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Sharing Care in Periodontics

Alan Woodman MSc BDS MRDRCS DGDP(UK) FICD

Specialist in Periodontics

Alan Woodman @ UPDA

WELCOME!

Alan Woodman @ UPDA

Alan Woodman @ UPDA

SHARING CARE IN PERIODONTICS COURSE PROGRAMME – 23 March 2012, UPDA

0900 REGISTRATION 0.23

0915 Introduction

0930 Current Concepts

1015 Assessing Treatment Needs

1045 Coffee 0.24

1100 Practical aspects of probing 0.23

1120 Communicating Treatment Needs

1200 Treatment Planning Exercise

1300 Lunch 0.24

1345 Root Instrumentation Ph. head

1410 Practical root instrumentation

1510 Tea 0.24

1520 Re-assessment 0.23

1540 Supportive Care

1600 Referral & the Role of Surgery

1620 Treatment plans and discussion

1700 CLOSE

Sharing Care in Periodontics • Current Concepts • Assessing Treatment Needs

– Practical aspects of probing

• Communicating Treatment Needs – Treatment Planning

• Root Instrumentation – Practical root instrumentation

• Re-assessment • Supportive Care • Referral & the Role of Surgery • Treatment plans and discussion

Alan Woodman @ UPDA

Who Needs Periodontal Care ?

The main factors:

• Biofilms

• Susceptibility

• Compromised immunity

• Smoking

• Surfaces

Alan Woodman @ UPDA

Alan Woodman @ UPDA

THE HUMAN BODY

1014 cells:

10% mammalian

90% microbial

PERIO REMAINS PLAQUE-

FOCUSSED, BUT OUR

ATTITUDES HAVE

CHANGED...........

Alan Woodman @ UPDA

TEETH: S. mutans

S. oralis

S. mitis

A. naeslundii

Gram-anaerobes

CHEEK: S. salivarius

S. mitis

TONGUE: S. salivarius

S. mitis

Haemophilus

Neisseria

Veillonella

Stomatococcus

MICROFLORA OF THE HUMAN MOUTH

OUR INTEREST IN

PARTICULAR SPECIES HAS LESSENED..........

Alan Woodman @ UPDA

BIOFILM: DENTAL PLAQUE

IS THIS, TRADITIONAL, VIEW OF PLAQUE

STILL WARRANTED........?

Alan Woodman @ UPDA

DENTAL PLAQUE: BIOFILM PROPERTIES

• spatial organisation • diverse & stable microbial composition • confers benefit (colonisation resistance) • resistance to antimicrobial agents - penetration - inactivation & neutralisation

Alan Woodman @ UPDA

MICROBIAL HOMEOSTASIS

community

balance

negative

feedback

antagonistic

& synergistic

interactions

host defence variability

diet

hormones

exogenous

species

Ec

olo

gic

al s

tres

s

WE HAVE LEARNED MUCH ABOUT EXTERNAL FACTORS

Alan Woodman @ UPDA

CONSEQUENCES OF MICROBIAL HOMEOSTASIS

community

balance

normal diet

diligent

oral hygiene

de-/re-

mineralisation

in equilibrium

low

inflammation/

slow GCF

Alan Woodman @ UPDA

= Health = Health > Disease

Major

ecological

pressure

Transmission

ORIGIN OF DENTAL PATHOGENS

Alan Woodman @ UPDA

• Dental plaque is a Biofilm & as such, OVERALL, is Beneficial to health (!) •Plaque-mediated diseases are due to: - changes in local environment - disruption of homeostasis & local de-regulation of the immune systems, allowing... - enrichment of minor bacterial populations •Biofilms are recalcitrant to antimicrobial agents

So.....

WHO ? & WHY ?

• 12 - 15% Worldwide

• Oral hygiene

• Anatomy

• Smokers

• Medically challenged

• A more Pathogenic plaque

• Compromised immunity – Medical

• Medication

• Disease/toxins – Cellular

• Bacterial cytokines

• Tissue cytokines

Alan Woodman @ UPDA

Diagnostic dilemmas

• Does familiarity breed contempt ?

• Does visual evidence of deposits sway our opinion vs. other observations ?

• Why do so many patients suffer from delayed diagnosis of perio problems ?

