The future of dentistry and periodontics lies in regeneration. The goals of periodontal therapy lies in not only the arrest of periodontal disease progression but also regeneration of the lost periodontal structures. This presentation provides a review of the current understanding of the regeneration of the periodontium and the procedures involved to restore the periodontal tissues around the teeth.
The future of dentistry and periodontics lies in regeneration. The goals of periodontal therapy lies in not only the arrest of periodontal disease progression but also regeneration of the lost periodontal structures. This presentation provides a review of the current understanding of the regeneration of the periodontium and the procedures involved to restore the periodontal tissues around the teeth.
Coronal advanced flap in combination with a connective tissue graft. Is the t...MD Abdul Haleem
Coronal advanced flap in combination with a connective tissue graft. Is the thickness of the flap a predictor for root coverage? - A prospective clinical study.
Department of Periodontology and Oral Implantology.
"A Journal Club Presentation"
The future of dentistry and periodontics lies in regeneration. The goals of periodontal therapy lies in not only the arrest of periodontal disease progression but also regeneration of the lost periodontal structures. This presentation provides a review of the current understanding of the regeneration of the periodontium and the procedures involved to restore the periodontal tissues around the teeth.
Coronal advanced flap in combination with a connective tissue graft. Is the t...MD Abdul Haleem
Coronal advanced flap in combination with a connective tissue graft. Is the thickness of the flap a predictor for root coverage? - A prospective clinical study.
Department of Periodontology and Oral Implantology.
"A Journal Club Presentation"
Non Surgical Periodontal Therapy by Dr Santosh Martandesantoshmds
Review and Essay Material on Non Surgical Periodontal Therapy. Illustrative Contents for proper presentation on all aspects of NSPT. The Presentation helps in drafting A to Z of NSPT. Readers are encouraged to add newer studies and ideas under each aspect of NSPT.
The periodontal dressing is a physical barrier that is placed in the surgical site to protect the healing tissues from the forces produced during mastication, for comfort and close adaptation.
Periodontitis is a chronic inflammatory disease of the tooth-supporting structures. The treatment of this condition is based on the removal of local factors and restoration of the bony architecture. Traditionally osseous surgery has been performed by either manual or motor-driven instruments. However, both these methods have their own advantages and disadvantages. Recently, a novel surgical approach using piezoelectric device has been introduced. It is a promising, meticulous and soft tissue sparing system based on low frequency ultrasonic microvibrations. The absence of macrovibration makes the instrument more manageable and allows greater intraoperative control with an increase in the cutting safety in the more difficult anatomical cutting zone. This presentation emphasizes the mechanism of action, instrumentation, advantages and limitations as well as its applications in periodontology and implantology.
Fundamentals of Soft Tissue Grafting Principles for Dental Clinicians
by Dr. Jin Y. Kim
Board-Certified Periodontist
Lecturer, UCLA School of Dentistry
Surgical v/s Non surgical periodontal therapy Achi Joshi
Both surgical and nonsurgical therapy produced improvement in the periodontal health.
Treatment approach was based on the comfort level of the practitioner.
In the late 60’s and continuing into the 70’s and 80’s, many series of longitudinal studies were conducted, aimed to document the immediate and most importantly long term clinical results following several types of periodontal therapy.
Furcation involvement is a common sequela of severe chronic periodontal disease. Its effective management has a profound influence on the outcome of periodontal therapy.
A brief description of all topics to recent advances,SDD, host modulation and diabetes, host modulation in smokers, chemically modified tetracyclines, bisphosphonates
Non Surgical Periodontal Therapy by Dr Santosh Martandesantoshmds
Review and Essay Material on Non Surgical Periodontal Therapy. Illustrative Contents for proper presentation on all aspects of NSPT. The Presentation helps in drafting A to Z of NSPT. Readers are encouraged to add newer studies and ideas under each aspect of NSPT.
The periodontal dressing is a physical barrier that is placed in the surgical site to protect the healing tissues from the forces produced during mastication, for comfort and close adaptation.
Periodontitis is a chronic inflammatory disease of the tooth-supporting structures. The treatment of this condition is based on the removal of local factors and restoration of the bony architecture. Traditionally osseous surgery has been performed by either manual or motor-driven instruments. However, both these methods have their own advantages and disadvantages. Recently, a novel surgical approach using piezoelectric device has been introduced. It is a promising, meticulous and soft tissue sparing system based on low frequency ultrasonic microvibrations. The absence of macrovibration makes the instrument more manageable and allows greater intraoperative control with an increase in the cutting safety in the more difficult anatomical cutting zone. This presentation emphasizes the mechanism of action, instrumentation, advantages and limitations as well as its applications in periodontology and implantology.
