Current approach in periodontal care

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Current approach in periodontal care, Rashidah Ayob, periodontal care, dentistry, Malaysian association of dental public health conference

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Current approach in periodontal care

  1. 1. CURRENT APPROACH IN PERIODONTAL CARE
  2. 2. CURRENT APPROACH IN PERIODONTAL CARE
  3. 3. o Initial Cause Related Therapy 52 yr old Male: Hypertensive, Controlled Diabetes type 2: CHRONIC PERIODONTITIS
  4. 4. Source : R. Ayob 2008 Persistent suppuration before and after RCT UL3 o Initial Cause Related Therapy
  5. 5. o Initial Cause Related Therapy 30yr old female: 3rd pregnancy, Painful swelling WITH bone loss
  6. 6. 21 yrs old female Caucasian: GENERALISED AGGRESSIVE PERIODONTITIS o Initial Cause Related Therapy Courtesy: Guerrero Eastman Dental Institute
  7. 7. Courtesy: Guerrero Eastman Dental Institute
  8. 8. o Initial Cause Related Therapy o Corrective Therapy o Supportive Therapy
  9. 9.  Eliminate the infection  Enhance cleaning ability  Increase comfort  Maintain or improve esthetic  Rehabilitate function  Improve prognosis
  10. 10. FORMATI ON OF PLAQUE BIOFILM
  11. 11. The concept of “CRITICAL MASS” (WWP 1989)
  12. 12. 1. Provide skeleton for bacterial attachment 2. Protection for micro-organisms from environmental factors 3. Nutrients uptake 4. Cross-feeding between species Facilitate removal of harmful metabolic products (utilization by other bacteria) 5. Development of an appropriate physicochemical environment  properly reduced oxidation potential ROLES OF BIOFILM
  13. 13. ANATOMY OF PERIODONTIUM Source: Lindhe Ingression of bacteria and bacterial products
  14. 14. HOST RESPONSE Source: Science Photo library edited RAyob
  15. 15. Source: R.Ayob 2006 BACTERIAL CHALLENGE NEW FINDINGS: Host Inflammatory response influences the composition of the biofilm
  16. 16. 2. Mechanical debridement • Antimicrobial as an adjunct to mechanical debridement (scaling and root debridement) 1. Customised Motivation and OHI • Input about association between periodontitis and systemic diseases • Modification of the biofilm/host response
  17. 17. 2. Mechanical debridement • Antimicrobial as an adjunct to mechanical debridement (scaling and root debridement) 1. Customised Motivation and OHI • Input about association between periodontitis and systemic diseases • Modification of the biofilm/host response
  18. 18. 1. Can periodontitis cause systemic disease? 2 If we have systemic disease,can we get aperiodontitis
  19. 19. PERIODONTITIS SYSTEMIC DISEASE Systemic disease worsen periodontal inflammation Periodontal inflammation influence systemic health
  20. 20. o o o o
  21. 21. o o o o
  22. 22. Herpes viruses (particularly CMV) and oral bacteria (P. gingivalis) can invade cells of vascular origin. Dorn BR, Dunn WA Jr, Progulske-Fox A. Invasion of human coronary artery cells by periodontal pathogens. Infect Immun 1999;67:5792-8. Source: Science library
  23. 23. (Haraszthy & Zambon 2000) Bacteria and toxin induce fat accumulation P. gingivalis and several other oral bacteria - induce foam cell formation in the murine macrophage line. Kuramitsu HK, Qi M, Kang IC, Chen W. Role for periodontal bacteria in cardiovascular diseases. Ann Periodontol 2001;6(1):41-7. Source: Science library
  24. 24. Oral bacteria such as S. sanguis and P. gingivalis can induce platelet aggregation in vitro and may increase the risk of developing acute thrombosis. Fong IW. Emerging relations between infectious diseases and coronary artery disease and atherosclerosis. CMAJ 2000;163(1):49-56 Source: Internet
  25. 25. 2. Periodontal inflammation may be implicated in the initiation or progression of coronary artery disease and stroke. • with raised systemic concentrations of C-reactive protein, fibrinogen • cytokines, all of which have been causally linked to atherosclerosis-induced disease. 1. Inflammation has been implicated in the cause & pathogenesis of atherosclerosis Paoletti R, Gotto AM Jr, Hajjar DP. Inflammation in atherosclerosis and implications for therapy. Circulation 2004; 109 (23 suppl 1): III20–26.