Alan Woodman @ UPDA

What constitutes “Disease” ?

• active inflammation ?

• the abnormal ?

• the unusual ?

• is gingivitis normal ?

• is gingivitis usual ?

• can we recognise normal ?

Alan Woodman @ UPDA

Assessing Treatment Needs

• Observations

• Recording

• Radiographs

• Treatment Planning

• Planning the treatment

• Reassessing

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Detailed observations

• BPE at regular C/up

• Full 6 point chart if code 3 or 4 with:

• bleeding

• mobility

• plaque

• recession

• furcations

• Occlusion : NWS & anterior interference

• Posterior support

• Radiographs

• Endodontic status

• Caries status

• % Root support

• Bone irregularities

Alan Woodman @ UPDA

Health factors

• Systemic disease

• Diabetes

• Systemic medication

• Immunosuppressives

• Transplant patients

• Treatment risk patients

• Stress

Alan Woodman @ UPDA

Which probe ? • Design

– 0.5 ball tip

• Markings – graduated

– epidemiological

• Force – standardised

– random / experience

– 25 gms

• Same probe

• Same person – Repeatability

• Same practice

• Same technique – Reproducibility

• Computerisation ? Alan Woodman @ UPDA

Which radiograph ?

• 2D view of 3D problem

• OPTG

– patient education

– / motivation

• Periapicals

– diagnosis

– / endodontic aspects

• Computerisation and CADIA for

definitive examination of change?

Alan Woodman @ UPDA

Which charts ?

• Time consuming, yet essential

– record the important

– record the repeatable

– use patient-friendly display

– avoid over-complication

• Post operative assessment!!!!!

• Computerisation ?

Alan Woodman @ UPDA

Which tests ?

• GCF

• Saliva

• Plaque

• Blood

• Tissue

• Inflammatory products of : – cellular breakdown

– cellular activity

– bacterial activity

– host response

• Or normal cell turnover ?

Alan Woodman @ UPDA

Observations > Diagnosis

• GINGIVITS

• ACUTE

• LOCALISED

• AGE INFLUENCE

• LOCAL FACTORS

• PERIODONTITIS

• CHRONIC

• GENERALISED

• RATE OF PROGRESSION

• SYSTEMIC FACTORS

Alan Woodman @ UPDA

But will our treatment vary with the diagnosis...................?

Smoking and Periodontal Diseases

• Nicotine effects locally and systemically

• Compromised blood flow

• Compromised healing

– cellular

– vascular

• Compromised Oral Hygiene

– increased deposits

– lact of tactile sensation (tongue)

Alan Woodman @ UPDA

less oral awareness

increased plaque

decreased bleeding

poorer healing

increased bone effects ?

SMOKING CESSATION IS A MUST FOR LONG TERM SUCCESS IN CIPD

Good periodontal prognosis

• Regular bone loss

• Natural recession

• Receptive to OHI

• Thick gingiva where surgery proposed

• Listeners

• Questionners

• Keen attenders

• Dextrous

Alan Woodman @ UPDA

Poor periodontal prognosis

• Irregular bone loss

• Heavy restorations

• Prostheses

• Thin gingiva

• Furcations

• Acute episodes

• OH strugglers

• Poor attenders

• Talkers (excuses!)

• Health complications

• Smokers

• History of surgery

Alan Woodman @ UPDA

Periodontitis - minor warnings

• L apsed attenders

• A ge >35

• N o subgingival / interdental OH

• C hronic progress

• S mokers

Alan Woodman @ UPDA

Periodontitis - major warnings

• Y oung age <35

• O ral hygiene appears good

• R apid breakdown

• K een attenders

• S mokers

Alan Woodman @ UPDA

• Y oung age <35

• O ral hygiene appears good

• R apid breakdown

• K een attenders

• S mokers

Alan Woodman @ UPDA

• L apsed attenders

• A ge >35

• N o subgingival / interdental OH

• C hronic progress

• S mokers

RECOGNISING RELATIVE RISK &

SUSCEPTIBILITY IS VITALLY

IMPORTANT FOR SUCCESSFUL

PERIODONTAL TREATMENT

Alan Woodman @ UPDA

DIAGNOSE not just from what you SEE but from what you OBSERVE

Periodontal diseases are simple to treat providing they are diagnosed early

Complicated treatment, LIKE THIS, generally follows an inability to recognise risk factors or our willingness to treat early disease

