! DR SIMON HINCKFUSS PERIODONTIST LEVEL 7, 20 COLLINS ST MELBOURNE
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1 MANAGEMENT OF DIFFICULT PERIODONTAL CASES! Unusual periodontal patients: A case series with tips on diagnosis and management! DR SIMON HINCKFUSS PERIODONTIST LEVEL 7, 20 COLLINS ST MELBOURNE
2 16 YR OLD BOY. Reason for referral: 16 yr old boy. Radiolucency 37 associated with deep periodontal pocket, suppuration and swelling. Tooth 37 confirmed as vital.
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4 PARADENTAL CYST Rare Lesion Epithelial remnants of Malassez most likely origin Exclusively in mandibular region, mainly third molars. Tooth is vital Enucleation preferred over marsupialization. Adding bone graft/emdogain?
5 DENTAL TRIVIA
6 DENTAL TRIVIA Which country had the first toothbrushes?
7 DENTAL TRIVIA Which country had the first toothbrush? China: originally boar hair and then horse hair when adopted in Europe during early 17th Century
8 ATYPICAL BLEEDING Reason for referral: Bleeding gums, pain.
9 ATYPICAL BLEEDING January 2013: Pt referred for management of perio Presenting Condition: Anxious. Hx of ortho and bonding. Tissues acutely tender to brushing and probing. Spontaneous bleeding on brushing. Smoker. Poor plaque control. Pockets 1-4mm.
10 ATYPICAL BLEEDING Management (March 2013): General anaesthesia for root planing. Result: Continued bleeding following GA. Bursts of bleeding followed by periods of remission. Widespread apthous ulcers as well as congealed blood. Culminating in admission to Alfred hospital 6 days post-op. Further bleeding on presenting to my rooms following discharge. Rx: Tranexamic acid mouth wash 5%, 10m l b.d Referred to Oral and Maxillofacial surgeon for opinion
11 ATYPICAL BLEEDING March 2013: OMFS reported no history of post-op bleeding after exo 8 s 10 years prior. Blood tests from Alfred reported as normal. rx vitamin supplements and referred to heamatologist. Referred to O/Med for management of major apthae. Perio review every three months
12 ATYPICAL BLEEDING April 2013: Haematologists report: Father had history of bleeding after dental extractions. Periods irregular but not heavy. vwf:rcof (Ristocetin cofactor mildly below normal limits but does not suggest functional abnormality. Suggested repeat test if clinical suspicion of von Willebrands disease high. No further correspondence. Pt attending for perio maintenance
13 Management August 2013: Referred to orthodontist to get lower lingual retainer removed as pt unable to clean lower incisor teeth. No recurrence of bleeding problems. Finally quit smoking in Reasonably stable since but never great.
14 DENTAL TRIVIA When was the first Nylon bristle tooth brush made?
15 DENTAL TRIVIA When was the first Nylon bristle toothbrush made? 1938: Made by Dupont
16 RECESSION AND MARGINAL INFLAMMATION Reason for referral: Recession and acute marginal erythema.!!
17 RECESSION AND MARGINAL INFLAMMATION Dental Hx: Attended GDP in 2012 as chipped tooth on walnut. Pt complaining about feeling tired when he wakes. Pt advised that his problems are due to incorrect bite and his clenching could be due to sleep apnoea. Sleep study and orthodontics had been recommended.
18 RECESSION AND MARGINAL INFLAMMATION 14th March 2012: Initial exam. Advised to brush gently, stop toothpaste. Rx Azithromycin. Was diagnosed as Vitamin C deficient. Started 2g Vit c per day. 18th March 2013: Significant improvement. Still bleeding interproximally when cleaning professionally. Pt notices flare up if misses one day. Attachment levels stable. Rx azithromycin. Curasept every second day. Biotene on other days. Only minor Erythema on 11 now. 10th Sep 2013: Bleeding after cleaning. Using floss. Didn t like interdental. Advised to floss 2xdaily. Was doing just at night. Stay on Biotene/Curasept gel. Sporadic Curasept rinse. Using Sensodyne brush. Loves it. 28th Jan 2014: Pt brought review forward as noticed bleeding. Advised must use interdental brush. Introduced Blue TePe rather than Yellow.
