Periodontics Lesson 6 PDF

Periodontics T 6- PERIODONTICS INTRODUCTION TO DENTISTRY ODONTOLOGY Agustina Muñoz Rodríguez Periodontics is the dental specialty focusing exclusively in the inflammatory disease that destroys the gums and other supporting structures around the teeth. Periodontology or periodontics is the specialty...

Periodontics T 6- PERIODONTICS INTRODUCTION TO DENTISTRY ODONTOLOGY Agustina Muñoz Rodríguez Periodontics is the dental specialty focusing exclusively in the inflammatory disease that destroys the gums and other supporting structures around the teeth. Periodontology or periodontics is the specialty of dentistry that studies supporting structures of teeth, as well as diseases and conditions that affect them. The supporting tissues are known as the periodontium, which includes the gingiva (gums), alveolar bone, cementum, and the periodontal ligament. Periodontics Introduction 2  Diagram of the periodontium. The Periodontium A. Enamel B. Dentine The term periodontium C. Alveolar bone is used to describe the D. Oral epithelium group of structures that E. Attached gingiva directly surround, F. Gingival margin support and protect the G. Gingival sulcus teeth. H. Junctional epithelium The periodontium is I. Alveolar crest fibres of composed largely of periodontal ligament [PDL] the gingival tissue and J. Horizontal fibres of PDL K. Oblique fibres of PDL the supporting bone. Periodontics Introduction 3 The Periodontium Periodontics Introduction 4 Gingiva Ø Normal gingiva may range in color from light coral pink to heavily pigmented. Ø The gingivae are categorised into three anatomical groups; the free, attached and the interdental gingiva. Ø Each of the gingival groups are considered biologically different; however, they are all specifically designed to help protect against mechanical and bacterial destruction. Periodontics Introduction 5 Gingiva Periodontics Introduction 6 Gingiva: free gingiva Ø The tissues that sit above the alveolar bone crest are considered the free gingiva. Ø In healthy periodontium, the gingival margin is the fibrous tissue that encompasses the cemento-enamel junction, a line around the circumference of the tooth where the enamel surface of the crown meets the outer cementum layer of the root. Ø A natural space called the gingival sulcus lies apically to the gingival margin, between the tooth and the free gingiva. A non-diseased, healthy gingival sulcus is typically 0.5-3 mm in depth, however, this measurement can increase in the presence of periodontal disease. The gingival sulcus is lined by a non-keratinised layer called the oral sulcular epithelium; it begins at the gingival margin and ends at the base of the sulcus where the junctional epithelium and attached gingiva begins. Periodontics Introduction 7  Gingiva: attached gingiva Ø The junctional epithelium is a collar-like band that lies at the base of the gingival sulcus and surround the tooth; it demarcates the areas of separation between the free and attached gingiva. Ø The junctional epithelium provides a specialised protective barrier to microorganisms residing around the gingival sulcus. Ø Collagen fibres bind the attached gingiva tightly to the underlying periodontium including the cementum and alveolar bone and varies in length and width, depending on the location in the oral cavity and on the individual. Ø The attached gingiva lies between the free gingival line or groove and the mucogingival junction. Ø The attached gingiva dissipates functional and masticatory stresses placed on the gingival tissues during common activities such as mastication, tooth brushing and speaking. Ø In health it is typically pale pink or coral pink in colour and may present with surface stippling or racial pigmentation. Periodontics Introduction 8 Gingiva: interdental gingiva Ø The interdental gingiva takes up the space beneath a tooth contact point, between two adjacent teeth. Ø It is normally triangular or pyramidal in shape and is formed by two interdental papillae (lingual and facial). Ø The middle or centre part of the interdental papilla is made up of attached gingiva, whereas the borders and tip are formed by the free gingiva. Ø The central point between the interdental papillae is called the col. It is a valley- like or concave depression that lies directly beneath the contact point, between the facial and lingual papilla. However, the col may be absent if there is gingival recession or if the teeth are not contacting. Ø The main purpose of the interdental gingiva is to prevent food impaction during routine mastication. Periodontics