1

Current Concepts in Non-Surgical Periodontal Therapy May 2019

Leah MacPherson RDHBS MHP

Current Concepts in Non-surgical Periodontal Therapy

This is a course for oral health-care providers interested in an update in non-surgical periodontal therapy This course will review the literature concerning periodontal risk factors and how to use the information to assess patients for risk verses treating disease The host response and the cascade of events which occur in periodontitis will be reviewed and some of the periodontal and systemic connections will be highlighted

Learning Objectivesbull Assess a patientrsquos periodontal condition using clinical attachment levels bone loss and health historybull Review the various types of periodontal conditions microbiology and their treatment

bull Determine a patientrsquos level of periodontal risk

bull Biofilm grow amp provide a protective environment

bull Protective matrixslime layer

ndash Protective amp stick to surfaces

bull Micros behave differently when in a biofilm than outside

ndash These microorganisms are more resistant within the biofilm than individually

bull Biofilm can be good amp protective

ndash probiotics to add ldquohealthy associatedrdquo bacteria to promote health

BiofilmBiofilm

bull Biofilms contain aqueous channels

ndash channels provide nutrients amp waste

bull Quorum sensing

bull Bacterial micro colonies

bull Protected by the slime layer

bull Fluid channels provide nutrients pH levels oxygenenzymes metabolites amp waste products

bull pH disease similar to caries

Scientific America 2001

Theories

bull The polymicrobial synergy and dysbiosis (PSD) entire colony of multiple different bacteria (polymicrobial) working together (synergy) to initiate periodontal disease (dysbiosis)leading to inflammation

ndashKeystone pathogens- Porphyromonasgingivalis elevates the virulence of the entire bacterial colony by altering their gene expression rendering them more aggressive

Indirect Damage Host Response

bull Host cells respond to the microorganisms amp produce a variety of inflammatory mediators

ndash Mediators can cause inflammatory responses

bull capillary permeability

bull Smooth muscle contraction

bull Vasodilation

bull Migration amp attraction of leukocytes

bull Some mediators play an important role in health others are important to defend the host

bull Many of the destructive mediators breakdown CT (bone collagen)

2

Key Mediators of the HostCollagenase

ndash powerful digestive enzymes that can kill bacteria amp host tissues

ndash released by PMNs

ndash damages CT

Matrix metalloproteinases (MMP)

ndash group of Zinc- dependent enzymes

ndash produced by PMNs

ndash in health facilitates normal tissue turnover

ndash degrades connective tissue matrix

Prostoglandins (PGE2)

bull Lipid compounds (technically hormones)

bull Produced from macrophages and PMNs

bull Inhibits bone amp collagen formation

bull PGE2 is found in levels in aggressive perio

Mediators Conrsquot Cytokines

bull proteins that affect the function of other cells

bull produced by t-cells Natural Killer cells amp macrophages

bull can cause tissue destruction amp promote repair ndash L-1 promotes bone resorption stimulates PGE2releases

mmps levels in active disease amp inflammation

ndash IL-2 promotes T-cells levels in aggressive perio disease

ndash IL-6 stimulates osteoclastic activity levels in perio amp refractory

ndash IL-8 produce mainly by macrophagesstimulate MMP collagen destruction

Key Mediators of the Host C ndash Reactive Protein (CRP)

bull CRP is considered the ldquoMarker of systemic inflammationrdquobull Acute phase proteins triggered by PGE2

bull These proteins are found in patients w inflammation or infectionndash High CRP serum levels have been linked w chronic systemic

diseases (periodontitis cardiovascular disease diabetes LBW miscarriages)

bull CRP increases clotting amp enhances uptake of cholesterol

CRP Testingbull Testing pts- CRP over 3 is considered at risk (may be at risk for 20 years after)bull High CRP levels w high lipids have more riskbull High CRP levels are treated w statins

Periodontal Risk Factors

bull Smoking pipe cigar marijuana

bull Diabetes

bull Immune amp PMNs related diseases

bull Rheumatoidosteoarthritis

bull Alcohol

bull Hormones

bull Genetic

bull Osteoporosis

bull Viruses cytomegalovirus Epstein- Barr

virus herpes papilloma

bull Medications

bull Stress distress amp Fatigue

bull Nutritional deficiencies K

C B9 calcium protein CoQQ10

bull Obesity

bull Previous periodontitis

Risk Based Care

bull Inform patient

bull Asses Risk

bull Intervention with the appropriate level of preventionndash High-risk patients needed more than two visits (recare)

per year (Giannobile Wet al 2013)

ndash Personalized medicine approach based on risk factors for disease may be useful in determining recall intervals for patients and would be more cost effective (GiannobileWet al 2013)

The Systemic Connection

Periodontal Medicine

The science to support an association between periodontal disease and

systemic consequences

3

Systemic Link

bull Cardiovascular Diseases amp Stroke

ndash perio appears to be a mildmoderate risk for coronary heart disease Perio is a stronger risk factor for stroke

ndash 2 -7 fold increased risk of stroke in those w perio

bull Diabetes

ndash bi-directional relationship

Systemic Linkbull Respiratory diseases

ndash Microrsquos from the oral nasal amp pharyngeal frequently contaminate the upper airway

ndash Increased risk due to poor OH

bull May increase risk in lung cancer

ndash periodontal disease pts have a 124-fold increased risk of developing lung cancer

bull MiscarriagesPre-term DeliveryLow Birth Weight Babies

ndash Women w perio may be 7-8X more predisposed to deliver premature infants w LBW

ndash CRP amp PGE2 trigger early uterine contractions amp PTD

ndash microbiome Project found the microbiome of the placenta most resembles the subgingival environment

Systemic Link

bull Alzheimers Diseasendash Early exposure to periodontitis and inflammatory

conditions may increase one for Alzheimers disease later in life

bull theories

ndashInflammation allows bacteria to enter the brain

ndashPeriodontal spirochetes disrupt the normal defenses and may lead to neuronal degeneration

ndashPg

Periodontal MedicineSystemic Connection

bull Non- dental professionals appreciate the impact of oral health

bull As patient awareness of perio amp systemic implications increases more seek preventive care (Williams amp Offenbacher periodontol200023(1)9-12)

bull Some strong links have been observed

bull Further studies are needed

Diagnosis

bull A periodontal diagnosis must be made to facilitate good decision-making for both the clinician amp pt for proper treatment planning

bull It can be very effective amp powerful

2017 Periodontal Classification

bull Proceedings of the World (American Academy of

Periodontology and the European Federation of

Periodontology) Workshop on the Classification of

Periodontal and Peri‐Implant Diseases and

Conditions

Caton J Armitage G Berglundh T Et al A new classification scheme for periodontal and peri‐implant diseases and conditions ndashIntroduction and key changes from the 1999 classification Journal of Periodontology 89 S1 (S1-S8) (2018)

httpsonlinelibrarywileycomtoc19433670201889S1

4

Key Points

bull Created by incredible researchers in the field of perio

bull Case definitions for research vs clinicaltreatment

ndashResearch guidelines were needed

bull Includes a holistic approach to periodontology

ndash Included risk factors modifiers and overall perio systemic connection

bull Creating space for future research

bull Addressing the borderline between gingivitis and periodontitis

Key Points

bull Excessive occlusal force- Traumatic occlusal force

bull Biologic width- Supracrestal tissue attachment

bull 3 disease of perio- perio systemic necrotizing

bull Necrotizing periodontal disease- dropped ulcerative

bull Linear gingivitis removed is new term is Candidosis

bull Added implant

bull Periodontal abscesses (PA) classified according to the etiological factors involved

bull added gingival pigmentation due to medication

Key Pointsbull Must probe implants lightly to monitor depth changes

and bleeding progression of perio is faster on implants

bull CAL-lack of training affects DX initial periodontitis in regards to CAL

-Interdental CAL is detectable at ge2 non‐adjacent teeth or Buccal CAL ge3 mm with pocketing gt3 mm is detectable at ge2 teeth

bull Proposal for staging and grading framework which would allow for complexity and risk

ndash 3 sets of parameters

bull RATE RISK RISK

bull The intention was to liken to cancer

httpswwwperioorg2017wwdc

5

Types of Periodontal diseasesGingival

Dental biofilm Induced Gingivitis Most commonbull Typically biofilm is proportionate

to the amount of inflammation

bull No bone loss no LOA

Types- New

bull Localized = BOPgt 10 amp lt30

bull Generalized plaque induced gingivitis gt 30 BOP

Microorganisms

bull Non-specific includes both Gram - amp Gram +

Treatment

bull self care deplaquingdebridementscaling

bull eliminate local contributory factors

Modifying Factors of Biofilm induced Gingivitis hormonalPregnancy Gingivitis

Etiologybull biofilm amp hormone changes

bull degree of inflammation parallels OH

ndash good OH can prevent pregnancy gingivitis

bull will exacerbate any previous periodontal disease

Pregnancy Gingivitis

Microorganism

bull Prevotella intermedia

Treatment

bull subsides after giving birth

bull exaggerated response can be prevented w excellent OH

bull frequent recalls Oral self care

bull Deplaquingdebridementscaling

Pyogenic Granuloma

Treatment

bull may resolve on own after debridement

bull may need surgical removal

6

Drug-influenced gingivitis

bull Gingival enlargement

ndashAnticonvulsants

bull Phenytoin

ndashCalcium channel blockers

bull Nifedipine 6-43

ndash Immunosuppressants

bull Cyclosporin 25

ndashAnabolic Androgenic Steroid

ndash Prostate cancer treatment

Gingival enlargement

bull Level of biofilm amp drug dosage accumulation can affect the severity of overgrowth

bull Consult w MD for drug substitution

bull Some cases of hypertrophic gingival tissue have been reported as Kaposirsquos sarcoma amp squamous cell carcinoma

Non-biofilm induced related to bull Specific bacteria

ndash Neissera gonorrhea treponema pallidum streptococci

bull Viralndash Herpes simplex 1 amp 2 varicella zoster papillmavirus

bull Fungal

bull Cultured for true diagnosis amp treat appropriately antibiotics antiviral amp or antifungal

bull Not common amp usually not known

Non-plaque induced gingival diseases of fungal origin

Candidosisformally Linear gingivitis

bull Generally fungalcandiasis

bull Linear amp very distinctive band of severe erythema on gingival margin

bull Disproportion of inflammatory intensity for the amount of biofilm present

Candidosis Treatment

ndash OHE consider chlorhexidine

ndash Does not respond well to improved OH or scaling

ndash Biofilm removal debridementscaling

ndash May need additional physician consult

Lichen Planus

Etiologybull Unknownbull Cell mediated Immune pathogenesis bull Systemic Diseases

ndash Diabetes hypertension hepatitis B amp C chronic graft-versus-host disease amp lupus

bull Medicationsndash antimalarial drugs antihypertensives amp non-steroidal anti

inflammatory (NSAIDS)

Signsbull Affects skin and mucous membranesbull Lesions may be mild to moderately painful amp burning

7

Lichen PlanusTypes

Reticular-plaque papular

Erosive Bullous Atrophic ulcerative

bull Erosive- gingival

ndash bulbous forms ulcerative amp painful

ndash red and raw

bull Reticular

ndash asymptomatic keratontic lines called stria

ndash lacy white lines

Lichen Planus

bull severity may relate to stressConsiderationsbull Higher risk for non- reticular types for malignant transformation

ndash LP pts have a 10 fold increased risk of developing squamous cell carcinoma

Treatmentbull Look for triggers allergies sensitivity bull Aloe Vera rinses amp gelbull Corticosteriods

ndash topical- fluocinonide dexamethadone dipropionate spray topical steroids may help- can cause candida

bull Periodic biopsies are necessary for areas that do not respond to treatment

bull Regular recalls

Inflammatory And Immune Conditions And Lesions

Hypersensitivity ReactionsAllergic gingivitis

Other names desquamative Plasma cell gingivitis idiopathic

gingivostomatitis atypical gingivostomatitis allergic gingivostomatitis hypersensitivity and plasmacytosis

Plasma cell gingivitis is an uncommon inflammatory condition usually affecting the anterior maxillary gingiva and of uncertain etiology While some authors have associated plasma cell gingivitis with a hypersensitivity response to antigens in various substances others have raised doubt whether plasma cell gingivitis is a distinct clinicopathologic entity

Allergic gingivitis

Etiology

bull auto immune

bull Allergy

bull Signs

bull sloughing of the epithelium which leaves raw red surface

bull The edematous tissue often extends to the mucogingival junction with a deep red appearance

Allergic gingivitis

Symptoms

painful

Treatment

topicalsystemic steroid therapy

remove etiological factor if possible

-spices toothpaste flavorings peppermint wintergreen menthol cinnamon preservatives mints gum candy

Possible Offending Products to Gingival Tissue

bull Commercially available toothpaste (tartar-control additives and flavoring agents [possibly

cinnamon] that mask the tartar control additives)

bull Mouth rinses

bull Cinnamon aldehyde

bull Sodium benzoate and methyl paraben

bull Food substances such as wheat dairy chocolate eggs peanuts and monosodium glutamate

bull Red wine (sulfides and tartrazine additives)

bull Preservatives

bull Essential oils such as peppermint spearmint and wintergreen found in gums candy and mouth rinses

bull Dark cola drinks

bull Strong spices

bull Chili peppers

bull Clove

bull Cardamom Burkhart NW Toothpaste allergy RDH 2007 27(6) 86107-108

8

Types of Periodontal diseasesPeriodontitis

Periodontitis

bull Chronic

bull Disease will progress unless treated

bull Typical age of onset is 35 yrs of age

bull Bone loss

- slow

ndash rate may vary depending on the modifiers

bull Severity is determined by bone loss and LOA

bull Can become inactive (stable) active (recurrent) refractory

Periodontitis

Microorganisms

bull Gram ndash

bull P gingivalis

bull P intermedia

bull Tannerella forsythensis (B forsythus)

Treatmentbull Self carebull Scrt

pldebridement bull Depending type of

defects amp severity ndashpossibly surgery

amp perio referral

Not includedAggressive

This category includes formally called diseases

bull Juvenile

bullEarly onset

bullPrepubertal

bullRapidly progressive

Localized Aggressive Localized Juvenile Periodontitis

bull More significant bone loss surrounding 1st molars amp incisors ndash typically angular type bone loss amp mirror image bilaterally

bull Rate of bone loss is rapid

bull OH can be good

9

Localized Aggressive LJP

bull Defects in PMNs or macrophagesbull respond slowly

bull chemotaxis defect

bull impaired phagocytosis

bull Onset typically during teenage years

bull Hereditary componentgenetic

bull more common in females amp blacks

Localized Aggressive Localized Juvenile Periodontitis

Microorganisms

Aggregatibacter Actinomycetemcomitans

P gingivalis

Treatmentbull scrt pldebridement but typically unresponsivebull Antibiotics to be administered with or just after debridement

ndash combo metronidazole wamoxicillin or metro w augmentinndash Clindamycin Azithromycin

bull possibly surgerybull prompt perio referralbull suggest family be evaluated (siblings children etc)bull sea salt being used as prevention of AA amp Tx

Generalized Aggressive Formally Generalized Juvenile Periodontitis

bull More rare than LJPbull Can affect most teeth but more severe on 1st molar

amp incisorsndash must involve gt 3 other teeth

bull Onset usually under 30 years oldbull Associated with neutrophil disorderbull Generally significant inflammation amp heavy

plaquecalculusbull Children w Gagp seem more prone to ear skin amp

upper respiratory tract infections

Generalized Aggressive Generalized Juvenile Periodontitis

MicroorganismsA actinomycetemcomitansPorphyromas gingivalis Eikenella corrodens

Treatmentscrt pldebridementantibiotics

ndash combo metronidazole wamoxicillin or metro w augmentin

possibly surgeryprompt perio referralbull Suggest family be evaluated (siblings children etc)

Periodontitis as a Manifestation of Systemic Disease

bull Systemic diseases that severely impair host response should be considered a periodontal manifestation of the systemic disease amp primary diagnosis should be the systemic disease according to International Statistical Classification of Disease (ICD)

ndash Excludes diabetes

bull Hematologicacquired neutropenias leukemias

bull Genetic disorderfamilial neutopenias down syndrome leukocyte adhesion deficiency syndrome papillon-lefreve syndrome chediak-higshi histocytosis syndromes Glycogen storage disease genetic agranulcytosis cohen syndrome Ehlers-Danlossyndrome hypophosphatsis

Necrotizing Periodontal Diseases NG amp NP

Etiologybull Unknown

bull Risk factorsexcessive stress lack of rest poor oral hygiene smoking HIV poor immune response

bull More common in underdeveloped countries

bull Less common now in the US

bull Susceptible to reoccurrence

Symptomsbull SUDDEN onset of burning

mouth inability to eat metallic taste excessive salvia amp PAINFUL

Microorganisms

spirochetes

Prevotella intermedia

Fusiform bacillus

Fusobacterium nucleatum

Ulcerative has been eliminated

10

NGSigns

bull 3 key features papilla necrosis bleeding and pain

bull Punched out papillae cratered like depressions covered by a white necrotic pseudomembrane(collection of PMNS) bright red margins spontenousbleeding may occur

bull Distinctive foul odor

bull May have systemic involvement

ndash lymphadenopathy fever

bull May be a systemic

manifestations

ndash HIV

NG Treatmentbull Advise to avoid smoking amp etoh get rest and proper nutrition (rec

multi vitamin soft nutritious diet)+ self care

bull Rinses with frac12 glass warm water amp 1 tbsp hydrogen peroxide w half glass or chlorhexidine

bull Pain medication

bull Antibiotics can be used especially if systemic involvement

ndash metronidazole tetracycline pen vk

bull Initial supragingival debridement then complete

bull Consider complete laboratory work ndashup amp medical consult

ndash (NUG may be the first sign of HIV)

bull May progress to NUP

bull Follow ndashup phone call or visit within 24 hrsndash Re-eval surgery referral debridement wlocal= recurrent nature

NP

bull Progression of NUG

bull May be related to systemic disease

bull HIV nutrition deficiency

bull NUG superimposed on a previous periodontal disease

NP

Signs amp symptoms

bull Intensely red necrosis white pseudomembrane

bull Painful odor punched-out papillae

bull Reports of deep aching pain or jaw pain

bull Extensive bone loss

bull Spontaneous bleeding

Treatment

bull Same as NUG

Peridex culture antibiotics (metronidazole) or antifungals

Refractory

bull Not included in the new guidelines

bull Unresponsive to treatmentndash surgery frequent scrt pl antibiotics

bull Can be localized or generalized

bull Usually smokers

bull Treatment clindamycin metronidazole metriwamoxicillin or Augmentin

Periodontal Phenotype (Biotypes)

bull The term describes the thickness of the gingiva in a bucco-lingual dimension

bull 3 types

Thick flat

Thick scalloped

Thin

bull Thick (85) is more prevalent than thin (15)

11

Thin Gingival Phenotype

bull Triangle shaped teeth vs square

bull Thin tissue

bull Susceptible to recession

bull Dehiscence present

bull Instrumentation must be done

Carefully due to thin biotype

bull Reacts to insult by recession

Thick amp Flat Gingival Phenotype

bull Square shaped

bull Thick tissue

bull Susceptible to pocketing

bull Reacts to insult by pocketing

Thick Scalloped

bull Thick fibrotic gingiva

bull Slender teeth

bull Narrow zone of KT

bull Gingival scalloping

Recession

Type 1 Type 2

Interproximal CEJ

is clinically not

detectable

The amount of

interproximal

attachment loss

is lt to buccal

Type 3

The amount of

interproximal

attachment loss

is gt

buccal

attachment loss

Implants

bull Treat perio prior to implantsbull It takes 2 weeks for the implants to

become colonized by the surrounding teeth

bull No horizontal fibers like a tooth so infection goes straight to bone and perio happens very quickly

bull This perimucosal seal is delicate ndashBe careful during instrumentation

12

Implants

bull The implant coatingsrough surfaces may create more risk for implantitis but better for osteointergration

ndash The calculus is more embedded on these surfaces than the previous smoother surfaces

Stages of Peri-implant DiseasePeri-implant mucositis

bull Reversible inflammation of the soft tissues

bull Occurs in about 50 of implants placed within 9 - 14 years

Peri-implantitis

bull Bone Loss

bull Occurs in 12- 47 of implants 5 years after placement

bull Risk factors-Hx of severe perio poor self care amp lack of maintenance care

bull Cement Implantitis

bull Some evidence linking cement and titanium particles bio corrosion

Peri-implantitis

Microorganisms

bull Gram - Fusobacterium species Prevotella intermedia

bull Implant failure is usually due to the microbial challenge occlusal load or excessive cementndash Cement has been found in the tissues

bull Failure is evidenced by gt2 mm MOBILITY

bull Bone loss buccal and lingual results in dehiscence

Cement Implantitis

New AAP Case definitionPeri-implantitis

bull BOP

bull Probing depth gt 6 mm

bull Bone levels gt 3 mm apical of the most coronal portion of the intraosseous part of the implant

Caton J Armitage G Berglundh T Et al A new classification scheme for periodontal and peri‐implant diseases and conditions ndash Introduction and key changes from the 1999 classification Journal of Periodontology 89 S1 (S1-S8) (2018)

Failing Criteria

bull Ailing (Peri-implant mucositis) inflammation present but no mobility

ndash bone appears normal or there may be an incipient lesion

bull Failing Peri-implantitis without mobility

ndash Inflammation has progressed to the bone as evidenced by radiographic lesion

bull Failed Peri-implantitis with mobility

ndash Implant has pronounced bone loss

Probing amp BOP

bull Metal probes on prosthetic part of the crown is fine

bull Some are concerned with metal probes on the threads

bull Must probe implants

bull Probe depths are generally deeper than natural tooth

bull BOP is not normal

threads

13

Treatment

bull Be aggressive amp prevent bone loss because very difficult to treat once initiated

bull Treatment

ndash Debride thoroughly

ndash Chlorhexidine

ndash Systemic antibiotics

ndash Bone grafts

ndash Arestin- local drug delivery

ndash Air flow polishing with glycine

Diagnosis Severity

bull Determining severity is based on CAL and bone loss

bull Clinical attachment level (CAL)

ndashdistance from the junctional epithelium to the CEJ

bull Probe depths alone are lacking because it does not take in account the gingival margin

ndashusing probe depths alone can result in over estimating or underestimating disease

Three possible relationships for gingival margin and CEJ

bull Gingival margin could be coronal to CEJ

bull Gingival margin could be level with CEJ

bull Gingival margin could be apical to CEJ

GM

bull Where should the GM be normallyndash 1-2 mm coronal to the CEJ

bull What is the pattern of CEJs interproximallyacross the mouthndash More Flat on the Posteriors

ndash More Curvature on the Anteriors

ndash For interproximal space look at the papillae does it fill the embrasure space

ndash A normal GM on the anteriors could be +1mm

ndash A normal GM on the posteriors could be +2 mm

Clinical attachment level

Depends on position of the gingival margin and CEJ

bull Gingival margin could be coronal to CEJ (-)

bull Gingival margin could be level with CEJ (same)

bull Gingival margin could be apical to CEJ (+)

Measuring CAL when gingival margin is coronal to CEJ

1 Measure probe depth

2 Measure from gingival margin to CEJ

3 Subtract second measurement from overall probe depth

FYI-This is a color

coded probe w

markings at 36912

14

Measuring CAL when gingival margin is levelwith CEJ

bull Probe depth is Clinical attachment level

Measuring CAL when gingival margin is apical to CEJ

bull Measure probe depthbull Measure recessionbull Add recession to probe depth

Grading

Bone Loss

Stage 1

Coronal 13

lt 15

Coronal 13

Mid 13

Last 13

15 Normal bone Height

33 stage 2

Stage 3Extends to mid third of root amp beyondStage 4Extends to mid third of root amp beyond

Stage 1

stage 3 amp 4

Predicting Activity

bull BOP

ndash 50 of all bleeding sites will not break down

ndash 50 of all bleeding sites will breakdown

ndash Sites that do not bleed will not breakdown

ndash The absence of bleeding provides more information than whether bleeding exists

ndash Therefore when sites bleed we say it is active

bull Inflammation

bull Nutrient canals

bull Rough looking crestal bone vs smooth amp well demarcated may indicate activity

15

Predicting Activity

bull Nutrient canals

ndash Highly visible canals may indicate active or rapid destruction

ndash canals are thought to be engorged large blood vessels

Crestal Bone

Rough looking crestal boneSmoother more demarcated crestal bone

Planningbull Systematic Informed consent

bull Diagnosis prognosis options risks benefits

ndashPatients must have all the information

bull Studies indicate slight reductions in PD s gt 6 mm after full-mouth scaling and root planingperformed in one appointment vs over longer intervals

bull These protocols particularly effective in patients with aggressive periodontitis andor pts w systemic conditions

Eberhard J et al J Clin Periodontol 200835591ndash604 amp Fang et al J Periodont Res October 19 2015)

ImplementationTreatment

bull Goals are to eliminate infection and risk factorsbull The objective is to remove all clinically detectable

calculus without excessive root planingndash bacterial endotoxins are weakly adherent to the root

surface (Nakib 1982)

bull The term debridement vs root planing

ImplementationTreatment

bull Treat patientrsquos significant otherbull 40 of the time spouses have the

same microbiotabull Donrsquot kiss dogs amp cats- they may have

periobull Avoid gross scaling

bull risk of abscessbull educationbull more difficult to re-insert

instruments

16

Air Polishing with glycine

ndashGlycine has anti inflammatory ampimmune modulation effectsbull Glycine receptor gingival tissue

ndashPerpulsionndashFDA approval for lt5 mmndashRemoval biofilm amp stainndashPerio maintenance ndashImplantsndashDecontaminate prior to grafts

Host-Modulating Treatmentbull Treating periodontitis by trying to resolve

inflammation

bull Resolvins

ndash Omega 3 Fatty acids correlated with less bone loss

ndash may be due to their ability to generate mediators that fight inflammation and aid in inflammation resolution

bull Low-dose doxycycline 20 mg 2x daily

ndash Matrix metalloproteinase inhibitor is the only FDA-approved

ndash Reduction of PD amp CAL gain over 3 months to 9 monthsGolub LM et al Doxycycline i hibits neutrophil (PMN)-type matrix metalloproteinases in human adult periodontitis gingiva J Clin Periodontol 199522100ndash109 amp

Golub LM et al Adjunctive treatment with subantimicrobial doses of doxycycline effects on gingival fluid collagenase activity and attachment loss in adult periodontitis J Clin Periodontol 200128146ndash156

Host-Modulating Treatment

bull NSAIDsndash Reduces PGE 2 which can reduce bone loss

ndash Flurbiprofen and topical (ketorolac)

ndash Case controls demonstrate decrease risk

bull Bisphosphonates ndash Used for treating Pagetrsquos bone pain amp osteoporosis

ndash Alendronate sodium (Fosamax) risedronate (Actonel)

ndash Investigating for its ability to modulate the host

bull Used experimentally in animals to inhibit bone resorption amp bone mineral content amp to interfere w breakdown of collagen in the periodontium

ndash WARNING case reports of bone necrosis after extractions

bull questions scrtpl w pts on drug

Treatment

bull Statins have an anti-inflammatory and immune effects reducing levels of C-Reactive Protein MMP Tumor Necrosis Factor-α

ndash Statins reduce bone resorption by inhibiting osteoclast formation

ndash Some results show lower alveolar bone loss and reduction of clinical signs of inflammation

