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Modern Concepts of Periodontology

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natali naeini

on 15 November 2013

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Transcript of Modern Concepts of Periodontology

Modern Concepts of Periodontology
Risk Factors
Periodontitis and Systemic Diseases - In April 2013 a workshop was held by the European Federation of Periodontology and American Academy of Periodontology, where many studies about the relationship between Periodontitis and its link with various factors were analysed. The outcomes have been published in the JCP.
Advances in Non-Surgical Treatment
Loose guideline of current treatment protocol:
1) OHI
2) SRP, Q/Q
3) Antibiotics
4) Review
5) Retreat
6) Review
7) Surgical
Advances in Surgical Treatment
Resective procedures
Conclusion
As with most aspects of dentistry, periodontitis is a field that is continuously being researched, and generally speaking, there can never be too much evidence!

One thing that remains constant is that no matter what classification the Periodontitis falls under, it is still the GDP's role to recognise and diagnose it, attempt to treat or know his/her limitations and refer when necessary.

Patient compliance and understanding will also always play a huge role in the success of the outcome of treatment.
Periodontitis
Multifactorial disease involving bacterial biofilms and the generation of an inflammatory response.

Affects one or more of the periodontal tissues:
1. alveolar bone
2. periodontal ligament
3. cementum
4. gingivae

2 categories;
gingivitis
periodontitis
CLASSIFICATION!
1. Chronic Periodontitis

2. Aggressive Periodontitis

3. Manifestation of Systemic Diseases

4. Necrotizing Periodontal Diseases

5. Abscesses of the Periodontium

6. Perio/ Endo Lesions

7. Developmental or Acquired Deformities and Conditions
a. Localized tooth-related factors that modify or predispose to plaque-induced dx
b. Mucogingival deformities
c. conditions on edentulous ridges
d. Occlusal trauma: primary or secondary

...according to Armitage (2004).
F.Y.I...
• Chronic generalized is >30% localized < 30%.



• Severity -
Mild: 1-2 mm attachment loss.
Mod: 3-5mm.
Severe: 5-7mm.



Smoking & stress
Immunosuppression
Genetics
Drugs
Smoking!
Results from United States National Health and Nutrition Examination Survey (NHANES ) demonstrated that, even though current smokers had higher levels of plaque and calculus, after adjusting OH and other variables, they still had greater periodontal destruction than former, or never, smokers.
The risk of bone loss in heavy smokers is 7X greater than that for attachment loss , compared to non/former smokers, as well as more tooth loss and furcation involvement
Johnson et al Impact of Tobacco Use on Periodontal. April 2001 Journal of Dental Education.

Why?!
1-Effect on subgingival flora
2-lower GCF
3-reduced vascularity therefore delayed healing
4-higher numbers of leukocytes centrally but not in gingival tissues



Diabetes!
More attachment loss in patients with poor glycaemic control
Diabetic with systemic complications have more loss of attachment (frequency and severity)

WHY!?
Reduced PMN function and defective chemotaxis

Increased collagenase and elastase activity

Defective remodelling and rapid degradation of synthesized collagen at healing sites
Pregnancy
1. Hypothesis – association between maternal periodontal disease and adverse pregnancy outcomes

Maternal periodontitis is modestly but significantly associated with LBW and preterm birth. However, treatment during pregnancy may be too late to have an impact on the baby. Ide et al (April 2013)

Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases had similar findings

Two major pathways have been identified;
- direct
- indirect
Effects of periodontitis on Systemic Conditions...
One Stage Full Mouth Disinfection (OSFMD)
Full mouth scaling and root planing (SRP) within 24 hours in combination with a disinfection of all intraoral niches by chlorhexidine applications

- viable approach to deal with severe generalised AgP
Aimetti et al ( J. Periodontol 2011)

•Systemic antibiotics
• Systemically administered antimicrobials could enhance the effects of mechanical treatment in Aggressive Periodontitis

• Most effective antibiotic regimen ( combination of metronidazole and amoxycillin)

- Systematic reviews of EFP & AAP

Or...
• Doxycline and tetracycline

• 20mg twice/day, long term use (e.g. 6months)

• No evidence of resistance

• A systematic review and meta-analysis showed that SDD led to improved clinical outcome compared to SRP alone (Sgolastra 2011)




Or...
• azithromycin - more effective in smokers (Mascarenhas 2005)
Timing
• timing either during initial therapy / maintenance.

