Perio Final

Bacteria Associated with Periodontitis

( 1) Porphyromonas gingivalis ( 2) Actinobacillus actinomycetemcomitans ( 3) Prevotella intermedia ( 4) Bacteroides forsythus ( 5) Treponema denticola ( 6) Treponema socranskii ( 7) Campylobacter rectus ( 8) Fusobacteriium nucleatum ( 9) Streptococcus intermedius (10) Eikenella corrodens (11) Actinomyces species (12) Eubacterium species

Periodontal Diseases Classification

(1) Extent Localized - <30% of sites involved Generalized - >30% of sites involved (2) Severity Slight - 1 or 2 mm of attachment loss Moderate - 3 or 4 mm of attachment loss Severe - >5 mm of attachment loss (3) Staging-four stages based on severity and complexity of management Stage I: Initial (Mild, Slight) Stage II: Moderate Stage III: Severe with potential for additional tooth loss Stage IV: Severe (very Severe) with potentioal for loss of the dentition (4) Grading-encompasses periodontitis progression, general health status, and other exposures Grade A: low risk, slow rate of disease progression Grade B: moderate risk, moderate rate of disease progression Grade C: high risk, rapid rate of disease progression

common clinical changes associated with periodontitis

(1) similar changes in the gingiva as seen in gingivitis, usually a more chronic appearance *color - varying degrees of bluish red *consistency - varies from soft and boggy (edematous) to firm (fibrotic) *texture - stippling is decreased *contour - marginal gingiva is rounded, and the interdental gingiva is blunted *size - gingiva is slightly enlarged *position - junctional epithelium has migrated apically from the CEJ (2) areas of gingival recession (3) bleeding on probing as a result of thinning of the crevicular epithelium, increased vascularity, and a close proximity of the engorged vessels to the pocket epithelium (4) periodontal attachment loss (5) true periodontal pockets (6) loose, extruded, or migrated teeth; diastemas may develop (7) exudate from gingival margin in response to pressure (8) symptoms - generally painless; patient may complain of itching gums, loose teeth, food impaction, and bad taste; relief is felt with pressure applied to gums (9) mobility - can be result of traumatic occlusion, bone loss, or short, conical roots: Degree of tooth mobility (grade) Grade N - normal, firm tooth Grade 1 - movement of tooth in both the facial and the lingual direction of up to and including 1 mm Grade 2 - movement of a tooth in both the facial and lingual directions of greater than 1 mm Grade 3 - movement of a tooth in both the facial and lingual directions of greater than 1 mm with easy depression (10) furcation involvement may be present - pathologic loss of bone in the furcation of a multirooted tooth Furcation classification Class I - early involvement, in which the probe can enter the tip of the furcation area approx. 1 or 2 mm; incipient bone loss; may not be visible radiographically Class II - moderate involvement, in which the probe can enter the furcation more than 1 or 2 mm but not pass through; partial bone loss; may be visible radiographically Class III -severe involvement, in which the probe can be passed between theroots; total bone loss; visible radiographically, may or may not beoccluded by the gingiva

Nonsurgical Periodontal Therapy

(Also called Initial Therapy or Phase I Therapy)

Classification of occlusal trauma

(Note: there is lack of agreement about the role of occlusal trauma in the etiology and pathogenesis of periodontitis) 1. Primary occlusal trauma - trauma results from excessive occlusal forces; result could be mobility, excessive wear of a tooth or teeth, sensitivity of involved of teeth, or fremitus 2. Secondary occlusal trauma - supporting periodontium is not normal (some loss of supporting structures is present); tooth or teeth are not able to withstand even normal occlusal forces without trauma; could result in mobility or sensitivity

1. Acute or chronic gingivitis

(review previous section on stages of gingivitis) - most forms are caused primarily by bacterial plaque a. early gingivitis (1) plaque is thicker and more complex than in health; 100 to 300 cells thick (2) Actinomyces organisms predominate (3) Mostly gram-positive organisms b. chronic gingivitis (1) gram-negative anaerobic organisms increase; rods form 75% of the subgingival flora (2) presence of Actinomyces, Fusobacterium, and Bacteroides (especially intermedius - Prevotella intermedia) organisms (3) spirochetes elevated at affected sites c. Treatment by clinician - removal of bacterial plaque and calculus deposits and other contributing factors by patient - daily removal of bacterial dental plaque

Periodontal Classification

*2017 International Workshop for a Classification of Periodontal Diseases and Conditions *American Academy of Periodontology and the European Federation of Periodontology proposed a new classification

Implant Success and Survival Rate

*Clinical immobility: no PDL= no modality at all *Absence of persistent and/or irreversible pain and infection *No peri-implant radiolucency: not pulp should be not a problem *No irreversible mechanical failures (e.g., implant fractures) *Support of a functional restoration *Lack of progressive bone loss beyond physiologic remodeling (0.2mm/year after the 1st year of implant loading)

Implant maintenance Program

*Continuing care of dental implant patients is important *Patient education *Assessment of plaque accumulation *Evaluation of hard and soft tissues 1. Review medical history 2. Head and neck examination, oral cancer screening 3. Take radiographs every three months for first year after implant restoration is placed; then yearly to check for bone loss. place radiographs in squential mounts. 4. Remove superstructure if neccessary and possible 5.Clean superstructure 6. Check tissues for surface inflammation 7. Check for plaque and review oral hygiene practices 8. Record probing depths using a plastic or nylon periodontal probe. 9. Record bleeding on probing 10. Clean implant abutments using speical non-metallic instruments 11. Irrigate with antimicrobial solution if indicated 12. Replace superstructure, if removed 13. Have occlusion checked 14. Review dental hygiene again with superstructure in place 15. Reschedule for three or four month recall depending on evaluation of tissue and oral hygiene

Bleeding on probing dental implants

*Controversy regarding use of bleeding on probing as a clinical assessment parameter for implants *Bleeding sites should be inspected for presence of plaque or other irritants *Bleeding may be caused by probing force rather than actual inflammation Gingiva Evaluate for minimal width of gingiva around implant Inadequate zone may lead to recession

2018 Classification of Periodontal and Peri-Implant Diseases and Conditions

*Describes distinct forms of periodontal diseases based on: *Clinical data *Radiographic data *Historical data

Importance of Disease Classification

*Diagnosis, prognosis, treatment planning, filing insurance claims *Documentation of changing classifications *Legal documentation

Identifying the Problem Implant: Criteria for Success

*Frequent inspection and debridement *No mobility *Prosthesis must fit accurately and securely *No trauma from occlusion *No radiographic radiolucencies around implant *Patient's dental behavior pattern

Dental implant blood supply

*Implants have less blood supply near their neck with more of a scar tissue appearance *Lack of a PDL limits the blood supply to the area to only the periosteal vessels and bone marrow space

Dental implant inflammatory lesion

*Oral biofilms grow faster on titanium than on enamel *More widespread inflammation around implants *Infected implants have earlier and more rapid bone loss

Clinical Parament of Evaluation: Soft Tissue Evaluation

*Similar procedures as with natural teeth and gingiva *Assess color, contour, consistency, and texture *Presence of erythema, edema, and suppuration *Probing *Use of probe is highly controversial *Some feel the probing depth is not important in the success of an implant *Probing may create a pathway for bacteria to enter through peri-implant seal *Probing forces are different since there is a lack of a connective tissue attachment Consensus that gentle probing (plastic probe) is recommended around implants if pathology is suspected *Changes in PD measurements over a period of time may indicate disease activity

Parts of the Periodontal Treatment Plan

- Initial periodontal treatment *concerned with controlling as many of the etiological factors as possible without involving the patient in periodontal surgery or definitive restorative and prosthetic treatment · Emergencies taken care of first o Pain, abscess, NUG, injury · Medical tx/Referrals · Non-restorable teeth are identified and extracted/teeth needing endo treated · Oral hygiene instruction · Periodontal debridement/oral prophylaxis (multiple appointments) · Tissue response: re-evaluation

Phase IV (Maintenance Care)

- Periodontal Maintenance/Continuing Care *consists of a long-term sequence of treatment that is individually designed for each patient according to specific needs; the aim of this stage of treatment is to prevent the recurrence of the periodontal disease · "would like everyone to end up" · Periodontal maintenance o To prevent continued and recurrent periodontal destruction o Frequency of visits § Individualized "2 months for some or 6 months for others based on need" "does not relapse" § Self-care

Phase II (Periodontal Surgery)

- Surgical access for thorough root planning, and reduction of probing depths, and correction of periodontal defects (pockets) · Reduction/elimination of inflammation before surgical phase · Access to deep periodontal pockets · Various surgeries o Arrestive or regenerative surgery o Periodontal plastic surgery (gingival recession) o Ridge augmentation o Crown lengthening

Periodontal assessment

- complete periodontal documentation should be based on a thorough periodontal assessment, which includes 1. Description of the gingival tissues, including visual signs of inflammation, such as erythema, edema, enlargement, hyperplasia, fibrosis, or any other changes in color, shape, size, surface texture, or consistency; severity also should be noted 2. Findings from the examination of the periodontium with a periodontal probe, which include a. Presence of bleeding - widely accepted as an indicator of inflammation; more sensitive than visual signs; however, inflamed sites do not always bleed and bleeding is a poor predictor of attachment loss (only 30%); results when sulcular lining is ulcerated b. Probing depth (also called sulcus/pocket depth) - gives a historical record of past periodontal disease activity; useful in monitoring success of periodontal therapy; important in determining patient's ability to maintain health through plaque control; the periodontal probe remains the best diagnostic aid for detecting periodontal pockets c. Clinical attachment level - measures from CEJ to attachment; determines amount of apical migration of the junctional epithelium or amount of loss periodontal support to the tooth d. Recession - measures from the CEJ to the gingival margin; indicates apical migration of the gingiva e. Presence of purulent exudate (suppuration) - in response to lateral digital pressure on the gingival margin or probing; suggests advanced lesion of periodontitis f. Adequacy of width of attached gingiva - measure from attachment to mucogingivaljunction; amount will vary depending on location; adequate zone necessary towithstand mechanical stresses from mastication; if none is present, gingival margin willmove with alveolar mucosa 3. Alternatives to use of standard periodontal probe for periodontal examination a. Periodontal screening and recording system (PSR) - designed to provide thorough screening and recording of all patients while saving time in recording aspect of initial exam (1) All tooth/implant surfaces are examined individually; however, only the highest score in each sextant is recorded (2) Scores range from zero (healthy) to 4 (indicating probing depth of 5.5 mm); a specially demarcated probe is used (3) Not intended to substitute for or replace full periodontal exam; patients with higher scores in any sextant or with clinical abnormalities must have comprehensive exam b. Computerized probes (1) Increase accuracy by reducing margin of error and standardizing pressure (2) Reduce time required for probing and recording; some are voice activated; some provide printouts of probing depths and/or attachment loss c. Temperature-sensitive probes - measure not only probing depths but also loss of attachment and changes in temperature that may be associated with inflammation 4. Presence and distribution of bacterial plaque and calculus (may use indices) 5. Condition of tooth proximal contacts - loose or open contacts permit food impaction 6. Degree of tooth mobility a. Grade N - normal, firm tooth b. Grade 1 - movement of tooth in both the facial and lingual direction of up to and including 1 mm c. Grade 2 - movement of a tooth in both the facial and lingual directions of greater than 1 mm d. Grade 3 - movement of a tooth in both the facial and lingual directions of greater than 1 mm with easy depression 7. Presence of furcation involvements a. Class I - early involvement, in which the probe can enter into the tip of the furcation area; incipient bone loss; may not be visible radiographically b. Class II - moderate involvement, in which the probe can enter the furcation but not pass through; partial bone loss; may be visible radiographically c. Class III - severe involvement, in which the probe can be passed between the roots; total bone loss; visible radiographically, may or may not be occluded by the gingival d. Class IV - furcation is open and exposed and clinically visible 8. Presence of malocclusion or malposition of teeth 9. Presence and condition of dental restorations and prosthetic appliances; missing teeth; dental implants 10. Presence of overhanging restorations (overhangs) - contributing etiologic factor in periodontal disease attributable to potential for accumulation of bacterial plaque and food impaction 11. Assessment of disease progression by longitudinal comparison of probing depths, attachment levels, and interproximal bone height (radiographic) 12. Interpretation of a satisfactory number of bitewing and periapical radiographs that are of diagnostic quality to assess a. Level of alveolar crest in relation to the cementoenamel junction b. Interdental bone c. Furcation areas d. Width of the periodontal ligament space e. Existing dental restorations and caries f. Periapical disease g. Length, shape, and position of roots h. Amount and general patterns of alveolar bone destruction (horizontal vs. vertical)

Mucogingival deformities (1) gingival recession (or gingival atrophy)

- exposure of the root surface caused by an apical shift in the position of the gingiva (a) severity of the recession is determined by the actual position of the gingiva (b) recession may be partially clinically visible and partially hidden (covered by inflamed pocket wall); total amount of recession is the sum of the clinical and hidden recession (NOTE: "recession" documented on periodontal charts is that which is clinically visible only) (c) recession refers only to the location of the gingiva, not the condition of the gingiva; may have recession of gingiva that is inflamed or noninflamed (d) etiology - the following factors have been implicated as possible etiologic factors: (i) gingival inflammation (ii) faulty toothbrushing (gingival abrasion) (iii) tooth position * in the arch * mesiodistal curvature of the tooth (iv) location and amount of pull on the margin of the frenum attachment (v) dehiscence (vi) impinging prosthetic appliances (vii) gingiva that is habitually injured with fingernails, pencils, hairpins, floss, or other sharp objects (e) clinical significance (i) exposed roots are susceptible to caries and abrasion (ii) wearing away of cementum on the exposed surface leaves exposed dentin, which may be sensitive to mechanical, chemical, or thermal stimuli (iii) interproximal recession creates space for accumulation of plaque and other debris (f) treatment (i) removal of etiologic or contributing factors (ii) maintenance of daily thorough plaque control (iii) root desensitization if needed (iv) gingival graft or periodontal flap surgery may be performed to prevent further recession and loss of attached gingiva (g) Classification of Recession (i) Recession Type 1- no loss of interproximal attachment (ii) Recession Type 2- associated with loss of interproximal attachment; < buccal attachment loss (iii) Recession Type 3- associated with loss of interproximal attachment; >buccal attachment loss (2) Mucogingival defect/problem (stress) - when exists, all keratinized tissue is detached, resulting in lack of adequate amount of attached gingiva; therefore, the base of the pocket extends apically to mucogingival junction

Assessment of occlusion

- includes 1. Angle's classification and anterior relationships 2. Degree of tooth mobility 3. Excessive wear patterns (facets) 4. Defective prematurities - isolated occlusal contacts that cause deflection in the pathway of physiologic mandibular movement 5. Teeth, restorations, or prosthetic appliances that may interfere with normal movements of the mandible 6. Temporomandibular joint dysfunction 7. Fremitus - vibration of root surfaces as the patient "taps" teeth together 8. Tooth sensitivity to pressure and to hot and cold substances

Gingivitis

- inflammation confined to the gingiva without clinical connective tissue attachment loss and bone loss

Abscesses of the Periodontium Dental abscess

- localized, circumscribed, purulent area of inflammation in the tissues surrounding the teeth. Dental abscesses may resemble each other from a clinical standpoint, differing only in point of origin and their specific path of infection.

