Welcome to Periodontics

October 21, 2011

From Novice to Competency

Ability to diagnose and treat various types of periodontal disease and maintain the patients dentition in health function, comfort, and esthetics.

Competent

Proficient

Continuum in Periodontics
Perio I CDM 1070 The basics didactically and clinically D1
SimLab CDM 1185 Instruments and how to work on a patient

Recare Clinic CDM 2501 Work on patients in D2 year Perio II & Perio III D2 year Periodontal diseases, diagnosis, treatment, microbiology, immunology of periodontal diseases

Continuum in Periodontics
Perio IV D3 first semester Surgically oriented treatment of periodontal diseases and conditions Clinical Periodontology CDM 3501 D3 clinical perio Postgraduate Periodontics rotation CDM 3503

Continuum in Periodontics
Clinical Periodontology CDM 4501 D4 clinical perio Periodontics Honors Program CDM 402H D4

Why is Periodontics Important?

Periodontal disease causes bone loss
Bone loss causes teeth to be loose, sore, uncomfortable, abscesses to form and teeth to be lost. One of the leading causes of tooth loss in adults

35% of adults have periodontal disease

13% have moderate to severe periodontitis (bone loss) These figures underestimate the amount of periodontal disease in the U.S.

Much more prevalent in underdeveloped countries

Why is Periodontics Important?

Periodontal disease is associated with
Increased risk of heart attack Increased risk of stroke Increased risk of preterm low birth weight Difficulty in managing diabetes

Why?

Pathogenesis of Periodontitis

IL-1 alpha IL beta

Microbial Challenge
Host ImmunoInflammatory Response Connective Tissue & Bone Metabolism Clinical Signs Of Disease initiation & Progression

IL-6 IL-8 TNF alpha

Genetic Risk Factors

Peri means around Dontal means tooth Periodontal means around the tooth

Periodontium
A functional system of different tissues, investing and supporting the teeth, including cementum, periodontal ligament, alveolar bone and gingiva.

Healthy Gingiva and Bone Levels

 Consider the following:

Clinical Features of the Periodontium

Color coral pink Physiologic pigmentation Size knife edge Contour scalloped Consistency firm versus edematous Surface texture stippling Position at or covering the cemento-enamel junction

Gingival Tissues Within Normal Limits

GINGIVA

Mucogingival junction

ALVEOLAR MUCOSA

Pigmentation of the Gingival Tissues

Mandibular Alveolar Bone

CANCELLOUS BONE

CORTICAL BONE

PDL

CLASSIFICATION OF PERIODONTAL DISEASES AND CONDITIONS

I. GINGIVAL DISEASES
A. PLAQUE-INDUCED GINGIVAL DISEASES B. NON-PLAQUE-INDUCED GINGIVAL LESIONS

II. CHRONIC PERIODONTITIS

A. LOCALIZED B. GENERALIZED

III.

AGGRESSIVE PERIODONTITIS

A. LOCALIZED B. GENERALIZED

IV. PERIODONTITIS AS A MANIFESTATION OF SYSTEMIC DISEASES V. NECROTIZING PERIODONTAL DISEASES

A. NECROTIZING ULCERATIVE GINGIVITIS (NUG) B. NECROTIZING ULCERATIVE PERIODONTITIS (NUP)

Moderate Gingivitis

Before probing

After probing

Comparing Pre and Post treatment

Pretreatment Post treatment

Oral Hygiene Instruction Tooth brushing Flossing Scaling and root planing AKA deep cleaning

Generalized Severe Gingivitis

Pretreatment

After Initial Therapy Oral hygiene instruction Scaling and root planing

Gingivectomy/Gingivoplasty

Six Months Postoperatively

Pretreatment

6 months post op

Necrotizing Ulcerative Gingivitis

Necrotizing Ulcerative Gingivitis

Leukemic Infiltration
Seen most often in patients with acute monocytic leukemia (66%) Also acute myelocytic-monocytic leukemia (19%) and acute myelocytic leukemia (4%) Leukemic gingival enlargement is not seen in edentulous patients or in patients with chronic leukemia.

Gingival Diseases Modified by MedicationsDrug Influenced

Chronic Periodontitis

Treatment for Periodontitis

Comprehensive examination, diagnosis, prognosis, treatment plan, including assessment of patients systemic health. Initial therapy
Plaque control instruction Motivation, tooth brush instruction, interproximal cleaning (flossing) Scaling and root planing (deep cleaning usually with local anesthesia) Correction of contributing factors (calculus, caries, defective restorations, extract hopeless teeth, areas of food impaction, smoking cessation)

Treatment for Periodontitis

Evaluation of initial therapy
Reduction of pocket depth, plaque control, elimination of contributing factors, tissue color, consistency, contour, tone, calculus removal

Surgical treatment plan

Flap with osseous recontouring, regenerative surgery (bone grafts), soft tissue grafts, implant placement

Evaluation of results of surgical phase

Treatment for Periodontitis

Maintenance therapy
Critically important to long term success of periodontal therapy Periodontal evaluation probing depths, bleeding on probing, etc. Plaque control instruction motivation, etc. Scaling and root planing as needed Usually done every three months

Adjuncts for Periodontal Treatment

Local delivery of antibiotics placed into the periodontal pocket
E.g. Arestin (minocycline), Periochip(chlorhexidine) Kill bacteria within the pocket

Subantimicrobial systemic tetracycline

E.g. Periostat (doxycycline) Reduce the immune response within the pocket to reduce destruction of collagen

Pre-treatment

1 yr. after bone graft

Adjuncts to Regenerative Surgery

Recombinant platelet derived growth factor
E.g. Gem21

Recombinant bone morphogenic protein 2

E.g. Infuse

Enamel matrix derivative

E.g. Emdogain

Osteotomy

Implant placement

Reentry at 16 weeks

Crown Delivery

What if There Isnt Enough Bone

Dental implants must have at least 1 mm of bone thickness completely surrounding them.
In the esthetic areas (maxillary anterior teeth especially) 2 mm of bone on the facial aspect of the implant is desired

Tooth #30 missing

Ridge too narrow for dental implant

Crest of ridge is narrow and tapers from occlusal to apical

4 Months After Guided Bone Regeneration

Preoperative width Post gone graft width

Muco-gingival Surgery

Subepithelial Connective Tissue Graft

Pre-Op

1 month Post-Op

Conclusion
Periodontics involves treating a variety of diseases and conditions
Some are bacterial/viral infections Some are acquired conditions (e.g. recession) Periodontal disease can affect the patients systemic condition and systemic diseases affect the patients periodontal tissues

Conclusion
Successfully treating periodontal diseases involves
Aspects of medicine Dental skills Aspects of psychology (behavior modification)

Periodontics is evolving and advancing in diagnostic and treatment capabilities which can be stimulating and challenging to the practitioner