seminar on controversy studies regarding different aspects in periodontal treatment

1. C O N T R O V E R S I E S
I N
P E R I O D O N T A L T H E R A P Y
DR FAVEENNA SUKUMARAN

2. INTRODUCTION
When a thing ceases
to be a matter of
controversy, it ceases
to be a matter of
interest
William Hazlitt (1778–
1830)
.

3. WHAT IS CONTROVERSY?
• Opinion or opinions over which parties are actively arguing
• A state of prolonged public dispute or debate concerning a matter of opinion
• Bradford’s law of controversy 1980:
passion to learn α 1
amount of real information available
Less we know about an issue..........more is intrigue &
passion to learn

4. Periodontal therapy is to achieve and
maintain optimal health, function and
esthetics of the dentition (Ramjford, 1999).
Applying proper therapy when the etiology
and pathogenesis of the disease are
thoroughly understood.

5. NON SURGICAL THERAPY
Microbial etiology
That contribute to gingival
and periodontal diseases
Halting the progression of
disease
Returning the dentition to a
state of health and comfort

6. The most difficult and
exacting skills to
master
To gain access
to root surfaces
Subgingival
scaling &
Root
planing
Periodontal
Surgery

7. Data -clinical
research
Long-term
success of
periodontal
treatment
Maintaining the
results achieved
with phase I
therapy
Any specific
surgical
procedures

8. Periodontal disease controlled with
phase I therapy and not require
further surgical intervention
Patients surgical treatment, phase I
therapy is advantageous
• Reduced inflammatory
infiltration
• Improving the surgical
management of the tissue
• Improving the healing response

9. 5 mm or more of attachment loss
and with pockets present after
phase I treatment-surgical
treatment
20% or less of tooth surfaces free of
plaque are poor candidates for successful
surgical outcomes
Monitored -recall maintenance program
until plaque control is established

10. ULTRASONIC
When power driven
&
manual scalers -no
statistical difference
clinical parameters
(Badersten et al 1984)
When power
driven & manual
scalers-both has
changes in clinical
parameters
(Cobb. C M 1996)

11. Calculus Removal-Similar degree of calculus removal with hand & ultra sonic
(Kocher et al 1997)
Studies indicate that power driven instruments may be more effective for
calculus removal
(Leon et al 1987)

12. Is root
planing
procedure
mandatory?
Removal of
bacterial
deposits
from supra &
subgingival
areas
Research
supports
that-Gentle
treatment
approach
Extensive
removal by
aggressive
instrumenta
tion
Controversy
for many
years

13. EVIDENCE: Cememtum -new pathogenic environment,structural
changes
Degradation of collagen fibres
Alteration in levels of calcium and phosphate
Decalcification of surface cementum
Hypercalcification
Absorption of bacterial toxins
Presence of endotoxins
Hatfield 1971,
Baumhammer
s et al 1975,
Aleo et al

14. Based on the concept that bacterial
endotoxins penetrate into the
cementum
(Hatfield & Baumhammers 1971, Aleo et
al. 1974)
Endotoxins were loosely adhering to
the surface of the root cementum and
not penetrating
(Hughes & Smales 1986, Moore et al.
1986, Hughes et al. 1988, Cadosch et al.
2003)

15. Penetration of microorganisms
CEJ
Periodontally involved cementum
removed during root planing –for
root surface free of bacterial
(Daly et al 1982)
Endotoxin solution extent &
penetration of endotoxin into
cementum.
No penetration-cementum,
binding of the endotoxin to the
root surface-weak(Nakib et al-
1982)

16. The roots treated with the hand curette and
roots treated with medium power ultrasonic
showed no significant differences
(Preethi Marda et al,Shobha Prakash et al-2012)
SRP conducted with curette compared with
ultrasonic scaler at medium power mode
Lowest surface roughness was seen on ultrasonic
scaler at medium power mode
(Pawan Kumar et al, Swarga Jyoti Das et al-2015)

17. Sigusch et al 2001,
No improvements
in probing depths
or attachment
levels following
scaling and root
planing
Purucker et al 2001
Scaling and root planing 2
months after scaling they
found that the deepest
sites in each quadrant
experienced ≈ 1 mm
reduction in probing depth
and a 0.5 mm gain in
attachment levels
GENERALIZED
AGGRESSIVE
PERIODONTITIS

