PERIODONTAL PATHOLOGY

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PERIODONTAL PATHOLOGY

  1. 1. TARRSON FAMILY ENDOWED CHAIR IN PERIODONTICS
  2. 2. UCLA SCHOOL OF DENTISTRY SECTION OF PERIODONTICS
  3. 3. Dr. E. Barrie Kenney Professor & Chairman Section of Periodontics Dr. Heddie O. Sedano Professor Emeritus & Lecturer Section of Periodontics Presents
  4. 4. PHASE ONE THERAPY (INITIAL THERAPY)
  5. 5. Comprehensive <ul><li>Emergency Therapy </li></ul><ul><li>Examination Diagnosis and Treatment Plan </li></ul><ul><ul><li>Phase one therapy (initial therapy) </li></ul></ul><ul><ul><li>Evaluation of phase one therapy </li></ul></ul><ul><ul><li>Phase two therapy </li></ul></ul><ul><ul><li>Evaluation of phase two therapy </li></ul></ul><ul><ul><li>Maintenance therapy </li></ul></ul>
  6. 6. Phase two therapy <ul><li>Periodontal surgery </li></ul><ul><li>Dental implants </li></ul><ul><li>Crown and bridge </li></ul><ul><li>Removable partial dentures </li></ul>
  7. 7. EMERGENCY THERAPY NECROTIZING ULCERATIVE GINGIVITIS (NUG)
  8. 8. Two weeks NUG resolved by root planning and good oral hygiene Proceed to complete examination and diagnosis
  9. 9. Phase one therapy <ul><li>Control of plaque </li></ul><ul><li>Control of diet </li></ul><ul><li>Control of systemic factors </li></ul><ul><li>Control of oral malodor and taste abnormalities </li></ul><ul><li>Control of tobacco smoking </li></ul>
  10. 10. CONTROL of PLAQUE Presence of plaque in red for 4 surfaces of each tooth
  11. 11. Presence of interproximal plaque is prominent Need to stress floss or interdental brush utilization
  12. 12. Plaque and bleeding scores at 4 time periods Progressive improvement to less than 20% of surfaces with plaque
  13. 13. CORRELATION OF MANUAL DEXTERITY AND KNOWLEDGE WITH ORAL HYGIENE
  14. 14. MANUAL DEXTERITY TEST
  15. 15. CORRELATION COEFFICIENTS BETWEEN RIGHT HAND DEXTERITY AND BUCCO-LINGUAL PLAQUE IN 59 ADULTS DAY 0 0.41 DAY 7 0.38 DAY 14 0.33
  16. 16. CORRELATION COEFFICIENTS BETWEEN KNOWLEDGE AND BUCCO-LINGUAL PLAQUE DAY 0 0.38 DAY 7 0.32 DAY 14 0.30
  17. 17. Patient with plaque induced gingivitis
  18. 18. Three weeks following compliance with excellent oral hygiene and plaque control
  19. 19. Soft brush positioned at 45° to gingiva Brush is vibrated by bass technique of oral hygiene
  20. 20. Dental Floss Best used for interproximal plaque when interdental papillae are present
  21. 21. Interdental brush Tuft brush
  22. 22. Interdental brush Best used when interdental papillae are reduced
  23. 23. Rubber interdental stimulator Least efficient interproximal cleaner
  24. 24. Use of gauze to clean distal surface of teeth adjacent to edentulous areas Gauze is most efficient for these teeth
  25. 25. Electric brushes used for patients with poor manual dexterity Electric brushes can motivate some patients to improve their oral hygiene
  26. 26. Clinical Evaluation of the Efficiency and Safety of a New Sonic Toothbrush Johnson, B.D., McInnes, C., J. Periodontol 65:692, 1994
  27. 27. 51 subjects got either Sonicare or hand brush. Instructed in use or Modified Bass Technique with Oral B 30.
  28. 28. Plaque scores, gingivitis scores and sulcular bleeding scores at 0, 1, 2, 4 weeks. 29 subjects seen at 6 months
  29. 29. All subjects got timer and did not use floss mouth rinses or other oral hygiene aids for first 4 weeks.
  30. 30. Plaque Index 1.38 1.16 1.30 1.86 Sonic 1.56 1.51 1.52 1.71 Manual 4 weeks 2 weeks 1 week 0
  31. 31. Sulcular Bleeding Index 40.7 45.7 49.2 57.5 Sonic 45.9 46.6 56.7 71.6 Manual 4 weeks 2 weeks 1 week 0
  32. 32. Gingivitis 1.26 1.30 1.37 1.47 Sonic 1.28 1.29 1.43 1.58 Manual 4 weeks 2 weeks 1 week 0
  33. 33. No increase in gingival recession or other oral lesions associated with either brush at 6 months.
