Sharing Care in Periodontics
Alan Woodman MSc BDS MRDRCS DGDP(UK) FICD
Specialist in Periodontics
Alan Woodman @ UPDA
WELCOME!
Alan Woodman @ UPDA
Alan Woodman @ UPDA
SHARING CARE IN PERIODONTICS COURSE PROGRAMME – 23 March 2012, UPDA
0900 REGISTRATION 0.23
0915 Introduction
0930 Current Concepts
1015 Assessing Treatment Needs
1045 Coffee 0.24
1100 Practical aspects of probing 0.23
1120 Communicating Treatment Needs
1200 Treatment Planning Exercise
1300 Lunch 0.24
1345 Root Instrumentation Ph. head
1410 Practical root instrumentation
1510 Tea 0.24
1520 Re-assessment 0.23
1540 Supportive Care
1600 Referral & the Role of Surgery
1620 Treatment plans and discussion
1700 CLOSE
Sharing Care in Periodontics • Current Concepts • Assessing Treatment Needs
– Practical aspects of probing
• Communicating Treatment Needs – Treatment Planning
• Root Instrumentation – Practical root instrumentation
• Re-assessment • Supportive Care • Referral & the Role of Surgery • Treatment plans and discussion
Alan Woodman @ UPDA
Who Needs Periodontal Care ?
The main factors:
• Biofilms
• Susceptibility
• Compromised immunity
• Smoking
• Surfaces
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Alan Woodman @ UPDA
THE HUMAN BODY
1014 cells:
10% mammalian
90% microbial
PERIO REMAINS PLAQUE-
FOCUSSED, BUT OUR
ATTITUDES HAVE
CHANGED...........
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TEETH: S. mutans
S. oralis
S. mitis
A. naeslundii
Gram-anaerobes
CHEEK: S. salivarius
S. mitis
TONGUE: S. salivarius
S. mitis
Haemophilus
Neisseria
Veillonella
Stomatococcus
MICROFLORA OF THE HUMAN MOUTH
OUR INTEREST IN
PARTICULAR SPECIES HAS LESSENED..........
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BIOFILM: DENTAL PLAQUE
IS THIS, TRADITIONAL, VIEW OF PLAQUE
STILL WARRANTED........?
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DENTAL PLAQUE: BIOFILM PROPERTIES
• spatial organisation • diverse & stable microbial composition • confers benefit (colonisation resistance) • resistance to antimicrobial agents - penetration - inactivation & neutralisation
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MICROBIAL HOMEOSTASIS
community
balance
negative
feedback
antagonistic
& synergistic
interactions
host defence variability
diet
hormones
exogenous
species
Ec
olo
gic
al s
tres
s
WE HAVE LEARNED MUCH ABOUT EXTERNAL FACTORS
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CONSEQUENCES OF MICROBIAL HOMEOSTASIS
community
balance
normal diet
diligent
oral hygiene
de-/re-
mineralisation
in equilibrium
low
inflammation/
slow GCF
Alan Woodman @ UPDA
= Health = Health > Disease
Major
ecological
pressure
Transmission
ORIGIN OF DENTAL PATHOGENS
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• Dental plaque is a Biofilm & as such, OVERALL, is Beneficial to health (!) •Plaque-mediated diseases are due to: - changes in local environment - disruption of homeostasis & local de-regulation of the immune systems, allowing... - enrichment of minor bacterial populations •Biofilms are recalcitrant to antimicrobial agents
So.....
WHO ? & WHY ?
• 12 - 15% Worldwide
• Oral hygiene
• Anatomy
• Smokers
• Medically challenged
• A more Pathogenic plaque
• Compromised immunity – Medical
• Medication
• Disease/toxins – Cellular
• Bacterial cytokines
• Tissue cytokines
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Diagnostic dilemmas
• Does familiarity breed contempt ?
• Does visual evidence of deposits sway our opinion vs. other observations ?
• Why do so many patients suffer from delayed diagnosis of perio problems ?
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What constitutes “Disease” ?
• active inflammation ?
• the abnormal ?
• the unusual ?
• is gingivitis normal ?
• is gingivitis usual ?
• can we recognise normal ?