Introduction 9 10 Alveolar mucosa Ø This area of tissue is non keratinized and is located beyond the mucogingival junction. Ø It is less firmly attached and is redder than attached gingiva. It provides for the movement of cheek and lips. Periodontics Introduction 11 Periodontal ligament Ø The periodontal ligament is the connective tissue that joins the outer layer of the tooth root, being the cementum, to the surrounding alveolar bone. Ø It is composed of several complex fibre groups that run in different directions and which insert into the cementum and bone via ‘Sharpey’s fibres’. Ø The periodontal ligament is composed mostly of collagen fibres, however it also houses blood vessels and nerves within loose connective tissue. Ø Mechanical loads that are placed on the teeth during mastication and other external forces are absorbed by the periodontal ligament, which therefore protects the teeth within their sockets. Periodontics Introduction 12 Alveolar bone Ø In periodontal health, the alveolar bone surrounds the teeth and forms the bony socket that supports each tooth. Ø The buccal and lingual plates and lining of the sockets are composed of thin, yet dense compact or cortical bone. Ø Within the cortical plates and dental sockets lies cancellous bone, a spongy or trabecular type bone which is less dense than compact bone. Periodontics Introduction 13 Cementum Ø Cementum is the outer layer of the tooth root; it overlies the dentine layer of the tooth and provides attachment for the collagen fibres of the periodontal ligament. Ø It also protects the dentine and provides a seal for the otherwise exposed ends of the dentinal tubules. Ø It is not as hard as enamel or dentine and is typically a light yellow colour. Periodontics Introduction 14 Periodontal Pathologies v Gingival diseases v Periodontal diseases Periodontics Introduction 15 Periodontal pathologies: Gingival diseases Ø Gingivitis is a common condition that affects the gingiva or mucosal tissues that surround the teeth. Ø The condition is a form of periodontal disease; however, it is the least devastating, in that it does not involve irreversible damage or changes to the periodontium (gingiva, periodontal ligament, cementum or alveolar bone). Ø It is commonly detected by patients when gingival bleeding occurs spontaneously during brushing or eating. Ø It is also characterised by generalised inflammation, swelling, and redness of the mucosal tissues. Periodontics Introduction 16  Periodontal pathologies: Gingival diseases Ø Gingivitis is typically painless and is most commonly a result of plaque biofilm accumulation, in association with reduced or poor oral hygiene. Ø Other factors may increase a person's risk of gingivitis, including but not limited to systemic conditions such as uncontrolled diabetes mellitus and some medications. Ø The signs and symptoms of gingivitis can be reversed through improved oral hygiene measures and increase plaque disruption. Ø If left untreated, gingivitis has the potential to progress to periodontitis and other related diseases that are more detrimental to periodontal and general health. Periodontics Introduction 17 Periodontal pathologies: Gingival diseases Bacterial plaque:“Accumulation of microorganisms and detritus intercellular surrounded by an array to join the surface of teeth and may not removed with water jet” Dental plaque is also known as microbial plaque, oral biofilm, dental biofilm, dental plaque biofilm or bacterial plaque biofilm. Plaque is a soft, sticky film that builds up on your teeth and contains millions of bacteria. The bacteria in plaque cause tooth decay and gum disease if they are not removed regularly through brushing and flossing. Dental plaque is a biofilm of microorganisms (mostly bacteria, but also fungi) that grows on surfaces within the mouth. It is a sticky colorless deposit at first, but when it forms tartar, it is often brown or pale yellow. Periodontics Introduction 18  Periodontal pathologies: Periodontal diseases Ø Encompasses a number of diseases of the periodontal tissues that result in attachment loss and destruction of alveolar bone. Ø Periodontal diseases take on many different forms but are usually a result of a coalescence of bacterial plaque biofilm accumulation of the red complex bacteria (e.g., P. gingivalis, T. forsythia, and T. denticola) of the gingiva and teeth, combined with host immuno-inflammatory mechanisms and other risk factors that can lead to destruction of the supporting bone around natural teeth. Ø Untreated, these diseases can lead to alveolar bone loss and tooth loss. Ø