Current approach in periodontal care

CURRENT APPROACH

IN PERIODONTAL CARE

DR. RASIDAH HJ AYOBPAKAR PERGIGIAN

(PERIODONTIK)

CURRENT APPROACH

IN PERIODONTAL CARE

DR. RASIDAH HJ AYOBPAKAR PERGIGIAN

(PERIODONTIK)

o Initial Cause Related Therapy

52 yr old Male: Hypertensive, Controlled Diabetes type 2: CHRONIC

PERIODONTITIS

Source : R. Ayob 2008

Persistent suppuration before and after RCT UL3

o Initial Cause Related Therapy

o Initial Cause Related Therapy

30yr old female: 3rd pregnancy, Painful swelling WITH bone loss

21 yrs old female Caucasian:

GENERALISED AGGRESSIVE PERIODONTITIS

o Initial Cause Related Therapy

Courtesy: Guerrero Eastman Dental Institute

Courtesy: Guerrero Eastman Dental Institute

o Initial Cause Related Therapy

o Corrective Therapy

o Supportive Therapy

Eliminate the infection Enhance cleaning ability Increase comfort Maintain or improve esthetic Rehabilitate function Improve prognosis

FORMATION OF

PLAQUE BIOFILM

FORMATION OF

PLAQUE BIOFILM

The concept of “CRITICAL MASS” (WWP 1989)

1. Provide skeleton for bacterial attachment

2. Protection for micro-organisms from environmental factors

3. Nutrients uptake

4. Cross-feeding between species Facilitate removal of harmful metabolic products (utilization by other bacteria)

5. Development of an appropriate physicochemical environment properly reduced oxidation potential

ROLES OF BIOFILMROLES OF BIOFILM

ANATOMY OF PERIODONTIUM

ANATOMY OF PERIODONTIUM

Source: Lindhe

Ingression of bacteria and bacterial products

HOST RESPONSEHOST RESPONSE

Source: Science Photo library edited RAyob

Source: R.Ayob 2006

BACTERIAL CHALLENGE BACTERIAL CHALLENGE

NEW FINDINGS:

Host Inflammatory response influences thecomposition of the biofilm

2. Mechanical debridement• Antimicrobial as an adjunct to mechanical

debridement (scaling and root debridement)

1. Customised Motivation and OHI• Input about association between periodontitis and

systemic diseases• Modification of the biofilm/host response

2. Mechanical debridement• Antimicrobial as an adjunct to mechanical

debridement (scaling and root debridement)

1. Customised Motivation and OHI• Input about association between periodontitis and

systemic diseases• Modification of the biofilm/host response

1. Can periodontitis cause systemic disease?2 If we have systemic disease,can we get

aperiodontitis

PERIODONTITIS

SYSTEMIC DISEASE

Systemic disease worsen periodontal

inflammation

Periodontal inflammation influence systemic health

o Periodontitis as a risk for cardiovascular disease

o Periodontitis as a risk for diabetic complications

o Periodontitis as a risk for adverse pregnancy outcomes

o Periodontitis as a risk for respiratory infections

o Periodontitis as a risk for cardiovascular disease

o Periodontitis as a risk for diabetic complications

o Periodontitis as a risk for adverse pregnancy outcomes

o Periodontitis as a risk for respiratory infections

Herpes viruses (particularly CMV) and oral bacteria (P. gingivalis) can invade cells of vascular origin.

Dorn BR, Dunn WA Jr, Progulske-Fox A. Invasion of human coronary artery cells by periodontal pathogens. Infect Immun 1999;67:5792-8.

Source: Science library

Atherosclerotic plaque are infected with periodontal pathogens (Haraszthy & Zambon 2000)

Bacteria and toxin induce fat

accumulation

P. gingivalis and several other oral bacteria - induce foam cell formation in the murine macrophage line. Kuramitsu HK, Qi M, Kang IC, Chen W. Role for periodontal bacteria in cardiovascular diseases. Ann Periodontol 2001;6(1):41-7.