Periodontitis

- loss of clinical connective tissue attachment (also referred to as clinical attachment loss)

Periodontal Diseases Treatment

- nonsurgical and/or surgical periodontal therapy, followed by maintenance therapy

Clinical connective tissue attachment loss

- the pathological detachment of collagen fibers from the cemental surfaces with the concomitant apical migration of the apical part of the junctional epithelium onto the root surface. The events leading to clinical connective tissue attachment loss also result in the destruction of alveolar and supporting bone

Pathology associated with occlusion (trauma from occlusion)

- tissue injury to the supporting attachment apparatus (bone, periodontal ligament, and cementum) as a consequence of normal or excessive occlusal force(s) applied to a tooth or teeth; characterized by breakdown of the PDL fibers, bone resorption, widening of the PDL space, and loosening of the teeth (1) Periodontal assessment/Clinical changes (a) degree of tooth mobility (review previous info) (b) presence of malocclusion or malposition of teeth (c) documentation of oral habits (i) bruxing (grinding) or clenching of the teeth (ii) chewing on fingernails or foreign objects (iii) movement of the temporomandibular joint (evidenced by crepitus, tenderness, or deviations) (d) assessment of occlusion - includes (i) Angle's classification and anterior relationships (ii) degree of mobility (iii) excessive wear patterns (facets) (iv) defective prematurities - isolated occlusal contacts that cause deflection in the pathway of physiologic mandibular movement (v) teeth, restorations, or prosthetic appliances that may interfere with normal movements of the mandible (vi) temporomandibular joint discomfort (vii) fremitus - vibration of root surfaces as the patient "taps" teeth together (viii) tooth sensitivity to pressure and to hot and cold substances (e) radiographic changes (i) widening of the crestal portion of the periodontal space (ii) irregular widening of the entire periodontal ligament space (iii) if periodontitis is also present, there is a tendency for a vertical or angular pattern of bone loss and radiolucencies in the furcation areas (2) Classification of traumatic occlusal forces (NOTE: Occlusal trauma does not initiate periodontal disease; however, by causing degenerative changes in the deep periodontal structures, the inflammatory process in the overlying gingival tissues is allowed to spread apically more rapidly and result in more severe periodontal tissue destruction) (a) Primary occlusal trauma - trauma results from excessive occlusal forces; result could be mobility, excessive wear of a tooth/teeth; sensitivity of involved tooth/teeth; or fremitus (b) Secondary occlusal trauma - supporting periodontium is not normal (some bone loss of supporting structures is present); tooth/teeth are not able to withstand even normal occlusal forces without trauma; could result in mobility or sensitivity (3) Etiology - most commonly recognized etiologic factor is bruxism (4) May be associated with disorders of the temporomandibular joints (TMJ) (5) Treatment - occlusal adjustment if there are signs and symptoms of traumatic occlusion or neuromuscular disturbances; not well-justified for treatment of inflammatory periodontal disease, parafunctional habits, or TMJ disorders; occlusal splint may relieve symptoms

Function

- to attach the tooth to the bone of the mandible and maxilla

Phase III (Restorative Care)

-Restorative care/dentistry is performed; final restorations and fixed /removable prostheses are designed and placed that satisfy aesthetic, comfort, and functional needs without compromising future periodontal health · Final restorations are completed · All dental clinicians involved o Dental hygienist o General dentist o Periodontist o Prosthodontist

Dystrophies

-pathologic condition caused by abnormal cell biology and physiology (1) types (a) atrophy - diminished size of the organ or tissue (b) hypertrophy - increase in size of the tissue or organ caused by an increase in size of its cells; does not occur in gingiva; can occur in periodontal ligaments, cementum, and alveolar bone because of an increase in functional influences (c) hyperplasia - abnormal increase in volume of the tissue or organ caused by the formation and growth of new normal cells (2) gingival hyperplasia - overgrowth of gingiva caused by an increase in the fibrous tissue component of the gingiva (a) localized "fibroma" - etiology may be unknown or local irritation; treated by surgical removal and elimination of local irritating factors (b) generalized gingival fibrous hyperplasia -rare; etiology unclear (c) idiopathic gingival hyperplasia (Fibromatosis) - genetic; seems to involve a defect in collagen metabolism; treatment may include surgery; condition tends to recur (d) pyogenic granuloma - exaggerated tissue response possibly initiated by minor trauma; if it occurs in pregnant woman, it is called a pregnancy tumor; high incidence of recurrence (e) medication-induced hyperplasia - hyperplastic reaction of epithelium and connective tissue to medication, usually with inflammation being secondary, complicating factor; treatment includes daily, thorough plaque control with or without surgery (gingivectomy); may also try changing the patient's drug or dosage

Alveolar Process Definition

. Bone that forms and supports the tooth sockets (alveoli) B. Consists of 1. Alveolar bone proper (cribriform plate) 2. Supporting bone Shape, Thickness, and Location A. Contour B. Shape C. Thickness D. Posterior areas E. Anterior areas F. Dehiscence G. Fenestration (window)

Gingiva Components

. Marginal gingiva . Attached gingiva . Interdental gingiva (papilla)

Marginal gingiva

. Unattached cufflike tissue that surrounds the teeth; marks the opening of the gingival sulcus b. Parts of the marginal gingiva 1) Gingival margin - coronal ass 2) Free gingival groove - 1-2 mm below 3) Gingival sulcus - space between tooth and gingiva in health= sulcus disease= pocket

Classification of gingivitis by a. Duration

1) Acute - sudden onset; short duration; usually some pain or tenderness noted 2)Chronic - long duration; painless; may be episodic in progression

Distribution

1) Localized - confined to a single tooth or group of teeth 2) Generalized - involves entire mouth 3) Papillary - involves interdental papilla only 4) Marginal - involves gingival margin and papilla 5) Diffuse - involves gingival margin, papilla, and attached gingiva

Types of suture materials

1. Absorbable - absorbed by the healing tissues a. natural surgical gut (natural material from intestines of sheep or cows) (1) difficult to manipulate (2) does not hold knot well (3) tends to harden and cause trauma around the surrounding mucosa (4) mild inflammatory reaction occurs during the absorption process b. synthetic (polyglactin 910 and poliglecaprone 25) (1) easier to handle (2) knot will not loosen easily (3) cause less tissue irritation and inflammation 2. Nonabsorbable - remain in tissues until removed a week to 10 days a. surgical silk (twisted or braided) Twisted are better commonly used (1) most widely used material in periodontal surgery (2) is a foreign protein and thus is treated by tissues as a foreign body (inflammatory reactions are usually limited if sutures are removed within 7 days) (3) braided material tends to trap bacteria within the material (4) relatively comfortable and easy to use b. surgical cotton and linen - weak material; not used in periodontics c. synthetic fibers (polyester, nylon, polypropylene) - strong and well tolerated by tissue; but difficult to knot

Sterilization Dental implant

1. Affects long-term success or failure of implant - critically important 2. Whenever microorganisms are introduced during a surgical procedure, healing can be impaired. Manufacturers prepare implants in sterile packages 3. Autoclaving or chemical sterilization of implant is contraindicated - produces residue 4. Radio frequency glow discharge (plasma glow) has been shown to leave biomaterial surface uncomtaminated and sterile

Treatment - based on assessment

1. Always includes encouragement of patient and oral hygiene reinstruction as needed 2. Healthy periodontium - removal of supragingival deposits; no root planing indicated 3. Presence of bleeding/inflammation of the gingiva - treatment depends on etiology and pocket depth; removal of deposits and contributing factors necessary; possible use of an antimicrobial rinse (e.g., Chlorhexidine [Peridex]) or sustained-release, locally delivered antibiotic or antimicrobial agent 4. Presence of periodontal pockets - scaling and periodontal debridement/root planing followed by reevaluation in 4 to 8 weeks to determine need for adjunctive therapy 5. Frequency of supportive treatment - must be individualized a. increases when patients have less than optimal oral hygiene b. longer interval if patient can control plaque c. goal is to control clinical signs of inflammation and stabilize attachment levels d. frequent intervals (3 months or less) generally necessary for subgingival and supragingival plaque and calculus removal e. generally, the shorter the interval, the greater the long-term success; particularly during healing phase (1 year) after surgery

Current thinking relevant to gingival curettage

1. Based upon previous research findings, the consensus of most periodontal therapists is that gingival curettage has limited, if any, current application in the treatment of chronic periodontitis 2. If new connective tissue attachment is the goal of a particular periodontal treatment plan, curettage has no justifiable application; healing occurs by means of a longer junctional epithelium and tissue shrinkage 3. Further research is needed to determine if gingival curettage is appropriate in other cases, including a. treatment of medically compromised patients b. maintenance debridement of localized sites of recalcitrant periodontitis c. treatment of localized aggressive periodontitis and other types of periodontitis d. cases in which aesthetics are a concern

Documentation of oral habits

1. Bruxing (grinding) or clenching of the teeth 2. Chewing on fingernails or foreign objects 3. Smoking habits 4. Alcohol habits 5. Movement of the temporomandibular joint (evidence by crepitus, tenderness, or deviations) 6. Tongue-thrusting - labioversion of maxillary and mandibular anterior teeth (deviant swallowing)

Homecare/Adjuncts

1. Cleaning superstructure by conventional means 2. Implant should be cleaned using materials that will not damage titanium surface Floss/floss cord/superfloss Rolled gauze Toothpicks Foam tips/plastic coated proxybrush specific for implants Chlorhexidine

Additional information obtained through patient interview

1. Complete documentation of the patient's past and current health status 2. Complete documentation of the patient's dental history 3. Patient's daily oral hygiene routine 4. Patient's attitude toward oral health 5. Patient's oral health knowledge level

Implant-tissue interface

1. Controversy exists regarding the implant-tissue interface, although it is agreed that this is the basis of implant success 2. Epithelial attachment to the implant may be similar to the attachment to a natural tooth (i.e., basal lamina and hemidesmosomes); no periodontal ligament; called perimucosal seal 3. Perimucosal seal, or biologic seal, is critical to implant retention 4. Osseointegration - contact established between normal and remodeled bone and the implant surface without the interposition of connective tissue

The patient as a cotherapist

1. Daily oral hygiene practices performed by the patient are important to the success of nonsurgical periodontal therapy 2. Patient must be involved in goal setting, making decisions about treatment and alternatives, and making a commitment to long-term protective oral health behaviors 3. It is the clinician's responsibility to assist the patient in identifying and performing oral hygiene practices and to individualize instructions according to patient's needs 4. The patient's ability to remove and control bacterial plaque also must be considered (pt. takes ownership)

Periodontal Diseases as Risk Factors for Systemic Conditions

1. Diabetes 2. Cardiovascular Disease 3. Premature Low-Birth-Weight Babies 4. Respiratory Diseases

Desired properties of a suture material

1. Easy to handle 2. Nonallergenic and does not create an environment conducive to bacterial growth 3. Does not shrink after placement 4. Knots hold securely and does not fray 5. Does not easily cut or tear through thin, delicate tissue 6. If absorbable, does so with minimal tissue reaction

Principles of nonsurgical periodontal therapy (NSPT)

1. Elimination or suppression of pathogenic microorganisms through removal and control of bacterial plaque 2. Controlling the source of infection and preventing reinfection 3. Resolution or elimination of inflammation by establishing an environment conducive to health 4. Consideration (of host factors) of systemic and environmental host factors and, if possible, controlling the factors (similar to treatment plan)

Intrinsic (systemic) Factors

1. Endocrine Factors 2. Nutritional Disorders and Deficiencies 3. Drugs a. phenytoin b. cyclosporine c. chemotherapeutic agents d. antihistamines e. anti-depressants/anti-psychotics f. steroids g. nicotine h. calcium channel blockers i. estrogen replacement therapy j. alcohol (chronic use) 4. Psychological (emotional) Factors 5. Hereditary 6. Metabolic Disease (diabetes mellitus) 7. Hematological Disturbances and Diseases a. leukemia b. anemia c. hemophilia d. neutropenia e. thrombocytopenia f. infectious mononucleosis 8. Host Resistance and Immunity Status a. allergy (hypersensitivity) b. diabetes mellitus c. opportunistic infections d. HIV (human immunodeficiency virus)

dressing material Ingredients

1. Eugenol type a. powder (1) zinc oxide - slightly astringent and/or antiseptic (2) rosin - filler for strength (3) tannic acid - hemostasis (need for this is questionable) b. liquid (1) eugenol - slightly anesthetic (2) peanut oil - regulates the setting time 2. Noneugenol type (chemical-cured) a. paste 1 (1) zinc oxide - slightly astringent and/or antiseptic (2) magnesium oxide and oils - regulate setting time b. paste 2 (1) rosin - strength (2) chlorothymol - bacteriostatic 3. Noneugenol type (visible-light-cured) a. gel (1) polyether urethane dimethacrylate resin (2) silanated silica (3) visible-light-cure photo-initiator and accelerator (4) stabilizer (5) colorant b. advantage: does not start to set until activated by light-curing unit (exposure before placement should be limited because daylight in a room can activate it slightly)