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Assessing Treatment Needs
• Observations
• Recording
• Radiographs
• Treatment Planning
• Planning the treatment
• Reassessing
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Detailed observations
• BPE at regular C/up
• Full 6 point chart if code 3 or 4 with:
• bleeding
• mobility
• plaque
• recession
• furcations
• Occlusion : NWS & anterior interference
• Posterior support
• Radiographs
• Endodontic status
• Caries status
• % Root support
• Bone irregularities
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Health factors
• Systemic disease
• Diabetes
• Systemic medication
• Immunosuppressives
• Transplant patients
• Treatment risk patients
• Stress
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Which probe ? • Design
– 0.5 ball tip
• Markings – graduated
– epidemiological
• Force – standardised
– random / experience
– 25 gms
• Same probe
• Same person – Repeatability
• Same practice
• Same technique – Reproducibility
• Computerisation ? Alan Woodman @ UPDA
Which radiograph ?
• 2D view of 3D problem
• OPTG
– patient education
– / motivation
• Periapicals
– diagnosis
– / endodontic aspects
• Computerisation and CADIA for
definitive examination of change?
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Which charts ?
• Time consuming, yet essential
– record the important
– record the repeatable
– use patient-friendly display
– avoid over-complication
• Post operative assessment!!!!!
• Computerisation ?
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Which tests ?
• GCF
• Saliva
• Plaque
• Blood
• Tissue
• Inflammatory products of : – cellular breakdown
– cellular activity
– bacterial activity
– host response
• Or normal cell turnover ?
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Observations > Diagnosis
• GINGIVITS
• ACUTE
• LOCALISED
• AGE INFLUENCE
• LOCAL FACTORS
• PERIODONTITIS
• CHRONIC
• GENERALISED
• RATE OF PROGRESSION
• SYSTEMIC FACTORS
Alan Woodman @ UPDA
But will our treatment vary with the diagnosis...................?
Smoking and Periodontal Diseases
• Nicotine effects locally and systemically
• Compromised blood flow
• Compromised healing
– cellular
– vascular
• Compromised Oral Hygiene
– increased deposits
– lact of tactile sensation (tongue)
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less oral awareness
increased plaque
decreased bleeding
poorer healing
increased bone effects ?
SMOKING CESSATION IS A MUST FOR LONG TERM SUCCESS IN CIPD
Good periodontal prognosis
• Regular bone loss
• Natural recession
• Receptive to OHI
• Thick gingiva where surgery proposed
• Listeners
• Questionners
• Keen attenders
• Dextrous
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Poor periodontal prognosis
• Irregular bone loss
• Heavy restorations
• Prostheses
• Thin gingiva
• Furcations
• Acute episodes
• OH strugglers
• Poor attenders
• Talkers (excuses!)
• Health complications
• Smokers
• History of surgery
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Periodontitis - minor warnings
• L apsed attenders
• A ge >35
• N o subgingival / interdental OH
• C hronic progress
• S mokers
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Periodontitis - major warnings
• Y oung age <35
• O ral hygiene appears good
• R apid breakdown
• K een attenders
• S mokers
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• Y oung age <35
• O ral hygiene appears good
• R apid breakdown
• K een attenders
• S mokers
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• L apsed attenders
• A ge >35
• N o subgingival / interdental OH
• C hronic progress
• S mokers
RECOGNISING RELATIVE RISK &
SUSCEPTIBILITY IS VITALLY
IMPORTANT FOR SUCCESSFUL
PERIODONTAL TREATMENT
Alan Woodman @ UPDA
DIAGNOSE not just from what you SEE but from what you OBSERVE
Periodontal diseases are simple to treat providing they are diagnosed early
Complicated treatment, LIKE THIS, generally follows an inability to recognise risk factors or our willingness to treat early disease
Tests required
• for the presence of disease
• for disease activity – past
– present
– future
• for bacterial sensitivity
• for future SUSCEPTIBILITY
Alan Woodman @ UPDA
Practical Aspects of Probing
Alan Woodman @ UPDA
Which probe ? • Design
– 0.5 ball tip
• Markings – graduated
– epidemiological
• Force – standardised
– random / experience
– 25 gms
• Same probe
• Same person – Repeatability
• Same practice
• Same technique – Reproducibility
• Computerisation ? Alan Woodman @ UPDA
Time
for
Coffee!
