Non-Surgical Control of Periodontal Diseases

Transcription

1 Non-Surgical Control of Periodontal Diseases

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3 Paul A. Levi, Jr. Robert J. Rudy Y. Natalie Jeong Daniel K. Coleman Non-Surgical Control of Periodontal Diseases A Comprehensive Handbook

4 Paul A. Levi, Jr. Department of Periodontology Tufts University School of Dental Medicine Boston, MA USA Robert J. Rudy Department of Periodontology Tufts University School of Dental Medicine Boston, MA USA Y. Natalie Jeong Department of Periodontology Tufts University School of Dental Medicine Boston, MA USA Daniel K. Coleman Department of Periodontology Tufts University School of Dental Medicine Boston, MA USA ISBN DOI / ISBN (ebook) Library of Congress Control Number: Springer Heidelberg New York Dordrecht London Springer-Verlag Berlin Heidelberg 2016 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper Springer-Verlag GmbH Berlin Heidelberg is part of Springer Science+Business Media (

5 This book is dedicated to the memory of Dr. Irving Glickman It is only in the past quarter century that the dental curriculum has undergone a major change insofar as periodontics is concerned. Only recently has the status of periodontics been changed from that of a peripheral subject tacked on somewhere in the third and fourth year, a position in which it could not impress the student attitude regarding the importance of periodontal health in the total dental care which should be provided by general practitioners. It gradually has become a major clinical discipline stressing the philosophy that the periodontal care of the American public is primarily the responsibility of the general practitioner and that restorative dentistry without necessary periodontal care is not an oral health service The concept of what constitutes the practice of dentistry must change. Dentistry s mission under its franchise must be clearly defi ned as primarily the preservation of the health of the natural structures through the prevention of disease and deformities, and secondarily the repair of destroyed tissue the replacement of lost parts and the correction of developmental anomalies. Irving Glickman. Preventive periodontics: a blueprint for the periodontal health of the American public. J Periodontol. 1967;(38):361.

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7 Purp ose The purpose of this book is to share information that is of great value and practical use to general dentists, dental students, dental hygiene students, dental assistants, dental assisting students and postgraduate periodontal residents. Two of the authors have had the very good fortune, early in their professional careers, of coming under the pedagogical influence of Dr. Irving Glickman. The other two authors, graduates of Tufts University School of Dental Medicine, were influenced by the Glickman philosophy of dental education, which today still strives to remain a strong component of the curriculum at Tufts. Dr. Glickman was Research Professor of Oral Pathology and Professor and Chairman of the Department of Periodontology at Tufts University School of Dental Medicine in Boston, Massachusetts. During four decades of active teaching and research (1940s 1970s), Dr. Glickman pioneered the teaching of a rigorous curriculum in periodontics, for all pre- and postdoctoral students. The rigorous nature of the program was necessary, he felt, to ensure that future general dentists were thoroughly prepared and motivated to serve the periodontal needs of all patients regardless of whether they practiced in a private office setting, a hospital or military setting, or a community health center. As Dr. Glickman so often said, There is no such thing as a periodontal patient, as all patients with natural teeth have a periodontium. Many of the ideas presented in this book can find their source in the numerous original writings of Dr. Glickman. Dr. Glickman was particularly concerned with fostering among his students a deep appreciation for the following ideas: (a) The importance of preventative dentistry measures in the daily practice of general dentistry (b) The importance of diagnosing periodontal diseases in the incipient stages, by examining the periodontal tissues with an uncompromising attention to detail (c) The importance of being capable of treating periodontal disease by providing nonsurgical therapy in the daily practice of general dentistry vii

