive for ages

surgical treatment of furcation-involved multi-rooted teeth - surgical treatment options

resective surgery

• furcation plasty

• root separation or root resection

regenerative surgery

furcation plasty

• diagnosing, txing and managing furcation areas, and predicting their prognosis are difficult due to variation in anatomy of multi rooted teeth

• perio pocket in furcation lesion is affected by the soft tissue phenotype (thin/thick), bone defect (horizontal/angular) and inter-radicular anatomy of the tooth

objective of furcation plasty

• enhance probability of pocket furcation closure following open flap

• odontoplasty (reshaping tooth), osteoplasty (reshaping bone), gingivoplasty (reshaping the gingiva) may be used

furcation plasty technique

• open flap in inter-radicular area

• odontoplasty to reduce the horizontal component of defect and widen the furcation entrance

• osteoplasty - reduce vertical component (get rid of intra-bony lesion) and horizontal component of defect (thickness of bone get rid of)

• position flap at level of alveolar bone crest

outcomes of furcation plasty

• improved access of furcation area for self care and professional supportive care

• aggressive odontoplasty should be avoided on vital teeth bc of hypersensitivity risk