Tests required

• for the presence of disease

• for disease activity – past

– present

– future

• for bacterial sensitivity

• for future SUSCEPTIBILITY

Alan Woodman @ UPDA

Practical Aspects of Probing

Alan Woodman @ UPDA

Which probe ? • Design

– 0.5 ball tip

• Markings – graduated

– epidemiological

• Force – standardised

– random / experience

– 25 gms

• Same probe

• Same person – Repeatability

• Same practice

• Same technique – Reproducibility

• Computerisation ? Alan Woodman @ UPDA

Time

for

Coffee!

Alan Woodman @ UPDA

Communication

Alan Woodman @ UPDA

Communicating with each other

C

Alan Woodman @ UPDA

C

DH/DT

GDP

PATIENT

GDP communicates diagnosis and treatment plan to patient.......

............but who makes the Decisions?

Alan Woodman @ UPDA

Communicating treatment needs

Alan Woodman @ UPDA

GDP to Patient:

• Role of the Hygienist/Therapist

• Time/how many appointments with Hygienist/LA and possibly chemical adjuncts may be required

• Cost-written estimate and treatment plan

• May be necessary to refer to GDP or Periodontist if treatment response unsatisfactory/extra cost

• Does the patient consent to treatment?

• Patient compliance is essential for the success of treatment

Alan Woodman @ UPDA

Alan Woodman @ UPDA

The Patients come in all shapes and sizes.....so DOES ONE-SIZE

TREATMENT FIT ALL?

Referring to a Hygienist

• Written prescription

• Patient aware of our role inc time, frequency & cost (referral if necessary)

• Radiographs inc. OPG

• BPE score

• Periodontal pocket chart

• Updated medical history

• TIME

Alan Woodman @ UPDA

Hygienist Appointments

• Assess patient: demeanour, nerves

• Examination (teeth, gingiva,& soft tissues) & explain treatment

• OHI & motivate patient (using radiographs and Perio chart)

• At least by Quadrant scaling, RSD with/without local

• Maximise treatment area, to minimise treatment visits to achieve rapid de-contamination

• Antibiotic therapy • Write comprehensive notes

Alan Woodman @ UPDA

Plaque as a Biofilm

Does anaerobic plaque need a “fresh” approach ?

Alan Woodman @ UPDA

Alan Woodman @ UPDA

What do we NOT see?

Remember the problems?

Subgingival Management

• Patient’s subgingival management

• Clinician’s subgingival management

Alan Woodman @ UPDA

Hygienist communicating with patient

Alan Woodman @ UPDA

SUB-GINGIVAL CLEANING SINGLE TUFTED BRUSH

• CTS

• PARO

Alan Woodman @ UPDA

DEMONSTRATING STB ON MODEL

Alan Woodman @ UPDA

DEMONSTRATING STB IN PATIENTS MOUTH

Alan Woodman @ UPDA

– will they?

– won`t they?

– can they?

Alan Woodman @ UPDA

The Subgingival tissues

BRUSHING ?

BOTTLE BRUSHES

• DENTOCARE PH brushes

• CURAPROX double and single ended

Alan Woodman @ UPDA

BOTTLE BRUSH IN FURCATION

Alan Woodman @ UPDA

INCORRECT USE OF BOTTLE BRUSH !

Alan Woodman @ UPDA

Alan Woodman @ UPDA

SONICARE ELITE CLAIM TO REMOVE BIOFILM INTERDENTALLY AND SUBGINGIVALLY

Alan Woodman @ UPDA

Hygienist to GDP

• Non responsive areas? discuss with GDP

• Check through patient records before each session, anything unclear discuss with GDP

• If during hygienist appointment a change of plan is required from the written prescription, explain to patient the findings, and then discuss with GDP.

Alan Woodman @ UPDA

Treatment Planning Exercises

Alan Woodman @ UPDA

3 case studies • Case A

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3 case studies • Case B

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3 case studies • Case C

Alan Woodman @ UPDA

• Time for Lunch !