(meta anyalsis Estanislau etal J Clin Pharmacol 2014 Dec)

ndash Topical gels (simvastatin atorvastatin)

Treatment

bull Probioticsndash Improved biofilm index and probe depths (Shimauchi 2008)

bull Valtrexbull Photodynamic therapy

ndash Light-sensitive drug is applied then a light laser directly on the area treated with the drug

ndash When the light is combined with the drug phototoxic reactions are induced which destroy bacterial cells

ndash Shows short term benefits (Sgolastra 2012)bull Periowave

bull Emdogainndash Enamel matrix derivative for periodontal tissue regeneration in

infrabony defects amp used w SRP to enhance resultsbull Derived from developing pig teethbull Stimulate adherence attachment to cementum

Treatmentbull Topical antioxidants

ndash Antioxidant gel and rinse

ndash Periosciences ndash toothpaste rinse gel

ndash Topical coenzyme COQ10

bull Due to correlation w perio oxidative stress markers amp low level of natural occurring salivary antioxidants looking at polyphenolsantioxidants in the mouth locally delivered

ndash needs more research

bull Hyaluronic acid (HA) gel and mouth rinsendash hyaluronic acid plays a large role in the collagen building 02

hyaluronan gel topically amp subgingivally

ndash Studies have been done to evaluate on wound healing amp improving perio outcomes

ndash Further evidence is needed

3

Systemic Link

bull Cardiovascular Diseases amp Stroke

ndash perio appears to be a mildmoderate risk for coronary heart disease Perio is a stronger risk factor for stroke

ndash 2 -7 fold increased risk of stroke in those w perio

bull Diabetes

ndash bi-directional relationship

Systemic Linkbull Respiratory diseases

ndash Microrsquos from the oral nasal amp pharyngeal frequently contaminate the upper airway

ndash Increased risk due to poor OH

bull May increase risk in lung cancer

ndash periodontal disease pts have a 124-fold increased risk of developing lung cancer

bull MiscarriagesPre-term DeliveryLow Birth Weight Babies

ndash Women w perio may be 7-8X more predisposed to deliver premature infants w LBW

ndash CRP amp PGE2 trigger early uterine contractions amp PTD

ndash microbiome Project found the microbiome of the placenta most resembles the subgingival environment

Systemic Link

bull Alzheimers Diseasendash Early exposure to periodontitis and inflammatory

conditions may increase one for Alzheimers disease later in life

bull theories

ndashInflammation allows bacteria to enter the brain

ndashPeriodontal spirochetes disrupt the normal defenses and may lead to neuronal degeneration

ndashPg

Periodontal MedicineSystemic Connection

bull Non- dental professionals appreciate the impact of oral health

bull As patient awareness of perio amp systemic implications increases more seek preventive care (Williams amp Offenbacher periodontol200023(1)9-12)

bull Some strong links have been observed

bull Further studies are needed

Diagnosis

bull A periodontal diagnosis must be made to facilitate good decision-making for both the clinician amp pt for proper treatment planning

bull It can be very effective amp powerful

2017 Periodontal Classification

bull Proceedings of the World (American Academy of

Periodontology and the European Federation of

Periodontology) Workshop on the Classification of

Periodontal and Peri‐Implant Diseases and

Conditions

Caton J Armitage G Berglundh T Et al A new classification scheme for periodontal and peri‐implant diseases and conditions ndashIntroduction and key changes from the 1999 classification Journal of Periodontology 89 S1 (S1-S8) (2018)

httpsonlinelibrarywileycomtoc19433670201889S1

4

Key Points

bull Created by incredible researchers in the field of perio

bull Case definitions for research vs clinicaltreatment

ndashResearch guidelines were needed

bull Includes a holistic approach to periodontology

ndash Included risk factors modifiers and overall perio systemic connection

bull Creating space for future research

bull Addressing the borderline between gingivitis and periodontitis

Key Points

bull Excessive occlusal force- Traumatic occlusal force

bull Biologic width- Supracrestal tissue attachment

bull 3 disease of perio- perio systemic necrotizing

bull Necrotizing periodontal disease- dropped ulcerative

bull Linear gingivitis removed is new term is Candidosis

bull Added implant

bull Periodontal abscesses (PA) classified according to the etiological factors involved

bull added gingival pigmentation due to medication

Key Pointsbull Must probe implants lightly to monitor depth changes

and bleeding progression of perio is faster on implants

bull CAL-lack of training affects DX initial periodontitis in regards to CAL

-Interdental CAL is detectable at ge2 non‐adjacent teeth or Buccal CAL ge3 mm with pocketing gt3 mm is detectable at ge2 teeth

bull Proposal for staging and grading framework which would allow for complexity and risk

ndash 3 sets of parameters

bull RATE RISK RISK

bull The intention was to liken to cancer

httpswwwperioorg2017wwdc

5

Types of Periodontal diseasesGingival

Dental biofilm Induced Gingivitis Most commonbull Typically biofilm is proportionate

to the amount of inflammation

bull No bone loss no LOA

Types- New

bull Localized = BOPgt 10 amp lt30

bull Generalized plaque induced gingivitis gt 30 BOP

Microorganisms

bull Non-specific includes both Gram - amp Gram +

Treatment

bull self care deplaquingdebridementscaling

bull eliminate local contributory factors

Modifying Factors of Biofilm induced Gingivitis hormonalPregnancy Gingivitis

Etiologybull biofilm amp hormone changes

bull degree of inflammation parallels OH

ndash good OH can prevent pregnancy gingivitis

bull will exacerbate any previous periodontal disease

Pregnancy Gingivitis

Microorganism

bull Prevotella intermedia

Treatment

bull subsides after giving birth

bull exaggerated response can be prevented w excellent OH

bull frequent recalls Oral self care

bull Deplaquingdebridementscaling

Pyogenic Granuloma

Treatment

bull may resolve on own after debridement

bull may need surgical removal

6

Drug-influenced gingivitis

bull Gingival enlargement

ndashAnticonvulsants

bull Phenytoin

ndashCalcium channel blockers

bull Nifedipine 6-43

ndash Immunosuppressants

bull Cyclosporin 25

ndashAnabolic Androgenic Steroid

ndash Prostate cancer treatment

Gingival enlargement

bull Level of biofilm amp drug dosage accumulation can affect the severity of overgrowth

bull Consult w MD for drug substitution

bull Some cases of hypertrophic gingival tissue have been reported as Kaposirsquos sarcoma amp squamous cell carcinoma

Non-biofilm induced related to bull Specific bacteria

ndash Neissera gonorrhea treponema pallidum streptococci

bull Viralndash Herpes simplex 1 amp 2 varicella zoster papillmavirus

bull Fungal

bull Cultured for true diagnosis amp treat appropriately antibiotics antiviral amp or antifungal

bull Not common amp usually not known

Non-plaque induced gingival diseases of fungal origin

Candidosisformally Linear gingivitis

bull Generally fungalcandiasis

bull Linear amp very distinctive band of severe erythema on gingival margin

bull Disproportion of inflammatory intensity for the amount of biofilm present

Candidosis Treatment

ndash OHE consider chlorhexidine

ndash Does not respond well to improved OH or scaling

ndash Biofilm removal debridementscaling

ndash May need additional physician consult

Lichen Planus

Etiologybull Unknownbull Cell mediated Immune pathogenesis bull Systemic Diseases

ndash Diabetes hypertension hepatitis B amp C chronic graft-versus-host disease amp lupus

bull Medicationsndash antimalarial drugs antihypertensives amp non-steroidal anti

inflammatory (NSAIDS)

Signsbull Affects skin and mucous membranesbull Lesions may be mild to moderately painful amp burning

7

Lichen PlanusTypes

Reticular-plaque papular

Erosive Bullous Atrophic ulcerative

bull Erosive- gingival

ndash bulbous forms ulcerative amp painful

ndash red and raw

bull Reticular

ndash asymptomatic keratontic lines called stria

ndash lacy white lines

Lichen Planus

bull severity may relate to stressConsiderationsbull Higher risk for non- reticular types for malignant transformation

ndash LP pts have a 10 fold increased risk of developing squamous cell carcinoma

Treatmentbull Look for triggers allergies sensitivity bull Aloe Vera rinses amp gelbull Corticosteriods

ndash topical- fluocinonide dexamethadone dipropionate spray topical steroids may help- can cause candida

bull Periodic biopsies are necessary for areas that do not respond to treatment

bull Regular recalls

Inflammatory And Immune Conditions And Lesions

Hypersensitivity ReactionsAllergic gingivitis

Other names desquamative Plasma cell gingivitis idiopathic

gingivostomatitis atypical gingivostomatitis allergic gingivostomatitis hypersensitivity and plasmacytosis

Plasma cell gingivitis is an uncommon inflammatory condition usually affecting the anterior maxillary gingiva and of uncertain etiology While some authors have associated plasma cell gingivitis with a hypersensitivity response to antigens in various substances others have raised doubt whether plasma cell gingivitis is a distinct clinicopathologic entity

Allergic gingivitis

Etiology

bull auto immune

bull Allergy

bull Signs

bull sloughing of the epithelium which leaves raw red surface

bull The edematous tissue often extends to the mucogingival junction with a deep red appearance

Allergic gingivitis

Symptoms

painful

Treatment

topicalsystemic steroid therapy

remove etiological factor if possible

-spices toothpaste flavorings peppermint wintergreen menthol cinnamon preservatives mints gum candy

Possible Offending Products to Gingival Tissue

bull Commercially available toothpaste (tartar-control additives and flavoring agents [possibly

cinnamon] that mask the tartar control additives)

bull Mouth rinses

bull Cinnamon aldehyde

bull Sodium benzoate and methyl paraben

bull Food substances such as wheat dairy chocolate eggs peanuts and monosodium glutamate

bull Red wine (sulfides and tartrazine additives)

bull Preservatives

bull Essential oils such as peppermint spearmint and wintergreen found in gums candy and mouth rinses

bull Dark cola drinks

bull Strong spices

bull Chili peppers

bull Clove

bull Cardamom Burkhart NW Toothpaste allergy RDH 2007 27(6) 86107-108

8

Types of Periodontal diseasesPeriodontitis

Periodontitis

bull Chronic

bull Disease will progress unless treated

bull Typical age of onset is 35 yrs of age

bull Bone loss

- slow

ndash rate may vary depending on the modifiers

bull Severity is determined by bone loss and LOA

bull Can become inactive (stable) active (recurrent) refractory

Periodontitis

Microorganisms

bull Gram ndash

bull P gingivalis

bull P intermedia

bull Tannerella forsythensis (B forsythus)

Treatmentbull Self carebull Scrt

pldebridement bull Depending type of

defects amp severity ndashpossibly surgery

amp perio referral

Not includedAggressive

This category includes formally called diseases

bull Juvenile

bullEarly onset

bullPrepubertal

bullRapidly progressive

Localized Aggressive Localized Juvenile Periodontitis

bull More significant bone loss surrounding 1st molars amp incisors ndash typically angular type bone loss amp mirror image bilaterally

bull Rate of bone loss is rapid

bull OH can be good

9

Localized Aggressive LJP

bull Defects in PMNs or macrophagesbull respond slowly

bull chemotaxis defect

bull impaired phagocytosis

bull Onset typically during teenage years

bull Hereditary componentgenetic

bull more common in females amp blacks

Localized Aggressive Localized Juvenile Periodontitis

Microorganisms

Aggregatibacter Actinomycetemcomitans

P gingivalis

Treatmentbull scrt pldebridement but typically unresponsivebull Antibiotics to be administered with or just after debridement

ndash combo metronidazole wamoxicillin or metro w augmentinndash Clindamycin Azithromycin

bull possibly surgerybull prompt perio referralbull suggest family be evaluated (siblings children etc)bull sea salt being used as prevention of AA amp Tx

Generalized Aggressive Formally Generalized Juvenile Periodontitis

bull More rare than LJPbull Can affect most teeth but more severe on 1st molar

amp incisorsndash must involve gt 3 other teeth

bull Onset usually under 30 years oldbull Associated with neutrophil disorderbull Generally significant inflammation amp heavy

plaquecalculusbull Children w Gagp seem more prone to ear skin amp

upper respiratory tract infections

Generalized Aggressive Generalized Juvenile Periodontitis

MicroorganismsA actinomycetemcomitansPorphyromas gingivalis Eikenella corrodens

Treatmentscrt pldebridementantibiotics

ndash combo metronidazole wamoxicillin or metro w augmentin

possibly surgeryprompt perio referralbull Suggest family be evaluated (siblings children etc)

Periodontitis as a Manifestation of Systemic Disease

bull Systemic diseases that severely impair host response should be considered a periodontal manifestation of the systemic disease amp primary diagnosis should be the systemic disease according to International Statistical Classification of Disease (ICD)

ndash Excludes diabetes

bull Hematologicacquired neutropenias leukemias

bull Genetic disorderfamilial neutopenias down syndrome leukocyte adhesion deficiency syndrome papillon-lefreve syndrome chediak-higshi histocytosis syndromes Glycogen storage disease genetic agranulcytosis cohen syndrome Ehlers-Danlossyndrome hypophosphatsis

Necrotizing Periodontal Diseases NG amp NP

Etiologybull Unknown

bull Risk factorsexcessive stress lack of rest poor oral hygiene smoking HIV poor immune response

bull More common in underdeveloped countries

bull Less common now in the US

bull Susceptible to reoccurrence

Symptomsbull SUDDEN onset of burning

mouth inability to eat metallic taste excessive salvia amp PAINFUL

Microorganisms

spirochetes

Prevotella intermedia

Fusiform bacillus

Fusobacterium nucleatum

Ulcerative has been eliminated

10

NGSigns

bull 3 key features papilla necrosis bleeding and pain

bull Punched out papillae cratered like depressions covered by a white necrotic pseudomembrane(collection of PMNS) bright red margins spontenousbleeding may occur

bull Distinctive foul odor

bull May have systemic involvement

ndash lymphadenopathy fever

bull May be a systemic

manifestations

ndash HIV

NG Treatmentbull Advise to avoid smoking amp etoh get rest and proper nutrition (rec

multi vitamin soft nutritious diet)+ self care

bull Rinses with frac12 glass warm water amp 1 tbsp hydrogen peroxide w half glass or chlorhexidine

bull Pain medication

bull Antibiotics can be used especially if systemic involvement

ndash metronidazole tetracycline pen vk

bull Initial supragingival debridement then complete

bull Consider complete laboratory work ndashup amp medical consult

ndash (NUG may be the first sign of HIV)

bull May progress to NUP

bull Follow ndashup phone call or visit within 24 hrsndash Re-eval surgery referral debridement wlocal= recurrent nature

NP

bull Progression of NUG

bull May be related to systemic disease

bull HIV nutrition deficiency

bull NUG superimposed on a previous periodontal disease

NP

Signs amp symptoms

bull Intensely red necrosis white pseudomembrane

bull Painful odor punched-out papillae

bull Reports of deep aching pain or jaw pain

bull Extensive bone loss

bull Spontaneous bleeding

Treatment

bull Same as NUG

Peridex culture antibiotics (metronidazole) or antifungals

Refractory

bull Not included in the new guidelines

bull Unresponsive to treatmentndash surgery frequent scrt pl antibiotics

bull Can be localized or generalized

bull Usually smokers

bull Treatment clindamycin metronidazole metriwamoxicillin or Augmentin

Periodontal Phenotype (Biotypes)

bull The term describes the thickness of the gingiva in a bucco-lingual dimension

bull 3 types

Thick flat

Thick scalloped

Thin

bull Thick (85) is more prevalent than thin (15)

11

Thin Gingival Phenotype

bull Triangle shaped teeth vs square

bull Thin tissue

bull Susceptible to recession

bull Dehiscence present

bull Instrumentation must be done

Carefully due to thin biotype

bull Reacts to insult by recession

Thick amp Flat Gingival Phenotype

bull Square shaped

bull Thick tissue

bull Susceptible to pocketing

bull Reacts to insult by pocketing

Thick Scalloped

bull Thick fibrotic gingiva

bull Slender teeth

bull Narrow zone of KT

bull Gingival scalloping

Recession

Type 1 Type 2

Interproximal CEJ

is clinically not

detectable

The amount of

interproximal

attachment loss

is lt to buccal

Type 3

The amount of

interproximal

attachment loss

is gt

buccal

attachment loss

Implants

bull Treat perio prior to implantsbull It takes 2 weeks for the implants to

become colonized by the surrounding teeth

bull No horizontal fibers like a tooth so infection goes straight to bone and perio happens very quickly

bull This perimucosal seal is delicate ndashBe careful during instrumentation

12

Implants

bull The implant coatingsrough surfaces may create more risk for implantitis but better for osteointergration

ndash The calculus is more embedded on these surfaces than the previous smoother surfaces

Stages of Peri-implant DiseasePeri-implant mucositis

bull Reversible inflammation of the soft tissues

bull Occurs in about 50 of implants placed within 9 - 14 years

Peri-implantitis

bull Bone Loss

bull Occurs in 12- 47 of implants 5 years after placement

bull Risk factors-Hx of severe perio poor self care amp lack of maintenance care

bull Cement Implantitis

bull Some evidence linking cement and titanium particles bio corrosion

Peri-implantitis

Microorganisms

bull Gram - Fusobacterium species Prevotella intermedia

bull Implant failure is usually due to the microbial challenge occlusal load or excessive cementndash Cement has been found in the tissues

bull Failure is evidenced by gt2 mm MOBILITY

bull Bone loss buccal and lingual results in dehiscence

Cement Implantitis

New AAP Case definitionPeri-implantitis

bull BOP

bull Probing depth gt 6 mm

bull Bone levels gt 3 mm apical of the most coronal portion of the intraosseous part of the implant

Caton J Armitage G Berglundh T Et al A new classification scheme for periodontal and peri‐implant diseases and conditions ndash Introduction and key changes from the 1999 classification Journal of Periodontology 89 S1 (S1-S8) (2018)

Failing Criteria

bull Ailing (Peri-implant mucositis) inflammation present but no mobility

ndash bone appears normal or there may be an incipient lesion

bull Failing Peri-implantitis without mobility

ndash Inflammation has progressed to the bone as evidenced by radiographic lesion

bull Failed Peri-implantitis with mobility

ndash Implant has pronounced bone loss

Probing amp BOP

bull Metal probes on prosthetic part of the crown is fine

bull Some are concerned with metal probes on the threads

bull Must probe implants

bull Probe depths are generally deeper than natural tooth

bull BOP is not normal

threads

13

Treatment

bull Be aggressive amp prevent bone loss because very difficult to treat once initiated

bull Treatment

ndash Debride thoroughly

ndash Chlorhexidine

ndash Systemic antibiotics

ndash Bone grafts

ndash Arestin- local drug delivery

ndash Air flow polishing with glycine

Diagnosis Severity

bull Determining severity is based on CAL and bone loss

bull Clinical attachment level (CAL)

ndashdistance from the junctional epithelium to the CEJ

bull Probe depths alone are lacking because it does not take in account the gingival margin

ndashusing probe depths alone can result in over estimating or underestimating disease

Three possible relationships for gingival margin and CEJ

bull Gingival margin could be coronal to CEJ

bull Gingival margin could be level with CEJ

bull Gingival margin could be apical to CEJ

GM

bull Where should the GM be normallyndash 1-2 mm coronal to the CEJ

bull What is the pattern of CEJs interproximallyacross the mouthndash More Flat on the Posteriors

ndash More Curvature on the Anteriors

ndash For interproximal space look at the papillae does it fill the embrasure space

ndash A normal GM on the anteriors could be +1mm

ndash A normal GM on the posteriors could be +2 mm

Clinical attachment level

Depends on position of the gingival margin and CEJ

bull Gingival margin could be coronal to CEJ (-)

bull Gingival margin could be level with CEJ (same)

bull Gingival margin could be apical to CEJ (+)

Measuring CAL when gingival margin is coronal to CEJ

1 Measure probe depth

2 Measure from gingival margin to CEJ

3 Subtract second measurement from overall probe depth

FYI-This is a color

coded probe w

markings at 36912

14

Measuring CAL when gingival margin is levelwith CEJ

bull Probe depth is Clinical attachment level

Measuring CAL when gingival margin is apical to CEJ

bull Measure probe depthbull Measure recessionbull Add recession to probe depth

Grading

Bone Loss

Stage 1

Coronal 13

lt 15

Coronal 13

Mid 13

Last 13

15 Normal bone Height

33 stage 2

Stage 3Extends to mid third of root amp beyondStage 4Extends to mid third of root amp beyond

Stage 1

stage 3 amp 4

Predicting Activity

bull BOP

ndash 50 of all bleeding sites will not break down

ndash 50 of all bleeding sites will breakdown

ndash Sites that do not bleed will not breakdown

ndash The absence of bleeding provides more information than whether bleeding exists

ndash Therefore when sites bleed we say it is active

bull Inflammation

bull Nutrient canals

bull Rough looking crestal bone vs smooth amp well demarcated may indicate activity

15

Predicting Activity

bull Nutrient canals

ndash Highly visible canals may indicate active or rapid destruction

ndash canals are thought to be engorged large blood vessels

Crestal Bone

Rough looking crestal boneSmoother more demarcated crestal bone

Planningbull Systematic Informed consent

bull Diagnosis prognosis options risks benefits

ndashPatients must have all the information

bull Studies indicate slight reductions in PD s gt 6 mm after full-mouth scaling and root planingperformed in one appointment vs over longer intervals

bull These protocols particularly effective in patients with aggressive periodontitis andor pts w systemic conditions

Eberhard J et al J Clin Periodontol 200835591ndash604 amp Fang et al J Periodont Res October 19 2015)

ImplementationTreatment

bull Goals are to eliminate infection and risk factorsbull The objective is to remove all clinically detectable

calculus without excessive root planingndash bacterial endotoxins are weakly adherent to the root

surface (Nakib 1982)

bull The term debridement vs root planing

ImplementationTreatment

bull Treat patientrsquos significant otherbull 40 of the time spouses have the

same microbiotabull Donrsquot kiss dogs amp cats- they may have

periobull Avoid gross scaling

bull risk of abscessbull educationbull more difficult to re-insert

instruments

16

Air Polishing with glycine

ndashGlycine has anti inflammatory ampimmune modulation effectsbull Glycine receptor gingival tissue

ndashPerpulsionndashFDA approval for lt5 mmndashRemoval biofilm amp stainndashPerio maintenance ndashImplantsndashDecontaminate prior to grafts

Host-Modulating Treatmentbull Treating periodontitis by trying to resolve

inflammation

bull Resolvins

ndash Omega 3 Fatty acids correlated with less bone loss

ndash may be due to their ability to generate mediators that fight inflammation and aid in inflammation resolution

bull Low-dose doxycycline 20 mg 2x daily

ndash Matrix metalloproteinase inhibitor is the only FDA-approved

ndash Reduction of PD amp CAL gain over 3 months to 9 monthsGolub LM et al Doxycycline i hibits neutrophil (PMN)-type matrix metalloproteinases in human adult periodontitis gingiva J Clin Periodontol 199522100ndash109 amp

Golub LM et al Adjunctive treatment with subantimicrobial doses of doxycycline effects on gingival fluid collagenase activity and attachment loss in adult periodontitis J Clin Periodontol 200128146ndash156

Host-Modulating Treatment

bull NSAIDsndash Reduces PGE 2 which can reduce bone loss

ndash Flurbiprofen and topical (ketorolac)

ndash Case controls demonstrate decrease risk

bull Bisphosphonates ndash Used for treating Pagetrsquos bone pain amp osteoporosis

ndash Alendronate sodium (Fosamax) risedronate (Actonel)

ndash Investigating for its ability to modulate the host

bull Used experimentally in animals to inhibit bone resorption amp bone mineral content amp to interfere w breakdown of collagen in the periodontium

ndash WARNING case reports of bone necrosis after extractions

bull questions scrtpl w pts on drug

Treatment

bull Statins have an anti-inflammatory and immune effects reducing levels of C-Reactive Protein MMP Tumor Necrosis Factor-α

ndash Statins reduce bone resorption by inhibiting osteoclast formation

ndash Some results show lower alveolar bone loss and reduction of clinical signs of inflammation

(meta anyalsis Estanislau etal J Clin Pharmacol 2014 Dec)

ndash Topical gels (simvastatin atorvastatin)

Treatment

bull Probioticsndash Improved biofilm index and probe depths (Shimauchi 2008)

bull Valtrexbull Photodynamic therapy

ndash Light-sensitive drug is applied then a light laser directly on the area treated with the drug

ndash When the light is combined with the drug phototoxic reactions are induced which destroy bacterial cells

ndash Shows short term benefits (Sgolastra 2012)bull Periowave

bull Emdogainndash Enamel matrix derivative for periodontal tissue regeneration in

infrabony defects amp used w SRP to enhance resultsbull Derived from developing pig teethbull Stimulate adherence attachment to cementum

Treatmentbull Topical antioxidants

ndash Antioxidant gel and rinse

ndash Periosciences ndash toothpaste rinse gel

ndash Topical coenzyme COQ10

bull Due to correlation w perio oxidative stress markers amp low level of natural occurring salivary antioxidants looking at polyphenolsantioxidants in the mouth locally delivered

ndash needs more research

bull Hyaluronic acid (HA) gel and mouth rinsendash hyaluronic acid plays a large role in the collagen building 02

hyaluronan gel topically amp subgingivally

ndash Studies have been done to evaluate on wound healing amp improving perio outcomes

ndash Further evidence is needed

4

Key Points

bull Created by incredible researchers in the field of perio

bull Case definitions for research vs clinicaltreatment

ndashResearch guidelines were needed

bull Includes a holistic approach to periodontology

ndash Included risk factors modifiers and overall perio systemic connection

bull Creating space for future research

bull Addressing the borderline between gingivitis and periodontitis

Key Points

bull Excessive occlusal force- Traumatic occlusal force

bull Biologic width- Supracrestal tissue attachment

bull 3 disease of perio- perio systemic necrotizing

bull Necrotizing periodontal disease- dropped ulcerative

bull Linear gingivitis removed is new term is Candidosis

bull Added implant

bull Periodontal abscesses (PA) classified according to the etiological factors involved

bull added gingival pigmentation due to medication

Key Pointsbull Must probe implants lightly to monitor depth changes

and bleeding progression of perio is faster on implants

bull CAL-lack of training affects DX initial periodontitis in regards to CAL

-Interdental CAL is detectable at ge2 non‐adjacent teeth or Buccal CAL ge3 mm with pocketing gt3 mm is detectable at ge2 teeth

bull Proposal for staging and grading framework which would allow for complexity and risk

ndash 3 sets of parameters

bull RATE RISK RISK

bull The intention was to liken to cancer

httpswwwperioorg2017wwdc

5

Types of Periodontal diseasesGingival

Dental biofilm Induced Gingivitis Most commonbull Typically biofilm is proportionate

to the amount of inflammation

bull No bone loss no LOA

Types- New

bull Localized = BOPgt 10 amp lt30

bull Generalized plaque induced gingivitis gt 30 BOP

Microorganisms

bull Non-specific includes both Gram - amp Gram +

Treatment

bull self care deplaquingdebridementscaling

bull eliminate local contributory factors

Modifying Factors of Biofilm induced Gingivitis hormonalPregnancy Gingivitis

Etiologybull biofilm amp hormone changes

bull degree of inflammation parallels OH

ndash good OH can prevent pregnancy gingivitis

bull will exacerbate any previous periodontal disease

Pregnancy Gingivitis

Microorganism

bull Prevotella intermedia

Treatment

bull subsides after giving birth

bull exaggerated response can be prevented w excellent OH

bull frequent recalls Oral self care

bull Deplaquingdebridementscaling

Pyogenic Granuloma

Treatment

bull may resolve on own after debridement

bull may need surgical removal

6

Drug-influenced gingivitis

bull Gingival enlargement

ndashAnticonvulsants

bull Phenytoin

ndashCalcium channel blockers

bull Nifedipine 6-43

ndash Immunosuppressants

bull Cyclosporin 25

ndashAnabolic Androgenic Steroid

ndash Prostate cancer treatment

Gingival enlargement

bull Level of biofilm amp drug dosage accumulation can affect the severity of overgrowth

bull Consult w MD for drug substitution

bull Some cases of hypertrophic gingival tissue have been reported as Kaposirsquos sarcoma amp squamous cell carcinoma

