Periodontics 2

U have been working in the clinic now for a semester. we were focus in the beginning in ur manual skills basically .but more important is clinical skills as clinicians not as technical work. Therefore, we should know what u r doing in the treatment? How we r do treatment? And, how we approach the treatment? It is true that some of u r already filling the forms ,but u really need to know what these form all about . u will start doing treatment plan ,as we say treatment plan is "the blue print" For case management. Blue print : we barrow that term from architects . when ever u do a design for building, factory or house u do what's called "blue print" because in older days before the new printing machines r available they used to print in ammonia paper and the color of the paper is blue . there fore, blue print means plan or scheme that how the treatment gonna to proceed. So, no treatment ever for any patient should be start before u establish a treatment plan , the treatment plan can change during that. but here we have to have certain guidelines we have to know how we r going? And, what we r doing? So, we should have what we call master plan for total treatment. master plan means major plan , some times we may have subdivisions of the treatment plan or different disciplines or certain steps that have been taken by other professionals, or the ones putting this treatment. It is very important to have coordination between all treatment procedures. For example : if the patient need perio , cons , root canal or probably some surgery .this has to be organize 1

or coordinated and very type treatment should be done on it is proper time and proper avenue. So , because we r not dealing with a tooth ,we dealing with full dentition in the mouth and this mouth for human being for a patient. Of coarse, we r talking a bout perio , but perio is not separated from other disciplines. Actually periodontology is the science that gather all dental disciplines, it is like foundation or like common ground for other dental procedures. So, we need to have successful dental treatment we should have a healthy periodontal environment. 1st thing we start with is the : 1-elimination of gingival inflammation and correction of the conditions that causes or perpetuates (means precipitates ) exaggerates or helps it. Now, what is the major causes gingivitis or periodontitis ? dental plaque, so just keep in mind that any thing that helps to develop , built ,retain dental plaque or make its removal difficult, correct it and u r in the right tract . 2-so, we need to eliminate root irritants. 3- Eliminate pockets or reduce them as much as can to give the patient the maximum that patient can brush or take care of . I'm not talking a bout CAL( the clinical attachment level ),I'm talking a bout probing depth, that should not exceed 3mm as much as possible cause these are the maximum the patient can clean , even if I have reduced periodontium .even if I have for example : CAL of 5 ,still I need maximum 3mm for probing . 4-i need to establish contours for the gingiva . 5-and, good relationship between the gingival and the mucosa in order to have harmony and reduce plaque retention and making cleaning very efficient. 2

6-restoration of caries,if the patient has caries. 7-we need to correct existing restoration. 8- we take in consideration occlusal relationships and understanding of occlusion is very important . 9- and then we have the supportive periodontal care.

The sequence of the treatment or therapeutic procedure is important . Foe example: I cant go from point A to point C with point B in the middle without passing point B .i cant go to point C and then come back to point B and then go back to point C. that’s not wise ,that’s not smart ,that’s not the right way to go things. Most important thing if the patient come screaming, shouting, in pain .OH, Dr: I couldn’t sleep last night OH, please. I don’t just leave pain. OH, look u have simple class І here and fissure sealant there, and the patient swelling, jumping ups and downs from pain. 1st thing if the patient come in pain I should elevate pain , mostly by elevate the cause . Remove the cause or at least start dealing with. So, 1st thing we should treat emergencies, most patients that couldn’t sleep the night before from pulpitis that’s the worse kind of pain, but also we have periodontal emergencies we will talk a bout them later like periodontal abscess or some suppuration or may be have acute infections or sometime gingival pain can be serious and severe. And also other emergencies like broken tooth with broken piece that moving around, chipped tooth or broker orthodontic wire 3

and irritating the patient .these r kind of emergencies that we should take care of it before any thing else. Now , we will start the phases of therapy ,and remember the sheet we fill we start with phase I.

