DENT 267: LO5- Aggressive Perio Cont...

post aggressive forms of perio (Post Juvenile)

-aggressive forms of perio

-clinical appearance/radiographic of either the localized or generalized aggressive perio but has stopped or significantly slowed

-seen in adults

-diagnosis based on severe bone loss around incisors and 1st molar

-prob a late diagnosis of AP

how is post aggressive (juvenile) perio treated

-tx by conventional techniques such as debridement, home care instruction and perio surgery

-antibiotics

-previous radiographs

screening of primary, mixed and permanent dentitions

-perform a perio exam (probing)

-review bw rads

-usually primary molar areas, distance from CEJ to crest is less than 2mm

hereditary factors in perio

-genetic variation helps to explain why some individuals are more susceptible to periodontal breakdown

-different types of aggressive forms of perio can be found in the same family

genetic variation

-some studies show over 60% of clients w/ severe perio are IL-1 positive (the WBC produce more cytokines - bone resorption mediators)

-PST+ has increased risk for severe perio

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genetic risk testing

-cheek swab method

-positive genetic test, interleukin 1 beta phenotype positive strong indicator of susceptibility to severe perio

genetic tests

-for mutations present in certain rare forms of perio that are associated w/ systemic disease

systemic disorders that hve a major impact on the loss of perio tissue by influencing perio inflammation

-genetic disorders (immunologic such as Downs Syndrome, Neutropenias)

-acquired immunodeficiency disease (acquired neutropenia, HIV)

-inflammatory disease (inflammatory bowel disease)

other systemic disorders that may contribute to perio tissue loss by influencing the pathogenesis of perio diseases

-stress

-depression

-smoking

-meds

systemic disorders that can result in loss of perio tissue independent of perio

-neoplasms

role of neutrophils (PMN)

-important role in host defense

-defective neutrophil production/function increases

-susceptibility to recurrent bacterial infections

hematologic

-neutropenia

-leukemia

-HIV/AIDS

periodontitis as a manifestation of systemic disease

-w/ some of these diseases, unlikely to encounter outside of a hospital dentistry setting

-life threatening

-can affect young children & cause severe inflammation and bone resorption around all primary teeth (leads to early tooth loss)

-diabetes was not on the list but now is

-presence of uncontrolled diabetes can alter the clinical course of disease and is a well known risk factor for perio

what can sometimes happen w/ perio as a manifestation of systemic disease

-permanent dentition may be affected

-may have defects in PMN's and macrophages

-frequent abscess formation, ear infection, URT infections

palmoplantar keratoderma (PPK) w/ dental abnormalities

-refers to a group of conditions characterized by thickening of the skin on the palms and soles often accompanied by dental probs

what is Papillon-Lefevre syndrome (PLS)

-where palmoplantar keratoderma is associated w/ severe perio and premature tooth loss

perio as a manifestation of systemic disease: Papillon Lefevre Syndrome

-palmoplantar keratosis

-severe perio associated w/ primary & permanent dentitions

Papillion Lefevre Syndrome: destruction usually begins around when

-4 years of age w/ exfoliation of the primary teeth and the permanent teeth by 15 tears of age for some

hypophosphatasia

-genetic skeletal disease that may result in loss of primary & permanent dentitions

neutropenia

-abnormally few numbers of neutrophils in blood (lower tahn 1500 cells/µL of blood

-leads to increased susceptibility for infection

-can be the result of bone marrow failure

-may be congenital

neutropenia & perio

-PMNs are first responders to fight off microbial invasion (fewer means poor immunity)

-consider patients w/ this disorder as being immunocompromised

perio as a manifestation of systemic disease: Down's Syndrome

-severity of perio disease exceeds that explainable by local factors

-prevalence is high

-decrease in resistance to infection due to poor vascularity, poor healing

-defect in T-cell maturation and PMN chemotaxis

-abnormal neutrophil function seen in approx 50% of all clients w/ Down's Syndrome

-poorer healing time

what would suggest a more thorough medical exam

-significant perio disease beyond what would be expected for the level of biofilm and calculus

etiology of perio as a manifestation of systemic disease

-related to a decrease in resistance to bacterial infections caused by the systemic disease which may be acquired or genetic

prognosis for perio as a manifestation of systemic disease

-prognosis depends on the tx of the systemic condition & rate and amount of bone loss

care plan for perio as a manifestation of systemic disease

-referral to periodontist

-referral to DMD if condition is undiagnosed

-cons w/ DMD re: care plan and need for prophylactic antibiotics

-debridement

-perio surgery

-antibiotic therapy

-frequent maintenance

Down's Syndrome

-genetic disorder that happens before birth

-nucleus contain 47 vs 46 chromosomes

-usually, 3 copies of the 21st chromosome

-also called trisomy 21

-lifelong

-varies in severity

-causes intellectual disability & developmental delay

characteristic facial features of Down's Syndrome

-underdeveloped midfacial region

-palate may appear highly vaulted and narrow due to unusual thickness of sides of palate

-lips may be large & thick w/ decreased muscle tone causing drooling

-tongue may appear cracked w/ fissures

-malocclusion due to delayed eruption

what are the medical concerns of Down's Syndrome

-increased risk for congenital heart defects

-susceptibility to infection

-respiratory problems

-GI abnormalities

-leukemia

-abnormal number of PMNs

-mild to mod mental delays

Down's Syndrome & perio

-often develop rapidly progressive perio

-substancial plaque-biofilm formation

-perio pathogens colonize gingival tissues in early childhood years; may lead to loss of permanent ant teeth

Down's Syndrome: implications for the DH

-early & frequent professional tx

-stress meticulous daily self care

-pts may need help from caregivers

-educate caregivers too

-power toothbrush and water flosser can be recommended

refractory disease

-not a single disease entity

-perio that does not respond to classical tx

-clients have undergone repeated attempts to control disease through perio surgery, frequent debridement & antibiotics

refractory periodontitis

-may have tenacious and resistant organisms

-a continuing disease that is unresponsive to therapy

refractory periodontitis: primary feature

-occurrence of additional attachment loss after repeated attempts to control the infection w/ conventional perio therapy

diagnosis of refractory perio

-should only be made in pts who satisfactorily comply w/ recommended OH procedures perio maintenance

-systemic disease should be ruled out

management of refractory periodontitis

-periodontist is required

-microbial diagnostic testing

-antibiotics (local, systemic)

-non-surgical therapy

-surgery

-frequent CC intervals

-control may not be possible

-attempt to slow progression of disease

when would we not use the term refractory to describe cases

-therapy is incomplete (non-compliant client)

-systemic conditions

-attachment loss is related to endo lesions or root fractures

-recurrence of perio after years of successful perio therapy

peri-implantitis

-peri-implant bone loss as well as soft tissue inflammatory lesion

-begins at coronal portion of the implant

-bone loss not clinically detectable until late stages

-chronic inflammation in tissues surround osseointegrated implant, resulting in bone loss

peri-implantitis: etiology

-biomechanical and bacterial

peri-implantitis: tx

-may involve occlusal therapy, anti-infective therapy and surgical techniques

pathological changes in implant tissues

-biofilm deposits on implants

-can result in inflammation of soft tissues around implant

-as disease progresses, partial or total loss of osseointegration ocurs

stages of peri-implantitis

-begins at coronal portion of implant while apical portion continues to be osseointegrated

-implant does not become mobile until final stages of disease

what should be done with mobile implants that show signs of loss of osseointegration?

-should be removed

cause of peri-implant disease

-bacterial infection

-biomechanical factors

-smoking

read over BS case studies

-ok BS case studies