North Charlotte Dental Hygiene Study Club. Periodontal Panel Discussion

Transcription

1 North Charlotte Dental Hygiene Study Club Periodontal Panel Discussion

2 General Information CE Certificate Periodontal Panel Discussion Handout Website Another Pathology question

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4 History #18 Gum irritation and pain Hard to brush and floss area Localized site On-going over past year RCT then performed no resolution of symptoms Patient referred Gingival pain and irritation ulcerated tissue Traumatized with mirror led to subepithelial hematoma developed over 2-3 minutes

5 Periodontal Panel Summary of Questions Scaling and Root Planning Periodontal Abscess Occlusion / Impact on Periodontal Disease Periodontal classification system Implants Recession Diagnosis Systemic Health Laser Assisted Periodontal Therapy Oral Pathology Chemotherapeutics 3-D imaging Cosmetic Periodontal Therapy Immediate Implants / Provisionalization

6 Latest Protocol; # of visits; ROT at 4-6 weeks Half-mouth vs full-mouth Equally effective No longer than 2 weeks apart reinfection Review of Therapy 4-6 weeks later Optimal response to therapy Oral hygiene and plaque check Opportunity for behavior modification

7 Debridement then ScRP? Influencing Factors 1. Amount of supra and subgingival 2. Pocket depths 3. Teeth impacted Total Surface Area vs Time Available

8 Hand Instrument vs. Ultrasonic Dry (Efficiency in Biofilm Disruption) With Water Disruption of Biofilm Approximate Position Of Scaler Tip WalmsleyAD J Periodontol. 15:9, p , 1988

9 Mechanical Debridement Primary Periodontal Instrumentation

10 PATIENTS WHO SHOULD BE TREATED BY A PERIODONTIST Any patient with: Severe chronic periodontitis Furcation involvement Vertical/angular bony defect(s) Aggressive periodontitis (formerly known as juvenile, earlyonset, or rapidly progressive periodontitis) Periodontal abscess and other acute periodontal conditions Significant root surface exposure and/or progressive gingival recession Peri-implant disease Any patient with periodontal diseases, regardless of severity, whom the referring dentist prefers not to treat.

11 PATIENTS WHOWOULD LIKELY BENEFIT FROM COMANAGEMENT BY THE REFERRING DENTIST AND THE PERIODONTIST Periodontal Risk Factors/Indicators Early onset of periodontal diseases (prior to the age of 35 years) Unresolved inflammation at any site (e.g., bleeding upon probing, pus, and/or redness) Pocket depths 5 mm Vertical bone defects Radiographic evidence of progressive bone loss Progressive tooth mobility Progressive attachment loss Anatomic gingival deformities Exposed root surfaces A deteriorating risk profile Medical or Behavioral Risk Factors/Indicators Smoking/tobacco use Diabetes Osteoporosis/osteopenia Drug-induced gingival conditions (e.g., phenytoins, calcium channel blockers, immunosuppressants, and long-term systemic steroids) Compromised immune system, either acquired or drug induced A deteriorating risk profile

12 PATIENTS WHO MAY BENEFIT FROM COMANAGEMENT BY THE REFERRING DENTIST AND THE PERIODONTIST Any patient with periodontal inflammation/infection and the following systemic conditions: Diabetes Pregnancy Cardiovascular disease Chronic respiratory disease Any patient who is a candidate for the following therapies who might be exposed to risk from periodontal infection, including but not limited to the following treatments: Cancer therapy Cardiovascular surgery Joint-replacement surgery Organ transplantation

13 Isolated areas that aren t responding to treatment; why? Access Line Angles CEJ Furcations: Dome Concavities Grooves Pseudopocket?

14 Where is the pockets? Soft tissue only Inflammation can be resolved Pocket will not go away Hard Tissue Inflammation can be resolved Pocket reduction can be addressed depending on severity and type of bone loss Combination Inflammation can be resolved Pocket reduction can be addressed depending on severity and type of bone loss

15 Host Pathway to Periodontal Disease Genetic Risk Factors Antibody Microbial Challenge Bio-film / Plaque / Calculus PMN Antigens LPS Other Virulence Factors Host Immunoinflammatory Response Cytokines Prostanoids MMPs Connective Tissue and Bone Metabolism Clinical Signs of Disease Environmental & Acquired Risk Factors Tissue Breakdown Products & Ecological Factors Kornman, 1997.