Periodontal disease is the second most common cause of tooth loss (second to dental caries). Ø Twice daily brushing and flossing are a way to help prevent periodontal diseases. Periodontics Introduction 19 Periodontal pathologies: Periodontal diseases Healthy gingiva can be described as stippled, pale or coral pink in Caucasian people, with various degrees of pigmentation in other races. Ø The gingival margin is located at the cemento-enamel junction without the presence of pathology. Ø The gingival pocket between the tooth and the gingival should be no deeper than 1-3mm to be considered healthy. Ø There is also the absence of bleeding on gentle probing. Periodontics Introduction 20 Periodontal pathologies: Periodontal diseases Periodontal diseases can be caused by a variety of factors, the most prominent being dental plaque. Ø Dental plaque forms a bacterial biofilm on the tooth surface, if not adequately removed from the tooth surface in close proximity to the gingiva a host-microbial interaction gets underway. This results in the imbalance between host and bacterial factors which can in turn result in a change from health to disease. Ø Other local and/or systemic factors can result or further progress the manifestation of periodontal disease. Ø Other factors can include age, socio-economic status, oral hygiene education and diet. Ø Systemic factors may include uncontrolled diabetes or tobacco smoking. Periodontics Introduction 21  PERIODONTITIS FACTORS 1. HERITAGE 2. HOST FACTORS 3. HYGIENE 4. HARMFUL HABITS Periodontal pathologies: Periodontal diseases 5. TOOTH MALPOSITIONS 6. TOBACCO Individual risk factors include: Gender, smoking and alcohol consumption, diabetes, obesity and metabolic syndrome, osteoporosis and Vitamin D conditions, stress and genetic factors. Signs and symptoms of periodontal disease: bleeding gums, gingival recession, halitosis (bad breath), mobile teeth, ill fitting dentures and build up of plaque and calculus. Periodontics Introduction 22 Periodontal pathologies: Periodontal diseases The American Academy of Periodontology (AAP) reworked the existing classification of periodontal diseases from 1989 to alter the weaknesses present. The old classification placed too much emphasis on the age of disease onset and rate of progression, which are often difficult to determine. I. Gingival Diseases A. Dental plaque-induced gingival diseases B. Non-plaque-induced gingival lesions Periodontics Introduction 23 Periodontal pathologies: Periodontal diseases II. Chronic Periodontitis (slight: 1–2 mm CAL; moderate: 3–4 mm CAL; severe: > 5 mm CAL) A. Localised B. Generalised (> 30% of sites are involved) III. Aggressive Periodontitis (slight: 1–2 mm CAL; moderate: 3–4 mm CAL; severe: > 5 mm CAL) A. Localised B. Generalised (> 30% of sites are involved) Periodontics Introduction 24 Periodontal pathologies: Periodontal diseases IV. Periodontitis as a Manifestation of V. Necrotizing Periodontal Diseases Systemic Diseases A. Necrotizing ulcerative gingivitis A. Associated with haematological disorders B. Necrotizing ulcerative periodontitis B. Associated with genetic disorders VI. Abscesses of the Periodontium C. Not otherwise specified A. Gingival abscess B. Periodontal abscess C. Pericoronal abscess Periodontics Introduction 25 Periodontal pathologies: Periodontal diseases VII. Periodontitis Associated With Endodontic Lesions A. Combined periodontic-endodontic lesions VIII. Developmental or Acquired Deformities and Conditions A. Localised tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis B. Mucogingival deformities and conditions around teeth C. Mucogingival deformities and conditions on edentulous ridges D. Occlusal trauma Periodontics Introduction 26 Periodontal pathologies: Periodontal diseases In 2018 a new classification of periodontal disease was announced. It was determined that the previous AAP 1999 classification did not cater for the needs of patients with peri-implant diseases and conditions. The new classification of periodontal and peri- implant diseases and conditions is as follows. Periodontal Health, Gingival Diseases and Conditions: Periodontal Health and Gingival Health Gingivitis: Dental-Biofilm Induced Gingival Diseases: Non-Dental Biofilm-Induced Periodontitis: Necrotizing Periodontal Diseases Periodontitis Periodontitis as a Manifestation of Systemic Disease Periodontics Introduction 27 Periodontal pathologies: Periodontal diseases Other Conditions Affecting The Periodontium: Systemic Diseases or conditions affecting the periodontal supporting tissues Periodontal Abscesses and