PBL SMOKING CESSATION

GROUP 2

LEARNING ISSUESWhat are the medical problem that associated with mobile

tooth and bad breath? Eg) DM• The pathophysiology?• Medication that may cause xerostomia• Effect of smoking to perio health Mobile tooth• causes & grading• Clinical features• management of mobile tooth

Bad breath• Causes and effect• Management of bad breath

Traumatic occlusion• How to access traumatic occlusion• causes• Clinical features• Management

Severe staining• Causes and effect• Management• Tx option

Fibrotic gum• Causes & Pathophysiology • Features• Management

Management of hypersensitivity tooth & furcation involvement

Based on OPG• How plaque influence the type of bone loss• Bone defect (causes, types and management)

Designated OHI for the patient (smoker)• Toothbrushing technique• Types of mouth wash• Interdental brush• Smoking cessation

MEDICAL PROBLEM THAT ASSOCIATED WITH MOBILE TOOTH

AND BAD BREATH

MECHANISMS OF INTERACTION BETWEEN DIABETES AND PERIODONTAL DISEASES.

• Functions of cells.• Altered wound healing• Proinflammatory cytokines

Oral health related conditions reported to be asscociated with diabetes:

• Periodontal disease• Dental caries• Oral candidiasis• Oral lichen planus• Xerostomia, burning mouth syndrome,

alterations in taste

Effects of smoking on periodontal health

• It mask clinical sign of periodontitis, due to effect of nicotine & other agents in smoke– Vasoconstriction– Reduce gingival bleeding & redness– Surface keratinization– # other studies show smoking may reduce the apoptotic

mechanism in oral cavity > epithelial cell hyperplasia & increase in thickness of the overlying orthokeratin layer

– # lower level of GCF related to nicotine related vasoconstrictor.• The reduction of vascular component of inflammatory response >

reduce availability of antibodies > decreade in passage of leukocytes into periodontal tissue.

Effect of tobacco smoking in periodontium

• More site with deeper pocket• Greater level of CAL/ bone loss• Accumulate more calculus• Demonstrate dose-response for PD

destruction ( higher pack year, higher PD destruction)

MOBILITY

Definition

• Horizontal and to a lesser degree, axial movement of a tooth in response to normal force.

Aetiology1) Excessive occlusal forces or premature contacts2) Loss of tooth support (bone loss) 3) Pregnancy

Increase in the fluid content of the periodontal structures, an increased vascularity and a proliferation of capillaries into the periodontal tissues.

4) Systemic diseases non-Hodgkin’s lymphoma, scleroderma and Cushing’s syndrome

5) Severe periodontal inflammation (periodontitis)6) teeth with a healthy but reduced periodontal support (that is, in patients

after successful periodontal treatment) 7) in the first weeks after periodontal surgery8) pathologic process of the jaws

Grading Features

grade 0 physiological mobility

grade 1 increased mobility but less than 1 mm in total

grade 2 pronounced increase; more than 1 mm in total

grade 3 more than 1 mm displacement combined with a displacement in vertical direction (tooth can be intruded).

Increased mobility vs increasing mobility

Increased mobility Increasing mobility The adaptation process of periodontium toward functional occlusal force. r/graph: widened PDL space + clinical dx =manifestations of adaptive changes to increased functional demand.

Loss of tooth supportTrauma from occlusionPeriodontal surgeryPathologic of alveolar boneHormoneExtension of inflammation

-May need removal of excess occlusal load through equilibrium -conventional splint

-Treating any localized inflammation/periodontal therapy, performing an occlusal equilibrium-stabilizing or splinting the affected mobile tooth

Management

Options Consideration factors

-no treatment -occlusal adjustment-splinting-extraction

-what are the factors that contribute to the mobility?- tooth alignment-will it interfere the working area?-will it compromise the periodontal health and/or aesthetic?

Splinting :

Indications mobile multiple of teeth due to gradual alveolar bone loss increased tooth mobility + pain or discomfort in the

affected teeth To gain stability, reduce or eliminate the mobility, and

relieve the pain and discomfort.• Contraindications – occlusal stability and optimal periodontal conditions

cannot be obtained

Principles of Splinting

objective: to decrease movement 3 dimensionally →ideal splint should reorient and redirect all

occlusal and functional forces along the long axis of teeth, prevent tooth migration and extrusion, and stabilize periodontally weakened teeth

Types of Splint 1) Provisional Splint

Objective: to absorb occlusal forces and stabilize the teeth for a limited amount of time.

