Perio II, Lecture 4 - General Principles of Periodontal Surgery (Dr. Ahmad)

What is the currette's effective range?

5mm

Define the following:

Refers to a range of surgical procedures designed to treat and manage periodontal diseases, restore periodontal health, and improve the aesthetics of the gingiva and surrounding tissues

Periodontal surgery

What is...

- Essential for managing advanced periodontal diseases

- Crucial for restoring oral health and function

- Impacts patient's overall well-being and quality of life

Periodontal surgery

The following are what indications for periodontal surgery?

- Persistent pockets 5mm or more after non-surgical therapy

- To facilitate maintenance and prevent disease progression

Pocket depth reduction

The following are what indications for periodontal surgery?

- Intrabony defects

- Furcation involvements

Regenerative procedures

The following are what indications for periodontal surgery?

- Restorative purposes

- Gummy smile

Crown lengthening

The following are what indications for periodontal surgery?

- Treatment of gingival recession

- Addressing root sensitivity and esthetics

Root coverage

The following are what indications for periodontal surgery?

- Areas inaccessible to non-surgical instrumentation

Access for root debridement

The following are what indications for periodontal surgery?

- Gingival enlargement

- Aberrant frenum attachments

Correction of anatomical defects

The following are what indications for periodontal surgery?

- Ridge augmentation

- Implant site development

Pre-prosthetic surgery

The following are the goals of what?

- Arrest progression of periodontal disease

- Restore lost tissues

- Create maintainable tissue contours

- Support restorative procedures

Periodontal surgery

The following are the expected results of what?

- Reduction in pocket depth

- Gain in clinical attachment level

- Improved aesthetics and function

Periodontal surgery

What are factors influencing success of periodontal surgery?

- Patient compliance

- Consistent oral hygiene maintenance

- Regular follow-up visits

T/F: Generalized horizontal bone loss is a reason for perio surgery

False

T/F: A vertical bone defect is a reason for perio surgery

True

What are the three types of periodontal surgery?

- Access

- Resective

- Regenerative

What type of perio surgery is open flap debridement?

Access surgery

What type of perio surgery is impacted tooth exposure?

Access surgery

What type of perio surgery is gingivectomy?

Resective surgery

What type of perio surgery is osseous surgery?

Resective surgery

What type of perio surgery is crown lengthening?

Resective surgery

What type of perio surgery is guided tissue regeneration?

Regenerative surgery

What type of perio surgery is guided bone regeneration?

Regenerative surgery

What type of perio surgery is gingival grafting?

Regenerative surgery

What is the purpose of access perio surgery?

Access root/bone surfaces

What is the purpose of resective surgery?

Cut away gingiva or bone structure

What is the purpose of regenerative surgery?

Regenerate the tissue/bone

ID the type of surgery:

- Flap opened in order to clean of root/ implant surfaces

Access surgery

ID the type of surgery:

- Done to expose more clinical crown for a crown preparation

Resective surgery

ID the type of surgery:

Regenerative surgery

ID the surgery:

Osseous surgery

ID the surgery:

Gingivectomy

ID the surgery:

Crown lengthening

What is this technique?

Open flap debridement

What is this technique?

Impacted tooth exposure (canine)

ID the surgery:

Guided bone regeneration

ID the surgery:

Gingival grafting

What are the essential preparatory steps before periodontal surgery?

- Complete non-surgical therapy (SRP, OHI)

- Re-evaluation of treatment response

- Patient education on surgical procedure

What are three benefits of preparation for periodontal surgery?

- Reduction in surgical sites

- Improved tissue condition for surgery

- Increased comfort with dental environment

- Enhanced trust in dental team

- Reduced anxiety about surgical procedure

- More predictable surgical outcomes

- Potentially faster healing

What is positive arcitecture?

No bony craters, no deep periodontal pockets

When is appropriate to consider periodontal surgery?

A) Recurrent subgingival calculus

B) Severe gingival inflammation

C) Grade III mobility

D) Vertical bone loss

D) Vertical bone loss

What two criteria makes a patient eligible of periodontal surgery?

- Patients who exhausted non-surgical treatment options

- Patients who are healthy enough to undergo surgery

ID the ASA status and if you can proceed with periodontal surgery:

- Healthy pt, non-smoking

ASA I, yes

ID the ASA status and if you can proceed with periodontal surgery:

- Mild systemic condition (Current smoker, social alcohol drinker, pregnancy, obesity (30

ASA II, yes

ID the ASA status and if you can proceed with periodontal surgery:

- Poorly controlled, severe systemic disease (not controlled BP or DM, history of MI, pacemaker, etc)

ASA III, depends

ID the ASA status and if you can proceed with periodontal surgery:

- Life-threatening condition

- Recent MI (

ASA IV, no

ID the ASA status and if you can proceed with periodontal surgery:

- Ruptured abdominal/thoracic aneurysm

- Massive trauma

- Intracranial bleed

ASA V, no

ID the ASA status and if you can proceed with periodontal surgery:

- A declared brain-dead patient whose organs are being removed for donor purposes

ASA VI, no

Patients on what three types of medications/therapies are of high concern when considering periodontal surgery?

