Chicken Pasta Flashcards
What are the BMI classifications?
a. Underweight < 18.5
b. Normal 18.5-24.9
c. Overweight 25-29.9
d. Obese >30 (class 1: 30-34, class 2: 35-39, class 3: 40+)
Discuss the new BP Classification criteria
a. Normal: <120/<80
b. Elevated: 120-129/<80
c. Stage 1: 130-139/80-89
d. Stage 2: >140/>90
Discuss the Miller Mobility Classification
a. Class 1 - first distinguishable sign of movement greater than normal
b. Class 2 - movement of the tooth which allows the crown to move 1mm in any direction
c. Class 3 - allows the tooth to move more than 1mm in any direction, or teeth that may be rotated or depressed in their alveoli.
Discuss the furcation arrow and its importance on radiographs?
a. Hardekopf
i. Dry skull study showed degree III furcation had furcation arrow >50% of the time and that more advanced bony defect led to increased incidence of furcation arrow.
b. Deas, Moritz, Mealey
i. Evaluated patients during surgery and compared with pre-op x rays
ii. Low inter-examiner agreement - 0.49
iii. Sensitivity - 38.7%, Specificity - 92%, PPV - 72%, NPV - 75%
iv. Most actual furcation invasions are not associated with furcation arrows
v. Data suggest that furcation arrow has limited usefulness as a diagnostic marker of furcation invasion. The image is difficult to interpret, highly subjective, and can correctly predict furcation invasions only 70% of the time when present on the radiograph. In addition, when furcation invasions are truly present, the furcation arrow is seen in <40% of sites.
When will you see radiographic bone loss?
Jeffcoat:
30-50% of demineralization is required before radiographic bone loss is visible
What do you know about the alveolar crest in relationship to the CEJ of teeth?
d. Richey and Orban
i. In health, alveolar interdental crest is parallel to CEJ
e. Hausman
i. Bone-CEJ in health is roughly 2mm
Discuss the modes of calculus attachment to the tooth?
a. Zander
I. Original study and Canis did study again with electron microscope
ii. Calculus attachment
1. To pellicle of tooth
2. Cemental irregularities
3. Mechanical undercuts and resorption bays
4. Penetration of bacteria into cementum (not found in Canis study)
What are the mechanisms of calculus formation?
i. Booster
1. Proteolytic activity of bacteria increases the local pH by urea and ammonium bi-products causing precipitation of mineral.
ii. Epitactic
1. Nucleation or crystal seeding within plaque matrix
What is the Kwok and Caton Prognostication system?
a. Kwok and Caton - periodontal stability as therapeutic end point (vs McGuire using tooth loss)
i. Favorable: Perio status can be stabilized with treatment and maintenance. Loss of periodontal tissue is unlikely.
ii. Questionable: Periodontal status of the tooth is influenced by local and/or systemic factors that may or may not be able to be controlled. The periodontium can be stabilized with comprehensive periodontal treatment and periodontal maintenance if these factors are controlled - otherwise, future periodontal breakdown may occur.
iii. Unfavorable: The periodontal status of the tooth is influenced by local and/or systemic factors that cannot be controlled. Periodontal breakdown is likely to occur even with comprehensive treatment and maintenance.
iv. Hopeless: The tooth must be extracted.
How much PD reduction can you expect to get from non-surgical therapy?
i. Hung and Douglass - meta analysis
1. 4-6mm PDs - Gain of 1mm PD and 0.5mm CAL gain
2. >6mm PDs - Gain of 2mm PD and 1.0mm in CAL gain
What is Chlorhexidine?
Cationic bisbiguanide - ruptures cell membranes, kills a lot of bacteria that dead cells can serve as nidus for calculus formation, 11% alcohol. Increased substantivity due to positive charge that binds to negatively charged membranes
i. 50% anti-plaque, 45% anti-gingivitis
Do you have better results when you do SRP before surgery?
Aljateeli and Koticha
- RCT showed MWF w/o SRP and with initial SRP both improved in PD and CAL from baseline but MWF with SRP had significantly greater PD reduction and slightly more radiographic bone fill
What is the anatomy (size) of the furcation entrance?
a. Bower
i. 81% of furcal openings are <1mm, 58% are <0.75mm.
ii. Curette width range = 0.75 to 1.1mmm
iii. Cavitron tip = 0.6mm width
Why do you measure the contralateral tooth of supracrestal attachment when determining crown lengthening?
15.2. Barboza:
Contralateral supragingival tissue measurements prior to crown lengthening may help determine the appropriate amount of bone removal necessary for an individual tooth. Due to the range of 1-6mm SGT measurements, the classic recommendation of 3mm bone removal for crown lengthening and 0.5mm margin into the sulcus is not appropriate for all patients.
Discuss average bone removal acquired during crown lengthening and the importance of the sutured flap?
15.8. Deas:
Evaluation of osseous reduction at treated sites showed 23.6% received 0 mm, 44.3% received 1 mm, 25.4% received 2 mm, 6.2% received 3 mm, and 0.3% received ≥4mm osseous reduction.
a. Tissue rebound 6 months following surgery was reported according to the distance from the flap margin to the alveolar crest following suturing: ≤1 mm yielded 1.33 mm rebound, 2 mm yielded 0.9 mm, 3 mm yielded 0.47 mm, and ≥4 mm yielded -0.16 mm.
b. BL: Significant soft tissue rebound occurs following crown lengthening, which may not be stabilized by 6 months. The amount of rebound appears to be related to the sutured position of the flap relative to the bony crest. Rely on osseous resection for gain in clinical crown height not apical position of the replaced flap.
Tell me everything you know about probing?
Line angle vs mid proximal?
8.2. Persson: For posterior teeth, mid-proximal measurements are approximately 1 mm more than line-angle measurements. Line-angle measurements may underestimate periodontal disease prevalence, and, mid-proximal probably yields the best data for diagnosis and treatment.
Probe tip diameter
8.3. Garnick: Greater the diameter, the more force you must have to create proper pressure for probing.
Probing inflammed tissue
8.4. Fowler:
Probe .45mm into CT in inflammed tissue, whereas you probe .73mm coronal to base of JE in healthy tissue. The probe tip usually does not reach the base of the JE in pockets treated by plaque control and root planing. In disease, the probe tip penetrates beyond JE
Probe reproducibility
8.7. Badersten: 90% of probing attachment level (PAL) measurements and probing pocket depths (PPD) were reproducible within + 1.0mm. Reproducibility varied between tooth type, tooth surface, and depth of pocket. Incisors, buccal surfaces and shallower pockets had the lowest variability.
Probing Force
- Mombelli: Higher probing forces results in more reproducible depth measurements, whereas lower probing forces allow better detection of small changes.
- 18 - Lang - Uncontrolled forces may lead to false positive BOP readings. There is a possibility for trauma to healthy gingival tissues if a probing force greater than 0.25N is used.