16 What is The Extent of Subgingival Scaling and Root Planing?

17 Limitations of Nonsurgical Therapy Pocket Depth 1-3mm 89% clean, 3-5mm 39% clean, >5mm 11% clean (Waerhaug 1978) 3.7 mm- Average PD that can be efficiently cleaned with Sc/RP (6.2mm- average limit) Root Anatomy Access CEPs, CEJ, Furcation, root flutes, line angles Long-term maintenance Sc/RP teeth require retreatment twice as often compared to surgical treatment (Ramfjord 1987) Patient compliance (OH, systemic health)

18 Is it realistic to perform ScRP in GD office? Does it benefit patient? Minimal osseous involvement? Biotype: thick vs thin Radiographic bone loss infrabony defects Severity of bone loss; depth of pocket Understanding type of pockets vs Expected Response Soft tissue pocket Hard tissue pocket Combination

19 Severe Bone Loss

20 Pre-op and 1 year Post-op

21 Do you prefer that we do ScRP prior to referring? Refer - Goals of therapy Understanding type of pockets vs Expected Response Soft tissue pocket Hard tissue pocket Combination

22 How do we get a patient to see you if we can t care for patient adequately? Pt has to own their problem If patient does not see the urgency in getting their own disease treated, then no amount of effort will work Time, Trust, Consistency, Urgency, Confidence

23 Periodontal Panel Summary of Questions Scaling and Root Planning Periodontal Abscess Occlusion / Impact on Periodontal Disease Periodontal classification system Implants Recession Diagnosis Systemic Health Laser Assisted Periodontal Therapy Oral Pathology Chemotherapeutics 3-D imaging Cosmetic Periodontal Therapy Immediate Implants / Provisionalization

24 How to treat? What is the cause? Etiology Food Impaction Diabetes Poor wound healing: systemic health Recent ScRP Severe probing depth areas Removal of etiology; antibiotics

25 Abscess Periodontal Endodontic Abscess etiology: periodontal infection / food impaction / root canal failure TX: Flap; Penrose Drain; Antibiotics; ScRP; I&D; Extraction

26 Periodontal Panel Summary of Questions Scaling and Root Planning Periodontal Abscess Occlusion / Impact on Periodontal Disease Periodontal classification system Implants Recession Diagnosis Systemic Health Laser Assisted Periodontal Therapy Oral Pathology Chemotherapeutics 3-D imaging Cosmetic Periodontal Therapy Immediate Implants / Provisionalization

27 What is the impact of occlusion on periodontal disease? Health Increase PD No Bone Loss Mobility Elimination of occlusal issue resolves periodontal issues Disease Increase PD Bone loss: Progressive Mobility Pathologic Migration Elimination of occlusal issue leave persistent periodontal issues

28 Occlusal Trauma and Periodontitis Historically there has been two conflicting schools of thought: Grinders Grind free Pathologic force (excessive or off axis) results/contributes to alterations in the inflammatory front around teeth. This in turn results in bone loss and attachment as collagenase and osteoclastic activity increases.

29 Occlusal Trauma and Periodontitis Intrabony defects associated with occlusal trauma assume many forms. The most commonly seen defect in My Chair seems to be the circumferential. What tooth is most commonly affected by occlusion??

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32 WHAT DO WE CALL IT? Non-Carious Cervical Lesion Cervical Erosion Cervical Abrasion Abfraction Dental Compression Syndrome Stress Corrosion Lesion Biodental Engineering Factorial Lesion

33 Occlusal Therapy Occlusal equilibration Fremitus Prematurities and Interferences Parafunctional habits Occlusal guards

34 Periodontal Panel Summary of Questions Scaling and Root Planning Periodontal Abscess Occlusion / Impact on Periodontal Disease Periodontal classification system Implants Recession Diagnosis Systemic Health Laser Assisted Periodontal Therapy Oral Pathology Chemotherapeutics 3-D imaging Cosmetic Periodontal Therapy Immediate Implants / Provisionalization

35 ALWAYS REMEMBER Your initial diagnosis is a presumptive diagnosis You must re-evaluate your diagnosis during treatment and after treatment to prevent missing the true diagnosis / etiology What is the prognosis of your treatment? What length of treatment benefit do you expect?