Non-biofilm induced related to bull Specific bacteria

ndash Neissera gonorrhea treponema pallidum streptococci

bull Viralndash Herpes simplex 1 amp 2 varicella zoster papillmavirus

bull Fungal

bull Cultured for true diagnosis amp treat appropriately antibiotics antiviral amp or antifungal

bull Not common amp usually not known

Non-plaque induced gingival diseases of fungal origin

Candidosisformally Linear gingivitis

bull Generally fungalcandiasis

bull Linear amp very distinctive band of severe erythema on gingival margin

bull Disproportion of inflammatory intensity for the amount of biofilm present

Candidosis Treatment

ndash OHE consider chlorhexidine

ndash Does not respond well to improved OH or scaling

ndash Biofilm removal debridementscaling

ndash May need additional physician consult

Lichen Planus

Etiologybull Unknownbull Cell mediated Immune pathogenesis bull Systemic Diseases

ndash Diabetes hypertension hepatitis B amp C chronic graft-versus-host disease amp lupus

bull Medicationsndash antimalarial drugs antihypertensives amp non-steroidal anti

inflammatory (NSAIDS)

Signsbull Affects skin and mucous membranesbull Lesions may be mild to moderately painful amp burning

7

Lichen PlanusTypes

Reticular-plaque papular

Erosive Bullous Atrophic ulcerative

bull Erosive- gingival

ndash bulbous forms ulcerative amp painful

ndash red and raw

bull Reticular

ndash asymptomatic keratontic lines called stria

ndash lacy white lines

Lichen Planus

bull severity may relate to stressConsiderationsbull Higher risk for non- reticular types for malignant transformation

ndash LP pts have a 10 fold increased risk of developing squamous cell carcinoma

Treatmentbull Look for triggers allergies sensitivity bull Aloe Vera rinses amp gelbull Corticosteriods

ndash topical- fluocinonide dexamethadone dipropionate spray topical steroids may help- can cause candida

bull Periodic biopsies are necessary for areas that do not respond to treatment

bull Regular recalls

Inflammatory And Immune Conditions And Lesions

Hypersensitivity ReactionsAllergic gingivitis

Other names desquamative Plasma cell gingivitis idiopathic

gingivostomatitis atypical gingivostomatitis allergic gingivostomatitis hypersensitivity and plasmacytosis

Plasma cell gingivitis is an uncommon inflammatory condition usually affecting the anterior maxillary gingiva and of uncertain etiology While some authors have associated plasma cell gingivitis with a hypersensitivity response to antigens in various substances others have raised doubt whether plasma cell gingivitis is a distinct clinicopathologic entity

Allergic gingivitis

Etiology

bull auto immune

bull Allergy

bull Signs

bull sloughing of the epithelium which leaves raw red surface

bull The edematous tissue often extends to the mucogingival junction with a deep red appearance

Allergic gingivitis

Symptoms

painful

Treatment

topicalsystemic steroid therapy

remove etiological factor if possible

-spices toothpaste flavorings peppermint wintergreen menthol cinnamon preservatives mints gum candy

Possible Offending Products to Gingival Tissue

bull Commercially available toothpaste (tartar-control additives and flavoring agents [possibly

cinnamon] that mask the tartar control additives)

bull Mouth rinses

bull Cinnamon aldehyde

bull Sodium benzoate and methyl paraben

bull Food substances such as wheat dairy chocolate eggs peanuts and monosodium glutamate

bull Red wine (sulfides and tartrazine additives)

bull Preservatives

bull Essential oils such as peppermint spearmint and wintergreen found in gums candy and mouth rinses

bull Dark cola drinks

bull Strong spices

bull Chili peppers

bull Clove

bull Cardamom Burkhart NW Toothpaste allergy RDH 2007 27(6) 86107-108

8

Types of Periodontal diseasesPeriodontitis

Periodontitis

bull Chronic

bull Disease will progress unless treated

bull Typical age of onset is 35 yrs of age

bull Bone loss

- slow

ndash rate may vary depending on the modifiers

bull Severity is determined by bone loss and LOA

bull Can become inactive (stable) active (recurrent) refractory

Periodontitis

Microorganisms

bull Gram ndash

bull P gingivalis

bull P intermedia

bull Tannerella forsythensis (B forsythus)

Treatmentbull Self carebull Scrt

pldebridement bull Depending type of

defects amp severity ndashpossibly surgery

amp perio referral

Not includedAggressive

This category includes formally called diseases

bull Juvenile

bullEarly onset

bullPrepubertal

bullRapidly progressive

Localized Aggressive Localized Juvenile Periodontitis

bull More significant bone loss surrounding 1st molars amp incisors ndash typically angular type bone loss amp mirror image bilaterally

bull Rate of bone loss is rapid

bull OH can be good

9

Localized Aggressive LJP

bull Defects in PMNs or macrophagesbull respond slowly

bull chemotaxis defect

bull impaired phagocytosis

bull Onset typically during teenage years

bull Hereditary componentgenetic

bull more common in females amp blacks

Localized Aggressive Localized Juvenile Periodontitis

Microorganisms

Aggregatibacter Actinomycetemcomitans

P gingivalis

Treatmentbull scrt pldebridement but typically unresponsivebull Antibiotics to be administered with or just after debridement

ndash combo metronidazole wamoxicillin or metro w augmentinndash Clindamycin Azithromycin

bull possibly surgerybull prompt perio referralbull suggest family be evaluated (siblings children etc)bull sea salt being used as prevention of AA amp Tx

Generalized Aggressive Formally Generalized Juvenile Periodontitis

bull More rare than LJPbull Can affect most teeth but more severe on 1st molar

amp incisorsndash must involve gt 3 other teeth

bull Onset usually under 30 years oldbull Associated with neutrophil disorderbull Generally significant inflammation amp heavy

plaquecalculusbull Children w Gagp seem more prone to ear skin amp

upper respiratory tract infections

Generalized Aggressive Generalized Juvenile Periodontitis

MicroorganismsA actinomycetemcomitansPorphyromas gingivalis Eikenella corrodens

Treatmentscrt pldebridementantibiotics

ndash combo metronidazole wamoxicillin or metro w augmentin

possibly surgeryprompt perio referralbull Suggest family be evaluated (siblings children etc)

Periodontitis as a Manifestation of Systemic Disease

bull Systemic diseases that severely impair host response should be considered a periodontal manifestation of the systemic disease amp primary diagnosis should be the systemic disease according to International Statistical Classification of Disease (ICD)

ndash Excludes diabetes

bull Hematologicacquired neutropenias leukemias

bull Genetic disorderfamilial neutopenias down syndrome leukocyte adhesion deficiency syndrome papillon-lefreve syndrome chediak-higshi histocytosis syndromes Glycogen storage disease genetic agranulcytosis cohen syndrome Ehlers-Danlossyndrome hypophosphatsis

Necrotizing Periodontal Diseases NG amp NP

Etiologybull Unknown

bull Risk factorsexcessive stress lack of rest poor oral hygiene smoking HIV poor immune response

bull More common in underdeveloped countries

bull Less common now in the US

bull Susceptible to reoccurrence

Symptomsbull SUDDEN onset of burning

mouth inability to eat metallic taste excessive salvia amp PAINFUL

Microorganisms

spirochetes

Prevotella intermedia

Fusiform bacillus

Fusobacterium nucleatum

Ulcerative has been eliminated

10

NGSigns

bull 3 key features papilla necrosis bleeding and pain

bull Punched out papillae cratered like depressions covered by a white necrotic pseudomembrane(collection of PMNS) bright red margins spontenousbleeding may occur

bull Distinctive foul odor

bull May have systemic involvement

ndash lymphadenopathy fever

bull May be a systemic

manifestations

ndash HIV

NG Treatmentbull Advise to avoid smoking amp etoh get rest and proper nutrition (rec

multi vitamin soft nutritious diet)+ self care

bull Rinses with frac12 glass warm water amp 1 tbsp hydrogen peroxide w half glass or chlorhexidine

bull Pain medication

bull Antibiotics can be used especially if systemic involvement

ndash metronidazole tetracycline pen vk

bull Initial supragingival debridement then complete

bull Consider complete laboratory work ndashup amp medical consult

ndash (NUG may be the first sign of HIV)

bull May progress to NUP

bull Follow ndashup phone call or visit within 24 hrsndash Re-eval surgery referral debridement wlocal= recurrent nature

NP

bull Progression of NUG

bull May be related to systemic disease

bull HIV nutrition deficiency

bull NUG superimposed on a previous periodontal disease

NP

Signs amp symptoms

bull Intensely red necrosis white pseudomembrane

bull Painful odor punched-out papillae

bull Reports of deep aching pain or jaw pain

bull Extensive bone loss

bull Spontaneous bleeding

Treatment

bull Same as NUG

Peridex culture antibiotics (metronidazole) or antifungals

Refractory

bull Not included in the new guidelines

bull Unresponsive to treatmentndash surgery frequent scrt pl antibiotics

bull Can be localized or generalized

bull Usually smokers

bull Treatment clindamycin metronidazole metriwamoxicillin or Augmentin

Periodontal Phenotype (Biotypes)

bull The term describes the thickness of the gingiva in a bucco-lingual dimension

bull 3 types

Thick flat

Thick scalloped

Thin

bull Thick (85) is more prevalent than thin (15)

11

Thin Gingival Phenotype

bull Triangle shaped teeth vs square

bull Thin tissue

bull Susceptible to recession

bull Dehiscence present

bull Instrumentation must be done

Carefully due to thin biotype

bull Reacts to insult by recession

Thick amp Flat Gingival Phenotype

bull Square shaped

bull Thick tissue

bull Susceptible to pocketing

bull Reacts to insult by pocketing

Thick Scalloped

bull Thick fibrotic gingiva

bull Slender teeth

bull Narrow zone of KT

bull Gingival scalloping

Recession

Type 1 Type 2

Interproximal CEJ

is clinically not

detectable

The amount of

interproximal

attachment loss

is lt to buccal

Type 3

The amount of

interproximal

attachment loss

is gt

buccal

attachment loss

Implants

bull Treat perio prior to implantsbull It takes 2 weeks for the implants to

become colonized by the surrounding teeth

bull No horizontal fibers like a tooth so infection goes straight to bone and perio happens very quickly

bull This perimucosal seal is delicate ndashBe careful during instrumentation

12

Implants

bull The implant coatingsrough surfaces may create more risk for implantitis but better for osteointergration

ndash The calculus is more embedded on these surfaces than the previous smoother surfaces

Stages of Peri-implant DiseasePeri-implant mucositis

bull Reversible inflammation of the soft tissues

bull Occurs in about 50 of implants placed within 9 - 14 years

Peri-implantitis

bull Bone Loss

bull Occurs in 12- 47 of implants 5 years after placement

bull Risk factors-Hx of severe perio poor self care amp lack of maintenance care

bull Cement Implantitis

bull Some evidence linking cement and titanium particles bio corrosion

Peri-implantitis

Microorganisms

bull Gram - Fusobacterium species Prevotella intermedia

bull Implant failure is usually due to the microbial challenge occlusal load or excessive cementndash Cement has been found in the tissues

bull Failure is evidenced by gt2 mm MOBILITY

bull Bone loss buccal and lingual results in dehiscence

Cement Implantitis

New AAP Case definitionPeri-implantitis

bull BOP

bull Probing depth gt 6 mm

bull Bone levels gt 3 mm apical of the most coronal portion of the intraosseous part of the implant

Caton J Armitage G Berglundh T Et al A new classification scheme for periodontal and peri‐implant diseases and conditions ndash Introduction and key changes from the 1999 classification Journal of Periodontology 89 S1 (S1-S8) (2018)

Failing Criteria

bull Ailing (Peri-implant mucositis) inflammation present but no mobility

ndash bone appears normal or there may be an incipient lesion

bull Failing Peri-implantitis without mobility

ndash Inflammation has progressed to the bone as evidenced by radiographic lesion

bull Failed Peri-implantitis with mobility

ndash Implant has pronounced bone loss

Probing amp BOP

bull Metal probes on prosthetic part of the crown is fine

bull Some are concerned with metal probes on the threads

bull Must probe implants

bull Probe depths are generally deeper than natural tooth

bull BOP is not normal

threads

13

Treatment

bull Be aggressive amp prevent bone loss because very difficult to treat once initiated

bull Treatment

ndash Debride thoroughly

ndash Chlorhexidine

ndash Systemic antibiotics

ndash Bone grafts

ndash Arestin- local drug delivery

ndash Air flow polishing with glycine

Diagnosis Severity

bull Determining severity is based on CAL and bone loss

bull Clinical attachment level (CAL)

ndashdistance from the junctional epithelium to the CEJ

bull Probe depths alone are lacking because it does not take in account the gingival margin

ndashusing probe depths alone can result in over estimating or underestimating disease

Three possible relationships for gingival margin and CEJ

bull Gingival margin could be coronal to CEJ

bull Gingival margin could be level with CEJ

bull Gingival margin could be apical to CEJ

GM

bull Where should the GM be normallyndash 1-2 mm coronal to the CEJ

bull What is the pattern of CEJs interproximallyacross the mouthndash More Flat on the Posteriors

ndash More Curvature on the Anteriors

ndash For interproximal space look at the papillae does it fill the embrasure space

ndash A normal GM on the anteriors could be +1mm

ndash A normal GM on the posteriors could be +2 mm

Clinical attachment level

Depends on position of the gingival margin and CEJ

bull Gingival margin could be coronal to CEJ (-)

bull Gingival margin could be level with CEJ (same)

bull Gingival margin could be apical to CEJ (+)

Measuring CAL when gingival margin is coronal to CEJ

1 Measure probe depth

2 Measure from gingival margin to CEJ

3 Subtract second measurement from overall probe depth

FYI-This is a color

coded probe w

markings at 36912

14

Measuring CAL when gingival margin is levelwith CEJ

bull Probe depth is Clinical attachment level

Measuring CAL when gingival margin is apical to CEJ

bull Measure probe depthbull Measure recessionbull Add recession to probe depth

Grading

Bone Loss

Stage 1

Coronal 13

lt 15

Coronal 13

Mid 13

Last 13

15 Normal bone Height

33 stage 2

Stage 3Extends to mid third of root amp beyondStage 4Extends to mid third of root amp beyond

Stage 1

stage 3 amp 4

Predicting Activity

bull BOP

ndash 50 of all bleeding sites will not break down

ndash 50 of all bleeding sites will breakdown

ndash Sites that do not bleed will not breakdown

ndash The absence of bleeding provides more information than whether bleeding exists

ndash Therefore when sites bleed we say it is active

bull Inflammation

bull Nutrient canals

bull Rough looking crestal bone vs smooth amp well demarcated may indicate activity

15

Predicting Activity

bull Nutrient canals

ndash Highly visible canals may indicate active or rapid destruction

ndash canals are thought to be engorged large blood vessels

Crestal Bone

Rough looking crestal boneSmoother more demarcated crestal bone

Planningbull Systematic Informed consent

bull Diagnosis prognosis options risks benefits

ndashPatients must have all the information

bull Studies indicate slight reductions in PD s gt 6 mm after full-mouth scaling and root planingperformed in one appointment vs over longer intervals

bull These protocols particularly effective in patients with aggressive periodontitis andor pts w systemic conditions

Eberhard J et al J Clin Periodontol 200835591ndash604 amp Fang et al J Periodont Res October 19 2015)

ImplementationTreatment

bull Goals are to eliminate infection and risk factorsbull The objective is to remove all clinically detectable

calculus without excessive root planingndash bacterial endotoxins are weakly adherent to the root

surface (Nakib 1982)

bull The term debridement vs root planing

ImplementationTreatment

bull Treat patientrsquos significant otherbull 40 of the time spouses have the

same microbiotabull Donrsquot kiss dogs amp cats- they may have

periobull Avoid gross scaling

bull risk of abscessbull educationbull more difficult to re-insert

instruments

16

Air Polishing with glycine

ndashGlycine has anti inflammatory ampimmune modulation effectsbull Glycine receptor gingival tissue

ndashPerpulsionndashFDA approval for lt5 mmndashRemoval biofilm amp stainndashPerio maintenance ndashImplantsndashDecontaminate prior to grafts

Host-Modulating Treatmentbull Treating periodontitis by trying to resolve

inflammation

bull Resolvins

ndash Omega 3 Fatty acids correlated with less bone loss

ndash may be due to their ability to generate mediators that fight inflammation and aid in inflammation resolution

bull Low-dose doxycycline 20 mg 2x daily

ndash Matrix metalloproteinase inhibitor is the only FDA-approved

ndash Reduction of PD amp CAL gain over 3 months to 9 monthsGolub LM et al Doxycycline i hibits neutrophil (PMN)-type matrix metalloproteinases in human adult periodontitis gingiva J Clin Periodontol 199522100ndash109 amp

Golub LM et al Adjunctive treatment with subantimicrobial doses of doxycycline effects on gingival fluid collagenase activity and attachment loss in adult periodontitis J Clin Periodontol 200128146ndash156

Host-Modulating Treatment

bull NSAIDsndash Reduces PGE 2 which can reduce bone loss

ndash Flurbiprofen and topical (ketorolac)

ndash Case controls demonstrate decrease risk

bull Bisphosphonates ndash Used for treating Pagetrsquos bone pain amp osteoporosis

ndash Alendronate sodium (Fosamax) risedronate (Actonel)

ndash Investigating for its ability to modulate the host

bull Used experimentally in animals to inhibit bone resorption amp bone mineral content amp to interfere w breakdown of collagen in the periodontium

ndash WARNING case reports of bone necrosis after extractions

bull questions scrtpl w pts on drug

Treatment

bull Statins have an anti-inflammatory and immune effects reducing levels of C-Reactive Protein MMP Tumor Necrosis Factor-α

ndash Statins reduce bone resorption by inhibiting osteoclast formation

ndash Some results show lower alveolar bone loss and reduction of clinical signs of inflammation

(meta anyalsis Estanislau etal J Clin Pharmacol 2014 Dec)

ndash Topical gels (simvastatin atorvastatin)

Treatment

bull Probioticsndash Improved biofilm index and probe depths (Shimauchi 2008)

bull Valtrexbull Photodynamic therapy

ndash Light-sensitive drug is applied then a light laser directly on the area treated with the drug

ndash When the light is combined with the drug phototoxic reactions are induced which destroy bacterial cells

ndash Shows short term benefits (Sgolastra 2012)bull Periowave

bull Emdogainndash Enamel matrix derivative for periodontal tissue regeneration in

infrabony defects amp used w SRP to enhance resultsbull Derived from developing pig teethbull Stimulate adherence attachment to cementum

Treatmentbull Topical antioxidants

ndash Antioxidant gel and rinse

ndash Periosciences ndash toothpaste rinse gel

ndash Topical coenzyme COQ10

bull Due to correlation w perio oxidative stress markers amp low level of natural occurring salivary antioxidants looking at polyphenolsantioxidants in the mouth locally delivered

ndash needs more research

bull Hyaluronic acid (HA) gel and mouth rinsendash hyaluronic acid plays a large role in the collagen building 02

hyaluronan gel topically amp subgingivally

ndash Studies have been done to evaluate on wound healing amp improving perio outcomes

ndash Further evidence is needed

5

Types of Periodontal diseasesGingival

Dental biofilm Induced Gingivitis Most commonbull Typically biofilm is proportionate

to the amount of inflammation

bull No bone loss no LOA

Types- New

bull Localized = BOPgt 10 amp lt30

bull Generalized plaque induced gingivitis gt 30 BOP

Microorganisms

bull Non-specific includes both Gram - amp Gram +

Treatment

bull self care deplaquingdebridementscaling

bull eliminate local contributory factors

Modifying Factors of Biofilm induced Gingivitis hormonalPregnancy Gingivitis

Etiologybull biofilm amp hormone changes

bull degree of inflammation parallels OH

ndash good OH can prevent pregnancy gingivitis

bull will exacerbate any previous periodontal disease

Pregnancy Gingivitis

Microorganism

bull Prevotella intermedia

Treatment

bull subsides after giving birth

bull exaggerated response can be prevented w excellent OH

bull frequent recalls Oral self care

bull Deplaquingdebridementscaling

Pyogenic Granuloma

Treatment

bull may resolve on own after debridement

bull may need surgical removal

6

Drug-influenced gingivitis

bull Gingival enlargement

ndashAnticonvulsants

bull Phenytoin

ndashCalcium channel blockers

bull Nifedipine 6-43

ndash Immunosuppressants

bull Cyclosporin 25

ndashAnabolic Androgenic Steroid

ndash Prostate cancer treatment

Gingival enlargement

bull Level of biofilm amp drug dosage accumulation can affect the severity of overgrowth

bull Consult w MD for drug substitution

bull Some cases of hypertrophic gingival tissue have been reported as Kaposirsquos sarcoma amp squamous cell carcinoma

Non-biofilm induced related to bull Specific bacteria

ndash Neissera gonorrhea treponema pallidum streptococci

bull Viralndash Herpes simplex 1 amp 2 varicella zoster papillmavirus

bull Fungal

bull Cultured for true diagnosis amp treat appropriately antibiotics antiviral amp or antifungal

bull Not common amp usually not known

Non-plaque induced gingival diseases of fungal origin

Candidosisformally Linear gingivitis

bull Generally fungalcandiasis

bull Linear amp very distinctive band of severe erythema on gingival margin

bull Disproportion of inflammatory intensity for the amount of biofilm present

Candidosis Treatment

ndash OHE consider chlorhexidine

ndash Does not respond well to improved OH or scaling

ndash Biofilm removal debridementscaling

ndash May need additional physician consult

Lichen Planus

Etiologybull Unknownbull Cell mediated Immune pathogenesis bull Systemic Diseases

ndash Diabetes hypertension hepatitis B amp C chronic graft-versus-host disease amp lupus

bull Medicationsndash antimalarial drugs antihypertensives amp non-steroidal anti

inflammatory (NSAIDS)

Signsbull Affects skin and mucous membranesbull Lesions may be mild to moderately painful amp burning

7

Lichen PlanusTypes

Reticular-plaque papular

Erosive Bullous Atrophic ulcerative

bull Erosive- gingival

ndash bulbous forms ulcerative amp painful

ndash red and raw

bull Reticular

ndash asymptomatic keratontic lines called stria

ndash lacy white lines

Lichen Planus

bull severity may relate to stressConsiderationsbull Higher risk for non- reticular types for malignant transformation

ndash LP pts have a 10 fold increased risk of developing squamous cell carcinoma

Treatmentbull Look for triggers allergies sensitivity bull Aloe Vera rinses amp gelbull Corticosteriods

ndash topical- fluocinonide dexamethadone dipropionate spray topical steroids may help- can cause candida

bull Periodic biopsies are necessary for areas that do not respond to treatment

bull Regular recalls

Inflammatory And Immune Conditions And Lesions

Hypersensitivity ReactionsAllergic gingivitis

Other names desquamative Plasma cell gingivitis idiopathic

gingivostomatitis atypical gingivostomatitis allergic gingivostomatitis hypersensitivity and plasmacytosis

Plasma cell gingivitis is an uncommon inflammatory condition usually affecting the anterior maxillary gingiva and of uncertain etiology While some authors have associated plasma cell gingivitis with a hypersensitivity response to antigens in various substances others have raised doubt whether plasma cell gingivitis is a distinct clinicopathologic entity

Allergic gingivitis

Etiology

bull auto immune

bull Allergy

bull Signs

bull sloughing of the epithelium which leaves raw red surface

bull The edematous tissue often extends to the mucogingival junction with a deep red appearance

Allergic gingivitis

Symptoms

painful

Treatment

topicalsystemic steroid therapy

remove etiological factor if possible

-spices toothpaste flavorings peppermint wintergreen menthol cinnamon preservatives mints gum candy

Possible Offending Products to Gingival Tissue

bull Commercially available toothpaste (tartar-control additives and flavoring agents [possibly

cinnamon] that mask the tartar control additives)

bull Mouth rinses

bull Cinnamon aldehyde

bull Sodium benzoate and methyl paraben

bull Food substances such as wheat dairy chocolate eggs peanuts and monosodium glutamate

bull Red wine (sulfides and tartrazine additives)

bull Preservatives

bull Essential oils such as peppermint spearmint and wintergreen found in gums candy and mouth rinses

bull Dark cola drinks

bull Strong spices

bull Chili peppers

bull Clove

bull Cardamom Burkhart NW Toothpaste allergy RDH 2007 27(6) 86107-108

8

Types of Periodontal diseasesPeriodontitis

Periodontitis

bull Chronic

bull Disease will progress unless treated

bull Typical age of onset is 35 yrs of age

bull Bone loss

- slow

ndash rate may vary depending on the modifiers

bull Severity is determined by bone loss and LOA

bull Can become inactive (stable) active (recurrent) refractory

Periodontitis

Microorganisms

bull Gram ndash

bull P gingivalis

bull P intermedia

bull Tannerella forsythensis (B forsythus)

Treatmentbull Self carebull Scrt

pldebridement bull Depending type of

defects amp severity ndashpossibly surgery

amp perio referral

Not includedAggressive

This category includes formally called diseases

bull Juvenile

bullEarly onset

bullPrepubertal

bullRapidly progressive

Localized Aggressive Localized Juvenile Periodontitis

bull More significant bone loss surrounding 1st molars amp incisors ndash typically angular type bone loss amp mirror image bilaterally

bull Rate of bone loss is rapid

bull OH can be good

9

Localized Aggressive LJP

bull Defects in PMNs or macrophagesbull respond slowly

bull chemotaxis defect

bull impaired phagocytosis

bull Onset typically during teenage years

bull Hereditary componentgenetic

bull more common in females amp blacks

Localized Aggressive Localized Juvenile Periodontitis

Microorganisms

Aggregatibacter Actinomycetemcomitans

P gingivalis

Treatmentbull scrt pldebridement but typically unresponsivebull Antibiotics to be administered with or just after debridement

ndash combo metronidazole wamoxicillin or metro w augmentinndash Clindamycin Azithromycin

bull possibly surgerybull prompt perio referralbull suggest family be evaluated (siblings children etc)bull sea salt being used as prevention of AA amp Tx