  26. 26. 3. Nonsurgical periodontal treatment • Reduce periodontal inflammation • Reduce serum inflammatory markers and C- reactive protein. Ebersole JL, Machen RL, Steffen MJ, et al. Systemic acute-phase reactants, C-reactive protein and haptoglobin, in adult periodontitis. Clin Exp Immunol 1997; 107: 347–52. D’Aiuto F, Nibali L, Parkar M, et al. Short-term effects of intensive periodontal therapy on serum inflammatory markers and cholesterol. J Dent Res 2005; 84: 269–73. D’Aiuto F, Casas JP, Shah T, et al. C-reactive protein (1444CT) polymorphism influences CRP response following a moderate inflammatory stimulus. Atherosclerosis 2005; 179: 413–17. D’Aiuto F, Parkar M, Andreou G, et al. Periodontitis and systemic inflammation: control of the local infection is associated with a reduction in serum inflammatory markers. J Dent Res 2004; 83:
  27. 27. Artheroscler osis High blood Pressure Strok e Liver & Pancreas Placenta & Uterus Heart Enter Vessel PERIODONTI TIS Bacteria/Toxin Initiation of Inflammation
  28. 28. • Having periodontitis contributes to the total infectious and inflammation burden. May lead to cardiovascular events and stroke in susceptible subjects. • Current evidence is insufficient to support that periodontal infections constitute and independent risk factor for CAD. • Although adjustment for established cardiovascular risk factors (smoking and diabetes), genetic factors that predisposes to both periodontitis and CAD may act as the confounding factor • The impact of periodontal therapy must be further investigated Periodontal diseases and health: Consensus Report of the Sixth European Workshop on Periodontology Kinane D, Bouchard P. Periodontal diseases and health: Consensus Report of the Sixth European Workshop o Periodontology. J Clin Periodontol 2008; 35 (Suppl. 8):333– 337.
  29. 29. o o o o Source: Internet
  30. 30. Presence of peiodontitis or periodontal inflammation can increase the risk for diabetic complications, principally poor glycemic control Taylor GW, Burt BA. Becker MP, Genco RJ, Shlossman M, Knowler WC & Pettit DJ (1996). Severe periodontitis and risk for poor glycemic control in patients with non-insulin- dependent diabetes mellitus. Journal of Periodontology 67 (10 Suppl), 1085-1093. R.Ayob 2010
  31. 31. Bacteria entering the blood may disrupt insulin function – causing increase blood glucose Moritz A, Mealey B. Periodontal disease, insulin resistance, and diabetes mellitus: a review and clinical implications. Grand Rounds Oral-Sys Med. 2006;2:13-20. Source: Internet
  32. 32. Constant hyperglycaemia results in accumulation of AGE (advanced glycated end product). AGE in turn affecting the immune system such as delay the body healing. Source: Online
  33. 33. Diabetes type 2 Liver & Pancreas Placenta & Uterus Heart Enter Vessel PERIODONTI TIS Bacteria/Toksin Initiation of Inflammation
  34. 34. o o o o
  35. 35. 1983 Greg Collin and Offenbacher: Pregnant Hamster challenged with gm negatif E.Coli LPS  Malformation fetuses, spontaneous abortion and low birth-weight E. Coli Vs Porphyromonas gingivalis  Similar effect?
