39073822 Periodontal Therapy Full Version

8/10/2019 39073822 Periodontal Therapy Full Version

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PERIODONTAL

THERAPYConsists of:PHASE I

PHASE II

PHASE III

PHASE IV


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E & D TREATMENTPLANNING

TREATMENT

INITIAL PHASE REASSESSMENT CORRECTIVE

PHASE

SURGICAL

PROCEDURES

RECONSTRUCTIVEPROCEDURES

OHE BEHAVIORAL

CHANGE

PROPHYLAXIS DEBRIDEMENT

OTHER DENTAL

TREATMENT

SUPPORTIVE PERIODONTAL CARE


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PHASE 1

Phase I therapy is referred to by many names;Initial / first line therapyNonsurgical periodontal therapyCause-related therapyEtiotropic phase of therapy


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PHASE 1

AIM of Therapy;

Elimination & prevention of recurrence ofsupra / subgingivally located bacterialdeposits.


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PHASE 1

Components:

Relief pain Patient education &

motivation

Behavioral change Plaque control & oral

hygiene care Prophylaxis Scaling & root

debridement Chemical control of

plaque deposition

Correction/ replacementof poorly fittingrestorations & prostheticdevices

Restorations of cariouslesions

Orthodontic toothmovements

Treatment of occlusaltrauma

Endodontic treatment Extraction of hopeless

teeth


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OHE Patient Information

Indications:

- Low oral health knowledge, awareness,motivation & compliance.

- Poor self performed plaque control,

smoking & other psychosocial behaviors.- High risk individuals to plaque induced

diseases.

PHASE 1


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OHE Patient Motivation

- Change in knowledge

- Change in understanding- Change in attitude

- Change in habit

- Use simple everyday language & avoidjargons

PHASE 1


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Behavioral Change

- Diet counseling encourage balanced dietand frequency.

- Smoking cessation (smoking risk factorfor periodontitis), it will increase inprogression of disease, alter the fibroblastfunction & impair wound healing.

PHASE 1


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OHI

- Tooth brushing method:

PHASE 1

Roll roll method or Modified Stillman technique

Vibratory Bass Technique

Circular Fones Technique

Vertical Leonard Technique

Horizontal Scrub Technique


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OHI

Recommendation of toothbrush design:

- Soft- Nylon bristle

- Toothbrushes need to be replaced about

every 3 months (or replace when it start toshow sign of matting).

PHASE 1


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OHI

- Powered toothbrush also can removeplaque effectively (properly used).

- Patients need to be instructed in the properuse of powered devices.

- Patients who are poor brushers, children &caregivers may particularly benefit fromusing powered toothbrushes.

PHASE 1


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OHI Interdental Cleaning Aids

- Cleans the interdental region (most commonsite for plaque retention).

- Most inaccessible site to tooth brushing.

- Dental floss

- Interdental space brush

PHASE 1


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OHI Interdental Cleaning Aids (Dental Floss)

Technique;

- 12 18 inches of floss wrapped around the fingers /

the ends may be tied together in a loop.- Stretch the floss tightly between the thumb &forefinger/ between both forefingers & pass it gentlythrough each contact area with a firm back-and-forth

motion.- Move the floss across the interdental gingiva &repeat the procedure on the proximal surface of theadjacent tooth.

PHASE 1


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Prophylaxis

- Removal of supragingival plaque & calculus(scaling & polishing).

- Removal of plaque retentive factors;Smooth roughness of restoration

Removal of overhangs

Ill-fitting / rough prosthesisRemoval of staining

PHASE 1


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Non

surgical Instrumentation

- Chemotherapeutic approaches

Topical application of antiseptics to prevent

plaque accumulation & to disinfect the rootsurfaces.

Mouthrinses

ChlorhexidineChip-perio chip

Solution injection elyzol/periocline

PHASE 1


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Non

surgical Instrumentation- Chemotherapeutic approaches

Systemic approach selective use of antibiotic

or host modulation of tissue destructiveenzymes (Doxycycline).

Rationale;

Pathogenic organisms that were not accessibleto mechanical removal by hand/power driveninstruments can be reduced/eliminated.