Generalized Aggressive Formally Generalized Juvenile Periodontitis

bull More rare than LJPbull Can affect most teeth but more severe on 1st molar

amp incisorsndash must involve gt 3 other teeth

bull Onset usually under 30 years oldbull Associated with neutrophil disorderbull Generally significant inflammation amp heavy

plaquecalculusbull Children w Gagp seem more prone to ear skin amp

upper respiratory tract infections

Generalized Aggressive Generalized Juvenile Periodontitis

MicroorganismsA actinomycetemcomitansPorphyromas gingivalis Eikenella corrodens

Treatmentscrt pldebridementantibiotics

ndash combo metronidazole wamoxicillin or metro w augmentin

possibly surgeryprompt perio referralbull Suggest family be evaluated (siblings children etc)

Periodontitis as a Manifestation of Systemic Disease

bull Systemic diseases that severely impair host response should be considered a periodontal manifestation of the systemic disease amp primary diagnosis should be the systemic disease according to International Statistical Classification of Disease (ICD)

ndash Excludes diabetes

bull Hematologicacquired neutropenias leukemias

bull Genetic disorderfamilial neutopenias down syndrome leukocyte adhesion deficiency syndrome papillon-lefreve syndrome chediak-higshi histocytosis syndromes Glycogen storage disease genetic agranulcytosis cohen syndrome Ehlers-Danlossyndrome hypophosphatsis

Necrotizing Periodontal Diseases NG amp NP

Etiologybull Unknown

bull Risk factorsexcessive stress lack of rest poor oral hygiene smoking HIV poor immune response

bull More common in underdeveloped countries

bull Less common now in the US

bull Susceptible to reoccurrence

Symptomsbull SUDDEN onset of burning

mouth inability to eat metallic taste excessive salvia amp PAINFUL

Microorganisms

spirochetes

Prevotella intermedia

Fusiform bacillus

Fusobacterium nucleatum

Ulcerative has been eliminated

10

NGSigns

bull 3 key features papilla necrosis bleeding and pain

bull Punched out papillae cratered like depressions covered by a white necrotic pseudomembrane(collection of PMNS) bright red margins spontenousbleeding may occur

bull Distinctive foul odor

bull May have systemic involvement

ndash lymphadenopathy fever

bull May be a systemic

manifestations

ndash HIV

NG Treatmentbull Advise to avoid smoking amp etoh get rest and proper nutrition (rec

multi vitamin soft nutritious diet)+ self care

bull Rinses with frac12 glass warm water amp 1 tbsp hydrogen peroxide w half glass or chlorhexidine

bull Pain medication

bull Antibiotics can be used especially if systemic involvement

ndash metronidazole tetracycline pen vk

bull Initial supragingival debridement then complete

bull Consider complete laboratory work ndashup amp medical consult

ndash (NUG may be the first sign of HIV)

bull May progress to NUP

bull Follow ndashup phone call or visit within 24 hrsndash Re-eval surgery referral debridement wlocal= recurrent nature

NP

bull Progression of NUG

bull May be related to systemic disease

bull HIV nutrition deficiency

bull NUG superimposed on a previous periodontal disease

NP

Signs amp symptoms

bull Intensely red necrosis white pseudomembrane

bull Painful odor punched-out papillae

bull Reports of deep aching pain or jaw pain

bull Extensive bone loss

bull Spontaneous bleeding

Treatment

bull Same as NUG

Peridex culture antibiotics (metronidazole) or antifungals

Refractory

bull Not included in the new guidelines

bull Unresponsive to treatmentndash surgery frequent scrt pl antibiotics

bull Can be localized or generalized

bull Usually smokers

bull Treatment clindamycin metronidazole metriwamoxicillin or Augmentin

Periodontal Phenotype (Biotypes)

bull The term describes the thickness of the gingiva in a bucco-lingual dimension

bull 3 types

Thick flat

Thick scalloped

Thin

bull Thick (85) is more prevalent than thin (15)

11

Thin Gingival Phenotype

bull Triangle shaped teeth vs square

bull Thin tissue

bull Susceptible to recession

bull Dehiscence present

bull Instrumentation must be done

Carefully due to thin biotype

bull Reacts to insult by recession

Thick amp Flat Gingival Phenotype

bull Square shaped

bull Thick tissue

bull Susceptible to pocketing

bull Reacts to insult by pocketing

Thick Scalloped

bull Thick fibrotic gingiva

bull Slender teeth

bull Narrow zone of KT

bull Gingival scalloping

Recession

Type 1 Type 2

Interproximal CEJ

is clinically not

detectable

The amount of

interproximal

attachment loss

is lt to buccal

Type 3

The amount of

interproximal

attachment loss

is gt

buccal

attachment loss

Implants

bull Treat perio prior to implantsbull It takes 2 weeks for the implants to

become colonized by the surrounding teeth

bull No horizontal fibers like a tooth so infection goes straight to bone and perio happens very quickly

bull This perimucosal seal is delicate ndashBe careful during instrumentation

12

Implants

bull The implant coatingsrough surfaces may create more risk for implantitis but better for osteointergration

ndash The calculus is more embedded on these surfaces than the previous smoother surfaces

Stages of Peri-implant DiseasePeri-implant mucositis

bull Reversible inflammation of the soft tissues

bull Occurs in about 50 of implants placed within 9 - 14 years

Peri-implantitis

bull Bone Loss

bull Occurs in 12- 47 of implants 5 years after placement

bull Risk factors-Hx of severe perio poor self care amp lack of maintenance care

bull Cement Implantitis

bull Some evidence linking cement and titanium particles bio corrosion

Peri-implantitis

Microorganisms

bull Gram - Fusobacterium species Prevotella intermedia

bull Implant failure is usually due to the microbial challenge occlusal load or excessive cementndash Cement has been found in the tissues

bull Failure is evidenced by gt2 mm MOBILITY

bull Bone loss buccal and lingual results in dehiscence

Cement Implantitis

New AAP Case definitionPeri-implantitis

bull BOP

bull Probing depth gt 6 mm

bull Bone levels gt 3 mm apical of the most coronal portion of the intraosseous part of the implant

Caton J Armitage G Berglundh T Et al A new classification scheme for periodontal and peri‐implant diseases and conditions ndash Introduction and key changes from the 1999 classification Journal of Periodontology 89 S1 (S1-S8) (2018)

Failing Criteria

bull Ailing (Peri-implant mucositis) inflammation present but no mobility

ndash bone appears normal or there may be an incipient lesion

bull Failing Peri-implantitis without mobility

ndash Inflammation has progressed to the bone as evidenced by radiographic lesion

bull Failed Peri-implantitis with mobility

ndash Implant has pronounced bone loss

Probing amp BOP

bull Metal probes on prosthetic part of the crown is fine

bull Some are concerned with metal probes on the threads

bull Must probe implants

bull Probe depths are generally deeper than natural tooth

bull BOP is not normal

threads

13

Treatment

bull Be aggressive amp prevent bone loss because very difficult to treat once initiated

bull Treatment

ndash Debride thoroughly

ndash Chlorhexidine

ndash Systemic antibiotics

ndash Bone grafts

ndash Arestin- local drug delivery

ndash Air flow polishing with glycine

Diagnosis Severity

bull Determining severity is based on CAL and bone loss

bull Clinical attachment level (CAL)

ndashdistance from the junctional epithelium to the CEJ

bull Probe depths alone are lacking because it does not take in account the gingival margin

ndashusing probe depths alone can result in over estimating or underestimating disease

Three possible relationships for gingival margin and CEJ

bull Gingival margin could be coronal to CEJ

bull Gingival margin could be level with CEJ

bull Gingival margin could be apical to CEJ

GM

bull Where should the GM be normallyndash 1-2 mm coronal to the CEJ

bull What is the pattern of CEJs interproximallyacross the mouthndash More Flat on the Posteriors

ndash More Curvature on the Anteriors

ndash For interproximal space look at the papillae does it fill the embrasure space

ndash A normal GM on the anteriors could be +1mm

ndash A normal GM on the posteriors could be +2 mm

Clinical attachment level

Depends on position of the gingival margin and CEJ

bull Gingival margin could be coronal to CEJ (-)

bull Gingival margin could be level with CEJ (same)

bull Gingival margin could be apical to CEJ (+)

Measuring CAL when gingival margin is coronal to CEJ

1 Measure probe depth

2 Measure from gingival margin to CEJ

3 Subtract second measurement from overall probe depth

FYI-This is a color

coded probe w

markings at 36912

14

Measuring CAL when gingival margin is levelwith CEJ

bull Probe depth is Clinical attachment level

Measuring CAL when gingival margin is apical to CEJ

bull Measure probe depthbull Measure recessionbull Add recession to probe depth

Grading

Bone Loss

Stage 1

Coronal 13

lt 15

Coronal 13

Mid 13

Last 13

15 Normal bone Height

33 stage 2

Stage 3Extends to mid third of root amp beyondStage 4Extends to mid third of root amp beyond

Stage 1

stage 3 amp 4

Predicting Activity

bull BOP

ndash 50 of all bleeding sites will not break down

ndash 50 of all bleeding sites will breakdown

ndash Sites that do not bleed will not breakdown

ndash The absence of bleeding provides more information than whether bleeding exists

ndash Therefore when sites bleed we say it is active

bull Inflammation

bull Nutrient canals

bull Rough looking crestal bone vs smooth amp well demarcated may indicate activity

15

Predicting Activity

bull Nutrient canals

ndash Highly visible canals may indicate active or rapid destruction

ndash canals are thought to be engorged large blood vessels

Crestal Bone

Rough looking crestal boneSmoother more demarcated crestal bone

Planningbull Systematic Informed consent

bull Diagnosis prognosis options risks benefits

ndashPatients must have all the information

bull Studies indicate slight reductions in PD s gt 6 mm after full-mouth scaling and root planingperformed in one appointment vs over longer intervals

bull These protocols particularly effective in patients with aggressive periodontitis andor pts w systemic conditions

Eberhard J et al J Clin Periodontol 200835591ndash604 amp Fang et al J Periodont Res October 19 2015)

ImplementationTreatment

bull Goals are to eliminate infection and risk factorsbull The objective is to remove all clinically detectable

calculus without excessive root planingndash bacterial endotoxins are weakly adherent to the root

surface (Nakib 1982)

bull The term debridement vs root planing

ImplementationTreatment

bull Treat patientrsquos significant otherbull 40 of the time spouses have the

same microbiotabull Donrsquot kiss dogs amp cats- they may have

periobull Avoid gross scaling

bull risk of abscessbull educationbull more difficult to re-insert

instruments

16

Air Polishing with glycine

ndashGlycine has anti inflammatory ampimmune modulation effectsbull Glycine receptor gingival tissue

ndashPerpulsionndashFDA approval for lt5 mmndashRemoval biofilm amp stainndashPerio maintenance ndashImplantsndashDecontaminate prior to grafts

Host-Modulating Treatmentbull Treating periodontitis by trying to resolve

inflammation

bull Resolvins

ndash Omega 3 Fatty acids correlated with less bone loss

ndash may be due to their ability to generate mediators that fight inflammation and aid in inflammation resolution

bull Low-dose doxycycline 20 mg 2x daily

ndash Matrix metalloproteinase inhibitor is the only FDA-approved

ndash Reduction of PD amp CAL gain over 3 months to 9 monthsGolub LM et al Doxycycline i hibits neutrophil (PMN)-type matrix metalloproteinases in human adult periodontitis gingiva J Clin Periodontol 199522100ndash109 amp

Golub LM et al Adjunctive treatment with subantimicrobial doses of doxycycline effects on gingival fluid collagenase activity and attachment loss in adult periodontitis J Clin Periodontol 200128146ndash156

Host-Modulating Treatment

bull NSAIDsndash Reduces PGE 2 which can reduce bone loss

ndash Flurbiprofen and topical (ketorolac)

ndash Case controls demonstrate decrease risk

bull Bisphosphonates ndash Used for treating Pagetrsquos bone pain amp osteoporosis

ndash Alendronate sodium (Fosamax) risedronate (Actonel)

ndash Investigating for its ability to modulate the host

bull Used experimentally in animals to inhibit bone resorption amp bone mineral content amp to interfere w breakdown of collagen in the periodontium

ndash WARNING case reports of bone necrosis after extractions

bull questions scrtpl w pts on drug

Treatment

bull Statins have an anti-inflammatory and immune effects reducing levels of C-Reactive Protein MMP Tumor Necrosis Factor-α

ndash Statins reduce bone resorption by inhibiting osteoclast formation

ndash Some results show lower alveolar bone loss and reduction of clinical signs of inflammation

(meta anyalsis Estanislau etal J Clin Pharmacol 2014 Dec)

ndash Topical gels (simvastatin atorvastatin)

Treatment

bull Probioticsndash Improved biofilm index and probe depths (Shimauchi 2008)

bull Valtrexbull Photodynamic therapy

ndash Light-sensitive drug is applied then a light laser directly on the area treated with the drug

ndash When the light is combined with the drug phototoxic reactions are induced which destroy bacterial cells

ndash Shows short term benefits (Sgolastra 2012)bull Periowave

bull Emdogainndash Enamel matrix derivative for periodontal tissue regeneration in

infrabony defects amp used w SRP to enhance resultsbull Derived from developing pig teethbull Stimulate adherence attachment to cementum

Treatmentbull Topical antioxidants

ndash Antioxidant gel and rinse

ndash Periosciences ndash toothpaste rinse gel

ndash Topical coenzyme COQ10

bull Due to correlation w perio oxidative stress markers amp low level of natural occurring salivary antioxidants looking at polyphenolsantioxidants in the mouth locally delivered

ndash needs more research

bull Hyaluronic acid (HA) gel and mouth rinsendash hyaluronic acid plays a large role in the collagen building 02

hyaluronan gel topically amp subgingivally

ndash Studies have been done to evaluate on wound healing amp improving perio outcomes

ndash Further evidence is needed

6

Drug-influenced gingivitis

bull Gingival enlargement

ndashAnticonvulsants

bull Phenytoin

ndashCalcium channel blockers

bull Nifedipine 6-43

ndash Immunosuppressants

bull Cyclosporin 25

ndashAnabolic Androgenic Steroid

ndash Prostate cancer treatment

Gingival enlargement

bull Level of biofilm amp drug dosage accumulation can affect the severity of overgrowth

bull Consult w MD for drug substitution

bull Some cases of hypertrophic gingival tissue have been reported as Kaposirsquos sarcoma amp squamous cell carcinoma

Non-biofilm induced related to bull Specific bacteria

ndash Neissera gonorrhea treponema pallidum streptococci

bull Viralndash Herpes simplex 1 amp 2 varicella zoster papillmavirus

bull Fungal

bull Cultured for true diagnosis amp treat appropriately antibiotics antiviral amp or antifungal

bull Not common amp usually not known

Non-plaque induced gingival diseases of fungal origin

Candidosisformally Linear gingivitis

bull Generally fungalcandiasis

bull Linear amp very distinctive band of severe erythema on gingival margin

bull Disproportion of inflammatory intensity for the amount of biofilm present

Candidosis Treatment

ndash OHE consider chlorhexidine

ndash Does not respond well to improved OH or scaling

ndash Biofilm removal debridementscaling

ndash May need additional physician consult

Lichen Planus

Etiologybull Unknownbull Cell mediated Immune pathogenesis bull Systemic Diseases

ndash Diabetes hypertension hepatitis B amp C chronic graft-versus-host disease amp lupus

bull Medicationsndash antimalarial drugs antihypertensives amp non-steroidal anti

inflammatory (NSAIDS)

Signsbull Affects skin and mucous membranesbull Lesions may be mild to moderately painful amp burning

7

Lichen PlanusTypes

Reticular-plaque papular

Erosive Bullous Atrophic ulcerative

bull Erosive- gingival

ndash bulbous forms ulcerative amp painful

ndash red and raw

bull Reticular

ndash asymptomatic keratontic lines called stria

ndash lacy white lines

Lichen Planus

bull severity may relate to stressConsiderationsbull Higher risk for non- reticular types for malignant transformation

ndash LP pts have a 10 fold increased risk of developing squamous cell carcinoma

Treatmentbull Look for triggers allergies sensitivity bull Aloe Vera rinses amp gelbull Corticosteriods

ndash topical- fluocinonide dexamethadone dipropionate spray topical steroids may help- can cause candida

bull Periodic biopsies are necessary for areas that do not respond to treatment

bull Regular recalls

Inflammatory And Immune Conditions And Lesions

Hypersensitivity ReactionsAllergic gingivitis

Other names desquamative Plasma cell gingivitis idiopathic

gingivostomatitis atypical gingivostomatitis allergic gingivostomatitis hypersensitivity and plasmacytosis

Plasma cell gingivitis is an uncommon inflammatory condition usually affecting the anterior maxillary gingiva and of uncertain etiology While some authors have associated plasma cell gingivitis with a hypersensitivity response to antigens in various substances others have raised doubt whether plasma cell gingivitis is a distinct clinicopathologic entity

Allergic gingivitis

Etiology

bull auto immune

bull Allergy

bull Signs

bull sloughing of the epithelium which leaves raw red surface

bull The edematous tissue often extends to the mucogingival junction with a deep red appearance

Allergic gingivitis

Symptoms

painful

Treatment

topicalsystemic steroid therapy

remove etiological factor if possible

-spices toothpaste flavorings peppermint wintergreen menthol cinnamon preservatives mints gum candy

Possible Offending Products to Gingival Tissue

bull Commercially available toothpaste (tartar-control additives and flavoring agents [possibly

cinnamon] that mask the tartar control additives)

bull Mouth rinses

bull Cinnamon aldehyde

bull Sodium benzoate and methyl paraben

bull Food substances such as wheat dairy chocolate eggs peanuts and monosodium glutamate

bull Red wine (sulfides and tartrazine additives)

bull Preservatives

bull Essential oils such as peppermint spearmint and wintergreen found in gums candy and mouth rinses

bull Dark cola drinks

bull Strong spices

bull Chili peppers

bull Clove

bull Cardamom Burkhart NW Toothpaste allergy RDH 2007 27(6) 86107-108

8

Types of Periodontal diseasesPeriodontitis

Periodontitis

bull Chronic

bull Disease will progress unless treated

bull Typical age of onset is 35 yrs of age

bull Bone loss

- slow

ndash rate may vary depending on the modifiers

bull Severity is determined by bone loss and LOA

bull Can become inactive (stable) active (recurrent) refractory

Periodontitis

Microorganisms

bull Gram ndash

bull P gingivalis

bull P intermedia

bull Tannerella forsythensis (B forsythus)

Treatmentbull Self carebull Scrt

pldebridement bull Depending type of

defects amp severity ndashpossibly surgery

amp perio referral

Not includedAggressive

This category includes formally called diseases

bull Juvenile

bullEarly onset

bullPrepubertal

bullRapidly progressive

Localized Aggressive Localized Juvenile Periodontitis

bull More significant bone loss surrounding 1st molars amp incisors ndash typically angular type bone loss amp mirror image bilaterally

bull Rate of bone loss is rapid

bull OH can be good

9

Localized Aggressive LJP

bull Defects in PMNs or macrophagesbull respond slowly

bull chemotaxis defect

bull impaired phagocytosis

bull Onset typically during teenage years

bull Hereditary componentgenetic

bull more common in females amp blacks

Localized Aggressive Localized Juvenile Periodontitis

Microorganisms

Aggregatibacter Actinomycetemcomitans

P gingivalis

Treatmentbull scrt pldebridement but typically unresponsivebull Antibiotics to be administered with or just after debridement

ndash combo metronidazole wamoxicillin or metro w augmentinndash Clindamycin Azithromycin

bull possibly surgerybull prompt perio referralbull suggest family be evaluated (siblings children etc)bull sea salt being used as prevention of AA amp Tx

Generalized Aggressive Formally Generalized Juvenile Periodontitis

bull More rare than LJPbull Can affect most teeth but more severe on 1st molar

amp incisorsndash must involve gt 3 other teeth

bull Onset usually under 30 years oldbull Associated with neutrophil disorderbull Generally significant inflammation amp heavy

plaquecalculusbull Children w Gagp seem more prone to ear skin amp

upper respiratory tract infections

Generalized Aggressive Generalized Juvenile Periodontitis

MicroorganismsA actinomycetemcomitansPorphyromas gingivalis Eikenella corrodens

Treatmentscrt pldebridementantibiotics

ndash combo metronidazole wamoxicillin or metro w augmentin

possibly surgeryprompt perio referralbull Suggest family be evaluated (siblings children etc)

Periodontitis as a Manifestation of Systemic Disease

bull Systemic diseases that severely impair host response should be considered a periodontal manifestation of the systemic disease amp primary diagnosis should be the systemic disease according to International Statistical Classification of Disease (ICD)

ndash Excludes diabetes

bull Hematologicacquired neutropenias leukemias

bull Genetic disorderfamilial neutopenias down syndrome leukocyte adhesion deficiency syndrome papillon-lefreve syndrome chediak-higshi histocytosis syndromes Glycogen storage disease genetic agranulcytosis cohen syndrome Ehlers-Danlossyndrome hypophosphatsis

Necrotizing Periodontal Diseases NG amp NP

Etiologybull Unknown

bull Risk factorsexcessive stress lack of rest poor oral hygiene smoking HIV poor immune response

bull More common in underdeveloped countries

bull Less common now in the US

bull Susceptible to reoccurrence

Symptomsbull SUDDEN onset of burning

mouth inability to eat metallic taste excessive salvia amp PAINFUL

Microorganisms

spirochetes

Prevotella intermedia

Fusiform bacillus

Fusobacterium nucleatum

Ulcerative has been eliminated

10

NGSigns

bull 3 key features papilla necrosis bleeding and pain

bull Punched out papillae cratered like depressions covered by a white necrotic pseudomembrane(collection of PMNS) bright red margins spontenousbleeding may occur

bull Distinctive foul odor

bull May have systemic involvement

ndash lymphadenopathy fever

bull May be a systemic

manifestations

ndash HIV

NG Treatmentbull Advise to avoid smoking amp etoh get rest and proper nutrition (rec

multi vitamin soft nutritious diet)+ self care

bull Rinses with frac12 glass warm water amp 1 tbsp hydrogen peroxide w half glass or chlorhexidine

bull Pain medication

bull Antibiotics can be used especially if systemic involvement

ndash metronidazole tetracycline pen vk

bull Initial supragingival debridement then complete

bull Consider complete laboratory work ndashup amp medical consult

ndash (NUG may be the first sign of HIV)

bull May progress to NUP

bull Follow ndashup phone call or visit within 24 hrsndash Re-eval surgery referral debridement wlocal= recurrent nature

NP

bull Progression of NUG

bull May be related to systemic disease

bull HIV nutrition deficiency

bull NUG superimposed on a previous periodontal disease

NP

Signs amp symptoms

bull Intensely red necrosis white pseudomembrane

bull Painful odor punched-out papillae

bull Reports of deep aching pain or jaw pain

bull Extensive bone loss

bull Spontaneous bleeding

Treatment

bull Same as NUG

Peridex culture antibiotics (metronidazole) or antifungals

Refractory

bull Not included in the new guidelines

bull Unresponsive to treatmentndash surgery frequent scrt pl antibiotics

bull Can be localized or generalized

bull Usually smokers

bull Treatment clindamycin metronidazole metriwamoxicillin or Augmentin

Periodontal Phenotype (Biotypes)

bull The term describes the thickness of the gingiva in a bucco-lingual dimension

bull 3 types

Thick flat

Thick scalloped

Thin

bull Thick (85) is more prevalent than thin (15)

11

Thin Gingival Phenotype

bull Triangle shaped teeth vs square

bull Thin tissue

bull Susceptible to recession

bull Dehiscence present

bull Instrumentation must be done

Carefully due to thin biotype

bull Reacts to insult by recession

Thick amp Flat Gingival Phenotype

bull Square shaped

bull Thick tissue

bull Susceptible to pocketing

bull Reacts to insult by pocketing

Thick Scalloped

bull Thick fibrotic gingiva

bull Slender teeth

bull Narrow zone of KT

bull Gingival scalloping

Recession

Type 1 Type 2

Interproximal CEJ

is clinically not

detectable

The amount of

interproximal

attachment loss

is lt to buccal

Type 3

The amount of

interproximal

attachment loss

is gt

buccal

attachment loss

Implants

bull Treat perio prior to implantsbull It takes 2 weeks for the implants to

become colonized by the surrounding teeth

bull No horizontal fibers like a tooth so infection goes straight to bone and perio happens very quickly

bull This perimucosal seal is delicate ndashBe careful during instrumentation

12

Implants

bull The implant coatingsrough surfaces may create more risk for implantitis but better for osteointergration

ndash The calculus is more embedded on these surfaces than the previous smoother surfaces

Stages of Peri-implant DiseasePeri-implant mucositis

bull Reversible inflammation of the soft tissues

bull Occurs in about 50 of implants placed within 9 - 14 years

Peri-implantitis

bull Bone Loss

bull Occurs in 12- 47 of implants 5 years after placement

bull Risk factors-Hx of severe perio poor self care amp lack of maintenance care

bull Cement Implantitis

bull Some evidence linking cement and titanium particles bio corrosion

Peri-implantitis

Microorganisms

bull Gram - Fusobacterium species Prevotella intermedia

bull Implant failure is usually due to the microbial challenge occlusal load or excessive cementndash Cement has been found in the tissues

bull Failure is evidenced by gt2 mm MOBILITY

bull Bone loss buccal and lingual results in dehiscence

Cement Implantitis

New AAP Case definitionPeri-implantitis

bull BOP

bull Probing depth gt 6 mm

bull Bone levels gt 3 mm apical of the most coronal portion of the intraosseous part of the implant

Caton J Armitage G Berglundh T Et al A new classification scheme for periodontal and peri‐implant diseases and conditions ndash Introduction and key changes from the 1999 classification Journal of Periodontology 89 S1 (S1-S8) (2018)

Failing Criteria

bull Ailing (Peri-implant mucositis) inflammation present but no mobility

ndash bone appears normal or there may be an incipient lesion

bull Failing Peri-implantitis without mobility

ndash Inflammation has progressed to the bone as evidenced by radiographic lesion

bull Failed Peri-implantitis with mobility

ndash Implant has pronounced bone loss

Probing amp BOP

bull Metal probes on prosthetic part of the crown is fine

bull Some are concerned with metal probes on the threads

bull Must probe implants

bull Probe depths are generally deeper than natural tooth

bull BOP is not normal

threads

13

Treatment

bull Be aggressive amp prevent bone loss because very difficult to treat once initiated

bull Treatment

ndash Debride thoroughly

ndash Chlorhexidine

ndash Systemic antibiotics

ndash Bone grafts

ndash Arestin- local drug delivery

ndash Air flow polishing with glycine

Diagnosis Severity

bull Determining severity is based on CAL and bone loss

bull Clinical attachment level (CAL)

ndashdistance from the junctional epithelium to the CEJ

bull Probe depths alone are lacking because it does not take in account the gingival margin

ndashusing probe depths alone can result in over estimating or underestimating disease

