TARRSON FAMILY ENDOWED CHAIR IN PERIODONTICS

UCLA SCHOOL OF DENTISTRY

SECTION OF PERIODONTICS

Dr. E. Barrie KenneyProfessor & ChairmanSection of Periodontics

Dr. Heddie O. SedanoProfessor Emeritus & Lecturer

Section of Periodontics

Presents

PHASE ONE THERAPY

(INITIAL THERAPY)(INITIAL THERAPY)

Comprehensive

• Emergency Therapy

• Examination Diagnosis and Treatment Plan– Phase one therapy (initial therapy)

– Evaluation of phase one therapy

– Phase two therapy

– Evaluation of phase two therapy

– Maintenance therapy

Phase two therapy

• Periodontal surgery

• Dental implants

• Crown and bridge

• Removable partial dentures

EMERGENCY

THERAPY

NECROTIZING

ULCERATIVE

GINGIVITIS (NUG)

Two weeks NUG resolved

by root planning and good oral

hygiene

Proceed to complete

examination and diagnosis

Phase one therapy

• Control of plaque

• Control of diet

• Control of systemic factors

• Control of oral malodor and taste abnormalities

• Control of tobacco smoking

CONTROL of PLAQUE

Presence of plaque in red

for 4 surfaces of each tooth

Presence of interproximal

plaque is prominent

Need to stress floss or

interdental brush

utilization

Plaque and bleeding scores at 4 time

periods Progressive improvement to less than 20% of surfaces

with plaque

CORRELATION OF MANUAL DEXTERITY

AND KNOWLEDGE WITH ORAL HYGIENE

MANUAL DEXTERITY

TEST

CORRELATION COEFFICIENTS BETWEEN RIGHT HAND DEXTERITY AND BUCCO-LINGUAL

PLAQUEIN 59 ADULTS

DAY 0 0.41

DAY 7 0.38

DAY 14 0.33

CORRELATION COEFFICIENTS BETWEEN KNOWLEDGE AND BUCCO-LINGUAL PLAQUE

DAY 0 0.38

DAY 7 0.32

DAY 14 0.30

Patient with plaque induced

gingivitis

Three weeks following

compliance with excellent oral

hygiene and plaque control

Soft brush positioned at 45° to gingiva

Brush is vibrated by

bass technique of oral hygiene

Dental Floss

Best used for interproximal plaque when interdental papillae are

present

Interdental brush

Tuft brush

Interdental brush

Best used when

interdental papillae are

reduced

Rubber interdental stimulator

Least efficient interproximal

cleaner

Use of gauze to clean distal

surface of teeth adjacent to edentulous

areas

Gauze is most

efficient for these teeth

Electric brushes used for patients with poor manual

dexterity

Electric brushes can motivate some patients to improve their oral hygiene

Clinical Evaluation of the Efficiency and Safety of aNew Sonic Toothbrush

Johnson, B.D., McInnes, C.,

J. Periodontol 65:692, 1994

51 subjects got either Sonicare orhand brush. Instructed in use orModified Bass Technique withOral B 30.

Plaque scores, gingivitis scoresand sulcular bleeding scores at0, 1, 2, 4 weeks.

29 subjects seen at 6 months

All subjects got timer and did notuse floss mouth rinses or otheroral hygiene aids for first 4 weeks.

Plaque Index

0 1 week 2 weeks 4 weeks

Manual 1.71 1.52 1.51 1.56

Sonic 1.86 1.30 1.16 1.38

Sulcular Bleeding Index

0 1 week 2 weeks 4 weeks

Manual 71.6 56.7 46.6 45.9

Sonic 57.5 49.2 45.7 40.7

Gingivitis

0 1 week 2 weeks 4 weeks

Manual 1.58 1.43 1.29 1.28

Sonic 1.47 1.37 1.30 1.26

No increase in gingival recessionor other oral lesions associatedwith either brush at 6 months.

Comparison of an Oscillating Rotating Electric Toothbrush and a Sonic Toothbrush in Plaque Removing Ability

Van Der Weijden, S.A., Timmerman,

M.F., Van Der Velden, V.

J Clin. Periodontol 23:407, 1996

35 non dental students given aSonicare and a Braun Oral B plakcontrol brush and instructed to useeach brush every other day.

2 weeks later subjects no brushingfor 24 hours then reevaluated thenmouth brushed by an examinersplit mouth using both brushes.

Plaque IndexAfter 2 minutes Professional Brushing

Baseline Enpoint

Braun Oral B 1.82 0.54

Sonicare 1.81 0.68

They repeated this 4 weeks laterwith brushing using Zendiumtoothpaste by the students.

Plaque IndexAfter 2 minutes Panellist Brushing

Baseline Enpoint

Braun Oral B 2.00 1.10

Sonicare 2.00 1.20

At end of study they could keepone brush. 34 out of 35 keptBraun brush.

Clinical efficacy of flossing versus use of antimicrobial rinses.Zimmer. S, et al J. Periodontol. 2006 77:1380

156 patients used brush +daily rinse 0.06% chlorhexidine 0.025% fluoride or brush+ 0.1% cetylpyridiniumchloride +fluoride or brush + floss or brush alone.Evaluated at 8 weeks.