PHASE 1


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Treatment Sessions

- The following conditions must considered toplan Phase 1 treatment sessions needed;

PHASE 1

General health & tolerance of

treatment

Number of teeth present

amount of subgingival calculus

Probing pocket depths &attachment loss

Furcation involvement

Alignment of teeth

Margins of restorations

Developmental anomalies

Physical barriers to access (limited

opening / tendency to gag)Patient cooperation & sensitivity

(requiring anesthesia / analgesia)


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Step 1 (Limited Plaque Control Instruction)

- Should start in 1stappointment & shouldinclude only the correct use of toothbrushon all surfaces of the teeth.

- Use of dental floss should await the removalof calculus & overhanging restorations.

PHASE 1


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Step 2 (Supragingival Removal of Calculus)

- Can be done by scalers, curettes orultrasonic instrumentation.

PHASE 1


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Step 3 (Recountouring DefectiveRestorations & Crowns)

- May require replacing the entire restorationor crown or correcting it with finishing bursor diamond-coated files mounted on thespecial handpiece.

PHASE 1


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Step 4 (Obturation of Carious Lesion)

- Involves complete removal of the carioustissue & placement of final or a temporaryrestoration.

PHASE 1


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Step 5 (Comprehensive Plaque ControlInstrumentation)

- Patient should learn to remove plaquecompletely from all supragingival areas,using toothbrush, floss & other necessarycomplementary method.

PHASE 1


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Step 6 (Subgingival Root Treatment)

- Complete calculus removal & root planningcan be effectively performed.

PHASE 1


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Step 7 (Tissue Reevaluation)

- The periodontal tissue reexamined todetermine the need for further therapy.

- Pocket are reprobed & all related anatomicalconditions are carefully evaluated to decidewhether surgical treatment is indicated.

PHASE 1


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CHEMICALPERIODONTAL THERAPY

Roles of chemical agents (antiseptic &

antibiotic) in periodonticsThe different of chemical plaque agent

Content, indication, limitation & effects of useof these agents


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CHEMICAL PERIODONTALTHERAPY

GOAL

Removal of supragingival & subgingivalbacteria.


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Supragingival plaque accessible to patient(can effectively disrupted / removed usingtoothbrush/ interproximal cleaning devices).

Mechanical plaque control can be effectivein preventing / reversing gingivitis.

If patient unable to perform mechanical

plaque removal use of chemotherapeuticagents as an adjunctmay be warranted.



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TERMINOLOGY:

- Plaque inhibitory effect: reducing plaque to a levelinsufficientto prevent the development of

gingivitis.- Anti-plaque effect: produces a prolonged &

profound reduction in plaque sufficient to preventthe development of gingivitis.

- Anti-gingivitis: anti-inflammatory effect on thegingival health notnecessarily mediated throughan effect on plaque.



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Antimicrobial agents;

- Antiseptics

- Antibiotics

Miscellaneous agents;

- Matrix protein- Growth factor

- Hydrogen peroxide


Can be used:

topically, locally

applied &

systemically


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ANTISEPTICS

Topically (mouthwashes)

- Oradex chlorhexidine 0.12%

- Listerine antiseptic mouthwash (phenoliccompound/ essential oil)

- Plax (triclosan)

Typically act supra-gingivally.



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ANTISEPTICS Locally applied

- Slow release devices (biodegradable polymer, gel, fibers,collagen)

- Applied into periodontal pockets:

Perio Chip (2.5 mg chloroxedine in gelatinmatrix)

Atrigel (5% sanguinarine)

Typically act sub-gingivally.



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TOPICALLY ACTING CHEMICAL AGENTS

Requirement:

- Effective in reducing plaque & gingivitis

- Effective & remains for a sufficient amount of time to accomplish the

desired results (substantivity)- Without development of resistant bacterial strains or damage to the

oral tissues.

- Cost-effective

- Pleasant to use

- Low toxicity without adverse effects

- High potency

- Good permeability & intrinsic efficacy



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ANTISEPTICS Mouthwashes

Quaternary ammonium compound (cetylpyridium chloride)

Hexidine Bactidol

Oxygenating agents

hydrogen peroxide Amine alcohols Delminol

Povidone iodine natural products sanguinarines

All these available either as mouthwashes, irrigation,toothpaste, gel/ spray.