Fundamentals of Soft Tissue Grafting Principles for Dental Clinicians
by Dr. Jin Y. Kim
Board-Certified Periodontist
Lecturer, UCLA School of Dentistry
Surgical v/s Non surgical periodontal therapy Achi Joshi
Both surgical and nonsurgical therapy produced improvement in the periodontal health.
Treatment approach was based on the comfort level of the practitioner.
In the late 60’s and continuing into the 70’s and 80’s, many series of longitudinal studies were conducted, aimed to document the immediate and most importantly long term clinical results following several types of periodontal therapy.
Furcation involvement is a common sequela of severe chronic periodontal disease. Its effective management has a profound influence on the outcome of periodontal therapy.
A brief description of all topics to recent advances,SDD, host modulation and diabetes, host modulation in smokers, chemically modified tetracyclines, bisphosphonates
Reconstructive periodontal therapy
Some of the slides may appear Blank/White/Black, those are the Videos that I added in the presentation.
Kindly Ignore those slides.
It is sometimes difficult in clinical and experimental situations to determine whether regeneration or new attachment has occurred and the extent to which it has occurred.
Although there are various evidences of reconstruction, the proof of principle for the type of healing is determined by histological studies.
Reconstructive periodontal surgery aims to treat deep pockets which have not be reduced after non surgical periodontal therapy. periodontal regenerative procedures mainly include the use of modified flap techniques , use of bone grafts and newer gene therapies. Biologic mediators play key role in the regeneration process. Guided tissue regeneration and Guided Bone regeneration are commonly used methods for periodontal regeneration. Minimally invasive surgical techniques are preferred surgical methods for treating deep infrabony pockets
Peri implantitis treatment with regenerative approachajayashreep
This study evaluates the clinical results and compare reentry hard tissue measurements following regenerative surgery after strict implant decontamination peri-implantitis cases.
Wound management has made rapid advances over the last 25 years. New innovations in dressing technology could have a huge impact on the greater wound care industry.
Classification of chemical antiplaque agents
1. FIRST GENERATION AGENTS
Poor substantivity and thus used 4-6 times daily.
Reduces plaque score by 20-50%
Examples:
Antibiotics like Penicillin, Erythromycin, Metronidazole
2. SECOND GENERATION AGENTS
Reduce plaque score by 70-90%
Used twice daily
Example: Bisbiguanides, Chlorhexidine, Alexidine
3. THIRD GENERATION AGENTS
Effective against specific periodontal pathogens
Example: Delmopinol
II. Vehicles for delivery of chemical agents
a. Toothpastes
b. Sprays
c. Irrigators
d. Chewing gums
e. Mouthwashes (Listerine, Chlorhexidine, Triclosan, Fluorides, Hydrogen peroxides, Povidone iodine)
Analgesic is a drug that relieves pain by acting on the CNS or on the peripheral pain mechanism without altering consciousness
Opioid analgesics
Non Opioid analgesics (NSAIDs)
NSAIDs are non-steroidal anti-inflammatory drugs. These are not only pain killers but also are anti-inflammatory drugs that are widely used in dentistry. These are weaker analgesics, also called nonnarcotic or aspirin-like or antipyretic analgesics. They do not depress CNS, do not produce physical dependence, and have no abuse liability. They act primarily on peripheral pain mechanisms.
It is a naturally occurring, semi-synthetic, or synthetic type of anti-infective agent that destroys or inhibits the growth of selective microorganisms, generally at low concentrations.
These drugs are used extensively in dentistry for two main reasons: to prevent an infection (chemoprophylaxis) and in the treatment of an infection. Their use in the management of periodontal diseases is often as an adjunct to conventional treatment.
INDICATIONS IN PERIODONTAL DISEASES
1. Patients who do not respond to conventional mechanical periodontal therapy
2. Patients with Aggressive periodontitis and other types of early-onset periodontitis
3. Patients with acute or recurrent periodontal infection
(Periodontal abscess, NUG / NUP, Peri-implantitis, Pericoronitis) associated with/without systemic manifestation)
4. Prophylaxis for medically compromised patients, endocarditis
Soft deposit that form the biofilm on teeth. Plaque is defined as structured, resilient, yellow grayish colored substance that adheres tenaciously to intra oral hard surfaces including restorations. The term plaque is derived from French word, meaning ‘to form a coverage’.Marginal plaque – cause gingivitis.
Supragingival plaque and tooth-associated subgingival plaque – cause calculus formation and root caries. Tissue-associated subgingival plaque- cause tissue destruction in periodontitis.