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Communication
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Communicating with each other
C
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C
DH/DT
GDP
PATIENT
GDP communicates diagnosis and treatment plan to patient.......
............but who makes the Decisions?
Alan Woodman @ UPDA
Communicating treatment needs
Alan Woodman @ UPDA
GDP to Patient:
• Role of the Hygienist/Therapist
• Time/how many appointments with Hygienist/LA and possibly chemical adjuncts may be required
• Cost-written estimate and treatment plan
• May be necessary to refer to GDP or Periodontist if treatment response unsatisfactory/extra cost
• Does the patient consent to treatment?
• Patient compliance is essential for the success of treatment
Alan Woodman @ UPDA
Alan Woodman @ UPDA
The Patients come in all shapes and sizes.....so DOES ONE-SIZE
TREATMENT FIT ALL?
Referring to a Hygienist
• Written prescription
• Patient aware of our role inc time, frequency & cost (referral if necessary)
• Radiographs inc. OPG
• BPE score
• Periodontal pocket chart
• Updated medical history
• TIME
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Hygienist Appointments
• Assess patient: demeanour, nerves
• Examination (teeth, gingiva,& soft tissues) & explain treatment
• OHI & motivate patient (using radiographs and Perio chart)
• At least by Quadrant scaling, RSD with/without local
• Maximise treatment area, to minimise treatment visits to achieve rapid de-contamination
• Antibiotic therapy • Write comprehensive notes
Alan Woodman @ UPDA
Plaque as a Biofilm
Does anaerobic plaque need a “fresh” approach ?
Alan Woodman @ UPDA
Alan Woodman @ UPDA
What do we NOT see?
Remember the problems?
Subgingival Management
• Patient’s subgingival management
• Clinician’s subgingival management
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Hygienist communicating with patient
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SUB-GINGIVAL CLEANING SINGLE TUFTED BRUSH
• CTS
• PARO
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DEMONSTRATING STB ON MODEL
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DEMONSTRATING STB IN PATIENTS MOUTH
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– will they?
– won`t they?
– can they?
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The Subgingival tissues
BRUSHING ?
BOTTLE BRUSHES
• DENTOCARE PH brushes
• CURAPROX double and single ended
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BOTTLE BRUSH IN FURCATION
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INCORRECT USE OF BOTTLE BRUSH !
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Alan Woodman @ UPDA
SONICARE ELITE CLAIM TO REMOVE BIOFILM INTERDENTALLY AND SUBGINGIVALLY
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Hygienist to GDP
• Non responsive areas? discuss with GDP
• Check through patient records before each session, anything unclear discuss with GDP
• If during hygienist appointment a change of plan is required from the written prescription, explain to patient the findings, and then discuss with GDP.
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Treatment Planning Exercises
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3 case studies • Case A
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3 case studies • Case A
Alan Woodman @ UPDA
3 case studies • Case A
Alan Woodman @ UPDA
3 case studies • Case A
Alan Woodman @ UPDA
3 case studies • Case B
Alan Woodman @ UPDA
3 case studies • Case B
Alan Woodman @ UPDA
3 case studies • Case B
Alan Woodman @ UPDA
3 case studies • Case B
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3 case studies • Case C
Alan Woodman @ UPDA
3 case studies • Case C
Alan Woodman @ UPDA
3 case studies • Case C
Alan Woodman @ UPDA
• Time for Lunch !
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Practical Root Instrumentation
• Opportunity to examine the roots, instruments and techniques in the Phantom Head Room
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SUBGINGIVAL TREATMENTS
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Periodontics - getting results
•Clean what matters
•Where it matters
•Keep it cleansable
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Plaque Management
• Creating a cleansable mouth
• Subgingival instrumentation
– fine tips U/S or Hand ?