Alan Woodman @ UPDA

Practical Root Instrumentation

• Opportunity to examine the roots, instruments and techniques in the Phantom Head Room

Alan Woodman @ UPDA

SUBGINGIVAL TREATMENTS

Alan Woodman @ UPDA

Periodontics - getting results

•Clean what matters

•Where it matters

•Keep it cleansable

Alan Woodman @ UPDA

Plaque Management

• Creating a cleansable mouth

• Subgingival instrumentation

– fine tips U/S or Hand ?

– surface treatment

• Maintaining a clean mouth

– preventing re-stagnation subgingivally

– reassessment and advice on home care

Alan Woodman @ UPDA


• Patient compliance dictates success

• Nothing you do can overcome what the patient will not, or cannot do

• Periodontitis is an incurable disease

• But it is MANAGEABLE

Alan Woodman @ UPDA


• Leaving pockets can only be justified when they can be adequately cleansed

• Infrabony pockets cannot be left with toxic root surfaces and scar tissue intact, thus inhibiting repair

Alan Woodman @ UPDA

Subgingival management

• What you do out of sight is the most important aspect of your management of the root surface

• Whatever you do make sure that you can show the patient some change – either by touch or appearance

Alan Woodman @ UPDA

Root instrumentation

• The root surface

• The instruments

• The action

Alan Woodman @ UPDA


• The root surface

– will always be irregular microscopically

– clinical smoothness is our only measure of success at treatment

– reduction of bleeding is the best measure of success after time

– endotoxins are only superficially placed

Alan Woodman @ UPDA

A good range of fine instruments is essential

Alan Woodman @ UPDA


• The instruments

– fine probes mean fine treatment tips

– “mini-Gracey” curettes

– maintenance instruments must be finer than those for initial treatment

– Cavitron Ultrafine tips

Alan Woodman @ UPDA


• The action

– Thorough instrumentation with true edged instruments

– Avoid over-vigorous actions

– Root debridement - is it enough ?

– Root planing - is it a valid term ?

Alan Woodman @ UPDA

Time

for

Tea!

Alan Woodman @ UPDA

Reassessment and Supportive Care

Alan Woodman @ UPDA

Initial course of treatment completed

- so what next?

-and for how long?

Alan Woodman @ UPDA

GDP support during and after DH treatment

Alan Woodman @ UPDA

• Review periodontal patient post DH treatment (with hygienist?)

TEAMWORK

• Re-record perio chart & compare

• Maintain patient enthusiasm

• Stress to patient importance of 3/12 hyg appts


• After initial therapy, review with GDP and subsequent 3/12 DH appts

• Good Communication & teamwork between DH & GDP regarding patients progress

• If patient compliance is satisfactory………..

………..move to

SUPPORTIVE CARE

Alan Woodman @ UPDA

Supportive Care Programmes

• Careful prescription

• The role of the dental hygienist

– Sharing care - not devolving responsibility

• Referral to the hygienist

– explanations !

• (2 or) 3 (or 4) monthly reviews for

– thorough subgingival plaque (deposit) removal

– OH advice and ENCOURAGEMENT

Alan Woodman @ UPDA

Supportive Periodontal Care

• Fine instruments

• Local anaesthetic

• Complete subgingival debridement

• Consistent probing

• Clear recording – Patient - friendly

• Clear communications

• Oral hygiene/motivation

• Tailored advice/sensitivity/fluoride

• Practical instruction and feed back – Models v. Mouth ?

– Life size / realistic

– Mirror problems

• Stock what you recommend

Alan Woodman @ UPDA


• Class 1 Furcations

• detectable with the probe

– Weakly keratinised

– Brushing difficult

– Plaque “disturbed”

– Recession helps

– a “PIT”


• detectable with the probe under the crown

– Weakly keratinised

– Brushing difficult

– Plaque “disturbed”

– a “CAVE”

Alan Woodman @ UPDA



• “through and through”

– Keratinised

– Manageable

– Plaque “swept”

– Recession helps

– a “TUNNEL”

• Lower molars – most predictable

• Upper molars – predictable with 2 roots!

• Upper first premolars – least manageable

– 3 roots impossible!

Alan Woodman @ UPDA

Root divergence helps >30 degrees

+ stability

Root convergence hinders <30 degrees

- stability


– can they?