External: fabricated using ligature wires, nightguards, interim fixed prostheses, and composite resin restorative materials

Internal: fabricated using composite resin restorative material with or without wire or fiber inserts

Uses:→ adjuncts to many different types of treatment → treating periodontally compromised patients with conventional fixed prosthodontics

re-evaluation : to determine if treatment should proceed to a definitive restoration

Occlusal devices are often recommended to patients with a history of bruxing and clenching to help stabilize teeth following selective occlusal adjustment.

Definitive Splint

placed only after the completion of periodontal therapy and once occlusal stability has been achieved in order

→to eliminate or prevent occlusal trauma →increase functional stability→Improve aesthetics on a long-term basis.

includes conventional fixed prostheses because they provide definitive rigidity and are better able to control and direct occlusal forces than removable splints

Partially edentulous patients: complete coverage fixed partial denture.

ORAL MALODOUR

Causes1. Tongue & tongue coating- Food remnant remain trapped on irregular surface of dorsal of the tongue2. Periodontal infections- Level of VSC in mouth correlate positively with depth of periodontal pocket, the deeper the pocket, the

more the bacteria and VSC(volatile sulphur compound) amount increase in number- Other relevant malodor pathologic menefestations of periodontium are pericoronitis, major recurrent oral

ulceration, herpetic gingivitis, necrotizing gingivitis• # microbiology observation ulcer infected with gram –ve anerob significantly more malodour

(prevotella and porphyromonas sp)3. Dental pathologies- Deep carious lesion with food impaction- Extraction wound with blood & purulent discharge- Acrylic denture (frequent used at night, poor denture hygiene)4. Dry mouth- Has high level of plaque on teeth & extensive tongue coating - Other causes of xerostomia are, medication, alcohol abuse, sjogren syndrome and diabetes

Treatment 1. Mechanical reduction of intraoral nutrient and microorganism- Cleaning of tongue with toothbrush/ tongue scrapper ( decrease halitosis level

75% over 1 week)- Chewing gum control bad breath temporarily as it stimulate salivary flow2. Chemical reduction of oral microbial load- Mouth rinsing common practice such as, chlorhexidine, chlorine dioxide

&triclosan- Chlorhexidine ( most effective antiplaque& antigingivitis agents), antibacterial

action done by disruption of bacterial cell membrane by chlorehexidine molecule resulting in lysis of cell.

3. Masking the malodor- Mouth spray, lozenges containing volatiles with pleasant odor for a short term.

STAINING

Extrinsic stainingNon-metallic stains: The non-metallic extrinsic stains are adsorped onto tooth surface

deposits such as plaque or the acquired pellicle. The possible aetiological agents include dietary components,

beverages, tobacco, mouthrinses and other medicaments. The most convincing evidence for the extrinsic method of tooth

staining comes from the differing amount of stain found in a comparison of smokers and non-smokers.45

The staining effect of prolonged rinsing with chlorhexidine mouthrinses46 and quarternary ammonium compounds used in mouthrinses47 is of considerable interest to the dental profession.

Management:

1.Bleaching Internal/non-vital External/vital1.Composite resin restoration2.Veneer(composite resin or porcelain)3.Crown4.Air abrasion

FIBROTIC GINGIVA

Causes

• drug induced: anticonvulsants, calcium channel blockers, immunosuppressant

• Associated with systemic factor: pregnancy, vitamin C deficiency, leukemia, neoplasm

• Inflammatory • Hereditary gingival fibromatosis

Pathophysiology

• Nicotine increase production of CCN2/CTGF protein without increasing mRNA expression.

• Type I collagen mRNA and protein also increase and significantly blocked by a CCN2/CTGF neutralizing antibody

• Overexpression of CCN2can exacerbate fibrosis • It is suggested that the induction of CCN2/CTGF

by nicotine may be a major promoter of periodontal fibrosis caused by smoking

Features

• Consistency: firm, hard.associated with pink colour stippling, bleeding only in depth of pocket

• Surface texture:Hard and firm with stippling. May be lobulated

• Position of gingival margin: Enlarged gingiva. Margin is higher on the tooth, above normal. Pocket deepened. Recession present with margin more apical, exposed root surface

Management

• Gingivectomy followed by plaque control

FURCATION INVOLVEMENT

Definition :

• refers to commonly occurring conditions in which the bifurcations and trifurcations of multi-rooted teeth are invaded by the disease process.

