D/x & Step 1 & 2

Question 1

Why is it not PTM?

Answer 1

According BURNSVOLD 2005
ther’s No teeth elongation (defying Thielman’s Law), no increased overjet (is in accordance, with the lower) no biprotusion of both of them, patient is going to do orthodontic ttm and it is reversible after perio-ttm.

Question 2

Root trunk length?

Answer 2

OSCHENBEIN 1986 (upper 3, 4, 5; Lower 2, 3, 4)

Question 3

PDL widening?

Answer 3

LINDHE & ERICSSON 1976 presented that PDL widening is an early indicator of perio breakdown when EP is combined with Occ.Trauma

Question 4

Root proximity?

Answer 4

VERMYLEN 2005: <0,3, 0,3-0,5, 0-8. OR 3.6. , In Perio pt +prevalent coronal third, frequently symmetical, worsens tooth prognosis.

Question 5

Open contacts?

Answer 5

HANCOCK 1980: Open contacts per se are not a factor, only when there’s food impaction leading to an increase of PPD, loose contacts are the worst.

Question 6

Calculus?

Answer 6

MENDEL & GAFFAR 1986, indirect and direct way: Porosity increase retention of toxic products, ATB without debridement limited efficacy, Subgingival calculus has a pathogenic effect, Frequent removal to prevent progression, Calculus cause periodontal disease. JEPSEN 2011: Calculus is a retentive facto for plaque accumulation.

Question 7

Restorations and EP/PPD?

Answer 7

Overhanging restaurations: HIGHFIELD & POWELL 1978, overhanging restauration, trappes more plque, therefore worse periodontal parameters

Question 8

BOP

Answer 8

LANG 1990, 1986. Low+predictive value 6% (90) for AL predictability and 30% (86). Lang 1990 says Absence of BOP has high+predictive value 98% for perio status stability.
MATULIENE 2008: (in SPT) Sites with BOP+PPD>=5mm had +probability TL and OR 44 for EP progression.

Question 9

Furcation involvement?

Answer 9

McGUIRE 1996, DONNEWITZ 2016, NIBALI 2016 demonstrated a worst prognosis for F.I., but mostly with F.I. 3&2.
Salvi 2014 OR 2.9 FI-2, type-3 OR 6.8
Tonetti 2017 FI-2 10y survival was 52%. Subclass A-90% (9.5-10y), B-70%, C-23%

Nibali 2016: RR of 1.7 (type II vs I), 1.8 (III vs II) and 3.1 (III vs I) with statistical significance

Question 10

Why this staging and grading?

Answer 10

Pt presents PD>=6mm (stage III) and %BL/age<0.25 (grade A)

Question 11

Crowding / malpositon?

Answer 11

ERCOLI 2018: Harder to maintain a good IHO.

Question 12

Why wait 8 weeks?

Answer 12

SEGELNICK 2006 4-8w C.Tx repair and 4-8w recolonization (mobility 1m to 6-12m); MAGNUSON 1984 also 4-8w recolonization, MOUSQUES 1980 Spirochette to baseline ~42d (6w)

Question 13

Calculus elimination?

Answer 13

BRAYER 1989: Experienced vs non experienced operator, (remove less calculus), RATEISCHAK plus 1992: calculus is present at the base of 75% of the PPD.

Question 14

Mobility?

Answer 14

KERRY 1982: After nst, there’s an increase of movility, due to the reorganization of the collagen fibers, that later mobility will reduce.

Question 15

SPT based on PRA

Answer 15

TONETTI & LANG 2003

LANG 2015: Validated PRA

Question 16

Overweight?

Answer 16

SUVAN 2015. OR: 2,5. Overweight & obese individuals seem to have an + risk of EP in comparison with normal BMI

Question 17

Female and EP?

Answer 17

Progesterone, increases permeability of the soft tissues and therefore maybe enhancing the predispose to periodontal disease.
SALVI 2014: OR: 2

Question 18

Mouth breather and EP?

Answer 18

its more predisposed to suffering gingivits, but not periodontitis.

Question 19

What do you expect from a NST?

Answer 19

PD reduction, CAL gain, pocket closure, reduction in BOP.
BADERSTEN 1981:Higher INITIAL PPD = higher PD reduction and attachment gain, Higher RESIDUAL PPD = higher BOP, SHALLOW PPD had CAL and recession. BADERSTEN 1984: Same+ Decision of surgery postponed at 6-9m. MATULIENE 2008: (in SPT) Sites with BOP+PPD>=5mm had +probability TL and OR 44 for EP progression.

