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Soft tissue inflammatory changes and their prevention

and managementLaurence J. Walsh

BDSc PhD DDSc FFOP(RCPA) GCEd FICD FADI FIADFE

© 2015

Gingival excess from space closure

Long standing inflammatory changes

Soft tissue Mxas part of caries prevention• Plaque retention sites

• Oral hygiene difficulties

• Gingival inflammatory enlargement

– Plaque maturity

– Increase in cariogenic bacteria

– Fermentation leads to decalcification around brackets and cervical margin 6

Gingivitis

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Experimental gingivitis: microflora

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Dealing with gingival inflammation

• Aetiology

• Plaque induced

• Syndromal factors

• Hormonal changes

• Neoplastic (e.g. AML)

• Oral contraceptives

• Other medications– Anticonvulsants

– Calcium channel blockers

– Cyclosporin

• Strategies

• Mechanical oral hygiene

• Interdental cleaning

• Anti-inflammatory biocides

– Essential oils (e.g. Listerine alcohol-free mouthrinse)

– Triclosan (e.g. Colgate Total toothpaste)

– Hydrogen peroxide rinses

– Stannous fluoride toothpaste

• Alter plaque ecology (e.g. GC Tooth Mousse Plus)

• Gingivoplasty

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Phenolic compounds

• Phenolics– Eugenol

– Thymol.

– Menthol

– Eucalyptol

– Cineole

– Terpinen-4-ol

– Triclosan (Irgacare)

Some phenolic compounds have inherent anti-inflammatory properties, by inhibiting enzyme pathways which produce cytokines and mediators

Can chemical plaque control compare to interdental cleaning?

• Colgate Total with NO interdental cleaning versus regular dentifrice WITH regular interdental cleaning

• Reduced plaque and gingivitis from baseline to comparable levels

• [Kocher et al. 2000]

• Brushing with Colgate Total with NO interdental cleaning versus regular dentifrice and daily flossing

• Interdental plaque formation and gingivitis was reduced to levels at or below that achieved by flossing.

• Kocher et al. 2000

• Brushing with a conventional toothpaste plus rinsing twice daily with Listerine with no flossingversus Brushing regular dentifrice and daily flossing

• Interdental plaque formation and gingivitis was reduced to levels at or below that achieved by flossing

• Sharma et al. 2002; Bauroth et al. 2003

Listerine uses Lipophilic actives that are insoluble in water but soluble in ethanol

– Thymol

– Eucalyptol

– Menthol

– Methyl salicylate

– Eugenol

– Cineole

– Terpinen-4-ol

It is now believed that efficacy and taste of antiseptic mouth rinses such as Listerine is due to the bioavailability after dissolution of the four active ingredients.

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Reduced ethanol: Listerine Zero

• Availability of the active ingredients is maintained by addition of propylene glycol and glycerin as co-solvents.

• The reduced alcohol antiseptic mouthwash has similar oral antimicrobial efficacy, clarity and taste as other compositions of Listerine.

• US Patent 5,723,106 (1998) Reduced alcohol mouthwash antiseptic and antiseptic preparation.

Direct comparison• Regular fluoride

toothpaste,

• plus Listerinemouthrinse (20 mL for 30 seconds twice daily for six months)

[Charles et al. 2001]

• Colgate Total toothpaste (brushed for 60 sec)

• plus a placebo rinse

Listerine rinse had greater effect on plaque.

No significant difference in gingivitis between the two options

Sequence & Flossing technique

• Sluicing action

• Break up biofilm

• Best before brushing

• Floss, brush, rinse

• Angle Orthodontist 2008

• Orthodontic patients 16.6 yr old

• Brushing + flossing

• Brushing + flossing + Listerine

• Twice daily use of 20 mL

• N=25 per group, 3 and 6 months

• Blinded examiner

Hydrogen peroxide

• Higher plaque oxygen tension –peroxide mouthrinses 0.5-1.5%

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Stabilized stannous fluoride dentifrice

• Oral-B Pro-Health fluoride toothpaste

• The combination of stabilised stannous fluoride and sodium hexametaphosphate solves the two major concerns which have limited the use of stannous fluoride in oral care products in the past - its stability in the product and its tendency to cause discolouration.

Bio-available Sn and F ions

Stabilized SnF2 dentifrice

• suppresses the development of dental plaque by impairing the normal adhesion and cohesion events which bind bacteria to one another and to the pellicle

• reduces the biomass and complexity of dental plaque, without the risk of developing resistant bacteria because the growth of most bacteria is suppressed equally

• typical reductions in bleeding of 57% over 6 months versus a negative control

FX on plaque and gingivitis

Lower plaque viability• Compared to a negative

control toothpaste which lacks stannous fluoride, Oral-B Pro-Health gives up to a 33% reduction in the levels of dental plaque bacteria at 12 hours following tooth brushing.

SHMP FX on calculus

SHMP is a polymeric phosphate with 10 to 12 repeating pyrophosphate subunits, giving it a stronger attraction to hydroxyapatite relative to other commonly used pyrophosphates; greater coverage of the tooth surface; and improved substantivity, thereby increasing its potential to prevent spontaneous crystallisation at the enamel surface (i.e. calculus formation). Compared with pyrophosphate, sodium hexametaphosphate has greater effectiveness as a mineralisation inhibitor because it resists hydrolysis and its degradation products (which are shorter-chain polyphosphates) maintain some level of activity.