8 viii Purpose (d) The importance of supportive therapy in the long-term maintenance of periodontal health once disease is eliminated (e) The importance of understanding clinical phenomena in terms of underlying microscopic tissue changes (f) The importance of working intelligently and with confidence as a co- therapist, when the nature of the case suggests referral to the periodontal specialist Dr. Glickman s teaching legacy endures to this day because, at its core, it addresses the most crucial dental needs of the public namely, the attainment and preservation of oral and dental health. The authors are grateful for his public health vision and for all the arduous work he shouldered in bringing his vision to reality. The intent of this book is to continue the Glickman philosophy a philosophy that at its heart embraces the idea that family dentists are responsible for the early diagnosis and appropriate treatment of the common periodontal diseases that afflict the public at large. Only through comprehensive training and familiarity with the detailed information presented in this handbook will dental clinicians and hygienists be prepared to meet their responsibility in providing an excellent standard of dental care to their patients. The hard-won achievement of oral health can also be counted upon to foster improved general health certainly another of the crucial needs that must be addressed and to which the public is entitled. Other students of Dr. Glickman have undertaken the challenging task of authoring textbooks in the fields of periodontology and oral pathology; taken together, the works of Drs. Jerome B. Smulow, Gerald Skhlar, Fali S. Mehta, Esther M. Wilkins, Edward Cohen, and Noshir Mehta, along with the present publication, represent a rich legacy to one of the truly great dental educators of the twentieth century Dr. Irving Glickman.

9 Acknowledgments We gratefully thank the following individuals for their major contributions to this book. Their efforts and expertise have greatly assisted the authors in creating a handbook, which can be utilized by the readers to provide valuable information in a concise and yet comprehensive manner. Stephen P. Comstock Fourth-year dental student at Tufts University School of Dental Medicine, medical and dental textbook illustrator All textbook illustrations Nevin Zablotsky, D.M.D. Periodontist and authority in smoking cessation, speaker for the American Dental Association, and teacher of smoking cessation for medical and dental students at Nova Southeastern University Wrote Section 7.2 on smoking cessation Lorenzo Mordini, D.D.S. Periodontist, fellow at Tufts University School of Dental Medicine, clinical photographer Contribution of clinical photographs Julia Zhogina, R.D.H. Practicing dental hygienist, professional photographer Dental product pictures Additionally we thank our spouses, Patty Levi and Shannon Coleman and our friends and relatives who supported us and provided us with excellent feedback throughout the process of writing this book. ix

10 About the Authors Dr. Robert J. Rudy earned his D.M.D. from Tufts University in After serving as a captain in the USAF, from 1970 to 1972, he earned a Certificate in Periodontology from the University of Washington, in Seattle, in Returning to Boston and the Tufts School of Dental Medicine, Dr. Rudy became a Clinical Instructor in the Department of Periodontology. Ten years later he became an Associate Clinical Professor. From , Dr. Rudy served as Director of Predoctoral Periodontology. Additionally, he maintained a private practice, in Brookline and Newton Centre, Massachusetts, from Dr. Y. Natalie Jeong is an Assistant Professor in the Department of Periodontology at Tufts University School of Dental Medicine. She earned her D.M.D. and her Certificate in Periodontology from Tufts University. She is a Diplomate and a Board Examiner of the American Board of Periodontology. She is a Director of Lincoln Dental Study Club and maintains a private practice limited to Periodontics and Implant surgery in Lincoln, Massachusetts.

11 About the Authors xi Dr. Paul A. Levi, Jr. is an Associate Clinical Professor in the Department of Periodontology at Tufts University School of Dental Medicine, Visiting Professor at Universitat Internacional de Catalunya in Barcelona, Spain, and a Clinical Instructor at the Harvard University School of Dental Medicine. He earned a B.S. at St. Lawrence University in Canton, NY, and his D.M.D. and Certificate in Periodontology from Tufts University. He is a Diplomate and a Director of the American Board of Periodontology. Additionally, he maintains a private practice limited to Periodontics and Implant surgery in Burlington, VT. Dr. Daniel K. Coleman is a Diplomate of the American Board of Periodontology. He is a Clinical Instructor in the Department of Periodontology at Harvard University School of Dental Medicine. Dr. Coleman earned his B.S. at Trinity College in Hartford, CT, and his D.M.D., M.S., and Certificate in Periodontology from Tufts University School of Dental Medicine Boston, MA. Additionally, he maintains a private practice limited to Periodontics and Implant Surgery in Rhode Island.