– will they?

– won`t they?

• BRUSHING ?

Alan Woodman @ UPDA

Single Tufted Brushes

with CHX gel/rinse additive or nil?

These brushes do not intentionally remove plaque subgingivally

They are DISTURBERS OF ANAEROBIC PLAQUE and its BIOFILM structure

Shaped head : conical, never flat

Angled heads available, eg PARO

Correct sizing is imperative

Definitive instruction on models and mouth with frequent reinforcement

Periodontal Supportive Therapy

A CONTINUING CYCLE:

• Diagnosis

• Treatment

• Reassessment

• Support

• Reassessment

• Support

• Indefinitely

Possibly requiring:

• Re-treatment

• Reassessment

• Support

Alan Woodman @ UPDA

Supportive Periodontal Care

• There are no set treatment plans or average patients

• Regular reviews, charts and advice

• Regular subgingival plaque removal

• Referral culture : – Dentist > Hygienist > < Dentist > ?Periodontist >

Dentist > < Hygienist……etc……..

Alan Woodman @ UPDA

The Interdental tissues – Spirals :

– Straight

– or Tapered ?

– Handles

– or Fingers?

– Mechanical ?

– Soft

– or Rigid ?

– Brushes ????

• FLOSSING contacts

• RINSING spaces

• BRUSHING spaces

Alan Woodman @ UPDA

Floss or Tape?

Dexterity

Accessibility

Restorations

Gadgets

CHX

CPC

Triclosan

Fluoride

on Spirals ?

on Brushes ?

on Floss ?

SUBSTANTIVITY?

The Subgingival tissues – Objectives?

• Reduction of gingivitis

• Limitation of periodontitis

• Control of pocket re-infection ????

• FLOSSING ?

• RINSING ?

• IRRIGATING?

• BRUSHING ?

Alan Woodman @ UPDA

Flossing in pockets is more traumatic than beneficial

Will rinses and mouthwashes reach sub-gingivally? NO!

Provided the needle tip is 2mm within the pocket, IRRIGANTS will reach the apical plaque border - regardless of its depth

Hardy & Newman 1982

BUT powered irrigators have little benefit, the irrigant bounces back

? is CHX substantive in the subgingival area

gels stay longer - but do they penetrate the apical plaque border?.

Interdental &

Subgingival cleaning

Nothing the dentist can do will overcome what the patient will

not, or cannot, do !

Alan Woodman @ UPDA

Alan Woodman @ UPDA

REASSESSING PATIENTS NEEDS

• How do we know if treatment is succeeding ?

• If not , why not ?

Post-treatment chart most important

Observations Acute symptoms

Bleeding on probing

Discharge

Plaque

Patient compliance

Sensitivity


If, after initial therapy, review with GDP and subsequent 3/12 DH appts.........

.....Patient compliance is satisfactory, but clinical results are disappointing………..

……Consider further action with GDP

Alan Woodman @ UPDA

Alan Woodman @ UPDA

• Was the original treatment plan realistic ?

• Was the correct delivery of information used ?

• Have goals been achieved ?

• Was patient feedback valued ?

CLINICAL FEEDBACK , WHAT NEXT ?

Re-address treatment plan

Re-set goals

Re-motivate & educate

Review recall time


Alan Woodman @ UPDA

TREATMENT IMPLICATIONS

• ? Future management of residual pockets.

• ? Restorative implications

• ? Cosmetic implications

Leading to:

? Further review period monitor OH skills

? Further instrumentation

? Chemical adjuncts

? Surgical therapy

? Referral


Reassessment

• Maybe GDP to provide some aspects of care:

• ? Occlusal analysis

• ? Further instrumentation?

• ? Improve / modify restorations or prostheses

• ? Endodontics

• ? Consider Chemical Adjuncts?

Alan Woodman @ UPDA

Chemical Adjuncts

• CHLORHEXIDINE – Corsodyl

– Eludril

– Chlorohex 2000

– Peridex

• Periochip

• Frequency of use ?

• Metronidazole – Elyzol

• Minocycline – Dentomycin

• Tetracycline – Actisite

• Doxycycline – Atridox

Alan Woodman @ UPDA

Reassessment

• Maybe GDP to provide some aspects of care:

• ? Occlusal analysis

• ? Further instrumentation?