Source: Science library

Oral bacteria such as S. sanguis and P. gingivalis can induce platelet aggregation in vitro and may increase the risk of developing acute thrombosis. Fong IW. Emerging relations between infectious diseases and coronary artery disease and atherosclerosis. CMAJ 2000;163(1):49-56

Source: Internet

2. Periodontal inflammation may be implicated in the initiation or progression of coronary artery disease and stroke. • with raised systemic concentrations of C-reactive

protein, fibrinogen• cytokines, all of which have been causally linked to

atherosclerosis-induced disease.

1. Inflammation has been implicated in the cause & pathogenesis of atherosclerosis

Paoletti R, Gotto AM Jr, Hajjar DP. Inflammation in atherosclerosis and implications for therapy. Circulation 2004; 109 (23 suppl 1): III20–26.

3. Nonsurgical periodontal treatment • Reduce periodontal inflammation • Reduce serum inflammatory markers and C-

reactive protein.

Ebersole JL, Machen RL, Steffen MJ, et al. Systemic acute-phase reactants, C-reactive protein and haptoglobin, in adult periodontitis. Clin Exp Immunol 1997; 107: 347–52.

D’Aiuto F, Nibali L, Parkar M, et al. Short-term effects of intensive periodontal therapy on serum inflammatory markers and cholesterol. J Dent Res 2005; 84: 269–73.

D’Aiuto F, Casas JP, Shah T, et al. C-reactive protein (1444CT) polymorphism influences CRP response following a moderate inflammatory stimulus. Atherosclerosis 2005; 179: 413–17.

D’Aiuto F, Parkar M, Andreou G, et al. Periodontitis and systemic inflammation: control of the local infection is associated with a reduction in serum inflammatory markers. J Dent Res 2004; 83:

Artherosclerosis

High blood Pressure

Stroke

Liver & Pancreas

Placenta & UterusHeart

Enter Vessel

PERIODONTITIS

Bacteria/Toxin

Initiation of Inflammation

• Having periodontitis contributes to the total infectious and inflammation burden. May lead to cardiovascular events and stroke in susceptible subjects.

• Current evidence is insufficient to support that periodontal infections constitute and independent risk factor for CAD.

• Although adjustment for established cardiovascular risk factors (smoking and diabetes), genetic factors that predisposes to both periodontitis and CAD may act as the confounding factor

• The impact of periodontal therapy must be further investigated

Periodontal diseases and health: Consensus Report of the Sixth European Workshop on Periodontology Kinane D, Bouchard P. Periodontal diseases and health: Consensus Report of the Sixth European Workshop o Periodontology. J Clin Periodontol 2008; 35 (Suppl. 8):333–337.

o Periodontitis as a risk for cardiovascular disease

o Periodontitis as a risk for diabetic complications

o Periodontitis as a risk for adverse pregnancy outcomes

o Periodontitis as a risk for respiratory infections

Source: Internet

Presence of peiodontitis or

periodontal inflammation can

increase the risk for diabetic complications,

principally poor glycemic control

Taylor GW, Burt BA. Becker MP, Genco RJ, Shlossman M, Knowler WC & Pettit DJ (1996). Severe periodontitis and risk for poor glycemic control in patients with non-insulin-dependent diabetes mellitus. Journal of Periodontology 67 (10 Suppl), 1085-1093.

R.Ayob 2010

Bacteria entering the blood may disrupt insulin function – causing increase blood glucose

Moritz A, Mealey B. Periodontal disease, insulin resistance, and diabetes mellitus: a review and clinical implications. Grand Rounds Oral-Sys Med. 2006;2:13-20.

Source: Internet

Constant hyperglycaemia results in accumulation of AGE (advanced glycated end product).

AGE in turn affecting the immune system such as delay the body healing.