18. LASERS IN PERIDONTICS:

19. Conventional
mechanical
debridement it vary
with skill and
experiences of
practice and
technique sensitive.
Laser introduced as
an adjuctive or
alternative tool for
mechanical
debridement

20. Laser are more significant
when compared with
mechanical debridement
Bacterial load
Bleeding
Georgios Romanos et al-2015
when compared
Laser and mechanical
debridement
No significant
difference
Schwartz et al-2001

21. Calculus removal was more
when done with laser
(Jorg Ebechard 2003)
When compared with Laser and
mechanical debridement no
significant difference
(Cobb et al-1992)

22. ROLE OF ANTIMICROBIALS IN
PERIODONTAL THERAPY

23. LOCAL DRUG DELIVERY
Elimination or regulation of
bacterial etiology
By mechanical means –
difficult and time consuming
and occasionally ineffective
LDD, anti infective agents
Varied techniques-LDD
Oral rinsing, subgingival
irrigation, oral irrigation
devices
Sustained release vehicles for
LDD

24. RATIONALE
Incomplete penetration
Stress response
Altered microenviroment within biofilm
Persisters

25. SRP + LDD -No statistical
significance difference
Hitzig C et al. (1997)
SRP + LDD
Statistical difference-
reduced Probing depth,
BOP
Riep et al. 1999

26. SRP + MINO
PD,CA,PI, GI, BOP
Van Steenberghe et al. 1993
SRP + MINO
No adjuctive effect
Meinberg et al. 2002

27. SYSTEMIC ANTIMICROBIAL THERAPY:
Initial
periodont
al therapy
Antibiotics
prescribed on
clinical need for
further treatment
Clinical response
to be evaluated
in 1-3 months-
no improvement
Microbial testing
& patientt
monitoring
1-3 months after
antimicrobial
therapy-repeat
microbial
analysis
After the condition
is stable put the pt
on SPT & recall
programme

28. The incidence of infection after periodontal surgery is very low
in patients treated with or without antibiotics. It was concluded
that unless there is a medical indication, there is no justification
for using antibiotics (Park and harber et al)
Studies conducted by Demolon et al.Loos et al. have
concluded that use of antibiotic may have helped to
control initial inflammation, but had no direct effects of
clinical significance on bone regeneration or soft tissue
attachment at 12 months.

29. Antibiotics commonly used
when performing certain
regenerative and implant
surgical procedures

30. •
COMBINATION
THERAPY
(Flemming et al 1998)
The use of
systemically
administered
adjunctive
antibiotics with &
without SRP-
improve clinical
(Van Winklehoff
1992)
Suppression of
subgingival
microflora-
combination of
metronidazole
& amoxicillin

31. Aggressive
periodontitis
Guerrero et al 2007
Compared the results of
scaling and root planing
alone with scaling and root
planing plus tsystemic
metronidazole and
amoxicillin,
Disease progression was
noted at 1.5% of sites in
patients of the antibiotic
group compared with 3.3%
of sites in controls
Sigusch et al 2001
Patients with
generalized aggressive
periodontitis
responded better to
non surgical therapy
when antibiotics was
used as an adjunct to
SRP

32. TRAUMA FROM OCCLUSION

33. The international workshop for classification of periodontal disease and
conditions in 1999.
.
Occlusal Trauma - It is injury resulting in tissue changes
within attachment apparatus as a result of occlusal forces.
Primary Occlusal Trauma – Injury resulting in tissue changes
from excessive occlusal forces applied to a tooth or teeth
with normal support.
Secondary trauma from occlusion – Injury resulting in
changes from normal or excessive occlusal forces applied to a
tooth or teeth with reduced support

34. Role of occlusion in pathogenesis of periodontal
.
1901 Karolyi
PERIODONTAL DISEASE
1917 & 1926 Stillman
Excessive occlusal force

35. Is there association
between excessive
occlusal forces and
progression of
periodontal disease?
At what point does an
occlusal force become
excessive. When
should treatment
initiated and how
should this treatment
accomplished?

