An Update on Periodontology

Transcription

1 Stockport 19 th May 2014 An Update on Periodontology Andrew Rawlinson Professor / Head of Academic Unit of Restorative Dentistry School of Clinical Dentistry University of Sheffield

2 An overview of periodon-cs Increasing complexity GTR/Mucogingival Gingivectomy / Flap surgery Non-surgical Periodontal Treatment with antimicrobials Non-surgical Periodontal Treatment Rela%vely less complexity

3 Aim and Objectives Aim To give an overview of current concepts of managing the periodontal patient successfully. Objectives By the end of the talk, participants should: Know how to identify periodontal disease and reach a diagnosis Be able to list the key elements of a treatment plan for the periodontal patient Know the current methods of providing non-surgical treatment and how to evaluate success Be aware of the options for managing patients who do not respond to initial periodontal treatment, including the use of antimicrobials and periodontal surgery Roles and responsibilities of dental hygienists Know when to refer for specialist care

4 Some key things to draw out when establishing a diagnosis - Symptoms, previous treatment (previous RSD under LA?) Expectations -cosmetic and functional

5 Risk factors Systemic disease Bleeding (disease / anticoagulants) Drugs (BP medications, phenytoin, cyclosporin) Diabetes Pregnancy Social factors Smoking

6 Stress Bakri I, Douglas CWI, Rawlinson A. The effects of stress on periodontal treatment: a longitudinal inves%ga%on using clinical and biological markers. Journal of Clinical Periodontology 2013;40: Pa%ents under psychosocial stress had a poorer outcome following non- surgical periodontal treatment. The assessment of psychosocial stress may be valuable in the holis%c management of periodontal disease.

7 Consider the role of genetic factors Single gene disorders Papillon Lefevre Syndrome (Toomes et al 1999) (autosomal recessive- locus mapped to chromosome 11q14- q21 candidate region to a 1.2- cm interval between D11S4082 and D11S931). Almost total loss of cathepsin C ac%vity and reduced ac%vity in obligate carriers. Familial clustering aggressive periodontitis (chronic periodontitis?) Nature v. nurture 50% of variance in periodontal disease susceptibility may be genetic (various twin studies Michalowicz et al ) Coding for cytokines or other proteins involved in the inflammatory process IL-1α, IL-1β, MMP-1etc Future clinical importance: testing to determine risk and target treatment?

8 Recent research: Patient Stratification for Preventive Care in Dentistry Giannobile, Braun, Caplis, Doucette-Stamm, Duff and Kornman JDentRes (8): High risk for progressive periodontitis 1 of risk factors smoking, diabetes, interleukin 1 genotype Low risk if none of above For high risk patients - 1 risk factor biannual preventive visits were associated with lower event rates (tooth loss over 16 years) than annual visits. More risk factors = more events, and more frequent visits may be needed.

9 Key Elements Periodontal Examination Whole mouth screening Soft tissues Teeth, caries, restorations BPE Full periodontal assessment Pocket depth Bleeding / suppuration Mobility Recession Furcation defects Vitality tests Plaque score and calculus present

10 Periodontal Screening a change to the scores to note Basic Periodontal Examination (BPE) Code 0 - No bleeding, plaque retentive factors or pocketing >3.5mm Code 1 - No pocketing >3.5mm or plaque retentive factors but BOP present Code 2 - BOP, no PD >3.5mm but plaque retentive factors Code 3 - PD mm Code 4 - PD >5.5 Code * - Furcation involvement

11 Basic Periodontal Examination current recommendations Screening tool WHO Probe Sextants All teeth examined except 3 rd molars walk round sulcus Each sextant given a BPE score equal to the highest individual sextant score Should be recorded at least annually for Scores of 0-2 Score of 3 full assessment and BPE for other sextants <3 Score of 4 full assessment of all sextants Score of 3 or 4 usually indicates need for radiographic examination Not for assessing treatment outcomes where scores or 3 or 4 were recorded full assessment Maintenance care patients - where scores of 3 or 4 recorded pretreatment full mouth probing depths at least annually Source: BSP 2011