• ? Improve / modify restorations or prostheses

• ? Endodontics

• ? Consider Chemical Adjuncts?

• ? Extraction

• ? Surgery, or…..

• …..OR is it TIME TO REFER

Alan Woodman @ UPDA

REASONS FOR REFERRAL

Alan Woodman @ UPDA

Alan Woodman @ UPDA

Reasons for Referral

• when to cry “HELP”

• what to expect

• how to help the patient

Referral to a Periodontist –WHO ?

• Clinical Criteria:

– Non - resolving sites

– Pocket depth = or >5mm

– Mobility <3

– Bleeding from pocket

– Abscess history

– Furcation involvement

– Unacceptable gingival architecture

– Persistent sensitivity

• Radiographic:

– >30% bone loss

– Irregular bone loss

– Perio-endo lesion

• Restorative:

– Abutment tooth

– Last sextant molar

– Occlusal co-factors

– Potential loss of posterior support

Alan Woodman @ UPDA

Alan Woodman @ UPDA


• what to expect – initial non-surgical re-treatment

– period of review and reassessment

– possible endodontic co-treatment

– possible occlusal co-treatment

– surgical treatment for ?50%

– long term hygienist support, initially or permanently within referral practice

Alan Woodman @ UPDA


• how to help the patient

– warn them of the likely COST !

– do not assume a surgical approach

– explain the origins of their disease and the reasons for your concern

– explain the alternatives to periodontal treatment

Referral to a Periodontist –HOW

• Patient details

• Patient contact and availability

• Purpose of referral:

– 2nd opinion

– Treatment plan

– Treatment

• Medical alert / status

• Patient’s original complaint / wishes

• Brief description of periodontal and general dental condition

• Specific site concerns

• Outline of treatment provided

• Copies of charts, radiographs & study casts if available

Alan Woodman @ UPDA

Referral to a Periodontist –WHERE ?

• University Dental School Periodontal Consultant *

• NHS General Hospital Restorative Consultant **

• Community Dental Service Periodontal Specialist ***

• Private Specialist in Periodontics ****

• * geographically inconvenient outside the main cities (Free)

• **rarely have funding for prolonged treatments (Free)

• *** few and far between (Usually Free)

• **** Increasingly available

but EXPENSIVE for many

Alan Woodman @ UPDA

CLINICAL AUDIT of PERIO PATIENTS in

Specialist Practice : APRIL 2004 - AUGUST 2010

CONSULTATION

> INITIAL (HYGIENIC PHASE)

TREATMENT >

SUPPORTIVE CARE

PATIENTS SEEN > PERIODONTIST HYGIENISTS > REVIEWS + HYGIENISTS

2036 997 959 4710 12256

> SECONDARY

PHASE REGEN REGEN

SURGICALS: REGEN REGEN REGEN TEETH TEETH

+

BioOss

+

Emdogain

+

Ceramic TREATED LOST

523 187 20 34 411 15

(3% LOST) (NIL LOST) (5% LOST) (<4%)

APICECTOMY VITAL ROOT > RCT > EXT. FRENECTOMY CT

RESECTION 22% 10% GRAFT

48 63 14 6 31 7

> PERIPHERAL TREATMENTS

PERIODONTAL SPLINT

METAL-

RESIN GINGIVAL OCCLUSAL OCCLUSAL

SPLINTS > REPAIR SPLINT VENEERS ANALYSIS > SPLINTS

334 639 61 178 993 91

Alan Woodman @ UPDA

Periodontal Health is the bedrock of lasting dentistry

• How much perio can you do in practice?

• How much will you abandon to the hygienist / therapist or specialist?

• How much will you refer?

– to the hygienist / therapist ?

– to the specialist ?

– to the forceps ?

Alan Woodman @ UPDA

Role of Surgery in Periodontal Care

• what to expect

– most surgical periodontal procedures are accompanied by gingival recession, desired or not !

– absolute OH compliance is a necessity

– smokers fare less well, but can be treated

– regeneration can only treat “craters” in vertical defect, not horizontal loss

Alan Woodman @ UPDA

Role of Surgery in Periodontal Care

• what can be achieved

– pocket elimination

– pocket reduction

– regeneration or approximation?