  34. 34. Comparison of an Oscillating Rotating Electric Toothbrush and a Sonic Toothbrush in Plaque Removing Ability Van Der Weijden, S.A., Timmerman, M.F., Van Der Velden, V. J Clin. Periodontol 23:407, 1996
  35. 35. 35 non dental students given a Sonicare and a Braun Oral B plak control brush and instructed to use each brush every other day.
  36. 36. 2 weeks later subjects no brushing for 24 hours then reevaluated then mouth brushed by an examiner split mouth using both brushes.
  37. 37. Plaque Index After 2 minutes Professional Brushing 0.68 1.81 Sonicare 0.54 1.82 Braun Oral B Enpoint Baseline
  38. 38. They repeated this 4 weeks later with brushing using Zendium toothpaste by the students.
  39. 39. Plaque Index After 2 minutes Panellist Brushing 1.20 2.00 Sonicare 1.10 2.00 Braun Oral B Enpoint Baseline
  40. 40. At end of study they could keep one brush. 34 out of 35 kept Braun brush.
  41. 41. Clinical efficacy of flossing versus use of antimicrobial rinses.Zimmer. S, et al J. Periodontol. 2006 77:1380
  42. 42. 156 patients used brush +daily rinse 0.06% chlorhexidine 0.025% fluoride or brush+ 0.1% cetylpyridiniumchloride +fluoride or brush + floss or brush alone.Evaluated at 8 weeks .
  43. 43. CHX NaF 1.58 CPC/NaF 1.54 FLOSS 2.10 BRUSH 2.00 / MODIFIED PROXIMAL PLAQUE INDEX
  44. 44. CHX /NaF 0.67 CPC/NaF 0.75 FLOSS 0.77 BRUSH 0.89 Papilla Bleeding Index
  45. 45. Additional effect of dentifrices on the instant efficacy of tooth brushing.Paraskevas S .et al J. Periodontol.2006 77:1522
  46. 46. 3 toothpastes used in 40 patients each after 48 hours plaque accumulation.Split mouth hand brush with or without paste .
  47. 47. Tooth paste gave average of 3% more plaque than brush alone.More abrasive pastes no more effective .
  48. 48. CONTROL OF DIET More benefit comes from reduction of sucrose in diet so less caries and less plaque minimal effect on gingival inflammation from other dietary modifications
  49. 49. CONTROL OF SYSTEMIC FACTORS CONSULT WITH PATIENT’S M.D. <ul><ul><ul><ul><li>Control of Hemostasis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Control of Bacteremia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Control of Diabetes </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Control of Medications </li></ul></ul></ul></ul>
  50. 50. CONTROL OF ORAL MALODOR AND TASTE ABNORMALITIES <ul><ul><ul><ul><li>Plaque control is most predictable way to reduce oral malodor together with daily tongue scarping to reduce bacterial load of oral cavity. </li></ul></ul></ul></ul>
  51. 51. CONTROL OF TOBACCO SMOKING <ul><ul><ul><ul><li>Elimination of smoking significantly improves tissue response to initial therapy. </li></ul></ul></ul></ul>
  52. 52. PHASE ONE THERAPY <ul><ul><ul><ul><li>Removal of pathologic tissue for biopsy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Removal of caries-endodontic therapy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Removal of hopeless teeth </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Removal of calculus </li></ul></ul></ul></ul>
  53. 53. Clinical diagnosis of possible malignant ulceration Biopsy should be done immediately in initial therapy
  54. 54. Exophitic growth from area previously diagnosed as lichen planus Immediate biopsy result diagnosis of squamous cell carcinoma
  55. 55. Non ulcerated lesion present for at least 3 years
  56. 56. Tissue removed includes periphery of normal tissue Diagnosed as benign hemangioma
  57. 57. Biopsy site sutured
  58. 58. Removal of caries Endodontic therapy Furcal bone loss resolved after endodontic treatment carried out before any periodontal care
  59. 59. Removal of hopeless teeth Tooth # 3 has 8 mm pockets and grade 3 mobility
  60. 60. Radiograph confirms hopeless prognosis for tooth # 3 Recommend extract tooth # 3 during initial therapy
  61. 61. Deep pockets seen of distal of tooth # 4
  62. 62. Tooth # 4 shows periodontal remodeling after extracting tooth # 3 Pocket depth improved on distal of tooth # 4