12 Some probes are more equal than others - improving the accuracy of probing measurements UNC 15 Probe (University of North Carolina) Markings every 1mm with black bands at 4-5mm, 9-10mm, 14-15mm Use of magnification

13 Bleeding / suppuration Consider recording bleeding scores: work out the % of sites bleeding useful for patient information, but be aware of the interpretation. - Suppuration a sign of tissue destruction Recording recession Measurement from CEJ to gingival crest, photos or models importance of record keeping

14 Mobility Index (Miller) 0 = No mobility 1 = Mobility <1mm bucco-lingually 2 = Mobility >1mm bucco-lingually 3 = Mobility >1 mm + vertical movement

15 Furcation Assessment (Millers) 0 = not probable I = < 1/3 rd horizontal loss of periodontal support II = > 1/3 rd horizontal loss of periodontal support III = through and through horizontal loss of periodontal tissue 2N Color-Coded Nabers Probe

16 Radiographic information - Historical evidence - Obvious changes over time

17 Recording clinical data

18 Diagnosis Currently used classification of Periodontitis Early onset periodontitis Pre-pubertal Juvenile Rapidly progressive Adult periodontitis Refractory Recurrent Necrotising periodontitis Chronic Periodontitis Localized Generalized Aggressive Periodontitis Localized Generalized Necrotizing Periodontal Diseases Necrotizing ulcerative gingivitis (NUG) Necrotizing ulcerative periodontitis (NUP)

19 Prognosis Good (secure) requiring relatively simple treatment Irrational to treat - extract Doubtful require comprehensive therapy to move to good prognosis

20 Overview of Treating Periodontal Diseases Key elements of periodontal treatment: Relief of pain and extraction of teeth with hopeless prognosis Oral health education and patient information Advice on plaque control brushing and Inter-dental cleaning Use of plaque scores Advice on smoking cessation Scaling and root surface debridement (LA) Review 1 month oral hygiene, 3 months clinical measurements

21 Review by van der Weijden and Slot: Summary of findings A single oral hygiene instruction + toothbrush demonstration + scaling - a significant albeit small positive effect on the reduction of gingival inflammation in adults with gingivitis. Lack of evidence that one specific toothbrush design is superior to another. Brushing twice daily probably optimal. Most people are not effective brushers. Manual brushes on average reduce plaque scores by half. Rotation/oscillation powered toothbrushes - plaque and gingivitis reductions further compared with manual brushing.

22 Summary of findings continued Triclosan /zinc citrate and triclosan/copolymer toothpastes have significant albeit small positive effects on plaque reduction and gingivitis. Toothpastes to reduce calculus formation also available. Usually contain a pyrophosphate or zinc system. Routine recommendation to use floss is not supported by scientific evidence. Many studies show no benefit of flossing on plaque or gingivitis. Interdental brushes less time consuming and more efficacious than floss for interdental plaque removal. Decision on which to use based on local anatomy and dexterity of an individual patient. There has also to be sufficient space to use an interdental brush. Specific advice and monitoring essential.

23 Plaque scores - Use of plaque scores (% of surfaces) - absolute versus improvements in plaque scores / susceptibility. Useful for motivation. Root Surface Debridement Indications: - removal of sub-gingival plaque & calculus - removal of surface toxins (endotoxin etc) - smooth surface?

24 Slimline ultrasonic Inserts Refinement Langer 1/2 Refinement Langer 3/4 Refinement Langer 5/6 Periodontal hoes (and files if needed)

25 Delivery of treatment quadrant versus full-mouth approach similar outcomes Both quadrant and full-mouth debridement efficacious and no differences (Apatidou and Kinane 2004) Single visit full-mouth mechanical debridement (ultrasonic) may have limited additional benefit over a quadrant approach but completed in a shorter time (Koshy et al 2005) No difference in the incidence of recurrence of diseased periodontal pockets between full-mouth ultrasonic debridement versus traditional quadrant approach 1 year follow up (Tomasi et al 2006)

26 Review - at 1 month Symptoms, risk factors and plaque scores

27 Review (3 months) Review of symptoms Review of risk factors Review of periodontal health probing depths, bleeding, recession, mobility Review of plaque scores