- 19 - Gerber - Implants bleed more readily in the absence of inflammation than do natural teeth. This is of importance to the clinician especially if he/she is trying to draw conclusions based on BOP. The clinician needs to be cognizant of the amount of force he/she is using when probing peri-implant sites and realize that BOP does not always indicate inflammation or disease. Probing pressure of 0.15 N is suggested to avoid false positives at peri-implant sites.
How often do we have accessory canals in a perio pocket?
16.4. Kirkham:
23% of the 100 teeth had accessory canals. Only 2% of all teeth (8.7% of the 23 teeth) had an accessory canal located within a periodontal pocket. The incidence of accessory canals in periodontal pockets is low.
Discuss the influence of endodontic infection on the progression of marginal bone loss in periodontitis pts?
Some say yes, some say no.
Jansson was in periodontitis patients whereas Miyashita was in non periodontitis patients.
- Jansson: YES. Retrospective radiographic study in periodontitis pts. In patients prone to periodontitis, the presence of active periapical pathology contributes to greater bone loss over time than in endodontically healthy teeth. Attachment loss was 3x higher in patients with endodontic infection and periodontitis (average = 0.19mm/yr vs. 0.06mm/yr in healthy).
- Miyashita: NO. Longitudinal cohort study with exam and radiographs of healthy pts. The pulp and/or periapical status did not seem to have any significant affect on alveolar bone levels in adults with little to no periodontal disease.
Can you get new attachment/repair on endodontically treated teeth?
6.13. Dunlap:
Growth was observed on all 10 root planed, endo-treated/non-vital sections with no difference in growth observed compared to vital teeth. Both vital and endodontically treated teeth are capable of forming new attachment following root planing in vitro. New attachment procedures should succeed on endodontically treated teeth.
Can aggressive perio therapy cause pulp necrosis?
16.17. De Sanctis:
Retrospective study of 137 pts. Teeth with localized severe periodontitis that undergo aggressive root planing in conjunction with regenerative therapy are not at an increased risk for pulpal necrosis. In general, preventive root canal therapy is not indicated in these teeth and should only be considered if the osseous defect extends to or beyond the apical foramen of the tooth.
Discuss the rationale and indications for implant cantilever crown?
- 6 Kim:
The presence of a cantilever in implant supported FDPs had no impact on marginal bone loss, the posterior mandible was the only exception, as the marginal bone loss for implants in the proximity to cantilevers in this region was higher. The presence of a cantilever did increase the rate of technical complications. These technical complications were often associated with subsequent biologic complications and marginal bone loss. Cantilever arm length >8mm was associated with higher rate of complications.
Discuss association of shallow vestibular depth and peri-implant parameters?
- Halperin-Sterfeld:
- A shallow vestibular depth (< 4 mm) was found to be significantly associated with increased recession (0.91 vs 0.47 mm), Relative attachment loss(4.23 vs 3.59 mm), Radiographic bone loss (2.18 vs 1.70 mm), BOP (p=0.017), GI (p=0.031), and decreased Keratinized mucosal width (1.24 vs 2.38 mm) when compared to sites with > 4mm VD.
Is granulation tissue removal during flap surgery necessary for proper healing?
- Lindhe and Nyman:
15 patients. Performed modified widman, modified kirkland, or SRP.
Results - Complete granulation tissue removal during surgery is not critical for proper healing.
- Lindhe and Nyman:
Will you get improvement in additional quadrants by performing surgery in other quadrants?
22.3. Radvar:
22 pts. Pt needed surgery in all 4 quadrants. Osseous was performed in 2 week intervals. They noticed after 3 quadrants of surgery that the 4th quadrant improved.
Discuss evidence that local anesthetics reduce vasculature to periodontium?
22.8 Retzepi: Injection of local anesthetic with vasoconstrictor reduced microvascular blood flow of 66-75%, which was similar in buccal and palatal papilla.
How much blood do you lose during surgery?
22.9 Baab:
30 pts underwent flap surgery. 134mL of blood lost on average but the range is large. Suggests limit of 2 hours per surgical area since no patients lost more than 125mL in this amount of time. Always recommend hydration post surgically. Be prepared for fluid replacement if >500mL blood is lost.
Discuss the rationale for the papilla preservation technique?
22.14 Takei:
Describes this technique to use in anterior of mouth with wide interdental spaces to help preserve normal papilla, obtain better esthetic result, prevent exposure of graft material and get primary closure, and prevent having an interdental crater. Did all suturing with cross external horizontal mattress.
Why do we typically wait 2 weeks for post op?
22.17 Hiatt:
16 dogs. Did flap surgery. Tested strength of flap adhesion. By 2 weeks, the flap couldn’t be completely separated from the tooth. Flap is secure at 2 weeks.
What is the mean induction time for clinical bone exposure in patients with ORAL bisphosphonate use?
Marx, 2003:
3 Years
Discuss implant complications in relation to anatomy?
Ramanauskaite 2019:
- Mandibular nerve average size: 2.1-5 mm
- Average distance of mandibular nerve to alveolar crest: 16.0 mm
- 70% of the time, the mandibular nerve follows the lingual plate
- A bifid mandibular canal prevalence is 0.35% via PANO and 65% of patients using CBCT
- Kim: Three-dimensional histologic reconstructions revealed that the inferior alveolar artery and the inferior alveolar vein traveled above the inferior alveolar nerve in 8 (80%) of 10 patients, with the artery being lingual to the vein.
- Anterior loop has been identified in 61.5% of patients.
- Anterior loop on average ranges from 0.4-6.0 mm (longer in males) - therefore a safety distance of 3-6 mm is recommended anterior to mental foramen.
- Mental foramen 3.47 mm tall and 3.59 mm wide. 46-62% of time located apical to apex of premolars, and 25-38% of time located coronal to apex. Accessory mental foramen are noted between 7-15% in CBCT scans.
- Lingual foramen: occur almost 100% of the time and are located about 14mm apical to alveolar crest. They are entrances of canals that lead from the cortical bone surface to itnraoessous region. These are branches from either the submental (facial artery branch) or sublingual (lingual artery branch) vessels. Perforation of the lingual cortical plate during implant preparation may result in injury either to the lingual nerve (if above mylohyoid muscle) or to the adjacent sublingual and/or submental arteries.(if below mylohyoid muscle).
- Incisive canal: Contains the nasopalatine nerve, terminal branch of nasopalatine artery, connective tissue, fat, veins, and salivary glands. Average length is 8.1-9.9 mm and terminates into the nasal cavity, usually two branches and mean diameter is 3.49 mm. After tooth loss, the incisive foramen may emerge from alveolar crest and can enlarge by about 32%.
- Maxillary Sinus: Lined by militated respiratory epithelium and exhibits a radiographic thickness of 0.8 - 1.99 mm. Average volume of sinus is 31cm^3. Tips of implants penetrating to depths of up to 2mm in experimental canine studies were found to be either fully or partially covered with newly formed bone and separated by intact membrane. When greater than 2mm, implants communicated with sinus but failed to induce any pathologic reactions. However, there are reports of chronic sinusitis when implants were penetrating into nasal cavity.