– better restorative management

– cosmetic changes

– oral hygiene facilitation

Alan Woodman @ UPDA

Alan Woodman @ UPDA

Surgical care Techniques available:

•Pocket elimination & Pocket reduction

- with or without Regenerative materials

•Surgical revelation for restorative investigation

•Root resection & Apicectomy, repair of

Resorption or Perforation lesions

•Crown lengthening with or without Osseous re-contouring

•Frenectomy, Gingival grafting & Connective tissue grafting

•Pre- & Post- Implant soft tissue management

•Implant placement surgery in the Aesthetic Zone

Alan Woodman @ UPDA

Surgical care •Pocket elimination & Pocket reduction - with Regenerative materials

BioOss

BioGide

Alan Woodman @ UPDA

Surgical care •Pocket elimination & Pocket reduction - with Regenerative materials

EMDOGAIN PERIOGLAS

Alan Woodman @ UPDA

Surgical care -Surgical revelation for restorative investigation

Alan Woodman @ UPDA

Surgical care •Root resection & Apicectomy, repair of Resorption or Perforation lesions

Alan Woodman @ UPDA

Surgical care •Root resection

Alan Woodman @ UPDA

Surgical care •Crown lengthening with (or without) Osseous re-contouring

Alan Woodman @ UPDA

Surgical care •Frenectomy, Gingival grafting & Connective tissue grafting

Alan Woodman @ UPDA

Surgical care •Implant placement surgery in the Aesthetic Zone

Treatment Plans

Discussion of the cases presented

Alan Woodman @ UPDA

3 case studies • Case A

Alan Woodman @ UPDA

3 case studies • Case A • Treatment history:

– Examination 17:02:2005

• Initial treatment: – 01:03:2005

– Root instrumentation (LA) Left

– Occlusal analysis

– OHI +STB

– Metronidazole (Elyzol) placement

– 10:03:2005

– Root instrumentation (LA) Right

– Occlusal review

– Metronidazole placement

– 17:03:2005

– Metronidazole placement

• Review 05:05:2005

• Future treatment discussed

• Periodontal splinting to UR3<>3UL

• UL2 extracted and re-fixed to splint as natural pontic

• 31:05:2005

• Impressions for labial veneer

• 09:06:2005

• Fit labial veneer

• 16:06:2005

• Hygienist appointment

• 30:08:2005

• Review and Hygienist appointment, planned pocket reduction surgery for upper teeth

Alan Woodman @ UPDA

3 case studies

• Case A

Alan Woodman @ UPDA

3 case studies

• Case A

• Treatment history:

• Examination

• Initial treatment

• Secondary treatment

Alan Woodman @ UPDA

3 case studies • Case A • Surgical treatment 1 • 01:11:2005

• Flaps to UR6-5-4-3 and 1-3-4-5-6UL

• Apically repositioned and thinned for access.

• 11:11:2005

• Suture removal and prophy

• 06:12:2005

• Review surgery & Hygienist appointment

• 06:04:2006

• Review & Hygienist appointment

• 13:07:2006

• Review & Hygienist appointment, plan surgery for LR6 distal infrabony lesion

• Surgical treatment 2 • 19:07:2006

• Localised flap to LR6 three-walled defect

• Regenerative approach with BioOss & BioGIde

• 04:08:2006

• Suture removal and radiograph

• 24:08:2006

• Post –op review

• Next appointment:

• Hygienist appointment on 17:10:2006

Alan Woodman @ UPDA

3 case studies

• Case A

• Treatment history:

• Examination



Alan Woodman @ UPDA

3 case studies

• Case A

Alan Woodman @ UPDA

3 case studies

• Case A


Alan Woodman @ UPDA

3 case studies • Case B

Alan Woodman @ UPDA

3 case studies

• Case B • Treatment history: • Examination 17:06:2005


• 27:07:2005

• Root instrumentation (LA)

