Current Concepts of Periodontitis

Incorporating “Quality’ periodontics into comprehensive Restorative Dentistry 2. Sites

1. Biofilms 3. Episodic Sam Low [email protected]

5 Commitments to Achieving Sequence Treatment Success in Periodontics § Commit to the comprehensive perio exam § Determine: § Define staff skills and limitations -manuals – Overall periodontal prognosis § Commit to the Phase I reevaluation – Gingival health § Commit to a recare appointment – Apical extent of caries – Probing depths § Maintain a quality dialogue with your – Level of alveolar crest periodontist – Root length and form

Dental History is critical in formulating a patient’s periodontal “Knowing” your patient status § Familial history § Who was your previous dentist .experiences § Medical status § Any symptoms of gum disease § Smoking habit § Has any dentist mentioned gum disease § When was your last “cleaning”? Frequency? § Stress activity § Brothers, sisters, parents.. any history of gum § Parafunctional habits disease § Tobacco use?? § Grind or clench your teeth..?

1 Data Collection Data Collection

 Radiographic Exam Etiology  Probing Diagnosis  Tissue Characteristics  Mobility Prognosis

Treatment Plan

Vertical Bitewings Periodontal Probing

§ Alveolar Crest Height § Pattern of Bone Loss 2N Nabors § CEJ Furcation Probe § Dentition Related Pathology PQOW Periodontal Probe

Automated Probing Furcation Involvement

Class I

Class II

Class II+ +

Class III

2 Prognosis Prognosis classification

§ A prediction of the probable course, § Excellent to good: duration, and outcome of a disease.. – No or minimal bone loss § Based on etiology and presence of risk – Compliance factors… – No systemic or environmental factors – Minimal or no mobility – Excellent crown root ratio – No furca involement

Prognosis classification Prognosis classification

§ Fair prognosis: § Poor prognosis: – Less than adequate bone support – Moderate to advanced bone loss – Class I furcation – Tooth mobility – Mobility < 1 – Class II furcation – Presence of limited or environmental factors – Doubtful patient cooperation – Presence of systemic or environmental factors

Prognosis classification Prognosis classification

§ Hopeless prognosis § Overall versus Individual tooth prognosis – Advanced bone loss – Consider both… – Class II+ or Class III furaction – Mobility of 2 to 3 – Non- maintainable sites

3 Factors in Determining a Prognosis Factors in Determining a Prognosis

§ Overall Clinical factors § Systemic and Environmental factors – Patient age – Smoking – Disease severity – Systemic disease or condition – Plaque control – Genetic Factors – Patient compliance – Stress

Factors in Determining a Prognosis Factors in Determining a Prognosis

§ Local Factors § Prosthetic and restorative factors – Biofilms – Abutment selection – Restorations – Caries – Tapered roots – Nonvital teeth – Concavities – Root resporption – Root Proximity – Furcations – Mobility

Predicting Periodontal Age Prognosis + Local Factors (subgingival calculus, 1. Increasing pocket depth plaque) 2. Furcation involvement + 3. Mobility Periodontitis (attachment loss, 4. Crown root ratio bone loss) 5. Smoking 6. Restorative dentistry “Resistance” McGuire, 1995

4 Age + Local Factors Susceptible Resistant (subgingival calculus, high moderate average moderate high + plaque) Periodontitis (attachment loss, radiographic bone loss) “Susceptibility”

Treatment outline Flap Surgery

§ Initial oral and radiographic assessment § Preserve keratinzed gingivae § Remove defective restoration § Access to osseous acceptable § Excavate the decay § Internal beveled incisions abaove the § Provisional restoration mucogingival junction § Endodontic therapy § Intrasulcular incisions § Periodontal therapy § Reevaluation § Surgery

Medications Associated with Basic Tenets of Surgery Periodontal Surgery § Access § Sedatives/ hypnotics § Hemostasis – Halcion, etc § “do no harm” § Antibiotics § Asepsis – Augmentation procedures § Anesthesia – Vasoconstriction § Analgesics – Non steroidal anti-inflammatory

5 Attached Gingivae Diagnosis of mucogingival defects

§ Direct measurement § Clincal findings § Amount of attached keratinized tissue § Other factors § Indications Parameter Alveolar Mucosa Gingivae Color red coral pink Surface smooth,shiny stippled Mobility loose,mobile firm,immobile

Clinical findings Classification of recession

§ Marginal gingivae inflamed § Sullivan and Atkins § Bleeding or exudate – Shallow and narrow § Obvious recession – Shallow and wide § Moving tissue by retracting the lip – Deep and narrow – Deep and wide