– surface treatment
• Maintaining a clean mouth
– preventing re-stagnation subgingivally
– reassessment and advice on home care
Alan Woodman @ UPDA
Periodontics - getting results
• Patient compliance dictates success
• Nothing you do can overcome what the patient will not, or cannot do
• Periodontitis is an incurable disease
• But it is MANAGEABLE
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Periodontics - getting results
• Leaving pockets can only be justified when they can be adequately cleansed
• Infrabony pockets cannot be left with toxic root surfaces and scar tissue intact, thus inhibiting repair
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Subgingival management
• What you do out of sight is the most important aspect of your management of the root surface
• Whatever you do make sure that you can show the patient some change – either by touch or appearance
Alan Woodman @ UPDA
Root instrumentation
• The root surface
• The instruments
• The action
Alan Woodman @ UPDA
Root instrumentation
• The root surface
– will always be irregular microscopically
– clinical smoothness is our only measure of success at treatment
– reduction of bleeding is the best measure of success after time
– endotoxins are only superficially placed
Alan Woodman @ UPDA
A good range of fine instruments is essential
Alan Woodman @ UPDA
Root instrumentation
• The instruments
– fine probes mean fine treatment tips
– “mini-Gracey” curettes
– maintenance instruments must be finer than those for initial treatment
– Cavitron Ultrafine tips
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Root instrumentation
• The action
– Thorough instrumentation with true edged instruments
– Avoid over-vigorous actions
– Root debridement - is it enough ?
– Root planing - is it a valid term ?
Alan Woodman @ UPDA
Time
for
Tea!
Alan Woodman @ UPDA
Reassessment and Supportive Care
Alan Woodman @ UPDA
Initial course of treatment completed
- so what next?
-and for how long?
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GDP support during and after DH treatment
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• Review periodontal patient post DH treatment (with hygienist?)
TEAMWORK
• Re-record perio chart & compare
• Maintain patient enthusiasm
• Stress to patient importance of 3/12 hyg appts
Reassessment and Supportive Care
• After initial therapy, review with GDP and subsequent 3/12 DH appts
• Good Communication & teamwork between DH & GDP regarding patients progress
• If patient compliance is satisfactory………..
………..move to
SUPPORTIVE CARE
Alan Woodman @ UPDA
Supportive Care Programmes
• Careful prescription
• The role of the dental hygienist
– Sharing care - not devolving responsibility
• Referral to the hygienist
– explanations !
• (2 or) 3 (or 4) monthly reviews for
– thorough subgingival plaque (deposit) removal
– OH advice and ENCOURAGEMENT
Alan Woodman @ UPDA
Supportive Periodontal Care
• Fine instruments
• Local anaesthetic
• Complete subgingival debridement
• Consistent probing
• Clear recording – Patient - friendly
• Clear communications
• Oral hygiene/motivation
• Tailored advice/sensitivity/fluoride
• Practical instruction and feed back – Models v. Mouth ?
– Life size / realistic
– Mirror problems
• Stock what you recommend
Alan Woodman @ UPDA
The Subgingival tissues
• Class 1 Furcations
• detectable with the probe
– Weakly keratinised
– Brushing difficult
– Plaque “disturbed”
– Recession helps
– a “PIT”
• Class 2 Furcations
• detectable with the probe under the crown
– Weakly keratinised
– Brushing difficult
– Plaque “disturbed”
– a “CAVE”
Alan Woodman @ UPDA
The Subgingival tissues
• Class 3 Furcations
• “through and through”
– Keratinised
– Manageable
– Plaque “swept”
– Recession helps
– a “TUNNEL”
• Lower molars – most predictable
• Upper molars – predictable with 2 roots!
• Upper first premolars – least manageable
– 3 roots impossible!
Alan Woodman @ UPDA
Root divergence helps >30 degrees
+ stability
Root convergence hinders <30 degrees
- stability
The Subgingival tissues
– can they?
– will they?
– won`t they?
• BRUSHING ?
Alan Woodman @ UPDA
Single Tufted Brushes
with CHX gel/rinse additive or nil?
These brushes do not intentionally remove plaque subgingivally
They are DISTURBERS OF ANAEROBIC PLAQUE and its BIOFILM structure
Shaped head : conical, never flat
Angled heads available, eg PARO
Correct sizing is imperative
Definitive instruction on models and mouth with frequent reinforcement
Periodontal Supportive Therapy
A CONTINUING CYCLE:
• Diagnosis
• Treatment
• Reassessment
• Support
• Reassessment
• Support
• Indefinitely
Possibly requiring:
• Re-treatment
• Reassessment
• Support
Alan Woodman @ UPDA
Supportive Periodontal Care
• There are no set treatment plans or average patients
• Regular reviews, charts and advice
• Regular subgingival plaque removal
• Referral culture : – Dentist > Hygienist > < Dentist > ?Periodontist >
Dentist > < Hygienist……etc……..