28 Review Outcomes Reduced probing depths Less bleeding No suppuration Improved tissue contour Recession Increased sensitvity Other complications

29 Is Periodontal Treatment Effective? Measures: Tooth retention true outcome measure Probing depths, attachment levels, reduced bleeding surrogate OHRQoL patient centered Can be audited

30 Is Periodontal Treatment Effective? Tooth loss Tooth loss during ac%ve treatment 2.4% Eickholz et al 2008) - 5.5% Checchi et al (2002) Tooth loss during SPT % various authors Overall tooth loss 2.3% Lindhe & Nyman (1984) 16.6% Kocher et al (2000) Various lengths of %me longest - Hirschfeld & Wasserman (1978) years 8.4% tooth loss during SPT

31 Probing depths and attachment levels What to expect (From Cobb 2002) Probing depths Initial probing depth (mm) Mean reduction in probing depth (mm) Mean loss/gain in clinical attachment (mm) Evaluation Greatest changes occur within 1-3 months post treatment Maturation of tissues can take 9-12 months (Morrison et al 1980, Badersten et al 1981 etc. to Cugini et al 2000)

32 When is periodontal treatment complete? Residual probing depths 6mm represent incomplete periodontal treatment and require further therapy Residual probing depths 6mm and BoP 30% represent a risk for further tooth loss. Study 11 years of maintenance care. (Matuliene et al 2008 JCP 35: )

33 Patient centered outcomes Pa%ents with periodontal disease have worse Oral Health Related Quality of life than healthy pa%ents, but this impact can be partly ameliorated by periodontal treatment. This implies that periodontal disease is not silent and that conven%onal non- surgical treatment (provided in a secondary referral centre) can be effec%ve from pa%ents perspec%ves. Psychosocial impact of periodontal disease and its treatment with 24- h root surface debridement Jowe; AK, Orr MTS, Rawlinson A, Robinson PG JCP 2009;36:

34 Outcomes of non-surgical treatment: Clinical Case Number of pockets 4mm Deepest pocket Bleeding Index Sept 2011 May 2012 Nov mm 7mm 4mm 65% 33% 18% Plaque Index 61% 28% 20%

35 Monitoring and maintenance care Monitoring - intervals and record keeping Maintenance: Information to patient on clinical findings Advice Reinforce brushing and interdental cleaning Scaling Subgingival instrumentation Control of sensitivity Arrangements for future monitoring, maintenance or active treatment Good record keeping

36 Antimicrobials an adjunct Found in: Mouth washes Toothpastes Systemic antibiotics Locally applied antimicrobials antibiotics / antiseptics

37 Adjunctive Use of Antimicrobials The role of systemic antibiotics Aggressive forms of disease Severe disease / disease not responding deep inflamed sites (bleeding / pus) Necrotising forms of periodontal disease Abscesses

38 Advantages of systemic antimicrobials Useful for aggressive / active / progressing sites (pus formation) Multiple sites Low cost Less clinical time 5/13/14

39 Disadvantages of systemic antimicrobials Dependent on patient compliance Unwanted side effects Can produce microbial resistance to antimicrobials Can lead to sensitivities and allergies 5/13/14

40 Aggressive Periodontitis (must accompany RSD initial treatment) Metronidazole (400mg) and amoxicillin (500mg) both TDS, 7 days Azithromycin 500mg daily for 3 days* (Formerly Tetracycline 500mg TDS, 3 weeks or Doxycycline 100mg daily, 3 weeks: Start 24h prior to RP or Tetracycline 250mg QDS, 2 to 3 weeks ) 5/13/14 * Cau%on with sta%ns

41 Severe disease / non-responding sites bleeding / suppuration (must accompany RSD) Amoxicillin / metronidazole combination Azithromycin 5/13/14 A note about timing.