Source: Online

Diabetes type 2

Liver & Pancreas

Placenta & UterusHeart

Enter Vessel

PERIODONTITIS

Bacteria/Toksin

Initiation of Inflammation

o Periodontitis as a risk for cardiovascular disease

o Periodontitis as a risk for diabetic complications

o Periodontitis as a risk for adverse pregnancy outcomes

o Periodontitis as a risk for respiratory infections

1983 Greg Collin and Offenbacher: Pregnant Hamster challenged with gm negatif E.Coli LPS Malformation fetuses, spontaneous abortion and low birth-weight

E. Coli Vs Porphyromonas gingivalis Similar effect?

Source: Internet

Landmark report by Offenbacher 1996

Adverse pregnancy outcomes linked with periodontitis as a possible risk:

1. Preterm birth & Low birthweight (PLBW)

2. Miscarriage or early pregnancy loss

3. Pre-eclampsia R.Ayob 2010

Periodontitis as a reservoir for: Gm –ve anaerobics with endotoxin (LPS) Inflammatory mediators : PGE2 TNFα PGE2 and TNFα inversely related to birth-weight (Collins et al 1994a,b)

May act as a potential threat to the fetal-placental unit (Collins et al 1994a,b)

Source: Internet

Toxin and bacterial product in the blood are able to enter placenta

Bacteria from the lesion of periodontitis is also found in amniotic fluidMcGaw 2002

Source: Online

Activation of immune system

Source: Internet

Inflammation of amniotic fluid may cause premature rupture of membranes

Source: Internet

Inflammation of the uterus and membranes represents a common causing mechanism Preterm low birthweight

Source: Internet

• Pre-term birth = <37 weeks gestational age (Martin et al. 2007)

• Low birth weight (LBW) = <2500 g (WHO 2005)

• Pre-term premature rupture of membranes (PPROM) = Spontaneous rupture of the membranes as <37 weeks gestation at least 1 h before the onset of contractions (Goldenberg et al. 2008)

Source: Internet

Source: Internet

Adverse pregnancy outcomes linked with periodontitis as a possible risk:

1. Preterm low birthweight Known risk:

• Young maternal age• Drug, alcohol and tobacco use• Maternal stress• Genetic background• Genitourinary tract infection• Chronic infection (Hill 1998, Goldenberg et al

2000, Scannapieco et al 2003c, Xiong et al 2006)

Source: Internet

Adverse pregnancy outcomes linked with periodontitis as a possible risk:

1. Preterm low birthweight 10% of annual birth 2/3 of overall infant mortality 1/3 are elective 2/3 are spontaneous (1/2 due to

premature rupture of membranes)

Source: Internet

Xiong and co-workers 2006 22 total studies From :

U.S(7), UK (3), Hungary (2) , Brazil, Turki, Croatia, Denmark, Colombia, Chile, Iceland, Spain , Sri Lanka,

Finland

7 studies found No association between periodontal disease and adverse pregnancy outcomes

15 studies found strong association between

periodontal disease and PLBW

Pre mature & Low birth

weight

Liver & Pancreas

Placenta & UterusHeart

Enter Vessel

PERIODONTITIS

Bacteria/Toksin

Initiation of Inflammation

o Periodontitis as a risk for cardiovascular disease

o Periodontitis as a risk for diabetic complications

o Periodontitis as a risk for adverse pregnancy outcomes

o Periodontitis as a risk for respiratory infections

Lung Infection

Biological plausibility

Bacteria from the periodontal pocket Can cause aspiration pneumonia

Lung Infection

Biological plausibility

Similar gram -ve periodontalpathogen

was found in the lung ofpneumonia patient. Slots et al 1988

2. Mechanical debridement• Antimicrobial as an adjunct to mechanical

debridement (scaling and root debridement)

1. Customised Motivation and OHI• Input about association between periodontitis and

systemic diseases• Modification of the biofilm/host response

1. Modification of the biofilm.• Antimicrobial Peptides

Gorr, S-U. & Abdolhosseini, M. (2011) Antimicrobial peptides and periodontal disease. Journal of Clinical Periodontology 38 (Suppl. 1), 126–141.

• ProbioticsTeughels, W., Loozen, G. & Quirynen, M. (2011) Doprobiotics offer opportunities to manipulate theperiodontal oral microbiota? Journal of ClinicalPeriodontology 38 (Suppl. 1), 158–176.