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TOPICALLY ACTING CHEMICAL AGENTS

CHEMICAL SUPRAGINGIVAL PLAQUE CONTROL

Bisguanides Chlorhexidine, Alexidine

Phenolic compounds Listerine, Thymol & other essential oils

Quartenary ammonium compound Amyloglucosidase, Glucose oxidase

Enzymes Cetylpyridium chloride, Benzalconium

chloride

Oxygenating agents Hydrogen peroxide, Peroxyborate

Fluorides Sodium fluoride, Stannus fluoride, Sodium

MFP

Other antiseptics Triclosan, Povidone Iodine, Hexetine


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CHLORHEXIDINE Bisguanide compound

Dicationic and strong base

Prolonged action

Concentration 0.2% or equivalent

The only product to kill bacteria

Not act as anti-adhesive

Only can penetrate into thin plaque not thick /mature(calculus) plaque.

Can inhibit the plaque formation but cannot eliminate theplaque in untreated mouth.



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CHLORHEXIDINE

Broad spectrum antiseptic which possess anti-plaqueactivity.

Mostly available in digluconate salts formulations.

Strong base & dicationic at pH levels above 3.5 with 2positive charges on either side of hexamethylene bridge.

At low concentration cause increase in cell membranepermeability & leakage of intracellular components.

At high concentration precipitation of bacterial cytoplasm& cell death.


C C O O


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PHENOLIC COMPOUNDS

Eg: Listerine

Have moderate plaque-inhibitory effects &some anti-gingivitis effect.

Less effective than chlorhexidine but morepowerful than triclosan.


CHEMICAL PERIODONTAL


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CHX

- As a broad spectrum antimicrobial agent,have no bacterial resistance reported & noevidence of superinfection by fungi / viruses.




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INDICATION:

CHX m/w indicated to post perio-surgical patient to reducethe bacterial load / to prevent plaque formation at timewhen mechanical cleaning may be difficult due discomfort.

Patient with mental & physically disabilities lack of manualdexterity in;

- Parkinson disease

- Adjunct to immunocompromised such as HIV/AIDS

- Cerebral palsy

In this situation, advisable agent would be CHX m/w.




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INDICATION:

CHX m/w can be prescribed to patientwearing orthodontic appliance & also forpatient with intermaxillary fixation followingtrauma / orthognathic surgery.

As an adjunct to mechanical instrumentation

in case such as refractory periodontitis &locally applied antimicrobial agents can beused.




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LIMITATION:

CHX particular inhibit plaque formation in aclean mouth but not significantly reducebacterial load in untreated mouth.

CHX m/w cannot penetrate into gingivalcrevice, therefore have no place in control of

chronic periodontitis presence of deeppocket of >5 mm.




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LIMITATION:

CHX have local side effects such as;

- Tooth & tongue staining

- Staining tooth-colored restorations (composite &porcelain)

Reversible parotid swelling

Numbness of tongue taste disturbance

Bitter taste

Mucosal erosion are also reported



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ANTIBIOTICS1. Use of antibiotics (systemically / local application) mainly

directed against specific bacteria & sub-gingival plaque totarget identified periodontal pathogens. Eg. In ANUG &

localized aggressive periodontitis.2. Antibiotics is directed against specific microorganisms, eg.AA in specific plaque hypothesis in ANUG/P & aggressiveperiodontitis.

3. While mechanical removal of plaque aimed at reduction ofbacterial load for non-specific plaque theory.




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ANTIBIOTICS

4. If unresponsive pockets (after reassessment therapy done& no response to therapy), chlorhexidine in slow releaseof polymer can be used locally, advantage of that, agents

can be sustained release within the pocket. Locally appliedantibiotics also can be used in this situation.

5. Used of antibiotics in periodontal abscess usually notnecessary if the abscess only localized unlessthere are

signs of spread of infection to systemic area / sign ofcellulitis/ lymphadenopathy.




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ANTIBIOTICS

6. Post surgical rinsing with chlorhexidine mouthwashmainly due to inability to mechanically removed

plaque because discomfort.7. Post surgical systemic antibiotic prescription may

not indicated, unlesscomplex surgical proceduresbeen carried out (post-implant surgery) / patient is

medically compromised.




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ANTIBIOTICS

8. Indication of use of antimicrobial agents topatient with lack of manual dexterity or

with patients with mental disability is clear.

9. Patient wearing orthodontics appliancescannot used chlorhexidine mouthwash for

a long term due to tooth & tongue stainingside effects.



