Periodontal Treatment PDF

PERIODONTAL TREATMENT  THERAPEUTIC GOALS OF PERIODONTAL TREATMENT Elimination of inflammation by removing the primary etiologic factors (plaque bacterial biofilm ) Arresting the progression of disease and prevent recurrence Regeneration of periodontal tissue The effectiveness of periodontal...

PERIODONTAL TREATMENT  THERAPEUTIC GOALS OF PERIODONTAL TREATMENT Elimination of inflammation by removing the primary etiologic factors (plaque bacterial biofilm ) Arresting the progression of disease and prevent recurrence Regeneration of periodontal tissue The effectiveness of periodontal therapy is predicated on: 1- completely eliminating calculus, plaque, and diseased cementum from the tooth surface. 2. Reduce the depth of the pocket. The short-term goal is to promote plaque biofilm control and to instrument the tooth surfaces until they are clean and smooth. The long-term goal of nonsurgical periodontal therapy is to restore periodontal health PHASES OF PERIODONTAL THERAPY Emergency Treatment of emergencies: Phase Periodontal abscess Phase I Surgical peio-endo Nonsurgicallesion PhasePhase (Phase (Phase I Therapy) II Therapy) Plaque control Extraction and patient of therapy, Periodontal hopeless education: teeth including placement Removal of calculus and root planing Phase II of Correction implants of restorative and prosthetic irritational Restorative factors Maintenance Phase Phase (Phase(Phase IV Therapy) III Therapy) Phase III Final Antimicrobial Periodic therapy (local or systemic) rechecking: restorations Occlusal therapy, splinting Fixed Plaque and calculus and removable prosthodontic Phase IV Minor orthodontic movement Gingival condition (pockets, appliances Evaluation inflammation) of response to restorative Occlusion, tooth mobility procedures Other pathologic changes Reevaluation After Phase I Therapy All patients should be treated initially with scaling and root planning and a final decision for periodontal surgery should be made only after a thorough evaluation of the effects of Phase I therapy include: The assessment is generally made no less than 3 months and sometimes as much as 9 months after the completion of Phase I therapy This reevaluation should include re-probing the entire mouth, with rechecking for the presence of calculus, root caries, defective restorations, and all signs of persistent inflammation. Rationale for Periodontal Surgery Periodontal surgery is indicated to control the progression of periodontal destruction and attachment loss when more conservative nonsurgical treatments are not sufficient. Periodontal surgery involves techniques that intentionally cut into soft tissues to control disease or change the size and shape of tissues OBJECTIVES OF THE SURGICAL PHASE The surgical phase of periodontal therapy has the following main Objectives: 1- Controlling or eliminating periodontal disease Removing etiological factor not removed by non- surgical phase Correcting anatomic conditions that may favor periodontal disease 2. Improvement of the prognosis of teeth and their replacements. 3. Improvement of esthetics 4. Placement of dental implants, including techniques for site development for implants (guided bone regeneration, sinus grafts)  Advantages of periodontal surgery The major benefit and indication for periodontal surgery is direct visualization , Accessibility of instruments to root surface. a. to gain access to root surfaces for SRP. b. improves access to the bony defect c. correction of root surface anomalies such as root grooves Allows augmentation or recontouring of soft tissues to facilitate plaque control/improve aesthetics Esthetic plastic surgeries Improve patient esthetics Pre-prosthetic techniques Exposing root surfaces for restorative dentistry Allows use of regenerative techniques INDICATIONS FOR PERIODONTAL SURGERY - Persistent inflammation in areas with moderate to deep pockets may require a surgical approach - Pockets on teeth in which a complete removal of root irritants is not considered clinically possible may call for surgery. This occurs frequently in molar and pre- molar areas - Intrabony pockets on teeth usually unresponsive to nonsurgical methods - In cases of furcation involvement of Grade II or III, a surgical approach ensures the - Areas with irregular bony contours, deep craters, and other defects usually require a surgical approach  Types of Periodontal Surgery Lang and Löe classified periodontal surgical procedures into five basic categories—procedures for: Access to the root surface Pocket reduction or elimination Treatment of osseous defects Correcting mucogingival defects New attachment  Pocket Therapy Deep pockets represents a greater risk of disease progression The goal : The transformation of the deep, active pocket Into a shallower, inactive, maintainable pocket Pocket heal by : Reduction of pocket depth Gain of attachment by long junctional epithelium , regeneration Non- Surgical Treatment SRP resolve the inflammatory process, and the gingiva therefore shrinks, reducing the pocket depth SRP ( long junctional