- Blood thinners (increased bleeding risk)

- Bisphosphonates (decreased bone turnover, MRONJ)

- Head/neck radiation therapy

INR values are only useful for patients on what medication?

A) Plavix (antiplatelet)

B) Xarelto (factor X antagonist)

C) Eliquis (factor X antagonist)

D) Warfarin/Coumadin (vitamin K antagonist, anticoag.)

D) Warfarin/Coumadin ( vitamin K antagonist, anticoag.)

Patients that are taking Warfarin (Coumadin) are eligible for surgery if their INR is less than ___

3.0

T/F: It is okay to stop a patients blood thinners just for a few days prior to periodontal surgery w/ out consulting their PCP

False, need med consult to alter

How do you manage bleeding for patients that take blood thinners?

- Compression

- Suturing

- Local hemostasis

What is the key point for managing patients on anticoagulant therapy?

Prioritize patient safety: Balance between bleeding risk and thromboembolic risk

What medication inhibits osteoclasts, decreasing bone turnover?

Bisphosphonates

For patients on bisphophonate therapy, what is the risk of medication-related osteonecrosis of the jaw (MRONJ) after periodontal therapy?

1.7%

Alendronate is associated with a higher incidence of MROJ with a 95% predilection for where in the mouth?

Posterior mandible

What is the most common prescription reason for bisphosponates?

Osteoporosis (Fosamax)

What is the main trigger for MRONJ?

Tooth extraction

What are the risk factors for bisphosphonates?

- IV administration

- Therapy duration

- Corticosteroid use

Consider discontinuation of oral bisphosphonates ____ months before/after surgery if therapy >3 years. Also, stage non-critical treatments ____ months between sextants

3 months, 2 months

What medication?

- Optimize dental health before therapy initiation

- Collaborative decision-making with medical team

- Emphasize oral hygiene and appropriate antibiotic use

IV bisphosphonates

T/F: According to American Association of Oral and Maxillofacial Surgeons position paper (2009), although the risk of developing MRONJ with oral bisphosphonates is low, it appears to increase when therapy lasts more than 3 years or in a shorter period with certain comorbidities such as chronic use of corticosteroids. They recommended that, systemic conditions permitting, the clinician consider discontinuing the use of oral bisphosphonates for a 3-month period before and after elective invasive dental surgery as a means of reducing the risk of MRONJ. The ADA recommends staging of non-critical dental treatment, allowing 2 months between sextants to assess for the development of MRONJ before the next one is treated.

True

T/F: If conditions permit, initiation of bisphosphonate therapy should be delayed until dental health has been optimized. This should be a collaborative decision by the treating physician, dentist, and other specialists involved in the care of the patient. MRONJ development may be reduced by optimizing oral hygiene and postoperatively using topical and systemic antibiotics as appropriate.

True

The following are complications of what treatment?

- Oral Mucositis

- Oral Infections (primarily candidiasis)

- Xerostomia

- Taste Dysfunction

- Osteoradionecrosis

Head and neck radiation

Evaluation and treatment of perio surgery (ex: extractions, surgery) should occur at least ____ weeks BEFORE radiation begins

2 weeks

What periodontal treatment can you do during radiation treatment?

None - have patient maintain rigorous oral hygiene

You should allow ___-___ months of healing AFTER radiation before resuming surgical or denture therapy

6-12 months

What are the key points for radiation therapy and periodontal considerations?

- Proactive approach crucial

- Interdisciplinary collaboration essential

- Long-term follow-up necessary

Med Consult should be obtained before performing periodontal surgery on all of the following EXCEPT

A) ASA I

B) Pts undergoing anticoagulant therapy

C) Immunosuppressed

D) Patients with history of head and neck radiation

A - should be ASA III (complex medical history, ex: Recent myocardial infarction, and Recent stroke, Pacemaker)

T/F: It is okay to prescribe medications without physician approval

NO!! Never alter prescribed medications without physician approval & Document all physician communications in electronic health record

What is the standard pre-operative procedure?

0.12% chlorhexidine (peridex) for 1 minute

When are antibiotics prescribed after periodontal therapy?

On a case-by-case basis

The AHA recommends premedication for what four conditions?

- Prosthetic cardiac valves

- History of infective endocarditis

- Unrepaired congenital heart disease

- Cardiac transplant recipients

What is the standard antibiotic pre-medication for patients that require it?

2g amoxicillin 1 hour before procedure

What is the standard antibiotic pre-medication for patients that require it and are allergic to penicillin?

Any of the following 1 hour before procedure:

- 2g Cephalexin

- 500mg Azithromycin

- 500mg Clarithromycin

Is antibiotic prophylaxis recommended for joint replacement patients?