Cementum is the mineralized dental tissue covering the anatomical root of teeth. It begins at the cervical portion of the tooth at the cementoenamel junction till the apex. It is one of the four tissues that support the tooth in the jaw (the periodontium).
The primary function- Provides attachment to collagen fibres of the periodontal ligament. It therefore is a highly responsive tissue maintaining the integrity of the root, helping to maintain the tooth in its functional position in the mouth, and being involved in tooth repair and regeneration.
Recent advances in periodontal diagnosisPerio Files
First generation:- Conventional probes.
Second generation:- Pressure controlled visual measurement recording probes
Third generation:-Pressure controlled electronic probes with direct computer data capture.
Fourth generation : Aim at recording sequential probing positions along the gingival sulcus.
Fifth generation : Ultrasonic device attached to the 4th generation probe.
Hormonal changes in female patients and periodontal diseasesPerio Files
Hormonal fluctuations and gingival changes in female patient occurs during Puberty, Menstruation, Pregnancy, Menopause,
Oral Contraceptives, Osteoporosis.
NEED FOR ASSESSMENT: To identify high-risk stages of female patients in prior so that preventive and treatment procedures can be tailored
During pregnancy, women undergo certain hormonal and physiological changes that can affect their mouths.
EFFECT OF PREGNANCY ON PERIODONTAL TISSUES
PREGNANCY GINGIVITIS
EFFECT OF PERIODONTITIS ON PREGNANCY
PRETERM LOW BIRTH WEIGHT (PLBW) INFANTS
PREECLAMPSIA
Oral-systemic link has been termed Periodontal Medicine. Significance: Periodontal disease is preventable and readily treatable, thus providing many new opportunities for preventing and improving several systemic diseases.
FOCAL INFECTION: Localized or Generalized infection caused by dissemination of microorganisms or toxic products from focus of infection.
FOCUS OF INFECTION Confined area that
(1) contains pathogenic microorganisms
(2) can occur anywhere in body
Diseases/Conditions affected by periodontitis
A PREGNANCY, PREECLAMPSIA
B ISCHEMIC HEART DISEASES, STROKE
C DIABETES MELLITUS
D PNEUMONIA, COPD
E OSTEOPOROSIS
F CANCER
G ALZHEIMER’S DISEASE
H. RHEUMATOID ARTHRITIS
*Increase in size of gingiva. Lead to false pockets.
*Difficulties associated with it are:
Difficulty in plaque control; Aesthetic concerns; Affect mastication
Interfere with speech
*TREATMENT:
Gingivectomy is the treatment of choice to remove false pockets.
In case of true pockets (osseous defects), gingivectomy with Flap surgery is done. First Gingivectomy is done. After that flap is raised and osseous surgery is performed (either osteotomy or regenerative depending upon the type of defect). Gingivectomy is done by scalpel or electro cautery/lasers (to minimize bleeding). Gingivectomy can be done only where at least 3mm of keratinized gingiva remains after completion of surgery. So it is contraindicated in patients with lack of sufficient keratinized gingiva
*REASONS OF RECURRENCE:
Responsible factors: Residual local irritation; and systemic or hereditary conditions causing noninflammatory gingival hyperplasia.
Recurrence of chronic inflammatory enlargements immediately after treatment indicates that all irritants have not been removed. Contributory local conditions like food impaction and overhanging margins of restorations are commonly overlooked.
If the enlargement recurs after healing is complete and normal contour is attained, inadequate plaque control by the patient is the most common cause.
All about gingivitis
*definition
*classification
*Signs and Symptoms: Increased GCF, Gingival Bleeding, Color change, Consistency, Surface texture (STIPPLING), Position of Gingiva, Gingival Contour, Size.
Treatment consisits of scaling and root planing. The more inflamed a gingival unit appears clinically, the better the chances of therapeutic measures resulting in a return to normal gingival health
2017 classification of periodontal and periimpalnt diseasesPerio Files
In World Workshop 2017, American Academy of Periodontology (AAP) and European Federation of Periodontology (EFP) with expert participants updated the 1999 classification of Periodontal Diseases.
Since 1999, new evidences have emerged regarding environmental and systemic risk factors, prompting the experts to develop new classification.
All furcation defects need to be classified and their possible prognosis should be defined. The treatment of the furcation defects should be carried out accordingly. Treatment include
Osteoplasty, Odontoplasty, Tunnel preparation, Root resection, Hemisection
A brief description of all topics to recent advances,SDD, host modulation and diabetes, host modulation in smokers, chemically modified tetracyclines, bisphosphonates
It restore alveolar bone to the level existing at the time of surgery or slightly more apical to this level. Aim is to achieve positive bony architecture.
