4: General Principles of Perio Sx

define perio surgery

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

why is perio sx important?

• Essential for managing advanced periodontal diseases

• Crucial for restoring oral health and function

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

what are some indications for perio sx?

• pocket depth reduction

• regenerative procedures

• crown lengthening

• root coverage

• access for root debridement

• correction of anatomical defects

• pre-prosthetic sx

which indication for perio sx:

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

• To facilitate maintenance and prevent disease progression

pocket depth reduction

which indication for perio sx:

• Intrabony defects

• Furcation involvement

regenerative procedures

which indication for perio sx:

• For restorative purposes

• To correct gummy smile

crown lengthening

which indication for perio sx:

• Treatment of gingival recession

• Addressing root sensitivity and esthetics

root coverage

which indication for perio sx:

• In areas inaccessible to non-surgical instrumentation

access for root debridement

which indication for perio sx:

• Gingival enlargement

• Aberrant frenum attachments

correction of anatomical defects

which indication for perio sx:

• Ridge augmentation

• Implant site development

pre-prosthetic sx

goals of perio sx

• Arrest progression of periodontal disease

• Restore lost tissues

• Create maintainable tissue contours

• Support restorative procedures

what are three expected results of perio sx?

• Reduction in pocket depth

• Gain in clinical attachment level

• Improved aesthetics and function

what are some factors that influence success of perio sx?

• Patient compliance

• Consistent oral hygiene maintenance

• Regular follow-up visits

what are the three categories of perio surgeries?

access, resective, regenerative

Open flap debridement and impacted tooth exposure are considered to be which type of perio sx?

access

gingivectomy, osseous sx, and crown lengthening are considered to be which type of perio sx?

resective

guided tissue regen, guided bone regen, andd gingival grafting are considered to be which type of perio sx?

regenerative

osseous sx: reshaping the jawbone and reducing deep pockets around the teeth

gingivectomy: removes excess, overgrown, or diseased gum tissue from around the teeth

crown lengthening: reshapes gum tissue and sometimes supporting bone to expose more of a natural tooth

open flap debridement: lifting the gum tissue away from the teeth to clean deep tartar and bacteria

impacted tooth exposure (canine)

guided bone regeneration: bone graft materials and a protective barrier membrane to regrow missing or weakened jawbone

guided tissue regeneration: uses a specialized barrier membrane to help the body regrow bone and connective tissue lost to advanced gum disease

gingival grafting: a dental surgery used to treat receding gums and cover exposed tooth root, stop recession

what are some essential preparatory steps for perio sx?

• Complete Non-Surgical Therapy (dont wanna work on bacteria loaded area):

  • Scaling and Root Planing (SRP)

  • Oral Hygiene Instruction (OHI)

• Re-evaluation of Treatment Response

• Patient Education on Surgical Procedure

what are some benefits of thorough prep for perio sx?

clinical advantages:

• Reduction in surgical sites

• Improved tissue condition for surgery

Patient-Centered Benefits:

• Increased comfort with dental environment

• Enhanced trust in dental team

• Reduced anxiety about surgical procedure

Treatment Optimization:

• More predictable surgical outcomes

• Potentially faster healing

what are some key considerations for pre-perio sx?

• Customize preparation based on individual patient needs

• Allow adequate time between non-surgical therapy and surgery

• Ensure improvement in patient's home care practices

• Ensure patient understanding and commitment to post-surgical care

ASA? Current smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40), well-controlled DM/HTN, mild lung disease

II - mild systemic disease

ASA? Poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, history (>3 months) of MI, CVA, TIA, or CAD/stents

III - severe systemic disease

ASA? Recent (<3 months) MI, CVA, TIA or CAD/stents, sepsis etc

IV - severe and constant threat to life

ASA? Ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed

V - moribund pt not expected to survive w/o operation

ASA? declared brain-dead organs being removed for donor purposes

VI

vitamin K antagonists, antiplatelet agents, and factor Xa inhibitors are…

anticoagulants

what is the acceptable INR for pts taking warfarin?