CHX NaF 1.58 CPC/NaF 1.54 FLOSS 2.10 BRUSH 2.00 /

MODIFIED PROXIMAL PLAQUE INDEX

CHX /NaF 0.67 CPC/NaF 0.75 FLOSS 0.77 BRUSH 0.89

Papilla Bleeding Index

Additional effect of dentifrices on the instant efficacy of tooth brushing.Paraskevas S .et al J. Periodontol.2006 77:1522

3 toothpastes used in 40 patients each after 48 hours plaque accumulation.Split mouth hand brush with or without paste.

Tooth paste gave average of 3% more plaque than brush alone.More abrasive pastes no more effective.

CONTROL OF DIET

More benefit comes from reduction of sucrose in diet so less caries and less plaque minimal effect

on gingival inflammation from other dietary modifications

CONTROL OF SYSTEMIC FACTORSCONSULT WITH PATIENT’S M.D.

Control of HemostasisControl of BacteremiaControl of DiabetesControl of Medications

CONTROL OF ORAL MALODORAND TASTE ABNORMALITIES

Plaque control is most predictable way to reduce oral malodor together with daily tongue scarping to reduce bacterial load

of oral cavity.

CONTROL OF TOBACCO SMOKING

Elimination of smoking significantly improves tissue response to initial

therapy.

PHASE ONE THERAPY

Removal of pathologic tissue for biopsyRemoval of caries-endodontic therapyRemoval of hopeless teethRemoval of calculus

Clinical diagnosis

of possible malignant ulceration

Biopsy should be

done immediately

in initial therapy

Exophitic growth from

area previously

diagnosed as lichen planus

Immediate biopsy result diagnosis of squamous

cell carcinoma

Non ulcerated lesion present for at least 3

years

Tissue removed includes

periphery of normal tissue

Diagnosed as benign

hemangioma

Biopsy site sutured

Removal of caries

Endodontic therapy

Furcal bone loss resolved

after endodontic treatment

carried out before any

periodontal care

Removal of hopeless

teeth

Tooth # 3 has 8 mm

pockets and grade 3 mobility

Radiograph confirms hopeless

prognosis for tooth # 3

Recommend extract tooth # 3 during

initial therapy

Deep pockets seen of distal of tooth # 4

Tooth # 4 shows

periodontal remodeling

after extracting tooth # 3

Pocket depth improved on

distal of tooth # 4

REMOVAL OF CALCULUS

Root Planing

Photomicrograph of calculus

embedded in cementum

Root planing is needed to remove

embedded calculus

Universal curets for

root planing

Gracey curet 5/6 Triangular shaped scaler

for small interproximal

spaces

Explorers are used to confirm

completion of root planing

Root surfaces should be

glassy smooth and free of

calculus

Root surface magnified

Prior to root planing with

curetes

S.EM of new sharp

curete

Note surface notches on

cutting edge

Root surface magnified after root

planing with curet

Note smooth surface with very slight striations

Ultrasonic scalers

Magneto strictive effect results in high

frequency complex

movement of tip

Root surface magnified after

ultrasonic instrumentation

Large ripples seen that can be detected

with explorer

MEAN TOOTH SURFACESROUGHNESS SCORES

Curette (Kerry) 8.30

Sickle (Green) 9.12

Hoes (Green) 12.89

Files (Green) 13.95

EW.PP (Kerry) 17.36

EW.PIO (Kerry) 17.68

Gross amounts of

calculus and plaque

Remove large deposits with ultrassonic scaler then root plane with curets

Radiographic evidence of

calculus

Needs root planing with

curets

Sublingual calculus with

acute inflammation of

gingiva

Root planing done with

curets and oral hygiene

optimized

Four weeks after initial

therapy

Normal healthy

gingiva. No bleeding on

proving

Pocket reduction No need for further periodontal therapy

Gingival inflammation

is combination of acute and

chronic changes

Interproximal pockets are 6 mm with attachment

loss and bone loss

Root planing with curete has resolved acute inflammation

Residual pockets and

bone loss require phase

two periodontal surgery

PHASE ONE THERAPY

Occlusal correction

Occlusal splints

Provisional splinting of teeth

Orthodontic movement

Occlusal Adjustment1. Correction of Centric

1. Stable centric relation

2. No interferences between CR and CO

2. Correction of lateral excurtions

1. Balancing interferences

2. Working interferences

3. Balancing interferences

3. Correction of protrusive excursions

1. Straight protrusive

2. Protrusolateral

4. Correction of centric occlusion

OCCLUSAL SPLINTS(ORTHOTICS)

PROVISIONAL SPLINTS

PHASE ONE THERAPY

Restorative correctionsOpen contactsOverhangsPoor marginsPoor contours

PHASE ONE THERAPY

Correction of inadequate removable partial dentures

Change in Alveolar Bone 4 Years After Partial Dentures as Percentage of Lengths of the Teeth

# of Abutments Mesial Distal

Denture Wearers 56 -2.3 (SD 3.3) -3.9 (SD 5.)

Non Denture Wearers 18 -0.1 (SD 2.7) -0.2 (SD 2.)

PHASE ONE EVALUATION

• Pocket depth

• Plaque score

• Bleeding on probing

• Caries

• Occlusal stability

• Mobility, fremitus

• Mucosal health status

• Mucogingival status

• Systemic status

• Radiographic evaluation

• Oral malodor and taste

• Esthetics

• Modification of phase two treatment plans

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