This document discusses refractory periodontitis. It begins by defining refractory periodontitis as a destructive periodontal disease where patients continue to experience attachment loss at sites despite conventional therapy. Several studies are summarized that investigated clinical features and microbial profiles of refractory periodontitis patients. In general, the studies found heterogeneity in clinical presentation and microbial profiles of refractory patients. Certain bacteria like Enterococcus faecalis and Streptococcus species were found at higher levels in refractory patients. The document concludes by discussing treatment considerations for refractory periodontitis, such as using antibiotics and intensified maintenance programs.
Phase I periodontal therapy is the first in the chronologic sequence of procedures that constitute periodontal treatment. It is also referred to as cause related therapy or non-surgical periodontal therapy.
Periodontitis is a complex infection initiated by bacteria –tissue destruction.
Host: the organism from which a parasite obtains its nourishment/ an individual who receives a graft
Modulation: the alteration of function or status of something in response to a stimulus or an altered physical or chemical environment
A brief description of all topics to recent advances,SDD, host modulation and diabetes, host modulation in smokers, chemically modified tetracyclines, bisphosphonates
INTRODUCTION
DEFINITION
TYPES OF TRAUMA FROM OCCLUSION
GLICKMAN CONCEPT
WAERHAUG CONCEPT
STAGES OF TISSUE RESPONSE TO INJURY
CLINICAL AND RADIOGRAPHIC FEATURES OF TFO
CLINICAL DIAGNOSIS OF TFO
TFO AND IMPLANTS
TREATMENT OF TFO
CONCLUSION
REFRENCES
Phase I periodontal therapy is the first in the chronologic sequence of procedures that constitute periodontal treatment. It is also referred to as cause related therapy or non-surgical periodontal therapy.
Periodontitis is a complex infection initiated by bacteria –tissue destruction.
Host: the organism from which a parasite obtains its nourishment/ an individual who receives a graft
Modulation: the alteration of function or status of something in response to a stimulus or an altered physical or chemical environment
A brief description of all topics to recent advances,SDD, host modulation and diabetes, host modulation in smokers, chemically modified tetracyclines, bisphosphonates
INTRODUCTION
DEFINITION
TYPES OF TRAUMA FROM OCCLUSION
GLICKMAN CONCEPT
WAERHAUG CONCEPT
STAGES OF TISSUE RESPONSE TO INJURY
CLINICAL AND RADIOGRAPHIC FEATURES OF TFO
CLINICAL DIAGNOSIS OF TFO
TFO AND IMPLANTS
TREATMENT OF TFO
CONCLUSION
REFRENCES
REFERENCES TAKEN FROM CARRANZA'S TEXTBOOK OF CLINICAL PERIODONTOLOGY AND LINDHE'S TEXTBOOK OF CLINICAL PERIODONTOLOGY AND IMPLANT DENTISTRY. CONTAINS ENOUGH AND MORE DETAILS OF THIS TOPIC FOR BDS STUDENTS.HOPE THIS PRESENTATION WILL HELP U GAIN SOME KNOWLEDGE ABOUT PERIODONTAL PLASTIC AND ESTHETIC DENTISTRY.
Certains medications have been associated with gingival enlargement.
the seminar gives a complete analysis of etilogy and pathogenesis involved in digo as well as sequlae of it
mucogingival surgery or plastic surgery of muco-gingival tissue is a surgical procedure targeted to correct and eliminate anatomic, developmental and traumatic alterations of gingiva.
Furcation involvement is a common sequela of severe chronic periodontal disease. Its effective management has a profound influence on the outcome of periodontal therapy.
REFERENCES TAKEN FROM CARRANZA'S TEXTBOOK OF CLINICAL PERIODONTOLOGY AND LINDHE'S TEXTBOOK OF CLINICAL PERIODONTOLOGY AND IMPLANT DENTISTRY. CONTAINS ENOUGH AND MORE DETAILS OF THIS TOPIC FOR BDS STUDENTS.HOPE THIS PRESENTATION WILL HELP U GAIN SOME KNOWLEDGE ABOUT PERIODONTAL PLASTIC AND ESTHETIC DENTISTRY.
Certains medications have been associated with gingival enlargement.
the seminar gives a complete analysis of etilogy and pathogenesis involved in digo as well as sequlae of it
mucogingival surgery or plastic surgery of muco-gingival tissue is a surgical procedure targeted to correct and eliminate anatomic, developmental and traumatic alterations of gingiva.
Furcation involvement is a common sequela of severe chronic periodontal disease. Its effective management has a profound influence on the outcome of periodontal therapy.