< 3 (worry about increased bleeding risk)

for pts on anticoagulation therapy what are we attempting to balance what two things?

balance bleeding risk and thromboembolic risk

bisphosphonates inhibit osteo(clasts/blasts/cytes) decreasing bone turnover

osteoclasts

higher MRONJ risk w IV or oral bisphosphonates

IV

which bisphosphonate is associated with the highest incidence of MRONJ?

alendronate

alendronate has a 95% predilection for posterior (maxilla/mandible)

mandible

alendronate has a (?)% spontaneous occurrence

50

what is the most common rx reason for bisphosphaonates?

osteoporosis Fosamax

what is the main trigger for MRONJ?

tooth ext

what are the risk factors associated with MRONJ?

IV admin, therapy duration corticosteroid use

management guidelines for oral bisphosphonates?

• Consider discontinuation 3 months before/after surgery if therapy >3 years

• Stage non-critical treatments (2 months between sextants)

management guidelines for IV bisphosphonates?

• Optimize dental health before therapy initiation

• Collaborative decision-making with medical team

• Emphasize oral hygiene and appropriate antibiotic use

prevention strategies for bisphosphonate use and perio sx?

• Thorough risk assessment

• Informed consent

• Regular follow-ups

• Optimize oral health before bisphosphonate therapy

what are some complications of head and neck radiation

• Oral Mucositis

• Oral Infections (primarily candidiasis)

• Xerostomia

• Taste Dysfunction

• Osteoradionecrosis

management protocol pre-radiation

• Comprehensive oral evaluation

• Necessary treatments (e.g., extractions, surgery)

• Complete at least 2 weeks BEFORE radiation

management protocol during radiation

Maintain rigorous oral hygiene

management protocol post-radiation

• Delay surgical or prosthetic interventions

• Allow 6-12 months healing period

key points of radiation therapy and perio considerations

• Proactive approach crucial

• Interdisciplinary collaboration essential

• Long-term follow-up necessary

when are medical consultations needed in perio sx?

• complex med hx: recent myocardial infarction, stroke, pacemaker

• anticoagulant therapy: warfarin (coumadin), clopidogrel (plavix), rivaroxaban (xarelto)

• immunosuppression: organ transplant recipients

• hx of head and neck radiation

best practices for

• Establish clear communication channels with physicians

• Provide concise, relevant information when consulting

• Follow up on recommendations promptly

critical reminders for medical consultations in perio sx

• Never alter prescribed medications without physician approval

• Document all physician communications in electronic health record

pre-operative infection control

• Patient rinse:

  • Standard: 0.12% Chlorhexidine (Peridex) for 1 minute

• Antibiotic premedication only when AHA guidelines apply

post-operative infection control

Prescribe antibiotics on a case-by-case basis

Cardiac Conditions Requiring Prophylaxis (AHA Recommendations)

• Prosthetic cardiac valves

• History of infective endocarditis

• Unrepaired congenital heart disease

• Cardiac transplant recipients

for pts not allergic to penicillin what is the antibiotic regimen?

amoxicillin 2g 1 hour pre-procedure

for pts allergic to penicillin what is the antibiotic regimen?

• cephalexin 2g 1 hour pre-procedure

• azithromycin 500mg 1 hour pre-procedure

• clarithromycin 500mg 1 hour pre-procedure

is routine prophylaxis recommended for jt replacement pts?

no but consider if specifically recommended by orthopedic surgeon

what are some perio sx instruments and materials

• Periodontal knives (e.g., Kirkland knife, Orban knife)

• Periosteal elevator

• Surgical blades

• Surgical curettes and scalers

• Periodontal chisels and files

Patient's own tissue so excellent biocompatibility

autograft

human donor tissue, no second surgical site required

allograft

Animal-derived (bovine/porcine), similar structure to human bone

xenografts

Synthetic materials, no disease transmission risk

alloplastic

what are the two types of membranes for perio sx?

resorbable and non-resorbable

what are some factors that affect healing?

• Patient factors (age, systemic health, smoking)

• Local factors (infection, tissue tension)

• Surgical technique

what are some potential perio sx complications?

• Bleeding

• Infection

• Swelling

• Tooth sensitivity

what is the cornerstone of surgical success?

hemostasis

what are some intraoperative benefits?

visualization, pt safety (min blood loss, no blood aspiration), procedural efficiency