42 Watch out for other interactions

43 SYSTEMIC ANTIMICROBIALS Evidence Base (1) Systematic review (Herrera et al. 2002) Additional benefit (CAL/PPD) - deep pockets Reduced risk of further CAL loss - progressive or active disease Aggressive disease - might have adjunctive benefit Amoxicillin and metronidazole combination 5/13/14

44 Systemic Antimicrobials Evidence Base (2) Amoxicillin and metronidazole improves clinical outcomes in aggressive periodontitis: Guerrero et al (J Clin Perio 2005; 32, ) Griffiths et al (J ClinPerio 2011; 38, 43-9) - better if prescribed in initial phase of therapy Azithromycin improved outcomes in chronic periodontitis in deep pockets: Smith et al (J Clin Perio 2002; 29, 54-61), Haffajee et al (J Clin Perio 2007; 34, ), Gomi et al (J Perio 2007; 78, 422-9) - periodontal abscesses Herrera et al (J Clin Perio 2000; 27, ) - as effective as amoxicillin/clavulanic acid 5/13/14 - Aggressive periodontitis improved clinical outcomes: Hass et al (J Clin Perio 2008; 35, ) - compared with placebo in controlled randomized double blind trial

45 Recent reviews on Azithromycin Azithromycin as an adjuvant treatment for periodontitis improves clinical and microbiological parameters when compared to conventional treatment alone. (Muniz FW, de Oliveira CC, de Sousa Carvalho R, Moreira MM, de Moraes ME, Martins RS. Eur J Pharmacol Apr 5;705(1-3):135-9). Macrolide antibiotics have antimicrobial properties and modulate inflammation. Azithromycin may be of value as an adjunct in the management of periodontitis which, although driven by an infectious component, is largely a result of uncontrolled chronic inflammation. (Bartold PM, du Bois AH, Gannon S, Haynes DR, Hirsch RS. Inflammopharmacology Aug;21(4):321-38). Azithromycin could have a triple role in the treatment and resolution of periodontal diseases: suppressing periodontopathogens, antiinflammatory activity and healing through persistence at low levels in macrophages and fibroblasts in periodontal tissues, even after a single course of three tablets. (Hirsch R, Deng H, Laohachai MN. J Periodontal Res Apr;47(2): ).

46 The role of locally applied antimicrobials isolated residual sites Metronidazole (Elyzol) Chlorhexidine (PerioChip) (Chlosite gel) Minocycline (Dentomycin) Doxycycline (Atridox) (no longer available in UK)

47 Systematic Review of Local Antimicrobials (Matesanz-Perez JCP 2013;40: ) Outcome measures for antimicrobials + RSD: PPD reduction most reduction with tetracycline fibres > doxycycline > minocycline (all < 1mm). Minimal reductions for chlorhexidine chips and metronidazole (<0.4mm) CAL gain most increase for chlorhexidine / xanthan gel (1 study 0.9mm gain in CAL). Metronidazole and other CHX products had no effect Overall scientific evidence supports use of adjunctive local antimicrobials in deep or recurrent sites, but no definitive practical advice given due to risk of bias in evidence published.

48 When is surgical treatment indicated? The role of basic surgical techniques treatment of residual deep pockets the replacement flap Flap procedures stages Local anaesthetic Incisions (use of relieving incisions) Raise flap Curettage RSD Irrigation Sutures (pack for Apically Repositioned Flap)

49 Choice of incisions and intra-crevicular

50 Access Root surface debridement and granulation tissue removal. Root surface treatment and application of therapeutic agents if appropriate. Odontoplasty Root division/amputation Osteoplasty Ostectomy Placement of GTR / graft materials

51 Flap management & Curenage Raising flaps Relieving incisions Replacement of flap Curettage or not? Methods of curettage

52 Root surface debridement Ultrasonic instrumentation Hand instruments Irrigation with saline Sutures Interrupted Continuous

53 Modified Widman Flap (Ramoord and Nissle 1974) Incision 1mm buccally from gingival margin preserving interdental papillae Flap raised exposing only a few mm of bone Intracrevicular / horizontal incisions to release pocket lining Careful curettage of bone Debridement of root surfaces Replace flaps to cover interdental bone and suture

54 Post- opera%ve Care What to expect blood stained saliva/bleeding, swelling, bruising, discomfort/pain Management of these Contact number Oral hygiene Follow up appointment for postoperative reviews (1 week, 1 month, 3 months etc.)