Procedure for dressing placement

1. Explain the process to the patient 2. Make sure bleeding has ceased 3. Mix the dressing according to the directions 4. Gently place the dressing and establish retention in the embrasure spaces 5. Ensure the dressing does not cover more than the cervical one third of the tooth, does not overextend into the mucobuccal fold, and does not interfere with muscle attachments or with the patient's occlusion 6. Ensure the surface of the dressing is smooth and well contoured 7. Evaluate the dressing to ensure that it has not been forced between the soft tissue flap and the underlying tissue or root surface 8. May place dry foil over the dressing until it has hardened (few hours); foil is then removed (not necessary to use the foil) 9. Provide postsurgical instructions to the patient

Procedure for suture removal

1. Gently grasp the knotted end with cotton pliers and pull it away from the tissue 2. Insert the tip of scissors under the suture and cut the suture material that had been in the tissue 3. Gently pull knotted end so that only suture material that had previously been incorporated within the tissue will pass through the tissue during the removal process 4. Count and record the number of sutures removed and compare this number with the suture placement record 5. Gently cleanse the wound sites (may use any oxygenating agent, warm water, and cotton swabs) 6. Check for bleeding points and control with gauze and pressure 7. Check for and gently remove any calculus or granulation tissue

Periodontium is composed of:

1. Gingiva 2. Periodontal ligament 3. Alveolar bone 4. Root cementum

Connective tissue (lamina propria)

1. Gingival fibers 1. Intercellular ground substance 3. Cells 4. Vessles and nerves

Periodic reevaluation and assessment

1. Health and dental history review and update 2. Radiographic review 3. Extraoral and intraoral soft tissue examination 4. Dental charting 5. Periodontal assessment and charting 6. Evaluation of patient's oral health behavior, attitude, and skill

Evaluation of nonsurgical periodontal therapy

1. Immediate evaluation is accomplished through visual and tactile inspection of tooth surfaces 2. Healing of tissues for 14 days should be permitted; gingival tissues are then visually reevaluated for response to care "Big change, must allow to repair" 3. Thorough reevaluation 4 to 8 weeks after scaling/root planing/periodontal debridement to determine need for additional therapy (e.g., surgery, antimicrobials, antibiotics)

Indications for retreatment

1. Increase in probing depth greater than or equal to 2 mm 2. Increase in attachment loss greater than or equal to 2 mm 3. Bleeding on probing that does not respond to supportive treatment 4. Dental implants with bone loss or mobility 5. Consider severity in determining treatment regimens 6. If generalized deterioration, systemic complications might be suspected 7. Retaining questionable teeth is not recommended

Periodontal Maintenance Therapy/Continuing Care/Phase IV A. An extension of periodontal therapy

1. Initiated after completion of active periodontal treatment and continued at various intervals 2. Also a mode of therapy for patients who are unable to undergo periodontal surgery because of medical complications or other reasons

Implant management

1. Periodic evaluation of implants, surrounding tissues, and oral hygiene essential to long-term success; considerations in periodic evaluation include the following a. Extent of plaque and calculus b. Clinical appearance of peri-implant soft tissue c. Radiographic appearance - no periodontal ligament space or bone loss d. Absence of occlusal interference or trauma; stability of implant and prostheses e. Probing depth (if other signs of disease present) f. Absence of bleeding and exudates g. Adequacy of maintenance interval h. Patient comfort and function 2. Goals a. Maintain health of implant and supporting tissues b. Prevent loss of perimucosal seal c. Prevent gingivitis and, failing that, prevent conversion of gingivitis to periimplantitis, a periodontitis-like disease process that can affect dental implants (1) Infectious failure - failing implants with a primarily infectious etiology (microflora characterized by spirochetes and motile rods with a predominance of Peptostreptococcus ssp, Fusobacterium ssp, and enteric Gram-negative rods) (2) Traumatic failure - failing implants with a primarily traumatic etiology (microflora characterized by organisms that are observed in periodontal health) d. Provide preventive and maintenance therapy with minimal damage, or surface scratching, to implants e. Control bacterial plaque

Components of nonsurgical periodontal therapy (NSPT)

1. Plaque control - a. involves clinician and patient in eliminating and controlling bacterial plaque; b. customized oral hygiene instruction, c. correction of plaque-retentive factors d. supragingival and subgingival debridement are key elements; e. antimicrobial or antigingivitis agents or devices may be used as adjuncts to mechanical oral self-care methods; f. long-term success of nonsurgical periodontal therapy depends upon adequate plaque control 2. Oral Prophylaxis versus NSPT a. Objective of oral prophylaxis is to prevent the initiation of gingivitis and, failing that, to prevent conversion of gingivitis to periodontitis b. Oral prophylaxis is performed for patients with healthy periodontium and patients with plaque-induced gingivitis; NSPT is performed for clients with slight to moderate loss of periodontal support c. Oral prophylaxis includes supragingival and subgingival debridement to remove deposits; removal or correction of plaque-retentive factors (e.g., overhanging margins, open contacts, defective restorations); followed by selective coronal polishing, if necessary, for plaque and stain removal or for patient satisfaction d. Scaling refers to supragingival or subgingival calculus removal without intentional removal of tooth surface e. Therapeutic goal of prophylaxis is to establish gingival health through elimination of causative factors; goals of NSPT are to alter or eliminate periodontal pathogens, to address contributing risk factors, to arrest progression of periodontitis, and to preserve health, comfort, and function of the dentition

Removal of the periodontal dressing

1. Remove the dressing within 7 days 2. Gently tease the edges of the dressing away from the teeth with a curet or cotton/college pliers; be sure that sutures are not embedded in the dressing 3. After the pack has been removed, gently cleanse the area with warm water or dampened cotton tips 4. Assess tissue healing but do not probe sulcular areas 5. Remove sutures 6. Gently cleanse the area again with an antimicrobial agent 7. Evaluate wound healing and determine if the area needs to have a new periodontal dressing

Elimination of inflammation and pathogenic microorganisms can be accomplished by

1. Removing and controlling bacterial plaque and endotoxins a. plaque removal b. plaque control c. scaling, root plaining, and debridement d. adjunctive use of antiplaque and antigingivitis agents (e.g. chlorhexidine [Peridex]) 2. Eliminating factors that favor bacterial accumulation a. root surface irregularities b. calculus deposits c. overhanging or poorly contoured restorations d. loose or open proximal contacts e. food impaction f. mouthbreathing

Components of supportive treatment

1. Requires cooperation of patient, dental hygienist, dentist, and periodontist 2. Emphasizes scaling, root planing/debridement, polishing, and reinstruction of patient in plaque removal to maintain attachment levels

Oral Defense Mechanisms

1. Saliva a. Importance Salivary secretions are protective in nature because they maintain the oral tissues in a physiologic state. Flow - 1 to 1.5 liters/day b. Role of Saliva in Oral Health 1) Functions a) assists in mastication of food b) serves as a solvent c) contributes to the digestion of carbohydrates d) lubricates food and oral tissues e) acts as a buffer f) cleanses the mouth by flushing out debris g) acts to inhibit the growth of some bacteria 2) Antibacterial Factors a) Lysozyme b) Lactoperoxidase-thiocyanate system c) Salivary antibodies d) Other enzymes e) Glycoproteins 3) Salivary Buffers and Coagulation Factors a) bicarbonate-carbonic acid system b) factors VIII, IX, and X; plasma thromboplastin antecedent (PTA); and Hageman factor 4) Leukocytes a) polymorphonuclear leukocytes b) orogranulocytic migratory rate c. Role in Periodontal Pathology 1) Influence a) plaque b) calculus c) periodontal disease d) dental caries 2) Xerostomia 2. Gingival Crevicular Fluid a. Flow b. Volume c. Antimicrobial products 3. Oral Epithelium a. Keratin b. Close attachment of epithelial cells c. Shedding of epithelial cells

Desired properties of a dressing material

1. Soft and flexible to allow for proper adaptation 2. Reasonable setting time 3. After setting, should be rigid but not brittle 4. Smooth dressing surface 5. Be non-toxic and non-irritating to the oral tissues C. Types 1. Zinc oxide-eugenol dressing - eugenol is added since it has a soothing (obtundent) effect on exposed root surfaces and connective tissue and has antiseptic properties; eugenol may have an irritating effect on bone; firm consistency of this dressing requires some pressure during placement 2. Zinc oxide-noneugenol dressing - softer dressing than eugenol type; also more pleasant tasting; reclassified into chemical-cure and visible-light-cure systems 3. Collagen dressing - absorbable; available in individual sterile packs; ideal for graft sites on palate; placed on bleeding wounds STILL USED

Use of systemic antibiotics

1. Sometimes used in conjunction with periodontal therapy (surgical or non-surgical); however, 2. There is no evidence that antibiotics alone arrest periodontal disease 3. Not recommended for routine treatment of gingivitis or chronic periodontitis; problems with drug hypersensitivity, development of resistant strains, and patient adherence limit widespread use 3. Can be beneficial in treatment of periodontitis in the presence of systemic disease and immuno-compromised states, refractory, and aggressive forms of periodontitis 4. Commonly used systemic antibiotics include tetracycline, metronidazole, metronidazole plus amoxicillin, clindamycin, ciprofloxacin, and amoxicillin and clavulanate potassium (Augmentin); selection depends upon causative bacterial species "might prescribe if auto-compromised or aggressive"

Major types of implants

1. Subperiosteal - custom-fabricated framework of metal that is supraalveolar (on top of the bone) but beneath the oral tissues; rests on the bone for support and may or may not be fixed a. Posts protrude through tissues to provide anchor for final bridge or denture b. Two-step surgery required - initial surgery to deflect soft tissues and make impression of alveolar bone, followed by placement of fabricated implant framework c. Use of computerized tomography - could eliminate first step in the future d. Not used frequently; used if there is inadequate bone mass for root-type implants 2. Endosteal or endosseous (inside bone) a. Implant is placed directly into a socket, which has been prepared by a process called trephining; uses a series of specially prepared drills and burs (1) Osseointegration refers to the implant being in direct contact with the bone without intervening connective tissue (i.e., no periodontal ligament or connective tissue attachment); the implant is in effect "ankylosed" within the bone (2) After initial loss of 1 to 2 mm alveolar bone during the first year, crestal bone should be stable with no more than 0.1 to 0.2 mm per year thereafter b. After the bone and softer tissues heal (about 6 months), the final bridge or denture is placed 3. Transosteal or transosseous a. The implant is placed through the bone b. Description - A metal plate, fitted to the inferior border of the mandible, has five to seven pins extending toward the occlusal surface. Usually, two terminal pins protrude into the oral cavity to hold the overdenture. The pins are connected by a crossbar. The transosteal implant can be used when the patient has an atrophic edentulous mandible or a congenital or traumatic deformity of the mandible. 4. Endodontic - placed inside the tooth through to pulpal canal to stabilize the tooth; they are used infrequently 5. Transitional (mini) - narrow diameter implants placed in a non-submerged fashion simultaneously with definitive implants; developed to support provisional fixed restorations during the phase of osseointegration of the definitive implants; designed for immediate loading

Patient adherence

1. Successful maintenance therapy requires a life-long commitment from patients for meticulous plaque control and regular supportive treatment visits 2. Because periodontal disease progresses slowly and is painless, it is perceived by patients as non-threatening 3. Reducing patient responsibilities to the minimum that are necessary tends to increase adherence 4. Repeated reinstruction is needed for development of long-term protective health behaviors 5. Evaluation of the patient's oral hygiene must be based upon clinical signs of inflammation rather than presence of bacterial plaque alone 6. Patients also must understand the importance of professional periodontal maintenance therapy, particularly in the control of subgingival deposits, because compliance with recommended maintenance intervals has been shown to be poor (ranging from 11% to 45%) 7. Reasons for nonadherence a. personal characteristics - high stress, unstable personal life b. unfavorable dental beliefs (fear) c. economics - care is unaffordable, or perceived to be d. lifestyle changes - moves, job changes e. internal health beliefs

Principal Fiber Groups

A. Alveolar crest group - B. Horizontal group - C. Oblique group - Largest Group D. Apical group - E. Interradicular group - Inbetween roots of teeth

Normal Clinical Features

A. Color - Pink/ pale Dark skinned- other colors than pink B. Texture 1. Gingival margin - 2. Attached - C. Consistency 1. Gingival margin - 2. Attached - Film and attached D. Contour and Shape 1. Papillary contour - Knife edge 2. Marginal contour - Follow contour 3. Contour varies with shape and alignment of teeth and with size and position of proximal contacts

POSTOPERATIVE CARE Patient Instructions and Education

A. Discomfort 1. Expect discomfort after the anesthesia wears off 2. Use the prescribed pain medication 3. Rest and limit physical activities during the first few days to prevent excessive bleeding and promote healing 4. Use an ice pack to prevent swelling 5. Eliminate spicy, hot, cold, or hard sticky foods/liquids and smoking to limit tissue irritants and protect the dressing B. Care of the periodontal dressing 1. Do not eat anything for the first few hours until the dressing hardens; may drink cool liquids 2. During the week, pieces of the dressing may chip off; call the office if the area is extremely sensitive, the entire dressing is loose, or the chipped area is irritating the tongue or mucosa C. Home-care recommendations 1. Do not rinse the mouth on the first day because this may disturb the blood clot 2. After the first day, may rinse gently with lukewarm water, a small amount of an antibacterial or antimicrobial rinse 3. Brush and floss nonsurgical area as usual 4. Gently brush occlusal surfaces of the surgical area 5. Using a soft brush and water, very gently clean the surface of the dressing 6. Brush the tongue 7. Use an antimicrobial agent to help control bacterial plaque (e.g., chlorhexidine) D. Bleeding 1. Slight seepage of blood during the first few hours is normal 2. Any unusual, persistent bleeding should be reported

The Bacteria-Host Challenge

A. Factors Influencing Host Susceptibility 1. Decrease in good bacteria 2. Critical mass of pathogenic bacteria 3. Favorable environment to cause disease 4. Susceptible host that reacts to the pathogen B. Bacteria's pathogenic effect on periodontium 1. Direct injury 2. Indirect toxicity

Periodontal disease activity

A. refers to the stage(s) of periodontal disease characterized by loss of alveolar bone and connective tissue attachment B. implies that the natural history of periodontal disease has periods of active destruction and periods of relative inactivity, although chronic inflammation persists C. three theories of periodontal disease activity 1. continuous paradigm - implies a slow, constant progression of periodontal degeneration 2. random burst theory - implies short periods of destruction followed by periods of no destruction, occurring randomly 3. asynchronous multiple burst theory - implies periodontal disease activity, and resultant destruction, occurs within a specific period of life and is followed by remission

Indication

ARESTIN is indicated as an adjunct to scaling and root planning (SRP) procedures for reduction of pocket depth in patients with adult periodontitis. ARESTIN may be used as part of a periodontal maintenance program, which includes good oral hygiene and SRP

Important safety information

ARESTIN should not be used in ant patient who has a known sensitivity to minocycline or tetracyclines. The use of drugs of the tetracycline class during tooth development mat cause permanent discoloration of the teeth, and therefore should not be used in children or in pregnant or nursing women. Hypersensitivity reactions that included, but not limited to anaphylaxis, angioneurotic edema, urticaria, rash, swelling of the face and pruritus have been reported with the use of ARESTIN. In clinical trials, the most frequently reported nondental treatment-emergent adverse events were headache, infection, flu syndrome and pain.