Three possible relationships for gingival margin and CEJ

bull Gingival margin could be coronal to CEJ

bull Gingival margin could be level with CEJ

bull Gingival margin could be apical to CEJ

GM

bull Where should the GM be normallyndash 1-2 mm coronal to the CEJ

bull What is the pattern of CEJs interproximallyacross the mouthndash More Flat on the Posteriors

ndash More Curvature on the Anteriors

ndash For interproximal space look at the papillae does it fill the embrasure space

ndash A normal GM on the anteriors could be +1mm

ndash A normal GM on the posteriors could be +2 mm

Clinical attachment level

Depends on position of the gingival margin and CEJ

bull Gingival margin could be coronal to CEJ (-)

bull Gingival margin could be level with CEJ (same)

bull Gingival margin could be apical to CEJ (+)

Measuring CAL when gingival margin is coronal to CEJ

1 Measure probe depth

2 Measure from gingival margin to CEJ

3 Subtract second measurement from overall probe depth

FYI-This is a color

coded probe w

markings at 36912

14

Measuring CAL when gingival margin is levelwith CEJ

bull Probe depth is Clinical attachment level

Measuring CAL when gingival margin is apical to CEJ

bull Measure probe depthbull Measure recessionbull Add recession to probe depth

Grading

Bone Loss

Stage 1

Coronal 13

lt 15

Coronal 13

Mid 13

Last 13

15 Normal bone Height

33 stage 2

Stage 3Extends to mid third of root amp beyondStage 4Extends to mid third of root amp beyond

Stage 1

stage 3 amp 4

Predicting Activity

bull BOP

ndash 50 of all bleeding sites will not break down

ndash 50 of all bleeding sites will breakdown

ndash Sites that do not bleed will not breakdown

ndash The absence of bleeding provides more information than whether bleeding exists

ndash Therefore when sites bleed we say it is active

bull Inflammation

bull Nutrient canals

bull Rough looking crestal bone vs smooth amp well demarcated may indicate activity

15

Predicting Activity

bull Nutrient canals

ndash Highly visible canals may indicate active or rapid destruction

ndash canals are thought to be engorged large blood vessels

Crestal Bone

Rough looking crestal boneSmoother more demarcated crestal bone

Planningbull Systematic Informed consent

bull Diagnosis prognosis options risks benefits

ndashPatients must have all the information

bull Studies indicate slight reductions in PD s gt 6 mm after full-mouth scaling and root planingperformed in one appointment vs over longer intervals

bull These protocols particularly effective in patients with aggressive periodontitis andor pts w systemic conditions

Eberhard J et al J Clin Periodontol 200835591ndash604 amp Fang et al J Periodont Res October 19 2015)

ImplementationTreatment

bull Goals are to eliminate infection and risk factorsbull The objective is to remove all clinically detectable

calculus without excessive root planingndash bacterial endotoxins are weakly adherent to the root

surface (Nakib 1982)

bull The term debridement vs root planing

ImplementationTreatment

bull Treat patientrsquos significant otherbull 40 of the time spouses have the

same microbiotabull Donrsquot kiss dogs amp cats- they may have

periobull Avoid gross scaling

bull risk of abscessbull educationbull more difficult to re-insert

instruments

16

Air Polishing with glycine

ndashGlycine has anti inflammatory ampimmune modulation effectsbull Glycine receptor gingival tissue

ndashPerpulsionndashFDA approval for lt5 mmndashRemoval biofilm amp stainndashPerio maintenance ndashImplantsndashDecontaminate prior to grafts

Host-Modulating Treatmentbull Treating periodontitis by trying to resolve

inflammation

bull Resolvins

ndash Omega 3 Fatty acids correlated with less bone loss

ndash may be due to their ability to generate mediators that fight inflammation and aid in inflammation resolution

bull Low-dose doxycycline 20 mg 2x daily

ndash Matrix metalloproteinase inhibitor is the only FDA-approved

ndash Reduction of PD amp CAL gain over 3 months to 9 monthsGolub LM et al Doxycycline i hibits neutrophil (PMN)-type matrix metalloproteinases in human adult periodontitis gingiva J Clin Periodontol 199522100ndash109 amp

Golub LM et al Adjunctive treatment with subantimicrobial doses of doxycycline effects on gingival fluid collagenase activity and attachment loss in adult periodontitis J Clin Periodontol 200128146ndash156

Host-Modulating Treatment

bull NSAIDsndash Reduces PGE 2 which can reduce bone loss

ndash Flurbiprofen and topical (ketorolac)

ndash Case controls demonstrate decrease risk

bull Bisphosphonates ndash Used for treating Pagetrsquos bone pain amp osteoporosis

ndash Alendronate sodium (Fosamax) risedronate (Actonel)

ndash Investigating for its ability to modulate the host

bull Used experimentally in animals to inhibit bone resorption amp bone mineral content amp to interfere w breakdown of collagen in the periodontium

ndash WARNING case reports of bone necrosis after extractions

bull questions scrtpl w pts on drug

Treatment

bull Statins have an anti-inflammatory and immune effects reducing levels of C-Reactive Protein MMP Tumor Necrosis Factor-α

ndash Statins reduce bone resorption by inhibiting osteoclast formation

ndash Some results show lower alveolar bone loss and reduction of clinical signs of inflammation

(meta anyalsis Estanislau etal J Clin Pharmacol 2014 Dec)

ndash Topical gels (simvastatin atorvastatin)

Treatment

bull Probioticsndash Improved biofilm index and probe depths (Shimauchi 2008)

bull Valtrexbull Photodynamic therapy

ndash Light-sensitive drug is applied then a light laser directly on the area treated with the drug

ndash When the light is combined with the drug phototoxic reactions are induced which destroy bacterial cells

ndash Shows short term benefits (Sgolastra 2012)bull Periowave

bull Emdogainndash Enamel matrix derivative for periodontal tissue regeneration in

infrabony defects amp used w SRP to enhance resultsbull Derived from developing pig teethbull Stimulate adherence attachment to cementum

Treatmentbull Topical antioxidants

ndash Antioxidant gel and rinse

ndash Periosciences ndash toothpaste rinse gel

ndash Topical coenzyme COQ10

bull Due to correlation w perio oxidative stress markers amp low level of natural occurring salivary antioxidants looking at polyphenolsantioxidants in the mouth locally delivered

ndash needs more research

bull Hyaluronic acid (HA) gel and mouth rinsendash hyaluronic acid plays a large role in the collagen building 02

hyaluronan gel topically amp subgingivally

ndash Studies have been done to evaluate on wound healing amp improving perio outcomes

ndash Further evidence is needed

7

Lichen PlanusTypes

Reticular-plaque papular

Erosive Bullous Atrophic ulcerative

bull Erosive- gingival

ndash bulbous forms ulcerative amp painful

ndash red and raw

bull Reticular

ndash asymptomatic keratontic lines called stria

ndash lacy white lines

Lichen Planus

bull severity may relate to stressConsiderationsbull Higher risk for non- reticular types for malignant transformation

ndash LP pts have a 10 fold increased risk of developing squamous cell carcinoma

Treatmentbull Look for triggers allergies sensitivity bull Aloe Vera rinses amp gelbull Corticosteriods

ndash topical- fluocinonide dexamethadone dipropionate spray topical steroids may help- can cause candida

bull Periodic biopsies are necessary for areas that do not respond to treatment

bull Regular recalls

Inflammatory And Immune Conditions And Lesions

Hypersensitivity ReactionsAllergic gingivitis

Other names desquamative Plasma cell gingivitis idiopathic

gingivostomatitis atypical gingivostomatitis allergic gingivostomatitis hypersensitivity and plasmacytosis

Plasma cell gingivitis is an uncommon inflammatory condition usually affecting the anterior maxillary gingiva and of uncertain etiology While some authors have associated plasma cell gingivitis with a hypersensitivity response to antigens in various substances others have raised doubt whether plasma cell gingivitis is a distinct clinicopathologic entity

Allergic gingivitis

Etiology

bull auto immune

bull Allergy

bull Signs

bull sloughing of the epithelium which leaves raw red surface

bull The edematous tissue often extends to the mucogingival junction with a deep red appearance

Allergic gingivitis

Symptoms

painful

Treatment

topicalsystemic steroid therapy

remove etiological factor if possible

-spices toothpaste flavorings peppermint wintergreen menthol cinnamon preservatives mints gum candy

Possible Offending Products to Gingival Tissue

bull Commercially available toothpaste (tartar-control additives and flavoring agents [possibly

cinnamon] that mask the tartar control additives)

bull Mouth rinses

bull Cinnamon aldehyde

bull Sodium benzoate and methyl paraben

bull Food substances such as wheat dairy chocolate eggs peanuts and monosodium glutamate

bull Red wine (sulfides and tartrazine additives)

bull Preservatives

bull Essential oils such as peppermint spearmint and wintergreen found in gums candy and mouth rinses

bull Dark cola drinks

bull Strong spices

bull Chili peppers

bull Clove

bull Cardamom Burkhart NW Toothpaste allergy RDH 2007 27(6) 86107-108

8

Types of Periodontal diseasesPeriodontitis

Periodontitis

bull Chronic

bull Disease will progress unless treated

bull Typical age of onset is 35 yrs of age

bull Bone loss

- slow

ndash rate may vary depending on the modifiers

bull Severity is determined by bone loss and LOA

bull Can become inactive (stable) active (recurrent) refractory

Periodontitis

Microorganisms

bull Gram ndash

bull P gingivalis

bull P intermedia

bull Tannerella forsythensis (B forsythus)

Treatmentbull Self carebull Scrt

pldebridement bull Depending type of

defects amp severity ndashpossibly surgery

amp perio referral

Not includedAggressive

This category includes formally called diseases

bull Juvenile

bullEarly onset

bullPrepubertal

bullRapidly progressive

Localized Aggressive Localized Juvenile Periodontitis

bull More significant bone loss surrounding 1st molars amp incisors ndash typically angular type bone loss amp mirror image bilaterally

bull Rate of bone loss is rapid

bull OH can be good

9

Localized Aggressive LJP

bull Defects in PMNs or macrophagesbull respond slowly

bull chemotaxis defect

bull impaired phagocytosis

bull Onset typically during teenage years

bull Hereditary componentgenetic

bull more common in females amp blacks

Localized Aggressive Localized Juvenile Periodontitis

Microorganisms

Aggregatibacter Actinomycetemcomitans

P gingivalis

Treatmentbull scrt pldebridement but typically unresponsivebull Antibiotics to be administered with or just after debridement

ndash combo metronidazole wamoxicillin or metro w augmentinndash Clindamycin Azithromycin

bull possibly surgerybull prompt perio referralbull suggest family be evaluated (siblings children etc)bull sea salt being used as prevention of AA amp Tx

Generalized Aggressive Formally Generalized Juvenile Periodontitis

bull More rare than LJPbull Can affect most teeth but more severe on 1st molar

amp incisorsndash must involve gt 3 other teeth

bull Onset usually under 30 years oldbull Associated with neutrophil disorderbull Generally significant inflammation amp heavy

plaquecalculusbull Children w Gagp seem more prone to ear skin amp

upper respiratory tract infections

Generalized Aggressive Generalized Juvenile Periodontitis

MicroorganismsA actinomycetemcomitansPorphyromas gingivalis Eikenella corrodens

Treatmentscrt pldebridementantibiotics

ndash combo metronidazole wamoxicillin or metro w augmentin

possibly surgeryprompt perio referralbull Suggest family be evaluated (siblings children etc)

Periodontitis as a Manifestation of Systemic Disease

bull Systemic diseases that severely impair host response should be considered a periodontal manifestation of the systemic disease amp primary diagnosis should be the systemic disease according to International Statistical Classification of Disease (ICD)

ndash Excludes diabetes

bull Hematologicacquired neutropenias leukemias

bull Genetic disorderfamilial neutopenias down syndrome leukocyte adhesion deficiency syndrome papillon-lefreve syndrome chediak-higshi histocytosis syndromes Glycogen storage disease genetic agranulcytosis cohen syndrome Ehlers-Danlossyndrome hypophosphatsis

Necrotizing Periodontal Diseases NG amp NP

Etiologybull Unknown

bull Risk factorsexcessive stress lack of rest poor oral hygiene smoking HIV poor immune response

bull More common in underdeveloped countries

bull Less common now in the US

bull Susceptible to reoccurrence

Symptomsbull SUDDEN onset of burning

mouth inability to eat metallic taste excessive salvia amp PAINFUL

Microorganisms

spirochetes

Prevotella intermedia

Fusiform bacillus

Fusobacterium nucleatum

Ulcerative has been eliminated

10

NGSigns

bull 3 key features papilla necrosis bleeding and pain

bull Punched out papillae cratered like depressions covered by a white necrotic pseudomembrane(collection of PMNS) bright red margins spontenousbleeding may occur

bull Distinctive foul odor

bull May have systemic involvement

ndash lymphadenopathy fever

bull May be a systemic

manifestations

ndash HIV

NG Treatmentbull Advise to avoid smoking amp etoh get rest and proper nutrition (rec

multi vitamin soft nutritious diet)+ self care

bull Rinses with frac12 glass warm water amp 1 tbsp hydrogen peroxide w half glass or chlorhexidine

bull Pain medication

bull Antibiotics can be used especially if systemic involvement

ndash metronidazole tetracycline pen vk

bull Initial supragingival debridement then complete

bull Consider complete laboratory work ndashup amp medical consult

ndash (NUG may be the first sign of HIV)

bull May progress to NUP

bull Follow ndashup phone call or visit within 24 hrsndash Re-eval surgery referral debridement wlocal= recurrent nature

NP

bull Progression of NUG

bull May be related to systemic disease

bull HIV nutrition deficiency

bull NUG superimposed on a previous periodontal disease

NP

Signs amp symptoms

bull Intensely red necrosis white pseudomembrane

bull Painful odor punched-out papillae

bull Reports of deep aching pain or jaw pain

bull Extensive bone loss

bull Spontaneous bleeding

Treatment

bull Same as NUG

Peridex culture antibiotics (metronidazole) or antifungals

Refractory

bull Not included in the new guidelines

bull Unresponsive to treatmentndash surgery frequent scrt pl antibiotics

bull Can be localized or generalized

bull Usually smokers

bull Treatment clindamycin metronidazole metriwamoxicillin or Augmentin

Periodontal Phenotype (Biotypes)

bull The term describes the thickness of the gingiva in a bucco-lingual dimension

bull 3 types

Thick flat

Thick scalloped

Thin

bull Thick (85) is more prevalent than thin (15)

11

Thin Gingival Phenotype

bull Triangle shaped teeth vs square

bull Thin tissue

bull Susceptible to recession

bull Dehiscence present

bull Instrumentation must be done

Carefully due to thin biotype

bull Reacts to insult by recession

Thick amp Flat Gingival Phenotype

bull Square shaped

bull Thick tissue

bull Susceptible to pocketing

bull Reacts to insult by pocketing

Thick Scalloped

bull Thick fibrotic gingiva

bull Slender teeth

bull Narrow zone of KT

bull Gingival scalloping

Recession

Type 1 Type 2

Interproximal CEJ

is clinically not

detectable

The amount of

interproximal

attachment loss

is lt to buccal

Type 3

The amount of

interproximal

attachment loss

is gt

buccal

attachment loss

Implants

bull Treat perio prior to implantsbull It takes 2 weeks for the implants to

become colonized by the surrounding teeth

bull No horizontal fibers like a tooth so infection goes straight to bone and perio happens very quickly

bull This perimucosal seal is delicate ndashBe careful during instrumentation

12

Implants

bull The implant coatingsrough surfaces may create more risk for implantitis but better for osteointergration

ndash The calculus is more embedded on these surfaces than the previous smoother surfaces

Stages of Peri-implant DiseasePeri-implant mucositis

bull Reversible inflammation of the soft tissues

bull Occurs in about 50 of implants placed within 9 - 14 years

Peri-implantitis

bull Bone Loss

bull Occurs in 12- 47 of implants 5 years after placement

bull Risk factors-Hx of severe perio poor self care amp lack of maintenance care

bull Cement Implantitis

bull Some evidence linking cement and titanium particles bio corrosion

Peri-implantitis

Microorganisms

bull Gram - Fusobacterium species Prevotella intermedia

bull Implant failure is usually due to the microbial challenge occlusal load or excessive cementndash Cement has been found in the tissues

bull Failure is evidenced by gt2 mm MOBILITY

bull Bone loss buccal and lingual results in dehiscence

Cement Implantitis

New AAP Case definitionPeri-implantitis

bull BOP

bull Probing depth gt 6 mm

bull Bone levels gt 3 mm apical of the most coronal portion of the intraosseous part of the implant

Caton J Armitage G Berglundh T Et al A new classification scheme for periodontal and peri‐implant diseases and conditions ndash Introduction and key changes from the 1999 classification Journal of Periodontology 89 S1 (S1-S8) (2018)

Failing Criteria

bull Ailing (Peri-implant mucositis) inflammation present but no mobility

ndash bone appears normal or there may be an incipient lesion

bull Failing Peri-implantitis without mobility

ndash Inflammation has progressed to the bone as evidenced by radiographic lesion

bull Failed Peri-implantitis with mobility

ndash Implant has pronounced bone loss

Probing amp BOP

bull Metal probes on prosthetic part of the crown is fine

bull Some are concerned with metal probes on the threads

bull Must probe implants

bull Probe depths are generally deeper than natural tooth

bull BOP is not normal

threads

13

Treatment

bull Be aggressive amp prevent bone loss because very difficult to treat once initiated

bull Treatment

ndash Debride thoroughly

ndash Chlorhexidine

ndash Systemic antibiotics

ndash Bone grafts

ndash Arestin- local drug delivery

ndash Air flow polishing with glycine

Diagnosis Severity

bull Determining severity is based on CAL and bone loss

bull Clinical attachment level (CAL)

ndashdistance from the junctional epithelium to the CEJ

bull Probe depths alone are lacking because it does not take in account the gingival margin

ndashusing probe depths alone can result in over estimating or underestimating disease

Three possible relationships for gingival margin and CEJ

bull Gingival margin could be coronal to CEJ

bull Gingival margin could be level with CEJ

bull Gingival margin could be apical to CEJ

GM

bull Where should the GM be normallyndash 1-2 mm coronal to the CEJ

bull What is the pattern of CEJs interproximallyacross the mouthndash More Flat on the Posteriors

ndash More Curvature on the Anteriors

ndash For interproximal space look at the papillae does it fill the embrasure space

ndash A normal GM on the anteriors could be +1mm

ndash A normal GM on the posteriors could be +2 mm

Clinical attachment level

Depends on position of the gingival margin and CEJ

bull Gingival margin could be coronal to CEJ (-)

bull Gingival margin could be level with CEJ (same)

bull Gingival margin could be apical to CEJ (+)

Measuring CAL when gingival margin is coronal to CEJ

1 Measure probe depth

2 Measure from gingival margin to CEJ

3 Subtract second measurement from overall probe depth

FYI-This is a color

coded probe w

markings at 36912

14

Measuring CAL when gingival margin is levelwith CEJ

bull Probe depth is Clinical attachment level

Measuring CAL when gingival margin is apical to CEJ

bull Measure probe depthbull Measure recessionbull Add recession to probe depth

Grading

Bone Loss

Stage 1

Coronal 13

lt 15

Coronal 13

Mid 13

Last 13

15 Normal bone Height

33 stage 2

Stage 3Extends to mid third of root amp beyondStage 4Extends to mid third of root amp beyond

Stage 1

stage 3 amp 4

Predicting Activity

bull BOP

ndash 50 of all bleeding sites will not break down

ndash 50 of all bleeding sites will breakdown

ndash Sites that do not bleed will not breakdown

ndash The absence of bleeding provides more information than whether bleeding exists

ndash Therefore when sites bleed we say it is active

bull Inflammation

bull Nutrient canals

bull Rough looking crestal bone vs smooth amp well demarcated may indicate activity

15

Predicting Activity

bull Nutrient canals

ndash Highly visible canals may indicate active or rapid destruction

ndash canals are thought to be engorged large blood vessels

Crestal Bone

Rough looking crestal boneSmoother more demarcated crestal bone

Planningbull Systematic Informed consent

bull Diagnosis prognosis options risks benefits

ndashPatients must have all the information

bull Studies indicate slight reductions in PD s gt 6 mm after full-mouth scaling and root planingperformed in one appointment vs over longer intervals

bull These protocols particularly effective in patients with aggressive periodontitis andor pts w systemic conditions

Eberhard J et al J Clin Periodontol 200835591ndash604 amp Fang et al J Periodont Res October 19 2015)

ImplementationTreatment

bull Goals are to eliminate infection and risk factorsbull The objective is to remove all clinically detectable

calculus without excessive root planingndash bacterial endotoxins are weakly adherent to the root

surface (Nakib 1982)

bull The term debridement vs root planing

ImplementationTreatment

bull Treat patientrsquos significant otherbull 40 of the time spouses have the

same microbiotabull Donrsquot kiss dogs amp cats- they may have

periobull Avoid gross scaling

bull risk of abscessbull educationbull more difficult to re-insert

instruments

16

Air Polishing with glycine

ndashGlycine has anti inflammatory ampimmune modulation effectsbull Glycine receptor gingival tissue

ndashPerpulsionndashFDA approval for lt5 mmndashRemoval biofilm amp stainndashPerio maintenance ndashImplantsndashDecontaminate prior to grafts

Host-Modulating Treatmentbull Treating periodontitis by trying to resolve

inflammation

bull Resolvins

ndash Omega 3 Fatty acids correlated with less bone loss

ndash may be due to their ability to generate mediators that fight inflammation and aid in inflammation resolution

bull Low-dose doxycycline 20 mg 2x daily

ndash Matrix metalloproteinase inhibitor is the only FDA-approved

ndash Reduction of PD amp CAL gain over 3 months to 9 monthsGolub LM et al Doxycycline i hibits neutrophil (PMN)-type matrix metalloproteinases in human adult periodontitis gingiva J Clin Periodontol 199522100ndash109 amp

Golub LM et al Adjunctive treatment with subantimicrobial doses of doxycycline effects on gingival fluid collagenase activity and attachment loss in adult periodontitis J Clin Periodontol 200128146ndash156

Host-Modulating Treatment

bull NSAIDsndash Reduces PGE 2 which can reduce bone loss

ndash Flurbiprofen and topical (ketorolac)

ndash Case controls demonstrate decrease risk

bull Bisphosphonates ndash Used for treating Pagetrsquos bone pain amp osteoporosis

ndash Alendronate sodium (Fosamax) risedronate (Actonel)

ndash Investigating for its ability to modulate the host

bull Used experimentally in animals to inhibit bone resorption amp bone mineral content amp to interfere w breakdown of collagen in the periodontium

ndash WARNING case reports of bone necrosis after extractions

bull questions scrtpl w pts on drug

Treatment

bull Statins have an anti-inflammatory and immune effects reducing levels of C-Reactive Protein MMP Tumor Necrosis Factor-α

ndash Statins reduce bone resorption by inhibiting osteoclast formation

ndash Some results show lower alveolar bone loss and reduction of clinical signs of inflammation

(meta anyalsis Estanislau etal J Clin Pharmacol 2014 Dec)

ndash Topical gels (simvastatin atorvastatin)

Treatment

bull Probioticsndash Improved biofilm index and probe depths (Shimauchi 2008)

bull Valtrexbull Photodynamic therapy

ndash Light-sensitive drug is applied then a light laser directly on the area treated with the drug

ndash When the light is combined with the drug phototoxic reactions are induced which destroy bacterial cells

ndash Shows short term benefits (Sgolastra 2012)bull Periowave

bull Emdogainndash Enamel matrix derivative for periodontal tissue regeneration in

infrabony defects amp used w SRP to enhance resultsbull Derived from developing pig teethbull Stimulate adherence attachment to cementum

Treatmentbull Topical antioxidants

ndash Antioxidant gel and rinse

ndash Periosciences ndash toothpaste rinse gel

ndash Topical coenzyme COQ10

bull Due to correlation w perio oxidative stress markers amp low level of natural occurring salivary antioxidants looking at polyphenolsantioxidants in the mouth locally delivered

ndash needs more research

bull Hyaluronic acid (HA) gel and mouth rinsendash hyaluronic acid plays a large role in the collagen building 02

hyaluronan gel topically amp subgingivally

ndash Studies have been done to evaluate on wound healing amp improving perio outcomes

ndash Further evidence is needed

8

Types of Periodontal diseasesPeriodontitis

Periodontitis

bull Chronic

bull Disease will progress unless treated

bull Typical age of onset is 35 yrs of age

bull Bone loss

- slow

ndash rate may vary depending on the modifiers

bull Severity is determined by bone loss and LOA

bull Can become inactive (stable) active (recurrent) refractory

Periodontitis

Microorganisms

bull Gram ndash

bull P gingivalis

bull P intermedia

bull Tannerella forsythensis (B forsythus)

Treatmentbull Self carebull Scrt

pldebridement bull Depending type of

defects amp severity ndashpossibly surgery

amp perio referral

Not includedAggressive

This category includes formally called diseases

bull Juvenile

bullEarly onset

bullPrepubertal

bullRapidly progressive

Localized Aggressive Localized Juvenile Periodontitis

bull More significant bone loss surrounding 1st molars amp incisors ndash typically angular type bone loss amp mirror image bilaterally

bull Rate of bone loss is rapid

bull OH can be good

9

Localized Aggressive LJP

bull Defects in PMNs or macrophagesbull respond slowly

bull chemotaxis defect

bull impaired phagocytosis

bull Onset typically during teenage years

bull Hereditary componentgenetic

bull more common in females amp blacks

Localized Aggressive Localized Juvenile Periodontitis

Microorganisms

Aggregatibacter Actinomycetemcomitans

P gingivalis

Treatmentbull scrt pldebridement but typically unresponsivebull Antibiotics to be administered with or just after debridement

ndash combo metronidazole wamoxicillin or metro w augmentinndash Clindamycin Azithromycin

bull possibly surgerybull prompt perio referralbull suggest family be evaluated (siblings children etc)bull sea salt being used as prevention of AA amp Tx

Generalized Aggressive Formally Generalized Juvenile Periodontitis

bull More rare than LJPbull Can affect most teeth but more severe on 1st molar

amp incisorsndash must involve gt 3 other teeth

bull Onset usually under 30 years oldbull Associated with neutrophil disorderbull Generally significant inflammation amp heavy

plaquecalculusbull Children w Gagp seem more prone to ear skin amp

upper respiratory tract infections

Generalized Aggressive Generalized Juvenile Periodontitis

MicroorganismsA actinomycetemcomitansPorphyromas gingivalis Eikenella corrodens

Treatmentscrt pldebridementantibiotics

ndash combo metronidazole wamoxicillin or metro w augmentin

possibly surgeryprompt perio referralbull Suggest family be evaluated (siblings children etc)