Local factors 1) Root trunk length• the distance from CEJ and entrance of furcation• shorter the root trunk, less attachment need to be lost before furcation involved• easier to be treated if exposed

2) Root length• Teeth with long root trunk and short root hard to be treated when furcation involved

3) Root form• Mesial root of most first and second mand.molar and mesiofacial root of max first molar typically curved

to the distal site. 4) Interradicular dimension• Closely approximated root difficult to clean

5. Anatomy of furcation• Presence of bifurcation ridges, accessory canal, may complicate the treatment and maintainance.

6) Cervical enamel projection• It can affect plaque removal, and nonsurgical treatment. Need to be removed to facilitate the

maintainance

Classification

Degree I Horizontal probing depth <3mmfrom one or two entrances

Degree II Horizontal probing depth >3mm in at most one entrance and/or in combination of degree I

Degree III Horizontal probing depth >3mm in two or more furcation entrance usually represent as through and through destruction of supporting tissue

Management :

• Objectives:1.To eliminate the microbial plaque from the

exposed surface of the root.2.To establish the anatomy of affected surface

that facilitates self performed plaque control.

Therapy:Therapy Involvement of furcation

- Scalling and root planning- Furcation plasty

Degree I

- Furcation plasty- Tunnel preparation- Root resection- GTR- Extraction

Degree II

- Tunnel preparation- Root resection- Extraction

Degree III

DENTINE HYPERSENSITIVITY

Characteristic :

Short sharp pain. Arising from exposed dentineIn response to stimuli typically thermal,

evaporative, tactile, chemical or osmoticWhich cannot be described to any other form

of dental defect or pathology

Management :• Control aetiological factors to prevent failure or recurrencea) Complete history taking ( about the pain and sensitivity)b) Clinical examination - Tactile exam with probe- Gentle flow of air from syringe- Percussion & biting : sensitive?- Radiograph: any pathology?- Exposure of dentin,cracked cusp,occlusal interferencea) Consider all ddxb) Treat secondary condition that has similar symptoms (restoration on open dentin,occ

interference)c) Identify aetiology and predisposing factors - Advice diet- Correct toothbrush type,technique,frequency

Management :• Home care: Desensitizing toothpastes : o Contain potassium salts (nitrate or chloride), strontium salts (chloride and acetate). o 2 weeks of application twice a day

• Professional management: Fluoride : varnish and gel (it occlude by crystallinization of dentinal tubule) Oxalate salts : potassium oxalate or ferric sulphate (form calcium oxalate crystal in

tubule Arginine : attract calcium to tubule,plug and seal it. Periodontal mucogingival surgery : root coverage with GTR Resin adhesives Laser therapy : coagulates tubular protoplasm-block tubules Endodontic tx : pulp extirpation and RCT.

Trauma From Occlusion

Outline

1. Definition .2. Physiologic adaptive capacity of the

periodontium to occlusal forces. 3. Factors that help increase traumatic forces. 4. Classification 5. Clinical features.6. Radiographic findings.7. Treatment

Definition

• “ a condition where injury results to the supporting structures of the teeth by the act of bringing the jaws into a closed position .”(Stillman -1917)

• “ damage in the periodontium caused by stress on the teeth produced directly or indirectly by teeth of the opposing jaw.” (WHO in 1978)

Physiologic adaptive capacity of the periodontium to occlusal forces

• The periodontium attempts to accommodate the forces exerted on the crown.

• This adaptive capacity varies in different persons and in the same person at different times.

• When occlusal forces exceeds the adaptive and reparative capacity of the periodontal tissues, tissue injury results (trauma from occlusion)

Factors that help increase traumatic forces: (Magnitude, direction & duration)

A) When magnitude of occlusal forces is increased:

1. the periodontium responds with a widening of the periodontal ligament space.

2. an increase in the number and width of periodontal ligament fibers.

3. increase in the density of alveolar bone.

Cont…

• B) Direction of the occlusal forces.

• the periodontal ligament fibers are arranged so that the occlusal forces are applied along the long axis of the tooth.

• Change in the direction of the occlusal forces lead to change the orientation of periodontal ligament fibers.

Cont…

• Duration and frequency of occlusal forces.

• Constant pressure on the bone is more injurious than intermittent forces.

• The more frequent the application of an intermittent force, the more injurious the force to the periodontium.

Classification

• Acute and Chronic Trauma

• Primary , Secondary and Combined TFO

Acute trauma from occlusion

• results from an abrupt occlusal impact, such as that produced by biting on a hard object (e.g., an olive pit). In addition, restorations or prosthetic appliances that interfere with the direction of occlusal forces on the teeth may induce acute trauma.

(CARRANZA'S clinical periodontology)

Acute trauma from occlusion

• Clinical features :

1. Tooth pain.

2. Sensitivity to percussion.

3. Tooth mobility.

Chronic trauma from occlusion

• is more common than the acute form and is of greater clinical significance.