36. Occlusal forces
were the initiating
factor in
periodontal
disease and led to
ongoing
progression of
periodontal lesion
Attempt to
demonstrate this
relationship
several animal
studies on sheep
and monkeys
were conducted

37. That traumatic
occlusion causes
changes in
attachment
apparatus
without involving
gingival unit.
Postulated that
change in
attachment
apparatus is
mainly due to
reduced blood
supply to
periodontal
ligament

38. That gingival
inflammation
extending in to
supporting bone was
the cause of
periodontal destruction
No relationship
between excessive
occlusal force and
periodontal destruction
Orban and Weinmann
in 1933 using human
autopsy material

39. GLICKMAN’S CONCEPT (1965)
Plaque associated gingival lesion
Changed if the forces of an abnormal
magnitude are acting on teeth harboring
subgingival plaque
Non traumatized exhibit suprabony pockets
& horizontal bone loss Traumatized exhibit
angular defects & infrabony pockets

40. Eastman Dental Center group
Squirrel monkeys, produced trauma by repetitive interdental
wedging and added mild to moderate inflammation, experimental
times were upto 10 weeks.
(Meitner, 1975, Polson, 1974, 1986, 1983)
Presence of trauma did not increase the loss of attachment induced
by periodontitis

41. Polson and Lindhe
studies to evaluate effect of plaque and excessive occlusal forces in
animal models
studies agreed removal of plaque and control of inflammation would
stop progression of periodontal disease whether or not excessive
occlusal forces are present.

42. WAERHAUGS CONCEPT
Angular defects & infrabony pockets - periodontal sites of teeth not
affected by TFO
TFOc played a role -spread of a gingival lesion into the zone of
destruction

43. TRAUMA FROM OCCLUSION AND GINGIVAL RECESSION
Excessive occlusal
force might be a
causative factor in
gingival recession
Stillman-1st to
describe a specific
type of gingival
recession, a narrow
triangular shaped cleft
Box (1930), Miller (1934)
and McCall (1921)
advocated the concept
that recession was
caused by trauma to the
periodontium as a result
of occlusal

44. GINGIVAL TRAUMA FROM OCCLUSION
GINGIVAL RECESSION Direct contact
Teeth with the gingiva
severe overbite
GINGIVAL RECESSION Occurs
Functional overload and/or
premature contacts
Controversy regarding whether or not overload is an aetiological factor in the recession,
Consequently whether or not the occlusion and the lateral guidance should be changed

45. ROOT BIOMODIFICATION:
Reduced collagen fibre insertion into the root
Alteration in the mineral density
Alteration in the surface composition
Root surface contamination

46. Chemical decalcification of the root
surface results in positive conditions
for connective tissue cells to attach
and migrate along the root surface.
(Boyko et al, JPR 1980; Pitaru et al, JPR 1987; Fardal et al,
JP 1990 )
1)Several human histologic
studies failed to demonstrate
regenerative potential of root
conditioning
2)(Stahl et al, JP 1977; Stahl et al, JP 1983; Stahl
et al, JP 1984)

47. Animal histologic studies showed improved
healing response- when decalcifying agents were
used for root conditioning.
(Selvig et al, JPR 1978, Act Odon Sc 1987; Polson et al, JCP
1982, JP 1983)
1)Human clinical studies failed to showed No
significant difference in the CAL gain between
the test and control groups.
2)( Garrett et al, JCP 1993; Blomlof et al, IJPRD, 2000; Erdinc
et al, Perio Clin Invest, 1995)

48. Human histologic studies
have also demonstrated
regenerative potential of
root biomodification.
(Albair et al, JP 1982; Cole et al,
1980; Frank et al, JP, 1980)
The rationale of using
Fibronectin for
biomodification is unclear
because serum already
contains high levels of
Fibronectin
(Bartold et al, Perio2000, 2000)

49. Kashani et al 1984
NO histological
difference
Stahl and Froum et al
Histological
difference

50. Alger et al 1999
New attachment +
cementogenesis
Erdinc et al 2000
NO significant difference
in PD , CAL gain

51. PERIODONTAL PACKS.....TO BE OR NOT TO BE?
Points in favour of periodontal
pack:
1. Patient comfort
2. Acts as a splint for flap
placement
3. Protection from trauma/
factors affecting healing
Points against periodontal
packs:
1. Allergy
2. No antibacterial property
3. Trapping of suture material
4. Forcing dressing material
under flap during placement
5. Flap displacement-Excessive
manipulation