Alan Woodman @ UPDA
The Interdental tissues – Spirals :
– Straight
– or Tapered ?
– Handles
– or Fingers?
– Mechanical ?
– Soft
– or Rigid ?
– Brushes ????
• FLOSSING contacts
• RINSING spaces
• BRUSHING spaces
Alan Woodman @ UPDA
Floss or Tape?
Dexterity
Accessibility
Restorations
Gadgets
CHX
CPC
Triclosan
Fluoride
on Spirals ?
on Brushes ?
on Floss ?
SUBSTANTIVITY?
The Subgingival tissues – Objectives?
• Reduction of gingivitis
• Limitation of periodontitis
• Control of pocket re-infection ????
• FLOSSING ?
• RINSING ?
• IRRIGATING?
• BRUSHING ?
Alan Woodman @ UPDA
Flossing in pockets is more traumatic than beneficial
Will rinses and mouthwashes reach sub-gingivally? NO!
Provided the needle tip is 2mm within the pocket, IRRIGANTS will reach the apical plaque border - regardless of its depth
Hardy & Newman 1982
BUT powered irrigators have little benefit, the irrigant bounces back
? is CHX substantive in the subgingival area
gels stay longer - but do they penetrate the apical plaque border?.
Interdental &
Subgingival cleaning
Nothing the dentist can do will overcome what the patient will
not, or cannot, do !
Alan Woodman @ UPDA
Alan Woodman @ UPDA
REASSESSING PATIENTS NEEDS
• How do we know if treatment is succeeding ?
• If not , why not ?
Post-treatment chart most important
Observations Acute symptoms
Bleeding on probing
Discharge
Plaque
Patient compliance
Sensitivity
Reassessment and Supportive Care
If, after initial therapy, review with GDP and subsequent 3/12 DH appts.........
.....Patient compliance is satisfactory, but clinical results are disappointing………..
……Consider further action with GDP
Alan Woodman @ UPDA
Alan Woodman @ UPDA
• Was the original treatment plan realistic ?
• Was the correct delivery of information used ?
• Have goals been achieved ?
• Was patient feedback valued ?
CLINICAL FEEDBACK , WHAT NEXT ?
Re-address treatment plan
Re-set goals
Re-motivate & educate
Review recall time
REASSESSING PATIENTS NEEDS
Alan Woodman @ UPDA
TREATMENT IMPLICATIONS
• ? Future management of residual pockets.
• ? Restorative implications
• ? Cosmetic implications
Leading to:
? Further review period monitor OH skills
? Further instrumentation
? Chemical adjuncts
? Surgical therapy
? Referral
REASSESSING PATIENTS NEEDS
Reassessment
• Maybe GDP to provide some aspects of care:
• ? Occlusal analysis
• ? Further instrumentation?
• ? Improve / modify restorations or prostheses
• ? Endodontics
• ? Consider Chemical Adjuncts?
Alan Woodman @ UPDA
Chemical Adjuncts
• CHLORHEXIDINE – Corsodyl
– Eludril
– Chlorohex 2000
– Peridex
• Periochip
• Frequency of use ?
• Metronidazole – Elyzol
• Minocycline – Dentomycin
• Tetracycline – Actisite
• Doxycycline – Atridox
Alan Woodman @ UPDA
Reassessment
• Maybe GDP to provide some aspects of care:
• ? Occlusal analysis
• ? Further instrumentation?
• ? Improve / modify restorations or prostheses
• ? Endodontics
• ? Consider Chemical Adjuncts?
• ? Extraction
• ? Surgery, or…..
• …..OR is it TIME TO REFER
Alan Woodman @ UPDA
REASONS FOR REFERRAL
Alan Woodman @ UPDA
Alan Woodman @ UPDA
Reasons for Referral
• when to cry “HELP”
• what to expect
• how to help the patient
Referral to a Periodontist –WHO ?