Contraindication Arestin

ARESTIN should not be used in any patient who has known sensitivity to minocycline or tetracyclines

Managing the Progression of a Periodontal Infection

Arestin (Minocycline HCI 1mg) microspheres · Antibiotic · Used in lab · Process evaluation

Care for the Periodontal Patient

Assessment Dental hygiene diagnosis Planning Implementation Evaluation Documentation All of the steps are used for the dental hygiene procedures in periodontal care

Assessment

Assessment is data collection/gathering all relevant information concerning the patient Must be performed before a dental hygiene diagnosis or observation of a disease Data collection starts with chief complaint and medical history Includes vitals, intra/extraoral exam, restorative charting, etc.

Attached and Keratinized Gingiva

Attached gingiva is calculated by subtracting the probing depth from the width of the keratinized gingiva

Cementum Definition

Calcified mesenchymal tissue that covers the surface of the root

Use of ARESTIN in patient with exiting conditions and other risk factors

Cardiovascular disease 58% greater pocket depth reduction Smokers 29% greater pocket depth reduction Over 50yo 33% greater pocket depth reduction

Gingivitis

Characterized by nBleeding nRedness nSwelling nExudate nTenderness

Furcation

Class I-early, probe can enter the furcation area Class II-moderate, probe can enter but not pass through Class III-severe, probe can pass through and through Class IV-furcation is open and exposed and clinically visible

Radiographic Evaluation

Complete series of radiographs Vertical bitewing radiographs nCalculus deposits nRoot fractures nRoot resorption nCaries nSupernumerary teeth nImpactions Complete Series Radiographs with Bitewings nUpdate bitewings every 2-3 years nCompare with previous series nBone loss becomes apparent at about a 40% loss Limitations nRadiographs provide a two dimensional view of a three dimensional condition

Periodontitis as a Manifestation of Systemic Disorders/Modified by Systemic Factors

Dental plaque initiates periodontal diseases but the form of disease and its progression is dependent on the host defenses to this challenge. Systemic conditions and environmental exposures may modify the normal defenses and influence the outcome of periodontal disease. a. PMN defect results in increased rate and severity of periodontal tissue destruction b. Numerous drugs predispose to gingival overgrowth in response to plaque and thus may effect in modifying preexisting periodontitis c. Systemic conditions (ex. Diabetes mellitus, Down syndrome, Papillon-Lefevre syndrome) appear to predispose individuals to periodontitis. These individuals have compromised host responses. d. Certain environmental conditions or exposures including cigarette smoking and emotional stress may modify periodontitis

Precautions Arestin

Do not give to patients that are pregnant or nursing women

Classification/Documentation of Gingivitis

Duration nAcute-sudden onset; short duration; usually some pain or tenderness nChronic-long duration; painless; may be episodic in progression Distribution nLocalized-confined to a single tooth or group of teeth nGeneralized-involves entire mouth nPapillary-involves interdental papilla only nMarginal-involves gingival margin and papilla nDiffuse-involves gingival margin, papilla, and attached gingiva Severity nMild nModerate nSevere

Types of Implants

Endosseous: In the bone (most used) threaded in the bone 3-6 to intergrads in the bone. Subperiosteal: (not used as much now.) Transosteal: through the bone Endodontic: in propared root after root canal, not used in the USA because of fractures and going through the root. Transitional: mini implants for ortho and holding implace, not might of long term

Planning

Establishment of realistic goals and treatment strategies to facilitate optimal periodontal health Development of a written treatment plan based on data collection and assessment

Interdental gingiva (papilla)

Extension of free Gingiva Shape: determined by contact + width of adjacent teeth + CEJ Anterior: Pyramidal

. Periodontal Ligament (PDL) Definition

Extension on connective tissue fibers

Gingival Assessment

Gingivitis nLocalized or generalized nColor change from light pink to dark red with severity nChronic inflammation - dark red to blue red nAcute inflammation - bright red nEarliest changes are seen in the interdental papilla nWith an increase in severity, color changes invade the marginal gingiva Procedures Include nProbing nVisual examination Dry tissue first Color Determined by degree of vascularity, epithelial keratinization, presence of melanin, thickness of epithelium In inflammation, color varies Gingival redness is not strongly associated with or a predictor of periodontal disease activity (process of currently having clinical attachment loss or apical migration of the JE) First evaluate at the free gingival margin Contour Determined by the shapes and positions of the teeth Margins and papillae should be evaluated for health versus disease nGingival clefts Consistency Firmness of gingival tissues Press side of probe against the gingiva Smokers vs. nonsmokers Firm, edematous, fibrotic Surface Texture Examine the attached gingiva Stippling vs. shiny and smooth If gingiva was stippled and subsequently lost stippling, then it is disease nChronic inflammation Size: Gingival Enlargement Coronal migration of the free gingival margin Hormonal changes nPregnancy, puberty, etc. Medications nPhenytoin, cyclosporine, calcium channel blockers, valproic acid nMouth breathing nHereditary gingival fibromatosis

Tooth Mobility

Grade N-normal, firm tooth Grade 1-slight mobility in buccal and lingual direction up to 1 mm Grade 2-mobility greater that 1 mm in buccal and lingual direction Grade 3-mobility greater than 1 mm in any direction with easy depression

Connective tissue (lamina propria) Intercellular ground substance

Ground substances is ajelly like substances

Initial Assessment

Health history signed by patient Dental history Current radiographs Clinical charting

APPLICATIONS FOR PRACTICE

I. ADVANTAGES OF PATIENT APPLIED DAILY IRRIGATION A. Reduction of Bleeding (daily) B. Removal of the Loosely Attached Biofilm from Subgingival and Problem Areas C. Special Needs Areas II. CONTRAINDICATION A. Premedication Requirement B. Incidence of Bacteremia (should be couses for pt. going into surgery) C. Consultation

DESCRIPTION OF IRRIGATORS

I. POWER-DRIVEN DEVICE A. Generates an intermittent or pulsating jet of fluid with an adjustable dial for regulation of pressure and flow B. Delivers irrigant through a hand-held interchangeable tip that rotates 360° for application at or below the gingival margin C. Maintains steady flow or pulsations of irrigant from a reservoir D. Provides reservoir container for convenient measurement of antimicrobial or other agent II. NON-POWER-DRIVEN DEVICE A. Attaches to a household water supply: faucet or shower B. Delivers water through a hand-held interchangeable tip that can be turned for application at the gingival margin C. Cannot definitively control water pressure D. Nonpulsating flow of irrigant E. Efficacy not tested in clinical studies

DELIVERY METHODS specialized

I. STANDARD JET TIP A. Delivery Tips B. Procedure C. Special Instructions II. SPECIALIZED TIPS A. Delivery Tips B. Procedure

Implants Versus Natural Teeth

Implant-tissue interface *Natural teeth surrounded by bone, cementum, PDL, and gingiva *Implant surrounded by per-implant tissue *There is no PDL (it has osseointegrated) *The abutment, like the crown of a tooth, is surrounded by gingiva *After surgery, the gingiva heals around the abutment and a gingival sulcus forms *On natural teeth, the junctional epithlium provides a seal at the base of the sulcus *On implants, a JE adheres to implant surfaces but the JE is referred to as a Perimucosal seal; It is not a thick seal *Implants do not have a cementum and connective tissus fibers inserting into the implant surface *There are connective tissus fibers but they are either parallel or circular *Very tight but like a purse string, not not want to desterb

In-office Irrigation

Irrigate to the base of the pocket Plastic irrigation tips or cannulas Do not be too aggressive in forcing tip At maintenance visits More controlled clinical studies need to be bone to support implant irrigation/May damage the biological seal

ORAL IRRIGATION

Irrigation is the targeted application of a pulsated or steady stream of water or other irrigant for preventive or therapeutic purposes.

Dental Hygiene Diagnosis

Made after assessment steps are completed Identifies the patient's actual or potential response to the disease process Focuses on problems or conditions that are responsive to dental hygiene intervention

Medical and Dental History

Medical history may uncover other conditions that may affect the periodontal condition.

Sanguinarine

Not ADA approved Burning Some studies

Gingival Bleeding

Objective clinical sign of inflammation; however, some visually inflamed sites do not bleed May be masked if the gingiva is fibrotic (smoking) Absence of bleeding strongly suggestive of low levels of inflammation Bleeding alone not a good predictor for periodontal disease progression BUT deeper probing depths plus bleeding is more indicative of periodontal disease activity Bleeding measured at gingival margin nStroke the crevicular lining

Implementation

Once the plan is presented to the patient, the implementation phase starts Includes: *Preparing the operatory *Using proper infection control *Periodontal debridement procedures *Pain management *Apply chemotherapeutic agents *Apply fluoride agents *Coronal polishing *Care of oral prostheses *Health education and preventive counseling smoking nutritional *Documentation

perio-implant inflammation lesion

Oral biofilm grow faster on titanium than enamel More widespread inflammation around implants Infected implants have earlier and more rapid bone loss

Evaluation

Outcomes of treatment/feedback on the effectiveness of treatment and procedures Occurs after treatment has been completed Follow-up visits for patient

Review of Stages of Peri-implant Disease

Peri-implant mucositis *Reversible inflammation of soft tissues *Plaque-induced inflammation *Similar to natural teeth Peri-implantitis *Graded from slight to severe *Loss of supporting bone *Treatment is similar to that of natural teeth

Assessment of Periodontal Diseases

Periodontal Therapy Dependent on Early intervention Thorough evaluation Adequate time must be allocated for thorough evaluation Recent Study 75% stated they would not get periodontal disease 57% reported bleeding gingiva during brushing Recent Study 4% of Americans believe they have gingivitis ADA estimates over 75% of adults have gingivitis Prior to Periodontal Therapy Assess "chief complaint" Assure patient acknowledgement of disease Rational treatment is Logical Orderly Detailed

Hard and Soft Tissue Deficiencies

Potential implant sites need: Keretineized tissue Adequate bone to support tissue and implant May never grafting prior to placement of implant

Periodontal Assessment

Probing Gains Insight into nSoft tissues nBone loss nCalculus nFurcation involvement nRoot anatomy

Dental Hygiene Process of Carefor the Periodontal Patient

Provides a framework within which the individualized needs of the patient can be met An assessment process involving five phases of a search for clues leading up to the identification and classification of the nature of the disease and the steps in patient care needed to alleviate the problem

Clinical parameter of Evaluation: Hard Tissue Evaluation

Radiographs *Panoramic radiographs commonly taken for baseline data *Individual periapical or vertical bitewings taken with gridded film *Bone height *Bone density *Implant success is 0.2mm or less of bone loss yearly *6-12 months radiographs Mobility *Recommended to remove prosthesis every year to test implant and abutment mobility *There should be zero mobility since there is no PDL and there is osseointegration *Mobility of superstructure is checked by wedging a cruet between the prosthesis and abutment head

Scope of Therapy is Growing

Recent advances in Understanding etiology Understanding disease progression Therapeutic products available in stores Diagnostic techniques and disease monitoring

DELIVERY METHODS

STANDARD JET TIP A. Delivery Tips (standard) B. Procedure (oral appliances, directy at the tooth) C. Special Instructions

Bacteriology dental implants

Similar pathogens found on natural teeth and implants Purphyromonas gingivalis *Compylobacter recta *Tannerella forsythensis *Prevotella intermedia *Peptostreptococcus micros *Actinobacillas actinomycetemcomitans Fusobacterium nucleatum *Eikenella corrodens *Eubacterium species *Selemonas species *Spirochetes Implants Versus Natural teeth biologic environment

Perio-implants Bacteriology

Similar to pathology found on nature teeth and implants

Perio-implant treatment

Slight: Treatment with OHI and nonsurgical local therapy (debridement, control-release antibiotic and mouth rinse) Moderate: Require systemic antibiotics or flap surgery Severe: flap surgery for access regenerative therapy, or removal of implant

Treatment of Peri-implantitis

Slightly problems: treatment with OHI and nonsurgical local therapy (debridement controlled-release antibiotics, and mouth rinses) Moderate problems: require systemic antibiotics or flap surgery Severe problems: flap surgery for access, regenerative therapy, or removal of implant Instrumentation Superstructure removal For better access for maintenance Some are removable prostheses Others are fixed with screws or cemented If present, calculus is not tenacious because it does not penetrate the implant surface Titanium is tough but easily scratchable Do not use stainless steel and carbon steel instruments Use plastic, graphite, Teflon, or nylon instruments If using ultrasonic/sonic scalers, specific plastic or nylon sleeves must be placed over the tip *Polishing Fine polishing paste Tin oxide/chlorhexidine slurry Soft rubber cup or point