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13 Contents 1 Fundamentals Introduction Anatomy Gingival Anatomy with Respect to Periodontal Diseases or Deformation Gingival and Tooth Anatomy with Respect to Professional Hygiene Therapy Gingival and Tooth Anatomy with Respect to Patient Hygiene Therapy Summary Periodontal Examination Diagnosis of Periodontal Diseases and Caries Gingivitis Periodontitis Peri-implant Mucositis Peri-implantitis Dental Caries Conclusion Etiology Prognosis Summary Further Reading Empowering Your Patients: From Compliance to Concordance Introduction Motivation of the Dental Patient to Remove Biofilm (Dental Plaque) Assurance That the Techniques Patients Are Using Are Effective and Correct Access: The Patient Must Be Able to Access the Root for Plaque Removal Probing Depth Supra- and Subgingival Calculus, Rough Roots Tooth Anatomic Irregularities Gingival Morphologic Alterations Malposed Teeth xiii

14 xiv Contents Orthodontic Appliances Defective Restorative Margins Provisional Fixed Restorations Tactile Root Sensitivity Improper Plaque Removal Techniques Improper Toothbrush Due to Bristle Stiffness, Type of Bristle, or Design of Brush Head Defective Toothbrush Due to Wear Ineffectual Dental Floss Technique or Floss Material Dental Implant Design Dental Implant-Supported Prostheses Summary Further Reading Methods of Plaque Removal by the Patient Detection of Dental Plaque with the Use of Disclosing Agents Bleeding on Probing (BOP) Using BOP for Motivation Supra- and Subgingival Calculus Calculus Attachment of Calculus to the Tooth Surface Detection of Supragingival Calculus Including Instruments, Materials, and Techniques Supragingival Calculus Detection Subgingival Calculus Detection Toothbrushes: Manual Toothbrushes: Power Tooth Brushing Techniques: Hand Brush The Bass Technique (BT) The Modified Bass Technique (MBT) The Stationary Bristle Technique (SBT) The Stillman s Technique (ST) Tooth Brushing Techniques: Power Brush Hand and Power Tooth Brushing with Fixed Orthodontic Appliances Conclusion: Tooth Brushing Interproximal Plaque Removal Dental Floss/Tape An Effective Technique for Flossing Interproximal Brushes Other Interproximal Cleaning Devices Rubber Tips Floss Threaders Toothpick-Type Devices Other Means of Reducing Oral Bacteria Summary Further Reading

15 Contents xv 4 Patient Examination and Assessment Preparation for Patient Encounter: Operatory, Instrument, and Materials Arrangement Patient/Provider Positioning and Operator Visibility Patient Interview and Initial Examination The Patient s Chief Complaint Patient s Expectations Baseline Vitals Medical/Social History Dental History Daily Oral Hygiene Habits Oral Habits Extraoral Exam Intraoral Soft Tissue Examination Gingival Tissue Evaluation Periodontal Charting Probing Depth Measurements Bleeding on Probing Recession Measurement Amount of Attached Gingiva Mucogingival Deformities Tooth Mobility Fremitus Furcation Involvement Calculus Detection Plaque Gingival Index Radiographic Interpretation Intraoral Radiographs Extraoral Radiographs Characteristics of an Acceptable Radiograph Analysis and Interpretation of Completed Radiographs Radiographic Changes in Periodontal Disease Additional Periodontal Documentation Summary Further Reading Instrumentation for Diagnosis and Basic Treatment of Gingivitis/Periodontitis Principles for Proper Use of Periodontal Instrumentation Grasp Wrist Position Fulcrum (Finger Rest Position) Adaptation Angulation