- Most common complication during sinus floor elevation is perforation of membrane, which occurs from 9-60% of time. Risk of perforation increases with septae. Which are cortical bone and oriented in both horizontal and vertical planes. Classified as primary (evolve during growth of face), or secondary (result from tooth loss and bone resorption).
The posterior superior alveolar artery and inferior orbital artery: major branches of the maxillary artery that provide blood supply to the bony walls and membrane of the sinus
- Ventialtion of the maxillary sinus is ensured via the osmium natural. The osmium is located in the upper apsect of the medial sinus well and has an oval or slit-shape.
Discuss average buccal plate thickness in extraction sockets?
- 17 Huynh-Ba, 2010:
- 87.2% of time, average buccal plate thickness is <1mm with average of 0.8mm.
What are the functions of IL-1?
- Upregulates complement and Fc receptors on neutrophils and monocytes
- Upregulates adhesion molecules on fibroblasts and leukocytes and endothelial cells
- Induces osteoclast formation and bone resorption (RANKL)
- Stimulates MMP and PG production by macrophages, PMNs, and fibroblasts
- Induces other interleukins and TNF-alpha
- Causes release of IL-8, which attracts PMNs. PMNs release enzymes that are capable of destroy pathogens
- Causes release of histamine and kinins which promote vasodilation, which enhance antibodies and complement
What is dysbiosis?
- Dysbiosis is a microbial shift, referring to the concept that some diseases are due to a decrease in the number of beneficial symbionts and an increase in the number of pathogens. The long standing paradigm is that, as periodontitis develops, the oral microbiota shifts from one consisting primarily of gram + aerobes, to one consisting of gram - anaerobes.
- Not everyone knows why this imbalance is created, a lot of people think this has to deal with the immune system and certain organisms that colonize.
- Another definition: In the structure of the dental plaque biofilm, there is a succession in microbial colonization with a dramatic shift in flora from health to disease and establishment of a gram- negative anaerobic flora in sites with periodontal pocketing.
What is the importance of Biofilm? - Deas
- Trap nutrients
- Engage in the primary production of their own nutrients
- Form a digestive consortium (By-products of one organism serve as nutrients for another)
- Protect other bacteria from antibacterial agents and phagocytes
What are the virulence factors for Porphymonas Gingivalis? MILLS
- 6 K antigen serotypes
- Induces proinflammatory cytokine production
- LPS induces IL-1, IL-6, IL-8 and activates osteoclasts
- Leukotoxin - pore forming protein leading to apoptosis and necrosis
- Proteolytic enzymes (gingipains)
- Degrades antibodies and complement
- Groel heat shock protein
- Fimbriae
- Promotes adhesion and epithelial invasion
What are 5 mechanisms in which smoking impacts the periodontitis and discuss epidemiological data that supports this?
- Cigarettes contain 2,550 known toxins including benzene, pesticides, tar, and carbon monoxide
- Smoking affects innate and specific immunities
- Innate - Neutrophil motility, chemotaxis, and phagoctyosis are reduced
- Specific - antibody production, especially IgG, and immune regulatory t-cells are reduced
- Smoking increases bacteria adhesion and is selective for more gram - bacteria
- Increased production of cytokines from neutrophils and macrophages in smokers (such as PGE-2, TNF-a, IL-1)
- Decreases oxygen tension in the sulcus which favors more gram- bacteria
- Nicotine has been shown to reduce fibroblast activity
- Suppression of OPG (which is protective)
- Decrease perfusion through blood vessels (but increased vessels)
- Direct cellular cytotoxicity of smoking
Literature:
- Periodontitis-free subjects who had smoked 5+ pack years were 18 times more likely to be infected by pathogenic bacteria than non smokers.
- Tomar & Asma (2000): Know that current smokers are 4x more likely to have periodontal disease and there is dose response relationship with periodontal disease. Use this paper of “how long should a patient quit smoking before they are considered a non-smoker?” - 11 years.
Tomar (2000) performed a study utilizing the NHANES data set - showed that current smokers were 4x more likely to have periodontitis than never smokers. Also, at ≥11 years, there were no differences noted in prevalence of periodontal disease for former smokers and never smokers.
Alharthi (2019) JPerio Paper: found with NHANES data set found that for each year of smoking cessation, patients have a reduction in odds of having periodontitis as 2.5-5.2% per year and smoking cessation is consistently associated with a reduction in tooth loss risk, with the risk of tooth loss approaching that of never smokers after 10-20 years of cessation.
Ravida, HL Wang (Michigan) (2020) J Clin Perio: A total of 258 patients were included in the review with at least one annual PMT visit followed for a mean duration of 290.7 months (24.2 years). 91.9% of the patients were well maintained, 7.4% were downhill, and 0.8% were in the extreme downhill group. A statistically significant association was found between increasing smoking intensity and tooth loss due to periodontitis (TLP). Former smokers (OR 2.56) and current smokers (OR 4.38) were statistically more likely to have any TLP compared to never smokers. A dose-response pattern was observed for TLP as never smokers through former and current light to current heavy smokers lost 2.5%, 4.1%, 5.6%, and 10.3% of their teeth respectively. The longer the duration since smoking cessation, the lower the probability of TLP for teeth for both former light and heavy smokers. Each additional year since quitting smoking reduced the risk of TLP by 6%. There was a washout period of 15 years for the risk of TLP for a former smoker to approximate the baseline risk of a never smoker. BL: Current and former smokers lost significantly more teeth due to periodontitis and exhibited a dose-response pattern compared to never smokers. It took 15 years of smoking cessation for the risk of tooth loss due to periodontitis for former smokers to reach that of never smokers.
Naji (2020): stated that the OR of being a poor responder was 2.4 compared to a non-smoker. Significantly more non-smokers are good responders compared to smokers.
What are the methods in which calculus attaches to the tooth surface?
Zander (1953) performed a study to evaluate this and found 4 mechanisms of which calculus attaches to the tooth:
- To the secondary cuticle (thought to derive from epithelial attachment as it contacts cementum)
- To microscopic irregularities in cementum where Sharpeys fibers attach
- By penetration of bacterial matrix in cementum
- Into mechanical undercuts of cemental resorption areas
- Then, Canis (1979) performed the same study and confirmed ¾ of Zanders findings, but did not find evidence through SEM of direct bacterial penetration as mode of calculus attachment.
Describe osteoimmunology (RANKL and OPG)
- Osteoimmunology refers to the study of regulation of osteoclastogenesis through the Receptor Activator of Nuclear Factor kB Ligand. RANKL has been described as the “master switch regulator” for osteoclastogenesis.