• Clinical Criteria:
– Non - resolving sites
– Pocket depth = or >5mm
– Mobility <3
– Bleeding from pocket
– Abscess history
– Furcation involvement
– Unacceptable gingival architecture
– Persistent sensitivity
• Radiographic:
– >30% bone loss
– Irregular bone loss
– Perio-endo lesion
• Restorative:
– Abutment tooth
– Last sextant molar
– Occlusal co-factors
– Potential loss of posterior support
Alan Woodman @ UPDA
Alan Woodman @ UPDA
Reasons for Referral
• what to expect – initial non-surgical re-treatment
– period of review and reassessment
– possible endodontic co-treatment
– possible occlusal co-treatment
– surgical treatment for ?50%
– long term hygienist support, initially or permanently within referral practice
Alan Woodman @ UPDA
Reasons for Referral
• how to help the patient
– warn them of the likely COST !
– do not assume a surgical approach
– explain the origins of their disease and the reasons for your concern
– explain the alternatives to periodontal treatment
Referral to a Periodontist –HOW
• Patient details
• Patient contact and availability
• Purpose of referral:
– 2nd opinion
– Treatment plan
– Treatment
• Medical alert / status
• Patient’s original complaint / wishes
• Brief description of periodontal and general dental condition
• Specific site concerns
• Outline of treatment provided
• Copies of charts, radiographs & study casts if available
Alan Woodman @ UPDA
Referral to a Periodontist –WHERE ?
• University Dental School Periodontal Consultant *
• NHS General Hospital Restorative Consultant **
• Community Dental Service Periodontal Specialist ***
• Private Specialist in Periodontics ****
• * geographically inconvenient outside the main cities (Free)
• **rarely have funding for prolonged treatments (Free)
• *** few and far between (Usually Free)
• **** Increasingly available
but EXPENSIVE for many
Alan Woodman @ UPDA
CLINICAL AUDIT of PERIO PATIENTS in
Specialist Practice : APRIL 2004 - AUGUST 2010
CONSULTATION
> INITIAL (HYGIENIC PHASE)
TREATMENT >
SUPPORTIVE CARE
PATIENTS SEEN > PERIODONTIST HYGIENISTS > REVIEWS + HYGIENISTS
2036 997 959 4710 12256
> SECONDARY
PHASE REGEN REGEN
SURGICALS: REGEN REGEN REGEN TEETH TEETH
+
BioOss
+
Emdogain
+
Ceramic TREATED LOST
523 187 20 34 411 15
(3% LOST) (NIL LOST) (5% LOST) (<4%)
APICECTOMY VITAL ROOT > RCT > EXT. FRENECTOMY CT
RESECTION 22% 10% GRAFT
48 63 14 6 31 7
> PERIPHERAL TREATMENTS
PERIODONTAL SPLINT
METAL-
RESIN GINGIVAL OCCLUSAL OCCLUSAL
SPLINTS > REPAIR SPLINT VENEERS ANALYSIS > SPLINTS
334 639 61 178 993 91
Alan Woodman @ UPDA
Periodontal Health is the bedrock of lasting dentistry
• How much perio can you do in practice?
• How much will you abandon to the hygienist / therapist or specialist?
• How much will you refer?
– to the hygienist / therapist ?
– to the specialist ?
– to the forceps ?
Alan Woodman @ UPDA
Role of Surgery in Periodontal Care
• what to expect
– most surgical periodontal procedures are accompanied by gingival recession, desired or not !
– absolute OH compliance is a necessity
– smokers fare less well, but can be treated
– regeneration can only treat “craters” in vertical defect, not horizontal loss
Alan Woodman @ UPDA
Role of Surgery in Periodontal Care
• what can be achieved
– pocket elimination
– pocket reduction
– regeneration or approximation?