– No evidence supporting use of antibiotics as monotherapy.

– Griffiths 2011- pts who had antibiotics at initial therapy had significantly better clinical outcome compared to those who had the antibiotics at the re-treatment stage.

Bisphosphonates
New treatment modalities intend to modulate the host response to bacterial aggression.

Works by inhibiting osteoclast activity.

Conflicting reports on clinical outcome
Lane 2005- 10mg/day of Alendronate led to clinical improvement in alveolar bone height after 6months
However, there is a lack of data determining the optimal prescription concentration and formulation.

Adverse outcomes + risk of AONJ

Occurrence of AONJ is limited and the risk seems to be small in comparison with overall health benefits for patients treated with BPs.
A favourable oral health status before BPs prescription is crucial to minimise the risk of AONJ
- (Sambrook et al, 2006).

Laser
Popular uses in dentistry:
Sulcular Debridement (sometimes termed Laser Curettage)
Laser-Assisted New Attachment Procedure (LANAP)
Reduction of Bacteria Levels in periodontal pockets (sometimes termed Pocket Sterilization)
Laser-facilitated Wound Healing, Laser Root Planing
Aid in the Diagnosis of Caries (Laser Fluorescence)
Hard Tissue Applications including endodontics.

Benefits include bleeding control, selective calculus ablation, as well as bactericidal and detoxification effects against periodontopathic pathogens - Schwarz et al, J Clin Periodontol 2008

Erbium-doped:yttrium-aluminium-garnet (Er:YAG)
One of the most promising laser types for periodontal therapy.
Clinical effectiveness remains controversial

Sgolastra et al. Efficacy of Er:YAG laser in the treatment of chronic periodontitis. May 2011
Osseous resective surgery
Periodontal surgery involving
modification of the bony support of the teeth.
Osteoplasty: reshaping of the alveolar process to achieve a more physiological form without removal of supporting bone.
Ostectomy: the excision of bone or portion of a bone. Iti is done to correct or reduce deformities caused by periodontitis, and includes the removal of supporting bone.

Osseous resective surgery is the combination of both.

Aims:
to re-establish the marginal bone morphology around the teeth.
minimal probing depths
gingival tissue morphology that enhances good self-performed oral hygiene and periodontal health.

Root Conditioning
Treatment of the root surface with demineralizing agents such as acids or EDTA
Aims to expose collagen fibrils.

Improves blood clot adhesion to exposed collagen fibrils.

Originally, citric acid was used but reports have shown that treatment with citric acid and phosphoric acid can result in root resorption and ankylosis
EDTA is more gentle


Enamel Matrix Proteins
EMPS's emerged late as a therapeutic option for periodontal regeneration.
Their use in dental practice began long before an adequate number of studies was available to scientifically explain for the positive effects of enamel matrix proteins on periodontal wound healing and regeneration.

Many clinical studies have shown positive effects of an enamel matrix derivative (Emdogain).
Histological studies have shown the formation of new cementum and new bone with inserting connective tissue fibres.

As with any other regenerative technique, patient and defect selection and recall programs are mandatory for successful outcomes.

GTR
Rationale:

to use a physical barrier to selectively guide cell proliferation and tissue expansion within tissue.
prevent gingival epithelium and connective tissue expansion
allow migration of cells from the periodontal ligament and alveolar bone into the periodontal defect.

Numerous experimental animal studies have proven that this principle leads to periodontal regeneration,

Drawbacks:
patient and defect selection in every day practice may not be as rigorous as in clinical studies.

Another problem relates to the exposure of membranes to the oral environment and contamination with bacteria

Collagen membranes are prone to collapse into the defect area and so need a bone filler to prevent this.
.

Regenerative materials
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