No (consider if specifically recommended by orthopedic surgeon)

ID type of material

- Patients own tissue

- Excellent biocompatibility

Autograft

ID type of material

- Human donor tissue

- No second surgical site required

Allograft

ID type of material

- Animal derived material (bovine/porcine)

- Similar structure to human bone

Xenograft

ID type of material

- Synthetic material

- No disease transmission risk

Alloplastic

What are four potential complications of periodontal surgery?

- Bleeding

- Infection

- Swelling

- Tooth sensitivity

What is known as the 'cornerstone of surgical success'?

Hemostasis

All of the following are intrraoperative benefits of hemostasis during surgery EXCEPT:

A) Ensures clear surgical field

B) Enhances precision of surgical manuevers

C) Increases blood loss

D) Prevents blood aspiration

E) Reduces interruptions

F) Optimizes surgical time

C) MINIMIZES blood loss

What is the first-line intervention for hemostasis in periodontal surgery?

Epinephrine in local anesthetic (1:100,000 or 1:50,000) - do not use for hemostasis just before dismissing patient

What are three intraoperative techniques for hemostatic surgery in periodontal surgery?

- Thorough removal of inflamed tissue

- Compression with moist gauze

- Strategic suturing

All of the following are ADVANCED Management of surgical bleeding EXCEPT:

A) Gelatin sponge (Gelfoam)

B) Oxidized cellulose (Surgicel)

C) Collagen (CollaTape, CollaPlug)

D) Tranexamic acid (oral rinse, tablet)

E) Electrocautery

F) Suturing

F - This is a FIRST LINE INTERVENTION technique for hemostasis

T/F: You can rely on vasoconstrictor-containing anesthetics for final hemostasis

False - avoid sole reliance (Be prepared to manage potential rebound bleeding)

What has the following advantages?

- Wound protection

- Patient comfort

- Surgical site stability

Periodontal dressing (Co-Pack)

What has the following characteristics?

- Composed of a base (xinc oxide, fatty acids, rosin) and catalyst (liquid containing metal salts)

- A two-component material that hardens into a stiff rubber-like compound after mixing

- Sets within 5-10 minutes

- It is used as wound covering for 7 days (removed at post-op appt)

- Also used for tissue positioning (e.g. apically positioned flap)

- It does not accelerate healing

- Plaque may accumulate underneath

- May loosen and irritate/discomfort patient

- Risk of infection

Periodontal dressing (Co-Pack)

T/F: Coe-Pak can be used to accelerate healing

False, does not accelerate healing

T/F: While periodontal dressings offer several benefits, their use should be judiciously considered based on specific case requirements and potential drawbacks.

True

What is prescribed as post-op pain management medication for most perio cases?

- Ibuprofen (400-800mg) every 6-8 hrs

- Or combination therapy: Ibuprofen 600mg + acetaminophen 500mg

What is prescribed as post-op pain management medication for perio cases (prescription-strength NSAIDs)?

- Naproxen sodium: 550mg twice daily

- Celecoxib: 200mg daily (for patients with GI concerns)

What can be prescribed as post-op pain management medication for complex perio cases?

Hydrocodone/acetaminophen (Vicodin) 5mg/325mg every 4-6hrs needed - limit to 3-day supply when possible

Before dismissing a patient, what are important post-operative care instructions to share?

- Take medication as prescribed

- Avoid alcohol

- Cold compress (intermittently for 24 hours)

- Expect some swelling; should subside within 3-4 days

- Mild oozing is normal for 24-48 hours

- - If persistent, apply gentle pressure with gauze

- Avoid brushing surgical area; maintain hygiene elsewhere

- Rinse gently with prescribed mouthwash or salt water

- Cold, soft diet for first few days (gradually return to normal diet as comfort allows)

- NO smoking

- Adequate rest (reduce physical activity for 48 hours)

All of the following are take-home messages for this lecture EXCEPT:

A) Periodontal surgery is a crucial tool for managing advanced periodontal disease and restoring oral health.

B) Careful patient selection and pre-surgical preparation are essential for successful outcomes.

C) Various surgical techniques are available to address different periodontal needs.

D Hemostasis is critical for optimal visualization, patient safety, and procedural efficiency.

E) Post-operative care and patient compliance are vital for long-term success.

F) The ultimate goal is to impair patients' quality of life through enhanced oral health and function.

F - The ultimate goal is to improve patients' quality of life through enhanced oral health and function.

Which is correct with regards to periodontal tissue properties?

A) Gingiva is movable over the periosteum

B) Mucosa is attached to the periosteum

C) Gingiva is more keratinized than the mucosa

D) Mucosa heals without scarring

C) Gingiva is more keratinized than the mucosa

At the end of crown lengthening procedure, you notice that blood is slowly seeping from under the flap. What is the appropriate next step?

A) Inject 2% lidocaine with 1:50,000 Epi

B) Have the patient wait in the waiting room for 15 min

C) Remove sutures and place tighter ones

D) Compress the flap with moist gauze

D) Compress the flap with moist gauze

Which is the indication for periodontal regeneration surgery?

A) Grade III mobility

B) Vertical bone loss

C) Recurrent subgingival calculus

D) Severe gingival inflammation

B) Vertical bone loss