Controlled Drug Delivery

Sustained-released, local delivery Objective is to eliminate periodontal pathogens with greater safety and compliance Available delivery systems including hollow fibers, gels, collagen film, and bioabsorbable materials

Periodontal Prognosis

The overall prognosis for a dentition affected by periodontal disease is the outlook for maintaining the dentition in periodontal health if comprehensive dental treatment is rendered. The individual prognosis should be established for certain teeth when conditions for them vary from those found throughout the mouth. · Outlook for maintaining the dentition or individual teeth in health if comprehensive dental treatment is rendered · Base on how much control we have over the etiological factors and which teeth remain with an adequate level of periodontal support · In the majority of patients, the single most important factor in determining the prognosis is whether an adequate level of plaque control can be established over a long period of time

Etiology

The science of causes and orgins

Periodontal Probing

There are a variety of periodontal probes available The most traditional design has markings in 1 mm increments Black millimeter markings are available Variations is shank design gain access in difficult to reach areas Nabers Probes - best used in furcations Probing Technique *Insert parallel to vertical axis of tooth *"Walked" around tooth *6 readings made Walking the probe around the tooth allows exploration of morphology Six measurements are taken on each tooth Detecting interdental craters *Place probe obliquely from facial or lingual Periodontal probe placement should be nearly parallel to the long axis of the tooth At the contact point, the probe should be angled slightly in the proximal area so that the tip is directly beneath the contact Probe readings: Round up to the nearest whole number Proper Probe Force Superimposed probe showing size relationship between the periodontal probe and junctional epithelium Proper Probe Force Even with light pressure, the probe can penetrate beyond the bottom of the sulcus, through the junctional epithelium Computerized Probes/Controlled Force Probes *Force can be calibrated *Can detect distance from tip of probe to the CEJ *Examples: Florida probe Interprobe Pocket Readings Vary Due to nProbe angulation nForce of probing nTissue health nProbe diameter nSite location and access nCalculus Probing Depth Defined nThe distance between the gingival margin and the apical depth of the periodontal probe tip penetration Factors Affecting Probe Readings nSize of probe nPatient sensitivity nProbe force (can affect readings by 1 - 2 mm) Factors Affecting Probe Readings Heavy Calculus *Obstructs probe from reaching base of pocket Factors Affecting Probe Readings nPatient Discomfort Management nTopical anesthetic nProbe after homecare and scaling have improved tissues Factors Affecting Probe Readings Site access visibility

BENEFICIAL EFFECTS FROM IRRIGATION

There are two bodies of evidence for oral irrigation, the use of home devices by the patient and professionally applied using a hand syringe, mechanized handpiece, or ultrasonic scaler. I. REDUCTION OF GINGIVITIS AND BLEEDING II. REDUCTION/ALTERATION OF DENTAL BIOFILM AND BY-PRODUCTS III. PENETRATION INTO POCKET: SUBGINGIVAL ACCESS IV. DELIVERY OF ANTIMICROBIAL AGENTS V. PERIODONTAL MAINTENANCE

Dental Implants Role of Dental Hygienist

Treatment and maintenance Educate patient about implants Picture documentation Show prospective patients potential end results Descriptive brochures

Chemical agents used as irrigants

Water Chlorhexidine Providone-iodine Essential oils Hydrogen peroxide Fluoride Tetracycline

Documentation

Written and visual documentation Patient consent form Computer technology

The clinical value of comprehensive treatment that includes Arestin (minocycline HCI) microspheres, 1 MG + SRP · WHY Arestin?

a. Arestin is a locally administered antibiotic (LAA) that contains minocycline, which targets infection using a unique delivery system b. Incorporation Arestin at the time of SRP helps prevent the recolonization of harmful bacteria c. Arestin + SRP provides significantly better results than SRP alone for up to 90 days

Necrotizing Ulcerative Periodontitis

a. Characterized by severe soft tissue necrosis and rapid destruction of periodontal attachment and bone; may lead to exposure of alveolar bone and sequestration b. Chief complaint may be "jaw pain" or "deep aching pain" c. Can be localized or generalized d. Often occurs in persons who have an immune dysfunction (ex. human immunodeficiency virus [HIV], severe malnutrition) e. Treatment requires conventional periodontal with povidone iodine irrigation therapy in conjunction with 0.12% chlorhexidine mouth rinsing and/or systemic antibiotics and more frequent maintenance therapy than indicated for persons with periodontitis

Connective tissue (lamina propria) 1. Gingival fibers

a. Circumferencial or circular fibers - b. Dentogingival fibers - c. Dentoperiosteal fibers - d. Alveologingival fibers (attached gingival) - e. Transseptal fibers -

Connective tissue (lamina propria) Cells

a. Fibroblasts (predominant cells) b. Other connective tissue cells 1) Mast cells 2) Macrophages 3) Polymorphonuclear (PMN) leukocytes 4) Lymphocytes 5) Plasma cells

1. Peri-Implant Health

a. No movement appearance of health. b. Plastic probe is okay in real world c. Absence of erythema, bleeding, swelling, suppuration. d. No visual difference between peri-implant and perio issues.

Oxidizing agents (chlorine dioxide)

a. No therapeutic value but recommended for breath freshening; also have been shown to effectively reduce halitosis "bad breath" b. Reduces volatile sulfur compounds believed to be responsible for halitosis c. well known representatives of this group are Oxyfresh and Retard

1. Nonsurgical periodontal therapy

a. Objective is to treat established periodontal disease and to create conditions conducive to health; contributing risk factors must be addressed because they affect treatment outcomes b. Rationale includes elimination of bacterial pathogens, endotoxins, calculus, and other irritants from the tooth surface to reduce inflammation, promote tissue regeneration, and create a biologically acceptable root surface; control, alteration, or elimination of risk factors (e.g., diabetes, smoking, stress, medications, substance abuse, pregnancy, etc.) c. Supragingival and subgingival scaling, periodontal debridement, root plaining, or a combination is performed; procedures are technically demanding; definitive treatment procedures designed to remove cementum or surface dentin that is rough or embedded with calculus, toxins, or microorganisms; often requires local anesthesia; when performed thoroughly, some unavoidable soft tissue removal occurs d. NSPT often requires multiple appointments to remove or correct all deposits and plaque- retentive factors; with root planning, controversy exists regarding need for extensive cementum removal and possibility of overtreatment e. Hand or ultrasonic instruments may be employed for root planing and periodontal debridement; ultrasonic instruments are advocated for debridement f. Scaling, periodontal debridement, and root planing have been shown to be successful in treating gingivitis, slight chronic periodontitis, and moderate chronic periodontitis; results are less predictable in periodontal pockets over 6mm in depth or when furcation involvement is present g. Root planing is contraindicated in healthy sulcus areas or shallow crevices; has been shown to cause a loss of attachment in crevices less than 3 mm h. Clinical objectives or initial endpoint (1) Control or elimination of microbial plaque, calculus, and other local factors contributing to chronic periodontitis (2) Root planing requires smooth, firm root surface free of embedded calculus and bacterial plaque (NOTE: need for root planing should be determined by health status of gingival tissues; a "rough" root without corresponding gingival inflammation is contraindicated for root planing) (3) Immediate evaluation of root planing and periodontal debridement is by visual and tactile inspection of the tooth surfaces (4) Periodontal debridement refers to treatment of periodontal disease through mechanical removal of tooth and root surface irregularities (including bacterial plaque, clinically detectable calculus, and all plaque retentive factors) only to the extent that adjacent soft tissues are healthy; removal of calculus is only considered important from the perspective of its plaque retentive nature (5) Difference between periodontal debridement and root planing is in the initial endpoint desired and its effect on the extent of instrumentation; root planing is performed until root smoothness is obtained, whereas debridement attempts to preserve tooth surface by removing only enough deposits and plaque-retentive factors to achieve gingival health (6) The trend is toward removal of as little tooth structure as possible; however, all clinically detectable calculus must be removed; root smoothness is not essential for healing, removal of bacterial irritants is the key; concept is based on the fact that 100% calculus removal is not successful on all root surfaces with any nonsurgical procedure and may not be desirable at the expense of lost tooth structure and dentinal hypersensitivity (pgs. 302-303 healing "top and bottom" longer probing depth to smaller major "6mm to 3mm) i. Evaluation of outcomes of NSPT or initial therapy - reevaluation of NSPT at an appropriate interval after initial therapy by means of a periodontal examination is critical to determine if clinical judgment regarding extent of root planning and periodontal debridement was adequate to achieve periodontal health; if unsuccessful, retreatment is indicated (1) Four to eight weeks is considered an appropriate interval for resolution of inflammation and periodontal tissue healing (2) Relevant findings of the reevaluation are documented in the patient's legal treatment record (3) Deplaquing, which includes removal or disruption of bacterial plaque and its toxins subgingivally following completion of periodontal debridement, or selective coronal polishing, often is performed at reevaluation and continued care appointments (4) Control, alteration, or elimination of both local and systemic risk factors are essential for successful NSPT a. Elimination of factors affecting bacterial accumulation (e.g., overhangs, large carious lesions, malocclusion, etc) b. Consideration of systemic factors and, if possible, treatment and control (e.g., hormonal - consult endocrinologist; drug associated - change medication; blood dyscrasia or diabetes - refer to physician for treatment)

Prebrushing rinse (sodium benzoate)

a. Sodium benzoate is not an antiplaque or antigingivitis agent; controlled long-term studies show NO beneficial effect in gingivitis (e.g. Plax) b. long-term studies suggest no therapeutic effectiveness; consumers often need clarification that these rinses are cosmetic or mouth freshening only c. safety is not a concern; no adverse effects d. NOT ADA approved "feels fresh but it contains soap"

Necrotizing Ulcerative Stomatitis

a. Soft tissue necrosis extends beyond the gingiva b. Bone exposure may occur through the alveolar mucosa c. Osteitis d. Formation of bone sequestrum

Epithelium 1. Epithelium on the outersurface of marginal and attached gingiva is parakeratinized (some retained nuclei) or keratinized (no nuclei). Composed of 4 layers of cells:

a. Stratum basale layer Basal layer b. Stratum spinosum layer Prickle or spinous cell layer c. Stratum granulosum layer Granular cell layer d. Stratum corneum layer Keratinized cell layer

Attached gingiva

a. That part of the gingiva that is attached to the underlying periosteum of the alveolar bone and to the cementum by connective tissue fibers and the epithelial attachment b. Boundaries c. Width varies Pigmentation: light color Stippling Total width of gingiva= Free gingiva + attached gingiva

Oxygenating agents (hydrogen peroxide)

a. antiinflammatory properties decrease clinical signs of inflammation, but bacterial pathogens may not be reduced b. long-term studies do not support use c. safety questions, such as tissue injury and cocarcinogenicity, have been raised with chronic use of hydrogen peroxide d. NOT ADA approved "short term use, NUG and NUP"

3. Stannous fluoride

a. antimicrobial mechanism of action appears to be related to the stannous (tin) ion rather than to the fluoride b. short-term and long-term studies have shown mixed results; however, significant reduction in bacterial plaque and gingivitis have been documented; further long-term study is warranted c. most often available in gel form (e.g. Stop, Gel-Kam) .4% concentration; rinses contain .63% concentrations (e.g., PerioMed, GumCare); no alcohol content d. stannous fluoride has moderate substantivity; once or twice-daily usage favors compliance e. adverse effects may include taste and mild tooth staining in some patients f. stannous fluoride products are accepted by the American Dental Association for their ability to deliver fluoride for anticaries activity but have not been accepted for their bacterial plaque - and gingivitis reducing properties; some also approved for hypersensitivity reduction

Phenolic compounds (essential oils)

a. approved by the American Dental Association as an antimicrobial agent and antigingivitis (Listerine) b. long-term studies indicate approximately 30% to 35% reduction in plaque and gingivitis c. available products have a high alcohol content (26.9% alcohol; pH 5) d. adverse effects include burning sensation and bitter taste; some report soft tissue irritation e. twice-daily use favors compliance

Desquamative gingivitis

a. clinical features - characterized by desquamation, or sloughing, of the gingival epithelium, leaving an intensely red surface as a result of vesiculation; may involve all or part of gingiva and other oral mucosal surfaces b. radiographic findings - none c. etiology - a sign rather than disease entity; may be oral manifestation of dermatologic disorders, erosive lichen planus, bullous pemphigoid, and pemphigus vulgaris d. treatment - requires different types of management, depending on underlying condition; careful examination and history, hematologic analysis, and/or biopsies may be needed for definitive diagnosis; local treatment is indicated in all cases; systemic therapy also may be used

Steroid-hormone influenced gingivitis

a. clinical features - clinical signs of gingival inflammation or gingival enlargement; may be marginal of diffuse, localized or generalized; severe cases may progress to pyogenic granuloma (pregnancy tumor) b. radiographic findings - none c. etiology - may be associated with puberty, pregnancy, birth control medication, or steroid therapy; subgingival growth of Bacteroides, Porphyromonas,or Pevotella species; characterized by exaggerated response to bacterial plaque d. treatment - removal of bacterial plaque and calculus deposits; in some cases, modification of hormone therapy or medications

Medication-influenced gingival overgrowth (also called drug associated)

a. clinical features - gingival inflammation and/or enlargement; overgrowth of gingival tissues may result; pseudopockets may be present b. radiographic findings - none c. etiology - may or may not require plaque-induced inflammation for development; usually plaque-associated gingivitis complicated by systemic drug administration (e.g., phenytoin, cyclosporin, nifedipine) d. treatment - removal of bacterial plaque and calculus deposits, gingival stimulation and plaque control by patient, may require alteration of drug therapy