Most important is; 1-plaque control ,and plaque control is achieved, how? Ans from the students:-brushing .Dr: we do brush for the patient. -scaling . Dr: we don’t jump to scaling - instruction . Dr: do u think instructions enough? -motivation (lastly!!) we make the patient motivated , interested ,egger, give him some zeal. We tell him the advantages of brushing, tell him consequence of not brushing, educate the patient, and make the patient come and do that willingly, then we threatened him .OK. 2- diet control, unfortunately, no body paying attention to it , they used to do that in the past ,but there is come back to that . Major source to plaque is food, plaque is group of bacteria need to eat. We supply the diet and nutrient for plaque through our diet . sometimes u see people with a lot of plaque , caries ,rampant caries.... and so on. We ask how do u eat? what do u eat ? ask about there eating habits. Some people take piece of sugar to bed so he can sleep, we know that’s wrong. This is kind of diet analysis. If the patient take much of purified sugar…and so on. 3-periodontal debridment: then we start do scaling and debridment (removal of debris).

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4- we correct restoration and prosthesis. Open cavity r consider from the 1st category, kind of emergency treatment , u should not leave open cavity, I should temporize it. I put temporary filling ,clean soft caries a little pit put temporary filling until finish my treatment. 5- Antimicrobial therapy: part of treatment if it needed patient has aggressive periodontitis she needed antimicrobial therapy that done with adjunction at the same time with debridment (mechanical treatment) . 6-occlusal therapy: then if we need occlusal correction , I should not do major correction . occlusion is the worst thing to play with never try to correct the occlusion for the patient for more than 1-2 slightly over erupted or premature contact . if you need major correction you need to refer the patient to an able prosthodontists who should do calibration of the patient after taking models , jaw registration , mount on kinetics or semikinetics articulator , then he can do the occlusal adjustment. because if he doesn't, he become like a story of the monkey with the 2 cats who stole the piece of cheese , they couldn’t divide it equally , so the monkey start eat from this from that until he finish both pieces and u know the story. And this what happened if you jump to occlsion therapy , you start trim from this part , from that until ruin the teeth .and I see cases that the dentition of the patient has been totally ruined that’s because of the lack of experience for the person who did it . 7- minor orthodontic movement: then if u need minor orthodontic movement can be carried as part of our treatment as well. 8- provisional splinting: u can do provisional splinting if we need it . 5

we don’t make provisional splinting (‫) تثبيت السنان‬routinely nowadays, in the past we used to think that mobility is some thing bad . provisional some thing temporary, splinting: means unite or joint teeth to gather . joint them with wire, bond it with composite . but we don’t make final splinting in this phase. You may want to extract the tooth later , but the patient cant go without a tooth for example , some times we extract the tooth , cut the root and put it back , fill it from the lower end of the tooth with composite .

After I finish phase 1 , we bring the patient back and we evaluate what have been done ,is it enough or not , we recheck : 1- pocket depth again. 2- we look for gingival inflammation and we see gingival index , plaque index and so on……. To see the patient doing his job or not , if not we have to repeat and keep after the patient , and I should not proceed to more advance treatment or more sophisticated treatment if this phase is not fully achieved .

Then phase 2 ,its more serious. for example if the problem persist , I couldn’t eliminate the pocket or some of the pockets, or there are other indication, because we will talk about periodontal surgery later

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1- periodontal surgery at this phase. 2-including implants , the first part we mean surgical part of the implant not the prosthesis. 3- and we finish the root canal therapy . we start the emergency root canal treatment in the first phase , we exacerbate the pulp , put non setting calcium hydroxide and then temporize it until we come to this phase . at this phase we will do the major treatment , then we go to phase 3.

and we reevaluate phase 2 before we go to phase 3 , especially if I do crown and bridges work ( fixed prosthesis) because after surgery patient need time to heal, the mobility become less and so on, so we do the prosthesis as well .

we do the final restoration. For example: If I had root canal, put the final restoration . if I had temporary fillings , I remove them put final restorations and we make crowns and bridges work and prosthesis.