19 RECESSION AND MARGINAL INFLAMMATION 8th Oct 2014: Pt reports bleeding when cleaning inter proximally. He switched to very small brush from Europe (rubber tip). Provided pt with Blue Oralis th March 2015: Pt reports occasional bleeding. Tissue pink/firm on region. Recession on 13 is 1mm greater than initially measured in th August 2015: All looking perfect. Pt getting married this weekend and moving to Ecuador. In a very relaxed mood. Using Blue Oralis360 8th March Bleeding inter proximally when cleaning. Has moved back to Melbourne. Slacked off using interdental brush in Ecuador
20 RECESSION AND MARGINAL INFLAMMATION Management Summary: Gentle brushing. Avoid SLS. Azithromycin/Curasept/Biotene. Reassurance. Recession documented. Customized OHI. Stress reduction. Aetiology: Plaque Risk Factors: Stress, vitamin deficiency, genetic predisposition
21 DENTAL TRIVIA Is floss or interdental brushing more effective?
22 DENTAL TRIVIA Is flossing or interdental brushing more effective? Interdental brushes. Less bleeding and increased pocket depth reduction (Gluch 2012) When is floss better?
23 44 YR OLD MALE: AGGRESSIVE GENERALIZED PERIO Reason for referral: Wanted second opinion after being told all lower teeth should be removed
24 MOBILITY Reason for referral: Loose 22
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26 Grafting is stable long term if maintenance adhered to Sculean 2007 No difference in resistance of a long junctional epithelium to a connective tissue attachment Beumont 1984
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29 DENTAL TRIVIA What is the diagnosis?
30 DENTAL TRIVIA Actinomyces species. Prevotella Melaninogenicus Produce hydrogen sulphide that precipitates iron from saliva Management?
31 No scientifically proven approach augmentin? Oxygenating mouthwashes (Colgate Peroxyl, Amosan, Therabreath)
32 LATERAL GROOVE Referral Oct 2014: Suppuration tooth 32 despite flap surgery.
33 LASERS: AMERICAN ACADEMY POSITION PAPER 2011 Minimal evidence to support the use of a laser for the purpose of sub gingival debridement either as mono therapy or adjunctive to SRP Do not reduce sub gingival microbial loads beyond that achieved by SRP alone Er:YAG laser can remove calculus but no better than hand instruments and greater potential for root surface damage.
34 LATERAL GROOVE Management: Initial exam October 2014 Flap and GBR Nov 2014 Stable since with 3mm pocket. Followed up with osseous surgery to reduce pockets on 17/27 distals!
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37 PERI-IMPLANTITIS
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39 Options: 1) Endo then either GBR or resect buccal root 2) Exo 24 then bridge ) Exo 24, provisional bridge 21-25, then implants 22, 24 region submerged in preparation if bridge lost.
40 FACIAL SWELLING June 2013: initial exam. Chronic severe generalized perio Smoker. Cutting down August 2013: SRP full mouth followed by GBR 46 furcation. Grafting failed. Pt started smoking again. 22 JAn 2014: Rev. All looking good except 46. July 2014: Lack of attached gingiva 33. Scheduled for FGG but didn't attend Nov 2014: Pt referred back for perio assessment. HAs had severe facial swelling LL for last month. Swelling noticed 5 days after hygiene appointment. Pt referred to endodontist. Endo has been started on 35. Not improving. Pockets 8mm on 33 and 35 buccal.!
41 FACIAL SWELLING
42 FACIAL SWELLING Management: 12th Nov 2014:Both 35 and 33 very mobile. Decided to extract. Advised pt presentation is atypical. 18th Nov 2014: Referred to OMFS for assessment of possible malignancy. Outcome: Pt referred to Peter McCallum for management
43 FACIAL SWELLING 15th March 2016: Pt referred back for periodontal review. Reported not cancer. Was Actinomyces infection! Normally responds to Penicillin but this didn t. Required resection of the mandible. Incidence: 1 per 300,000 people Possible Cause? Reported after oral surgery most commonly. Requires a break in the mucous membrane plus co-pathogens
44 SUDDEN DEVELOPMENT OF MOBILITY Current periodontal patient in maintenance. Last treated for GBR on tooth 14. Type 1 diabetic. Reported as well controlled diabetes Presented in March 2016 complaining of mobility 23
45 SUDDEN DEVELOPMENT OF MOBILITY Tooth 14 had GBR in Tooth 23 was root planed.
46 SUDDEN DEVELOPMENT OF MOBILITY Tooth 23 Grade III mobile. Pocket on buccal probing seemingly to apex
47 SUDDEN DEVELOPMENT OF MOBILITY
48 SEVERE CHRONIC PERIODONTITIS
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52 UNDIAGNOSED
53 QUESTIONS? Request free professional demonstration pack Include name, and practice address
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