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ANTIBIOTIC Local Application

Antibiotics can be in form of:

Gel for topical application onto surface orsub-gingival application.

May present in polymer.

Also present in the form of biodegradableslow, release gel, hollow or solid fibers.




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ANTIBIOTIC Local Application

Examples:

a. Elyzol gel - 25% of Metronidazole

b. Dentomycin gel - 2% of minocycline

c. Actisitetetracycline fibers (hollow/solid)

d. Periocline- 2% minocyclinee. Atridox- 42.5 mg Doxycycline

f. Arestin- 1 mg minocycline




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ANTIBIOTIC Systemic Uses

In the form of liquid, tablets or capsules suitable if patients diagnosed with

aggressive periodontitis ONLY.

Must finish antibiotic simultaneously withthe therapy/ root debridement.




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ANTIBIOTICSystemic Uses

(Aggressive Periodontitis )

Amoxicillin in combination with Metronidazole (if allergic to penicillin

give clindamycin);- 250 mg amoxicillin & 200 mg Metronidazole tds for 4 to 7 days.

Tetracycline

- 250 mg tetracycline for 14 days

- Doxycycline 100 mg once a day for 14 days (double dose for first daybecause half of it will bind to plasma & another half will be in blood).




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ANTIBIOTIC Systemic Uses(ANUG/P)

In case of ANUG/P, Metronidazolemay be needed

for 3 4 days only.- 200 mg Metronidazole tds for 3 4 days.

- Analgesic may be prescribed to patient diagnosedwith ANUG/P due to pain.

- Since the ANUG/P lesions being very painful tomechanical plaque control, chlorhexidinemay begiven.




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ANTIBIOTIC Systemic Uses

For post-surgical systemic antibiotic,Metronidazole may be needed for 1 7 days.

- 400 mg Metronidazole tds for 1 day.

- Analgesic may also prescribed.

- Chlorhexidinemouthwashes must be givensince the wound may be painful tomechanical plaque removal.




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ANTIBIOTIC Systemic Uses Periostat is available as a- 20 mg doxycycline taken twice daily about an

hour before or 2 hours after meals.- Adjunct to scaling & root planning.- Act as collagenase inhibitor (degrade collagen

at periodontal ligament/gingiva but not to

controlled the bacteria) at low concentration.- Danger to develop bacterial resistance.- Take about a month.



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INDICATION:

Antibiotic prophylactic agents in which the risks ofbacterimia & infective endocarditis is high.

Systemic antibiotics prescribed are directed against specific

microorganisms as an adjunct to mechanicalinstrumentation in aggressive periodontitis & ANUG/P.

The used of systemic antibiotic without cautions can lead todevelopment of bacterial resistance.

Certain individual may suffered from immediatehypersensitivity which can be fatal.



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General terms for a chemical substancesprovides a clinical therapeutic benefit.

CHEMOTHERAPEUTICAGENTS

COMMON ANTIBIOTIC REGIMENS TO TREAT PERIODONTAL


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Regimen Dosage/Duration

Single Agent

Amoxicillin 500 mg tds for 8 days

Azithromycin 500 mg Once daily for 47 days

Ciprofloxacin 500 mg Twice daily for 8 days

Clindamycin 300 mg tds daily for 10 days

Doxycycline or Minocycline 100- 200 mg Once daily for 21 days

Metronidazole 500 mg tds for 8 days

Combination TherapyMetronidazole + amoxicillin 250 mg of each tds for 8 days

Metrinidazole + ciprofloxacin 500 mg of each Twice daily for 8 days

COMMON ANTIBIOTIC REGIMENS TO TREAT PERIODONTAL

DISEASES

Data from Jorgensen MG, Slots J: Compend Contin Educ Dent 21:111, 2000


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CHEMOTHERAPEUTIC AGENTS

Monocycline

Effective against broadspectrum ofmicroorganisms.

Suppresses spirochetes &motile rods as effectivelyscaling & rootdebridement.

Less phototoxicity & renaltoxicity than tetracyclinebut may cause reversedvertigo.

Doxycycline

Same spectrum of activityas minocycline & may beequally effective.


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Metronidazole

Bactericidal to anaerobicorganisms & is believed todisrupt bacterial DNA synthesis

in conditions with a lowreduction potential.