Question 20

What type of healing do you have after NST?

Answer 20

FOWLER 1982. Long JE.

SEGELNICK 2006 2 weeks Epith.attach. ,4-8w C.Tx repair and 4-8w recolonization (mobility 1m to 6-12m)

Question 21

If we would have given ATB, how many mm would we expect to reduce?

Answer 21

KEESTRA 2015: ATB+SCRP; 
PD

Moderate: 0.25mm
Severe: 0.74mm 
CAL 
Modere: 0.21mm 
Severe: 0.61mm
BoP:3.8%

Question 22

Lindhe’s 2008 prognosis: Doubtful

Answer 22

Doubtful: good prognosis by means of additional therapy
o Periodontal
- F.I. II or III
- Angular bony defects
- Horitzontal bone loss involving 2/3 root 
o Endodontic
- Incomplete root canal therapy
- Periapical pathology
- Presence of voluminous post/screws
o Dental
- Extensive root caries

Question 23

Lindhe’s 2008 prognosis: Irrational to treat

Answer 23

Irrational to treat
o Periodontal
- Recurrent periodontal abscesses
- Combined periodontal-endodontic lesions 
- Attachment loss to the apical region
o Endodontic
- Root perforation in the apical half 
- Extensive periapical lesions
o Dental
- Vertical fracture
- Oblique fracture in the middle third of the root 
- Caries lesions extending into the root canal

Question 24

Why haven’t you gave ATB?

Answer 24

She has a lot of contributory factors that once we remove them and perform step II cause related therapy, the patient will have a good response to treatment and we do not need to give her an adjunctive antibiotic therapy.
Based on EICKHOLZ 2019 ATB threshold study, Vanessa might be a good candidate to ATB adjunctive ttm by her young age 28y (<55y), But her PPD sites =>5mm was 24% (should be >35%).

Question 25

Changes in the OHI? Why electric? Why inteproximal?

Answer 25

Electric: VAN DER WEIJDEN 1993: electric vs manual. electric vs recession ROSEMA 2014 and McCRACKEN 2009: It can not be demonstrated the association of electric and recessions.
Interprox.Brush: SALZER 2015: interdental hygiene Interproximal hygiene reduces gingivitis in 34% and plaque in 32%. JACKSON 2006: interproximal vs floss: More reduction of interproximal plaque, PD, BoP, and papilla shortening

Question 26

Triclosan

Answer 26

Rule 2005, due to the ph= Cancerigeno.

GI (Escribano 2010, Figuero 2019) showed best results for dentifrice GI ttm

Question 27

Toothpaste? Elimination of plaque

Answer 27

Valkenburg 2017: Same plaque removal, with or without tooth paste 49% vs 50%.

Question 28

Oral contraceptives and EP / PD?

Answer 28

KNIGHT 1974: GI slightly higher for test group but not significant. BUT women taking oral.contrac. for more than 1.5y showed a significant perio-destruction. (0.6 vs 0.8mm)
PRESHAW 2001: study demonstrated that current OC formulations do not affect the inflammatory response of the gingiva to dental plaque.

Question 29

Signs of occlusal trauma

Answer 29

Clinical
- Fremitus *
- Mobility (progressive)
- Occlusal discrepancies
- Dental wear
- Tooth migration
- Fractures
- Dental sensibility
- Pulpitis
- Higher probing depth
- Alteration in chewing habits

Radiological
- Enlargement of periodontal ligament (coronal aspect: Funneling lesión *)
- No continuity of lamnina dura
- Vertical bone loss pattern
- Radiolucency in furcation or apex areas
- Radicular resorption

Histological:
- Higher loss of attachment
- Fibers disorganization
- Increased osteoclasts
- Extended immune complexes

Fan 2018_“histological term to describe injury resulting in tissue changes within the attachment apparatus, including PDL, supporting A.B. and cementum, as a result of occlusal forces.”
- 1ry occlusal trauma: injury resulting in tx changes from excessive occlusal forces applied to teeth with normal support
- 2ry occlusal trauma: injury resulting in tx changes from normal or excessive occlusal forces applied to teeth with reduced support

Question 30

Absence of Crestal Lamina Dura

Answer 30

Presence suggests STABLE periodontal support.