Miscellaneous gingival changes

a. clinical features - includes all other pathologic alterations in the gingival tissues; changes include clinical signs of inflammation, atrophy, cyst formation, neoplasia, and degeneration b. radiographic changes - none c. etiology - associated with blood dyscrasias, nutritional deficiencies, tumors, genetic factors, mouthbreathing, and diffuse bacterial and viral infections d. treatment - depending on etiology; may require local and/or systemic therapeutic modalities e. Examples: 1) Hereditary Fibromatosis 2) Irritative Fibromatosis Factors: othro, heavy plaque, poor oral hygiene Clinically: Growth increases 3) Mouth Breathing Factors: Due to obstruction of nasal passageways Clinically: shiny red gingiva inflammation and enlarged from maxillary canine to canine 4) Blood Dyscrasias Sickle cell anemia Agranullocytosis Leukemia Cyclic neutropenia 5) Nutritional Deficiencies Vitamin C, B,D, A 6) Viral Infections- secondary causes from stress, sun, trauma 7) Allergic Gingivitis Not plaque induced, contact sensitivity to antigen, toothpaste, mouthrinses, chewing gum

Additional Clinical Interventions A. Surgical procedures 1. Rationale

a. eliminate active infection b. render the periodontium more cleansable by the patient (1) improvement in hard and soft tissue contours (2) pocket elimination c. replace damaged or destroyed periodontium (1) soft tissue replacement (gingival grafts) (2) hard tissue replacement (osseous grafts) d. surgery is rarely performed to remove inflammation or infection, but rather to (1) eliminate both hard and soft defects created by disease (2) try to restore normal architecture (3) try to gain new attachment of the supporting structures

Reevaluation should include

a. evaluation of the patient's home care "redisclose" b. updated periodontal assessment c. reassessment of the clinical health of tissues; if areas still show signs of inflammation, the cause should be determined (1) bacterial plaque present - review or supplement home care (2) deposits of calculus still present - scale, debride, or root plane as needed (3) no plaque or calculus noted - check the root surface to determine whether debridement is needed and retreat as indicated (4) pocket depth still moderate to severe - surgical procedures might be warranted (5) inflammation still severe and etiology and contributory factors cannot be identified - consider physical examination by a physician for a possible systemic risk factor "if patient isn't responding" d. determine maintenance schedule "no magic number based on individual"

Periodontitis Radiographic features

a. fuzziness and discontinuity of the lamina dura at the proximal aspects of the crest of the interdental septum b. a wedge-shaped radiolucent area is formed between the mesial or distal aspects of the alveolar crest and the root surface of the involved tooth; also called triangulation c. center of the crestal portion of the interdental septum also becomes fuzzy; and faint cup-shaped areas of alveolar crest bone loss appear d. progression of interdental bone loss 1) horizontal bone loss - reduction in height of the interdental septa; however, the crest is parallel to an imaginary line connecting adjacent cementoenamel junctions 2) angular or vertical bone loss - crest is reduced in a manner that creates angular defects e. limitations of radiographs in diagnosis of periodontitis 1) radiograph does not reveal minor destructive changes in bone 2) involvement of facial and lingual surfaces cannot be seen 3) angulation errors can affect radiographic image of alveolar bone 4) internal morphology of infrabony craters or defects cannot be seen 5) as a general rule, bone loss is always greater than the radiograph reveals

Types

a. gingival curettage - procedure to remove the ulcerated, chronically inflamed tissue lining a pocket b. gingivectomy - surgical procedure for pocket reduction by complete removal of the soft tissue pocket wall (1) indications (a) gingival pockets composed of enlarged fibrotic tissue (b) suprabony periodontal pockets with adequate zones of keratinized gingiva (c) correction of severe gingival overgrowth (2) contraindications (a) reduction of infrabony pockets (b) reduction of pockets that extend to or into the alveolar mucosa c. periodontal flaps - may be used as a method of surgical curettage or for pocket elimination by apically repositioning the soft tissues (1) advantages (depending on the type of flap) (a) better access to achieve thorough scaling and root planing (b) thorough removal of the pocket lining (c) elimination of pockets (d) means to obtain access to the alveolar bone to correct osseous defects (2) indications (a) probing depths in presence of intrabony defects; probing depths greater than 5 mm after initial therapy; furcation involvements; presence of root anomalies or irregularities (b) following unsuccessful nonsurgical periodontal therapy (c) to enhance cleansibility of areas unaccessible to home care (d) need to treat diseased roots subgingivally (e) in conjunction with other procedures to treat intrabony defects (f) progressive attachment loss (3) contraindications (a) if periodontal disease can be treated and controlled by a more conservative approach (nonsurgical periodontal therapy) (b) in the presence of excessive mobility (c) advanced attachment loss; poor prognosis (d) inadequate gingiva, poor crown root ratios, or anatomic preclusions (e) systemic disorders that contraindicate surgery (f) noncompliant client d. excisional new attachment procedure (ENAP) - a procedure using internally beveled incision to remove the crevicular lining and junctional epithelium, allowing root preparation e. osseous resective surgery (1) objective - removal of alveolar bone to produce a more physiologic architecture or contour; ultimately pocket reduction in one-walled infrabony or vertical defects; also for lengthening the clinical crown for root restoration; goal is to remove minimal amount of bone (2) indications - vertical alveolar defects or exostoses requiring reshaping (osteoplasty) or surgical crown lengthening (ostectomy) for access to deep root caries lesions or fractures f. regenerative surgery and guided tissue regeneration (1) objective - promote regeneration of the connective tissue, periodontal ligament, cementum, and alveolar bone (2) indications - two- and three-walled vertical defects, Class II furcation defects, circumferential defects (3) two options available (a) guided tissue regeneration - involves using a semipermeable membrane between the epithelium and the underlying ligament and bone to prevent rapid downgrowth epithelium which would interfere with connective tissue regrowth after surgical debridement of the defect; nonresorbable or resorbable membranes are used but the former must be removed 1 to 2 months following surgery (b) bone grafts - involve placing bone grafting material into a debrided defect to the level of the uninvolved crest to promote bone healing and regeneration (osseoinduction); the graft stimulates new bone formation and thus new attachment; autografts are bone grafts obtained from the same client; allografts are processed human cadaver bone that is usually freeze-dried or demineralized; alloplasts are a synthetic type of bone substitute; and xenografts are a type of natural bone substitute derived from a genetically different species (e.g., bovine) g. mucogingival surgery (1) objectives (a) prevent additional loss of keratinized attached gingiva and/or recession (b) increase the band of attached gingiva (c) root coverage (2) indications (a) base of the pocket extending apically to the mucogingival junction (b) inadequate zone of keratinized attached gingiva (c) frenum pull on the gingiva, causing gingival recession (d) localized gingival recession associated with inflammation (3) treatment options (a) pedicle grafts (b) free gingival grafts (c) free connective tissue grafts (d) partial or full frenectomy h. root hemisection or resection (1) objective - removal of the crown and/or root to eliminate the involved furcation (2) indication - severe furcation involvement that cannot be treated by osseous surgery or regenerative surgery (4) two options available (a) hemisection - performed on mandibular molars; crown and root is sectioned in half to create two individual roots thus eliminating furcation; sometimes one root must be removed because of instability or severe attachment loss (b) root resection - involves removal of one root of a multirooted tooth without sectioning the crown; most often performed on maxillary molars

Methods for delivery of antimicrobial agents

a. most common methods of delivery for antimicrobials are mouthrinsing and oral irrigation; dentifrices and gels also are used b. mouthrinses deliver agents supragingivally; subgingival penetration is only 0 to 1 mm c. oral irrigation can deliver agent subgingivally; complete plaque removal is not achieved, but periodontal pathogens found in loosely adherent plaque can be removed; must be used as an adjunct to mechanical plaque control d. oral irrigation can be accomplished with water or antimicrobial agents; both reduce bleeding and gingivitis, but antimicrobials are more effective in removing bacterial plaque; effect on periodontitis is not well documented e. depth of penetration with oral irrigation is related to type of tip used f. oral irrigation can have value in conjunction with daily self-care regimen for mechanical plaque removal in treatment of gingivitis or in periodontal maintenance therapy g. professionally administered oral irrigation has been studied with and without root planing and periodontal debridement; main benefit is from mechanical debridement; a single application of an antimicrobial irrigant has little value because of low substantivity in the periodontal pocket due to the presence of serum, proteins, and crevicular fluid

Chlorhexidine

a. most effective agent for reducing plaque and gingivitis long-term (45% - 61%); .12% concentration b. high substantivity - ability to remain in the mouth for a long duration while releasing active ingredient c. alcohol content - 11.6%; pH 5.5 (Alcohol-free chlorhexidine from GUM) d. adverse effects - staining, reversible desquamation, poor taste or alteration of taste, increase in supragingival calculus deposits e. approved by the American Dental Association as an antimicrobial and antigingivitis agent (Peridex or PerioGard) f. twice-daily use favors compliance "positively changed, 30 mintues after or before brushing "do not want to bind to fluoride"

Quaternary ammonium compounds (cetylpyridinium chloride - CPC)

a. short-term studies show some reduction in bacterial plaque and gingivitis; results inconclusive but therapeutic value is questionable; low substantivity b. may have some benefit in reducing halitosis; patients purchase for mouth-freshening benefits c. long-term studies needed to document effectiveness d. adverse reactions include possible staining and burning sensation e. well-known representatives of this group are Scope, Cepacol, Crest Pro-Health Rinse f. alcohol content: Scope (18%); Cepacol (14%); Crest Pro-Health (0%) g. pH: Scope (6.5); Cepacol (5.5)

Periodontitis Associated with Endodontic Lesions Periapical abscess

develops from an infection of the pulpal tissue Combined periodontic-endodontic lesions - occur where an endodontically induced periapical lesion exists on a tooth that is also periodontally involved

Gingival abscess

develops through a break in the gingival tissue surface as a result of an acute injury or localized infection of the gingiva; an acute localized inflammatory reaction of gingiva caused by a break in the epithelial tissue due to foreign material forced into the gingiva (toothbrush bristles, toothpicks, food impaction); bacteria invade through this abrasion causing the localized infectious process (1) usually confined to marginal and interdental papilla; begins as a localized red swelling with a smooth, shiny surface; as it progresses, it becomes pointed and purulent exudate may exit through a fistula tract (2) treatment - incise and drain; keep area clean; reassure patient

Pericoronal abscess (pericoronitis)

inflammation of the tissue flap (operculum) surrounding the crown of a partially erupted tooth (1) most frequent in third molars (mandibular) (2) may be acute, subacute, or chronic (3) clinical findings if acute (a) extremely red, swollen lesion with exudate is present (b) area is extremely tender, with pain radiating to the ear, throat, and floor of the mouth (c) there is a foul taste in the mouth (d) inflammation may progress so that swelling, trismus (limited mandibular movement), fever, and malaise may be present; symptoms are less obvious as the situation becomes more chronic (4) etiology - accumulation of food debris and bacterial growth between the soft tissue flap and tooth; tissue inflammation may be compounded by trauma from the opposing tooth (5) treatment (a) give antibiotics if fever, swelling, or lymphadenopathy is present (b) cleanse the area (lavage and curettage) and create access for drainage of the exudate (c) have the patient rinse frequently with warm saltwater; have the patient return for retreatment after 24 hours (d) after pain subsides and the infection is controlled, either extract the involved tooth or remove (excise) the soft tissue flap - recurrence is likely if not removed

Necrotizing ulcerative gingivitis (NUG)

inflammatory destructive disease of the gingiva that has a sudden onset with periods of remission and exacerbation; predisposing conditions may be preexisting (e.g., gingivitis, smoking, period of severe stress, radical change in eating or sleeping habits) a. clinical findings are characterized by crater-like depressions at the crest of the interdental papilla that progress into the marginal gingiva (1) surface of the lesion(s) is covered by a gray, necrotized slough surrounded by an obvious erythematous (red) zone (2) bleeding may be spontaneous and also will occur when necrotic tissue is removed gently (3) initially moderate pain increases as the disease advances (4) fetid odor and increased salivation are present (5) swelling and tenderness of regional lymph nodes (especially submandibular nodes) are present (6) fever and malaise may be present b. radiographic findings - none unless the disease has not been treated and has led to destruction of supporting structures (necrotizing ulcerative periodontitis) c. etiology - predisposing factors are present, with intermediate-sized spirochetes, Prevotella intermedia and Fusobacterium species found within the tissue; however the primary etiologic factor is uncertain d. treatment (1) plaque and debris removal - initially by clinician and daily by the patient (may be difficult because of pain); ultrasonic debridement may have some benefit (2) antibiotics may be prescribed if systemic symptoms (lymphadenopathy, fever, etc.) are evident (3) soft nutritious diet (4) avoidance of spicy foods, alcohol, and smoking (5) after acute symptoms disappear, gingival tissues may need to be surgically recontoured if destruction resulted in a reverse architecture

Gingival Diseases

n Dental plaque-induced gingival lesions n Can occur on a periodontium with no attachment loss or on a periodontium with attachment loss that is not progressing n Include plaque-associated gingivitis and gingival diseases modified by systemic factors such as the endocrine system (hormonal), blood dyscrasias, medication, and malnutrition n Non-plaque-induced gingival lesions n Include gingival diseases of specific bacterial, viral, fungal, or genetic origin n Gingival manifestations of systemic conditions such as mucocutaneous disorders and allergic rxns n Traumatic lesions, foreign body rxns, and otherwise nonspecified gingival lesions

Dental History Provides Information on:

nBaseline nPatient attitude nPrevious dental problems nResponse to treatment nHomecare

Symptoms of Periodontal Problems

nHalitosis nDiscomfort nFeeling pressure in gingiva or jaws nBleeding nExudate nRedness Mobility

Four Phases

nMedical and dental history nRadiographic assessment nPeriodontal assessment nPlaque and calculus evaluation

Systematic Approach

nPatient's chief complaint nFamily background nCurrent and past medical history nMedications nReview of organ system Patient should update medical history at each visit

Clinical Parameters

nPocket probing depths nBleeding upon probing nGingival recession nBacterial plaque, calculus and suppuration nTooth mobility nFurcations nMeasurement of attached and keratinized gingiva nMicrobiological monitoring (selectively)

Radiographs are used to assess

nRoot length and morphology nClinical crown to root ratio nBone destruction nPosition of maxillary sinus nHorizontal and vertical resorption nFurcation involvement

Ask Open-ended Questions

nWhat changes in your health, medication, or hospitalization have occurred since your last visit? nWhat about your mouth is bothering you? nWhat brings you to this appointment?

