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Dr Van K Perio Q & a 5-4-21 Periodontal Q & A CHRIS VAN KESTEREN DDS NORTHSTATEPERIO Good Evening • Interactive Perio Panel using Poll Everywhere •Text 22333 with Chrisv811 • You will get a reply • Answer the questions typically as A, B, etc or in some cases as a word or sentence • I will present a question; discuss the answers; and provide a periodontist perspective • I will check every so often to let people in the lecture What information is needed for crown lengthening? • PA • Mobility • Smile • Gum health • Neighboring teeth • Clinical crown visible • Crown : Root ratio • Dry Mouth • Endo health • Risk for recurrent decay • RCT history • Post and Core Crown Lengthening #5 now? What is a pseudopocket? Where is the Pocket? NORMAL SOFT TISSUE EXCESSIVE TISSUE BONE LOSS EXCESSIVE BONE When do you treat a pseudo-pocket? •Food entrapment •Restorative needs with limited to no access •Pseudopocket with true bone loss Impact of Bruxing and NightGuard Use on Periodontal Health Occlusal Trauma and Periodontitis • Intrabony defects associated with occlusal trauma assume many forms. • The most commonly seen defect in “My Chair” seems to be the circumferential So what happens under occlusal force? • Primary OT • Secondary OT • More mobility • More mobility • Widened PDL • Widened PDL • Loss of crestal bone height • Increase loss of CT and volume attachment and bone Force removed? Force removed? Bone density increases Bone regeneration not automatic; Likely get repair Less mobility Need to control inflammation Less mobility Lindhe, Polson, Harrel and Nunn studies Occlusal Trauma Clincial Signs: Radiographic Signs: •Tooth mobility •Widened PDL •Fremitus •Vertical bone loss •Wear Facets •Furcation bone loss •Tooth Migration •Root Resorption •Tooth Fracture •Thickened Lamina Dura •Pulpal Symptoms (Cold sensitivity) Take Home Messages •Diagnosis: Perio Dz and Occlusal Trauma •Have the right radiographs •Have an accurate and complete probings •Check Occlusion: Patient symptoms important •Check Mobility •Cold Sensitivity can be related to occlusion…I see this quite frequently •Consider splinting and/or biteguard How did I get Periodontal Disease? How do I answer this? My Explanation to Patients • Teeth are bone-like that sticks through the skin • The tissue attaches to the tooth to seal around it • Bacteria can break through this attachment • Your immune system reaction can lead to bone loss • Uncontrolled diabetes and smoking affect your fight against the bacteria and creates an environment for the worse bacteria to exist • I will check all factors that guide my diagnosis and it turn what treatment I will recommend to improve the prognoses of your teeth • I explain the teeth that may not respond as well. Expectation of results • I review pros and cons of non-surgical and surgical options and give my recommendations • If they elect less than ideal care, I explain the compromise • I review why I need to see them 4-6 weeks after ScRP for a reevaluation • I review treatment without commitment to periodontal maintenance as waste of time and money What is the Genetic Predisposition to Periodontal Disease? Host Pathway to Periodontal Disease Genetic Risk Factors Antibody Cytokines PMN Connective Microbial Host Immuno- Antigens Tissue Clinical Signs Challenge inflammatory Prostanoids and of Response LPS Bone Bio-film / Disease Metabolism Plaque / Other MMPs Calculus Virulence Factors Environmental & Acquired Risk Factors Tissue Breakdown Products & Ecological Factors Kornman, 1997 Top 3 reasons implants fail? Top 3 reasons implants fail? 1. Infection during and after placement: Failed integration (surgical technique); smoking and diabetes; peri-implantitis; periodontal disease 2. Exposed implant threads: Remodeling or implant disease: Chronic bone loss and cement 3. Placed in the wrong position: Occlusal trauma; off-axis forces; insufficient restorative space; clenching / grinding Susceptibility to Bone Loss Tooth Implant Host response = = Bacterial Invasion Low Greater (>) Bone Loss Low Greater (>) Biofilm #1 #1 Hx of Perio Dz Greater (>) Greater (>) Peri-Implant Disease Causes • Cement • Crown not seated properly • Poor OH • Previous Periodontal Disease • Lack of routine maintenance • Occlusal Overload • Heavy smoking and/or • Thin Bone drinking • Exposed implant surface • Uncontrolled Diabetes • Implants too close together • Loose crown/abutment • Inaccessibility to clean Explantation STRAUMANN 05 May 36 2021 STRAUMANN 05 May 2021 37 Range: 4 months -16+ years Clinical Recommendations •Identify risk factors associated with developing peri-implant diseases •Establish radiographic baseline at the time of implant placement and at final prosthesis insertion •Monitor implant health and determine inflammatory complications as part of a regular periodontal maintenance program •Establish an early diagnosis and intervention What are the most effective treatment of Peri-Implantitis? Peri-Implantitis Treatment •Surgical Debridement •Implant surface detoxification •Bone grafting of osseous defects and / or •Laser Assisted Implant Therapy •Adjunctive Systemic Antibiotics •30 Day Follow-Up •Tight maintenance follow-up •6 month healing then reassessment Guided Tissue Regeneration Anterior Posterior • Cosmetic implications • Limited blood supply in • Thinner bone can have furcations blow through bone loss • Hard to clean 100% esp in • Occlusal trauma can be furcation dome and grooves problematic • Hard to clean afterwards • Prone for pocket redevelopment What are the most common ways to treat bony defects? The Furcation Problem Variations in root anatomy Rateitschak, 1989 The Furcation Problem Variations in root anatomy: Rateitschak, 1989 The Furcation Problem Degrees of furcation invasion: Rateitschak, 1989 The Furcation Problem Degrees of furcation invasion: Rateitschak, 1989 The Furcation Problem Cervical Enamel Projections Treatment Options • Non-Surgical Perio Dz • Occlusal Therapy • Prophy • Ltd vs Comp adjustment • ScRP • Appliance • ScRP + Antibiotics • Restorative Care • Surgical Perio Dz • Accessible vs Inaccessible • Flap for access • Crown Lengthening • Gingivectomy • Osseous Sx • Esthetic Care • Laser Perio Therapy • Restorations • Regeneration • Tissue Grafting • Extraction OsteoConductive Emdogain + Allograft What periodontal findings suggest active bone loss? What criteria are used to determine active periodontal disease? Clinical Findings Increase in pocketing Purulence 2mm+ Change & BOP BOP Mobility Increase bone loss Why is this occurring? Altered Passive vs Altered Active Eruption Can you re-treat a connective tissue graft site if it fails? Why would a tissue graft fail? •Blood supply compromise •Suture failure •Unrealistic expectations (root coverage) •Exposure of an allograft When is a tissue graft needed? •Progressive Recession: Unstable •Lack of keratinized/attached gingiva •Vestibular Pull •Aberrant frenum / muscle position •Gingival excess •Esthetics •Temperature sensitivity Annals of Periodontology 1999 Definitions • Gingival Recession • Keratinized Gingiva • Hidden Recession • Attached Gingiva • Mucogingival Junction • Alveolar Mucosa Are you concerned with this lesion? What is your impression on this lesion? When to refer No FMX Vertical bone loss < 35 y.o. Uncertain diagnosis and prognosis Periodontitis Stage 3 or 4 Grade C Risk/Susceptibility Failure to meet your treatment outcomes Complex medical history: smoking and diabetes Complex medical treatment(s) Peri-implant disease Result of incorrect or late diagnosis and prognosis of periodontal disease or disease around dental implants Swelling, bleeding, redness, pus, and pain at gums Tooth movement Tooth looseness Recession (gum coming away from the tooth or crown to expose the root or implant) resulting in Esthetic concerns (teeth appear taller) Tooth sensitivity Tooth loss Implant loss Next Lectures September 14th October 26th Send any topic suggestions to Chrissy at [email protected] Assume a Zoom meeting but hopefully transitioning to group meetings again at the Great Wolf Lodge More to come…..
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