36 How often should you perio chart an adult patient? Periodontal Disease pt Changes charted every periodontal maintenance visit Annual full mouth charting Healthy Annually full mouth charting

37 How young should you begin perio charting? Look at clinical parameters: radiographs and clinical presentation Deciduous and Mixed Dentition Aggressive Periodontal Disease: Early onset, localized juvenile periodontitis Adult Previously addressed

38 Peridontal Disease Classification Gingival Diseases Chronic Periodontitis Aggressive Periodontitis Periodontitis as a Manifestation of Systemic Dz Necrotizing Periodontal Diseases Abscesses of the Periodontium Periodontitis Associated with Endodontic Lesions Developmental or Acquired Deformities and Conditions

39 Plaque Associated Gingivitis Inflammation confined to the gingiva Rateitschak 1989

40 Non-Plaque Associated Gingivitis

41 Chronic Periodontitis Case

42 Aggressive Periodontitis

43 Localized Aggressive Periodontitis

44 Necrotizing Ulcerative Periodontitis NUG NUP

45 Oral Manifestation of a Systemic Dz

46 Periodontal Abscesses

47 Recession

48 Gingivitis: Are 3-4mm PD s acceptable to ID gingivitis Healthy Periodontium Inflammation Reduced Periodontium Even with recession; a 1-4mm probing depth will still be considered healthy or gingivitis given inflammation

49 Prognosis Short Term (3-5 years) Long Term (7-10 years) Define: Periodontal and Restorative Excellent: No issues Good: Slight issues but managable Fair: Compromised but with treatment can do well Poor: 3-5 years Guarded: Reevaluate after initial therapy Hopeless: No amount of treatment will work

50 Periodontal Panel Summary of Questions Scaling and Root Planning Periodontal Abscess Occlusion / Impact on Periodontal Disease Periodontal classification system Implants Recession Diagnosis Systemic Health Laser Assisted Periodontal Therapy Oral Pathology Chemotherapeutics 3-D imaging Cosmetic Periodontal Therapy Immediate Implants / Provisionalization

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52 Discuss causes of inflamed tissue around implants Cement Plaque Tissue quality: lack of attached tissue

53 What s wrong with this x-ray?

54 Earliest age for implant placement? Congenitally missing teeth Growth Boy : Girls: Mini-implants Conventional implants

55 Time period b/w implant placement and crown What if you had to wait a long time to restore Implant stability Type of bone Amount of bone Grafting needed Risks Still get bone remodeling as if nothing is there. Loading important in maintaining bone Super-eruption of opposing teeth Tilt of adjacent teeth over the implant

56 Can you place an immediate implant on a posterior tooth

57 Immediate implants; success rates Patient Selection very important Success vs Survival rates Stability - Key Restorability - Critical Equal success rates dependent on patient selection

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59 Periodontal Panel Summary of Questions Scaling and Root Planning Periodontal Abscess Occlusion / Impact on Periodontal Disease Periodontal classification system Implants Recession Diagnosis Systemic Health Laser Assisted Periodontal Therapy Oral Pathology Chemotherapeutics 3-D imaging Cosmetic Periodontal Therapy Immediate Implants / Provisionalization

60 Loss of IP papillae (w or w/o bone loss) Bone Loss Restorative Contact point

61 Crest The of Effect Bone of on the the Distance Presence From or the Absence Contact Point of the to the Crest Interproximal of Bone on the Dental Presence Papilla or Absence of the Tarnow DP, Magner AW, Fletcher P J Periodontol 1992; 63: Interproximal Dental Papilla ontact Contact point point of natural of natural oth tooth crest to of crest ridge: of ridge 5 mm 5mm - papilla present almost 100% of of time time 6 mm present 56% of time 6mm - present 56% of time 7 mm present 17% of time 7mm present 17% of time > 8 mm present 10% of time > 8 mm present 10% of time

62 At what point do you get best root coverage IP bone #1 factor Root prominence Before or after ortho

63 Recession classification I II III IV

64 When is the best time to refer for TG referral? How much recession should a patient have to consider a TG? Progressive Inflammation Cold sensitivity Esthetics patient driven Lack of facial attached/keratinized tissue

65 Definitions Gingival Recession Hidden Recession Mucogingival Junction Keratinized Gingiva Attached Gingiva Alveolar Mucosa

66 Tongue piercing: what damage are you seeing? Lingual recession

67 What else can we do for recession besides hard nightguards? Occlusion important but only a contributing factor Diagnosis of tissue quality and quantity Other important contributing factors to recession

68 Esthetic Periodontal Procedures Principles CEJ / Bone level / Soft Tissue level

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70 Esthetic Periodontal Therapy Location ST Bone CEJ Why does tissue rebound?