The relationship between periodontitis and systemic diseases have been a debatable topic since over a century, yet the debate is still ongoing. Various epidemiological and interventional studies have been carried out to prove its biologic plausibility. This ppt compiles the main systemic diseases that have consistently shown to have an impact because of periodontal infection.
Epidemiology of gingival & periodontal diseasesChetan Basnet
It is the “study of the distribution and determinants of health related states or events in a specified population, and the application of this study to control of health problems.”
-John M. Last(1988)
The presentation three main topics :
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Human Gut Mycobiota is still a mistery for us. Most of the reasearch on this topichas been conducted in the last 5 years. We are starting to comprehend the interactions with our gastrointestinal system and the virus and bacterial communities. 13% of gut microbiota in weight, about 150 species; most of them can shift from commensalism to virulent parassitosis according to our immune competence. Gut fungal overgrowth is actually underestimated in dignaosis and treatment. Many FGIDS and SIBO are frequently mixed bacteral and fungal dysbiosis
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pathogens in periodontal microbiology. the red complex bacteria described in detail. recent updates regarding proteases and virulence factors of all pathogens.
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Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
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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
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7. • A destructive periodontal disease in patients
who, when longitudinally monitored,
demonstrates additional attachment loss at one
or more sites despite well-executed therapeutic
and patient efforts to stop the progression of
disease
Refractory Periodontitis
8. Etiology:
• conventional therapy failed to eliminate
microbial reservoirs of infection
• Emergence or superinfection of opportunistic
pathogen
• Unknown factors
Refractory Periodontitis
Photos from:; kohaladental.com; photos.com
10. Refractory Periodontitis
Not applicable to patients who:
1. Have received incomplete or inadequate
conventional therapy
2. Have identifiable systemic condition that
increases susceptibility to infections
3. Have localized areas of rapid attachment loss
related to local factors
4. Have recurrence of progressive periodontitis of
many years of successful maintenance
13. Clinical and microbiological
features of refractory
periodontitis subjects
• Aim: to compare clinical parameters and the site
prevalence and levels of 40 subgingival species
in successfully treated and refractory
periodontitis subjects
14. methodology
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94 subjects
CLINICAL EXAM
•Gingival redness
•Suppuration
•BOP
•PI
•PD
•CAL
Baseline
Every 3 mo
Scaling and Root
planing
Modified Widman + Tetracycline
250mg QID for 28 days
15. methodology
66 successful tx
14
28 refractory pt
CAL > 3 sites,
>2.5mm in 1 year
Photos from:clicker.com; tokeyclub.com; www.scielo.cl;pinterest.com
Checkerboard DNA-
DNA hybridization
Bacterial culture in blood
agar plate
PCR
1
2
19. Fig 3. % of sites
colonized at baseline
by different levels of
the 40 subgingival taxa
-Reject the hypothesis that
periodontal pathogens were
higher or more prevalent in
refractory
-Streptococcus constellatus:
-12.6±3.6 for refractory
-3.7±1.1 for successfully
Results
*
*
*
*
*
24. Conclusion
• Refractory subjects CANNOT BE distinguished
through clinical features prior to therapy.
• Refractory subjects had lower prevalence and levels
of the 40 test species in their sites than subjects in the
successfully treated group.
• Putative perio pathogens were found in more sites of
successfully treated than in refractory subjects prior to
therapy.
• Higher frequency of Streptococcus species in
refractory. S. constellatus in refractory
26. Aim: to examine subgingival microbial
profiles associated with refractory
periodontitis and to seek such profiles in
periodontally healthy, periodontally well-
maintained elder and untreated
periodontitis subjects
Subgingival microbial profiles in
refractory periodontal disease
33. results
I - streptococcus
species of yellow
complex
II – low prevalence
of all taxa; orange
III – wider
distribution; A.
naeslundii and V.
parvula
IV- red and
orange complex;
B. forysthus strep constellatus in all group
35. Conclusion
• Refractory perio, on average, have similar
microbiota to that seen in untreated perio
• Refractory perio have heterogenous
subgingival microbiota
• Microbial profiles of refractory is seen in
perio subjects as well as some healthy
and some well maintained
36. Conclusion
• prevalence of Streptococcus species is
not seen in refractory groups
• Detection of different microbial profiles
design individual treatment for each
patient
37. Comparison of subgingival
microbial profiles of refractory
periodontitis, severe
periodontitis, and Periodontal
Health using the Human Oral
Microbe Identification
Microarray• Colombo et al. (2009)
38. Comparison of subgingival
microbial profiles of RP,
GRs,PH using the HOMIM
• Aim: to compare subgingival microbiota of
subjects with refractory (RP), treatable
periodontitis (GRs= good responders) or
periodontal health (PH) using the human
oral microbe identification microarray
39. methodology
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CLINICAL EXAM
•Gingival redness
•Suppuration
•BOP
•PI
•PD
•CAL
Baseline
Every 3 mo
Scaling and Root
planing
Modified Widman + Amox 500mg +
Metro 250mg TID for 14 days
PERIODONTALLY
HEALTHY
N=20
•No PPD > 3mm
or CAL > 2mm
PERIO
N=47
•Atleast 5 sites
with PD and CAL
≥6mm
44. Microbiologic
profiles of 3 groups
at baseline:
Prevalence of
Streptococcus
species
Most species were
seen in perio pt
28% of all
species/genera/
clones is not seen
in PH
perio pathogen
in RP
46. Comparison of microbiota
in sites that lost
attachment vs
healthy/gained
attachment
• S. intermedius/
constellatus, S.