Other factors Current indications

§ Other teeth involved § Persistent inflammation in a narrow gingivae § Age of the patient § Root senstitivity § Overall dental needs § Esthetic concerns § Oral Hygiene level § Withstand planned restoration § Continuous attachment loss § Mucosa around implants

6 Crown Lengthening Procedures Purpose of Crown lenghthening

§ Considerations: § Provide proper form and retention of – Biologic width restorations – Attached gingivae § Access to subgingival caries – Furcations § Access to subgingival fractures – Restorability § Esthetic enhancement of patient’s smile – Support loss to the adjacent tooth

Contraindications for surgical crown Indications of crown length lengthening § Subgingival caries § Non-restorable tooth § Subgingival fractures § Adjacent teeth will be severely compromised § Endodontic perforations § Inadequate interdental width § Short clinical crowns § Poor crown/root ratio § Overall expense

MUSTS before crown length Common reasons to avoid crown surgery length surgery § Remove all caries! § Reduce time/expense § If possible define the most apical margins § Lack of understanding of biologic width § Break contacts § Uncomfortable with proper procedures to § Prep teeth correct the situation § Place fantastic easily removed provisionals

7 Problems with invading the biologic Expectations of a periodontist width § Marginal leakage § Relation of restorative margins to gingival § Inaccurate impressions margins § Poor finish lines – 5 millimeters supragingivally! § Recurrent decay § Materials for restorative margins – Cast gold collars § Irreversible effect on the periodontium § Embrasure spaces – Big black triangles § Pontics – High water --sanitary

The “Ideal” Subgingival “Biologic Width” Restoration § One must consider: – Health of the sulcus – Local anatomy – Management of the tissue – Location of the margin – Integrity of the margin – Contour of the restoration

Surgical instrumentation Gingivectomy

§ Periodontal probe: § Ultrasonic tip § Limited for psuedopockets UNC 12 § Universal currette § Adequate keratinized gingivae § Furcation probe § # 8 Round burr § No osseous access required § Double sided mirror § Oschenbien chisels § External beveled incisions above the § Blade holder round § Castrojevo needle mucogingival junction § 15/16 kirkland knife holder § 1 / 2 Orban § Hemostat § Periosteal elevator § Tissue forceps § 13 K Chisel

8 Procedures for Pocket Reduction Gingivectomy --- NO!!

§ Excisional periodontal surgery § Access to osseous is critical – Gingivectomy § Incisional periodontal surgery § Minimal or no attached gingivae – Flap surgery

What is attractive?? Gingivectomy -- Yes!!

§ Supraboney pockets-Access top osseous not important § Gingival enlargement § Fibrotic gingivae § Adequate attached gingivae Teeth Smile Lips Eyes Nose

Periodontal Clinical Conditions Rule of Golden Proportion

§ Color § Size § Shape 1:1.6 § Texture § Consistency § Sulcular Depth

9 Introducing Different Absorption Characteristics: Chu’s Aesthetic Gauges Blue: Water Red: Hydroxyapatite

UV Visible IR Ho:YAG 2.12um HO 2 Tm:YAG CO CO2 2 Er,Chr:YSSG2.09um Er:YAG Er:YAG 10.60010.6um nm 2.780 nm 2.94um2.940 nm a

, HO HA 2 n o i t Nd:YAG c 1.06um n i

t 1.064 nm x E

Diode e HA v

i 810 or 980 nm t a l e R

0.1 0.2 0.3 0.5 0.8 1 2 3 5 10 (um)

Wavelength (microns)

Laser-Tissue Interaction Absorption Characteristics of Dental Lasers Modes of Laser Operation:

Diode 812-980 nm Solid Melanin, Water § Continuous Wave Nd:YAG 1064 nm Solid Melanin, Water Dentin Maximizes coagulation and speed

Ho:YAG 2120 nm Solid Water, Dentin § Pulsed Wave (Gated or Free-Running) Minimizes thermal damage and pain Erbium 2780-2940 nm Solid Water Hydroxyapatitie

CO2 10.6 um Gas Hydroxyapatite, Water

Advantages of Lasers in Soft Tissue Surgical Procedures § De-epitheliaze Laser Cut More Visible To Eye / Dry Field § Degranulate Laser Sterilizes Wound As It Cuts § Denature proteins Decreased Post Operative Pain And Edema Decreased Post Operative Infection § Gingivectomy The theory of “Sealing” and “Sterilizing” the § Inhibit epithelial migration…clot wound? establishment Less Wound Contraction And Scarring

10 Hard tissue Access

§ Tooth § Hemostasis – Cementum § Visualize site – Calculus – Dentin § Bone – Removes – Biostimulates

6 Key Decisions Antibacterial… Cosmetic Crown Lengthening

§ Bio-films 4. Leave papilla intact at 1. Sound the osseous crest base § Bacterialcidal (3.0 mm osseous crest- proposed GM) 5. Thin osseous crest but leave minimum of 1mm 2. Zone of keratinized thickness gingiva Scallop desired lengths if 6. Will Dentin / Root Surfaces >3mm will be retained be exposed?