epithelium) Probing Pocket Depth More probing depth Less plaque control by patient Favorable environment for growth anaerobic g- bacteria More Difficult to remove plaque and calculus by dentist More Diseases progression More periodontal tissue destruction Surgical pocket therapy Vs Non –surgical therapy Nonsurgical Scaling and root planning are effective in controlling periodontal disease to probing depths of approximately 4 mm. Pockets deeper than 5 mm are difficult to instrument and often remain infected after the best dental hygiene care. Lindhe et al compared the effect of root planning alone and with a modified Widman flap on the resultant level of attachment and in relation to initial pocket depth. They reported that scaling and root-planning procedures induce loss of attachment if performed in pockets shallower than 2.9 mm, whereas gain of attachment occurs in deeper pockets. The modified Widman flap induces loss of attachment if done in pockets shallower than 4.2 mm but results in a greater gain of attachment than root planning in pockets deeper than 4.2 mm.  surgical pocket therapy Reduce or eliminate pocket depth - Increase accessibility to the root surface, making it possible to remove all Irritants - making it possible for the patient to maintain the root surfaces free of plaque Eliminate the pathologic changes in the pocket walls Reshape soft and hard tissues to attain a harmonious topography  METHODS OF POCKET THERAPY I- Removal of the pocket wall Two main approaches to surgical treatment 1- “pocket reduction techniques Direct access to the root surface— to treat the pocket by achieving effective root surface debridement and allowing the pocket to heal Modified Widman Flap 2- “pocket elimination” techniques Excisional periodontal surgery (gingivectomy) Gingivectomy—excision of the gingiva Gingivoplasty—surgical reshaping of the gingival tissue METHODS OF POCKET THERAPY 1.New attachment techniques eliminate pocket depth by reuniting the gingiva to the tooth at a position coronal to the bottom of the preexisting pocket 2.Removal of the pocket wall It can be removed by the following: Retraction or shrinkage, in which scaling and root planning procedures resolve the inflammatory process and the gingiva therefore shrinks, reducing the pocket depth. Surgical removal performed by the gingivectomy technique or by means of an undisplaced flap. Apical displacement with an apically displaced flap. 3. Removal of the tooth side of the pocket, which is accomplished by tooth extraction or by partial tooth extraction (hemisection or root resection). General Considerations for Periodontal Surgery Therapy for Gingival Pockets Factors are taken into consideration: 1- The character of the pocket wall Edematous - tissue shrinks after SRP alone Fibrotic - need surgical resection by gingivectomy 2- Accessibility of the pocket 3- Aesthetics Anterior teeth advantages of SRP they are all single rooted and easily accessible plaque control are easier Factors are taken into consideration: Age and general health of the patient Patient cooperation, including ability to perform effective oral hygiene. Smokers must be willing to stop their habit Importance of the tooth to function Existence of mucogingival problems Response to Phase I therapy General Principles of Periodontal Surgery Tissue Management Operate gently and carefully Observe the patient at all times Be certain the instruments are sharp Control bleeding  Periodontal Dressings (Periodontal Packs) Improved healing and Patient comfort Minimizes postoperative infection and hemorrhage Facilitates Healing by preventing surface trauma during mastication Reduce pain induced by contact of the wound with food or the tongue during mastication Zinc Oxide–Eugenol Packs Non-eugenol Packs allergic reaction - redness Two tubes burning sensation 1- zinc oxide, Lorothidol (a fungicide) 2- tube contains liquid coconut fatty acids thickened with rosin chlorothymol (a bacteriostatic agent +/- antibiotics  Preparing the surgical pack (Coe-Pak). Retention of Packs. Kept in place mechanically by interlocking in interdental spaces and joining the lingual and facial portions of the pack  Postoperative Instructions Patients should be told to rinse with 0.12% chlorhexidine gluconate immediately after the surgical procedure and twice daily thereafter until normal plaque control technique can be resumed Avoid hot, spicy food and drinks for the first 24 hours. Eat soft, semisolid or minced foods. Do not drink alcohol or smoke. Do not brush over the pack / healing area for at least a week. On the first day, apply ice intermittently on the face over the operated area. If there is any swelling 1-2 days after the surgery, apply moist heat over the area The following complications may arise in the first postoperative week Persistent bleeding after surgery Sensitivity to percussion. Swelling. In the first 2 postoperative days, some patients may report a soft, painless swelling of the cheek in the surgical Lymph node enlargement The temperature may be slightly elevated Feeling of weakness Tooth Mobility