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Battle of the brands• Compared to Colgate Total ®, a commonly used

fluoride toothpaste based on triclosan copolymer technology, Oral-B Pro-Health ™ has shown greater inhibitory effects on dental plaque formation in clinical trials, at 3 weeks (17-30% less), and at 6 weeks (45% less).

Total® low-responders• 38 low responders selected from 91 subjects using

Colgate Total for 6 months were then enrolled in a further study in which they were crossed over to ProHealth. They had shown no or minimal gingivitis response to Total.

• They used Oral-B Pro-Health for 3 months, brushing twice daily for 60 seconds.

• They gained a 54% reduction in gingivitis compared to their baseline, with a 55% reduction in their bleeding scores.

• Archila L, He T, Winston JL, Riesbrock AR, McClanahan SF, Bartizek RD. Antigingivitis efficacy of a stabilized stannous fluoride/sodium mexametaphosphate dentifrice in subjects previously nonresponsive to a Triclosan/Copolymer dentifrice. Compend Contin Educ Dent. 2005;26(suppl 1):12-18.

Does SnF2 work for caries prevention?

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Mixing and matching

• Toothbrush –manual or powered

• Toothpaste

• Interdental cleaners (several?)

• Mouthrinse

• Tooth Mousse Plus or plain Tooth Mousse

Combining products togetherExample of combination strategy 1

• Oral-B powered brush with feedback system to track areas/force/time

• Colgate Total or Oral-B Pro-Health toothpaste

• Philips Airfloss with Listerine liquid for interdental cleaning

• Listerine rinse after flossing and brushing

• Smear on GC Tooth Mousse Plus before bed

Example of combination strategy 2

• Oral-B powered brush with feedback system to track areas/force/time

• Oral-B Pro-Health toothpaste

• Airfloss loaded with Pro-Health CPC rinse

• Oral-B Pro-Health CPC rinse

• Smear on GC Tooth Mousse Plus

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Optimal aesthetics

• The appearance and form of the gingival tissues must be

– Free of inflammation

– Symmetrical: correct heights and zeniths

– Harmoniously balanced with the dentition and peri-oral tissues.

Points to ponder

• oral hygiene habits

• periodontal attachment levels

• mucogingival architecture

• tissue biotype

• gingival tissue thickness and consistency

• papilla form

• crown/root ratios

• crestal bone levels

• Will there be infringement of the biological width, and thus is resection of bone required ?

Aesthetic Workup

• Oral hygiene

• Gingival colour and consistency

• Papillae form

• Amount of keratinized attached gingiva

• BIOTYPE– Thick – brachyfacial, square

arch form, pocketing more likely

– Thin – thin tissues, recession prone, high vaulted palate, dolicofacial

• Probing depths

• Tooth mobility

• Lip lines rest/smiling

• Occlusion– Anterior guidance

– Canine guidance or group function on lateral excursions

– Incisor relationship (OB/OJ)

• Radiographs– Crestal bone levels

(PA/OPG)

– Crown:root ratio.

Normal proportions

• Gillen (1994) analyzed normative tooth proportion and reported: – a) central incisors and canines are approximately equal in

length and are usually 20% longer than the lateral incisors

– b) with respect to the width, the central incisors are 25% wider than the laterals and 10% wider than the canines.

– C) The length-to-width ratio of the canines and the lateral incisors are both 1.2:1 whereas the length-to-width ratio of central incisors are 1.1:1.

Gingival Height of Contour (HOC)The HOC of the central incisors is at the same level of the

canines, whereas the HOC of the laterals incisors are about 1 mm lower.

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Gingival Zenith (GZ)GZ is slightly distal to the midline for MX central incisors and canines, whereas GZ is at the midline on MX lateral incisors.

Biologic Width

Larger, more complex and expensive lasers for a wider range of oral surgery

Biolase Waterlase MD

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Erbium lasers

Walsh 2010

YSGG gingivoplasty: no LA (RM)

YSGG gingivoplasty: no LA (RM)After Er:YAG laser

After 1 weekAfter 2 weeks

Baseline

Er:YAG gingivoplasty: no LA (MB)

Gingivoplasty

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Gingivectomy / Gingivoplasty

• Indications: to eliminate gingival enlargements, interdental craters, reverse soft tissue architecture where there is sufficient width of attached gingiva.

• Contraindications:

• where there is minimal amount of attached keratinized gingiva,

• the base of the pockets approaches or extends beyond the mucogingival junction,

• when osseous defects exists or new attachment procedures are planned.

Choice of instrumentation

• Minor gingivoplasty on a single tooth– Trichloracetic acid (extreme care needed!)

– Ceramic bur

• Multiple teeth or gingivectomy?– Scalpel

– Electrosurgery

– Lasers: greater precision• Contact or defocussed

• Wavelength? Multiple diode lasers available

Low cost, portable diode lasersfor minor surgical procedures

Gingivoplasty:using diode lasers

• During treatment or at the end of treatment

• In-house control of procedure

• No bleeding, excellent healing

• Don’t violate biological width (know what to refer out!)

Advantages• Minimal anaesthesia

requirements

– Topical OraQuix, or EMLA, Wand, microinjector, Injex, TENS, ComfortPulse modes.

• Excellent haemostasis

• Healing period free of pain and discomfort

• Predictable healing due to minimum collateral effects (no damage to bone etc)

Laser gingivoplasty (NP)

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Gingival excess between MX centrals (KL)

Gingival excess between MX centrals (KL)

Gingival excess 11-21 (BG): baseline

Gingival excess (BG)Gingival excess (BG)