www.drluzvillanueva.comwww.drluzvillanueva.com

Non- Surgical Non- Surgical Treatment & Treatment & MaintenanceMaintenance

www.drluzvillanueva.comwww.drluzvillanueva.com

INITIAL PHASE OF TXINITIAL PHASE OF TX

Patient’s ROLEPatient’s ROLE

removal of removal of supragingival supragingival plaqueplaque

Dentist’s ROLEDentist’s ROLE

eliminate or reduce eliminate or reduce factors which factors which retain plaque, retain plaque, potentiate its potentiate its growth and re-growth and re-establisment or establisment or hinder its removal hinder its removal by the pxby the px

Patients’ rolePatients’ role Mechanical oral Mechanical oral

hygiene aideshygiene aides

1.1. General Brushing- General Brushing- toothbrush (miniscrub toothbrush (miniscrub or bass technique)or bass technique)

2.2. Interproximal surfaces Interproximal surfaces – ( floss, wooden sticks)– ( floss, wooden sticks)

3.3. Bridge pontics- Bridge pontics- superfloss, floss superfloss, floss threaders, bottle threaders, bottle brushesbrushes

4.4. oral irrigatorsoral irrigators

Good home oralGood home oral

hygiene is still thehygiene is still the

most effective toolmost effective tool

for maintaining healthfor maintaining health

and for preventingand for preventing

periodontal disease.periodontal disease.

Rationale for removing Rationale for removing plaqueplaque

To restore gingival health by To restore gingival health by completely removing elements that completely removing elements that provoke gingival inflammation from provoke gingival inflammation from the tooth surfacethe tooth surface

Phase I therapy Phase I therapy American Academy American Academy

of Periodontologyof Periodontology 1. 1. Evaluation and alteration of patient’s Evaluation and alteration of patient’s

systemic risk factors ( smoking /anti systemic risk factors ( smoking /anti smoking advice, medications, substance smoking advice, medications, substance abuse)abuse)

Substance abuse:How Meth Can Substance abuse:How Meth Can Damage Your Mouth Damage Your Mouth

Methamphetamine use damages dental health in several ways: Methamphetamine use damages dental health in several ways: During the “high” produced by this drug, users usuallyDuring the “high” produced by this drug, users usually

experience experience cravings for sugary carbonated beverages, which is cravings for sugary carbonated beverages, which is bad for teeth. bad for teeth.

The “high” from this drug lasts about 12 hours, during which The “high” from this drug lasts about 12 hours, during which time users will time users will probably not probably not brush or or floss, therefore leaving the therefore leaving the sugary substances on their teeth for long periods of time. sugary substances on their teeth for long periods of time.

The acidic contents of this drug can damage teeth. Ingredients The acidic contents of this drug can damage teeth. Ingredients can include battery acid, lantern fuel, antifreeze, hydrochloric can include battery acid, lantern fuel, antifreeze, hydrochloric acid, drain cleaner, lye and over-the-counter cold medications acid, drain cleaner, lye and over-the-counter cold medications containing ephedrine. containing ephedrine.

Users of methamphetamines usually tend to Users of methamphetamines usually tend to clench and / or grind their teeth.

Methamphetamines dry up Methamphetamines dry up protective saliva around the teeth. around the teeth.

Phase I therapy Phase I therapy American Academy American Academy

of Periodontologyof Periodontology 1. 1. Evaluation and alteration of patient’s systemic Evaluation and alteration of patient’s systemic

risk factors ( smoking, medications, substance risk factors ( smoking, medications, substance abuse)abuse)

2. Plaque control by patient (Patient motivation, 2. Plaque control by patient (Patient motivation, education, Oral hygiene instructionseducation, Oral hygiene instructions

3. Removal of microbial plaque and calculus from 3. Removal of microbial plaque and calculus from tooth surfaces-Supragingival and subgingival tooth surfaces-Supragingival and subgingival scaling and root planingscaling and root planing

4. appropriate use of antimicrobial agents and 4. appropriate use of antimicrobial agents and devicesdevices

5. control or elimination of contributing local 5. control or elimination of contributing local factors – factors –

Contributing factorsContributing factors CalculusCalculus Treatment of poorly Treatment of poorly

fitting restoration/ fitting restoration/ margins/ over margins/ over contoured resto/ lack contoured resto/ lack of embrasure spacesof embrasure spaces

Correction of poorly Correction of poorly fitting prosthetic fitting prosthetic devicesdevices

Restoration of carious Restoration of carious lesions- root caries , lesions- root caries , class Vclass V

Treatment of food Treatment of food impaction areaimpaction area

Treatment of Treatment of occlusal traumaocclusal trauma

Extraction of Extraction of hopeless hopeless teeth ????????teeth ????????

OdontoplastyOdontoplasty Tooth movementTooth movement

CLINICIAN’S ROLECLINICIAN’S ROLE

Instruction and monitoring Px plaque Instruction and monitoring Px plaque controlcontrol

Reduce or remove factors that hinder px Reduce or remove factors that hinder px efforts to remove plaque close to or efforts to remove plaque close to or beneath gingival margins. (supra and beneath gingival margins. (supra and subgingival plaque removal)subgingival plaque removal)

Prescribe antimicrobialsPrescribe antimicrobials

Scaling and root planingScaling and root planing

SCALING – process SCALING – process by which plaque and by which plaque and calculus are removed calculus are removed from both supra and from both supra and sub gingival tooth sub gingival tooth surfacessurfaces

Subgingival scaling- Subgingival scaling- removal of deposits removal of deposits of subgingival of subgingival calculus detected by calculus detected by touch. touch.