  63. 63. REMOVAL OF CALCULUS Root Planing
  64. 64. Photomicrograph of calculus embedded in cementum Root planing is needed to remove embedded calculus
  65. 66. Universal curets for root planing
  66. 67. Gracey curet 5/6 Triangular shaped scaler for small interproximal spaces
  67. 68. Explorers are used to confirm completion of root planing Root surfaces should be glassy smooth and free of calculus
  68. 69. Root surface magnified Prior to root planing with curetes
  69. 70. S.EM of new sharp curete Note surface notches on cutting edge
  70. 71. Root surface magnified after root planing with curet Note smooth surface with very slight striations
  71. 72. Ultrasonic scalers Magneto strictive effect results in high frequency complex movement of tip
  72. 73. Root surface magnified after ultrasonic instrumentation Large ripples seen that can be detected with explorer
  73. 74. MEAN TOOTH SURFACES ROUGHNESS SCORES 17.68 (Kerry) EW.PIO 17.36 (Kerry) EW.PP 13.95 (Green) Files 12.89 (Green) Hoes 9.12 (Green) Sickle 8.30 (Kerry) Curette
  74. 75. Gross amounts of calculus and plaque Remove large deposits with ultrassonic scaler then root plane with curets
  75. 76. Radiographic evidence of calculus Needs root planing with curets
  76. 77. Sublingual calculus with acute inflammation of gingiva Root planing done with curets and oral hygiene optimized
  77. 78. Four weeks after initial therapy Normal healthy gingiva. No bleeding on proving
  78. 79. Pocket reduction No need for further periodontal therapy
  79. 80. Gingival inflammation is combination of acute and chronic changes Interproximal pockets are 6 mm with attachment loss and bone loss
  80. 81. Root planing with curete has resolved acute inflammation Residual pockets and bone loss require phase two periodontal surgery
  81. 82. PHASE ONE THERAPY <ul><ul><li>Occlusal correction </li></ul></ul><ul><ul><li>Occlusal splints </li></ul></ul><ul><ul><li>Provisional splinting of teeth </li></ul></ul><ul><ul><li>Orthodontic movement </li></ul></ul>
  82. 83. Occlusal Adjustment <ul><li>Correction of Centric </li></ul><ul><ul><li>Stable centric relation </li></ul></ul><ul><ul><li>No interferences between CR and CO </li></ul></ul><ul><li>Correction of lateral excurtions </li></ul><ul><ul><li>Balancing interferences </li></ul></ul><ul><ul><li>Working interferences </li></ul></ul><ul><ul><li>Balancing interferences </li></ul></ul><ul><li>Correction of protrusive excursions </li></ul><ul><ul><li>Straight protrusive </li></ul></ul><ul><ul><li>Protrusolateral </li></ul></ul><ul><li>Correction of centric occlusion </li></ul>
  83. 98. OCCLUSAL SPLINTS (ORTHOTICS)
  84. 111. PROVISIONAL SPLINTS
  85. 149. PHASE ONE THERAPY <ul><li>Restorative corrections </li></ul><ul><ul><li>Open contacts </li></ul></ul><ul><ul><li>Overhangs </li></ul></ul><ul><ul><li>Poor margins </li></ul></ul><ul><ul><li>Poor contours </li></ul></ul>
  86. 160. PHASE ONE THERAPY <ul><li>Correction of inadequate </li></ul><ul><li> removable partial dentures </li></ul>
  87. 161. Change in Alveolar Bone 4 Years After Partial Dentures as Percentage of Lengths of the Teeth -0.2 (SD 2.) -0.1 (SD 2.7) 18 Non Denture Wearers -3.9 (SD 5.) -2.3 (SD 3.3) 56 Denture Wearers Distal Mesial # of Abutments
  88. 166. PHASE ONE EVALUATION <ul><li>Pocket depth </li></ul><ul><li>Plaque score </li></ul><ul><li>Bleeding on probing </li></ul><ul><li>Caries </li></ul><ul><li>Occlusal stability </li></ul><ul><li>Mobility, fremitus </li></ul><ul><li>Mucosal health status </li></ul><ul><li>Mucogingival status </li></ul><ul><li>Systemic status </li></ul><ul><li>Radiographic evaluation </li></ul><ul><li>Oral malodor and taste </li></ul><ul><li>Esthetics </li></ul><ul><li>Modification of phase two treatment plans </li></ul>
  89. 167. SECTION OF PERIODONTICS UCLA TO EXIT CLICK THE SCAPE KEY ON THE KEY BOARD TO REVIEW THIS COURSE CLICK ON THIS LINK

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