- Osteoblasts express RANKL on their cell membrane. When this ligand binds to the RANK receptor on a pre-osteoclast, it signals the cell to differentiate into an active osteoclast. The decoy receptor for RANKL, called osteoprotegerin, blocks this activation mechanism, thus helping to maintain bone homeostasis. In periodontal disease, the ratio of RANKL to osteoprotegerin increases, whereas in health, the ratio is decreased.
- Osteoblasts and periodontal ligament fibroblasts express RANKL on their cell membrane. T cells not only express membrane bound RANKL, but also secrete it in soluble form. The pro-inflammatory cytokines interleukin-1 and interleukin-6, TNF-a, and PGE2 signal these cells to express membrane bound RANKL, and the T cell to secrete RANKl. These cells are already increased in the periodontal lesion and are indirectly involved in periodontal bone loss. Thus, when the lesion has advanced toward the periodontal ligament and alveolar bone, the up-regulation of RANKL may lead to bone loss and subsequent deepening of the periodontal pocket.
- Gingival fibroblasts produce osteoprotegerin, which may help prevent bone resorption in the earlier stages of periodontal disease where the lesion is primarily confined to an area beneath the epithelium.
Does osteoporosis increase the risk for bone loss and periodontal disease?
- Bone loss
- Kribbs (1983) showed that decreased bone mineral density in systemic skeleton leads to reduction in oral bone density (maxilla and mandible)
- J Prosth (1992) published article that osteoporosis increases resorption of residual ridge after tooth extraction in maxilla and mandible.
- Tooth loss
- Daniell and Krall (1983,1994) showed risk of tooth loss increases with OP and there is greater prevalence of edentulism in osteoporosis.
- Periodontitis
- Epidemiologic
- Penoni (2017) - there is a significant relationship between osteoporosis and clinical attachment loss (0.32mm) but the magnitude of the effect is not impressive.
- Longitudinal (Cross-sectional)
- Yoshihara (2004) examined the relationship between BMD and clinical attachment level changes over 3 years (progressive sites defines as CAL with change >3mm). The number of progressive sites was about double in men that had osteoporosis than those without.
- Haas (2009) showed that a group fo Brazilian women who were taking HRT had similar prevalence of periodontitis with women who were premenopausal, than those women who were not taking HRT which had significantly higher prevalence of periodontitis and greater % of teeth with CAL >5mm. (Not strong level of evidence).
- Interventional trial evaluating HRT vs Calcium/Vitamin D supplement
- Civitelli (2002) evaluated tens of thousands of women comparing those on HRT and those just on supplements. Found that those taking only vitamin D/Ca, it was the same or better than those taking HRT.
Discuss the prevalence of open contacts between implants and natural teeth?
20.3 Varthis - Retrospective cross sectional study. Overall prevalence of ICL was 52.8% (92/174 implants): 78.2% was on the mesial surface and 21.8% on the distal surface
Discuss the evidence of bone loss with early cover screw exposure.
- 20.9 Van Assche: Retrospective. Early CS exposures averaged 1.96mm of marginal bone loss (range: 0.2-3.2 mm) , 2 stage submerged averaged .01mm, and 1 stage averaged .14mm of bone loss. Stage 1 and 2 implants were not significantly different but early exposures had significantly more bone loss.
Discuss the risk of peri-implantitis with excess cement and differences between the cements?
- 20.11 Staubli - Korsch et al. (2014, 2015): reported differences in the prevalence of BOP depending on the cements applied. Less BOP was found with temporary zinc oxide-eugenol cement (46%) than methacrylate cement (96%). BL: Excess cement could serve as a risk indicator for peri-implant disease, especially for restorations with submucosal crown margins and short soft tissue healing time. The type of cement and frequency of maintenance may also play a role in this process.
- Excess cement was not observed when restorations were cemented with zinc oxide-eugenol based cements. Methacrylate-based cements are associated with presence of excess cement, an alteration of the peri-implant microbiome favoring the colonization of periodontal pathogens and the development of suppuration. Zinc oxide-eugenol based cements may be a good alternative.
Discuss the importance of soft tissue thickness on marginal bone loss around implants?
- 20.28 Saurez-Lopez and Wang HL: Systematic Review. BL: Soft tissue thickness of more than 2mm is required for the establishment of biologic width to minimize early MBL and Platform Switching is only effective with adequate mucosal thickness. Therefore, evaluation of soft tissue thickness at time of implant placement and the use of soft tissue graft with presence of thin tissue are strongly recommended.
What effects do occlusal discrepancies have on periodontal disease in humans?
- Non-working contacts
- Youdelis and Mann, 1965
- Retrospective study of 54 patients looking at RECORDS, not patients
- 53% of patients had non working contacts and those teeth had significantly greater mobility, bone loss, PD in teeth with nonworking contacts
- These patients had significant disease though
- Shefter and McFall, 1984
- Periodontal exams on 66 patients
- 56% of patients had nonworking contacts (Most common was 2nd molar)
- No relationship between nonworking contacts and periodontal disease but these were young patients with minimal disease
- Jin and Cao, 1992
- 32 Chinese patients
- No relationship between nonworking contacts and PD, AL, bone height
- Teeth with mobility/fremitus had greater PD, AL, bone loss
- Occlusal discrepancies
- Nunn & Harrel, 2001
- Retrospective review of 89 patients in private practice
- Teeth with occlusal discrepancies had significantly deeper mean PDs (5.8mm) compared to teeth without discrepancies (4.8mm).
- Nunn & Harrel, 2009 (CROSS-SECTIONAL VERSION)
- Following situations had significantly deeper PD than those without occlusal discrepancies
- Centric prematurity (0.9mm deeper)
- Slide in centric (0.8-1.2mm deeper)
- Balancing contact only (1.0mm deeper)
- Balancing and working contact (1.0mm deeper)
- Protrusive contact on posterior tooth (0.5mm deeper)
- Protrusive contact on anterior tooth (0.2mm shallower)
- Bernhardt, 2006 (SHIP STUDY)
- Largest cross sectional study to date with excellent occlusal exams (n=2980)
- Non-working contacts increased PD by 0.13mm and CAL by 0.14mm
- CONCLUSION: presence of non-working contact on a tooth is associated with increased PD and CAL, but magnitude of effect is fairly small
What are the clinical signs of occlusal trauma?
- Increased mobility, fremitus, wear facets, tooth migration, tooth fracture, pulpal symptoms
What effect does mobility have on regenerative therapy?
- Cortellini, 2001
- 55 pts had GTR with membrane, 54 pts had GTR without membrane. Mobility negatively affected CAL gain.
- The greater the mobility at baseline, the smaller the CAL gain at 1 year
- Trejo & Weltman, 2004
- Retrospective study. 36 teeth with Miller 0, 13 teeth with miller 1, 15 teeth with miller 2.
- No significant difference in PD reduction or CAL gain in different mobility categories.