STEPS INCLUDE:
1.VERTICAL GROOVING
2. RADICULAR BLENDING
3. FLATTENING INTERPROXIMAL BONE
4. GRADUALIZING MARGINAL BONE
PREFERRED TREATMENT FOR ONE WALLED PERIODONTAL BONE DEFECTS (HEMISEPTUM)
Evidence based practice is Integration of best research evidence with clinical expertise and patient values.
Advantages: QUALITY OF CLINICAL PRACTICE IMPROVES BY INCORPORATING LATEST EFFECTIVE CLINICAL TECHNIQUES INTO PATIENT CARE.
Dental practitioner should try to adopt quality evidences in dental practice, accept evidence based new practices and letting go existing theories.
Evidence collected should be combined with clinical experience and patient preferences. Positive environment with advancement in science can help facilitate evidence based change in future.
This topic include all the drugs that are locally applied in periodontal pocket so that their levels in GCF should be more than blood.
Advantages:
Can attain higher concentrations at base of pocket
Can use drugs that are not suitable for systemic administration
Patient compliance is not required
Alternative for patients predisposed to adverse drug reactions from systemic administration.
Reduced risk for drug resistant microbe development
Lower total drug dose
INDICATIONS:
As an adjunct to mechanical therapy in pockets of 5 mm or greater depth
In patients who are systemically compromised & cannot undergo periodontal flap surgery
Localized recurrent pockets with supportive periodontal therapy
In refractory periodontitis (that is resistant to treatment)
Inflammation and Immunity in periodontitis pptPerio Files
Local destruction of periodontium occurs mostly by activation of immune and inflammatory response, initiated by plaque. First innate immune response is activated followed by specific immune response.
Useful for BDS and MDS students
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
5. To reduce or eliminate gingival inflammation
caused by bacterial plaque and its byproducts
To correct anatomic defects caused by the
disease process.
6. The goal of regenerative periodontal therapy
is to reconstruct what has been destroyed by
periodontitis.
7. The goal of regenerative periodontal therapy
is to histologically regenerate lost alveolar
bone, periodontal ligament and cementum
over a previously diseased root surface
8. Melchers concept (1976)
The type of cell that repopulates
the root surface after
periodontal surgery, determines
the nature of the attachment
9. After surgery the root surface may be repopulated
by four different cell types:
Epithelial cells
Cells derived
from the
gingival
connective
tissue
Cells derived
from bone
Cells derived
from the
periodontal
ligament
13. Cells derived from
the periodontal
ligament leads to
formation of-
PARTIAL
PERIODONTAL
REGENERATION
14. Melchers concept (1976)
He further added that surgical
procedures should be designed such
that both periodontal ligament and
bone be allowed to migrate
coronally, that can regenerate and
maintain the periodontium
15. Indications Of Regenerative Therapy
Deep intraosseous
defects
Tooth retention
Support for
critical teeth Aesthetics
18. Objectives of periodontal regeneration
Pocket reduction
and Clinical
attachment gain
Bone fill of the
osseous defect
Regeneration of
new cementum,
PDL, and bone as
determined by
histologic analysis.
To obtain healthy
maintainable
environment
19. Requirements for predictable regeneration
Undisturbed
Healing
Wound Stability Space Provision
Thorough Root
Planing
Preparation of
Osseous Defects
For New
Attachment
24. Removal of Junctional Epithelium
Can be achieved by curettage, chemical agents and
surgical methods.
Curettage being closed procedure not reliable.
Chemical agents - depth of penetration can not be
controlled, so not used nowadays.
25. Removal of Junctional Epithelium
Surgical methods: Gingivectomy was used, but not
indicated now.
Modified Widman flap is indicated as it removes
pocket epithelium and provide knife edge margins.
This technique is used to elevate flap for better
exposure of underlying area.
26. Impeding or slowing the migration of
Junctional epithelium
Coronally advanced flap: increases distance between
epithelial wound edge and underlying healing area
Principle of this flap is based on the fact that
epithelium from excised margin proliferate rapidly
downwards, thus impeding regeneration from bone
and periodontal ligament.
27. Impeding or slowing the migration of
Junctional epithelium
Coronally advanced flap can be used with root
biomodification and grafting procedures
Particularly helpful in mandibular molar furcations
29. Rationale of Root Biomodification
Periodontitis induces
alterations on the root surface
like reduced collagen fiber
insertion, alterations in mineral
density or surface composition,
and root surface contamination
by bacteria and their
endotoxins.
