STUDENT NUMBER: 1164231 ASSIGNMENT 1 WORD COUNT: 2871 MSc RESTORATIVE DENTISTRY

Contents
Contents.....................................................................................................................................2 DEFINITION ............................................................................................................................2 FACTORS ASSCIATED WITH PERIODONTAL DISEASE......................................................3 GENETIC FACTORS.............................................................................................................3 HOST RESPONSE ................................................................................................................3 MICROORGANISMS..............................................................................................................4 TREATMENT PROCEDURES...................................................................................................4 NONSURGICAL PHASE........................................................................................................4 MOTIVATION AND PLAQUE CONTROL..........................................................................5 ROOT INSTRUMENTATION, ULTRASONIC AND LASER .............................................7 ANTIMICROBAL THERAPY.............................................................................................10 SURGICAL PHASE..............................................................................................................13 PURPOSES OF PERIODONTAL SURGERY..................................................................13 INDICATIONS...................................................................................................................13 POCKET CLASSIFICATION............................................................................................13 TYPES OF PERIODONTAL SURGERY..........................................................................13 REFERENCES.........................................................................................................................16

DEFINITION
Periodontal disease is an inflammatory and destructive process of the supportive teeth structures such as periodontal-ligament, gingiva and alveolar bone caused by specific microorganisms or groups of microorganisms. The main clinical features related to periodontal disease are: Formation of periodontal pockets due to alveolar bone loss

Changing of colour and contour of the gingiva Bleeding on probing

FACTORS ASSCIATED WITH PERIODONTAL DISEASE

GENETIC FACTORS
Nowadays, more and more emphasis is put on the existence of genetic predisposition towards periodontal disease. Le et al. found that among people deprived completely from oral hygiene some develop disease quicker than the others and symptoms are more expressed. That means that some individuals are more susceptible than others. Periodontal disease is a multifactorial disease which means that its etiology includes genetic and environmental factors such as smoking, diabetes, poor oral hygiene, pathogenic microorganisms. Genetic factors have minimal clinical importance since they are beyond our control.

HOST RESPONSE
The extent and progression of periodontal disease rely on the interaction between pathogenic microorganisms and individual genetic factors. Page et al. 1997 depictured the relation between pathogenic microorganisms and host response. Bacterial related products such as Antigens and Lipopolysaccharides (LPSs) induce immune-inflammatory response which under the influence of genetic factors, from one side, and environmental and acquired factors, from another, leads to connective tissue and bone destruction. The direct factors responsible for this destruction are the complex of matrix metalloproteinases (MMPs), their inhibitors, Prostaglandin E2(PGE2) and cytokines.

MICROORGANISMS
Bowen et al. 1976 describes dental plaque as structured, yellow-greyish substance which adheres to the intraoral hard surfaces, including removable and fixed restorations. Costerton et al 1999, Costerton et al 1995 find that dental plaque: is a biofilm with heterogeneous structure contains lots of channels filled with fluid uses these channels for nutrients supply the matrix in the biofilm creates environment which makes bacteria existing in the biofilm different from bacteria freely floating in the saliva bacteria related products stay and concentrate within the biofilm

According to Mah et al. 2001 and Xu et al. 2000, Bacteria within the dental plaques biofilms: have increased resistance to antimicrobial agents comparing to freely floating microorganisms the increased resistance is due to different mechanisms related to different bacteria and different antimicrobial agents the resistance towards antimicrobial agents can be changed by changings in their temperature, pH, growth rate and sub-effective doses of antimicrobial agents

TREATMENT PROCEDURES
NONSURGICAL PHASE
This is the phase where all etiological factors should be taken into consideration and eliminate. The aim of this part of the treatment plan is to stop the progression of periodontal disease.
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MOTIVATION AND PLAQUE CONTROL

1. CO-DIAGNOSIS AND EDUCATION It is common misunderstanding among patients that visiting a dentist automatically will lead to eliminating the disease process and the whole responsibility lies upon dentist. Nowadays, it is well-known that patients should take an active role in treatment process. However, it is the dentist who is responsible for educating and motivating them. Involving patients into the process of diagnosis it is known as co-diagnosis. In order to for patient to understand his condition and what the treatment plan exactly means dentist should provide all the necessary information and take his time to explained it. Intraoral camera Tv-screens Digital x-rays Models Pictures Leaflets