  36. 36. Landmark report by Offenbacher 1996 Adverse pregnancy outcomes linked with periodontitis as a possible risk: 1. Preterm birth & Low birthweight (PLBW) 2. Miscarriage or early pregnancy loss 3. Pre-eclampsia R.Ayob 2010
  37. 37. Periodontitis as a reservoir for:  Gm –ve anaerobics with endotoxin (LPS)  Inflammatory mediators : PGE2  TNFα PGE2 and TNFα inversely related to birth-weight (Collins et al 1994a,b) May act as a potential threat to the fetal-placental unit (Collins et al 1994a,b) Source: Internet
  38. 38. Toxin and bacterial product in the blood are able to enter placenta McGaw 2002 Source: Online
  39. 39. Activation of immune system Source: Internet
  40. 40. Inflammation of amniotic fluid may cause premature rupture of membranes Source: Internet
  41. 41. Inflammation of the uterus and membranes represents a common causing mechanism Preterm low birthweight Source: Internet
  42. 42. • Pre-term birth = <37 weeks gestational age (Martin et al. 2007) • Low birth weight (LBW) = <2500 g (WHO 2005) • Pre-term premature rupture of membranes (PPROM) = Spontaneous rupture of the membranes as <37 weeks gestation at least 1 h before the onset of contractions (Goldenberg et al. 2008) Source: Internet
  43. 43. Source: Internet
  44. 44. Adverse pregnancy outcomes linked with periodontitis as a possible risk: 1. Preterm low birthweight  Known risk: • Young maternal age • Drug, alcohol and tobacco use • Maternal stress • Genetic background • Genitourinary tract infection • Chronic infection (Hill 1998, Goldenberg et al 2000, Scannapieco et al 2003c, Xiong et al 2006) Source: Internet
  45. 45. Adverse pregnancy outcomes linked with periodontitis as a possible risk: 1. Preterm low birthweight  10% of annual birth  2/3 of overall infant mortality  1/3 are elective  2/3 are spontaneous (1/2 due to premature rupture of membranes) Source: Internet
  46. 46. Xiong and co-workers 2006 22 total studies From : U.S(7), UK (3), Hungary (2) , Brazil, Turki, Croatia, Denmark, Colombia, Chile, Iceland, Spain , Sri Lanka, Finland 7 studies found No association between periodontal disease and adverse pregnancy outcomes 15 studies found strong association between periodontal disease and PLBW
  47. 47. Pre mature & Low birth weight Liver & Pancreas Placenta & Uterus Heart Enter Vessel PERIODONTI TIS Bacteria/Toksin Initiation of Inflammation
  48. 48. o o o o
  49. 49. 2. Mechanical debridement • Antimicrobial as an adjunct to mechanical debridement (scaling and root debridement) 1. Customised Motivation and OHI • Input about association between periodontitis and systemic diseases • Modification of the biofilm/host response
  50. 50. 1. Modification of the biofilm. • Antimicrobial Peptides Gorr, S-U. & Abdolhosseini, M. (2011) Antimicrobial peptides and periodontal disease. Journal of Clinical Periodontology 38 (Suppl. 1), 126–141. • Probiotics Teughels, W., Loozen, G. & Quirynen, M. (2011) Do probiotics offer opportunities to manipulate the periodontal oral microbiota? Journal of Clinical Periodontology 38 (Suppl. 1), 158–176. Biological approaches to the development of novel periodontal therapies. Maurizio S. Tonetti & Chapple. J Clin Periodontol 2011; 38 (Suppl. 11): 114–118
  51. 51. 2. Modification of the host response • Nutritional modulation of periodontal inflammation - Increased caloric (include refine sugars) intake induces inflammation directly - Adiposity (Visceral fat accumulation) induces inflammation indirectly • Dietary recommendation - Reducing caloric intake and refined sugars - the dental team incorporating advice to increase dietary intake of fiber, fish oils, fruits, vegetables and berries Biological approaches to the development of novel periodontal therapies. Maurizio S. Tonetti & Chapple. J Clin Periodontol 2011; 38 (Suppl. 11): 114–118