Root debridement generates a
smear layer that contains
micro-organisms & toxins, that
interfere in periodontal
healing
30. Rationale of Root Biomodification
These agents remove
smear layer
Expose the collagen
fibers to obtain
biologically acceptable
tooth surfaces
Thus, it promotes linking
of biomolecules (eg-
extracellular matrix
proteins) to exposed
collagen in the root
surface
35. Fibronectin: Glycoprotein required by
fibroblasts to attach to the root surfaces.
• Promotes attachment of cell to one another and to
extracellular matrix & collagen
• CHEMO ATTRACTANT for fibroblast & periodontal
ligament cells.
• enhances early phases of wound healing, prevents
separation of flap, favours haemostasis & regeneration.
36. EDTA:
• Chelating Agent
• Removes smear layer.
• Effects partial demineralization to a
depth of 20-30µ
37. Method of Application of Root
Biomodifier
• Raise a mucoperiosteal flap
• Instrumentation of the root surface.
• Apply cotton pledgets soaked in agent and keep there
for 2-5minutes,depending on the application time.
• Irrigate the root surface thoroughly with water
40. Guided Tissue Regeneration
Guided tissue regeneration (GTR) is the method of
preventing the epithelial migration along the
cemental wall of the pocket while maintaining space
for clot stabilization.
The classical studies on GTR were done by Nyman,
Lindhe, Karring and Gottlow
41. Principle of GTR
Based on the principle that the periodontal
ligament cells have the potential to regenerate the
lost attachment apparatus of the tooth. Since
migratory rate of epithelium is more, so by placing
membrane over bone and periodontal ligament,
overlying gingival epithelium and connective
tissue are excluded, thus guiding periodontal
ligament and bone cells to form new attachment
apparatus at defect site.
42. Objectives of GTR
Maintain space in which regenerating tissues
may form.
Protect and stabilize blood clot.
43. Objectives of GTR
Promote cellular growth from periodontal
ligament.
Exclude gingival epithelium and connective
tissue which may interfere with regeneration.
Gain new clinical attachment
44. Indications of Guided Tissue
Regeneration (GTR)
Grade II and
Grade III
Furcation
Defects
Narrow 2-wall or
3-wall infrabony
defects
Ridge
deficiencies
augmentation
Root Recession
Coverage
45. Indications of Guided Tissue Regeneration
Sinus lift
procedures
Healing of
extraction
sockets.
Repair of
apicoectomy
defects
47. Barrier design criteria
47
Scantlebury, Gottlow and Hardwilk(1993) described these five criterias
TISSUE INTEGRATION
CELL OCCLUSIVITY
CLINICAL MANAGEABILITY
SPACE-MAKING
BIOCOMPATIBILITY
48. Tissue integration
The membrane outer surface should integrate
completely with full thickness flap to prevent
membrane exposure and bacterial infection
The membrane inner surface should allow the
blood clot under the membrane to be
stabilized.
49. Cell occlusion
Barrier membrane should be impermeable for overlying epithelial
cells; as these faster growing cells will populate the wound site
and form long junctional epithelium, thus inhibiting the
regeneration.
Clinically manageability
Should be cut, shaped easily with
good clinical handling
50. Space-provision & Biocompatibility
The membrane should provide adequate
space for the regenerating cells and should
not fall over the bone defect.
Should not cause any foreign body immune
response
52. Non resorbable membrane
The most common among these is
polytetrafluoroethylene (PTFE) membrane.
It is biocompatible, good stiffness that helps
maintaining space between membrane and bone defect;
and has shown good regenerative effects, but it has to
be removed after 3-6 weeks. 52
53. Resorbable GTR membranes fall into two
major categories:
Natural
• Collagen
• Duramater
• Cargile membrane
• Oxidized cellulose
• Laminar bone
• Periosteum
Synthetic
• Polyglycolic acid
& polylactic acid
• Polyurethane
membrane
53
55. Some available Resorbable
membranes
Bioguide: A bilayer collagen membrane (porcine derived).
Most popular membrane
BioMend: Tendon collagen (bovine derived)
Atrisorb: Polylactic acid gel
55
57. FACTORS AFFECTING OUTCOME OF GTR
THERAPY
Oral hygiene Smoking
Diabetes
Mellitus
Root surface
preparation
Adequate
amount of
attached gingiva
58. FACTORS AFFECTING OUTCOME OF GTR
THERAPY
Resorbable membranes are
commonly used nowadays; but
tends to fall on bony defects,
leaving no space for bone
regeneration. Thus, greater
regenerative results when
membranes combined with
bone grafts
59. Guided Bone Regeneration (GBR)
Technique of bone regeneration that has evolved from guided tissue regeneration
(GTR)
GTR is used for regeneration of lost periodontium (root cementum, periodontal
ligament, and alveolar bone) while GBR is for the regeneration of supporting bone
In GBR procedure, cell-occlusive physical barrier is placed between the connective
tissue and the alveolar bone defect
60. Uses
GBR increase bone volume in the areas with bone resorption due to long
standing lost of tooth/teeth.