16 xvi Contents Lateral Pressure Strokes (Activation of the Instrument) Periodontal Instrumentation: Armamentarium Classification of Periodontal Instruments Introduction to Periodontal Instruments Diagnostic Instruments Dental Mirror or Mouth Mirror Air/Water Syringe Periodontal Probes Periodontal Probing: What Is Its Value? The Ten Critical Applications of the Periodontal Probe Functions of the Periodontal Probe Automated Periodontal Probes Explorers Periodontal Hand Instrumentation Scalers Curettes Comparison of the Working Edges of: Universal Scalers, Universal Curettes, and Gracey Curettes Adjunctive Hand Instruments Power Instrumentation Sonic, Magnetostrictive Ultrasonic, and Piezoelectric Instruments Advantages and Disadvantages of Power Instruments Polishing Instruments Rubber Cup Air-Powder Polishing Instrument Sharpening Instrument Sharpening Theory Sharpening Techniques for Hand Instruments Summary Further Reading Therapy Phasing of Therapy Advantages of Phasing Treatment Plans Phase I Therapy Phase II Therapy Phase III Therapy Phase IV Therapy (see Chap. 8) Clinical Treatment The Rationale for Dental Prophylaxis and Scaling and Root Planing Procedures Scaling Root Planing Gingival Curettage: Coincidental vs. Closed

17 Contents xvii 6.3 Patient Management Protocol for the Dental Prophylaxis Procedure Patient Management Protocol for the Scaling and Root Planing Procedure Therapy Choices for Specific Clinical Situations Summary Local Anesthesia Necessary for Scaling and Root Planing Anatomy for Periodontal Local Anesthesia Non-injectable Topical Anesthesia Injectable Local Anesthesia Injection Techniques Used for Both Maxillary and Mandibular Anesthesia Summary Treatment of Dentinal Hypersensitivity Associated with Periodontal Therapy Etiology and Treatment Options Treatment Modalities for Dentinal Hypersensitivity Treatment Recommendations Summary Further Reading Adjunctive Therapy Pharmacotherapeutics Introduction Systemic Antibiotics Local Delivery Antibiotic Therapy Conclusions The Importance of Smoking Cessation Introduction The Systemic Impact of Tobacco Use The Dental Implications of Tobacco Use The Role of the Dental Practitioner in Smoking Cessation Pharmacological Therapies for Smoking Cessation E-Cigarettes and Electronic Nicotine Delivery Systems (ENDS) Smoking Cessation Counseling and Referrals Five Major Steps to Intervention (The 5 As ) Stages of Readiness Laser Therapy Oral Bacterial Culturing and Sensitivity Testing DNA Probe Sampling Periodontal Endoscope Further Reading

18 xviii Contents 8 Maintenance Therapy/Necessary for Long-Term Success Introduction The Maintenance Therapy Program Getting Started High-Risk Patients Treatment Principles Regarding the Prevention of Gingivitis and Periodontitis Basic Features of a Structured Maintenance Therapy Program Guidelines for Evaluation: What Are the Key Signs to Look for in Early Disease? The Maintenance Therapy Appointment: The Basic Protocol Implant Maintenance Anatomy of a Dental Implant and its Supporting Prosthesis Evaluation of Implant Health Instrumentation of Dental Implants Protocol for Home Care for Patients Knowing Your Diagnostic Goals Knowing the Treatment Goal of Periodontal Therapy Knowing the Psychological Difficulties Associated with the Maintenance Therapy Program Understanding Anatomic Realities: The Degree of Attachment Loss and the Presence of Pockets Extending the Vision of Success: Does Maintenance Therapy Work? The Challenge of Compliance Further Reading Concluding Statement Further Reading Appendix A: American Academy of Periodontology Classification of Periodontal Diseases Appendix B: Antibiotic Prophylaxis Guidelines Appendix C: Treating Tobacco Use: Pharmacological Therapy Appendix D: Fagerstrom Test Appendix E: Sample Patient Brochure Describing the Maintenance Therapy Program Index