Periodontitis as a Manifestation of Systemic Disease

bull Systemic diseases that severely impair host response should be considered a periodontal manifestation of the systemic disease amp primary diagnosis should be the systemic disease according to International Statistical Classification of Disease (ICD)

ndash Excludes diabetes

bull Hematologicacquired neutropenias leukemias

bull Genetic disorderfamilial neutopenias down syndrome leukocyte adhesion deficiency syndrome papillon-lefreve syndrome chediak-higshi histocytosis syndromes Glycogen storage disease genetic agranulcytosis cohen syndrome Ehlers-Danlossyndrome hypophosphatsis

Necrotizing Periodontal Diseases NG amp NP

Etiologybull Unknown

bull Risk factorsexcessive stress lack of rest poor oral hygiene smoking HIV poor immune response

bull More common in underdeveloped countries

bull Less common now in the US

bull Susceptible to reoccurrence

Symptomsbull SUDDEN onset of burning

mouth inability to eat metallic taste excessive salvia amp PAINFUL

Microorganisms

spirochetes

Prevotella intermedia

Fusiform bacillus

Fusobacterium nucleatum

Ulcerative has been eliminated

10

NGSigns

bull 3 key features papilla necrosis bleeding and pain

bull Punched out papillae cratered like depressions covered by a white necrotic pseudomembrane(collection of PMNS) bright red margins spontenousbleeding may occur

bull Distinctive foul odor

bull May have systemic involvement

ndash lymphadenopathy fever

bull May be a systemic

manifestations

ndash HIV

NG Treatmentbull Advise to avoid smoking amp etoh get rest and proper nutrition (rec

multi vitamin soft nutritious diet)+ self care

bull Rinses with frac12 glass warm water amp 1 tbsp hydrogen peroxide w half glass or chlorhexidine

bull Pain medication

bull Antibiotics can be used especially if systemic involvement

ndash metronidazole tetracycline pen vk

bull Initial supragingival debridement then complete

bull Consider complete laboratory work ndashup amp medical consult

ndash (NUG may be the first sign of HIV)

bull May progress to NUP

bull Follow ndashup phone call or visit within 24 hrsndash Re-eval surgery referral debridement wlocal= recurrent nature

NP

bull Progression of NUG

bull May be related to systemic disease

bull HIV nutrition deficiency

bull NUG superimposed on a previous periodontal disease

NP

Signs amp symptoms

bull Intensely red necrosis white pseudomembrane

bull Painful odor punched-out papillae

bull Reports of deep aching pain or jaw pain

bull Extensive bone loss

bull Spontaneous bleeding

Treatment

bull Same as NUG

Peridex culture antibiotics (metronidazole) or antifungals

Refractory

bull Not included in the new guidelines

bull Unresponsive to treatmentndash surgery frequent scrt pl antibiotics

bull Can be localized or generalized

bull Usually smokers

bull Treatment clindamycin metronidazole metriwamoxicillin or Augmentin

Periodontal Phenotype (Biotypes)

bull The term describes the thickness of the gingiva in a bucco-lingual dimension

bull 3 types

Thick flat

Thick scalloped

Thin

bull Thick (85) is more prevalent than thin (15)

11

Thin Gingival Phenotype

bull Triangle shaped teeth vs square

bull Thin tissue

bull Susceptible to recession

bull Dehiscence present

bull Instrumentation must be done

Carefully due to thin biotype

bull Reacts to insult by recession

Thick amp Flat Gingival Phenotype

bull Square shaped

bull Thick tissue

bull Susceptible to pocketing

bull Reacts to insult by pocketing

Thick Scalloped

bull Thick fibrotic gingiva

bull Slender teeth

bull Narrow zone of KT

bull Gingival scalloping

Recession

Type 1 Type 2

Interproximal CEJ

is clinically not

detectable

The amount of

interproximal

attachment loss

is lt to buccal

Type 3

The amount of

interproximal

attachment loss

is gt

buccal

attachment loss

Implants

bull Treat perio prior to implantsbull It takes 2 weeks for the implants to

become colonized by the surrounding teeth

bull No horizontal fibers like a tooth so infection goes straight to bone and perio happens very quickly

bull This perimucosal seal is delicate ndashBe careful during instrumentation

12

Implants

bull The implant coatingsrough surfaces may create more risk for implantitis but better for osteointergration

ndash The calculus is more embedded on these surfaces than the previous smoother surfaces

Stages of Peri-implant DiseasePeri-implant mucositis

bull Reversible inflammation of the soft tissues

bull Occurs in about 50 of implants placed within 9 - 14 years

Peri-implantitis

bull Bone Loss

bull Occurs in 12- 47 of implants 5 years after placement

bull Risk factors-Hx of severe perio poor self care amp lack of maintenance care

bull Cement Implantitis

bull Some evidence linking cement and titanium particles bio corrosion

Peri-implantitis

Microorganisms

bull Gram - Fusobacterium species Prevotella intermedia

bull Implant failure is usually due to the microbial challenge occlusal load or excessive cementndash Cement has been found in the tissues

bull Failure is evidenced by gt2 mm MOBILITY

bull Bone loss buccal and lingual results in dehiscence

Cement Implantitis

New AAP Case definitionPeri-implantitis

bull BOP

bull Probing depth gt 6 mm

bull Bone levels gt 3 mm apical of the most coronal portion of the intraosseous part of the implant

Caton J Armitage G Berglundh T Et al A new classification scheme for periodontal and peri‐implant diseases and conditions ndash Introduction and key changes from the 1999 classification Journal of Periodontology 89 S1 (S1-S8) (2018)

Failing Criteria

bull Ailing (Peri-implant mucositis) inflammation present but no mobility

ndash bone appears normal or there may be an incipient lesion

bull Failing Peri-implantitis without mobility

ndash Inflammation has progressed to the bone as evidenced by radiographic lesion

bull Failed Peri-implantitis with mobility

ndash Implant has pronounced bone loss

Probing amp BOP

bull Metal probes on prosthetic part of the crown is fine

bull Some are concerned with metal probes on the threads

bull Must probe implants

bull Probe depths are generally deeper than natural tooth

bull BOP is not normal

threads

13

Treatment

bull Be aggressive amp prevent bone loss because very difficult to treat once initiated

bull Treatment

ndash Debride thoroughly

ndash Chlorhexidine

ndash Systemic antibiotics

ndash Bone grafts

ndash Arestin- local drug delivery

ndash Air flow polishing with glycine

Diagnosis Severity

bull Determining severity is based on CAL and bone loss

bull Clinical attachment level (CAL)

ndashdistance from the junctional epithelium to the CEJ

bull Probe depths alone are lacking because it does not take in account the gingival margin

ndashusing probe depths alone can result in over estimating or underestimating disease

Three possible relationships for gingival margin and CEJ

bull Gingival margin could be coronal to CEJ

bull Gingival margin could be level with CEJ

bull Gingival margin could be apical to CEJ

GM

bull Where should the GM be normallyndash 1-2 mm coronal to the CEJ

bull What is the pattern of CEJs interproximallyacross the mouthndash More Flat on the Posteriors

ndash More Curvature on the Anteriors

ndash For interproximal space look at the papillae does it fill the embrasure space

ndash A normal GM on the anteriors could be +1mm

ndash A normal GM on the posteriors could be +2 mm

Clinical attachment level

Depends on position of the gingival margin and CEJ

bull Gingival margin could be coronal to CEJ (-)

bull Gingival margin could be level with CEJ (same)

bull Gingival margin could be apical to CEJ (+)

Measuring CAL when gingival margin is coronal to CEJ

1 Measure probe depth

2 Measure from gingival margin to CEJ

3 Subtract second measurement from overall probe depth

FYI-This is a color

coded probe w

markings at 36912

14

Measuring CAL when gingival margin is levelwith CEJ

bull Probe depth is Clinical attachment level

Measuring CAL when gingival margin is apical to CEJ

bull Measure probe depthbull Measure recessionbull Add recession to probe depth

Grading

Bone Loss

Stage 1

Coronal 13

lt 15

Coronal 13

Mid 13

Last 13

15 Normal bone Height

33 stage 2

Stage 3Extends to mid third of root amp beyondStage 4Extends to mid third of root amp beyond

Stage 1

stage 3 amp 4

Predicting Activity

bull BOP

ndash 50 of all bleeding sites will not break down

ndash 50 of all bleeding sites will breakdown

ndash Sites that do not bleed will not breakdown

ndash The absence of bleeding provides more information than whether bleeding exists

ndash Therefore when sites bleed we say it is active

bull Inflammation

bull Nutrient canals

bull Rough looking crestal bone vs smooth amp well demarcated may indicate activity

15

Predicting Activity

bull Nutrient canals

ndash Highly visible canals may indicate active or rapid destruction

ndash canals are thought to be engorged large blood vessels

Crestal Bone

Rough looking crestal boneSmoother more demarcated crestal bone

Planningbull Systematic Informed consent

bull Diagnosis prognosis options risks benefits

ndashPatients must have all the information

bull Studies indicate slight reductions in PD s gt 6 mm after full-mouth scaling and root planingperformed in one appointment vs over longer intervals

bull These protocols particularly effective in patients with aggressive periodontitis andor pts w systemic conditions

Eberhard J et al J Clin Periodontol 200835591ndash604 amp Fang et al J Periodont Res October 19 2015)

ImplementationTreatment

bull Goals are to eliminate infection and risk factorsbull The objective is to remove all clinically detectable

calculus without excessive root planingndash bacterial endotoxins are weakly adherent to the root

surface (Nakib 1982)

bull The term debridement vs root planing

ImplementationTreatment

bull Treat patientrsquos significant otherbull 40 of the time spouses have the

same microbiotabull Donrsquot kiss dogs amp cats- they may have

periobull Avoid gross scaling

bull risk of abscessbull educationbull more difficult to re-insert

instruments

16

Air Polishing with glycine

ndashGlycine has anti inflammatory ampimmune modulation effectsbull Glycine receptor gingival tissue

ndashPerpulsionndashFDA approval for lt5 mmndashRemoval biofilm amp stainndashPerio maintenance ndashImplantsndashDecontaminate prior to grafts

Host-Modulating Treatmentbull Treating periodontitis by trying to resolve

inflammation

bull Resolvins

ndash Omega 3 Fatty acids correlated with less bone loss

ndash may be due to their ability to generate mediators that fight inflammation and aid in inflammation resolution

bull Low-dose doxycycline 20 mg 2x daily

ndash Matrix metalloproteinase inhibitor is the only FDA-approved

ndash Reduction of PD amp CAL gain over 3 months to 9 monthsGolub LM et al Doxycycline i hibits neutrophil (PMN)-type matrix metalloproteinases in human adult periodontitis gingiva J Clin Periodontol 199522100ndash109 amp

Golub LM et al Adjunctive treatment with subantimicrobial doses of doxycycline effects on gingival fluid collagenase activity and attachment loss in adult periodontitis J Clin Periodontol 200128146ndash156

Host-Modulating Treatment

bull NSAIDsndash Reduces PGE 2 which can reduce bone loss

ndash Flurbiprofen and topical (ketorolac)

ndash Case controls demonstrate decrease risk

bull Bisphosphonates ndash Used for treating Pagetrsquos bone pain amp osteoporosis

ndash Alendronate sodium (Fosamax) risedronate (Actonel)

ndash Investigating for its ability to modulate the host

bull Used experimentally in animals to inhibit bone resorption amp bone mineral content amp to interfere w breakdown of collagen in the periodontium

ndash WARNING case reports of bone necrosis after extractions

bull questions scrtpl w pts on drug

Treatment

bull Statins have an anti-inflammatory and immune effects reducing levels of C-Reactive Protein MMP Tumor Necrosis Factor-α

ndash Statins reduce bone resorption by inhibiting osteoclast formation

ndash Some results show lower alveolar bone loss and reduction of clinical signs of inflammation

(meta anyalsis Estanislau etal J Clin Pharmacol 2014 Dec)

ndash Topical gels (simvastatin atorvastatin)

Treatment

bull Probioticsndash Improved biofilm index and probe depths (Shimauchi 2008)

bull Valtrexbull Photodynamic therapy

ndash Light-sensitive drug is applied then a light laser directly on the area treated with the drug

ndash When the light is combined with the drug phototoxic reactions are induced which destroy bacterial cells

ndash Shows short term benefits (Sgolastra 2012)bull Periowave

bull Emdogainndash Enamel matrix derivative for periodontal tissue regeneration in

infrabony defects amp used w SRP to enhance resultsbull Derived from developing pig teethbull Stimulate adherence attachment to cementum

Treatmentbull Topical antioxidants

ndash Antioxidant gel and rinse

ndash Periosciences ndash toothpaste rinse gel

ndash Topical coenzyme COQ10

bull Due to correlation w perio oxidative stress markers amp low level of natural occurring salivary antioxidants looking at polyphenolsantioxidants in the mouth locally delivered

ndash needs more research

bull Hyaluronic acid (HA) gel and mouth rinsendash hyaluronic acid plays a large role in the collagen building 02

hyaluronan gel topically amp subgingivally

ndash Studies have been done to evaluate on wound healing amp improving perio outcomes

ndash Further evidence is needed

9

Localized Aggressive LJP

bull Defects in PMNs or macrophagesbull respond slowly

bull chemotaxis defect

bull impaired phagocytosis

bull Onset typically during teenage years

bull Hereditary componentgenetic

bull more common in females amp blacks

Localized Aggressive Localized Juvenile Periodontitis

Microorganisms

Aggregatibacter Actinomycetemcomitans

P gingivalis

Treatmentbull scrt pldebridement but typically unresponsivebull Antibiotics to be administered with or just after debridement

ndash combo metronidazole wamoxicillin or metro w augmentinndash Clindamycin Azithromycin

bull possibly surgerybull prompt perio referralbull suggest family be evaluated (siblings children etc)bull sea salt being used as prevention of AA amp Tx

Generalized Aggressive Formally Generalized Juvenile Periodontitis

bull More rare than LJPbull Can affect most teeth but more severe on 1st molar

amp incisorsndash must involve gt 3 other teeth

bull Onset usually under 30 years oldbull Associated with neutrophil disorderbull Generally significant inflammation amp heavy

plaquecalculusbull Children w Gagp seem more prone to ear skin amp

upper respiratory tract infections

Generalized Aggressive Generalized Juvenile Periodontitis

MicroorganismsA actinomycetemcomitansPorphyromas gingivalis Eikenella corrodens

Treatmentscrt pldebridementantibiotics

ndash combo metronidazole wamoxicillin or metro w augmentin

possibly surgeryprompt perio referralbull Suggest family be evaluated (siblings children etc)

Periodontitis as a Manifestation of Systemic Disease

bull Systemic diseases that severely impair host response should be considered a periodontal manifestation of the systemic disease amp primary diagnosis should be the systemic disease according to International Statistical Classification of Disease (ICD)

ndash Excludes diabetes

bull Hematologicacquired neutropenias leukemias

bull Genetic disorderfamilial neutopenias down syndrome leukocyte adhesion deficiency syndrome papillon-lefreve syndrome chediak-higshi histocytosis syndromes Glycogen storage disease genetic agranulcytosis cohen syndrome Ehlers-Danlossyndrome hypophosphatsis

Necrotizing Periodontal Diseases NG amp NP

Etiologybull Unknown

bull Risk factorsexcessive stress lack of rest poor oral hygiene smoking HIV poor immune response

bull More common in underdeveloped countries

bull Less common now in the US

bull Susceptible to reoccurrence

Symptomsbull SUDDEN onset of burning

mouth inability to eat metallic taste excessive salvia amp PAINFUL

Microorganisms

spirochetes

Prevotella intermedia

Fusiform bacillus

Fusobacterium nucleatum

Ulcerative has been eliminated

10

NGSigns

bull 3 key features papilla necrosis bleeding and pain

bull Punched out papillae cratered like depressions covered by a white necrotic pseudomembrane(collection of PMNS) bright red margins spontenousbleeding may occur

bull Distinctive foul odor

bull May have systemic involvement

ndash lymphadenopathy fever

bull May be a systemic

manifestations

ndash HIV

NG Treatmentbull Advise to avoid smoking amp etoh get rest and proper nutrition (rec

multi vitamin soft nutritious diet)+ self care

bull Rinses with frac12 glass warm water amp 1 tbsp hydrogen peroxide w half glass or chlorhexidine

bull Pain medication

bull Antibiotics can be used especially if systemic involvement

ndash metronidazole tetracycline pen vk

bull Initial supragingival debridement then complete

bull Consider complete laboratory work ndashup amp medical consult

ndash (NUG may be the first sign of HIV)

bull May progress to NUP

bull Follow ndashup phone call or visit within 24 hrsndash Re-eval surgery referral debridement wlocal= recurrent nature

NP

bull Progression of NUG

bull May be related to systemic disease

bull HIV nutrition deficiency

bull NUG superimposed on a previous periodontal disease

NP

Signs amp symptoms

bull Intensely red necrosis white pseudomembrane

bull Painful odor punched-out papillae

bull Reports of deep aching pain or jaw pain

bull Extensive bone loss

bull Spontaneous bleeding

Treatment

bull Same as NUG

Peridex culture antibiotics (metronidazole) or antifungals

Refractory

bull Not included in the new guidelines

bull Unresponsive to treatmentndash surgery frequent scrt pl antibiotics

bull Can be localized or generalized

bull Usually smokers

bull Treatment clindamycin metronidazole metriwamoxicillin or Augmentin

Periodontal Phenotype (Biotypes)

bull The term describes the thickness of the gingiva in a bucco-lingual dimension

bull 3 types

Thick flat

Thick scalloped

Thin

bull Thick (85) is more prevalent than thin (15)

11

Thin Gingival Phenotype

bull Triangle shaped teeth vs square

bull Thin tissue

bull Susceptible to recession

bull Dehiscence present

bull Instrumentation must be done

Carefully due to thin biotype

bull Reacts to insult by recession

Thick amp Flat Gingival Phenotype

bull Square shaped

bull Thick tissue

bull Susceptible to pocketing

bull Reacts to insult by pocketing

Thick Scalloped

bull Thick fibrotic gingiva

bull Slender teeth

bull Narrow zone of KT

bull Gingival scalloping

Recession

Type 1 Type 2

Interproximal CEJ

is clinically not

detectable

The amount of

interproximal

attachment loss

is lt to buccal

Type 3

The amount of

interproximal

attachment loss

is gt

buccal

attachment loss

Implants

bull Treat perio prior to implantsbull It takes 2 weeks for the implants to

become colonized by the surrounding teeth

bull No horizontal fibers like a tooth so infection goes straight to bone and perio happens very quickly

bull This perimucosal seal is delicate ndashBe careful during instrumentation

12

Implants

bull The implant coatingsrough surfaces may create more risk for implantitis but better for osteointergration

ndash The calculus is more embedded on these surfaces than the previous smoother surfaces

Stages of Peri-implant DiseasePeri-implant mucositis

bull Reversible inflammation of the soft tissues

bull Occurs in about 50 of implants placed within 9 - 14 years

Peri-implantitis

bull Bone Loss

bull Occurs in 12- 47 of implants 5 years after placement

bull Risk factors-Hx of severe perio poor self care amp lack of maintenance care

bull Cement Implantitis

bull Some evidence linking cement and titanium particles bio corrosion

Peri-implantitis

Microorganisms

bull Gram - Fusobacterium species Prevotella intermedia

bull Implant failure is usually due to the microbial challenge occlusal load or excessive cementndash Cement has been found in the tissues

bull Failure is evidenced by gt2 mm MOBILITY

bull Bone loss buccal and lingual results in dehiscence

Cement Implantitis

New AAP Case definitionPeri-implantitis

bull BOP

bull Probing depth gt 6 mm

bull Bone levels gt 3 mm apical of the most coronal portion of the intraosseous part of the implant

Caton J Armitage G Berglundh T Et al A new classification scheme for periodontal and peri‐implant diseases and conditions ndash Introduction and key changes from the 1999 classification Journal of Periodontology 89 S1 (S1-S8) (2018)

Failing Criteria

bull Ailing (Peri-implant mucositis) inflammation present but no mobility

ndash bone appears normal or there may be an incipient lesion

bull Failing Peri-implantitis without mobility

ndash Inflammation has progressed to the bone as evidenced by radiographic lesion

bull Failed Peri-implantitis with mobility

ndash Implant has pronounced bone loss

Probing amp BOP

bull Metal probes on prosthetic part of the crown is fine

bull Some are concerned with metal probes on the threads

bull Must probe implants

bull Probe depths are generally deeper than natural tooth

bull BOP is not normal

threads

13

Treatment

bull Be aggressive amp prevent bone loss because very difficult to treat once initiated

bull Treatment

ndash Debride thoroughly

ndash Chlorhexidine

ndash Systemic antibiotics

ndash Bone grafts

ndash Arestin- local drug delivery

ndash Air flow polishing with glycine

Diagnosis Severity

bull Determining severity is based on CAL and bone loss

bull Clinical attachment level (CAL)

ndashdistance from the junctional epithelium to the CEJ

bull Probe depths alone are lacking because it does not take in account the gingival margin

ndashusing probe depths alone can result in over estimating or underestimating disease

Three possible relationships for gingival margin and CEJ

bull Gingival margin could be coronal to CEJ

bull Gingival margin could be level with CEJ

bull Gingival margin could be apical to CEJ

GM

bull Where should the GM be normallyndash 1-2 mm coronal to the CEJ

bull What is the pattern of CEJs interproximallyacross the mouthndash More Flat on the Posteriors

ndash More Curvature on the Anteriors

ndash For interproximal space look at the papillae does it fill the embrasure space

ndash A normal GM on the anteriors could be +1mm

ndash A normal GM on the posteriors could be +2 mm

Clinical attachment level

Depends on position of the gingival margin and CEJ

bull Gingival margin could be coronal to CEJ (-)

bull Gingival margin could be level with CEJ (same)

bull Gingival margin could be apical to CEJ (+)

Measuring CAL when gingival margin is coronal to CEJ

1 Measure probe depth

2 Measure from gingival margin to CEJ

3 Subtract second measurement from overall probe depth

FYI-This is a color

coded probe w

markings at 36912

14

Measuring CAL when gingival margin is levelwith CEJ

bull Probe depth is Clinical attachment level

Measuring CAL when gingival margin is apical to CEJ

bull Measure probe depthbull Measure recessionbull Add recession to probe depth

Grading

Bone Loss

Stage 1

Coronal 13

lt 15

Coronal 13

Mid 13

Last 13

15 Normal bone Height

33 stage 2

Stage 3Extends to mid third of root amp beyondStage 4Extends to mid third of root amp beyond

Stage 1

stage 3 amp 4

Predicting Activity

bull BOP

ndash 50 of all bleeding sites will not break down

ndash 50 of all bleeding sites will breakdown

ndash Sites that do not bleed will not breakdown

ndash The absence of bleeding provides more information than whether bleeding exists

ndash Therefore when sites bleed we say it is active

bull Inflammation

bull Nutrient canals

bull Rough looking crestal bone vs smooth amp well demarcated may indicate activity

15

Predicting Activity

bull Nutrient canals

ndash Highly visible canals may indicate active or rapid destruction

ndash canals are thought to be engorged large blood vessels

Crestal Bone

Rough looking crestal boneSmoother more demarcated crestal bone

Planningbull Systematic Informed consent

bull Diagnosis prognosis options risks benefits

ndashPatients must have all the information

bull Studies indicate slight reductions in PD s gt 6 mm after full-mouth scaling and root planingperformed in one appointment vs over longer intervals

bull These protocols particularly effective in patients with aggressive periodontitis andor pts w systemic conditions

Eberhard J et al J Clin Periodontol 200835591ndash604 amp Fang et al J Periodont Res October 19 2015)

ImplementationTreatment

bull Goals are to eliminate infection and risk factorsbull The objective is to remove all clinically detectable

calculus without excessive root planingndash bacterial endotoxins are weakly adherent to the root

surface (Nakib 1982)

bull The term debridement vs root planing

ImplementationTreatment

bull Treat patientrsquos significant otherbull 40 of the time spouses have the

same microbiotabull Donrsquot kiss dogs amp cats- they may have

periobull Avoid gross scaling

bull risk of abscessbull educationbull more difficult to re-insert

instruments

16

Air Polishing with glycine

ndashGlycine has anti inflammatory ampimmune modulation effectsbull Glycine receptor gingival tissue

ndashPerpulsionndashFDA approval for lt5 mmndashRemoval biofilm amp stainndashPerio maintenance ndashImplantsndashDecontaminate prior to grafts

Host-Modulating Treatmentbull Treating periodontitis by trying to resolve

inflammation

bull Resolvins

ndash Omega 3 Fatty acids correlated with less bone loss

ndash may be due to their ability to generate mediators that fight inflammation and aid in inflammation resolution

bull Low-dose doxycycline 20 mg 2x daily

ndash Matrix metalloproteinase inhibitor is the only FDA-approved

ndash Reduction of PD amp CAL gain over 3 months to 9 monthsGolub LM et al Doxycycline i hibits neutrophil (PMN)-type matrix metalloproteinases in human adult periodontitis gingiva J Clin Periodontol 199522100ndash109 amp

Golub LM et al Adjunctive treatment with subantimicrobial doses of doxycycline effects on gingival fluid collagenase activity and attachment loss in adult periodontitis J Clin Periodontol 200128146ndash156

Host-Modulating Treatment

bull NSAIDsndash Reduces PGE 2 which can reduce bone loss

ndash Flurbiprofen and topical (ketorolac)

ndash Case controls demonstrate decrease risk

bull Bisphosphonates ndash Used for treating Pagetrsquos bone pain amp osteoporosis

ndash Alendronate sodium (Fosamax) risedronate (Actonel)

ndash Investigating for its ability to modulate the host

bull Used experimentally in animals to inhibit bone resorption amp bone mineral content amp to interfere w breakdown of collagen in the periodontium

ndash WARNING case reports of bone necrosis after extractions

bull questions scrtpl w pts on drug

Treatment

bull Statins have an anti-inflammatory and immune effects reducing levels of C-Reactive Protein MMP Tumor Necrosis Factor-α

ndash Statins reduce bone resorption by inhibiting osteoclast formation

ndash Some results show lower alveolar bone loss and reduction of clinical signs of inflammation

(meta anyalsis Estanislau etal J Clin Pharmacol 2014 Dec)

ndash Topical gels (simvastatin atorvastatin)

Treatment

bull Probioticsndash Improved biofilm index and probe depths (Shimauchi 2008)

bull Valtrexbull Photodynamic therapy

ndash Light-sensitive drug is applied then a light laser directly on the area treated with the drug

ndash When the light is combined with the drug phototoxic reactions are induced which destroy bacterial cells

ndash Shows short term benefits (Sgolastra 2012)bull Periowave

bull Emdogainndash Enamel matrix derivative for periodontal tissue regeneration in

infrabony defects amp used w SRP to enhance resultsbull Derived from developing pig teethbull Stimulate adherence attachment to cementum