- Teeth with mobility up to and including Miller class 2 respond similar to nonmobile teeth one year following regeneration surgery
- NOTE: teeth that clinicians felt needed splinting were excluded from this study
- Schulz, 2000
- Prospective trial (Germany) to evaluate effect of splinting on bone replacement grafts
- 33 subjects had bony defects treated with Biocoral (natural coralline calcium carbonate)
- 11 subjects had 18 test teeth splinted before surgery
11 subjects had 16 test teeth splinted at suture removal (1 week POT)
11 subjects had 17 teeth not splinted at all - Splints were FPDs, temporary crowns, light cured resin
- Splints removed 8-11 months after surgery
- PD reduction and CAL gain significantly better in both splinted groups compared to non-splinted group
- Better PD reduction/CAL gain in teeth splinted before surgery than 1 week after surgery, but not significantly so
- Schulz et al. Clin Oral Invest 2000
- Occlusal Adjustment/Mobility and Periodontal Therapy
PD Reduction (mm) CAL Gain (mm)
Splinted before surgery 5.4* 5.1†
Splinted 1 week after surgery 4.3* 3.5 †
Not splinted 2.2 1.7
What are some things you can do to improve oral hygiene performance over time?
- 21.2. Emler: Repetition and reinforcement were of significant value in improving the oral hygiene performance of the school children over a period of one year.
- 21.4 Glavind: Regardless of the method of instruction, improvements in home care occur with instruction.
Are electric toothbrushes more effective than manual tooth brushes?
- 21.12 Dorfer, 2016
- Brushing twice/day over 36 months with a powered or manual tooth brush showed no significant differences in gingival recession progression.
- 21.13 Tritten, 1996
- Both a standard manual toothbrush and a sonic toothbrush (Sonicare) are capable of removing supragingival plaque and reducing signs of gingival inflammation. However, the sonic toothbrush was statistically superior in removal of plaque from hard to reach areas such as interproximal regions.
What is the active ingredient in anti-calculus toothpaste and how does it work?
- 21.15 Fairbrother, 2000.
- Pyrophosphates
- Inhibits conversion of calcium phosphate to hydroxyapatite thereby decreasing crystallization and crystal growth
- Lower amounts of pyrophosphates are found in heavy calculus formers
Does toothpaste use help to remove plaque?
- 21.17 Valkenburg, 2016.
- Systematic review. Tooth brushing with a dentifrice does not provide an added effect for the mechanical removal of dental plaque.
What affect does osteoporosis have on implant success?
- 18.9 Temmerman: 5 yr prospective study. 48 postmenopausal women. Implants have similar survival rates in osteoporotic patients as healthy pts.
Discuss success rates of implants in patients undergoing radiation therapy?
- 18.12. Colella: Systematic Review. Implant failure in irradiated patients is significantly greater in the maxilla than mandible. Most implant failures occurred within 36 months of surgery, and failure was rare when the radiation dose was <45Gy. The timing of implant placement and radiation therapy was not found to significantly influence implant failure.
Discuss success of implants in previous failed implant sites?
- 18.13. Machtei: Implants placed after removal of a failed implant have a lower survival rate than the first implant placed. Failure was not associated with any particular implant or patient related factors. The authors hypothesize that failure may be associated with a possible negative effect of the particular implant site or “site specific etiological background” in which previous failure had occurred.
- 18.14 Chrcanovic: Retrospective study. 11,000 implants. Survival 1st attempt = 93.6%, 2nd attempt = 73.6%, 3rd attempt = 64.3%. Failure rates are higher for implants placed at previously failed sites, this study did not show a difference in failure rates between a 2nd and a 3rd implant. Poor bone quality was associated with increased failure rates. Use of SSRI’s and antithrombotic agents increased failure rates.
What are the 4 kinds of tissue we would like to regenerate and how quickly do they regenerate a day?
- Oral epithelium and CT (500um a day)
- Woven bone (30-50um a day)
- Lamellar bone (0.9-1.0um a day)
PDL (50-60um a day)
Lamellar bone and PDL are hard to get.
What are the keys and principles of guided tissue regeneration?
- Regeneration of lost periodontal structures through differential tissue responses
- Prevention of epithelial migration
- Barrier membranes used to cover bone and periodontal ligament
- Only the PDL cells have the potential for regeneration of the attachment apparatus
- PDL cells have ability to differentiate to become cementoblasts, osteoblasts, and fibroblasts. PDL cells carry this potential.
- Most regeneration occurs within 1 month (4-6 weeks) allowing the PDL cells to beat the epithelial cells
- Barrier membrane techniques: epithelium exclusion from the root or existing bone surface
- Principles of GTR:
- Clot stabilization
- Wound protection
- Space creation
Discuss the different types of resorbable membranes, what they are made of, and how long it takes for them to resorb?
- CollaPlug - type 1 bovine collagen - 0.5 months
- Ossix Plus - type 1 porcine collagen - 4-6 months
- Bio-Gide - type 1, 3 porcine collagen - 6 months
- Cytoplast (RTM Collagen) - 6-10 months
- BioXclude (Amnion chorion tissue) - Unsure
Describes cross linking and its affects on resorbable membranes?
Different ways you can cross link collagen (main way is through chemical modification) which allows for low solubility, increased stability - which can help for membranes to last long.
What are the factors that affect bone regeneration in GTR?
- Defect morphology
- # of walls remaining: Cortellini, 1993
- Depth of defect: Cortellini, 2017
- Width of defect: Stavropoulos, 2017
- Angle of defect: Steffensen, 1989, Cortellini, Tonetti, 1999
- Oral hygiene/compliance with maintenance: Cortellini, 1996
- Systemic health status: Reynolds, 2015
- Smoking: Reynolds, 2015 - Cortellini, 2004
- Surgical factors
- flap design, defect and root morphology, material employed, flap position, membrane exposure
Does width matter in regeneration?
- Stavropoulos, 2010: Wide/deep and narrow/shallow defects healed similar in dog study and did not make difference between the two. They used bio-oss and biogide.
Does bone defect angle make a difference in regeneration?
Defect angle:
- Bjorn Steffensen
- <45 degs = bone gain
- > 45 degs = bone loss
- Cotellini and Tonetti, 1999
- Angle ≤25 degs vs angle ≥37 degs
- More favorable with ≤25 degs
Discuss soft tissue management and different flap reflection techniques?
- Papilla preservation flap - Takei, 1985
- Modified papilla preservation - Cortellini, 1995
- Simplified papilla preservation - Cortellini, 1999
- Minimally invasive surgical technique - Cortellini, Tonetti, 2007
- Single flap approach - Tromebelli, Rassperini, 2013
- Modified MIST (minimal flap with single flap approach)zx- Corellini, Tonetti, 2009
- Soft tissue wall technique - Rasperini, 2013
- Connective tissue wall technique - Zucchelli, 2014
- Entire papilla preservation, Aslan, 2015
What is the evidence that osseous resection is an effective therapy?