Rams 94: utility of crestal lamina dura in predicting periodontal disease activity. Presence of the lamina dura correlates with periodontal stability has a HIGH positive predictive value (~100%) O.R. 2,6 for STABILITY and and Low positive predictive value for recurrence O.R.=0.4

Question 31

Nutrition and Periodontitis

Answer 31

Staudte 2005: 2 grapefruits/ day increased vitamin C levels and improved BOP scores (no PPD change)
Leggott 91 & Royzman 2004: vitamin C deficiency or ingestion of aspirin can cause significant gingival bleeding through mechanisms that may not be primarily related to plaque accumulation.

Question 32

Why stage 4?

Herrera 2022 guidelines

Answer 32

Distinction between periodontitis stage III and stage IV is primarily based on advanced loss of periodontal tx support, which include:
1. tooth loss, resulting in <20 remaining teeth (<10 opposing pairs)
2. masticatory dysfunction
3. tooth mobility grade ≥2
4. severe alveolar ridge defects
5. occlusal collapse (tooth drifting, flaring)
These features of stage IV present a higher level of complexity, but also need an inter-disciplinary approach for rehabilitation of the impaired dentition (Papapanou et al., 2018; Tonetti et al., 2018; Tonetti & Sanz, 2019).

Question 33

Occlusal adjustment

Answer 33

For OA, based on Burgett 1992. After 1 and 2 years, OA led to an improved CAL of approximately 0.4 mm (mean) following non-surgical periodontal therapy. Although this improvement may not be considered as clinically relevant, OA may remove jiggling forces, facilitate patients’ chewing capabilities and resolve pain perception when premature contacts are removed.

Question 34

In stage IV periodontitis patients, when should orthodontic therapy start?

Herrera 2022 guidlines stage 4

Answer 34

In successfully treated stage IV periodontitis patients in need of orthodontic therapy, it is recommend starting OT once the endpoints of periodontal therapy have been achieved [no PPD=5 mm & BOP and no PPD ≥6mm (Sanz 2020)

when EP is not fully treated (inflammation is not arrested) prior/during OT, these orthodontic (biomechanical) forces within the periodontal tx with remaining inflammatory processes will re-initiate and/or accelerate the progression of periodontal destruction, leading to further CAL and supporting alveolar bone. ((-Eliasson et al., 1982; Ericsson et al., 1977; Melsen, 1986; Wennstrom et al., 1993).

no detrimental effects of orthodontic tooth movements have been observed when these movements are exerted on
teeth with healthy (non-inflamed) reduced periodontal support.

Question 35

what should be the time interval between the periodontal regenerative and orthodontic therapies?

Herrera 2022 guidlines stage 4

Answer 35

these intra-bony defects should be treated during the step 3 of peri- odontal therapy by surgical periodontal regenerative interventions.
comparing OT starting early versus late, after the periodontal regenera- tive intervention, demonstrated a potential beneficial effect of the early OT, since no statistically significant differences were observed in terms of CAL gain (5.4mm for early; 4.5 mm for late OT, or PPD reduction 4.2 mm in the early group versus 3.9 mm in the late group. Similarly, pocket closure (PPD ≤ 4 mm) occurred in 91% of the early OT treated teeth versus 85% in late OT (Jepsen 2021).

combined treatment significantly improves periodontal outcomes (increased CAL gain, PD reduction and RBL gain) and significantly reduces gingival inflammation (BOP).
2.suggest not to wait for a prolonged healing period after the regenerative intervention, before initiating OT, since there is evidence that a short (1 month) and a prolonged (6 months) period between periodontal/ regenerative and OT result in comparable outcomes.
(Kloukos et al., 2021; Martín et al., 2021; Papageorgiou et al., 2021)

Question 36

What case type is it of a stage 4?

Herrera 2022 guidlines stage 4

Answer 36

Case type 1: the patient with tooth hypermobility due to secondary occlusal trauma that can be corrected without tooth replacement. Temporary tooth splinting and initial occlusal adjustment (mostly relief of fremitus in combination with splinting) can be implemented during step 1 of therapy to manage secondary occlusal trauma and the impact of tooth hypermobility on patient comfort. The need for and the implementation of longer-term splinting needs to be re- assessed following completion of steps 2 and 3 of periodontal therapy (Herrera 2022 guidlines stage 4)