Treatment Plan Restorative 3. Bevel papilla areas Procedures (later you can apically position and adjust levels) Bobby Butler

Practical Procedures and Aesthetic Dentistry Vol 18 #3 - May 2006 Connective Tissue 1.07 mm

Epithelial Attachment 0.97 mm

Sulcus Depth 0.69 mm

11 Characteristics of Gingiva Gingival Esthetic Examination in Esthetics

Tooth Form

A. Exposure : Repose versus Smile • Length

B. Form : Scallop versus flat • Length - Width

C. Level : Gingival margin to CEJ • Embrasure Form

D. Thick or Thin Gingiva • Dominance

Gingival Esthetic Examination

Periodontics and the • Dimensions of Gingiva Placement of Dental • Clinical Crown Length Implants • Anatomical Crown Length

• Bone Level and Thickness

5 Commitments to Achieving Recare Evaluation Success in Periodontics § Patient signs / symptoms § Commit to the comprehensive perio exam § Periapical radiographs: § Define staff skills and limitations -manuals – 2 X per year first 2 years § Commit to the Phase I reevaluation – 1X per year thereafter § Commit to a recare appointment § Soft tissue evaluation § Probing § Stability

12 Periodontal Recare The “60” minute recare

§ Medical History § 5 minutes : Seat patient § Plaque Control PASS SCORE____% E § 5 minutes : Update medical history – Recommendations: § 10 minutes : Clinical exam § Areas of Concern – BP, H&N, OH,Caries, Perio,etc... § 25 minutes : Subgingival debridment § 5 minutes : Supragingival debridment § Therapy Today § 5 minutes : Dismiss the pateint § Next recare/ Comments § 5 minutes : Write up chart

Periodontal Recare Periodontal Surgery

§ Medical History: Reviewed, BP 140/80, H&N WNL 2 month Sporadic recall recall § PASS: 60% E Plaque Score 16% 66% – Recommendations: Proxybrush 614 Bleeding 2% 55% § Areas of Concern Pocket Depth 1.5mm 2.9mm *2-3 -12 Attachment maintained lost 1.8mm 31-30 19 Axelsson, Lindhe § Therapy Today: Ultra/Manual,^ Betadine AOC^ 1981 § Next recare/ Comments: 6-02, check caries d #3

Periodontal Referral Patterns Increase Frequency...... 1980 Versus 2000 Fewer patients use tobacco 1. Poor plaque control performance. Patients had a greater loss of teeth 2. Increasing pocket depth, bleeding, More severe disease suppuration. Required extraction of a greater number of 3. Radiographic increase of bone loss. teeth 4. Increasing furcation involvement. 5. Complex restorative cases. Cobb, et al J Perio October 2003

13 5 Commitments to Achieving Patients with poor plaque control Success in Periodontics § Commit to the comprehensive perio exam § Document in records § Define staff skills and limitations -manuals § Increase frequency of recare § Commit to the Phase I reevaluation § Place emphasis gently-do not challenge! § Commit to a recare appointment § Power toothbrushes § Maintain a quality dialogue with your § Rinses after debridement periodontist § Local delivery antimicrobials

Patients who refuse a “root Patients who are inconsistent planing” treatment plan with recare appointments ! § Document in records § Document with records..mandatory § Attempt to establish rapport through § Consider 2 appointments …1 week education apart..recare can not be completed in 1 § Education equals treatment acceptance appointment § Dismiss from practice if “prophy” is last § Consider rinses following recare resort § Progressive periodontitis and caries

Patients who refuse to see a periodontist or have periodontal surgery!!

§ Document with records!! “Know Your Patient” § Root planing must be very competent ! § Increase frequency of recare ..2-3 months L. D. Pankey § Emphasis on plaque control § Pharmaceutical intervention § Compromised restorative care

14 § “The goal of my practice is simply to help my patients retain their teeth all of their lives if possible...... In maximum comfort, function, health, and esthetics”

Dr. L. D. Pankey

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