- Lindhe, Nyman 1984
- 14 year follow up in osseous patients - 61 patients
- Extracted hopeless teeth prior to therapy
- Strict maintenance every 3-6 months
- 93% of sites had PD <4 mm, <1% developed >6 mm
- 1.2% of teeth lost due to periodontitis
- Washington (Ammons and Olsen), 1980, 1985
- Split mouth study design with APF with/without osseous - 5 year follow up - 8 patients
- More breakdown seen in sites without osseous, especially deeper sites
- you were more likely to have PD reduction at sites >5mm and less likely to have 4+mm pockets with BOP after 5 years (18% vs 42%).
- Nebraska (Kaldahl, 1988, 1996)
- 51 patients in split mouth study design followed up at 7 years
- Flap osseous had significantly greater probing depth reduction in sites ≥5mm
- Flap osseous had less breakdown in sites with initial PD ≥7mm versus root planing and MWF
- Hopeless teeth extracted to obtain physiologic architecture
Contrast this evidence with Becker (Arizona) and Ramfjord (Michigan) studies
Discuss the microbiological changes post osseous surgery?
- Mobelli, 1995
- 4 patients, 52 teeth
- Evaluated micro differences between osseous resection surgery with/without root planing and did plaque sampling
- Decreased pathogens in both groups
- Alteration in ecological environment affected microbiological composition
What are the determinants of osseous defect morphology?
- CEPs
- Root flutings
- Palato-radicular grooves
- Tooth position
- Trauma
- Other entities (plaque/calculus)
- Colonization of pathogenic microorganisms (sphere of influence - Waerhaug)
- Tooth/tooth - root/root relationship (Tal)
What is the prevalence of buccal exostoses and mandibular tori?
- Horning, 2000 - live studies
- Buccal exostoses/lipping - 76.9% at patient level
- 7% of all teeth
- Mandibular tori
- Dry Skull
- 27% overall, 25% in caucasian, 34% in African-American
How much bone loss/crestal resorption do you expect to have following osseous surgery?
- Wilderman, 1970
- Following osseous surgery, you will get 1.2mm of resorption and 0.4mm of repair, leaving a net loss of 0.8mm.
Discuss the rationale for the palatal/lingual approach for osseous?
- PALATAL APPROACH (Ochsenbein, Bohannan) 1963
- Avoids buccal furcation exposure
- Avoids a shallow buccal vestibule
- More cancellous bone on palate
- All keratinized tissue
- Wider interdental space
- Greater access
- Natural cleansing action of tongue
- LINGUAL APPROACH - (Tibbetts, Ochenbein) 1976
- Avoids buccal furcation exposure
- Avoids dealing with shallow vestibule
- Base of defects are usually lingual
- Thicker bone
- Slightly wider embrasures
- Natural cleansing action of tongue
What are the risk factors for periodontitis?
- Genetic factors (not modifiable)
- Racial/ethnic group (not modifiable)
- Smoking (#1 environmental factor)
- Poor oral hygiene (infrequent dental care)
- Systemic disease
- Compromised host immuno-inflammatory defense
- Obesity
Is diabetes associated with increased gingivitis? Does level of glycemic control affect degree of gingival inflammation?
- Ervasti, 1985:
- When you look at patients with just diabetes compared to non-diabetic group, there is no difference in gingival bleeding between the two groups. But poorly controlled diabetic patients have markedly increase in bleeding.
- “In diabetic patients where their blood sugar control is good, they kind of look like people without diabetes on average. In diabetic patients where their blood sugar control is not as good, they then will have more bleeding.”
Does periodontal treatment have an impact on glycemic control? (6 references)
INTERVENTIONAL DATA
- Sgolastra, 2013
- SR/MA - 315 patients - 5 studies
- compared SRP alone (no systemic antibiotics) to no treatment or coronal scaling
- SRP was associated with a significantly greater reduction in HbA1c of 0.65% compared to controls
- Engebretson, 2013, Periodontal Medicine Workshop
- MA of 9 studies, 719 patients
- Any type of periodontal therapy with/without antibiotics
- SRP was associated with a significantly greater reduction in HbA1c of 0.36% compared to controls
- Chapple, Genco, 2013 Periodontal Medicine Workshop
- SUMMARY: Randomized control trials consistently demonstrate that mechanical periodontal therapy associates with approximately 0.4% reduction in HbA1c at 3 months, a clinical impact equivalent to adding a second drug to a pharmacological regime for diabetes.
- Engebretson, 2013, JAMA, RCT
- Largest RCT we have - 240 subjects that only had SRP with no antibiotics, 235 patients with only oral hygiene instruction
- No significant change in HbA1c in either group from baseline to 3-6 months. No significant change in HOMA (insulin sensitivity).
- KEY NOTES: only minor/average periodontal response to treatment (SRP alone not enough treatment to associated with HbA1c change) and MOST subjects had well to moderately well controlled DM (7-9%).
- D’Aiuto, Lancelet, 2018
- 244 patients RCT
- Evaluated effect of “intensive periodontal therapy”
- At 12 months, HbA1c in intensive periodontal therapy group had mean 0.6% lower HbA1c than control group.
- So if you want to see dramatic increase in A1c, this will happen more frequently with intensive periodontal treatment.
- Quintero, 2018
- 93 Type 2 DM patients
- SRP more likely to have impact on glycemic control when baseline HbA1c control is poor (>9%)
Discuss autogenous bone grafting from previous extraction site and rationale for doing?
- Soehren and Van Swol, 1979
- Limited bone quantity
- Based on clinical experience, recommended cancellous bone harvest at 8 weeks in maxilla and 12 weeks in mandible.
- 8-12 weeks optimal time Perio to capture osteoblastic phase and mature tabeculae
Discuss calculus and effect on periodontitis?
- Calculus alone is not a primary etiologic factor for periodontitis (Allen & Kerr) and long junctional epithelium can attach to calculus (Listgarten & Ellegaard)
- Sites with calculus tend to have more attachment loss due to plaque
(Cercek) - Residual calculus delays healing
(Fujikawa)
Which antibiotics work by inhibiting nucleic acid synthesis?