52. Prichard et al
Pt comfort ,wound protection
Prevent post operative
bleeding and protect clot
Baer et al
Pt comfort, wound protection,
Not to be used to control post
op bleeding and protect clot

53. Löe and
Silness
(1961)
Absence
of a
dressing
Complete
healing still
took place
Dressing little
influence on
healing
surgical area is
kept clean.
STAHL ET AL.
(1969)
Compared
the healing
sequence of
dressed and
undressed
gingivectomie
s
No significant
differences in the healing
-the presence of
inflammation at the
wound site had more to
do with than whether or
not a dressing is placed.

54. Loe and Sillness 1961
Noted complete healing
without pack
Concluded-Pack has little
inflamed on healing -Provided
the area is clean
Not significant
Heaney & Appletona 1978
Pack in periodontal healthy
mouths
Little damage to periodontal but
more inflammation than
undressed areas
Concluded-Removed within one
week prevent alterations in
healing patterns

55. WHICH RECONSTRUCTIVE PROCEDURES
ARE EFFECTIVE FOR TREATING THE
PERIODONTAL INTRAOSSEOUS DEFECT?

56. The rationale of favoring
bone growth with the use of
bone transplants is highly
questionable"
(Karring et al, 1980).
"Osseous grafting therapy
has been shown to be
clinically successful for time
intervals exceeding 20 years”
(Schallhorn, 1980).

57. Spectacular results of "bone
fill" in intrabony pockets
have been reported with or
without bone implantation“
(Ramfjord, 1984)
"Bone grafting materials will
enhance regeneration of a
new attachment apparatus"
(Bowers et al, 1989).

58. No significant differences have
been found clinically between
FDBA and DFDBA in primarily
intraosseous defects
(Piattelliet al. 1996a; Rummelhart et al.
1989; Francis et al. 1995)
FDBA may stimulate earlier, more
rapid and more substantial new
bone formation than DFDBA in a
monkey jaw defect model system
(Yukna and Vastardis 2005)

59. PONTORIERO 1987,1988,1989,1992 –
GRADE II and iii defects with membrane –
90% OF GRADE II and 25 to 35% of GRDE III
defects were non probable - stated that
grade III furcation with less than 3mm
entrance height can have complete closure
METZER ET AL 1991 - GTR has limited
therapeutic modality for mesial and distal
maxillary grade II furcations.

60. No additional benefits of
combination treatments of
barrier & grafts were
detected in models of 3 wall
intrabony, Class II furcation or
fenestration defects
Consensus report Sixth European
Workshop on Periodontology, 2008
In supraalveolar defects &
two wall defect models of
periodontal regeneration,
additional use of grafts
gave superior results of
bone repair to barriers
(Sculean et al 2008)

61. Iliac marrow grafts in healing of
intrabony lesions in monkeys –
ankylosis & root resorption
Ellegard et al (1974)
Iliac cancellous bone & marrow
grafts-great potential for
supporting new bone growth
[Cushing 1969, Sottosnati 1975]

62. GINGIVAL MASSAGE INCREASES
KERATINISATION???
Several attempts were made to prove
the above mentioned theory by
Gottlieb but, however, none could
establish-association between gingival
massage via brushing & the produced
friction altering the gingival structure
thereby enhancing resistance against
inflammation.
Castenfelt 1952, Fraleigh 1965
Old concept; the principle function
of tooth brushing is to provide
massage which increases the
resistance of the gingival tissues by
increasing keratinization.
Gottlieb (1921) and by Fish (1935, 1944)

63. SUPPORTIVE PERIODONTAL TREATMENT
. Costa et al-Every 5.5 months for the study duration of 5 years (Regular
compliers)-annual tooth loss per patient of 0.12 teeth. PM visit on average
every 11.6 months (Irregular compliers)-annual tooth loss per patient of
0.36.
Checchi et al.,reported that those who returned for PM interval less than
every 3–4 months were 5.6 times more likely to lose teeth
Ng et al. reported no statistically significant difference between tooth loss in
Regular Compliers (RC) – Mean interval every 4.4 months and Irregular
Compliers (IC), the mean interval – every 6.7 months. No statistical
difference was also reported by Seirafi et al