• It most often develops from gradual changes in occlusion produced by tooth wear, drifting movement, and extrusion of teeth, combined with parafunctional habits such as bruxism and clenching,

(CARRANZA'S clinical periodntology 9th edition - 396)

Primary trauma from occlusion

• A tissue reaction, which is elicited around a tooth with normal height of the periodontium (no attachment loss!)

(Clinical Periodontology and Implant Dentistry)

• It can caused by high filling. faulty restorations or fixed and removable prosthesis, causing large force on the abutment or opposing teeth.

(CARRANZA'S clinical periodntology)

Secondary trauma from occlusion

• It is related to situations in which occlusal forces cause damage in a periodontium of reduced height (attachment loss present)

Combined

• It is the injury that occurs to the periodontium resulting from abnormal occlusal forces that are applied to a tooth or teeth with abnormal periodontal support.

• (CARRANZA'S clinical periodntology 9th edition)

Clinical features

• 1) Mobility (progressive)• 2) Pain on chewing or percussion• 3) Fremitus• 4) Occlusal prematurities/discrepancies• 5) Wear facets in the presence of other

clinical indicators• 6) Tooth migration• 7) Chipped or fractured tooth (teeth)• 8) Thermal sensitivity

Radiographic findings

• Increased width of periodontal ligament space.• Thickening of lamina dura.• Vertical or angular bone loss.• Radiolucency in furcation areas.

Treatment

• A goal of periodontal therapy in the treatment of occlusal traumatism should be to maintain the periodontium in comfort and function.

• In order to achieve this goal a number of treatment considerations must be considered including one or more of the following :

1. Occlusal adjustment2. Management of parafunctional habits3. Temporary, provisional or long-term stabilization

of mobile teeth with removable or fixed appliances

4. Orthodontic tooth movement5. Occlusal reconstruction6. Extraction of selected teeth

BONE DEFECT

Bone Defect

Main Types• Horizontal Bone Loss• Vertical bone loss/angular defect • Osseous Craters

Horizontal Bone Loss• most common pattern of bone loss in

periodontal disease• Bone reduce in height, but bone margin

perpendicular to tooth surface• Affect interdental septa, facial and lingual

plate

Vertical Bone Loss• a sign of progressive periodontal breakdown• Occur in oblique direction• Leave hollowed-out trough in bone alongside the

root• Base of defect apical to surround bone• Interdental defect can appear on r/g• Facial, lingual or palatal defect may not seen on r/g

Angular Defect• Classified by number of osseous wall

Management

• Phase I: Periodontal Therapy (non-surgical)• Phase II: Periodontal Therapy (Surgical)

• Subtractive osseous surgery• Additive osseous surgery• Osteoplasty• osteotomy

Resective Osseous Surgery

• Non-bone graft associated new attachment• Bone graft associated new attachment

Reconstructive Periodontal Surgery

OHI for patient

OHI for patient

• Toothbrushing– Dentifrices• Anti-plaque : eg. stannous fluoride (SnF(2))

– Techniques1. Bass2. Modified bass3. Charter4. Modified stillman5. Fones

• Provides gingival stimulation (vibratory motion)

• Suitable for gingival recession (Toothbrush bristle ends not directed into sulcus)

• Less traumatic to the gingiva• Who should use this? People with

continuous gingival recession

Stillman’s method

• Chemical plaque control

FIRST GENERATION • Antibiotic, phenol, quarternary ammonium

compounds & sanguinarine

SECOND GENERATION • Bisbiguanides,(chlorhexidine)

THIRD GENERATION• Eg: delmopinol

• Chewing Gums• Interdental Brush

SMOKING CESSATION

Smoking Cessation – 5AsASK ~ Ask patient about smoking status

ADVICE ~ Provide clear, strong advice to quit with personalized messages about the impact of smoking

ASSESS ~ Assess the willingness of the patient to make a quit attempt within the next 30 days.

ASSIST ~ Suggest and encourage the use of problem-solving methods and skills for cessation. Provide social support as part of the treatment.

ARRANGE ~ Periodically assess smoking status and, if she is a continuing smoker, encourage cessation.

Smoking Cessation - 5RsRelevance• Encourage the patient to indicate why quitting is personally relevant

Risks• Ask the patient to identify potential negative consequences of tobacco use.

Rewards• Ask the patient to identify potential benefits of stopping tobacco use.

Roadblocks• Ask the patient to identify barriers or impediments to quitting.

Repetition • The motivational intervention should be repeated every time an unmotivated

patient has an interaction with a clinician. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.

• http://imuoralhealth.blogspot.com/2010/07/importance-and-various-tooth-brushing.html