71 Periodontal Panel Summary of Questions Scaling and Root Planning Periodontal Abscess Occlusion / Impact on Periodontal Disease Periodontal classification system Implants Recession Diagnosis Systemic Health Laser Assisted Periodontal Therapy Oral Pathology Chemotherapeutics 3-D imaging Cosmetic Periodontal Therapy Immediate Implants / Provisionalization

72 Kornman, 1997 Host Pathway to Periodontal Disease Genetic Risk Factors Antibody Microbial Challenge Bio-film / Plaque / Calculus PMN Antigens LPS Other Virulence Factors Host Immunoinflammatory Response Cytokines Prostanoids MMPs Connective Tissue and Bone Metabolism Clinical Signs of Disease Environmental & Acquired Risk Factors Tissue Breakdown Products & Ecological Factors

73 Women s Health Adolescence Smoking Stress Pregnancy Diabetes Menopause Osteoporosis/Osteopenia Cardiovascular Disease Stroke Sjogren s Syndrome Medications Autoimmune Dz Immune Deficiency Periodontal Disease Inflammation Attachment lost Susceptibility Aggressive Chronic NUG / NUP Systemic Health

74 Correlation between osteoporosis and bone loss? Osteoporosis / Osteopenia Bone remodeling equilibrium dysfunction Decreased bone mass Fragility, deformity, and fracture Diagnosis: Dexa scan: > -1: Normal bone density -1 to -2.5: Osteopenia < -2.5: Osteoporosis

75 Impact on Periodontal Health Oral bone density decreases Increased ridge resorption after extraction Increased risk of tooth loss? 1% density loss -- 4x risk for tooth loss Increased risk for periodontal disease? Greater progressive loss of attachment

76 Bisphosphonates: options for implants and bone grafts Oral vs IV drugs Total cumulative dose Rules of thumb Cumulative dose > 7 years

77 Bisphosphonate Related OsteoNecrosis of the Jaw (BRONJ) What do you do with periodontally involved teeth?

78 Periodontal Panel Summary of Questions Scaling and Root Planning Periodontal Abscess Occlusion / Impact on Periodontal Disease Periodontal classification system Implants Recession Diagnosis Systemic Health Laser Assisted Periodontal Therapy Oral Pathology Chemotherapeutics 3-D imaging Cosmetic Periodontal Therapy Immediate Implants / Provisionalization

79 Are you using a laser for tissue reduction? Lasers available: Nd:Yag; Diode; CO2; Er:Yag; Argon Nd:Yag Readily absorbed in pigments (dark pathogens, blood) No readily absorbed by water and HA Standard protocol and training Research and Results

80 Clinical effects of Nd: Yag laser Removes the pocket epithelium Kills pathogens Neutralizes endotoxin Reduces inflammation and inflammatory products (PGE, IL, MMP, TNF) Biostimulation (increased growth factors and cell activity)

81 Why we use a Nd:Yag laser Hybrid between surgery and Sc/Rp Avoids Sc/Rp charge so increases treatment acceptance and decreases time for case completion Do not have to take patient off of anticoagulant therapy Less invasive for older patients and patients with poor systemic health Prevents significant recession unless you purposely create it No sutures to create tension or irritation No coronal creep of papilla over the mesial concavities of premolars Most likely prevents the 0.5-1mm of crestal resorption associated with flap reflection Patients love it and tell their friends! (Polar opposite of traditional surgery) Will we be able to use it as a future definitive therapy in patients on IV bisphosphonates?

82 Is it effective in PD reduction? Failed GTR LAPT

83 Laser Presentation 4 th study club meeting More in-depth information Review of research Clinical results

84 Periodontal Panel Summary of Questions Scaling and Root Planning Periodontal Abscess Occlusion / Impact on Periodontal Disease Periodontal classification system Implants Recession Diagnosis Systemic Health Laser Assisted Periodontal Therapy Oral Pathology Chemotherapeutics 3-D imaging Cosmetic Periodontal Therapy Immediate Implants / Provisionalization

85 Oral Pathology The following are questions to think about when evaluating oral lesions: 1. Review medical history: smoking, diabetes, medications, radiation therapy, cancer history 2. Review dental history: look for causes of tissue trauma 3. Extraoral and Intraoral Exams (palpation of lymph nodes, lesions): size, soft, firm, fixed 4. Etiology: calculus, plaque, habits, appliances 5. Pain: If no pain and it looks like it should hurt, this can be a red flag. 6. Duration: new; present longer than 2 weeks 7. Frequency: new or recurring 8. Pattern: localized or generalized; unilateral 9. Location: attached gingiva, mucosal tissue, tongue, FOM, retromolar pad 10. Palpation: does surface wipe off, bleeding, soft, firm, fixed 11. Radiographic findings: crestal bone loss, -luscency, -opacity, calculus present Take Home Message 1. Duration: If a lesion is present longer than 2 weeks biopsy warranted! Do not wait until next cleaning to check lesion. Bring back in 2 weeks if necessary. 2. If you have no idea, ask your dentist to evaluate. May need to refer to a Periodontist or OMS 3. If you are not looking, you may not notice a lesion until it has progressed too far.

