Periodontal Regeneration
Regeneration The most ideal treatment Attempts to recreate the tissues destroyed by periodontitis Cement, bone and ligament Reduces the risk for recession and sensitivity (could actually improve it) Disadvantages: Cost Difficulty Predictability?
Regeneration Based on the principle of epithelial discussion Membrane Blood clot Allows the different other tissue producing cells to repopulate the space Osteoblasts Fibroblasts Cementoblasts
Regeneration Options: Bone graft (autogenic, allogenic, xenogenic) Membrane Amelogenins PDGF Combination
Mrs. AC Untreated patient requiring regeneration Chronic Perio Localized Severe Probing: 10mm Re-eval 12 months Bleeding: 3mm Regenerative therapy with Demineralized Freeze-Dried Bone Allograft
GTR T C 3 3 8 3 8 3 3 3 3 3 5 3 3 3 9 3 3 3 3 3 4 3 2 3 18-02-2011 22-03-2013
Lasers in Periodontics
Laser Several lasers have been recommended, unfortunately without strong scientific evidence. In addition, the proposed protocols often require repeated visits and arbitrary parameters, without scientific rigor.
Periowave Diodes Er:YAG Er,Cr,YSSG (Waterlase) CO2 Different wavelengths Different interactions
Tissue Absorption Émail Dentine
Laser Photodynamic Therapy (PerioWave) Surgical lasers
PERIOWAVE Non-thermal diode laser
PerioWave Photodynamic Therapy: Aims to neutralize or destroy pathological tissues through the use of photosensitizing chemicals that have the property of becoming toxic when activated by light Used in medicine in some cancer therapy
Periowave Mode of Action: Photo-disinfection 1. Scaling and root planing 2. Application of a photosensitive solution in the pocket where it adheres to pathogenic bacteria 3. Illumination with laser, which activates the solution and kills the bacteria selectively
PHOTODYNAMIC THERAPY Systematic Review 2010 SRP SRP + PDT Difference PD reduction 0.63mm 0.87mm 0.25mm CAL gain 0.43mm 0.78mm 0.34mm
PerioWave Disadvantages: Cost Time Efficiency? Studies fail to demonstrate a clinically and statistically significant difference in a systematic way However, some clinicians have managed to have a resolution of major bone defects by using it. Protocol???
Periowave And Photodynamic Therapy Conclusions Limited advantages Inconclusive scientific evidence Certain results can look impressive Difficult to reproduce No scientific proof of regeneration
Diode Lasers Many manufacturers Multiple wavelengths 810 nm 810 nm Easy to use Less expensive than other lasers 940 nm 980 nm
Diode Lasers Absorbed by soft tissue and pigmented tissue Long and weak pulsations Tendency to carbonize
Diode Lasers Indications Frenectomy Biopsy Sulcus preparation for impression taking Coagulation Disinfection
Adjunct Use of Diode Laser with Debridement Systemic review Slot et al. 2014: Debridement vs Debridement + diode No difference in the depth reduction of the pockets and in the improvement of the level of attachment Slight advantage for reducing bleeding with diode
Er:YAG Multi-use system Non-selective Can remove calculus Very well absorbed by water and the root High damage risk
Er:YAG Allongement de couronne Study by McGuire et Scheyer Flapless approach as recommended by manufacturer
Er:YAG Comprehensive Periodontal Pocket Therapy Case report by Aoki Multiple appointments necessary Ablation of external epithelium to be repeated each week. # of repetitions depends on the expected probing depth reduction (1mm par week) No published articles
Er,Cr;YSSG Similar to Er:YAG Air and water spray to cool down tissues Non-selective ablation
Er,Cr;YSSG Protocole DPT (Deep Pocket Therapy) Radial Firing Perio Tip Similar to protocol with Er:YAG
Er,Cr;YSSG 2 clinical studies: Dyer & Sung 2012: Preliminary Retrospective Clinical Study Significant PD reduction with minimal recession Kelbauskiene et al. 2011: Split-mouth study vs debridement Statistically significant PD reduction of 0.8mm
CO2 Bulky and difficult to use Non-selective tissue ablation Easily damages hydroxyapatite Risk of bone necrosis
CO2 Biopsy Frenectomie Surface surgery Gingivectomy / gingivoplasty Distal wedge
Nd:YAG Wavelength of 1064nm Absorbed by pigments (melanin, hemoglobin, pigmented bacteria) Poorly absorbed by collagen and hydroxyapatite (root and enamel) Not absorbed by water and cell membranes
Periolase Nd:YAG Eliminates the pigmented bacteria (P. gingivalis) Disinfects the pocket and the surrounding tissues
LANAP Protocol
Surgical Objectives in Regeneration Eliminate sulcular epithelium Disinfect Restrict the apical migration of the junctional epithelium Stabilize the blood clot Prichard 1977
Modified Minimally Invasive Surgical Technique M-MIST Micro-surgery Buccal flap only Intact interproximal tissue M-MIST M-MIST + Emdo M-MIST + Emdo/Biooss CAL gain 4,1mm 4,1mm 3,7 mm Bone fill 77% 71% 78% Cortellini et al 2011
LANAP: Periodontal Regeneration Selective Disinfects Seals the pocket
Nevins 2012 - Human Histology 12 hopeless teeth Clinical results Grade III mobility Pockets of 8-16 mm 4 molars - grade III furcations LANAP and extracted en-bloc after 9 months All teeth were clinically and radiographically healthy Pocket reduction of 5.4mm Attachment gain of 3.8mm
Nevins 2012 - Human Histology Histological Results (9 months) 50% regeneration 10% new attachment 40% long junctional epithelium N.b.: The teeth in this study were initially considered hopeless.