  52. 52. 2. Mechanical debridement • Antimicrobial as an adjunct to mechanical debridement (scaling and root debridement) 1. Customised Motivation and OHI • Input about association between periodontitis and systemic diseases • Modification of the biofilm/host response
  53. 53. 28 yr old Chinese patient with excellent oral hygiene Source: Rayob 2008 Melaka
  54. 54. Source: Tay Shieh Fung , R.Ayob 2013
  55. 55. GENERALISED AGGRESSIVE PERIODONTITIS Aggregatibacter actinomycetemcomitans Source: Eastman Dental Institute (UCL)
  56. 56. Aggregatibacter actinomycetemcomitans (A.a) Strain JP2 or serotype b Release Leukotoxin LTxA and CDT (cytolethal Distending Toxin)
  57. 57. Full mouth periodontal therapy • Systemic Antibiotic with Full Mouth SRD 24hour in Generalised Aggressive Periodontitis
  58. 58. Griffiths, Ayob R, Guerrero A, Nibali L, Suvan J, Moles DR, Tonetti MS. Amoxcillin and metronidazole as an adjunctive treatment in generalised aggressive periodontitis. RCCT. J. Clin Periodontol 2011; 38: 43-49 Baseline 1 year after therapy
  59. 59. Laser Vs conventional mechanical debridement in chronic periodontitis? Er:YAG laser - resulted in similar clinical outcomes in short- and long- term (1 yr) insufficient evidence to support the clinical application of either CO2, Nd:YAG, Nd:YAP, or diode laser * Er:YAG laser:Weak evidence CO2, Nd:YAG, Nd:YAP, or diode laser : no significant clinical added value. Potential thermal injury to the adjacent periodontal tissues Laser application in non-surgical periodontal therapy: a systematic review F. Schwarz, A. Aoki, J. Becker, A. Sculean
  60. 60. o Initial Cause Related Therapy o Corrective Therapy o Supportive Therapy
  61. 61. Source : R. Ayob 2006
  62. 62. R. Ayob 2003
  63. 63. R. Ayob 2008 GTR in perio-endodontic case
  64. 64.  Resective or subtractive procedures
  65. 65.  Regenerative or additive procedures
  66. 66. Position paper American Academy of Periodontology in 2001:  Soft Tissue Grafts  Bone Replacement Grafts  Root Biomodifications  Guided Tissue Regeneration  Combination thereof Greenwell H, Committee on Research, Science and Therapy, American Academy of Periodontology. Position Paper: Guidelines for Periodontal Therapy (2001). J.Periodontol 72, 1624-1628 Osseous, Furcation Recession
  67. 67. 1. Periodontal Regeneration development: • Material and armamentarium • Technique  Conventional  Minimally Invasive Surgical Technique (MIST)  Modified MIST (M-MIST)
  68. 68. Source : R.Ayob 2003
  69. 69. Source : R.Ayob 2003 GTR with resorbable synthetic membrane
  70. 70. GTR alone with resorbable synthetic membrane Source : R. Ayob 03/04
  71. 71. The biologic concept applied by Hammarstrom 1997 , Gestrelius et al 2000: The Enamel matrix (amelogenins): Commercially available product  Emdogain® = purified acid extract of porcine origin contains enamel matrix derivatives, water and Propylene glycol alginate (PGA) carrier. Source: Straumann
  72. 72. Has been in clinical use for more than 15 years Clinical efficacy is very well establlished Source: Straumann
  73. 73. Conclusion from review 103 papers: EMP affect many different cell types (cell attachment, spreading, chemotaxis, proliferation and survival) and expressed Growth factors, cytokines for bone formation and remodelling STRONG EVIDENCE for EMPs to support wound healing and periodontal regeneration
