28 - Principles of Surgery II Mike

Question 1

Systematic review for root surface modifiers

Answer 1

Mariotti 2003

BL: Citric acid, tetracycline, and EDTA provide no clinically significant benefit in terms of regeneration

Citric acid: 4/8 histology studies showed regeneration
Tetracycline: 1 histology study w/ 3/7 showing regeneration
EDTA: No histologic studies

Question 2

Histologic animal study for attachment to roots with citric acid

Answer 2

Polson 1983

BL: With application of citric acid, fibrin linked to exposed root collagen fibrils to allow new CT attachment rather than apical migration of epithelium

• Squirrel monkeys
• Teeth extracted and rinsed with citric acid or saline and re-implanted. Teeth examined at 1/3/7/21 days

Question 3

Histologic human study for attachment to roots with citric acid

Answer 3

Cole 1980

BL: Citric acid on root planed periodontally involved roots induced formation of CT attachment to dentin

• Notch at apical extent of calculus
• OFD + citric acid, extraction at 4 months for evaluation
• JE 1.2-2.6mm above notch. Bone level increase 0.8mm

Question 4

Effect of etching agents on periodontal tissues

Answer 4

Blomlof 1995

BL: Citric acid and orthophosphoric acid (low pH) have necrotizing effect on periodontal tissue at 20 seconds and 3 minutes. EDTA no necrosis

• Monkey study
• Measured with lactate dehydrogenase, a marker for cellular activity

Question 5

Effect of EDTA on smear layer

Answer 5

Blomlof 1997

BL: EDTA sufficiently removes HA smear layer and preserves collagen fibers

• Smear layer 2-10um w/ no difference using ultrasonic/curette/bur
• EDTA removed smear layer the same for the 3 treatment modalities

Question 6

Systematic review for efficacy of diode laser in conjunction w/ SRP

Answer 6

Slot 2014

BL: No significant difference in periodontal parameters with SRP/diode compared to SRP alone
-Some studies showed BOP were improved w/ diode, but effect was small and not clinically relevant

Question 7

Histologic response to LANAP

Answer 7

Yukna 2007

BL: 6 single rooted periodontally involved teeth had a positive histologic response to LANAP, PD reduction, and CAL gain
-Tx then EXT at 3 months
-PD reduction 4.7mm vs 3.7mm
CAL gain 4.2mm vs 2.4mm
-New cementum and CT attachment
***Funded by Millennium Dental Technology

Question 8

What is the LANAP protocol and what laser is used?

Answer 8

Nd:YAG laser (Periolase)

• Occlusal adjustment + splint mobile teeth
• Laser to remove pocket lining
• SRP/ultrasonic for root debridement
• Laser to seal pocket and form clot

Question 9

What does LANAP stand for?

Answer 9

Laser Assisted New Attachment Procedure

Question 10

Second histologic study for LANAP

Answer 10

Nevins 2012

BL: LANAP can result in periodontal regeneration and improve periodontal parameters

• TX, monthly maintenance, EXT at 9 months
• 12 defects in healthy, non-smokers
• CAL gain 3.8mm, PD reduction 5.4mm, recession 2.7mm
• Regeneration 5/10
• Long JE 4/10

Question 11

Who is the man or woman behind LANAP who is probably a millionaire because of it?

Answer 11

Yukna

Question 12

Critical probing depth for CAL gain in LANAP is _____ according to ______

Answer 12

4.88mm

Nevins

Question 13

Should Er:YAG laser be used as a monotherapy or adjunct to SRP

Answer 13

Zhao 2014

Systematic review

Answer = NO

BL: No SS difference in clinical outcomes when using Er:YAG as a monotherapy or adjunct compared to SRP alone.

-Had results up to a 12 month follow-up

Question 14

Should lasers be used as an adjunct to surgical therapy?

Answer 14

Behdin 2015

Systematic review + meta-analysis

Answer: NO

BL: No SS difference in PD/CAL gain/recession for OFD and GTR w/ or w/o a laser. When considering OFD/Emdogain, there was a significant difference for PD reduction and CAL gain

Question 15

Should lasers be used for implant surface decontamination?