2. PLAQUE SCORING SYSTEMS Serve not only for regular assessment from one visit to another but they are also great motivation tool for patients OLeary Index, OLeary et al. 1972

According to this scoring system, patient uses either disclosing solution or tablets to show up the plaque. Occlusal surfaces do not get into account. The number of plaque-covered surfaces is divided by the total number of surfaces and then multiplied by 100. A reasonable score is around 15% Silness and Loe scoring index- similar to OLeary but patient does not use disclosing solution which makes it less educational and motivating. Bleeding point index, Lenox et al. 1973

This index does not show the presence or absence of plaque but existing bleeding on probing. By using periodontal probe into sulcus brushing movements are applied from distal to mesial. Quadrant by quadrant, the presence of bleeding is noted in such a way that each tooth has only four scoring surfaces.

3. TOOTHBRUSHING Manual Manual toothbrushes on the market have different design: size, length, hardness, position and inclination of the bristles However, Claydon et al. 1996, concluded that there is not enough evidences supporting that one toothbrush design is significantly superior over another. Electrical powered toothbrushes Electrically powered toothbrushes rely on rotating motions for cleaning tooth surface. Robinson et al. 2005 found that powered toothbrushes with oscillating movements remove significantly more plaque comparison to manual toothbrushes. 4. INTERDENTAL CLEANING Dental Floss Dental floss also varies. On the market there could be found: thin or thick, waxed or non-waxed. But according to Finkelstein et al. 1979 there is no significant difference in the result achieved with different types of floss. On the market are also available powered flossing devices which also do not show any superiority over finger flossing. Interdental Brushes Interdental brushes are specifically useful on irregular shaped and concave surfaces due to their specific cylindrical or cone shaped.

5. ORAL RINSES Chlorhexidine Rinse Chlorhexidine is one of the most efficient antiseptic with significant plaque and gingivitis reduction, Lang et al. 1982. The studies do not show significant difference between 0.12% and 0.2% concentration solutions according to Keijser et al 2003. The negative aspects of chlorhexidine include brownish staining on teeth, tongue and resin restorations and transitory taste perception. Essential Oil Rinse Essential Oil Rinses contain Thymol, Eucalyptol and Menthol. They show also significant plaque reduction potential according to Fine et al 1985 and Gordon et al 1985. Pre-brusing oral rinses The active component in pre-brushing oral rinses is sodium benzoate. The researches, however, do not support the idea that using pre-brushing rinses with brushing is significantly more effective than only the brushing without rinsing, Beiswander et al 1990.

ROOT INSTRUMENTATION, ULTRASONIC AND LASER

1. Hand instruments Sickle scalers- they are used to remove supragingival calculus Curettes-they are used to remove supra- and sub-gingival calculus, root planning and soft-tissue curettage. Chisel and File scalers- are used for removing heavy deposites of calculus supra- and sub-gingival

One of the most important things when it comes to hand instrumentation, besides the proper technique, is the sharpness of the instruments. The sharpness of a instrument depends on the angulation between the two surfaces of the blade. The instrument is accepted as sharp when the junction between these surfaces is a fine line. The more the instrument has been used the more rounded that junction becomes losing its cutting properties, Antonini et al. 1977. 2. Sonic and Ultrasonic Instruments They are used for removing plaque and calculus, supra- and subgigival, also soft tissue wall cleaning of periodontal pockets. The result from sonic and ultrasonic instrumentation depends on: Frequency The term frequency related to Sonic and Ultrasonic Instrumentation is defined by the number of movements of the tip, back and forth, per second. The higher the frequency is the smaller active are of the tip is. Stroke Stroke is defined as the distance which the tip travels for one cycle. Water Flow The combination between water flow and Sonic/Ultrasonic instrumentation leads to three clinically very important physiologic effects which are the basis of disrupting microflora in periodontal pockets, Walmsley et al. 1984 and Walmsley et al. 1988: Acoustic streaming-this is the unidirectional flow of the fluid as a result of the sound/ultrasound waves. Acoustic turbulence-the movement of the tip causes flow acceleration, turbulence.