Other

preliminary studies are being conducted on various other agents including but not limited to enzymes, plaque modifiers, and agents affecting bacterial attachment

Gingival Curettage A. Definition -

procedure to remove the ulcerated, chronically inflamed tissue lining a pocket

Peri-implantitis

term used for inflammatory changes in the soft tissues leading to loss of supporting bone around a functioning implant Treatment - may include periodontal debridement, oral hygiene instruction, mouthrinses, systemic antibiotics, periodontal surgery, or removal of the implant Depending on stage of perio will depend on treatment

Peri-implant mucositis

term used to describe reversible inflammation in the gingival around a functioning implant. Plaque-induced similar to natural teeth

Use of host-modulating drugs - drugs that target the host response 1.Doxycycline hyclate (Periostat)

used systemically in sub-antimicrobial doses to decrease collagenase activity and periodontal disease progression "low dose, less systemic" a. has not been shown to substitute for meticulous home care and supportive periodontal therapy b. administered 20 mg twice per day or 40mg once a day "better 40mg, 6 months" c. research has shown slight gains in clinical attachment and slight reductions in probing depths; changes may be so small that patients must be informed of the costs of host- modulating drug therapy in time, money, and effort versus the limited benefit

Irrigation

§Remove calculus deposits prior to irrigation §Supragingival irrigation as an adjunct to OH, may be of value in treatment of gingivitis §Professional subgingival irrigation takes time, is done infrequently, and shows no advantage to S/RP alone

Treatment Planning

· "Requires assessment, preventive, therapeutic, and evaluative skills. · Blueprint for management of the case · Essential aspect of successful therapy · Includes all procedures performed to attain and maintain long-term oral health · Involves all members of the oral health care team and the patient" · occurs after the assessment of all clinical data · reflects the diagnosis and prognosis of the patient. · The treatment plan defines the methods and sequence of delivering appropriate treatment. · Except for emergency care, the dental hygiene treatment logically precedes other phases of treatment.

Arestin Delivery

· Delivery system: microspheres- effective delivery and easy to use a. Sustained release formula means ARESTIN keeps working for up to 14 days b. Ready to use powder form c. Bio-adhesive ("sticks" to the site) d. Bioresorbable (no need for a visit to remove the product from the site) e. What clinical endpoint are most important to you when evaluationg a patient after periodontal treatment? f. How would you define successful treatment outcomes? i. Healthy pink tissue, less bleeding,

Collection of data to assess the status of the periodontium B. Formulation of initial treatment plan based on data collected and assessment

· Determine etiologic and contributing factors · Removal or control of these factors · Organized order of treatment · Consider prognosis "over all health or systemic health"

Prognosis

· Factors used in determining a prognosis o Box 19-9, page 262 · Prognostic classification for individual teeth o Box 19-10 pg 262

1. Determination of all etiologic and contributing factors

· Honesty to patient · Prior to treatment, inform patient if there is a possibility of potential referrals · Prior to treatment, discuss prognosis of individual teeth vs. entire dentition · Schedule shorter, more frequent appointment vs. one long appointment in order to assess plaque levels and provide patient education/oral hygiene instructions · Advise patient: o Therapy is not a cure, but is designed to control the disease process o Proper oral hygiene and strict maintenance are critical to long-term success o Retreatment may be necessary

Use of topical antimicrobial agents as adjuncts (also referred to as local chemotherapy)

· Indicated for control of supragingival plaque and gingivitis; "does not reach but 1mm" · effectiveness in periodontitis has not been documented; · used to augment oral hygiene efforts of patients who are only partially effective; · also recommended for extensive restorative cases and dental implants; · aids healing following periodontal surgery

Referral to Periodontist

· Initial treatment usually in General Practice office · Team approach to care (between perio office and dental office) · Guidelines for referral o Aggressive periodontitis o Periodontitis with systemic factors o Refractory cases o Moderate to severe periodontitis 2. Removal or control of factors in an organized, logical sequence to include a. plaque removal and control b. pocket reduction or elimination c. when possible, removal of contributing factors 3. Order of treatment will depend on a. severity of the patient's periodontal condition b. general health status of the patient c. patient's motivation and cooperation d. prognosis

How to administer ARESTIN ( Minocycline HCI) Microspheres, 1 mg

· Locally administered antibiotic · Delivery deep into the pocket, to target infection 1. Attach cartridge to handle 2. Insert cartridge tip into periodontal pocket 3. Administer ARESTIN into periodontal pocket

Limitation of mechanical therapies

· Mechanical therapies, such as hand or ultrasonic scaling and laser debridement, cannot completely treat infections · Scaling instruments are limited in area of restricted access and cannot eliminate periodontal bacteria · Following mechanical therapy, bacteria remain, multiply, and can return to baseline levels within days · Even the most intensive mechanical treatment on its own cannot completely address the bacterial nature of periodontal infection and fully optimize the environment needed for healing

Like many other bacterial infections, a periodontal infection should be treated comprehensively when indicated

· Patient need to understand that periodontal disease is a chronic bacterial infection · Like many other bacterial infections, an antibiotic should be considered as part of the treatment

D. Patient Management E. Specific Treatment Plans for AAP Case Types

· Periodontal health pg. 254 · Gingivitis pg. 255 · Slight chronic perio pg. 256 · Moderate chronic perio pg. 257 · Severe Chronic perio pg. 258 "multiple appointments to get through all these steps"

Instructions for your patients after use of ARESTIN Tell your patient

· Resume brushing after 12 hours · Wait at least 10 days before using floss, toothpicks, or other devices to clean between teeth and around treated areas · Don't touch treat areas for 1 week except for routine brushing · Avoid eating hard, crunchy, or sticky food for 1 week · Talk to your patients about good oral hygiene routine · Follow up with dentist and DH by keeping your scheduled appointment

The American dental association and American academy of periodontology consider SRP the gold standard for treating periodontal disease

· SRP is the foundation of periodontal disease treatment; however it has important limitation

Types of Surgeries

· Two-stage surgery: most common, covered up and given sometime to heal 3-6 months, second surgery and then abutment is placed then given time to heal and placement of tooth, pt. must be paitent. This is almost a year long deal · Single-stage surgery o Immediate or early laoding o Not given time to heal into the bone, must be the right area and right patient

Importance of Periodontics to the Dental Hygienist

•Dental Hygienist is most likely to detect periodontal disease •Dental Hygienist is the initial therapist •Dental Hygienist must be able to educate patient

PREVALENCE

•Periodontal disease is the major cause of tooth loss in adults -Before age 25 - CARIES -After age 35 - PERIODONTAL DISEASE -After age 55 - ROOT CARIES •Gingivitis affects every patient no matter of age •Periodontitis - prevalence increases with age •75-90% of Americans over 40 years old have some form of inflammatory periodontal disease

Periodontist

•Practitioner of periodontics (2-3 years of education after completion of dental school).

Periodontics

•The branch of dentistry that deals with the science and treatment of periodontal diseases

Periodontology

•The science and study of the periodontium both in health and disease

Periodontium

•The tissues that surround and support the teeth. Anatomically, the periodontal structures are described as the -Gingiva -Periodontal ligament -Alveolar bone -Cementum

Periodontal Diseases

•Those diseases that affect the periodontium

Bacterial Plaque

1. Initiating (activating) factor of periodontal disease 2. Definition- Alive, filmy adhere to tooth or hard material 3. Categories a. supragingival b. subgingival 4. Stages in supragingival plaque formation a. acquired pellicle- Bacteria free, adheres immediately after cleaning teeth, helps prevent biofilm to attach b. bacterial plaque- rate is at different times for ppl, premature bacteria at first, makeup of film changes over time, negitive bacteria decrease, anarobic starts growing sub, gingival mergin changes and inflammation over biofilm 5. Subgingival plaque a. growth, accumulation, and pathogenicity b. structure and organization c. attached (tooth-associated) subgingival plaque- oldest: die and minerilized, it is attached, must be touched to remove. d. loosely adherent (epithelium-associated) subgingival plaque- still alive, loosely adherent, can attacked tissue, rapid destruction more difficult to remove e. unattached- is still has to be remove with floss, f. bacterial invasion of periodontal tissues- diffent kinds of bacteria cause differnent disease, if pateint is not responing to treatment swabs can be taken to get antibio to treat g. bacterial specificity 6. Calculus a. mineralization can begin from 24 to 48 hours or up to 2 weeks after plaque deposition b. earliest mineralization occurs along the inner surface of plaque c. composition- mostly nonliving, minerals 70-90% water 10-30% plaque builds on calculus causes more calculus d. classification 1) supragingival 2) subgingival e. modes of attachment to teeth 1) by acquired pellicle 2) direct attachment to tooth 3) by mechanical locking f. effect on the periodontium 7. Pathogenic effect on the periodontium (review) a. direct injury b. indirect toxicity 8.Host response (review)

Preventive instrumentation

1. It is possible that a smooth surface is more conducive to a plaque-free environment and roughening will predispose surface to plaque retention 2. Surface changes in descending order a. Ultrasonic/sonic scaling devices - not recommended unless covered with a specially designed plastic or nylon sleeve; sleeves are commercially available to cover metal tips b. Stainless steel, carbon, or titanium tipped curets - not recommended c. Interdental brushes - unitufted brushes or interdental brushes with plastic-coated wire preferred; hand or motorized soft toothbrushes on the superstructure; tufted dental floss (e.g., Superfloss) or floss cords (e.g., PostCare) d. Polishing pastes - fine grit or tin oxide (e.g., Abutment Glo or Ora Ti) can be used on the superstructure; air polishing not recommended e. Antimicrobials - 0.12% chlorhexidine mouth rinse commonly recommended by practitioner; a cotton swab or interdental brush, dipped in the solution, can be applied directly to the gingival margins to help to prevent staining of oral tissues or tooth-color restorations f. Nonmetallic curets such as plastic, nylon, or Teflon-coated curets that can effectively instrument the subgingival area without changing the implant surface topography are recommended for calculus removal g. Plastic periodontal probes are recommended for assessing clinical attachment loss around dental implants if inflammation is present; no probing necessary if tissue is healthy; radiographs also recommended when inflammation is present

Factors That Influence Periodontal Health

1. Local (extrinsic) etiologic factors a. Irritating 1) Initiating factor- biofilm 2) Predisposing (contributing) factors- stain, matria albua, calcus, smoking, food impactions, bad DH work, soft sticky food, improper brushing, using tooth picks. b. Functional factors- Mssing teeth, rotated teeth, mouth breathing, mouth rings. 2. Systemic (intrinsic) etiologic factors Over all body play role in lower the resistant of the host making them more susceptible to infections, smoking, stress, emotional, genes, blood disease

Contributing factors influencing the prognosis

1. Local factors a. degree of periodontal destruction (amount of attachment loss) b. rate of periodontal destruction (amount of attachment lost per unit of time) c. presence of contributing factors (e.g. malocclusion, parafunctional habits, position of teeth in alveoli, malalignment, root proximity, missing teeth) d. quality of restorations present 2. Systemic factors - patient's general health (presence or absence of systemic disease) 3. Personal considerations a. patient's home care habits, motivation, and willingness to assume responsibility for oral hygiene b. patient's ability to finance specific types of periodontal treatment and restorative/prosthetic needs

Predisposing (Contributing) Factors

1. Materia Alba 2. Food Debris (retention and impaction) 3. Food consistency 4. Dental stains 5. Calculus 6. Improper Oral Hygiene 7. Deficient dental treatment a. fillings b. crowns/pontics c. removable prosthodontics d. orthodontics 8. Caries 9. Smoking and tobacco

Other diagnostic tests

1. Microbiologic monitoring a. Microbiologic monitoring diagnostic tests are available to identify selected periodontal pathogens within one or more diseased sites b. Examples of various tests include DNA probes, culturing media, enzyme test (BANA); use of darkfield or phase-contrast microscopy is not recommended for purposes of microbiologic monitoring but may be useful in patient education c. Data from microbiologic monitoring tests may be useful in early-onset/aggressive or refractory periodontitis cases or in selection of an appropriate systemic antibiotic regimen 2. Biochemical diagnostic tests are also developed to evaluate host response to periodontal pathogens

Functional Factors

1. Missing teeth 2. Malocclusion 3. Tongue thrusting 4. Mouth breathing 5. Parafunctional habits (not part of normal function) 6. Traumatogenic occlusion 7. Oral piercings

Changes in the periodontium may be a result of:

1. Morphologic and functional alterations 2. Changes in the oral environment 3. Age 4.Grinding 5.Autoimmune disease 6. Years of poor hygiene

Definition - artificial replacements of teeth that are permanently affixed into the alveolar bone

1. Offers an alternative to removable dentures to edentulous or partially edentulous patients 2. Implants provide a permanent anchor for artificial teeth by serving as an abutment for fixed or removable prostheses a. Implant - portion surgically placed within the bone b. Abutment - metallic post attached to the implant so a restoration can be placed over it c. Superstructure - prosthetic replacement (e.g., crown, bridge, or denture) that is affixed to the abutment or a removable replacement tooth that the client can remove and clean

Sustained-release, local delivery of antibiotics and other drugs (also referred to as controlled drug delivery)