– better restorative management
– cosmetic changes
– oral hygiene facilitation
Alan Woodman @ UPDA
Alan Woodman @ UPDA
Surgical care Techniques available:
•Pocket elimination & Pocket reduction
- with or without Regenerative materials
•Surgical revelation for restorative investigation
•Root resection & Apicectomy, repair of
Resorption or Perforation lesions
•Crown lengthening with or without Osseous re-contouring
•Frenectomy, Gingival grafting & Connective tissue grafting
•Pre- & Post- Implant soft tissue management
•Implant placement surgery in the Aesthetic Zone
Alan Woodman @ UPDA
Surgical care •Pocket elimination & Pocket reduction - with Regenerative materials
BioOss
BioGide
Alan Woodman @ UPDA
Surgical care •Pocket elimination & Pocket reduction - with Regenerative materials
EMDOGAIN PERIOGLAS
Alan Woodman @ UPDA
Surgical care -Surgical revelation for restorative investigation
Alan Woodman @ UPDA
Surgical care •Root resection & Apicectomy, repair of Resorption or Perforation lesions
Alan Woodman @ UPDA
Surgical care •Root resection
Alan Woodman @ UPDA
Surgical care •Crown lengthening with (or without) Osseous re-contouring
Alan Woodman @ UPDA
Surgical care •Frenectomy, Gingival grafting & Connective tissue grafting
Alan Woodman @ UPDA
Surgical care •Implant placement surgery in the Aesthetic Zone
Treatment Plans
Discussion of the cases presented
Alan Woodman @ UPDA
3 case studies • Case A
Alan Woodman @ UPDA
3 case studies • Case A
Alan Woodman @ UPDA
3 case studies • Case A
Alan Woodman @ UPDA
3 case studies • Case A
Alan Woodman @ UPDA
3 case studies • Case A • Treatment history:
– Examination 17:02:2005
• Initial treatment: – 01:03:2005
– Root instrumentation (LA) Left
– Occlusal analysis
– OHI +STB
– Metronidazole (Elyzol) placement
– 10:03:2005
– Root instrumentation (LA) Right
– Occlusal review
– Metronidazole placement
– 17:03:2005
– Metronidazole placement
• Review 05:05:2005
• Future treatment discussed
• Periodontal splinting to UR3<>3UL
• UL2 extracted and re-fixed to splint as natural pontic
• 31:05:2005
• Impressions for labial veneer
• 09:06:2005
• Fit labial veneer
• 16:06:2005
• Hygienist appointment
• 30:08:2005
• Review and Hygienist appointment, planned pocket reduction surgery for upper teeth
Alan Woodman @ UPDA
3 case studies
• Case A
Alan Woodman @ UPDA
3 case studies
• Case A
• Treatment history:
• Examination
• Initial treatment
• Secondary treatment
Alan Woodman @ UPDA
3 case studies • Case A • Surgical treatment 1 • 01:11:2005
• Flaps to UR6-5-4-3 and 1-3-4-5-6UL
• Apically repositioned and thinned for access.
• 11:11:2005
• Suture removal and prophy
• 06:12:2005
• Review surgery & Hygienist appointment
• 06:04:2006
• Review & Hygienist appointment
• 13:07:2006
• Review & Hygienist appointment, plan surgery for LR6 distal infrabony lesion
• Surgical treatment 2 • 19:07:2006
• Localised flap to LR6 three-walled defect
• Regenerative approach with BioOss & BioGIde
• 04:08:2006
• Suture removal and radiograph
• 24:08:2006
• Post –op review
• Next appointment:
• Hygienist appointment on 17:10:2006
Alan Woodman @ UPDA
3 case studies
• Case A
• Treatment history:
• Examination
• Initial treatment
• Secondary treatment
Alan Woodman @ UPDA
3 case studies
• Case A
Alan Woodman @ UPDA
3 case studies
• Case A
Alan Woodman @ UPDA
3 case studies
• Case A
• Secondary treatment
Alan Woodman @ UPDA
3 case studies • Case B
Alan Woodman @ UPDA
3 case studies • Case B
Alan Woodman @ UPDA
3 case studies • Case B
Alan Woodman @ UPDA
3 case studies • Case B
Alan Woodman @ UPDA
3 case studies
• Case B • Treatment history: • Examination 17:06:2005
• Initial treatment
• 27:07:2005
• Root instrumentation (LA)
• Metronidazole placement
• OHI + STB
• Occlusal analysis
• 03:08:2005
• Occlusal review and adjustment NWSI UR7:LR7
• Metronidazole placement