Cavitation-the high turbulence caused by a tip movement leads to bubbles production. These bubbles then implode leading to spreading shock waves across the fluid. Sonic instruments rely on air pressure to produce vibrations. Their tips have elliptic working orbit and universal design. Ultrasonic instruments are: Piezoelectric- rely on piezoelectric technology. Magneto-strictive

According to Baehni et al. 1992, ultrasonic instrumentation and sonic instrumentation are both effective in disrupting plaque microflora with prevalence of ultrasonic instruments. Obeid et al. 2004, find no significant difference in scaling and root-planning performed by ultrasonic, sonic and hand instruments 3. Lasers Diode Lasers (=810mm)

Have excellent bacteria reduction rate, especially over Actinobacillus actimycetemcomitans. Moritz et al. 1997 prove the effectiveness of diode laser as an addition to instrumental therapy. In another study, Moritz et al. 1998, investigate the long term effect of diode laser therapy and find that there is significant bacteria reduction as well as reduction in the bleeding index comparison to the control group. In contrast to their excellent bacteria reduction rate diode lasers show no advantage in forming a new attachment, Kreisler et al. 2001. Nd:YAG Lasers (=1,064mm)

They have similar effect to Diode Lasers. Liu et al. 1999, compare the effect of periodontal therapy with Nd:YAG laser only, mechanically scaling and root planning only and mixed. The best results were achieved by

using laser and afterwards mechanical scaling whilst the worst results were achieved by using laser therapy only. Neil et al. 1997, in a double-blind study also find that the best results are achieved by using combination of laser and mechanical scaling and root planning therapy. Er:YAG Lasers

Er:YAG lasers show not only excellent antimicrobial activity but also great potential for calculus and plaque removal from root surface. Aoki et al. 1994, in their in vitro study show the effectiveness of calculus removal by Er:YAG laser with water irrigation with no significant temperature increasing. Watanabe et al. 1996, describe the calculus removal as easy in 95% of the cases despite some irregularities and also achieve less bleeding and quicker healing comparison to conventional methods. Despite the positive in-vitro studies of Er:YAG laser therapy some in-vivo studies find no significant difference between it and hand-scaling in terms of attachment regaining, Sculean et al. 2004 and Schwarz et al. 2003.

ANTIMICROBAL THERAPY
The usage of antimicrobial agents as a part of the periodontal therapy relies on the bacterial nature of periodontal disease. Antimicrobial agents can be applied systemically or locally. 1. Systemic antimicrobials They are released through the pockets wall into the crevicular fluid When used as a part of combined periodontal therapy with scaling and root planning the results are better, Herrera et al. 2002 Have some disadvantages: -Gastro-intestinal upset -possible allergic reactions -development of resistance
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-interaction with other medications a) Amoxicillin - semisynthetic, gram-positive and gram-negative bacterial spectrum, high absorption level, susceptible to penicillinase and -lactamase enzymes. b) Erythromycin- cannot be found in crevicular fluid which makes it not very effective in periodontal therapy but otherwise is an alternative to amoxicillin. c) Clindamycin- antibiotic effective against anaerobic microorganisms, alternative to amoxicillin in case of existing allergy and refractory periodontitis, Walker et al.1993 d) Metronidazole effective against anaerobic microorganisms. As a part of periodontal treatment should only be used as a combination with another antibiotic, Griffiths et al. 2011 and Walter et al. 2011. Metronidazole also interferes with most of the medications so extra precautions should be taken when prescribe it. e) Ciprofloxacin quinolone, effective against gram-negative rods, active against all strains of A. actinomycetemcomitans. Very effective when used in combination with metronidazole, Dannewitz et al. 2007 and Jorgensen et al. 2005 f) Doxycycline tetracycline, broad spectrum of activity, very convenient for patient due to the fact that it can only be taken once per day. Positive effect on tissue destruction due to his anti-collagenase activity. 2. Full Mouth Disinfection Technique The technique is based on full mouth debridement in 24 hours instead of quadrant cleaning with a week or two intervals. The idea behind this technique is avoiding possible recolonisation in these a week or two intervals. However, several studies show no difference in the results achieved, Forman et al. 2008 and Swierkot et al. 2009. On the other hand, when combined with antimicrobial therapy (Amoxicillin/Metronidazole) significant results can be reached, Cionca et al. 2009. The good effect of full mouth disinfection technique might be partially due to boosting the immune system, Apatzidou 2006 3. Local antimicrobials

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The usage of local administrated antimicrobial agents relies on the fact that the microorganisms responsible for periodontal disease are located into periodontal pocket. In order to be effective local antimicrobials should be: Proven effective against targeted microorganisms Their concentration should stay constantly high enough to be effective They should be slow-released in order to overcome the quick turnover of crevicular fluid Used only on localised refractory lesions