- Ciprofloxin
- Metronidazole
- Rifampin
Discuss the Cairo Recession Classification and The Pino-Prato Subclassification
a. Cairo et al
i. Recession type 1 (RT1): Gingival recession with no loss of interproximal attachment. Interproximal CEJ is clinically not detectable at both mesial and distal aspects of the tooth.
ii. Recession type 2 (RT2): Gingival recession associated with loss of interproximal attachment. The amount of interproximal attachment loss (measured from the interproximal CEJ to the depth of the interproximal sulcus/pocket) is less than or equal to the buccal attachment loss (measured from the buccal CEJ to the apical end of the buccal sulcus/pocket).
iii. Recession type 3 (RT3): Gingival recession associated with loss of interproximal attachment. The amount of interproximal attachment loss (measured from the interproximal CEK to the apical end of the sulcus/pocket) is greater than the buccal attachment loss (measured from the buccal CEJ to the apical end of the buccal sulcus/pocket).
b. Pini-Prato et al: Subclassification of recession
i. Classified the presence/absence of CEJ as:
1. Class A (detectable CEJ)
2. Class B (undetectable CEJ)
ii. And the presence/absence of cervical concavities or “step” on rot surface as:
1. Class + (presence of cervical step >0.5mm)
2. Class - (absence of cervical step)
iii. Class (A-): CEJ detectable without step
iv. Class (A+): CEJ detectable with step
v. Class (B-): CEJ undetectable without step
vi. Class (B+): CEJ undetectable with step
Discuss the Hamp Furcation Index and Tarnow and Fletcher subclassification
a. Hamp Index (measured from furcation entrance to furthest extent into furcation)
i. Degree 1: Horizontal bone loss that does not exceed 1/3rd of the tooth width. Probe penetration up to 3mm into the furcation. This means from the furcation entrance, NOT the soft tissue.
ii. Degree 2: Horizontal loss that exceeds 1/3rd of the tooth width but is not through and through. Probe penetration greater than 3mm but not communication with opposite side.
iii. Degree 3: Horizontal loss that is through and through
b. Tarnow and Fletcher (Subclassification of vertical bone loss)
i. Subclass A - 0-3mm
ii. Subclass B - 4-6mm
iii. Subclass C - >7mm
Do open contacts contribute to periodontitis?
a. Hancock: young population
i. Open contacts leads to food impaction which can lead to increased probing depths. No direct correlation between open contacts and pocket depths though in this population
b. Jernberg: Adult patients - open contact meant floss slipping through during mastication
i. Open contacts had increased probing depths and attachment loss
Discuss what you know about radiographic diagnosis of calculus?
i. Buchanan
1. Sensitivity - 43%, Specificity - 92%, PPV - 92%, NPV - 46%
ii. Hyer, Deas
1. Low sensitivity, high specificity, high PPV
2. If calculus is present on >30% of root surface area, then sensitivity will increase. Also if diameter of calculus was >0.5mm
3. Changes in digital images did not increase sensitivity
Discuss the evidence/importance of root proximity to sinus when performing osseous surgery and extractions?
Sharan
i. Superior curvature of sinus floor, and extraction of maxillary molars can lead to sinus pneumatization
ii. Also need to be careful when doing osseous is close presence to sinus floor
Discuss the prevalence of exostoses, mandibular tori, and palatal tori?
a. Sonnier and Horning - skulls from museum
i. Palatal tubercles - 56%
ii. Mandibular tori - 27% (increased prevalence in males)
iii. Palatal tori - 20% (increased prevalence in females)
b. Holtzclaw
i. 78% prevalence in live patients
What is the significance of close root proximity in periodontitis?
a. Sphere of influence
i. Waerhaug - average of 1.63mm, range of 0.5-2.7mm
b. Heins and Weider
i. Distance between roots and histology of bone
ii. 0-0.3mm - no bone, direct PDL attachment between teeth
iii. 0.3-0.5mm - cortical bone only, no cancellous
iv. >0.5mm - cortical and cancellous bone
c. Haim Tal
i. Distance between roots and type of bone loss - correlates well with sphere of influence
ii. <2.5mm - mostly horizontal bone loss
iii. 2.5-3.1mm - possibility to have single intra-bony defect
iv. >3.1mm possibly to have 2 intra-bony defects
d. Kim
i. Mandibular anterior teeth with <0.8mm inter-root distance will have 56% more likely to lose >1mm bone over 10 years
What is the significance of maligned teeth and periodontitis?
a. Silness
i. Increased plaque and inflammation due to inability to clean the teeth properly
What causes gingival cyanosis and its significance?
a. Matheny
i. Inflammation causes increase in number of blood vessels, but decreased perfusion of blood vessels, which leads to stagnant O2 poor blood (cyanosis).
Discuss the importance of bone sounding and is it reliable?
a. Ursell
i. Bone sounding vs surgical measurements correlation coefficient 97% with mean 0.29mm difference.
b. Mealey
i. Bone sounding in furcation is accurate within 1mm 85% of time. Average distance between bone sounding and surgical measurements was 0.5mm. Bone sounding increases diagnostic accuracy 10% of clinical detection of furcation invasion.
Discuss the significance of calculus and how it attributes to periodontal disease?
i. Tan
1. Viable bacteria are found within calculus using SEM
ii. Allen and Kerr
1. Sterile or non-sterile calculus implanted into guinea pigs
a. Sterile calculus produced foreign body reaction
b. Non-sterile calculus produced constant abscess with suppuration
iii. Anerud
1. Sri-lankans develop subgingival calculus 6-8 years following eruption of tooth, calculus contributed to more rapid AL compared to Norwegians without calculus
iv. Richardson and Bowers
1. Calculus is generally found about ½ depth into intrabony defects
v. Fujukawa
1. Healing with calculus in place is delayed, but is possible with good oral hygiene
What is calculus made of and its development order?
i. Hydroxyapatite (58%) - mature calculus
ii. Magnesium whitlockite (21%)
iii. Osteocalcium phosphate (12%)
iv. Brushite (9%) - 1st crystalline to form in immature calculus
v. Development order
1. Brushite - osteocaclium phosphate - magnesium whitlockite -hydroxyapatite
Discuss the role of gender as an etiologic factor for periodontitis?
a. Shiau
i. There are genetic risk factors that may explain males having higher prevalence.
ii. Also, increase in estrogen for females are bone protective, while testosterone in men increases bone metabolism.
iii. Males have increased innate immune response, and females have higher adaptive immune response.
What are the tooth related factors and patient related factors for molar prognosis?
i. Graetz
1. Maxillary molars with FI-3 and advanced bone loss have greatest risk of tooth loss. Increased mobility, furcation invasion, residual PD associated with higher risk of molar loss during SPT.
ii. Nibali (2017)
1. Untreated site with irregular perio therapy (SHIP study) led to significantly higher risk for tooth loss with all three degrees of furcation invasion comparing to molar without furcation.
iii. Nibali (2016)
1. Systematic review/meta analysis that were treated and in frequent maintenance, presence of furcation invasion approximately doubles the risk of tooth loss for up to 10-15 years. However, only 30% of FI 3 molars lost in between 5-15 years.
iv. Salvi
1. Showed smokers, noncompliance with SPT and deep residual PDS = risk for tooth loss. Hamp 1 was not worse than no furcation but Hamp 2 and 3 are risk for tooth loss.
What are the goals of non-surgical therapy?
Removal of local factors
PD Reduction and CAL Gain
Reduce Inflammation
Reduce Microbiological Parameters
Get to know patient
Bone Sounding
How effective are we are removing plaque and calculus during non-surgical therapy?
i. Caffesse
1. Performed SRP on teeth and then extracted the teeth and evaluated of % free calculus surfaces. Results showed we are good at closed SRP in shallow pockets, but not good in deeper pockets.