  74. 74. Application of Modified MIST : M-MIST (2009) Source: R.Ayob 2010
  75. 75. 0 day Application of Modified MIST : M-MIST (2009) 18 days post op Source: R.Ayob 2011
  76. 76. Baseline Application of Modified MIST : M-MIST (2009) R. Ayob 2011R. Ayob 2010 8 months Post Op
  77. 77. Source: R.Ayob 2011 Source: R.Ayob 2013
  78. 78. Soft tissue regeneration LEAVE IT……..OR TO AUGMENT? PATIENT WITH NO PROBLEM BUT THIN MUCOGINGIVAL TISSUE Source: R.Ayob 2011 Source: R.Ayob 2013
  79. 79. CONCLUSION: 1. Gingival augmentation surgery (FGG) is effective in providing a significant increase in keratinized tissue with thin gingiva and recessions 2. Sites treated with gingival augmentation surgery  (reduced recession) coronal displacement 3. Sites NOT treated  further recessions not only on existing but new sites Soft tissue regeneration
  80. 80. Type of soft tissue graft Connective tissue graft with epithelial collar Epithelial graft Sub epithelial Connective tissue graft
  81. 81. Type of soft tissue graft Epithelial graft
  82. 82.  Epithelialized Free Gingival Graft (FGG) Source: R.Ayob 2008
  83. 83. Soft tissue regeneration Sub epithelial Connective tissue graft
  84. 84. R. Ayob 2010 UL3(L) Defect : 6mm width 4 mm height
  85. 85. R. Ayob 2010 5 day post op Soft tissue regeneration
  86. 86. R. Ayob 2011 1 week post op
  87. 87. 5% 2.5mm 100% 10% 2.0mm 100% 13% 1.5mm 75 % CEJ 28% 1.0mm 71% 17% 0.5mm 40 % 3. Technique-related factors • Gingival margin position post-operatively Flap margin level to CEJ % Complete root coverage J Periodontol 2005;76:713 - 722 % n (patients)
  88. 88. Modified MIST : M-MIST (2009) Source: R.Ayob 2010
  89. 89. R. Ayob 2011 R. Ayob 2010 Baseline 1 year review
  90. 90. Type of soft tissue graft Connective tissue graft with epithelial collar R. Ayob 2006
  91. 91. Connective Tissue with Epithelial collar R. Ayob 2013
  92. 92. Connective Tissue with Epithelial collar
  93. 93. Connective Tissue with Epithelial collar R. Ayob 2013 R. Ayob 2014
  94. 94. o Initial Cause Related Therapy o Corrective Therapy o Supportive Therapy
  95. 95. SUPRAGINGIVAL AND SUBGINGIVAL PLAQUE Source: R.Ayob 2011
  96. 96. Supportive Periodontal Therapy PDT as an exclusive therapy may be considered a non-invasive alternative for treating residual pockets, offering advantages in the modulation of cytokines some species of bacteria
  97. 97. Photosensitizer Low powered LASER Activated photosensitizer FREE RADICALS Damaging bacteria cell wall/DNA
  98. 98. Supportive Periodontal Therapy
  99. 99. Peri implantitis
  100. 100. General and Final Conclusions 1. Periodontal medicine – Periodontitis association NOT causal. Collaboration between DO and MO needed
  101. 101.     
  102. 102. General and Final Conclusions 2. Concept of biofilm and controlling factors
  103. 103. A major goal of periodontal therapy is to reduce the quantity (mass) of bacterial plaque to a level (critical) that results in an equilibrium between the residual microbes and the host response,
  104. 104. REGENERATIVE PERIODONTAL THERAPIES WHY IS IT APPEARED SIMPLE, YET SO DIFFICULT? The structural and interactive complexity of periodontal tissues and course of disease process became the reasons why it is so difficult to regenerate the periodontium.
  105. 105. General and Final Conclusions 3. Successful regenerative procedures need a profound knowledge in molecular biology, good armamentarium, operator’s experience and skill.

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