64. IMPLANT PLACEMENT?

65. Direct bone –implant contact (BIC)
No significant
difference was
found in the (BIC)
between
submerged and
loaded implant
after 4 weeks of
function
(Sharawy et al 2000)
By comparing 10
immediate - loaded
implants for 90 days
with 5 control non
loaded implants , the
study demonstrated
that immediate -
loaded implants may
have higher (BIC) than
non-loaded implants
(Suzuky et al 2007)
No statistical
difference
between
immediate
and delayed
loaded
implants
(Romans et al 2001)

66. ENDO PERIO

67. Microflora of non carious, non
vital pulps & deep periodontal
pocket
Retrograde infection
(Keproti et al)
There is no correlation between
the severity of the periodontal
disease and morphological
changes of the pulp tissue
(Mohnould. T et al)

68. Pulp succumbs only when
periodontal lesions involve the apical
foramen. Otherwise only minor
changes occur in the pulp.
(Langeland. K. et al)
Periodontal disease coupled with
extensive restorations ends up with
more frequent pulpitis than either
cause alone
(Selzer & Bender)

69. Lovdal et al
Endodontic infection
alone,does not
initiate marginal
gingivitis
Dental plaque evoked
inflammatory
response
Prichard & Simon
pulpal lesion doesnot
change its character,it
become marginal
periodontitis when it
reaches gingival
margin

70. Untreated root canal infection in
conjunction with plaque it cause
inflammatory response in connective
tissue of marginal gingiva
(Ehnevid 1993 & Blomlof 1992)
Untreated endoinfection which
hampers periodontal healing by
higher attachment loss
(Janson 1993)

71. Formation of plaque on the
root surface induces
pathological changes in the
pulp
pathological changes &
subsequent necrosis due to
periodontal disease, when
accessory canals are present
(Seltzer)
But the study done by
schilder suggest thaf there is
no changes in the pulp
(Schilder, Mazur, Massler
&Czarnecki)

72. The prognosis of combined lesion rests on the efficacy
of periodontal treatment
Teeth with endo infection correlated to deep
periodontal pocket, more attachment loss & less
probing reduction over time
( Janson)
Treatment of combined lesion is challenging
Endo treatment resolution of endo lesion has no
effect on periodontal involvement
RCT can free the bacteria of pulp cavity is unlike
periodontal treatment there where over zealous
scaling that increases the risk of attachment
(Vanderhaug)

73. FLAP PROCEDURE

74. Carranza- When the bone is
stripped off from the
periosteum , a loss of marginal
bone results and this loss is
prevented when the
periosteum is left on the bone.
Freidman-Although the bone loss
after mucoperiosteal flap is not
clinically significant, the difference
may be significant in some cases

75. Knowles etal(1979)-modified widman procedure
is routinely associated excellent long term
results and reasonable gain in clinical
attachment in infrabony defects
Rosling et al (1976) modified widman flap was
carried out in an area with deep infrabony
lesions, bone repair may occur.
Westfelt etal( 1983), Caffese etal ( 1987)
modified widmans flap procedures failed to give
better pocket reduction and intrabony defects
with no osseous surgery.

76. flap surgery by Widman (1980) &
Neumann (1924) were widely
practiced for pocket
elimination. Much bone and
gingiva were sacrificed during
this procedure considering
them being necrosed.
Kronfeld (1935) & Orban (1939)
periodontal pocket was nether
necrotic nor infected but
destroyed by an inflammatory
process.

77. SPLINTING

78. No correlation between splinting and
reduced tooth mobility during initial
periodontal therapy .Control of tooth
mobility with splinting after osseous surgery
did not reduce mobility of the individual
teeth (Kegel et al., 1979).
Mobility can be controlled and managed
with splinting and will improve periodontal
prognosis. (Pollack, 1999; Laudenbach et al.,
1977; Amsterdam, 1974).