Endodontic-Periodontal Lesions Mucogingival Deformities and Conditions Traumatic Occlusal Forces Tooth and Prosthesis Related Factors Peri-Implant Diseases and Conditions: Peri-Implant Health Peri-Implant Mucositis Peri-Implantitis Peri-Implant Soft and Hard Tissue Deficiencies. Periodontics Introduction 28 Periodontal pathologies: Periodontal diseases Periodontics Introduction 29 Periodontal pathologies: Periodontal diseases Prevention: The most effective prevention method is what can be achieved by the patient at home, for example, using the correct tooth brushing technique, interdental cleaning aids such as interdental brushes or floss and using a fluoridated toothpaste. It is also advised that patients receive bi annual check ups from their dental health provider along with thorough cleaning. Periodontics Introduction 30 Periodontal pathologies: Periodontal diseases Treatment: Along with specialist periodontist treatment, a general dentist or oral health therapist/dental hygienist can perform routine scale and cleans using either hand instruments or an ultrasonic scaler (or a combination of both). The practitioner can also prescribe specialised plaque removal techniques (tooth brushing, interdental cleaning). The practitioner can also perform a plaque index to indicate to the patient areas of plaque they are not removing on their own. This can be removed through the procedure of a dental prophylaxis. Periodontics Introduction 31 Periodontal pathologies: Periodontal diseases, PERIIMPLANTITIS Periodontology also involves the placement and maintenance of dental implants, including the treatment of peri-implantitis (inflammatory bone loss around dental implants). The etiology of peri-implantitis is thought to be very similar to periodontal disease. Periodontics Introduction 32 Periodontal diagnosis Periodontitis and associated conditions are recognised as a wide range of inflammatory diseases that have unique symptoms and varying consequences. In order to identify disease, classification systems have been used to categorise periodontal and gingival diseases based on their severity, aetiology and treatments. Having a system of classification is necessary to enable dental professionals to give a label to a patient's condition and make a periodontal diagnosis. A diagnosis is reached by firstly undertaking thorough examination of the patient's medical, dental and social histories, to note any predisposing risk factors (see above) or underlying systemic conditions. Then, this is combined with findings from a thorough intra and extra oral examination. Indices such as periodontal screening record (PSR) and the Community Periodontal Index of Treatment Needs (CPITN) are also used in making a diagnosis and to order or classify the severity of disease. Periodontics Introduction 33 Periodontal diagnosis Periodontics Introduction 34 Periodontal diagnosis If disease is identified through this process, then a full periodontal analysis is performed, often by dental hygienists, oral health therapists or specialist periodontists. This involves full mouth periodontal probing and taking measurements of pocket depths, clinical attachment loss and recession. Along with this other relevant parameters such as plaque, bleeding, furcation involvement and mobility are measured to gain an overall understanding of the level of disease. Radiographs may also be performed to assess alveolar bone levels and levels of destruction. Periodontics Introduction 35 Periodontal diagnosis 1. Visual inspection 2. Periodontal exploration 3. Radiological study – Periapical series – Ortopantomografía 4. Others – Microbiological study Periodontics Introduction 36 Periodontal treatment Phases of Periodontal Therapy Contemporary periodontal treatment is designed based on the ‘Trimeric Model’, and is performed in 4 phases. These phases are structured to ensure that periodontal therapy is conducted in a logical sequence, consequently improving the prognosis of the patient, in comparison to indecisive treatment plan without a clear goal. Phase I Therapy (Initial Therapy - Disease Control Phase) Non-surgical Phase The non-surgical phase is the initial phase in the sequence of procedures required for periodontal treatment. This phase aims to reduce and eliminate any gingival inflammation by removing dental plaque, calculus (dental), restoration of tooth decay and correction of defective restoration as these all contribute to gingival inflammation, also known as gingivitis. Periodontics Introduction 37 Periodontal treatment Phases of Periodontal Therapy Phase I Therapy (Initial Therapy - Disease Control Phase) Phase I consists of treatment of emergencies, antimicrobial therapy, diet control, patient education and motivation, correction of iatrogenic factors, deep caries, hopeless teeth, preliminary scaling, temporary splinting, occlusal adjustment, minor orthodontic tooth movement and debridement (dental). Periodontics Introduction 38 Periodontal treatment Re-evaluation Phase During this phase, patients after 3–6 weeks from initial therapy; it is required to re- evaluate the steps carried out after the phase I therapy. Usually 3–6 weeks re-evaluation is crucial in severe cases of periodontal disease. The elements which are required to be re-evaluated are the results of initial therapy (Phase I Therapy), oral hygiene and status, bleeding and plaque scores and a review of diagnosis and prognosis and modification of the whole treatment plan if necessary. Periodontics Introduction 39 Periodontal treatment Phase II Therapy (Surgical Phase) After post Phase I, it is necessary to evaluate the requirement of periodontium for surgery. Factors identifying the Surgical phase is required are: periodontal pocket management in specific situations, irregular bony contours or deep craters, areas of suspected incomplete removal of local deposits, degree II and III furcation involvements, distal areas of last molars with expected mucogingival junction problems, persistent inflammation, root coverage and removal of gingival enlargement. Phase III Therapy (Restorative Phase) During this phase, any defects need to be restored with removable or fixed through dental prosthesis, prosthodontics, or other restoration process. Periodontics Introduction 40 Periodontal treatment Phase IV Therapy (Maintenance Phase) The last phase of Periodontal Therapy requires the preservation of periodontal health. In this phase, patients are required to re-visit through a scheduled plan for maintenance care to prevent any re-occurrence of the disease.The maintenance phase constitutes the long-term success for periodontal treatment, thus contributes to a long relation between the oral health therapist/dentist/periodontist and the patient. Periodontics Introduction 41 Periodontal treatment Periodontal and Restorative Interface The prognosis of the restorative treatment is determined by the periodontal health. The goals for establishing periodontal health prior to restorative treatment are as follows: 1.Periodontal treatment should be managed to assure the establishment of firm gingival margin prior to tooth preparation for restoration. Absence of bleeding tissue during restorative manipulation provides accessibility and aesthetic outcome. 2.Certain periodontal treatment is formulated to increase sufficient tooth length for retention. Failure to accomplish these methods prior restorations can lead to the complexity or risk of failure of treatment such as impression making, tooth preparation and restoration. 3.Periodontal therapy should follow restorative method as the resolution of gingival inflammation may result in the repositioning of teeth or in soft tissue and mucosal changes. Periodontics Introduction 42 Periodontal treatment Standard of Periodontal Treatment Non-surgical therapy is the golden standard of periodontal therapy which consists of debridement (dental) with a combination of oral hygiene instructions and patient motivation. It mainly focuses on the elimination and reduction of pathogens and shifting the microbial flora to a favourable environment to stabilise periodontal disease. Debridement (dental) is thorough mechanical removal of calculus and dental biofilm from the root surfaces of the tooth. It is the basis of treatment for inflammatory periodontal diseases and remains the golden standard for surgical and non-surgical treatment in the initial therapy. It is conducted by hand instrumentation such as curettes or scalers and ultrasonic instrumentation. It requires a few appointments, depending on time and clinician skills for effective removal of supragingival and subgingival calculus (dental), when periodontal pocket is involved. It can assist in periodontal healing and reduce periodontal pocketing by changing the subgingival ecological environment. Periodontics Introduction 43 Periodontal treatment Prevention of periodontal disease and maintenance of the periodontal tissues following initial treatment requires on the patient's ability to perform and maintain effective dental plaque removal. This requires patient to be motivated in improving their oral hygiene and requires behaviour change in terms of tooth brushing, interdental