Implants placement is difficult in such areas due to bone resorption.
GBR procedure increases bone volume, thus facilitating implant placement
with long term stability.
61. Principles of guided bone regeneration
1. Cell exclusion
2. Tenting
3. Scaffolding
4. Stabilization
5. Framework
Wang et al 2006Wang et al 2001
62. Indications of Guided Bone Regeneration
(GBR)
Horizontal or
vertical alveolar
ridge
deficiencies
Dehiscence and
fenestrations
associated with
implants
Bone defects
associated with
failing implants
Residual bone
lesions
63. Indications of Guided Bone Regeneration
(GBR)
Repair of sinus
membrane
perforations.
Osseous fill
around
immediate
implants
64. Advantages of GBR/GTR with Bone
Grafting
Support the
membrane to avoid
membrane collapse
Act as a scaffold for
bone in growth or
stimulate bone in
growth from the
recipient site
Protect the
augmented volume
from resorption
Supply a mechanical
shield against
pressure from the
overlying soft
tissues
66. • New bone formed by live osteoblasts in the grafted material
Osteogenic
• Grafted material does not contribute to new bone formation
• Acts as a scaffold for bone formation that originates from
adjacent bone
Osteoconductive
• Bone formation is induced in the surrounding soft tissue
immediately adjacent to the grafted material by release of
growth factors or other stimulatory mediators
Osteoinductive
67. BONE GRAFTS (CLASSIFICATION)
Autogenous grafts
Transferred from one site to another in same individual
Harvested extraorally (iliac crest) or intraorally (mandibular symphysis)
Osteogenic graft
Allogeneic grafts
Between genetically dissimilar members of the same species
eg. Demineralized freeze dried bone (DFDBA): Osteoinductive
Freeze dried bone (FDBA): Osteoconductive
68. BONE GRAFTS
Xenogeneic grafts
Taken from a donor of another species
eg. Bovine Bio-Oss: osteoconductive
Non Bone Graft materials
Synthetic or inorganic materials that can be used as bone
substitutes.
eg Hydroxyapatite, β-tricalcium phosphate, polymers:
Osteoconductive
69. Graft Materials
Bone Graft None-Bone Grafts
Auto Graft
Intra Oral
Extra Oral
Osseous Coagulum
Bone Blend
Cancellous Bone marrow
Bone Swaging
Iliac Autografts
Allografts
Decalcified Freeze Dried Bone
Undecalcified Freeze Dried Bone
Xenograft
Bovine derived bone
replacement graft
70. NON BONE GRAFT MATERIALS
Sclera Cartilage Plaster of Paris Biomaterials
Calcium phosphate biomaterials
(TCP, HA)
Bioactive Glass
Coral- Derived Materials
71. AUTOGENOUS BONE GRAFTS
Autogenous bone still remains gold standard of the bone
graft materials.
Contains viable bone cells (osteoblasts) and thus yields
most predictable results.
It can be cortical graft or cancellous graft
72. A cortical graft is strong initially but weakens overtime before
regaining strength.
Cancellous grafts tend to be weak initially due of their open
architecture but gain strength over a period of time.
Cancellous grafts have the ability to revascularize sooner due
of their spongy architecture. This revascularization starts
around the fifth day.
73. Osseous Coagulum
Described and termed by R. Earl Robinson.
Sources
Lingual Ridges of mandible
Exostoses
Edentulous ridges
Bone distal to last tooth
Bone removed during osteoplasty or ostectomy techniques
74. Method
carbide bur # 6 or # 8 at speeds between 5000 and 30,000 rpm are
used to remove cortical bone. Small particles in the form of bone
dust is placed in a sterile dappen dish.
The mixture of bone dust and blood is used to fill the defect.
Small particle size increases its surface area for cellular and vascular
interaction.
76. Bone Blend
Sources include - extraction socket, exostosis, edentulous area
Bone is removed, triturated in the autoclaved capsule with pestle to plastic-
like mass that can be easily packed into bony defects.