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Now, how to evaluate the response to the restorative procedures. you see we have sheets called recall sheet , I need every time I see the patient to take certain landmarks and write it down because I will forget with time . I see patient I have been treated them for 10 years how could I remember how she or he was ? So if I have good record , then we can look how this patient coming up , and its also called(maintance phase) . we cant drive car forever , for example without maintaining the car even, if its in good shape , if you check the oil and so on, you are not fixing broken car or you r maintaining the car in good condition . So we assume by phase 3 we finish the treatment then we have to put the patient in (maintance phase)which is phase IV . and then I cant leave the patient just go . We start with every month recall interval , if the patient doing fine we extend them for 4-5 months or even 6 months but we shouldn’t extend it for more than 1 year . Some periodontal patients we see them once a year and that’s enough for them . Now, the 1st 3 months like experiment time , testing period for this patient or the performance of this patient .and we keep after the plaque and calculus ,we keep after the gingival condition . Check the occlusion and other pathological changes. And the most important thing every time, keep it in ur mind, always ,always ,always…∞ recheck the medical history because people don’t stay healthy for ever. Some time u have good loyal patient that stick with u for 10,15 or 20 years during that patient may get married ,have children , get sick, get certain disease .so every time recheck the medical history again. 8

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Now, why we do all of this ??? we talk about periodontal therapy, what is rationale behind periodontal therapy??? unfortunately what most people remember about dentistry is pain .that’s why so many people don’t go to dentist unless they are in pain, that sever and in an excruciated pain(‫ )ألم قوي وموجع‬. 1- Elimination of pain , we need to eliminate pain that part of our treatment ,that’s good rationale , that’s good reason , that’s good excuse . 2- Eliminate gingival inflammation . 3- Eliminate gingival bleeding ,some people complain from bleeding when they eating an apple for example . and gingival bleeding might be something more serious we have to look for reason for this bleeding . last month I had a patient that came with something like (…….,fill the blank) granuloma but it turn to be CA( squamous cell carcinoma) life threatening disease. 4- Eliminate infection . 5- Reduce periodontal pocket. 6- Reduce periodontal mobility ,we need to reduce it, because mobility bothers the patient , patients complain about mobility. 7- Prevent recurrence : also we prevent recurrence, it is not important only to treat periodontal disease, it is important to keep it away. as well periodontal disease is not curable, unfortunately you don’t get rid of it totally , once the patient has periodontitis he is a periodotitis patient .once patient has diabetes, he is diabetic patient.

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Now, if he doesn’t take care of himself that’s uncontrolled so the disease gets worse, if its controlled more or less not totally he can live normal life. If he doesn’t eat this or that he will be fine . periodontitis the major thing he has to stay with us under strict care in order to prevent the recurrence of disease, and as we know its infectious disease, so we need to eliminate and prevent reinfection . ‫بحذر‬ 8- Eliminate suppuration. 9- Arrest destruction of bone and reduce bone loss. 10- Reduce tooth loss: our major goal as periodontist is to keep and maintain the dentition. The major task or the biggest challenge for periodontist is not to extract, but the major task of oral surgeon is how to pull a tooth ,for us how not to let that guy not to use his forceps .that's the conflict of interest. 11-esthetics :the major rationale for perio treatment is to have healthy dentition , esthetics is very important nowadays is the first goal of dentistry and its quality of life, make patient comfortable . medicine today the change of medicine nowadays is the quality of life not the life. (‫) رب عيش أهون منه الموت الزؤام‬ you don’t understand the important of teeth until you start losing them .

Local therapy depends on removal of plaque or/and all factors that favor its accumulation as we said earlier. And keep in mind that’s plaque is a biofilm and the best way to get rid of

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its by mechanical removal, mechanically disturb them because they are at least (1000*100) more resistance to antibiotics. And as we know also that’s part of normal flora they live with us all the time , if you give antibiotics then the inflammation go away for a week then its come back . and this is the worst thing the dentist to do outside is patient with gingivitis they prescribe antibiotics and strong antibiotics and say ok. When the inflammation subside come back and then I clean your teeth this is stupid, ridiculous and unaccepted . The best way we give antibiotics only when they are needed. and they are not needed that much . so we should remove all the plaque and all the factor that favor its accumulation its our primary consideration . Plaque, keep in mind, remove plaque then you will have a healthy gingiva.