cleaning, and other oral hygiene techniques. Personal oral hygiene is often the considered an essential aspect of controlling chronic periodontitis Research has shown that it is important to appreciate the motivation of the patient behaviour changes that has originated from the patient. Patients must want to improve their oral hygiene and feel confident that they have the skills to do this. It is crucial for the clinician to encourage patient changes and to educate the patient appropriately. Motivational interviewing is a good technique to ask open-ended questions and express empathy towards the patient. Periodontics Introduction 44 Periodontal maintenance After periodontal treatment, whether it be surgical or non-surgical, maintenance periodontal therapy is essential for a long term result and stabilization of periodontal disease. There is also a difference in the maintenance of different types of periodontal disease, as there are different types, such as: Gingivitis The reversible inflammation of the gums, is easily maintained and easily done by patients alone. After the removal of the inflammatory product, usually plaque or calculus, this allows the gums room to heal. This is done by patients thoroughly cleaning teeth every day with a soft bristle toothbrush and an interdental aid. This can be floss, flosset, pikster or what is preferred by patient. Without patient compliance and constant removal of plaque and calculus, gingivitis cannot be treated completely and can progress in to periodontitis that is irreversible. Periodontics Introduction 45 Periodontal maintenance Necrotising ulcerative gingivitis (NUG) Also Acute necrotising ulcerative gingivitis and necrotising ulcerative periodontitis, a type of periodontal disease, different than many other periodontal diseases, clinical characteristics of, gingival necrosis (break down of the gums), gingival pain, bleeding, and halitosis (bad breath), also has a grey colour to the gingiva and a punched out appearance. It is treated through debridement usually under local aesthetic due to immense pain. To maintain and treat the condition completely, a Chlorhexidine mouth wash should be recommended to the patient to use twice daily, oral health instruction should be provided, using a soft bristle toothbrush twice a day or an electric toothbrush and an interdental cleaning aid, such as floss or piksters which cleans the areas that the toothbrush cannot reach. Periodontics Introduction 46 Periodontal maintenance Necrotising ulcerative gingivitis (NUG) Ø Patient should also be educated on proper nutrition and diet, and also healthy fluid intake, also to complete cease disease smoking cessation should be done not just to completely eradicate disease but also for health od patient. Ø Pain control can be done through ibuprofen or Panadol. Ø In the case of an immunocompromised patient antibiotics should be prescribed. Ø Assessment of treatment should be done after 24 hours of treatment and continued to do so every 3–6 months until signs and symptoms are resolved and gingival health and function restored. Periodontics Introduction 47 Periodontal maintenance Chronic periodontitis Ø The inflammation of the gums and irreversible destruction of the alveolar bone and surrounding structures of the teeth, usually slow progressing but can have bursts. Ø Local factors explain presence of disease, such as, diet, lack of oral hygiene, plaque accumulation, smoking etc. Ø Characterised by pocket formation and recession (shrinkage of the gums) of the gingiva. Ø Treatment and maintenance are important in stopping disease progression and to resolve the inflammation, treatment usually consist of scaling and root planning, surgical therapy, regenerative surgical therapy. Periodontics Introduction 48 Periodontal maintenance Chronic periodontitis Ø After treatment, patient care and regular maintenance check ups are important to completely eradicate disease and present reappearance of the disease. Ø This is done through patient effective plaque control and removal, done through daily toothbrushing of twice a day and interdental cleaning once a day, chlorhexidine mouthwash can also be effective. Ø Patient should also present to dentist for maintenance check ups at least every three-months for in office check-up and if necessary, plaque control. Periodontics Introduction 49 Periodontal maintenance Aggressive periodontitis Ø Involves inflammation of the gingiva and rapid and severe destruction of the periodontal ligament, alveolar bone and surrounding structures, different to chronic periodontitis often