Answer 15

Mailoa 2014

Systematic review and meta-analysis

BL: Similar results for PD reduction, CAL gain, and X-ray bone fill for CO2 and Er:YAG lasers

• 4 human surgery studies, 3 human non-surgery studies. NO difference for laser vs control
• Animal studies showed greater CAL gain and higher bone-to-implant contact in rough surface implants vs smooth surface

Question 16

Perio 2000 article on periodontal and peri-implant wound healing following laser therapy

Answer 16

Aoki 2015

-This is a long article, review the abstract for more in depth information

Question 17

What determines the degree of absorption of a laser?

What lasers are deeply penetrating?

What lasers are superficially penetrating?

Answer 17

The wavelength (lower absorption into water, deeper penetration into tissue)

Deep: Nd:YAG, diode

Superficial: CO2, Er:YAG (less heating of tissue, implant)

Question 18

What effect does epinephrine in anesthetics have on catecholamine levels?

Answer 18

Davenport 1990

BL: Significant elevations in venous epinephrine and norepinephrine 2 and 8 minutes after administration of 2% lidocaine w/ 1:100K epi. No change in heart rate or mean arterial pressure

• Levels returned to baseline by 16 minutes
• Reported that Lidocaine alone was unacceptable for hemostasis and anesthesia

Question 19

What is the effect of IV sedation on patient stress during surgery?

What drugs were used?

Answer 19

Shepherd 1988

Pentobarbital, Meperidine, Diazepam

BL: Cortisol SS increased in the surgery group with only local anesthetic

• Took venous blood samples
• 10 males w/ surgery 3 weeks apart during the same time of day due to diurnal nature of cortisol

Question 20

Where did the evidence for 2 carpules of anesthetic for cardiovascular disease patients come from?

Answer 20

A textbook, according to Mealey

Question 21

Comparison of IV Midazolam and Diazepam

Indications for each?

What test did they use?

Answer 21

Staretz 2004

Midazolam: Short procedures for fast onset of action, rapid recovery, and predictable amnesia

Diazepam for procedures 45+ minutes, wider margin of safety during titration, consistent amnesia, and gradual recovery

Perceptual speed test

Question 22

JADA article on oral sedation

What is the problem with sedating children?

Answer 22

Dionne 2006

Kids: Unpredictable rate of absorption, delayed onset, and prolonged recovery. Hard to titrate orally. Pulse ox cannot reduce death/injury in office

Skill of monitoring/resuscitation more important

Question 23

Benzodiazepine

• MOA
• Therapeutic effects
• Adverse effects

Answer 23

Agonist of y-aminobutyric acid receptor

Therapeutic: Anticonvulsant, anxiolytic, muscle relaxant, amnesia, sedation

Adverse: Memory/psychomotor impairment, drowsiness, altered EEG, and cortisol/growth hormone influence

Question 24

Triazolam

• Characteristics
• Dose
• Peak effect
• Metabolism
• Bioavailability

Answer 24

Short half-life, minimal respiratory/CV effects

0. 25-0.5mg = 10-20mg diazepam IV
   - Peak effect may take over 1 hour
   - CYP3A metabolism in intestine/liver
   - 45% bioavailability

Question 25

Is continuous or interrupted suture better for apically positioned flaps?

Answer 25

Nelson

BL: No difference at 6 months for PD, loss of attachment, recession, and bone loss

Clinical impression: Interrupted produced better flap adaptation

Question 26

What is the tissue response to silk vs e-PTFE sutures?

Answer 26

Leknes 2005

BL: Silk demonstrates a greater inflammatory reaction, conduction of bacterial migration, and risk of slack of the suture loop than ePTFE

Question 27

Two studies discussing infection rates with periodontal surgery?

Answer 27

Pack 1983 - 1% infection rate

Powell, Mealey, Deas 2005 - 2.09% infection rate

Prophylactic or post-surgical ABC did not demonstrate a lower infection rate

Question 28

Background knowledge question - lasers and their wavelength

Answer 28

diode laser (most common) = 809-980 nm
NdYAG = 1064 nm
CO2 laser = 10600 nm

Question 29

What would you use a diode laser for?

Answer 29

soft-tissue applications (incision, hemostasis, coagulation, removal of pocket epithelium)

soft tissue penetration from 0.5-3 mm (Aoki) with poor energy absorption on mineralized tissues (thus it is not good for calculus removal)