anginosus, P. micra,
Selenomonas spp, etc
are higher in sites losing
attachment
47. Conclusion
• Role of species that play in the initiation
and /or progression of RP, the effect of
periodontal therapy on this unusual
microbiota and the interaction between
these species and oral microorganism are
unknown
48. Conclusion
• Abx may be effective against pathogenic
bacteria but may not be effective against
unusual species overgrowth
continuous perio destruction
• More studies are needed
50. DETECTION OF
ENTEROCOCCUS FAECALIS IN
SUBGINGVIVAL BIOFILM OF
PATIENT WITH CHRONIC
REFRACTORY PERIODONTITIS
• Aim: to investigate the presence of E. faecalis in
subgingival biofilm of patients with chronic
refractory periodontal diseases
52. Enterococcus Faecalis
• Normal human commensals adapted to nutrient-
rich, oxygen-depleted and ecologically complex
environments
• 1 of the top 3 nosocomial bacterial pathogen
• strain resistant to antibiotics
• Found in 60% of school children with high caries
and 75% of pt w/ endodontic infection
• Most commonly isolated or detected species
from oral infection
53. methodology
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100 non-smoking
Chronic
periodontitis
subjects
CLINICAL EXAM
•Gingival redness
•Suppuration
•BOP
•PI
•PD
•CAL
Baseline
Every 3 mo
Scaling and Root
planing
Modified Widman + Tetracycline
250mg QID for 28 days
55. methodology
Photos from:clicker.com; tokeyclub.com; christianberdy.com; Colgate.com; clipartlord.com
73 successful get 27
27 Refractory
•Mean attachment
level gain
•No sites w/ CAL
>2.5mm after 1 yr
of perio therapy
•Mean attachment
loss and/or >3
sites w/ CAL >
2.5mm after perio
therapy
culture in blood agar
plate to determine
presence of E.
faecalis
57. Conclusion
• Within the limitations of this study,
detection of E. faecalis in refractory sites
seem to have a role in pathogenesis of
refractory periodontitis
• Sound knowledge of pathogen can help
develop effective treatment strategies
• Patients with refractory are candidates for
bacterial culturing
58. How do We Proceed with
Treatment?
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59. 1. Arrest the disease
2. Slow the progression of disease
• Control may not be possible in all instances
just slow the progression
Therapeutic Goals
60. 1. Collection of subgingival microbial
samples
2. Selection and administration of an
appropriate antibiotic regimen
3. antimicrobial regimen + conventional
therapies may be used
Treatment Considerations
61. 4. Re-evaluation with microbiological testing
as indicated
5. Identification and attempt to control risk
factors (ex. Smoking)
6. Intensified periodontal maintenance
program shorter intervals between
appointment with microbiologic testing if
indicated
Treatment Considerations
62. 1. Desired outcome is to arrest or control
the disease
2. If control is not possible, the treatment
objective is to slow the progression of the
disease
Outcome Assessment
This isa 40 year old patient who came to your office with a chief complaint of bleeding gums when brushing his teeth. Patient claims to be systemically healthy. Clinical exam revealed clinicall attachment loss of 4-6mm
Radiographic exam revealed patient has fairly good amount of one remaining with bone support generally ranging from 60-80%. You gave this patient a diagnosis of generalized moderate with localized severe chornic periodontitis.
After clinical and radiographic
However, despite your attempts to control the infection with conventional periodontal therapy, Additional clinical attachment loss occurred. So you begin to think did I miss out anything?
Superinfection - infection occurring after or on top of an earlier infection, especially following treatment with broad-spectrum antibiotics.
Not applicable to patients who:
Have received incomplete or inadequate conventional therapy
Have identifiable systemic condition that increases susceptibility to infections
Have localized areas of rapid attachment loss related to local factors
Have recurrence of progressive periodontitis of many years of successful maintenance
1st phase: all underwent Checkerboard to compare microbiotia before tx
2nd phase: from 14 refractory, do another checkerboard, bacterial culture and PCR