Biological approaches to the development of novel periodontal therapies. Maurizio S. Tonetti & Chapple. J Clin Periodontol 2011; 38 (Suppl. 11): 114–118

2. Modification of the host response• Nutritional modulation of periodontal

inflammation- Increased caloric (include refine sugars)

intake induces inflammation directly- Adiposity (Visceral fat accumulation)

induces inflammation indirectly

• Dietary recommendation- Reducing caloric intake and refined sugars- the dental team incorporating advice to

increase dietary intake of fiber, fish oils, fruits, vegetables and berries

Biological approaches to the development of novel periodontal therapies. Maurizio S. Tonetti & Chapple. J Clin Periodontol 2011; 38 (Suppl. 11): 114–118

2. Mechanical debridement• Antimicrobial as an adjunct to mechanical

debridement (scaling and root debridement)

1. Customised Motivation and OHI• Input about association between periodontitis and

systemic diseases• Modification of the biofilm/host response

28 yr old Chinese patient with excellent oral hygieneSource: Rayob 2008 Melaka

Source: Tay Shieh Fung , R.Ayob 2013

GENERALISED AGGRESSIVE PERIODONTITIS

Aggregatibacter actinomycetemcomitansSource: Eastman Dental Institute (UCL)

Aggregatibacter actinomycetemcomitans (A.a)

Strain JP2 or serotype b

Release Leukotoxin LTxA and CDT (cytolethal Distending

Toxin)

Aggregatibacter actinomycetemcomitans (A.a)

Strain JP2 or serotype b

Release Leukotoxin LTxA and CDT (cytolethal Distending

Toxin)

Full mouth periodontal therapy• Systemic Antibiotic with Full Mouth SRD 24hour in

Generalised Aggressive Periodontitis

Griffiths, Ayob R, Guerrero A, Nibali L, Suvan J, Moles DR, Tonetti MS. Amoxcillin and metronidazole as an adjunctive treatment in generalised aggressive periodontitis. RCCT. J. Clin Periodontol 2011; 38: 43-49

Baseline

1 year after therapy

Laser Vs conventional mechanical debridementin chronic periodontitis?

Er:YAG laser - resulted in similar clinical outcomes in short- and long-term (1 yr)

insufficient evidence to support the clinical application of either CO2, Nd:YAG, Nd:YAP, or diode laser *Er:YAG laser:Weak evidence

CO2, Nd:YAG, Nd:YAP, or diode laser : no significant clinical added value.

Potential thermal injury to the adjacent periodontal tissuesLaser application in non-surgical periodontal therapy: a systematic review F. Schwarz, A. Aoki, J. Becker, A. Sculean

o Initial Cause Related Therapy

o Corrective Therapy

o Supportive Therapy

Source : R. Ayob 2006

R. Ayob 2003

R. Ayob 2008

GTR in perio-endodontic case

Resective or subtractive procedures

Regenerative or additive procedures

Position paper American Academy of Periodontology in 2001:

Soft Tissue Grafts

Bone Replacement Grafts

Root Biomodifications

Guided Tissue Regeneration

Combination thereofGreenwell H, Committee on Research, Science and Therapy, American Academy of Periodontology. Position Paper: Guidelines for Periodontal Therapy (2001). J.Periodontol 72, 1624-1628

Osseous,

Furcation

Recession

1. Periodontal Regeneration development:• Material and armamentarium• Technique

Conventional Minimally Invasive Surgical Technique (MIST) Modified MIST (M-MIST)

Source : R.Ayob 2003

Source : R.Ayob 2003

GTR with resorbable synthetic membrane

GTR alone with resorbable synthetic membrane

Source : R. Ayob 03/04

The biologic concept applied by

Hammarstrom 1997 , Gestrelius et al 2000:

The Enamel matrix (amelogenins):

Commercially available product Emdogain® = purified acid extract of porcine origin contains enamel matrix derivatives, water and Propylene glycol alginate (PGA) carrier.

