“Introduction to Periodontal and Implant ”

Professor Jon B. Suzuki, DDS, PhD, MBA Temple University Professor of Microbiology and Immunology (Med) Professor of and Oral Implantology (Dent) Associate Dean for Graduate Education Director, Periodontology Residency Program DIAGNOSIS

Initial Therapy S/RP (2-4 Appts)

Surgery Non-Surgery

Maintenance Treatment Plan 1. Review Med/Dental Hx 2. Dx: Periodontitis 3. Initial Tx: -OHI -Occlusal Control -Rx CHX, phenol, Cetylpyridium rinses -Ultrasonics Scaling/RP/Polish - Evaluation (4-6 weeks) 4. Periodontal Surgery 5. Maintenance ( q 3 mos) Antimicrobials*

, 0.12% (Peridex, Periogard, Oris)  Phenols/Essential Oils (Listerine)  Cetylpyridium Cl (Crest ProHealth)  Stannous Fluoride

*FDA Approved “PRE-PROCEDURAL” RINSING

 Safety for both Patient and Clinician  A pre-procedural rinse of 0.12% CHX reduces risk of IE (formerly “SBE”) (Pts) and reduces airborne oral microbes (Staff)

Worrall, SF,. Br Dent J 1987;163:118-119. American Society of Anesthesiology

ASA I: A patient without systemic disease: a normal healthy patient ASA II: A patient with mild systemic disease ASA III: A patient with severe systemic disease that limits activity, but is not incapacitating ASA IV: A patient with incapacitating systemic disease that is a constant threat to life Measured Blood Pressure Dental Systolic Diastolic Follow-up Treatment Normal <130 <85 Annual OK Recheck High Normal 130 to 139 85 to 89 Annual OK Recheck Hypertns Stage I 2 Month (mild) 140 to 159 90 to 99 Recheck OK Stage II (Moderate) 160 to 179 100 to 109 Refer to MD OK Stage III Refer to MD Emergencies (Severe) 180 to 209 110 to 119 ASAP no Epi

Stage IV (Very Refer to MD Emergencies Severe) ≥ 210 ≥ 120 ASAP no Epi Measured Blood Pressure (extractions/surgery)

PerioSX/Extr Systolic Diastolic Follow-up Treatment Normal <130 <85 Annual OK Recheck High Normal 130 to 139 85 to 89 Annual OK Recheck Hypertns Stage I 2 Month (mild) 140 to 159 90 to 99 Recheck Caution/No Stage II (Moderate) 160 to 179 100 to 109 Refer to MD No Stage III Refer to MD Emergencies (Severe) 180 to 209 110 to 119 ASAP no Epi Stage IV Refer to MD Emergencies (Very Severe) ≥ 210 ≥ 120 ASAP no Epi Medical (examples)

 BP: excess bleeding  Liver: excess bleeding  Heart: Rx Antibiotics  Lungs: coughing during sx  Diabetes mellitus: impaired wound healing  CT diseases: impaired wound healing  Arthritis (Rheum or Osteo): Medications (examples)

 Blood thinners: Bleeding  Steroids: Impaired wound healing  Inhalants: Coughing during Sx  Bisphosphonates (IV, Oral): ONJ  Organ Transplant meds: Wound Healing  Antineoplastic meds: Wound Healing Treatment Plan 1. Review Med/Dental Hx 2. Dx: Periodontitis /Insurance Codes 3. Initial Tx: -OHI -Occlusal Control -Rx CHX, phenol, Cetylpyridium rinses -Ultrasonics Scaling/RP/Polish - Evaluation (4-6 weeks) 4. Periodontal Surgery 5. Maintenance ( q 3 mos)  Periodontal Therapies: Surgical Suprabony pockets – Flap Surgery Pseudopockets – Infrabony pockets – Regeneration*

 *Regeneration Approaches  Osseous Defects  Extraction Sockets  Implants Healthy

Systemic Diseases Plaque Medication Stress Smoking Pockets Pregnancy Hormones

OHI Non Sx Sx

S/RP “Three Types of Pockets” Polish

1. Antimicrobials Rx Pseudo (gingival) Pockets Suprabony Pockets Infrabony Pockets 2. Antibiotics Gingivectomy Modified “Resection” “Regeneration” 3. Periostat Widman Flap

4. NSAID? APF -Bone Grafts -GTR -Amelogenin -Combinations Periodontal

Gingivectomy: (soft tissue) Gingival Hyperplasia Osseous Sx: Crown Lengthening (hard tissue) Resection Free Gingival Grafts: Keratinized Gingiva Connective Tissue Grafts: Root Coverage Regeneration: New Bone, PDL, Implants: Replace Missing Teeth Steps of Periodontal Surgery

 A. Patient selection  B. Instrument selection  C. Patient Documentation  D.CHX prerinse  E.Surgical Incisions  F. and S/RP  E.Suture  G.Post Op Instructions and Rx Two (2) Surgical Kits

“Always have a sterilized back-up surgical kit”

A. Infection controlled maintained if you drop an instrument B. You will not have to interrupt the surgery C. Patient peace of mind Steps of Periodontal Surgery

 A. Patient selection  B. Instrument selection  C. Patient Documentation  D. CHX prerinse  E. Surgical Incisions  F. Debridement and S/RP  E .Suture  G. Post Op Instructions and Rx Summary of Periodontal Surgeries

Flap Surgery Mucogingival Procedures  open flap debridement   osseous resection  connective tissue graft  regenerative  pedicle flaps  implant placement  semi-lunar flap  ridge modification / graft harvest Other Periodontal Surgeries

frenectomy gingivectomy canine exposure vestibuloplasty fiberotomy Incision Design

 external bevel incision  marginal / internal bevel incision  submarginal incision  sulcular incision

 crestal  para-crestal Incision Design Marginal vs. Sulcular  Histological study of sulcular incision flaps vs. internal bevel incision flaps in humans  By 21 days of healing, the 2 surgical methods were indistinguishable histologically  “It is suggested that the inverse bevel primary incision traditionally advocated for apically positioned flap surgeries may be replaced by the more rapid and simple sulcular incision as the preferred technique.” Pippin 1990 Incision Design

 external bevel incision  marginal / internal bevel incision  submarginal incision  sulcular incision

 crestal  para-crestal Incision Design

 Edentulous ridge incisions

 crestal – preferred design

 para-crestal – access – keratinized tissue – incision line placement Incision Design – loss of blood flow in area coronal to horizontal incisions

– loss of vascularity as the width of the flap decreased; recommended the width be at least half the height of the flap

– loss of vascularity when flaps were placed under tension

Mormann, 1977 Periodontal Dressings

 3 major reasons to use

– to protect wounds postsurgically – to obtain and maintain close adaptation of flap to bone – for patient comfort Periodontal Dressings – Coe-Pak (mix), Barricaid (light cure)

– incorporating antibacterial components probably is not effective

– Sanz et al., 1989: dressings with CHX rinses were better than dressings with a placebo rinse in terms of plaque formation, GI, and probably patient comfort

– antibacterial mouth rinsing alone may be more effective than rinsing with a dressing