We give Systemic therapy as well we describe medications but we describe them for a reason ,and should be a strong reason and not for gingivitis . They adjunct means complimentary and not the major. Our major method of treatment is the mechanical , primary is the mechanical debridment. That’s why I would like you to master your hand instruments I know its easier to use ultrasonic . in past we used to allow it, the only reason to allow is the short time you have , just to help you): if you want to learn , you should learn to master the curette and the scaler. you become the best clinician not only in perio but also in other discipline. because perio treatment depend highly on tactile sensation not only visualization but also

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tactile sensation. And that’s what distinguish between skilled dentist from poor dentist at the end of the day. We should make dentistry pleasant not as punishment for the patients. That’s how we bring them back. So ,what we use to describe : 1- NSAIDs :they are not of researches, the major reason we use them to reduce inflammation especially after surgery or trauma , there are strong evidence that they slow gingivitis and bone loss as well . 2- We give antibiotics they are required for some periodontal disease not every disease. we give them only when we need them. we give them only as adjunct to mechanical debridment, especially in case of aggressive periodontitis. Because we need to attack the pathogens that cause massive destructions from within the pocket and from within the body , because some of these pathogens are already penetrate deeper in the tissue, and you cant eliminate them mechanically, so we attack them simultaneously. we don’t do scaling then give antibiotics or give antibiotics and do scaling later .I should do them together , I should do the root planning deep work under antibiotics cover . so I insure that I have eliminated the bad bacteria such as p.gingivalis, AA.

Now , after periodontal therapy expect healing and there many factors that affect healing that include local and systemic factors now local factors are :

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1- excessive trauma in tissues during treatment : the most important factor we focus on is trauma because the less traumatize your patient the less pain you have . we have patients we do surgery for them and they didn’t Take one tablet of acetaminophen or panadol , no postoperative pain what so ever. The gentler you are with your work the better the outcome, the less the trauma, the less pain and the faster the healing. That’s why we keep saying perio is the difficult-easy (‫السهل‬ ‫)الممتنع‬ that’s the difference between surgery and us they are tuff , they have to cut bone use chisel and hummer, but we use a tiny instrument and we should use them carefully.

There are factors that’s will interfere with healing for example, the ability for healing diminish by : 1- Infection: our body is stressed specially if the infection is local, for example : in the presence of pus, inflammation, infection and you do surgery, dirty wound will not healed like clean wound . Even if there is systemic infection somewhere else ,it will interfere with bad healing . 2-It is less in patients also who are diabetic .we know that healing ability and liability of infection .The healing ability comes down and the liability comes up and you know they are liable to infection ,so more than nondiabetic patients .

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3-Healing retarded by insufficient food and nutrients. Diet is the elements of building of tissue . Tissue needs to rebuilt it, and most of tissues are made of collagens (protein). So we needs good protein diet, we need minor dietary elements, like vitamins that help in establishment the healing. Good diet with highly protein and good vitamins specially vitamin C because of hydroxylation of collagen . 4-Also, it affected by hormones :as diabetes like insulin ,but other hormones like female hormones ,it affect healing . if estrogen is high, healing will impaired. As well if pregnant female specially in the middle trimester will not heal as good as female after delivery because progesterone level will render the tissue more liable to infection and inflammation .

Now, we talk about new concept in healing which is regeneration .This means growth and differentiation of new cell and intercellular substances to form new tissue or parts. That’s mean we replace the missing part or the destroyed part with new part with the same composition . exactly the same. to regenerate something , to create this thing again. Genesis means creation from here comes regeneration . Growth from the same type of tissue and as should here continuous physiological process from periodontium ,and removal of plaque enable the patient to benefit from inherent regenerative capacity of the tissue . Now , When we are doing scaling and root planning treatment, You remove something called granulation tissue, granulation tissue : it’s the tissue that died in

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trial to repair itself. So it’s the wrong tissue , by removing this tissue u refresh this area, eliminate the plaque ,we give the body the chance to regenerate itself with good type of tissue , the removal of plaque enable patient to try to regenerate .