• Metronidazole placement

• OHI + STB

• Occlusal analysis

• 03:08:2005

• Occlusal review and adjustment NWSI UR7:LR7

• Metronidazole placement

• Discussed surgery UL3

• Surgical treatment • 27:10:2005

• Localised surgery to Ul3

• Regenerative approach with BioOss & BioGide

• 08:11:2005

• Suture removal, radiograph and prophy

• 29:11:2005

• Post-op review

• Own practice hygienist support

• 19:04:2006

• Review and radiograph – for annual reviews in future

Alan Woodman @ UPDA

3 case studies

• Case B

Alan Woodman @ UPDA

3 case studies • Case C

Alan Woodman @ UPDA

3 case studies • Case C • Treatment history continued:

- 22:11:2005

- SURGICAL TREATMENT UR4 with BioOss and BioGide

- 02:12:2005

- Suture removal & radiograph

- 23:12:2006

- Post-op review

- 17:01:2006

- Review and hygienist appointment

- 19:04:2006

- Review and hygienist appointment, radiograph of UR4 site

Alan Woodman @ UPDA

3 case studies • Case C • Treatment history: • Examination 30:03:2005

• Initial treatment • 04:04:2005

• Root instrumentation (LA) Left • OHI + STB • Metronidazole placement • 11:04:2005 • Root instrumentation (LA) Right • Occlusal analysis • Metronidazole placement • 18:04:2005 • Metronidazole placement • Occlusal review and adjustment to LL7

and LR2

• Secondary treatment • 12:07:2005

• Hygienist appointment

• 17:10:2005

• Review and hygienist appointment

• Radiograph UR4 infection

- Metronidazole again x2

- 08:11:2005

- Review and plan surgery for localised infrabony / furcation lesion UR4

Alan Woodman @ UPDA

3 case studies

• Case C

Alan Woodman @ UPDA

Have a good weekend!

Alan Woodman @ UPDA

A little bit more.....

PERIO - ENDO ? Or ENDO - PERIO ?

Getting to the Root

of the Problem

Alan Woodman @ UPDA

PERIO - ENDODONTIC INTERFACE

• Bacterial contamination

– Active plaque

– Residual toxins

• Anaerobic environment

• Difficult instrumentation

– Blind ; tactile

• Results difficult to assess

– Time ; radiographs ; clinical observation

Alan Woodman @ UPDA

Diagnosis • Acute apical periodontitis ?

• Acute lateral periodontitis ?

• Pressure

• Site

• Sinus tract

• Radiography

• History and symptoms

Alan Woodman @ UPDA

Aetiology • Caries subgingivally

• Lateral canals

• Accessory canals

• Root dentine instrumentation

• Root dentine exposure and subsequent infection

• Pulp death - cause or effect ?

• Loss of apical supporting tissue

Alan Woodman @ UPDA

Presentation • Upper molars

• Upper premolars

• Lower molars

• Single rooted teeth

• Are there other periodontally involved teeth ?

• Is there a periodontal history ?

• Is this an isolated lesion ?

Alan Woodman @ UPDA

Endodontic risk factors

• Sinus tract damage to periodontal ligament

• Excessive bone resorption in apical lesion

• Root fracture

• Root perforation

• Posts

• Overpreparation ?

• Overfilling ?

Alan Woodman @ UPDA

Vitality tests

• Tests on multi - rooted teeth are notoriously unreliable

• How many canals are non-vital ?

• Often one canal is hyper- reactive

• Misdiagnosis is easy, get a big bur out !

• Persuading referring practitioners to carry out endodontics can be frustrating

Alan Woodman @ UPDA

Treating Perio - Endo lesions

• Generalised Perio • Treat conventionally for CIPD

• Root surface debridement

• Sub-G OHI

• Antibiotic adjuncts

• Assess response

• Localised lesion • Endo investigation

– Endo treatment

– Reassess

• If vital – local RSD

– Reassess response

• ? Chemotherapeutics or Surgery ?

Alan Woodman @ UPDA

Treatment of advanced lesions

• Endo treatment prior to any planned surgical periodontal therapy

• Allow a period of review ; 3 - 4 months to assess residual bone support

• Surgical techniques – Root amputation or resection

– Hemisection

– Apicetomy

• Regeneration

• Extraction

• Implant placement

Alan Woodman @ UPDA

Have a good weekend!

Alan Woodman @ UPDA

Sharing Care in Periodontics - Oxford Deanery care UPDA minimum.pdf · Sharing Care in Periodontics...

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