Patient : 57 year-old woman Medical history: Normal, non-smoker Diagnosis: Chronic Periodontitis localized severe 6 months post-op 35 36 37 Bu 2 2 2 4 2 11 4 3 4 Li 10 10 8 3 4 10 5 2 5 35 36 37 Bu 2 2 2 4 2 5 4 2 3 Li 3 2 4 3 2 5 3 2 2
Patient : 52 year old woman Medical history: Normal, non-smoker Diagnosis: Chronic Periodontitis generalized severe
9 months post-op 17 16 15 14 Bu 6 3 6 8 3 5 8 6 7 7 4 6 Li 7 4 6 8 3 5 10 8 6 8 3 6 17 16 15 14 Bu 3 3 3 2 2 2 2 2 2 2 1 3 Li 4 2 3 3 2 3 3 2 3 3 2 3
9 months post-op 13 12 11 Bu 6 3 5 8 7 5 5 3 4 Li 7 5 4 8 8 5 5 3 3 13 12 11 Bu 2 2 3 3 2 3 2 2 2 Li 3 2 3 3 2 2 2 2 2
Laser: Conclusion Until now, the Nd:YAG with the LANAP protocol is the only laser to have histologically demonstrated a new attachment and even regeneration Other lasers and protocols appear promising, but scientific evidence is still weak Further research is needed in this area
Maintenance Phase
Maintenance Phase! The most important factor for successful treatment as well as long-term control of periodontal disease The frequency depends on: - Control of the plaque - Severity of disease - Degree of inflammation (bleeding on probing, suppuration) In general: 3 to 4 months
The Importance of the Maintenance Phase Group with maintenance : 0.2 teeth lost in 6 years Group with no maintenance:: 0.7 teeth lost in 6 years Axelsson & Lindhe (1981)
Long-term maintenance of patients treated for advanced periodontal disease 61 pts, with 50% or more loss of periodontal support OHI, SRP, Pocket reduction surgeries, maintenance appointments every 3-6 months for 14 years 92-99% of sites maintained pockets <4 mm Less than 1% of the sites developed PD> 6 mm During the 14 years, 2.3% of the teeth were lost (30/1330) Lindhe & Nyman, 1984
Maintenance Appointment! The time allocated must be based on the needs of each patient Includes 5 parts (60 minutes for a regular patient): 1) Review, reassessment and diagnosis (5-10 min) 2) Motivation and re-instruction (5 min) 3) Instrumentation (30 min) 4) Treatment of re-infected sites (10 min) 5) Polishing and planning of future maintenance appointments (5 min)
Periodontal Protocol for Your Clinic
Periodontal Protocol for Your Clinic DIAGNOSIS!!! PSR III ou IV requires a periodontal evaluation
Periodontal Evaluation Hygienist or dentist? Fees? Enough time to do it at the recall or separate periodontal assessment appointment? Taking the chart and X-rays Evaluation of risk factors Explanation of periodontitis Development of treatment plan
Periodontal Protocol for Your Clinic Patients with pockets of 4-6 mm and horizontal bone loss can usually be treated non-surgically Effective debridements completed within a reasonable period of time (2-4 weeks). Systemic antibiotics for aggressive and / or immuno-compromised patients Re-evaluation after 4-12 weeks Cases with residual pockets of 5mm require more attention, especially if presence of inflammation
Periodontal Protocol for your Clinic Patients with: Pockets of 7 mm Deep furcations Surgical intervention anticipated Vertical defects
Management 1. Personalized oral hygiene instructions 2. Debridement (2 appointments) 3. Control of risk factors Re-evaluation after 4-12 semaines (+/- supportive periodontal maintenance) Residual pockets 5mm + inflammation Pockets 4mm + absence of inflammation Additional interventions Maintenance *Nightguard, Orthodontics, Prosthodontics
Periodontal Protocol for Your Clinic Once active treatments are completed, the patient should enter maintenance Depending on the case, frequency between 3 to 6 months Every 3 months the first year In slight cases, can be reduced to every 4 months; or when PDs 4mm without BOP Do not hesitate to return to 3 months if situation worsens If the patient was referred, the periodontist will dictate the frequency and schedule of cleanings (alternating)
Periodontal Protocol for Your Clinic Recurrence: A few pockets of 5mm : Reinforce oral hygiene Increase the frequency of recalls Repeat localized Sc/Rp +/- local antibiotics or Periowave? Re-evaluation at next recall
Periodontal Protocol for your Clinic Recurrence: Multiple pockets of 5mm : Reinforce oral hygiene Increase the frequency of recalls Generalized Sc/Rp +/- systemic antibiotics? Re-evaluation at next recall
Periodontal Protocol for your Clinic Recurrence: Negative results to previous treatments or residual pocket of 6 mm : Refer the patient
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