Proposed to overcome the problems associated with osseous coagulum, but
lack of effectiveness is major drawback
77. Intraoral Cancellous Bone Marrow Transplants
Sources include - extraction socket, maxillary tuberosity, edentulous area
Maxillary tuberosity usually contains a good amount of cancellous bone, particularly when the third molars
are absent. After healing period of 8-12 weeks in extraction sockets, area is re-entered and bone is removed
from apical areas.
Lack of effectiveness is major drawback
78. Bone Swaging
Requires the existence of an edentulous area near the defect
The bone is pushed into defect area without fracturing it from its base.
Limitation of this Technique – Chances of fracture.
79. Disadvantage of auto grafts from intra-
oral sites
Amount of available graft material
Second surgical site created with their
harvest
80. BONE FROM EXTRAORAL SITES
In 1923, Hegedus pioneered the use of extraoral sites, with use
of tibia into periodontal osseous defects. Schallhorn and Hiatt in
1960s proposed the use of iliac crest.
81. Iliac Autografts
This fresh or preserved iliac cancellous
marrow has been extensively used by
orthopedic surgeons; in periodontal defects
and furcation areas
82. PROBLEMS ASSOCIATED WITH ITS USE (NOT
USED NOW IN PERIODONTAL DEFECTS)
Infection
Exfoliation
and
sequestration
Recurrence
of defects
Increased
cost
Difficulty in
procuring the
graft
83. Allograft
Derived from human
cortical bone within 12
hours of donor death
No need to create second
surgical site as required
for autografts
Antigenic potential of
allografts and xonografts
are suppressed by
radiation, freezing,
chemical treatments
during processing
84. Allograft: It is of two types
Freeze-dried
bone allograft
(FDBA)
• Osteoconductive
Demineralized
freeze-dried bone
allograft (DFDBA)
• Osteoinductive
• “Gold standard”
graft in
periodontal
regeneration84
85. Freeze dried bone allograft (FDBA)
Freeze-drying the
bone decreases
the antigenicity
of the allograft
Formation of
bone by
osteoconduction
Radiopaque as it
is not
demineralized
86. Demineralized freeze dried bone
allograft (DFDBA)
Demineralization in cold and
dilute HCl exposes bone
morphogenetic proteins (BMP’s)
BMPs are bone-inductive
proteins that induce bone
formation by differentiating
undifferentiated mesenchymal
cells into osteoblasts
It is both osteoinductive and
osteoconductive; better than
FDBA; efficacy equivalent to
autografts
87. Particle size
Particle size of range of
250 to 750um is
recommended for
periodontal bone grafting
procedures
A pore size in the range
of 100 to 200 um is
considered optimal for
endothelial and
fibroblastic in growth
Pore size is distance between
two graft particles. It is
important when considering new
bone growth.
89. Bovine derived bone replacement
graft- Bio-Oss (Osteohealth)
Organic part is eliminated leaving a
hydroxyapatite structure of cortical and
cancellous bone, similar to that of human bone
Act as osteoconductive scaffold that
enables clot stabilization,
revascularization and osteogenesis with
subsequent migration of osteoblasts.
90. Bovine derived bone replacement
graft- Pepgen P-15 (Dentsply)
Recently Yukna et al combines Bio-Oss with a
cell binding polypeptide that is a synthetic
clone of the 15 amino acid sequence of type I
collagen.
Enhanced bone regenerative potential
as compared to Bio-Oss
91. Nonbone Graft Materials
Sclera, Cartilage and Plaster of Paris are no
longer in use for periodontal regeneration
Calcium phosphate biomaterials,
Bioactive glass, Coral derived materials
are used
93. Calcium phosphate biomaterials (Non-
antigenic, osteoconductive)
Hydroxyapatite
(HA)
•Nonresorbable
•Calcium to
phosphate ratio
is 1.67 (similar
to bone)
Tricalcium
phosphate (TCP)
• Partially resorbable
material
• Calcium to
phosphate ratio is
1.5 (is B-
whitlockite)
93
94. Bioactive Glass
Available as Perioglas with particle size 90-
170um; BioGran with particle size 300-355um
‘bioactive’means ability to bond to
bone and enhance bone-tissue
formation.
95. Bioactive Glass
It bonds directly to bone by
formation of a surface layer of
carbonated hydroxyapatite
(calcium phosphate-rich layer),
promotes adsorption of proteins
like chondroitin sulphate and
gylcosaminoglycans and attracts
osteoblasts to form bone.