86 What do we see? Oral Manifestations of Systemic Disease Pemphigus / Pemphigoid Lichen Planus Mucocele Fibroma: Irritation POF, PG, PGCG

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88 Periodontal Panel Summary of Questions Scaling and Root Planning Periodontal Abscess Occlusion / Impact on Periodontal Disease Periodontal classification system Implants Recession Diagnosis Systemic Health Laser Assisted Periodontal Therapy Oral Pathology Chemotherapeutics 3-D imaging Cosmetic Periodontal Therapy Immediate Implants / Provisionalization

89 Why don t perio offices employ Arestin Tx for non-sx pockets? Goal of Therapy Radiographic defect present? Residual calculus present? Clinical vs statistical significance? Long term results vs other treatment modalities

90 Efficacy of Antibiotic Therapy Depends on: Anti-microbial spectrum and drug characteristics Drug binding to tissues Protection of pathogens by non-target organisms Biofilm phenomena Total bacterial load vs. max antibiotic concentration Effectiveness of host defenses Pathogens in sites not affected by therapy

91 Do you think Arestin helps much in reducing PD s? What do you find is the typical result / application? What is the frequency of application? What is the value of the therapy?

92 What criteria for Arestin use? Soft tissue refractory cases Inflammation Localized deepening pockets

93 Chemotherapeutics All local delivery antibiotics must be combined with Scaling and Root planing! Do not use them as a stand alone therapy Residual calculus is an issue. Even sterilized calculus acts as a chronic irritant Local antibiotics are beneficial in certain situations but should not be used in 50 sites at every maintenance appointment If you were bleeding to death would you keep putting new band-aids/neosporin on the wound every 2 minutes or would you go the hospital to fix the problem?

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95 Chemotherapeutics Obstacles Residual calculus Inflammation causes outflow of GCF at a rate of 44ul/min. The flow/pressure is out of the sulcus! Deep intrabony defects have tissue bridging the defect. This will not miraculously close. Allergy Costly Over medicated culture Patients are referred to us after several rounds of Sc/Rp and Arestin and still need surgery are enraged unless the dentist communicated adequately. Meta analysis only shows modest short term gains in attachment

96 Periostat use? No longer on the market Concept: Low Dose Doxycycline $$, 3 x 3 months Statistical vs Clinical significance

97 Low Dose Doxycycline PERIOSTAT (doxycycline hyclate 20 mg capsules) No longer available

98 Low Dose Doxycycline (LDD) Periostat acts as an Enzyme Suppressor Studies show that doxycycline hyclate 20 mg bid has no antimicrobial action No change in bacterial flora after 18 months No induction of resistance after 18 months

99 How long can a patient stay of Peridex? Concentration: full strength vs diluted Alternating days Stain effects Calculus formation Why is being used?

100 Anything new on subgingival therapy? Traditional GTR Pocket Reduction Surgery Flap Currettage Latest Treatment Protocol Laser Assisted Periodontal Therapy / LANAP

101 Periodontal Panel Summary of Questions Scaling and Root Planning Periodontal Abscess Occlusion / Impact on Periodontal Disease Periodontal classification system Implants Recession Diagnosis Systemic Health Laser Assisted Periodontal Therapy Oral Pathology Chemotherapeutics 3-D imaging Cosmetic Periodontal Therapy Immediate Implants / Provisionalization

102 PA vs 3-D imaging

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104 CT Scan

105 Fenestrations

106 Lingual Undercuts and/or Tori

107 Thin Ridges

108 F.J. Implant Planning

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113 Periodontal Panel Summary of Questions Scaling and Root Planning Periodontal Abscess Occlusion / Impact on Periodontal Disease Periodontal classification system Implants Recession Diagnosis Systemic Health Laser Assisted Periodontal Therapy Oral Pathology Chemotherapeutics 3-D imaging Cosmetic Periodontal Therapy Immediate Implants / Provisionalization

114 Immediate Implant Placement Extraction Fractured crown, non-restorable Failed/Re-infected RCT Vertical Root Fracture Root perforations Caries Combination of Factors Immediate Implant Contraindication?

115 Ideal Immediate Placement Concerns Surface area engaged by internal walls / Tooth morphology Bio-Type: Thick or Thin Beyond apex of tooth Maxillary sinus proximity PARL - infection Bone quality/density Stability Restorability

116 What is a good immediate implant site?

117 What is a good immediate implant site?

118 What is a good immediate implant site?

119 Temporary Provisionalization

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