1. Systems are available for local delivery of antibiotics or antimicrobials to specific subgingival sites (e.g. hollow fibers, gels, collagen film, bioabsorbable material); objective is to eliminate periodontal pathogens; these methods of local delivery provide for the benefits of antibiotic therapy with greater safety and compliance; delivery mechanisms allow antibiotic or antimicrobial agent for 7 to 14 days (varies by product) after placement 2. Studies show little or no adjunctive affects when sustained-release antimicrobial or antibiotic agents are combined with mechanical periodontal debridement; they may provide similar effects as debridement on a short-term basis; long-term studies are needed to determine to what extent rebounds can be expected; some benefit also has been shown in maintenance therapy for localized recalcitrant or refractory sites 3. Currently available sustained-release agents have been shown to be effective in nonresponsive sites after initial therapy; effectiveness in initial periodontal therapy less clear a. tetracycline-containing (25%) ethylene vinyl acetate fiber placed subgingivally for 10 days; must be removed professionally (Actisite) b. minocycline gel (2%), biodegradable, total of three applications, at intervals of 2 months (Dentomycin) c. doxycycline hyclate (10%), solidifying, biodegradable polymer, total of two applications at intervals of 4 months (Atridox) d. metronidazole benzoate gel (25%), biodegradable, total of two applications at intervals of 7 days (Elyzol) e. chlorhexidine gluconate chips (2.5 mg), total of three applications at intervals of 3 months (PerioChip) f. minocycline HCl (1 mg) microspheres, biodegradable, applied and retained for 14 days (Arestin) 4. Local delivery offers the advantage of sustained-release of a high concentration of the active ingredient to the site of periodontal infection without systemic involvement 5. Research is being conducted to improve delivery systems and expand therapeutic agents available to include other antibiotics, antimicrobials, and non-steroidal anti-inflammatory agents

Materials commonly used for dental implants

1. Titanium - a metallic element; pure or plasma-sprayed 2. Hydroxyapatite - plasma-sprayed

Objectives of supportive treatment

1. To preserve health, comfort, and function of the teeth 2. Long-term control of bacterial plaque 3. Reevaluation of results after active periodontal therapy 4. Reinforcing oral hygiene instructions and encouraging patient's long-term protective oral health behaviors 5. Determining need for additional treatment

Historical overview Gingival curettage

1. Until recently, gingival curettage was a recommended treatment procedure for areas of gingival inflammation and/or increased probing depths to reduce inflammation and probing depths through shrinkage of tissues and healing by a long junctional epithelium 2. Studies of gingival curettage almost always have combined this technique with root planing 3. Research indicates that gingival curettage is ineffective and root planing alone can, in many cases, reduce inflammation, result in tissue shrinkage, and promote healing of the junctional epithelium 4. In some states, gingival curettage is a legally permissible procedure for dental hygienists to perform, and many clinicians have received education and training for clinical competence in gingival curettage

Sutures DH can remove sutures in KY DH can not place sutures in KY A. Objectives

1. Used to hold soft tissues in place until the healing process has progressed to the point where tissue placement can be self-maintained 2. Stabilizing the soft tissue helps a. maintain the blood clot around the wound b. protect the wound area during the healing process

Periodontal documentation

1. Uses - documentation of existing periodontal status; baseline for future reference 2. Updated periodically to determine changes in periodontal health 3. Necessary for treatment planning 4. Serves as a guide for the clinician during treatment and evaluation 5. Serves as a legal document 6. Serves as a technique for managing risks associated with failure to diagnose and treat periodontal disease

Periodontitis

1. disease resulting from the inflammatory process originating in the gingiva (gingivitis) and extending into the supporting periodontal structures; may have periods of activity and remission

Host response

1. role in inflammatory periodontal infections 2. inflammatory cells migrate by chemotaxis in response 3. antibodies or immunoglobulin are produced 4. classification of immunoglobulin a. IgG 70% -75% of the total b. IgM Fastest to respond c. IgE Alergic reaction d. IgD e. IgA Secretions *Saliva, tears, breast milk 5. Complement is activated 6. lysosomes are released - tissue destruction results 7. lymphocytes are stimulated and lymphokines are produced 8. bacterial antigen is neutralized but tissue destruction occurs concurrently 9. protective function vs. overreaction or hypersensitivity

The Oral Mucosa Collectively, all the soft tissues of the mouth are known as the oral mucosa. A. Three different types:

1.Masticatory mucosa - Gingiva, Hard palate 2. Lining mucosa - Alveolar mucosa, floor of mouth 3. Specialized mucosa - Dorsum of tongue

Keratinization is a protective adaptation to function which increases with gingival stimulation.

2. Sulcular epithelium - 3. Junctional epithelium - 4. Epithelial attachment - 5. Rete pegs -

Progression of Gingivitis into Periodontitis

A. Gingivitis - inflammation of the gingiva 1. Clinical features a. Stage I, or initial lesion - 2 to 4 days following plaque accumulation 1) changes are not clinically visible 2) histologic changes a) "widening" of small capillaries b) increase in leukocytes, particularly polymorphonuclear leukocytes (PMNs), in the connective tissue, junctional epithelium, and gingival sulcus c) increase in flow of gingival crevicular fluid into the sulcus d) inflammatory infiltrate occupies 5-10% of the gingival connective tissue where collagen has been lost b. Stage II, or early lesion - begins 4 to 7 days following plaque accumulation; may persist for 21 days or longer 1) clinical signs of gingivitis appear (erythema and bleeding upon stimulation) 2) histologic changes a) persistence of inflammation from initial lesion b) leukocytes infiltration into the connective tissue dominated by lymphocytes (75%), macrophages, plasma cells and mast cells c) junctional epithelium becomes densely infiltrated with neutrophils and may begin to show development of rete pegs d) destruction of collagen fibers (especially circular and dentogingival) in the infiltrated area e) migration of leukocytes into junctional epithelium and gingival sulcus f) flow of gingival crevicular fluid peaks at 6 to 12 days following clinical signs of gingivitis g) sulcular lining is ulcerated c. Stage III, or established (chronic) lesion - time period variable; may persist for months or years without progressing to Stage IV (periodontitis) 1) clinical changes a) erythema (redness) of the gingiva as a result of proliferation of capillaries (begins in the papillary area) and/or a bluish hue superimposed over the reddened gingiva as a result of congested blood vessels and sluggish blood flow b) bleeding may occur on probing as a result of thinning and/or ulceration of the sulcular epithelium c) color changes begin in the papillary area, spread to the gingival margin, and then to attached gingiva d) consistency may be either soft and spongy or firm and leathery; depends on whether destructive changes or reparative changes within the gingiva are dominant e) texture may be either * smooth and shiny (destructive, exudative factors dominant) or * stippled and nodular (reparative, fibrotic proliferation dominant) f) increase in size of gingiva (enlargement) h) increase in depth of the gingival sulcus - may be caused by enlargement of the gingival tissue only; creates a gingival or pseudopocket * begins with papillary enlargement * extends into margins, producing rounded and bulbous gingival margins i) progression of inflammation * may remain only within the gingival tissues (gingivitis) * may extend into the supporting periodontal tissues in Stage IV (periodontitis) Note: periodontitis must be preceded by gingivitis, but gingivitis does not always progress into periodontitis 2) histologic changes a) increase in number and predominance of plasma cells and B lymphocytes, which invade deep into the connective tissue b) widened intercellular spaces in the junctional epithelium contains lysosomes, lymphocytes, and monocytes c) junctional epithelium protrudes into the connective tissue, creating rete pegs d) collagenase actively breaking down connective tissue collagen e) simultaneous proliferation of collagen fibers and epithelium f) sulcular lining is ulcerated g) bone loss has not occurred

Postoperative care Follow-up Visit

A. Patient returns approximately 7 days after surgery B. Dressing and sutures are removed; new dressing may or may not be applied C.Dental hypersensitivity may be experienced; desensitization indicated for dentinal hypersensitivity; desensitization methods may be prescribed D. Home care instructions are provided for plaque control E. Long-term postoperative care requires periodic evaluation (also known as continued care)

Periodontal Ligament (PDL) Functions

A. Physical/Mechanical - Suspensory B. Formative - Remodeling C. Resorptive - shock absorber D. Nutritive - Blood supply: vascular E. Sensory - Contraceptive/ tactile pressure

Periodontal Dressings: DH can place and remove

A. Rationale for use of a periodontal dressing is to protect the tissues after surgery; no curative properties; it has been demonstrated that wound healing progresses at the same rate with or without a dressing; however, periodontal dressings are sometimes used for the following reasons 1. Patient comfort, especially if the surgical procedure has left exposed connective tissue or exposed root surfaces 2. Protection of the wound against trauma (e.g., from sharp, hard food or toothbrush bristles) and prevention of the tongue from constantly rubbing the area 3. Maintenance of the initial blood clot - dressing may be helpful in preventing the initial blood clot from being dislodged; dressing should be applied only after bleeding has been controlled 4. Tissue placement - maintains the desired location of the soft tissue flap position (if performed)

Goals or Objectives of Treatment Sequencing

A. To eliminate and control etiologic and predisposing disease factors B. To eliminate the signs and symptoms of disease C. To restore normal function "oral cavity back to oral function" D. To maintain health and prevent the recurrence of disease

Blood Supply to the Periodontium

A. To the gingiva via supraperiosteal arterioles B. To the periodontal ligament via inferior and superior alveolar arteries C. To the alveolar process

Definition A.Total Treatment Plan

A. Total Treatment Plan - "all"sequential outline of the essential services and procedures to be provided by the dental health care team for the patient to eliminate disease and restore the oral cavity to health and function. B. Dental Hygiene Treatment Plan - consists of services that are performed by the dental hygienist within the total treatment plan.

Periodontal (or lateral) abscess

develops when the inflammatory drainage from a periodontal pocket is blocked; localized, purulent area of inflammation within the periodontal tissue (1) clinical findings (a) abscess may be in the supporting periodontal tissues on the lateral aspect of the root, which results in a sinus (fistula) through the bone extending out to the external surface (b) abscess may develop in the soft tissue wall of a deep, narrow periodontal pocket (i) acute - extreme pain, sensitivity, mobility, enlarged lymph nodes * gingival area is edematous, red, and smooth with a shiny surface * exudate may be expressed from the gingival margin on pressure (ii)chronic - usually asymptomatic or episodes of dull pain; elevation of the tooth; desire to grind on the tooth (may have acute episodes); usually has a sinus opening onto the gingival mucosa along the root (2) radiographic findings (many variations according to the location, stage, and extent of the lesion) - typical appearance is that of a discrete radiolucent area along the lateral aspect of the root (3) prognosis - bone regeneration following acute infection is much better than following chronic infection (4) treatment (a) proper diagnosis - distinguish from periapical abscess (pulp test) (b) reduction of abscess and acute inflammation (i) incise and drain - drainage can be established by curetting the pocket or incising the abscess (ii)extracting the tooth if necessary (c) antibiotics for lymphadenopathy and/or fever (d) reduce pocket depth - surgery (e) occlusal adjustment if necessary (f) root canal therapy to allow healing if periodontal tissues surrounding the apex of the root are involved NOTE: Diabetic patients with periodontal disease are susceptible to developing periodontal abscesses

Periodontitis

disease resulting from the inflammatory process originating in the gingiva (gingivitis) and extending into the supporting periodontal structures; may have periods of activity and remission 1. Clinical features a. Stage IV - advanced lesion - transition from gingivitis to periodontitis 1) generally follows the course of the blood vessels through soft tissues and into the alveolar bone 2) pattern of inflammatory pathway affects the pattern of bone destruction 3) initially, inflammation penetrates and destroys gingival fibers near the gingival fiber attachment to the cementum, then spreads a) interproximally * into the bone and periodontal ligament * from the bone to the periodontal ligament b) facially and lingually * from the gingiva to the outer periosteum and periodontal ligament * from the periosteum into the bone b. Formation of the periodontal pocket - persistent, chronic gingivitis may progress to periodontitis, which results in loss of connective tissue attachment, bone destruction, and periodontal pocket formation 1) periodontal pocket - pathologic deepening of the gingival sulcus produced by destruction of the supporting tissues and apical migration of the epithelial attachment 2) classification a) suprabony pocket - base of the pocket is coronal to the alveolar crest; also called supracrestal or supraalveolar b) infrabony pocket - base of the pocket is apical to the alveolar crest; also called intrabony, intraalveolar, subcrestal 3) histopathology a) gingival epithelium may show evidence of inflammatory changes * epithelium proliferates into the connective tissue in fingerlike projections * inflammatory cells are found in the epithelium * epithelium lining the pocket may be ulcerated * coronal portion of junctional epithelium becomes detached from the root surface as the remaining portion migrates apically b) connective tissue changes * inflammatory cells (lymphocytes, plasma cells, and macrophages) infiltrate the connective tissue * inflammatory infiltration proceeds through the loose connective tissue along vascular pathways * degeneration of gingival connective tissue fibers c) changes within the supporting bone as inflammatory processes progress * osteoclastic cells become evident * bone marrow component (fatty tissue) is replaced with inflammatory cell infiltrate, fibroblastic proliferation, and deposition of collagen fibers * cortical plate of the interdental septum is the first area to be involved (central crestal area where blood and lymph vessels emerge) * once this central breakthrough has occurred, the supporting bone is destroyed in a lateral direction c. Common clinical changes associated with periodontitis 1) similar changes in the gingiva as seen in gingivitis, usually a more chronic appearance *color - varying degrees of bluish red *consistency - varies from soft and boggy (edematous) to firm (fibrotic) *texture - stippling is decreased *contour - marginal gingiva is rounded, and the interdental gingiva is blunted *size - gingiva is slightly enlarged *position - junctional epithelium has migrated apically from the CEJ 2) areas of gingival recession 3) bleeding on probing as a result of thinning of the crevicular epithelium, increased vascularity, and a close proximity of the engorged vessels to the pocket epithelium 4) periodontal attachment loss 5) true periodontal pockets 6) loose, extruded, or migrated teeth; diastemas may develop 7) exudate from gingival margin in response to pressure 8 ) symptoms - generally painless; patient may complain of itching gums, loose teeth, food impaction, and bad taste; relief is felt with pressure applied to gums

Nonsteroidal antiinflammatory drugs (NSAIDs)

have been shown to inhibit bone loss, inflammation, and pocket depth in periodontal diseases; (Ibuprofen, flurbiprofen naproxen, Advil, Motrin); not approved in the United States for treatment of periodontal disease; still under investigation