happens in patients with good oral health and plaque control and can be genetic. Ø Patients generally appear clinically healthy. Ø It can be localised, which generally has a circumpubertal onset, and generalised which usually occurs in individuals above the age of 35. Ø Treatment is determined on the severity of the disease and the age of the patient. Usually supra gingival (above gums) and sub gingival (under gums) debridement and antibiotics are sometimes necessary. Periodontics Introduction 50 Periodontal maintenance Aggressive periodontitis Ø To maintain the treatment and prevent reoccurrence of disease patient care is necessary, such as oral hygiene, like all other forms of periodontitis and gingivitis, brushing twice a day and interdental cleaning is a necessity in maintaining a healthy periodontium and preventing the continuation of periodontal destruction. Ø Regular periodontal check ups are also necessary, every 3–6 months. Periodontics Introduction 51 Periodontal maintenance Periodontitis as a manifestation of systemic disease Ø Periodontitis that is caused by systemic disease, there are currently at least 16 systemic diseases that have been linked with periodontal disease, such as, diabetes mellitus, haematological disorders such as acquired neutropenia and leukemia, down syndrome etc. Ø Treatment and preventions are a very important concept in the management and maintenance of periodontitis as a manifestation of systemic disease. Treatment can consist of either surgical or non surgical treatment depending on severity. Ø After treatment patient compliance is important which includes oral hygiene which is tooth brushing twice a day, interdental brushing at least once a day and chlorohexidine mouth wash may also be helpful. Periodontics Introduction 52 PERIODONTITIS COMPLICATIONS MEDICATION PERIODONTIUM IMPACT: 1.Tooth loss 1. Antimitotic 2.Masticatory alterations 2. Immunosuppressants 3.Tooth migration 3. Antiepileptic 4.Aesthetics alterations. 5.Abscesses Periodontics Introduction 53 HYGIENIC PHASE 1. Scaler “Removal of the remains of Tartar or calculus accumulated on the surface of the teeth to supragingival. Material level: ultrasonic device”. 2. Scaling and root planing (RAR) “It is to remove plaque, calculus and bacteria attached to the tooth to supragingival and subgingival level and leave a smooth surface”. Material: curettes and ultrasonic instruments rotary. Periodontics Introduction 54 CORRECTIVE PHASE Periodontal surgery “It is to eliminate periodontal pockets and any retentive area that tends to accumulate plaque”. For it, this surgical material is used because it is necessary for periodontal tissue excision surplus. For this surgery, we have: Planning case (diagnosis, correct anamnesis, rx) Anesthesia Depth reduction bags Debonding flap. Periodontics Introduction 55  Inflammatory tissue removal. Gingival thickness decrease. Break and compression. Medication (antibiotics..). Tracing. MAINTENANCE PHASE Controls: visual, radiographic, exploration periodontal.. » MOTIVATION ¡¡¡ Periodontics Introduction 56 57  EXERCISE 1 Say which case is worse, watching the following Rx: A B Periodontics Exercises 58  EXERCISE 2 Say which case is worse, watching the following images: A B Periodontics Exercises 59  EXERCISE 3 Watching the following images, name these instruments: A B Periodontics Exercises 60  EXERCISE 4 Say which case is worse, watching the following images: A B Periodontics Introduction 61  EXERCISE 5 Name these instruments, are they the same?: A B Periodontics Introduction 62  EXERCISE 6 What is the use/differences of these instruments in Periodontics, and name them: A B Periodontics Introduction 63  EXERCISE 7 What is the use/differences of these products in Periodontics, and name them: A B Periodontics Exercises 64  EXERCISE 8 Indicates according to the measurement of the periodontal probing which teeth have periodontitis: 4 4 4 3 22 1 1 1 2 2 3 4 5 4 4 4 6 5 44 2 2 3 4 244 5 4 6 4 Periodontics Exercises 65  EXERCISE 9 Say if this case is gingivitis or periodontitis: Periodontics Exercises 66  EXERCISE 10 Read these sentences and say which one is true or false: 1. Gingival sulcus and periodontal pocket are the same. 2. Healthy gums usually bleed. 3. Supragingival and subgingival calculus are similar in severity and characteristics. 4. Gingivitis patients have severe pain. 5. Halitosis is a bad taste in the mouth Periodontics Exercises 67  EXERCISE 4 AND 5 NABERS PROBE GRACEY CURETTES EXERCISE 6 WHO PERIODONTAL PROBE INTERDENTAL BRUSH WATERPIK EXERCISE 7 ANTISEPTIC REGENERATOR Periodontics Exercises 68