Treatmentbull Topical antioxidants

ndash Antioxidant gel and rinse

ndash Periosciences ndash toothpaste rinse gel

ndash Topical coenzyme COQ10

bull Due to correlation w perio oxidative stress markers amp low level of natural occurring salivary antioxidants looking at polyphenolsantioxidants in the mouth locally delivered

ndash needs more research

bull Hyaluronic acid (HA) gel and mouth rinsendash hyaluronic acid plays a large role in the collagen building 02

hyaluronan gel topically amp subgingivally

ndash Studies have been done to evaluate on wound healing amp improving perio outcomes

ndash Further evidence is needed

10

NGSigns

bull 3 key features papilla necrosis bleeding and pain

bull Punched out papillae cratered like depressions covered by a white necrotic pseudomembrane(collection of PMNS) bright red margins spontenousbleeding may occur

bull Distinctive foul odor

bull May have systemic involvement

ndash lymphadenopathy fever

bull May be a systemic

manifestations

ndash HIV

NG Treatmentbull Advise to avoid smoking amp etoh get rest and proper nutrition (rec

multi vitamin soft nutritious diet)+ self care

bull Rinses with frac12 glass warm water amp 1 tbsp hydrogen peroxide w half glass or chlorhexidine

bull Pain medication

bull Antibiotics can be used especially if systemic involvement

ndash metronidazole tetracycline pen vk

bull Initial supragingival debridement then complete

bull Consider complete laboratory work ndashup amp medical consult

ndash (NUG may be the first sign of HIV)

bull May progress to NUP

bull Follow ndashup phone call or visit within 24 hrsndash Re-eval surgery referral debridement wlocal= recurrent nature

NP

bull Progression of NUG

bull May be related to systemic disease

bull HIV nutrition deficiency

bull NUG superimposed on a previous periodontal disease

NP

Signs amp symptoms

bull Intensely red necrosis white pseudomembrane

bull Painful odor punched-out papillae

bull Reports of deep aching pain or jaw pain

bull Extensive bone loss

bull Spontaneous bleeding

Treatment

bull Same as NUG

Peridex culture antibiotics (metronidazole) or antifungals

Refractory

bull Not included in the new guidelines

bull Unresponsive to treatmentndash surgery frequent scrt pl antibiotics

bull Can be localized or generalized

bull Usually smokers

bull Treatment clindamycin metronidazole metriwamoxicillin or Augmentin

Periodontal Phenotype (Biotypes)

bull The term describes the thickness of the gingiva in a bucco-lingual dimension

bull 3 types

Thick flat

Thick scalloped

Thin

bull Thick (85) is more prevalent than thin (15)

11

Thin Gingival Phenotype

bull Triangle shaped teeth vs square

bull Thin tissue

bull Susceptible to recession

bull Dehiscence present

bull Instrumentation must be done

Carefully due to thin biotype

bull Reacts to insult by recession

Thick amp Flat Gingival Phenotype

bull Square shaped

bull Thick tissue

bull Susceptible to pocketing

bull Reacts to insult by pocketing

Thick Scalloped

bull Thick fibrotic gingiva

bull Slender teeth

bull Narrow zone of KT

bull Gingival scalloping

Recession

Type 1 Type 2

Interproximal CEJ

is clinically not

detectable

The amount of

interproximal

attachment loss

is lt to buccal

Type 3

The amount of

interproximal

attachment loss

is gt

buccal

attachment loss

Implants

bull Treat perio prior to implantsbull It takes 2 weeks for the implants to

become colonized by the surrounding teeth

bull No horizontal fibers like a tooth so infection goes straight to bone and perio happens very quickly

bull This perimucosal seal is delicate ndashBe careful during instrumentation

12

Implants

bull The implant coatingsrough surfaces may create more risk for implantitis but better for osteointergration

ndash The calculus is more embedded on these surfaces than the previous smoother surfaces

Stages of Peri-implant DiseasePeri-implant mucositis

bull Reversible inflammation of the soft tissues

bull Occurs in about 50 of implants placed within 9 - 14 years

Peri-implantitis

bull Bone Loss

bull Occurs in 12- 47 of implants 5 years after placement

bull Risk factors-Hx of severe perio poor self care amp lack of maintenance care

bull Cement Implantitis

bull Some evidence linking cement and titanium particles bio corrosion

Peri-implantitis

Microorganisms

bull Gram - Fusobacterium species Prevotella intermedia

bull Implant failure is usually due to the microbial challenge occlusal load or excessive cementndash Cement has been found in the tissues

bull Failure is evidenced by gt2 mm MOBILITY

bull Bone loss buccal and lingual results in dehiscence

Cement Implantitis

New AAP Case definitionPeri-implantitis

bull BOP

bull Probing depth gt 6 mm

bull Bone levels gt 3 mm apical of the most coronal portion of the intraosseous part of the implant

Caton J Armitage G Berglundh T Et al A new classification scheme for periodontal and peri‐implant diseases and conditions ndash Introduction and key changes from the 1999 classification Journal of Periodontology 89 S1 (S1-S8) (2018)

Failing Criteria

bull Ailing (Peri-implant mucositis) inflammation present but no mobility

ndash bone appears normal or there may be an incipient lesion

bull Failing Peri-implantitis without mobility

ndash Inflammation has progressed to the bone as evidenced by radiographic lesion

bull Failed Peri-implantitis with mobility

ndash Implant has pronounced bone loss

Probing amp BOP

bull Metal probes on prosthetic part of the crown is fine

bull Some are concerned with metal probes on the threads

bull Must probe implants

bull Probe depths are generally deeper than natural tooth

bull BOP is not normal

threads

13

Treatment

bull Be aggressive amp prevent bone loss because very difficult to treat once initiated

bull Treatment

ndash Debride thoroughly

ndash Chlorhexidine

ndash Systemic antibiotics

ndash Bone grafts

ndash Arestin- local drug delivery

ndash Air flow polishing with glycine

Diagnosis Severity

bull Determining severity is based on CAL and bone loss

bull Clinical attachment level (CAL)

ndashdistance from the junctional epithelium to the CEJ

bull Probe depths alone are lacking because it does not take in account the gingival margin

ndashusing probe depths alone can result in over estimating or underestimating disease

Three possible relationships for gingival margin and CEJ

bull Gingival margin could be coronal to CEJ

bull Gingival margin could be level with CEJ

bull Gingival margin could be apical to CEJ

GM

bull Where should the GM be normallyndash 1-2 mm coronal to the CEJ

bull What is the pattern of CEJs interproximallyacross the mouthndash More Flat on the Posteriors

ndash More Curvature on the Anteriors

ndash For interproximal space look at the papillae does it fill the embrasure space

ndash A normal GM on the anteriors could be +1mm

ndash A normal GM on the posteriors could be +2 mm

Clinical attachment level

Depends on position of the gingival margin and CEJ

bull Gingival margin could be coronal to CEJ (-)

bull Gingival margin could be level with CEJ (same)

bull Gingival margin could be apical to CEJ (+)

Measuring CAL when gingival margin is coronal to CEJ

1 Measure probe depth

2 Measure from gingival margin to CEJ

3 Subtract second measurement from overall probe depth

FYI-This is a color

coded probe w

markings at 36912

14

Measuring CAL when gingival margin is levelwith CEJ

bull Probe depth is Clinical attachment level

Measuring CAL when gingival margin is apical to CEJ

bull Measure probe depthbull Measure recessionbull Add recession to probe depth

Grading

Bone Loss

Stage 1

Coronal 13

lt 15

Coronal 13

Mid 13

Last 13

15 Normal bone Height

33 stage 2

Stage 3Extends to mid third of root amp beyondStage 4Extends to mid third of root amp beyond

Stage 1

stage 3 amp 4

Predicting Activity

bull BOP

ndash 50 of all bleeding sites will not break down

ndash 50 of all bleeding sites will breakdown

ndash Sites that do not bleed will not breakdown

ndash The absence of bleeding provides more information than whether bleeding exists

ndash Therefore when sites bleed we say it is active

bull Inflammation

bull Nutrient canals

bull Rough looking crestal bone vs smooth amp well demarcated may indicate activity

15

Predicting Activity

bull Nutrient canals

ndash Highly visible canals may indicate active or rapid destruction

ndash canals are thought to be engorged large blood vessels

Crestal Bone

Rough looking crestal boneSmoother more demarcated crestal bone

Planningbull Systematic Informed consent

bull Diagnosis prognosis options risks benefits

ndashPatients must have all the information

bull Studies indicate slight reductions in PD s gt 6 mm after full-mouth scaling and root planingperformed in one appointment vs over longer intervals

bull These protocols particularly effective in patients with aggressive periodontitis andor pts w systemic conditions

Eberhard J et al J Clin Periodontol 200835591ndash604 amp Fang et al J Periodont Res October 19 2015)

ImplementationTreatment

bull Goals are to eliminate infection and risk factorsbull The objective is to remove all clinically detectable

calculus without excessive root planingndash bacterial endotoxins are weakly adherent to the root

surface (Nakib 1982)

bull The term debridement vs root planing

ImplementationTreatment

bull Treat patientrsquos significant otherbull 40 of the time spouses have the

same microbiotabull Donrsquot kiss dogs amp cats- they may have

periobull Avoid gross scaling

bull risk of abscessbull educationbull more difficult to re-insert

instruments

16

Air Polishing with glycine

ndashGlycine has anti inflammatory ampimmune modulation effectsbull Glycine receptor gingival tissue

ndashPerpulsionndashFDA approval for lt5 mmndashRemoval biofilm amp stainndashPerio maintenance ndashImplantsndashDecontaminate prior to grafts

Host-Modulating Treatmentbull Treating periodontitis by trying to resolve

inflammation

bull Resolvins

ndash Omega 3 Fatty acids correlated with less bone loss

ndash may be due to their ability to generate mediators that fight inflammation and aid in inflammation resolution

bull Low-dose doxycycline 20 mg 2x daily

ndash Matrix metalloproteinase inhibitor is the only FDA-approved

ndash Reduction of PD amp CAL gain over 3 months to 9 monthsGolub LM et al Doxycycline i hibits neutrophil (PMN)-type matrix metalloproteinases in human adult periodontitis gingiva J Clin Periodontol 199522100ndash109 amp

Golub LM et al Adjunctive treatment with subantimicrobial doses of doxycycline effects on gingival fluid collagenase activity and attachment loss in adult periodontitis J Clin Periodontol 200128146ndash156

Host-Modulating Treatment

bull NSAIDsndash Reduces PGE 2 which can reduce bone loss

ndash Flurbiprofen and topical (ketorolac)

ndash Case controls demonstrate decrease risk

bull Bisphosphonates ndash Used for treating Pagetrsquos bone pain amp osteoporosis

ndash Alendronate sodium (Fosamax) risedronate (Actonel)

ndash Investigating for its ability to modulate the host

bull Used experimentally in animals to inhibit bone resorption amp bone mineral content amp to interfere w breakdown of collagen in the periodontium

ndash WARNING case reports of bone necrosis after extractions

bull questions scrtpl w pts on drug

Treatment

bull Statins have an anti-inflammatory and immune effects reducing levels of C-Reactive Protein MMP Tumor Necrosis Factor-α

ndash Statins reduce bone resorption by inhibiting osteoclast formation

ndash Some results show lower alveolar bone loss and reduction of clinical signs of inflammation

(meta anyalsis Estanislau etal J Clin Pharmacol 2014 Dec)

ndash Topical gels (simvastatin atorvastatin)

Treatment

bull Probioticsndash Improved biofilm index and probe depths (Shimauchi 2008)

bull Valtrexbull Photodynamic therapy

ndash Light-sensitive drug is applied then a light laser directly on the area treated with the drug

ndash When the light is combined with the drug phototoxic reactions are induced which destroy bacterial cells

ndash Shows short term benefits (Sgolastra 2012)bull Periowave

bull Emdogainndash Enamel matrix derivative for periodontal tissue regeneration in

infrabony defects amp used w SRP to enhance resultsbull Derived from developing pig teethbull Stimulate adherence attachment to cementum

Treatmentbull Topical antioxidants

ndash Antioxidant gel and rinse

ndash Periosciences ndash toothpaste rinse gel

ndash Topical coenzyme COQ10

bull Due to correlation w perio oxidative stress markers amp low level of natural occurring salivary antioxidants looking at polyphenolsantioxidants in the mouth locally delivered

ndash needs more research

bull Hyaluronic acid (HA) gel and mouth rinsendash hyaluronic acid plays a large role in the collagen building 02

hyaluronan gel topically amp subgingivally

ndash Studies have been done to evaluate on wound healing amp improving perio outcomes

ndash Further evidence is needed

11

Thin Gingival Phenotype

bull Triangle shaped teeth vs square

bull Thin tissue

bull Susceptible to recession

bull Dehiscence present

bull Instrumentation must be done

Carefully due to thin biotype

bull Reacts to insult by recession

Thick amp Flat Gingival Phenotype

bull Square shaped

bull Thick tissue

bull Susceptible to pocketing

bull Reacts to insult by pocketing

Thick Scalloped

bull Thick fibrotic gingiva

bull Slender teeth

bull Narrow zone of KT

bull Gingival scalloping

Recession

Type 1 Type 2

Interproximal CEJ

is clinically not

detectable

The amount of

interproximal

attachment loss

is lt to buccal

Type 3

The amount of

interproximal

attachment loss

is gt

buccal

attachment loss

Implants

bull Treat perio prior to implantsbull It takes 2 weeks for the implants to

become colonized by the surrounding teeth

bull No horizontal fibers like a tooth so infection goes straight to bone and perio happens very quickly

bull This perimucosal seal is delicate ndashBe careful during instrumentation

12

Implants

bull The implant coatingsrough surfaces may create more risk for implantitis but better for osteointergration

ndash The calculus is more embedded on these surfaces than the previous smoother surfaces

Stages of Peri-implant DiseasePeri-implant mucositis

bull Reversible inflammation of the soft tissues

bull Occurs in about 50 of implants placed within 9 - 14 years

Peri-implantitis

bull Bone Loss

bull Occurs in 12- 47 of implants 5 years after placement

bull Risk factors-Hx of severe perio poor self care amp lack of maintenance care

bull Cement Implantitis

bull Some evidence linking cement and titanium particles bio corrosion

Peri-implantitis

Microorganisms

bull Gram - Fusobacterium species Prevotella intermedia

bull Implant failure is usually due to the microbial challenge occlusal load or excessive cementndash Cement has been found in the tissues

bull Failure is evidenced by gt2 mm MOBILITY

bull Bone loss buccal and lingual results in dehiscence

Cement Implantitis

New AAP Case definitionPeri-implantitis

bull BOP

bull Probing depth gt 6 mm

bull Bone levels gt 3 mm apical of the most coronal portion of the intraosseous part of the implant

Caton J Armitage G Berglundh T Et al A new classification scheme for periodontal and peri‐implant diseases and conditions ndash Introduction and key changes from the 1999 classification Journal of Periodontology 89 S1 (S1-S8) (2018)

Failing Criteria

bull Ailing (Peri-implant mucositis) inflammation present but no mobility

ndash bone appears normal or there may be an incipient lesion

bull Failing Peri-implantitis without mobility

ndash Inflammation has progressed to the bone as evidenced by radiographic lesion

bull Failed Peri-implantitis with mobility

ndash Implant has pronounced bone loss

Probing amp BOP

bull Metal probes on prosthetic part of the crown is fine

bull Some are concerned with metal probes on the threads

bull Must probe implants

bull Probe depths are generally deeper than natural tooth

bull BOP is not normal

threads

13

Treatment

bull Be aggressive amp prevent bone loss because very difficult to treat once initiated

bull Treatment

ndash Debride thoroughly

ndash Chlorhexidine

ndash Systemic antibiotics

ndash Bone grafts

ndash Arestin- local drug delivery

ndash Air flow polishing with glycine

Diagnosis Severity

bull Determining severity is based on CAL and bone loss

bull Clinical attachment level (CAL)

ndashdistance from the junctional epithelium to the CEJ

bull Probe depths alone are lacking because it does not take in account the gingival margin

ndashusing probe depths alone can result in over estimating or underestimating disease

Three possible relationships for gingival margin and CEJ

bull Gingival margin could be coronal to CEJ

bull Gingival margin could be level with CEJ

bull Gingival margin could be apical to CEJ

GM

bull Where should the GM be normallyndash 1-2 mm coronal to the CEJ

bull What is the pattern of CEJs interproximallyacross the mouthndash More Flat on the Posteriors

ndash More Curvature on the Anteriors

ndash For interproximal space look at the papillae does it fill the embrasure space

ndash A normal GM on the anteriors could be +1mm

ndash A normal GM on the posteriors could be +2 mm

Clinical attachment level

Depends on position of the gingival margin and CEJ

bull Gingival margin could be coronal to CEJ (-)

bull Gingival margin could be level with CEJ (same)

bull Gingival margin could be apical to CEJ (+)

Measuring CAL when gingival margin is coronal to CEJ

1 Measure probe depth

2 Measure from gingival margin to CEJ

3 Subtract second measurement from overall probe depth

FYI-This is a color

coded probe w

markings at 36912

14

Measuring CAL when gingival margin is levelwith CEJ

bull Probe depth is Clinical attachment level

Measuring CAL when gingival margin is apical to CEJ

bull Measure probe depthbull Measure recessionbull Add recession to probe depth

Grading

Bone Loss

Stage 1

Coronal 13

lt 15

Coronal 13

Mid 13

Last 13

15 Normal bone Height

33 stage 2

Stage 3Extends to mid third of root amp beyondStage 4Extends to mid third of root amp beyond

Stage 1

stage 3 amp 4

Predicting Activity

bull BOP

ndash 50 of all bleeding sites will not break down

ndash 50 of all bleeding sites will breakdown

ndash Sites that do not bleed will not breakdown

ndash The absence of bleeding provides more information than whether bleeding exists

ndash Therefore when sites bleed we say it is active

bull Inflammation

bull Nutrient canals

bull Rough looking crestal bone vs smooth amp well demarcated may indicate activity

15

Predicting Activity

bull Nutrient canals

ndash Highly visible canals may indicate active or rapid destruction

ndash canals are thought to be engorged large blood vessels

Crestal Bone

Rough looking crestal boneSmoother more demarcated crestal bone

Planningbull Systematic Informed consent

bull Diagnosis prognosis options risks benefits

ndashPatients must have all the information

bull Studies indicate slight reductions in PD s gt 6 mm after full-mouth scaling and root planingperformed in one appointment vs over longer intervals

bull These protocols particularly effective in patients with aggressive periodontitis andor pts w systemic conditions

Eberhard J et al J Clin Periodontol 200835591ndash604 amp Fang et al J Periodont Res October 19 2015)

ImplementationTreatment

bull Goals are to eliminate infection and risk factorsbull The objective is to remove all clinically detectable

calculus without excessive root planingndash bacterial endotoxins are weakly adherent to the root

surface (Nakib 1982)

bull The term debridement vs root planing

ImplementationTreatment

bull Treat patientrsquos significant otherbull 40 of the time spouses have the

same microbiotabull Donrsquot kiss dogs amp cats- they may have

periobull Avoid gross scaling

bull risk of abscessbull educationbull more difficult to re-insert

instruments

16

Air Polishing with glycine

ndashGlycine has anti inflammatory ampimmune modulation effectsbull Glycine receptor gingival tissue

ndashPerpulsionndashFDA approval for lt5 mmndashRemoval biofilm amp stainndashPerio maintenance ndashImplantsndashDecontaminate prior to grafts

Host-Modulating Treatmentbull Treating periodontitis by trying to resolve

inflammation

bull Resolvins

ndash Omega 3 Fatty acids correlated with less bone loss

ndash may be due to their ability to generate mediators that fight inflammation and aid in inflammation resolution

bull Low-dose doxycycline 20 mg 2x daily

ndash Matrix metalloproteinase inhibitor is the only FDA-approved

ndash Reduction of PD amp CAL gain over 3 months to 9 monthsGolub LM et al Doxycycline i hibits neutrophil (PMN)-type matrix metalloproteinases in human adult periodontitis gingiva J Clin Periodontol 199522100ndash109 amp

Golub LM et al Adjunctive treatment with subantimicrobial doses of doxycycline effects on gingival fluid collagenase activity and attachment loss in adult periodontitis J Clin Periodontol 200128146ndash156

Host-Modulating Treatment

bull NSAIDsndash Reduces PGE 2 which can reduce bone loss

ndash Flurbiprofen and topical (ketorolac)

ndash Case controls demonstrate decrease risk

bull Bisphosphonates ndash Used for treating Pagetrsquos bone pain amp osteoporosis

ndash Alendronate sodium (Fosamax) risedronate (Actonel)

ndash Investigating for its ability to modulate the host

bull Used experimentally in animals to inhibit bone resorption amp bone mineral content amp to interfere w breakdown of collagen in the periodontium

ndash WARNING case reports of bone necrosis after extractions

bull questions scrtpl w pts on drug

Treatment

bull Statins have an anti-inflammatory and immune effects reducing levels of C-Reactive Protein MMP Tumor Necrosis Factor-α

ndash Statins reduce bone resorption by inhibiting osteoclast formation

ndash Some results show lower alveolar bone loss and reduction of clinical signs of inflammation

(meta anyalsis Estanislau etal J Clin Pharmacol 2014 Dec)

ndash Topical gels (simvastatin atorvastatin)

Treatment

bull Probioticsndash Improved biofilm index and probe depths (Shimauchi 2008)

bull Valtrexbull Photodynamic therapy

ndash Light-sensitive drug is applied then a light laser directly on the area treated with the drug

ndash When the light is combined with the drug phototoxic reactions are induced which destroy bacterial cells

ndash Shows short term benefits (Sgolastra 2012)bull Periowave

bull Emdogainndash Enamel matrix derivative for periodontal tissue regeneration in

infrabony defects amp used w SRP to enhance resultsbull Derived from developing pig teethbull Stimulate adherence attachment to cementum

Treatmentbull Topical antioxidants

ndash Antioxidant gel and rinse

ndash Periosciences ndash toothpaste rinse gel

ndash Topical coenzyme COQ10

bull Due to correlation w perio oxidative stress markers amp low level of natural occurring salivary antioxidants looking at polyphenolsantioxidants in the mouth locally delivered

ndash needs more research

bull Hyaluronic acid (HA) gel and mouth rinsendash hyaluronic acid plays a large role in the collagen building 02

hyaluronan gel topically amp subgingivally

ndash Studies have been done to evaluate on wound healing amp improving perio outcomes

ndash Further evidence is needed

12

Implants

bull The implant coatingsrough surfaces may create more risk for implantitis but better for osteointergration

ndash The calculus is more embedded on these surfaces than the previous smoother surfaces

Stages of Peri-implant DiseasePeri-implant mucositis

bull Reversible inflammation of the soft tissues

bull Occurs in about 50 of implants placed within 9 - 14 years

Peri-implantitis

bull Bone Loss

bull Occurs in 12- 47 of implants 5 years after placement

bull Risk factors-Hx of severe perio poor self care amp lack of maintenance care

bull Cement Implantitis

bull Some evidence linking cement and titanium particles bio corrosion

Peri-implantitis

Microorganisms

bull Gram - Fusobacterium species Prevotella intermedia

bull Implant failure is usually due to the microbial challenge occlusal load or excessive cementndash Cement has been found in the tissues

bull Failure is evidenced by gt2 mm MOBILITY

bull Bone loss buccal and lingual results in dehiscence

Cement Implantitis

New AAP Case definitionPeri-implantitis

bull BOP

bull Probing depth gt 6 mm

bull Bone levels gt 3 mm apical of the most coronal portion of the intraosseous part of the implant

Caton J Armitage G Berglundh T Et al A new classification scheme for periodontal and peri‐implant diseases and conditions ndash Introduction and key changes from the 1999 classification Journal of Periodontology 89 S1 (S1-S8) (2018)

Failing Criteria

bull Ailing (Peri-implant mucositis) inflammation present but no mobility

ndash bone appears normal or there may be an incipient lesion

bull Failing Peri-implantitis without mobility

ndash Inflammation has progressed to the bone as evidenced by radiographic lesion

bull Failed Peri-implantitis with mobility

ndash Implant has pronounced bone loss

Probing amp BOP

bull Metal probes on prosthetic part of the crown is fine

bull Some are concerned with metal probes on the threads

bull Must probe implants

bull Probe depths are generally deeper than natural tooth

bull BOP is not normal

threads

13

Treatment

bull Be aggressive amp prevent bone loss because very difficult to treat once initiated

bull Treatment

ndash Debride thoroughly

ndash Chlorhexidine

ndash Systemic antibiotics

ndash Bone grafts

ndash Arestin- local drug delivery

ndash Air flow polishing with glycine

Diagnosis Severity

bull Determining severity is based on CAL and bone loss

bull Clinical attachment level (CAL)

ndashdistance from the junctional epithelium to the CEJ

bull Probe depths alone are lacking because it does not take in account the gingival margin

ndashusing probe depths alone can result in over estimating or underestimating disease

Three possible relationships for gingival margin and CEJ

bull Gingival margin could be coronal to CEJ

bull Gingival margin could be level with CEJ

bull Gingival margin could be apical to CEJ

GM

bull Where should the GM be normallyndash 1-2 mm coronal to the CEJ

bull What is the pattern of CEJs interproximallyacross the mouthndash More Flat on the Posteriors

ndash More Curvature on the Anteriors

ndash For interproximal space look at the papillae does it fill the embrasure space

ndash A normal GM on the anteriors could be +1mm

ndash A normal GM on the posteriors could be +2 mm

Clinical attachment level

Depends on position of the gingival margin and CEJ

bull Gingival margin could be coronal to CEJ (-)

bull Gingival margin could be level with CEJ (same)

bull Gingival margin could be apical to CEJ (+)

Measuring CAL when gingival margin is coronal to CEJ

1 Measure probe depth

2 Measure from gingival margin to CEJ

3 Subtract second measurement from overall probe depth

FYI-This is a color

coded probe w

markings at 36912

14

Measuring CAL when gingival margin is levelwith CEJ

bull Probe depth is Clinical attachment level

Measuring CAL when gingival margin is apical to CEJ

bull Measure probe depthbull Measure recessionbull Add recession to probe depth

Grading

Bone Loss

Stage 1

Coronal 13

lt 15

Coronal 13

Mid 13

Last 13

15 Normal bone Height

33 stage 2

Stage 3Extends to mid third of root amp beyondStage 4Extends to mid third of root amp beyond

Stage 1

stage 3 amp 4

Predicting Activity

bull BOP

ndash 50 of all bleeding sites will not break down

ndash 50 of all bleeding sites will breakdown

ndash Sites that do not bleed will not breakdown

ndash The absence of bleeding provides more information than whether bleeding exists

ndash Therefore when sites bleed we say it is active

bull Inflammation

bull Nutrient canals

bull Rough looking crestal bone vs smooth amp well demarcated may indicate activity