The researches regarding usage of local delivery systems are controversial. 1. Periochip - chlorhexidine Sakellari et al. 2010 in their short 6-month research find no difference in probing depth reduction and reduction in perio-pathogens comparison to simple scaling and root planning. Daneshmand et al. 2002 reach to the same conclusion in their randomized control trial. However, Stabholz et al. 2000, find PerioChip as an adjunctive therapy useful and improving achieved results. 2. Atridox- 10% doxycycline gel system Jorgensen et al. 2004, find no beneficial effect of using Atridox as a adjunctive therapy over scaling and root planning. Salvi et al. 2002, show the opposite, significant effect of using Atridox after initial periodontal therapy in pocket probing depth and attachment levels. 3. Dentomycin- 2% Minocycline gel Jarrold et al. 1997, find the usage of dentomycin to improve the outcome of periodontal therapy. 4. Elyzol- 25% Metronidazole Griffiths et al. 2000, does not show clinically significant difference by using Elyzol as a adjunctive therapy

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SURGICAL PHASE
PURPOSES OF PERIODONTAL SURGERY
1. To eliminate or facilitate control of periodontal disease 2. To correct anatomical factors which might be reason for progression of periodontal disease or facilitate further restorative procedures 3. Aesthetic improvement

INDICATIONS
1. Areas with abnormal bone contours and deep pockets 2. Areas with deep pockets where non-surgical scaling and root planning are not possible 3. Areas with furcation involvement to ensure complete root planning, sometimes hemisection needs to be considered 4. Areas with moderate and deep pockets where inflammation is persistent despite good oral hygiene maintenance

POCKET CLASSIFICATION
Pocket formation as mention before is a result from destruction of supportive periodontal tissue. 1. Supra-bony horizontal, supracrestal. The bottom of supra-bony pockets is coronally positioned in respect to alveolar bone 2. Infra-bony vertical, infracrestal. The bottom of the pocket is apically positioned in respect to alveolar bone level. They can be one-, two- or three-walled defects depending on number of bone walls surrounding the defect.

TYPES OF PERIODONTAL SURGERY

1. Resective periodontal surgery

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This type of surgery is indicated with one-wall pockets and some two-wall pockets( shallow and wide). The purpose of resective surgery is not only eliminating periodontal pocket but recontouring and reshaping the bone in the way maximally to resemble normal alveolar bone structure and thus providing easier maintenance. 2. Regenerative periodontal surgery This type of surgery is indicated with three-wall pockets and some two-wall pockets. The ideal outcome of regenerative therapy is forming of new attachment, however other outcomes are also possible: forming of long junctional epithelium, recessions and combination of these. Guided Tissue Regeneration (GTR)- in order to expect forming of new attachment it is imperative to have completely removed junctional and pocket epithelium and preventing of further epithelium migration during the healing period, Gottlow et al. 1986. GTR relies on placing a barrier from a different type in such a way to completely cover the underlying bone and connective tissue. Polytetrafluoroethylene (PTFE) nonresorbable membrane

The results of using PTFE for GTR are variable. Yamanouchi et al.1995, mention statistically significant results in the group treated with PTFE and also better results in maxillary treated defects than mandibular group and better response in class 3 defects over class 2. However, Metzler et al. 1991, six months post-surgically find no statistically significant difference between the group treated by GTR and the group treated only with open flap surgery. Resorbable membranes- different materials have been tested so far and have shown good results, Camargo et al. 2000. Enamel Matrix Proteins- are a group of proteins which are believed to be of great importance to inducing cementum formation and so attachment regeneration, Hammarstrom et al. 1997.

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Emdogain is resorbable material consisting of enamel-derived proteins in gel consistency for easier application which show excellent potential, Esposito et al. 2009. Graft Materials used in GTR Autografts- obtained from the same individual Allografts- obtained from a different individual but the same species Xenografts- obtained from a different species a) Osteogenic materials- the development of new bone is expected to be from cells of the transplanted material b) Osteoinductive materials- the development of new bone is expected to be as a result of stimulation from molecules from graft material. c) Osteoconductive materials- the development of new bone is due to cell penetration into graft material and further differentiation Bio-Oss- is bovine-derived bone, osteoconductive with porous structure which provides excellent conditions for cell migration, vascularization and further osteogenesis. Bio-Oss has been successfully used in bone regeneration procedures, Lekovic et al. 2001, Sculean et al. 2004

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