Closed Open
1-3mm 86% 86%
4-6mm 43% 76%
>6mm 32% 50%
ii. Waerhaug
1. SRP in combination flap surgery in some cases
a. <3 mm PD: 89% plaque free
b. 3-5mm PD: 63% plaque free
c. >5mm PD: 11% plaque free
iii. Stambaugh & Dragoo:
1. You are not good at scaling beyond 4mm and cannon reach below 5.5mm
a. Average curette efficiency was 3.73mm
b. Average instrument limit is 5.52mm - how deep the curette tip can reach
What are critical probing depths?
Lindhe
- 2.9mm for NST (Loss of AL below this number, and gain AL if PD above this)
- 4.2mm for surgical therapy
- 5.4mm where you will gain more attachment with surgical rather than NST
Discuss the evidence that non-surgical treatment reduces inflammation?
i. Caton - gingival biopsies before and after treatment showed less inflammatory infiltrate, less bleeding, less ulcerated CT, and less BOP
ii. Davenport - Histology on hopeless teeth showed bleeding sites have more inflammatory infiltrate, widened intracellular spacing, more fluid flow, more leukocytes
Why do we perform the re-evaluation at 4-6 weeks?
i. Caton, Proye, Polson
1. After SRP, all parameters improved at 4 weeks and maintained to 16 weeks.
2. “The significant decreases in plaque, gingival and bleeding indices, and pocket depth as well as the significant gingival recession and gain of clinical attachment which were present at the 4 week point were maintained at 8-16 weeks after root planing. It was concluded that the favorable clinical changes which occur in periodontal pockets within 1 month after a single episode of subgingival root planing combined with improved oral hygiene can be maintained for an additional 3 month period.”
How does healing occur after non-surgical therapy?
i. Waerhaug
1. Showed healing occurs with LJE
Is there any evidence that non-surgical therapy reduces microbiological parameters?
i. Cugini
1. SRP resulted in decrease in number of red complex microbes up to 12 months following SRP, however, all were not totally eliminated and some species increased
ii. Jones, O’Leary
1. SRP was able to render root surfaces approximately as free of detectable endotoxins as were uninvolved healthy root surfaces.
What are the active ingredients of Listerine?
Thymol, Eucalyptol, Menthol, Methylsalicylate
What is Listerine and its effectiveness?
i. Essential oil that disrupts the cell wall and inhibits bacterial enzymes. Vehicle is alcohol, 22-27% content.
ii. There is up to 34% reduction in gingival inflammation and plaque with Listerine use x2 daily
iii. Gunsolley
1. 25% anti-plaque and 16-30% anti-gingivitis, 60% effectiveness of CHX
What is the best inter-proximal cleaner?
I want the patient to use whatever interproximal aid that is easiest for them, and that they will actually use. Use proxabrush as soon as patient loses papillary guidance.
In a 3 way crossover design, Kiger showed that TB+proxabrush had lower plaque levels, especially interproximal compared to TB alone or TB+floss.
Discuss the evidence of why improved access is beneficial during surgical treatment?
i. Fleischer
1. Multirooted teeth showed that an open approach allowed for significantly more calculus removal, especially for a periodontal resident - also showed that even when opened and experienced clinician, yielded calculus free furcation only 68%
ii. Brayer
1. Single rooted teeth with 4+ mm PDs needed open approach for calculus removal
iii. Caffesse
1. Probability of leaving residual calculus increases as pocket depth increases. Over 4mm it is 30-40% closed and 50-75% open.
iv. Waerhaug
1. Sites >5mm 90% of surfaces have remaining plaque which gives rise to new plaque formation and prevention of junctional epithelium.
Discuss the Washington studies?
Ammons and Olsen
i. Less recurrence of disease at 5 years compared with apically positioned flap.
ii. Osseous has less residual pockets and less BOP compared to flap curettage 5 years out
Discuss Nebraska studies?
Kaldahl and Kalkwarf
I. Better PD reduction and fewer extractions over 7 years compared to MWF flap.
II. Osseous had better PD reduction especially at deeper sites
Does furcation invasion in molars affect prognosis?
a. Ross and Thompson
i. 88% of maxillary molars with furcation invasions survived 5-24 years (degree 1 furcation mainly). NO surgery performed, only soft tissue therapy and coronal reshaping.
b. Graetz - 18 year follow up molar prognosis
i. Degree 0 or 1 furcation invasion is not a risk factor for molar loss.
ii. Maxillary molars with FI-3 and advanced bone loss are at greatest risk of tooth loss
iii. Increased mobility, furcation invasion and residual pocket depth are associated with a higher risk of molar loss during maintenance
iv. 1.89x risk of molar loss for every 1mm of residual PD following active therapy
Why do we perform periodontal maintenance at 3 months? Does regular maintenance help retain teeth?
a. Why 3 months?
i. Ramjford and Morrison showed that 3 months maintenance is adequate to maintain the periodontal condition even if patients hygiene is not perfect (however in this population, they had good OH - since they have low GI)
ii. Mousques
1. Without proper OH, the proportions of microorganisms will return to baseline values at 3 months.
b. Regular maintenance
i. Axelsson and Nystrom
1. 30 year maintenance of patient with NST and MWF if necessary. Pt was recalled at 3,6,12 month intervals. Plaque scores at 30 years was less than baseline and incidence of tooth loss was low in all groups.
ii. Lindhe and Nyman
1. Showed patient with advanced periodontitis could be maintenance with treatment and regular maintenance.
How wide is the supracrestal attachment?
15.1. Gargiulo: 30 microscopic human specimens.
Sulcus .69mm
JE .97mm
CT 1.07mm
What is the max distance from bone crest to tooth contacts to get 100% papilla fill?
15.3. Tarnow - When the distance from the base of the contact to the crest of the bone increased, the percentage of sites with an intact papilla decreased. Distance % Times Papilla Present 3 - 5 mm 100% 6 mm 56% 7 mm 27%
BL: When the distance was ≤5 mm, the papilla was almost always present, whereas the papilla was usually missing when the distance was ≥7 mm.
Discuss desired vs actual amount of surgical crown lengthening achieved (Does location on tooth matter?)
15.7. Herrero:
A biologic width of 3 mm is rarely obtained following crown lengthening procedures. Clinicians should be more aggressive in their surgical treatment and should take measurements during the procedure to prevent impingement of biological width following placement of a restoration. According to this article, you are more likely to remove more on the facial and less on the the distolingual.
Do marginal ridge discrepancies cause periodontal disease?
15.12. Kepic and O’leary: 100 pts. (NO)
There were low correlations found between pocket depth, attachment loss, plaque, calculus, or gingival inflammation with the status of the marginal ridge relationship. Uneven marginal ridges discrepancies are less important than plaque and calculus deposits in periodontal health.
Philstrom: (YES) Max 1st molars with uneven marginal ridges means difference in CEJ level which means vertical defects. These sites show increased PDs, BL, and LOA.