15

Predicting Activity

bull Nutrient canals

ndash Highly visible canals may indicate active or rapid destruction

ndash canals are thought to be engorged large blood vessels

Crestal Bone

Rough looking crestal boneSmoother more demarcated crestal bone

Planningbull Systematic Informed consent

bull Diagnosis prognosis options risks benefits

ndashPatients must have all the information

bull Studies indicate slight reductions in PD s gt 6 mm after full-mouth scaling and root planingperformed in one appointment vs over longer intervals

bull These protocols particularly effective in patients with aggressive periodontitis andor pts w systemic conditions

Eberhard J et al J Clin Periodontol 200835591ndash604 amp Fang et al J Periodont Res October 19 2015)

ImplementationTreatment

bull Goals are to eliminate infection and risk factorsbull The objective is to remove all clinically detectable

calculus without excessive root planingndash bacterial endotoxins are weakly adherent to the root

surface (Nakib 1982)

bull The term debridement vs root planing

ImplementationTreatment

bull Treat patientrsquos significant otherbull 40 of the time spouses have the

same microbiotabull Donrsquot kiss dogs amp cats- they may have

periobull Avoid gross scaling

bull risk of abscessbull educationbull more difficult to re-insert

instruments

16

Air Polishing with glycine

ndashGlycine has anti inflammatory ampimmune modulation effectsbull Glycine receptor gingival tissue

ndashPerpulsionndashFDA approval for lt5 mmndashRemoval biofilm amp stainndashPerio maintenance ndashImplantsndashDecontaminate prior to grafts

Host-Modulating Treatmentbull Treating periodontitis by trying to resolve

inflammation

bull Resolvins

ndash Omega 3 Fatty acids correlated with less bone loss

ndash may be due to their ability to generate mediators that fight inflammation and aid in inflammation resolution

bull Low-dose doxycycline 20 mg 2x daily

ndash Matrix metalloproteinase inhibitor is the only FDA-approved

ndash Reduction of PD amp CAL gain over 3 months to 9 monthsGolub LM et al Doxycycline i hibits neutrophil (PMN)-type matrix metalloproteinases in human adult periodontitis gingiva J Clin Periodontol 199522100ndash109 amp

Golub LM et al Adjunctive treatment with subantimicrobial doses of doxycycline effects on gingival fluid collagenase activity and attachment loss in adult periodontitis J Clin Periodontol 200128146ndash156

Host-Modulating Treatment

bull NSAIDsndash Reduces PGE 2 which can reduce bone loss

ndash Flurbiprofen and topical (ketorolac)

ndash Case controls demonstrate decrease risk

bull Bisphosphonates ndash Used for treating Pagetrsquos bone pain amp osteoporosis

ndash Alendronate sodium (Fosamax) risedronate (Actonel)

ndash Investigating for its ability to modulate the host

bull Used experimentally in animals to inhibit bone resorption amp bone mineral content amp to interfere w breakdown of collagen in the periodontium

ndash WARNING case reports of bone necrosis after extractions

bull questions scrtpl w pts on drug

Treatment

bull Statins have an anti-inflammatory and immune effects reducing levels of C-Reactive Protein MMP Tumor Necrosis Factor-α

ndash Statins reduce bone resorption by inhibiting osteoclast formation

ndash Some results show lower alveolar bone loss and reduction of clinical signs of inflammation

(meta anyalsis Estanislau etal J Clin Pharmacol 2014 Dec)

ndash Topical gels (simvastatin atorvastatin)

Treatment

bull Probioticsndash Improved biofilm index and probe depths (Shimauchi 2008)

bull Valtrexbull Photodynamic therapy

ndash Light-sensitive drug is applied then a light laser directly on the area treated with the drug

ndash When the light is combined with the drug phototoxic reactions are induced which destroy bacterial cells

ndash Shows short term benefits (Sgolastra 2012)bull Periowave

bull Emdogainndash Enamel matrix derivative for periodontal tissue regeneration in

infrabony defects amp used w SRP to enhance resultsbull Derived from developing pig teethbull Stimulate adherence attachment to cementum

Treatmentbull Topical antioxidants

ndash Antioxidant gel and rinse

ndash Periosciences ndash toothpaste rinse gel

ndash Topical coenzyme COQ10

bull Due to correlation w perio oxidative stress markers amp low level of natural occurring salivary antioxidants looking at polyphenolsantioxidants in the mouth locally delivered

ndash needs more research

bull Hyaluronic acid (HA) gel and mouth rinsendash hyaluronic acid plays a large role in the collagen building 02

hyaluronan gel topically amp subgingivally

ndash Studies have been done to evaluate on wound healing amp improving perio outcomes

ndash Further evidence is needed

13

Treatment

bull Be aggressive amp prevent bone loss because very difficult to treat once initiated

bull Treatment

ndash Debride thoroughly

ndash Chlorhexidine

ndash Systemic antibiotics

ndash Bone grafts

ndash Arestin- local drug delivery

ndash Air flow polishing with glycine

Diagnosis Severity

bull Determining severity is based on CAL and bone loss

bull Clinical attachment level (CAL)

ndashdistance from the junctional epithelium to the CEJ

bull Probe depths alone are lacking because it does not take in account the gingival margin

ndashusing probe depths alone can result in over estimating or underestimating disease

Three possible relationships for gingival margin and CEJ

bull Gingival margin could be coronal to CEJ

bull Gingival margin could be level with CEJ

bull Gingival margin could be apical to CEJ

GM

bull Where should the GM be normallyndash 1-2 mm coronal to the CEJ

bull What is the pattern of CEJs interproximallyacross the mouthndash More Flat on the Posteriors

ndash More Curvature on the Anteriors

ndash For interproximal space look at the papillae does it fill the embrasure space

ndash A normal GM on the anteriors could be +1mm

ndash A normal GM on the posteriors could be +2 mm

Clinical attachment level

Depends on position of the gingival margin and CEJ

bull Gingival margin could be coronal to CEJ (-)

bull Gingival margin could be level with CEJ (same)

bull Gingival margin could be apical to CEJ (+)

Measuring CAL when gingival margin is coronal to CEJ

1 Measure probe depth

2 Measure from gingival margin to CEJ

3 Subtract second measurement from overall probe depth

FYI-This is a color

coded probe w

markings at 36912

14

Measuring CAL when gingival margin is levelwith CEJ

bull Probe depth is Clinical attachment level

Measuring CAL when gingival margin is apical to CEJ

bull Measure probe depthbull Measure recessionbull Add recession to probe depth

Grading

Bone Loss

Stage 1

Coronal 13

lt 15

Coronal 13

Mid 13

Last 13

15 Normal bone Height

33 stage 2

Stage 3Extends to mid third of root amp beyondStage 4Extends to mid third of root amp beyond

Stage 1

stage 3 amp 4

Predicting Activity

bull BOP

ndash 50 of all bleeding sites will not break down

ndash 50 of all bleeding sites will breakdown

ndash Sites that do not bleed will not breakdown

ndash The absence of bleeding provides more information than whether bleeding exists

ndash Therefore when sites bleed we say it is active

bull Inflammation

bull Nutrient canals

bull Rough looking crestal bone vs smooth amp well demarcated may indicate activity

15

Predicting Activity

bull Nutrient canals

ndash Highly visible canals may indicate active or rapid destruction

ndash canals are thought to be engorged large blood vessels

Crestal Bone

Rough looking crestal boneSmoother more demarcated crestal bone

Planningbull Systematic Informed consent

bull Diagnosis prognosis options risks benefits

ndashPatients must have all the information

bull Studies indicate slight reductions in PD s gt 6 mm after full-mouth scaling and root planingperformed in one appointment vs over longer intervals

bull These protocols particularly effective in patients with aggressive periodontitis andor pts w systemic conditions

Eberhard J et al J Clin Periodontol 200835591ndash604 amp Fang et al J Periodont Res October 19 2015)

ImplementationTreatment

bull Goals are to eliminate infection and risk factorsbull The objective is to remove all clinically detectable

calculus without excessive root planingndash bacterial endotoxins are weakly adherent to the root

surface (Nakib 1982)

bull The term debridement vs root planing

ImplementationTreatment

bull Treat patientrsquos significant otherbull 40 of the time spouses have the

same microbiotabull Donrsquot kiss dogs amp cats- they may have

periobull Avoid gross scaling

bull risk of abscessbull educationbull more difficult to re-insert

instruments

16

Air Polishing with glycine

ndashGlycine has anti inflammatory ampimmune modulation effectsbull Glycine receptor gingival tissue

ndashPerpulsionndashFDA approval for lt5 mmndashRemoval biofilm amp stainndashPerio maintenance ndashImplantsndashDecontaminate prior to grafts

Host-Modulating Treatmentbull Treating periodontitis by trying to resolve

inflammation

bull Resolvins

ndash Omega 3 Fatty acids correlated with less bone loss

ndash may be due to their ability to generate mediators that fight inflammation and aid in inflammation resolution

bull Low-dose doxycycline 20 mg 2x daily

ndash Matrix metalloproteinase inhibitor is the only FDA-approved

ndash Reduction of PD amp CAL gain over 3 months to 9 monthsGolub LM et al Doxycycline i hibits neutrophil (PMN)-type matrix metalloproteinases in human adult periodontitis gingiva J Clin Periodontol 199522100ndash109 amp

Golub LM et al Adjunctive treatment with subantimicrobial doses of doxycycline effects on gingival fluid collagenase activity and attachment loss in adult periodontitis J Clin Periodontol 200128146ndash156

Host-Modulating Treatment

bull NSAIDsndash Reduces PGE 2 which can reduce bone loss

ndash Flurbiprofen and topical (ketorolac)

ndash Case controls demonstrate decrease risk

bull Bisphosphonates ndash Used for treating Pagetrsquos bone pain amp osteoporosis

ndash Alendronate sodium (Fosamax) risedronate (Actonel)

ndash Investigating for its ability to modulate the host

bull Used experimentally in animals to inhibit bone resorption amp bone mineral content amp to interfere w breakdown of collagen in the periodontium

ndash WARNING case reports of bone necrosis after extractions

bull questions scrtpl w pts on drug

Treatment

bull Statins have an anti-inflammatory and immune effects reducing levels of C-Reactive Protein MMP Tumor Necrosis Factor-α

ndash Statins reduce bone resorption by inhibiting osteoclast formation

ndash Some results show lower alveolar bone loss and reduction of clinical signs of inflammation

(meta anyalsis Estanislau etal J Clin Pharmacol 2014 Dec)

ndash Topical gels (simvastatin atorvastatin)

Treatment

bull Probioticsndash Improved biofilm index and probe depths (Shimauchi 2008)

bull Valtrexbull Photodynamic therapy

ndash Light-sensitive drug is applied then a light laser directly on the area treated with the drug

ndash When the light is combined with the drug phototoxic reactions are induced which destroy bacterial cells

ndash Shows short term benefits (Sgolastra 2012)bull Periowave

bull Emdogainndash Enamel matrix derivative for periodontal tissue regeneration in

infrabony defects amp used w SRP to enhance resultsbull Derived from developing pig teethbull Stimulate adherence attachment to cementum

Treatmentbull Topical antioxidants

ndash Antioxidant gel and rinse

ndash Periosciences ndash toothpaste rinse gel

ndash Topical coenzyme COQ10

bull Due to correlation w perio oxidative stress markers amp low level of natural occurring salivary antioxidants looking at polyphenolsantioxidants in the mouth locally delivered

ndash needs more research

bull Hyaluronic acid (HA) gel and mouth rinsendash hyaluronic acid plays a large role in the collagen building 02

hyaluronan gel topically amp subgingivally

ndash Studies have been done to evaluate on wound healing amp improving perio outcomes

ndash Further evidence is needed

14

Measuring CAL when gingival margin is levelwith CEJ

bull Probe depth is Clinical attachment level

Measuring CAL when gingival margin is apical to CEJ

bull Measure probe depthbull Measure recessionbull Add recession to probe depth

Grading

Bone Loss

Stage 1

Coronal 13

lt 15

Coronal 13

Mid 13

Last 13

15 Normal bone Height

33 stage 2

Stage 3Extends to mid third of root amp beyondStage 4Extends to mid third of root amp beyond

Stage 1

stage 3 amp 4

Predicting Activity

bull BOP

ndash 50 of all bleeding sites will not break down

ndash 50 of all bleeding sites will breakdown

ndash Sites that do not bleed will not breakdown

ndash The absence of bleeding provides more information than whether bleeding exists

ndash Therefore when sites bleed we say it is active

bull Inflammation

bull Nutrient canals

bull Rough looking crestal bone vs smooth amp well demarcated may indicate activity

15

Predicting Activity

bull Nutrient canals

ndash Highly visible canals may indicate active or rapid destruction

ndash canals are thought to be engorged large blood vessels

Crestal Bone

Rough looking crestal boneSmoother more demarcated crestal bone

Planningbull Systematic Informed consent

bull Diagnosis prognosis options risks benefits

ndashPatients must have all the information

bull Studies indicate slight reductions in PD s gt 6 mm after full-mouth scaling and root planingperformed in one appointment vs over longer intervals

bull These protocols particularly effective in patients with aggressive periodontitis andor pts w systemic conditions

Eberhard J et al J Clin Periodontol 200835591ndash604 amp Fang et al J Periodont Res October 19 2015)

ImplementationTreatment

bull Goals are to eliminate infection and risk factorsbull The objective is to remove all clinically detectable

calculus without excessive root planingndash bacterial endotoxins are weakly adherent to the root

surface (Nakib 1982)

bull The term debridement vs root planing

ImplementationTreatment

bull Treat patientrsquos significant otherbull 40 of the time spouses have the

same microbiotabull Donrsquot kiss dogs amp cats- they may have

periobull Avoid gross scaling

bull risk of abscessbull educationbull more difficult to re-insert

instruments

16

Air Polishing with glycine

ndashGlycine has anti inflammatory ampimmune modulation effectsbull Glycine receptor gingival tissue

ndashPerpulsionndashFDA approval for lt5 mmndashRemoval biofilm amp stainndashPerio maintenance ndashImplantsndashDecontaminate prior to grafts

Host-Modulating Treatmentbull Treating periodontitis by trying to resolve

inflammation

bull Resolvins

ndash Omega 3 Fatty acids correlated with less bone loss

ndash may be due to their ability to generate mediators that fight inflammation and aid in inflammation resolution

bull Low-dose doxycycline 20 mg 2x daily

ndash Matrix metalloproteinase inhibitor is the only FDA-approved

ndash Reduction of PD amp CAL gain over 3 months to 9 monthsGolub LM et al Doxycycline i hibits neutrophil (PMN)-type matrix metalloproteinases in human adult periodontitis gingiva J Clin Periodontol 199522100ndash109 amp

Golub LM et al Adjunctive treatment with subantimicrobial doses of doxycycline effects on gingival fluid collagenase activity and attachment loss in adult periodontitis J Clin Periodontol 200128146ndash156

Host-Modulating Treatment

bull NSAIDsndash Reduces PGE 2 which can reduce bone loss

ndash Flurbiprofen and topical (ketorolac)

ndash Case controls demonstrate decrease risk

bull Bisphosphonates ndash Used for treating Pagetrsquos bone pain amp osteoporosis

ndash Alendronate sodium (Fosamax) risedronate (Actonel)

ndash Investigating for its ability to modulate the host

bull Used experimentally in animals to inhibit bone resorption amp bone mineral content amp to interfere w breakdown of collagen in the periodontium

ndash WARNING case reports of bone necrosis after extractions

bull questions scrtpl w pts on drug

Treatment

bull Statins have an anti-inflammatory and immune effects reducing levels of C-Reactive Protein MMP Tumor Necrosis Factor-α

ndash Statins reduce bone resorption by inhibiting osteoclast formation

ndash Some results show lower alveolar bone loss and reduction of clinical signs of inflammation

(meta anyalsis Estanislau etal J Clin Pharmacol 2014 Dec)

ndash Topical gels (simvastatin atorvastatin)

Treatment

bull Probioticsndash Improved biofilm index and probe depths (Shimauchi 2008)

bull Valtrexbull Photodynamic therapy

ndash Light-sensitive drug is applied then a light laser directly on the area treated with the drug

ndash When the light is combined with the drug phototoxic reactions are induced which destroy bacterial cells

ndash Shows short term benefits (Sgolastra 2012)bull Periowave

bull Emdogainndash Enamel matrix derivative for periodontal tissue regeneration in

infrabony defects amp used w SRP to enhance resultsbull Derived from developing pig teethbull Stimulate adherence attachment to cementum

Treatmentbull Topical antioxidants

ndash Antioxidant gel and rinse

ndash Periosciences ndash toothpaste rinse gel

ndash Topical coenzyme COQ10

bull Due to correlation w perio oxidative stress markers amp low level of natural occurring salivary antioxidants looking at polyphenolsantioxidants in the mouth locally delivered

ndash needs more research

bull Hyaluronic acid (HA) gel and mouth rinsendash hyaluronic acid plays a large role in the collagen building 02

hyaluronan gel topically amp subgingivally

ndash Studies have been done to evaluate on wound healing amp improving perio outcomes

ndash Further evidence is needed

15

Predicting Activity

bull Nutrient canals

ndash Highly visible canals may indicate active or rapid destruction

ndash canals are thought to be engorged large blood vessels

Crestal Bone

Rough looking crestal boneSmoother more demarcated crestal bone

Planningbull Systematic Informed consent

bull Diagnosis prognosis options risks benefits

ndashPatients must have all the information

bull Studies indicate slight reductions in PD s gt 6 mm after full-mouth scaling and root planingperformed in one appointment vs over longer intervals

bull These protocols particularly effective in patients with aggressive periodontitis andor pts w systemic conditions

Eberhard J et al J Clin Periodontol 200835591ndash604 amp Fang et al J Periodont Res October 19 2015)

ImplementationTreatment

bull Goals are to eliminate infection and risk factorsbull The objective is to remove all clinically detectable

calculus without excessive root planingndash bacterial endotoxins are weakly adherent to the root

surface (Nakib 1982)

bull The term debridement vs root planing

ImplementationTreatment

bull Treat patientrsquos significant otherbull 40 of the time spouses have the

same microbiotabull Donrsquot kiss dogs amp cats- they may have

periobull Avoid gross scaling

bull risk of abscessbull educationbull more difficult to re-insert

instruments

16

Air Polishing with glycine

ndashGlycine has anti inflammatory ampimmune modulation effectsbull Glycine receptor gingival tissue

ndashPerpulsionndashFDA approval for lt5 mmndashRemoval biofilm amp stainndashPerio maintenance ndashImplantsndashDecontaminate prior to grafts

Host-Modulating Treatmentbull Treating periodontitis by trying to resolve

inflammation

bull Resolvins

ndash Omega 3 Fatty acids correlated with less bone loss

ndash may be due to their ability to generate mediators that fight inflammation and aid in inflammation resolution

bull Low-dose doxycycline 20 mg 2x daily

ndash Matrix metalloproteinase inhibitor is the only FDA-approved

ndash Reduction of PD amp CAL gain over 3 months to 9 monthsGolub LM et al Doxycycline i hibits neutrophil (PMN)-type matrix metalloproteinases in human adult periodontitis gingiva J Clin Periodontol 199522100ndash109 amp

Golub LM et al Adjunctive treatment with subantimicrobial doses of doxycycline effects on gingival fluid collagenase activity and attachment loss in adult periodontitis J Clin Periodontol 200128146ndash156

Host-Modulating Treatment

bull NSAIDsndash Reduces PGE 2 which can reduce bone loss

ndash Flurbiprofen and topical (ketorolac)

ndash Case controls demonstrate decrease risk

bull Bisphosphonates ndash Used for treating Pagetrsquos bone pain amp osteoporosis

ndash Alendronate sodium (Fosamax) risedronate (Actonel)

ndash Investigating for its ability to modulate the host

bull Used experimentally in animals to inhibit bone resorption amp bone mineral content amp to interfere w breakdown of collagen in the periodontium

ndash WARNING case reports of bone necrosis after extractions

bull questions scrtpl w pts on drug

Treatment

bull Statins have an anti-inflammatory and immune effects reducing levels of C-Reactive Protein MMP Tumor Necrosis Factor-α

ndash Statins reduce bone resorption by inhibiting osteoclast formation

ndash Some results show lower alveolar bone loss and reduction of clinical signs of inflammation

(meta anyalsis Estanislau etal J Clin Pharmacol 2014 Dec)

ndash Topical gels (simvastatin atorvastatin)

Treatment

bull Probioticsndash Improved biofilm index and probe depths (Shimauchi 2008)

bull Valtrexbull Photodynamic therapy

ndash Light-sensitive drug is applied then a light laser directly on the area treated with the drug

ndash When the light is combined with the drug phototoxic reactions are induced which destroy bacterial cells

ndash Shows short term benefits (Sgolastra 2012)bull Periowave

bull Emdogainndash Enamel matrix derivative for periodontal tissue regeneration in

infrabony defects amp used w SRP to enhance resultsbull Derived from developing pig teethbull Stimulate adherence attachment to cementum

Treatmentbull Topical antioxidants

ndash Antioxidant gel and rinse

ndash Periosciences ndash toothpaste rinse gel

ndash Topical coenzyme COQ10

bull Due to correlation w perio oxidative stress markers amp low level of natural occurring salivary antioxidants looking at polyphenolsantioxidants in the mouth locally delivered

ndash needs more research

bull Hyaluronic acid (HA) gel and mouth rinsendash hyaluronic acid plays a large role in the collagen building 02

hyaluronan gel topically amp subgingivally

ndash Studies have been done to evaluate on wound healing amp improving perio outcomes

ndash Further evidence is needed

16

Air Polishing with glycine

ndashGlycine has anti inflammatory ampimmune modulation effectsbull Glycine receptor gingival tissue

ndashPerpulsionndashFDA approval for lt5 mmndashRemoval biofilm amp stainndashPerio maintenance ndashImplantsndashDecontaminate prior to grafts

Host-Modulating Treatmentbull Treating periodontitis by trying to resolve

inflammation

bull Resolvins

ndash Omega 3 Fatty acids correlated with less bone loss

ndash may be due to their ability to generate mediators that fight inflammation and aid in inflammation resolution

bull Low-dose doxycycline 20 mg 2x daily

ndash Matrix metalloproteinase inhibitor is the only FDA-approved

ndash Reduction of PD amp CAL gain over 3 months to 9 monthsGolub LM et al Doxycycline i hibits neutrophil (PMN)-type matrix metalloproteinases in human adult periodontitis gingiva J Clin Periodontol 199522100ndash109 amp

Golub LM et al Adjunctive treatment with subantimicrobial doses of doxycycline effects on gingival fluid collagenase activity and attachment loss in adult periodontitis J Clin Periodontol 200128146ndash156

Host-Modulating Treatment

bull NSAIDsndash Reduces PGE 2 which can reduce bone loss

ndash Flurbiprofen and topical (ketorolac)

ndash Case controls demonstrate decrease risk

bull Bisphosphonates ndash Used for treating Pagetrsquos bone pain amp osteoporosis

ndash Alendronate sodium (Fosamax) risedronate (Actonel)

ndash Investigating for its ability to modulate the host

bull Used experimentally in animals to inhibit bone resorption amp bone mineral content amp to interfere w breakdown of collagen in the periodontium

ndash WARNING case reports of bone necrosis after extractions

bull questions scrtpl w pts on drug

Treatment

bull Statins have an anti-inflammatory and immune effects reducing levels of C-Reactive Protein MMP Tumor Necrosis Factor-α

ndash Statins reduce bone resorption by inhibiting osteoclast formation

ndash Some results show lower alveolar bone loss and reduction of clinical signs of inflammation

(meta anyalsis Estanislau etal J Clin Pharmacol 2014 Dec)

ndash Topical gels (simvastatin atorvastatin)

Treatment

bull Probioticsndash Improved biofilm index and probe depths (Shimauchi 2008)

bull Valtrexbull Photodynamic therapy

ndash Light-sensitive drug is applied then a light laser directly on the area treated with the drug

ndash When the light is combined with the drug phototoxic reactions are induced which destroy bacterial cells

ndash Shows short term benefits (Sgolastra 2012)bull Periowave

bull Emdogainndash Enamel matrix derivative for periodontal tissue regeneration in

infrabony defects amp used w SRP to enhance resultsbull Derived from developing pig teethbull Stimulate adherence attachment to cementum

Treatmentbull Topical antioxidants

ndash Antioxidant gel and rinse

ndash Periosciences ndash toothpaste rinse gel

ndash Topical coenzyme COQ10

bull Due to correlation w perio oxidative stress markers amp low level of natural occurring salivary antioxidants looking at polyphenolsantioxidants in the mouth locally delivered

ndash needs more research

bull Hyaluronic acid (HA) gel and mouth rinsendash hyaluronic acid plays a large role in the collagen building 02

hyaluronan gel topically amp subgingivally

ndash Studies have been done to evaluate on wound healing amp improving perio outcomes

ndash Further evidence is needed

17

LasersNeodymium lasersbull Ex NdYAG NdYAP lasers

bull FDA approved-PerioLase (FRNdYAG) patented procedure LANAPshown to regenerate cementum bone amp PDL

bull No histological studies LANAP with regeneration ( Linden E Laser Basics Dimensions of dental hygiene april 2016)

Diode Lasersbull Most commonly used by RDHs

bull Wide range of wavelengths

bull Used to reduce bacteria amp remove inflammatory byproducts

bull Absorbed by pigmented structures hemoglobin amp melanin

bull Warming amp ablation

bull There is insufficient evidence

Evaluation

bull Evaluating the host response

1 week acute or painful conditions

4-6 weeks changes in attachment level

12 weeks microbiota returns to pre TX levels

bull Complete final diagnosis

bull Many lawsuits exist due to lack of follow-up where as before it was due to failure to diagnose

Evaluation

bull Responded well

ndashDetermine appropriate PMP interval

bull Unresponsive

ndashProblem solve

bull Try to determine whyndashVirulent microorganisms Inadequate host

response Ineffective initial therapy or contributory amp risk factors

ndashFormulate new plan

Possible Solutions

bull Improve initial therapyndash re-scale root plan re-root plan

ndash self care

ndash adjunctive chemotherapeutics necessary

bull Reduce risk amp contributory factors

ndash smoking restorative

bull ex Overhangs

bull Medical consult periodontal referral Advanced diagnostic

Advanced Diagnostics

bull A test to determine active disease or predict an active episode of disease

bull currently we are not able to do this well

bull Many new tests are being developed still under investigation and still being assessed for usefulness

bull Many are not available yet or very expensive

bull Provide information that adds to the clinical exam

bull If it would be nice to know but not change anything we need to ask the questionhellip

bull Is the benefit worth the cost

Testing

OralDNA Labs Inc- httpwwworaldnacom

bull Genetic risk bacterial profile HPV-related oral cancers Herpes Candida Chlamydia trachomatis(CT) Neisseria gonorrhea(NG) gene markers related to inflammatory response DNA DrugMaptrade

micro-Ident- DNA probes

bull httpswwwhain-lifesciencecom

Oravital-Toronto based company uses biofilm testing the use of prescribed antibiotic antimicrobial rinses httpswwworavitalcom

Temple Oral Microbiology testing service 800-788-6687

USC Oral microbiology testing Lab 213-740-3163

UNC Oral microbiology Lab oralmicrodentistryuncedu