55 Signs of success flap surgery Decrease in inflammation Less bleeding on probing Decrease in pocket depth Increase in attachment Eliminate pus No increase in mobility Improvement of tissue contour Stabilisation of bone levels

56 Evidence A systema%c review of the effect of surgical debridement vs. non- surgical debridement for the treatment of chronic periodon%%s (Heltz- Mayfield, Trombelli, Heitz, Needleman and Moles; Journal of Clinical Periodontology 2002;29:92-102) Both effec%ve treatments in terms of anachment gain and reduc%on in gingival inflamma%on Greater pocket depth reduc%on and clinical anachment gain in deeper pockets with open flap debridement

57 Basic surgical techniques residual gingival enlargement - gingivectomy Gingivectomy - incisions

58 Gingivectomy Removal of gingival tissue Scaling Removal of granulation / tissue tags Haemostasis Periodontal dressing Healing and follow up

59 Referral Guidelines (BSP) Complexity 1 BPE 1-3 in any sextant GDP Complexity 2 BPE 4 any sextant / surgery GDP or referred Complexity 3 BPE 4 in any sextant and 1 or more of the following: <35 years Smoking 10+ cigarettes daily Medical condition affecting periodontal tissues Root morphology adversely affecting prognosis Rapid periodontal breakdown >2mm attachment loss in any 1 year Surgical procedures with implants Surgical procedures / tissue augmentation/ bone removal (eg regeneration or crown lengthening) Referral to DwSI, specialist, consultant

60 Referral Guidelines( CCDH) General principles Opinion and advice - referring dentist to undertake the proposed treatment. The referring GDP must inform the patient of the purpose of the referral. Patients presenting with acute conditions (e.g. periodontal abscesses) should be treated in General Dental Practice. Patients with an uncomplicated medical history e.g. Rheumatic fever, those on Warfarin, asymptomatic Hepatitis B and related virus carriers should be treated in General Dental Practice with the usual appropriate precautions. The referring GDP must use the pro forma referral letter. (copies may be obtained from the office of the Director of Dental Public Health, Sheffield.) The following information is essential for the allocation of an appointment BPE score (or periodontal pocket charting) Radiographs of diagnostic quality Details of root surface debridement (subgingival root planning) undertaken in last year and outcomes observed after a minimum of 3 months have elapsed. Whether OHE has been given (brushing techniques, interdental cleaning methods) Smoking Cessation Advice given (if appropriate) Desirable Information Whether the practice has hygienist, who could provide initial therapy and subsequent supportive (maintenance) therapy If the referral letter contains insufficient information - further details requested. The patient will be informed that further information has been requested, and the appointment will be delayed until the additional information has been received. Non Acceptance Irregular attenders Patients who are unable or unwilling to meet NHS or private charges for treatment. Patients who consistently demonstrate poor concordance with plaque control and dental health advice. Patients who have not received non-surgical periodontal treatment within the previous twelve months.

61 Roles and Responsibilities of Dental Hygienists GDC Scope of Practice 2013 (provided trained, competent and indemnified) Prevention and treatment of periodontal disease: Carry out treatment direct to patients or under prescription from a dentist Dental & medical history, clinical examination, take and interpret radiographs, diagnose, treatment plan, treat, screen and monitor Liaise with dentists over treatment of periodontal disease, caries and tooth wear Advice including oral hygiene and smoking cessation Undertake scaling and RSD under LA (infiltration and IDNB) Use antimicrobial therapy (this means locally applied) Adjust restored surfaces in relation to periodontal treatment, but not unrestored surfaces Refer If working on prescription vary detail, but not direction of prescription according to patient needs

62 Summary In this session on periodontics we have updated knowledge on: Screening and assessment of patients with periodontal diseases Risk factors for periodontal diseases Current diagnosis of periodontal diseases Current concepts of non-surgical treatment Monitoring and maintenance for the periodontal patient The current role of antimicrobials as an adjunct to treatment The role of surgical treatment Referral guidelines Roles and responsibilities of dental hygienists