• Discussed surgery UL3
• Surgical treatment • 27:10:2005
• Localised surgery to Ul3
• Regenerative approach with BioOss & BioGide
• 08:11:2005
• Suture removal, radiograph and prophy
• 29:11:2005
• Post-op review
• Own practice hygienist support
• 19:04:2006
• Review and radiograph – for annual reviews in future
Alan Woodman @ UPDA
3 case studies
• Case B
Alan Woodman @ UPDA
3 case studies
• Case B
Alan Woodman @ UPDA
3 case studies
• Case B
Alan Woodman @ UPDA
3 case studies • Case C
Alan Woodman @ UPDA
3 case studies • Case C
Alan Woodman @ UPDA
3 case studies • Case C
Alan Woodman @ UPDA
3 case studies • Case C • Treatment history continued:
- 22:11:2005
- SURGICAL TREATMENT UR4 with BioOss and BioGide
- 02:12:2005
- Suture removal & radiograph
- 23:12:2006
- Post-op review
- 17:01:2006
- Review and hygienist appointment
- 19:04:2006
- Review and hygienist appointment, radiograph of UR4 site
Alan Woodman @ UPDA
3 case studies • Case C • Treatment history: • Examination 30:03:2005
• Initial treatment • 04:04:2005
• Root instrumentation (LA) Left • OHI + STB • Metronidazole placement • 11:04:2005 • Root instrumentation (LA) Right • Occlusal analysis • Metronidazole placement • 18:04:2005 • Metronidazole placement • Occlusal review and adjustment to LL7
and LR2
• Secondary treatment • 12:07:2005
• Hygienist appointment
• 17:10:2005
• Review and hygienist appointment
• Radiograph UR4 infection
- Metronidazole again x2
- 08:11:2005
- Review and plan surgery for localised infrabony / furcation lesion UR4
Alan Woodman @ UPDA
3 case studies
• Case C
Alan Woodman @ UPDA
3 case studies
• Case C
Alan Woodman @ UPDA
Have a good weekend!
Alan Woodman @ UPDA
A little bit more.....
PERIO - ENDO ? Or ENDO - PERIO ?
Getting to the Root
of the Problem
Alan Woodman @ UPDA
PERIO - ENDODONTIC INTERFACE
• Bacterial contamination
– Active plaque
– Residual toxins
• Anaerobic environment
• Difficult instrumentation
– Blind ; tactile
• Results difficult to assess
– Time ; radiographs ; clinical observation
Alan Woodman @ UPDA
Diagnosis • Acute apical periodontitis ?
• Acute lateral periodontitis ?
• Pressure
• Site
• Sinus tract
• Radiography
• History and symptoms
Alan Woodman @ UPDA
Aetiology • Caries subgingivally
• Lateral canals
• Accessory canals
• Root dentine instrumentation
• Root dentine exposure and subsequent infection
• Pulp death - cause or effect ?
• Loss of apical supporting tissue
Alan Woodman @ UPDA
Presentation • Upper molars
• Upper premolars
• Lower molars
• Single rooted teeth
• Are there other periodontally involved teeth ?
• Is there a periodontal history ?
• Is this an isolated lesion ?
Alan Woodman @ UPDA
Endodontic risk factors
• Sinus tract damage to periodontal ligament
• Excessive bone resorption in apical lesion
• Root fracture
• Root perforation
• Posts
• Overpreparation ?
• Overfilling ?
Alan Woodman @ UPDA
Vitality tests
• Tests on multi - rooted teeth are notoriously unreliable
• How many canals are non-vital ?
• Often one canal is hyper- reactive
• Misdiagnosis is easy, get a big bur out !
• Persuading referring practitioners to carry out endodontics can be frustrating
Alan Woodman @ UPDA
Treating Perio - Endo lesions
• Generalised Perio • Treat conventionally for CIPD
• Root surface debridement
• Sub-G OHI
• Antibiotic adjuncts
• Assess response
• Localised lesion • Endo investigation
– Endo treatment
– Reassess
• If vital – local RSD
– Reassess response
• ? Chemotherapeutics or Surgery ?
Alan Woodman @ UPDA
Treatment of advanced lesions
• Endo treatment prior to any planned surgical periodontal therapy
• Allow a period of review ; 3 - 4 months to assess residual bone support
• Surgical techniques – Root amputation or resection
– Hemisection
– Apicetomy
• Regeneration
• Extraction
• Implant placement
Alan Woodman @ UPDA
Have a good weekend!
Alan Woodman @ UPDA