Effective against Porphyromonasgingivalis & provetellaintermedia.

Used in ANUG, chronicperiodontitis & aggressiveperiodontitis

Clindamycin

Effective against anaerobicbacteria.

Effective in situations inpatient is allergic topenicillin.

Shown efficacy in patientwith refractoryperiodontitis.



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Ciprofloxacin

Quinolone active againstgram-negative rods,including all facultative &some anaerobic putativeperiodontal pathogens.

Minimal effect onStreptococcusspecies.

To fight AA.

Amoxicillin

Semisynthetic penicillinwith extendedantiinfective spectrum thatincludes gram-positive &gram-negative bacteria.

Used in management ofaggressive periodontitis in

both localized &generalized forms.

Susceptible topenicillinase.



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Amoxicillin

Clavulanatepotassium

= Augmentin

Useful in managing patient

with localized aggressiveperiodontitis or refractoryperiodontitis.

This antiinfective agent isresistant to penicillinaseenzymes produced bysome bacteria.


Guidelines for use of antimicrobial therapy


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Clinical diagnosis

Health Chronic periodontitis Aggressive, refractory or medicallyrelated periodontitis

Periodontal therapy including:

-Oral hygiene

-Root debridement

-Supportive periodontal treatment-Surgical excess for root debridement or

-Regenerative therapy

-Antibiotic as indicated by microbial analysis

Microbial analysis

Effective Ineffective

Supportive periodontal treatment


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PHASE 2

Assessment of Periodontal Treatment Outcome

Periodontal Risk Assessment


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PERIODONTAL RISK ASSESSMENT

DEFINITION: Risk

probabilitythat an event will occur in the future/ probability that an individualdevelops a given disease.

Can divide into:

- Risk factor- Risk indicator (determinant)

- Risk predictor

Risk Assessment

it is a processwhich qualitative / quantitative assessment are made of likelihoodfor adverse effect to occur as a result of exposure to specified health hazards, soit can be reduced, avoided / managed.


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IMPORTANCE OF PRA Periodontal disease is an imbalance of bacterial plaque & host susceptibility.

Role of the bacteria as initiator to periodontal disease & 1o etiology ofperiodontal disease.

Host related factors (influence the presentation & progression of periodontal

disease). All people are not equally susceptible to periodontal disease. (in longitudinal

study of Sri Lankan tea plantation)

All people are not equally response to periodontal therapy.(in longitudinal studyof well maintained 600 patients were followed for 22 years)

Successful of periodontal therapy.- Early & corrective diagnosis

- Risk management

- Effective treatment


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RISK TO LOOK FOR:


RISK FACTOR RISK INDICATOR RISK PREDICTOR

Biological plausible as a

causative agent for disease.

Biological plausible as a

causative agent for disease.

No current biological

plausible as a causative

agent.

Shown to precede the

development of the disease

in prospective clinical

studies & longitudinal

studies.

Where the associated only

show by cross-sectional

studies.

Shown to be associated

with disease on a cross-

sectional/ longitudinal

studies.

Eg: smoking & diabetes Eg: patient with HIV/ age/

gender/ race/

osteoporosis/ genetic

factors/ bacterial/ stress

Eg: markers/ historical

measure of disease/

number of missing teeth.


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METHOD TO IDENTIFY INDIVIDUAL AT RISK

Diagnostic test Clinical parameters, PD, BOP &

r/g. GCF analysis & saliva-oral microorganism,

neutrophil defects, genetic markers & antibody.

Subjective risk assessment

asking environmentalrisk.



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PRA MODEL


RISK BOP

(%)

PPD

>5mm

TOOTH

LOSS

BL/AGE SMOKING/

day

GENETIC/

SYSTEMATIC

LOW 0-9 0-4 0-4 0.05 - -

MOD 10-25 5-8 5-8 >0.05

1.0

10 - 19 -

HIGH >25 >8 >8 >1.0 >19 +

Coding System For PRA:

LOWall low risk + 1 MOD risk

MOD 2 MOD + 1 HIGH risk

HIGH 2 HIGH risk

BOPbleeding on probing

PPDperiodontal pocket depth

BLbone loss

MODmoderate

Coding System For PRA (Lang & Tonetti 2003)


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39073822 Periodontal Therapy Full Version

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