Source: Straumann

Has been in clinical use for more than 15 years

Clinical efficacy is very well establlished

Source: Straumann

Conclusion from review 103 papers:

EMP affect many different cell types (cell attachment, spreading, chemotaxis, proliferation and survival) and expressed Growth factors, cytokines for bone formation and remodelling

STRONG EVIDENCE for EMPs to support wound healing and periodontal regeneration

2008

Application of Modified MIST : M-MIST (2009)

Source: R.Ayob 2010

0 day

Application of Modified MIST : M-MIST (2009)

18 days post op

Source: R.Ayob 2011

Baseline

Application of Modified MIST : M-MIST (2009)

R. Ayob 2011R. Ayob 2010

8 months Post Op

Source: R.Ayob 2011

Source: R.Ayob 2013

Soft tissue regenerationSoft tissue regeneration

LEAVE IT……..ORTO AUGMENT?

PATIENT WITHNO PROBLEM BUT THIN MUCOGINGIVAL

TISSUE

Source: R.Ayob 2011Source: R.Ayob 2013

CONCLUSION:1. Gingival augmentation surgery (FGG) is effective in

providing a significant increase in keratinized tissue with thin gingiva and recessions

2. Sites treated with gingival augmentation surgery (reduced recession) coronal displacement

3. Sites NOT treated further recessions not only on existing but new sites

Soft tissue regenerationSoft tissue regeneration

Type of soft tissue graft

Type of soft tissue graft

Connective tissue graft with epithelial collar

Epithelial graft

Sub epithelial Connective tissue graft

Type of soft tissue graft

Type of soft tissue graft

Epithelial graft

Epithelialized Free Gingival Graft (FGG)

Source: R.Ayob 2008

Soft tissue regenerationSoft tissue regeneration

Sub epithelial Connective tissue graft

R. Ayob 2010 UL3(L) Defect : 6mm width 4 mm height

R. Ayob 2010 5 day post op

Soft tissue regenerationSoft tissue regeneration

R. Ayob 2011 1 week post op

5% 2.5mm 100%10% 2.0mm 100%13% 1.5mm 75 %

CEJ 28% 1.0mm 71%17% 0.5mm 40 %

3. Technique-related factors• Gingival margin position post-operatively

Flap margin level to CEJ

% Complete root coverage

J Periodontol 2005;76:713 - 722

% n (patients)

Modified MIST : M-MIST (2009)

Source: R.Ayob 2010

R. Ayob 2011R. Ayob 2010

Baseline 1 year review

Type of soft tissue graft

Type of soft tissue graft

Connective tissue graft with epithelial collar

R. Ayob 2006

Connective Tissue with Epithelial collar

R. Ayob 2013

Connective Tissue with Epithelial collar

Connective Tissue with Epithelial collar

R. Ayob 2013 R. Ayob 2014

o Initial Cause Related Therapy

o Corrective Therapy

o Supportive Therapy

SUPRAGINGIVAL AND SUBGINGIVAL

PLAQUE

SUPRAGINGIVAL AND SUBGINGIVAL

PLAQUE

Source: R.Ayob 2011

Supportive Periodontal Therapy

Supportive Periodontal Therapy

PDT as an exclusive therapy may be considered a non-invasive alternative for treating residual pockets, offering advantages in the modulation of cytokines some species of bacteria

Photosensitizer

Low powered LASER Activated

photosensitizer

FREE RADICALS

Damaging bacteria cell wall/DNA

Supportive Periodontal TherapySupportive Periodontal Therapy

Peri implantitis

General and Final Conclusions1. Periodontal medicine – Periodontitis association

NOT causal. Collaboration between DO and MO needed

Criteria to prove that periodontitis is a risk for systemic diseases

Consistency in strong association

Dose dependent (exposure)

Correct timing/stage of disease process

Biological plausibility

Evidence from animal and human experiments

General and Final Conclusions

2. Concept of biofilm and controlling factors

A major goal of periodontal therapy is to reduce the quantity (mass) of bacterial plaque to a level (critical) that results in an equilibrium between the residual microbes and the host response,

REGENERATIVE PERIODONTAL THERAPIESREGENERATIVE PERIODONTAL THERAPIES

WHY IS IT APPEARED SIMPLE, YET SO DIFFICULT?

The structural and interactive complexity of periodontal tissues and course of disease process became the reasons

why it is so difficult to regenerate the periodontium.

General and Final Conclusions

3. Successful regenerative procedures need a profound knowledge in molecular biology, good armamentarium, operator’s experience and skill.