96. Natural Coral & Coral derived porous
hydroxyapatite
Compatible, but slow resorbtion hindered
their regenerative results
98. Biologic Mediators
Bone grafting in periodontal defects have
shown regeneration in only apical aspect of
defect, that is not sufficient in quantity and
has low predictability
Thus, there arises need of growth
factors that accelerates cells in defect
area to proliferate and differentiate to
fibroblasts, cementoblasts and
osteoblasts
99. Biologic Mediators
Various biologic mediators like
Platelet-derived growth factor
(PDGF), Bone Morphogenetic Proteins
(BMPs), Enamel Matrix Derivatives,
Platelet-rich plasma (PRP) are being
used along with bone grafts to
enhance regeneration
100. Platelet-derived growth factor
(PDGF)
Recombinant human PDGF (rhPDGF)-BB has been combined with beta-tri calcium
phosphate (β-TCP) and available as GEM 21S. It has shown regeneration in
periodontal defects.
rhPDGF-BB has been approved by the FDA for periodontal regeneration
rhPDGF-BB has also been combined with DFDBA and has shown periodontal
regeneration histologically.
101. Bone morphogenetic proteins
Bone Morphogenetic Proteins (BMPs) is a unique group of proteins
within the Transforming Growth Factor beta (TGFb) superfamily.
BMPs demonstrate chemotactic properties and they
induce the differentiation of mesenchymal progenitor
cells into osteoblasts.
102. Bone morphogenetic proteins
BMP-2 has shown strongest bone producing property; BMP-7
(osteogenic protein -1) and BMP-3 (osteogenin) also stimulate
bone formation.
Bovine type I collagen combined with rhBMP-2 is
available commercially and cleared by FDA. Bovine
type I collagen allows slow release of BMP over a
period of 2-3 weeks, that slowly allows osteoblasts
differentiation over period of time forming new bone.
103. Enamel Matrix Derivatives
During tooth development, the inner cells of Hertwig’s epithelial root sheath
secrete enamel matrix proteins called amelogenin that eventually lead to
cementum formation, PDL and bone formation.
Enamel matrix protein derivatives obtained from developing porcine teeth
has been approved by the FDA and is marketed as Emdogain.
Histologic evidence of periodontal regeneration when Emdogain used with
autograft and allograft.
104. Platelet Rich Plasma (PRP)
Platelet Rich Plasma is first generation platlet concentrate. Blood
is mixed with sodium citrate dextrose (anticoagulant) in test tube
and centrifuged at 1300rpm for 10 minutes (slow spin). Second
centrifugation is done at 2000rpm for 20 minutes(hard spin)
Its in liquid form, not used nowadays due to life
threatening reactions by use of anticoagulant.
105. PROBLEMS ASSOCIATED WITH PRP
Requirement of
anticoagulant
Time period of
release of
growth factors
is less
Liquid nature of
PRP complicates
handling
106. Platelet Rich Fibrin
It is second generation platlet concentrate. Blood is placed in
test tube and centrifuged at 3000rpm for 10 minutes without use
of anticoagulant
In PRF 3-dimensional cross linked fibrin matrix act as
binding medium for platelets and WBC (that release
growth factors)
107. Platelet Rich Fibrin as membrane
As a thick matrix it stimulates migration of fibroblasts and
endothelial cells, resulting in angiogenesis; aids in clot
stabilization and prevent migration of non desirable cells into the
bony defect
Release growth factors like platelet derived growth
factors(PDGF), insulin like growth factors(IGF),
fibroblast growth factor(FGF), Transforming growth
factor(TGF), Vascular endothelial growth factor(VEGF)
108. Advantages of PRF
Used as
membrane (high
flexibility)
3D fibrin network
aids in release of
growth factors for
extended periods
Anticoagulant not
required
Can be used with
graft
111. Injectable Platelet Rich Fibrin (iPRF)
It is second generation platlet concentrate. Blood is placed in
test tube and centrifuged 700rpm for 3 minutes without use of
anticoagulant
More prolonged release of growth factors as compared
to PRF
112. Injectable Platelet Rich Fibrin (iPRF)
It is second generation platlet concentrate. Blood is placed in
test tube and centrifuged 700rpm for 3 minutes without use of
anticoagulant
Has high number of platelets, more prolonged release
of growth factors, higher fibroblast migration and
higher microbial activity as compared to PRF and PRP
113. Injectable Platelet Rich Fibrin (iPRF)
Its in liquid state, can be mixed with powered graft particles to
form sticky bone, that makes the graft particles clumped
together, more retentive, mouldable according to defect site with
higher number of growth factors.
iPRF has shown to increase gingival thickness
115. Combined Techniques
It is being proposed that combined use of
root conditioning agents, bone grafts,
biologic mediators, resorbable membrane
along with coronally advanced flaps can
result in an increased percentage of cases
with successful new attachment and
periodontal reconstruction.