Unfortunately, most of healing as see is by repair , not by regeneration ,you should take this material in pathology as squeal of inflammation ,the body heals itself by regeneration or by repair . Here we restore the continuity of diseased marginal gingiva and we re-establish the normal marginal sulcus at the same level on root . but we are healing here by scar . Assume you have cut in your skin, if it regenerates totally you will have skin as if it new . But unfortunately ,what happened the wound is closed , that’s what we mean by continuity but you have a mark that’s scar tissue .That’s repair, that’s not the same tissue but you are stored the function . Skin is there ,its continuous but its not the same . Again the same here in gingiva . We arrest bone destruction without increase more height . its another problem we face it in perio , crestal bone ,you look on the radiograph you see that bone level has been decreased , our major hope to stop bone loss at that level . we cannot re-grow bone to crest of the ridge. Its terminal bone, few animals can do that like ( ‫سلمندر‬, (‫ أبو بريص‬is the only animal that can replace leg. For example; ‫ سلمندر‬is in between lizards and snakes may be.

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U write something called CAL (clinical attachment level)not loss .which measures the loss, if you have CAL of 5 we have lost 5mm,but if CAL is 0 , we have CAL its equal 0 it where it should be ,but we don’t have loss. Then you have new attachment that’s means you have new PDL fiber into new cementum ,new sharpees fiber and new gingival epithelium to a tooth surface ,and every thing is new. Is regenerated . Its delusive goal we try to achieve it, but its not fully achievable so far. "from word document" . Dr says it’s the same but there is more details on it .

1- We need to take personal data including medical history (MH) and again I cannot overemphasize on the importance of medical history .The most important thing in your sheet . 2-Examination and charting .its what you do . 3- Diagnosis. 4-Prognosis is base on your diagnosis you give your prognosis ,prognosis is the outcome of disease ,the patient will ask you and you have to know how to answer. Then base on that all what you did so far you do your treatment plane .

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So prognosis : actually is prediction of the course and termination of the disease and its response of treatment . Never ever brag , never ever make your patient over confidence. If you sure about 80%that this tooth save for example, give him 70% because you don’t know what will happen in the course ,and you should give your patient the condition that in which you built your assumptions, but if you don’t do the treatment you definitely lose this tooth , but if you do treatment we have the chance to do so and so .base on what you learn and base on your experience .sometime there is reason ,sometime the patient doesn’t aware in what he/she has, you assume that patient healthy and the patient is not for example . So prognosis is determined after the diagnosis and before the treatment plane ,because the prognosis will guides u through your treatment plane , and prognosis is often confuse with the term risk . Risk generally referred to probability of acquiring the disease before its start ,but prognosis we r predicting the outcome of a disease that already there. So if u smoker u r at risk of cancer ,the prognosis is if you get cancer is you goanna to die ‫ ) )ل سمح ال‬of lung cancer if you keep smoking . Many time ,the risk factors and the prognosis factors are the same ,they interfere like in case of diabetes . the diabetes is risk factor for perio-disease ,but again it interferes with prognosis as well . We have to know that there : 1-prognosis of gingival disease. 2- prognosis of periodontal disease . and we have:

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1- overall prognosis .and 2- prognosis for individual or single tooth . Now, we do treatment plan . treatment plan r very important ,but it is not holy ,it can be modified during the course of treatment , but u should not start without it. Now, extraction of hopeless tooth , provisional replacement treatment part of phase 1 sometime . patients have very hopeless teeth ,you extract then you cement it back or make RPD temporary ,so the patient will not embarrassed specially if the patient with high profile nature. like teacher. Dr.says: he had a patient who is teacher and young, somebody made for him implant , and the implant is failed and he treat him for implant failure . The tooth is central incisor . can I send this guy to school without central incisor? no way , because the kids may make fun of him , you know kids are evil some of you are I ask the prosthodontics to make temporary or immediate partial denture. So we remove the implant ,raise a flap ,remove all necrotic tissue and do bony graft ,we close it with suture ,and the patient psychologically is at ease .

THE END ‫شكر خاص وحار وجزيل لخواتي أيسر طشطوش ودعاء العودات و رانية‬ ‫ لجهودهم الجبارة في كتابة هذه المحاضرة) جزاكم ال خيرا‬.‫)البصول‬.

Done by: AMAL ABU OMAR.

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