79. Glickman
et al-1961
In a study on rhesus monkeys-it was
observed that forces applied to one
tooth in a splint are distributed over the
entire unit.It was concluded that
splinting of tooth helps in redistributing
the occlusal forces over a larger area.
Mandel
and
Viidik-
1989
In a study of vervet monkeys to
determine the effect of rigid splinting
on anterior teeth following extrusion of
teeth. Results of the study showed that
rigid splinting of luxated teeth did not
improve the mechanical properties of
the periodontal ligament during healing
Rateitschak
1963
In a study to determine the effect of initial
preparation and occlusal adjustment on
tooth mobility, it was observed that for
teeth with initial mobility of greater than
0.2 mm there was a decrease in tooth
mobility up to 20%

80. ATTACHED GINGIVA

81. Inadequate zone of gingiva would
also:favor attachment loss & soft tissue
recession because of less tissue
resistance to apical spread of plaque-
associated gingival lesions
(Stern& Ruben 1979)
In a clinical study comparing the width of
attached gingiva and the prevalence of
gingival recessions found no significant
correlation between oral hygiene and gingival
recession and width of attached gingiva –
(Tenenbaum)

82. The narrow zone of gingiva was
insufficient to protect the
periodontuim form injury
dissipate the pull on the
gingival margin
Friedman 1957, Oshenbien 1960,
Friedman & levine 1964
Patients maintaining a proper
plaque control, the lack of an
"adequate" zone of attached
gingiva does not result in an
increased incidence of soft
tissue recessions.
Wennstrom

83. Keratinized attached gingiva is capable of withstand the stresses of
mastication, tooth brushing, trauma from the foreign objects,
subgingval restoration preparation, inflammation, and frenum pull
FRIEDMAN 1962
The width of attached gingiva is not significant to maintain
periodontal health, thin gingival tissues around teeth with
restorations or undergoing labial orthodontic tooth movement
may be more susceptible to recession.
The functional need for attached gingiva around implants
has not been established but its aesthetic value has been
widely accepted
 PAYAL MEHTA, LUM PENG LIM

84. FULL MOUTH DISINFECTION

85. It emphasized the
superiority of FMD
over SRP
BOLLEN CM 1998
Some studies
reported no
significant
differences between
the SRP and FM
QUIRYNEN M-1995

86. Samples from the tongue,
mucosa, saliva and the 4 deepest
proximal sites of single-root &
multi-root teeth using dark field
microscopy & cultured-no
significant differences between
the FDM & SRP
Quirynen et al
Four proximal sites of single-
root & multi-root teeth using
Checkerboard DNA-DNA
hybridization -slightly greater
reduction in microorganisms of
FDM group.
De Soete et al

87. • A coin having 2 sides is clearly suggestive of any factor having 2 lines of
choices…..and so accepting just one of it whole heartedly might not do justice
• So let us all have this attitude even while planning a treatment protocol while
simultaneously accepting its pros and cons

88. REFERENCES..
• Perio2000,30, Controversies in periodontology, 2002
• Perio2000,36, Nonsurgical periodontal therapy, 2004
• Perio2000,37, Evidence-based periodontal disease prevention and treatment, 2005
• Perio2000,39, Critical issues in periodontal diagnosis, 2005
• Dental implants: matters of course & controversies; Perio 2000: 2008

89. REFERENCES
• Application of lasers in periodontics: true innovation or myth?
Periodontology 2000, Vol. 50, 2009, 90–126.
• Changing concepts in periodontics. Sigurd P. Ramfjord. THE
JOURNAL OF PROSTHETIC DENTISTRY. 2000
• Does Toothbrushing Affect Gingival Keratinization? by Ian C
Mackenzie. Proc. roy. Soc. Med. Volume 65 December 1972.
• The evidence base for the efficacy of antibiotic prophylaxis in
dental practice. J Am Dent Assoc 2007;138;458-474.
• Efficacy of chemical root surface modifiers in the treatment of
periodontal defect. Ann Periodontol 2003:8:205-226

90. REFERENCES..
• Current status of periodontal dressings; JP 1984, vol 55
• Non surgical periodontal therapy - where do we stand? Perio 2000, 2004,vol
36, 9- 13.
• Local anti infective therapy ; pharmacological agents. Ann
periodontol2003,;8:79-98.
• Chemotherapuetics; antibiotics and other antimicrobials. Perio 2000, vol 36,
2004, 146- 165.
• Viruses in periodontal diseases . Oral diseases 2005:11;219- 229
• Which reconstructive procedure are effective for treating the periodontal
intraosseous defects.. Perio 2000, vol 37, 2005. 88- 105