Root planing-Removal of Root planing-Removal of subgingival plaque and subgingival plaque and calculus calculus (“root surface (“root surface

debridement”)debridement”) removal of removal of cementum (and/or cementum (and/or dentin)exposed within the dentin)exposed within the pocket to maximise chance pocket to maximise chance of removing all components of removing all components of the subgingival plaque of the subgingival plaque (bacteria) that may invade (bacteria) that may invade dentinal tubules, and to dentinal tubules, and to produce a smooth , hard produce a smooth , hard clean surface (criteria for clean surface (criteria for completion)completion)

debridementdebridement

also called periodontal debridement,also called periodontal debridement, traditionally was described as scaling and traditionally was described as scaling and

root planingroot planing It involves the non-surgical, mechanical It involves the non-surgical, mechanical

removal of tooth surface irritants using removal of tooth surface irritants using manual and/or ultrasonic methodsmanual and/or ultrasonic methods

is the treatment of gingival and periodontal is the treatment of gingival and periodontal inflammation through supra gingival and subinflammation through supra gingival and sub

gingival debridement and deplaquing within the gingival debridement and deplaquing within the gingival sulcus or periodontal pocketgingival sulcus or periodontal pocket

Methods of detecting supra Methods of detecting supra and sub gingival calculusand sub gingival calculus

Visual exam- use Visual exam- use compressed air to compressed air to detect chalky detect chalky white depositswhite deposits

Tactile exploration Tactile exploration of tooth surfaces in of tooth surfaces in subgingival subgingival pockets – use pockets – use explorer or probeexplorer or probe

Use of perioscopeUse of perioscope

Tx planning methodsTx planning methods

Single appointments- for small Single appointments- for small amounts of calculus and healthy amounts of calculus and healthy tissuestissues

One or two long appointments to One or two long appointments to remove pathogens from entire mouth remove pathogens from entire mouth as quickly as possible so as not to re-as quickly as possible so as not to re-infect previously instrumented areas. infect previously instrumented areas. ( 45 min to root plane 7 teeth with ( 45 min to root plane 7 teeth with moderately deep pockets)moderately deep pockets)

Treatment sessions Treatment sessions depends on basis depends on basis

# of teeth# of teeth Severity of inflammationSeverity of inflammation Amount and location of calculusAmount and location of calculus Depth and activity of pocketsDepth and activity of pockets Presence of furcation invasionsPresence of furcation invasions Px comprehension of and Px comprehension of and

compliance with oral hygiene compliance with oral hygiene instructionsinstructions

Need for local anestesiaNeed for local anestesia

Essential Conditions for Essential Conditions for ScalingScaling

   Operation must be undertaken Operation must be undertaken

methodicallymethodically Correct instrument should be usedCorrect instrument should be used Each stroke should be deliberate Each stroke should be deliberate

and effective (exploratory stroke and and effective (exploratory stroke and the working stroke)the working stroke)

Tooth surface should be clean and Tooth surface should be clean and smoothsmooth

PREIODONTAL PREIODONTAL INSTRUMENTATIONINSTRUMENTATION

Periodontal probesPeriodontal probes Explorers Explorers Scaling, root planing and curetting Scaling, root planing and curetting

instruments instruments

- Sickle scalers- Sickle scalers

- curettes- curettes

-hoe, chisel and file scalers-hoe, chisel and file scalers

- ultrasonic instruments- ultrasonic instruments

Cleaning and polishing instrumentsCleaning and polishing instruments

PROBES PROBES

Used to assess periodontal pocket depths, Used to assess periodontal pocket depths, attachment levels, anatomy configurations attachment levels, anatomy configurations and gingival bleedingand gingival bleeding

Community Periodontal Index of Treatment Needs, PERIODONTAL SCREENING AND RECORDING, PERIODONTAL SCREENING AND RECORDING

Supra gingival scalingSupra gingival scaling Sickles- Macfarlane Sickles- Macfarlane

4/54/5 Ultra sonic Ultra sonic

instrumentsinstruments CurretesCurretes

CAVITRON DentsplyCAVITRON Dentsply 1950's as an 1950's as an

electronic alternative electronic alternative to manual scaling.to manual scaling.- works by applying a - works by applying a high-frequency (either high-frequency (either 25,000 or 30,000 Hz) 25,000 or 30,000 Hz) oscillating magnetic oscillating magnetic field across a field across a conductive metallic conductive metallic stack, in which is stack, in which is induced a reactive induced a reactive magnetic field. magnetic field.

Periodontal ScalerPeriodontal Scaler used to remove calculus used to remove calculus

and stain from the clinical and stain from the clinical crown of the tooth. crown of the tooth.

The scaler has pointed The scaler has pointed blades along each side and blades along each side and is used with a pull stroke. is used with a pull stroke.

The scaler may either be The scaler may either be single-ended or double- single-ended or double- ended. ended.

examples are the McCall examples are the McCall 13-14S and 17-18S, 13-14S and 17-18S, Younger-Good 7/8, Orban Younger-Good 7/8, Orban straight sickle 14, Crane-straight sickle 14, Crane-Kaplan 6, Towner U-15, Kaplan 6, Towner U-15, Kirkland 13K/13KL, and Kirkland 13K/13KL, and Pritchard. Pritchard.

Universal Curette Design Universal Curette Design triangular bladetriangular blade

are designed so that the are designed so that the working ends can be working ends can be adapted to all tooth adapted to all tooth surfaces of all regions of the surfaces of all regions of the mouth with one double-mouth with one double-ended instrument.ended instrument.

The blade is honed at 90 The blade is honed at 90 degrees to the lower shank. degrees to the lower shank.

The two cutting edges on a The two cutting edges on a blade are straight and blade are straight and parallel to each other. parallel to each other. There is no curvature of the There is no curvature of the blade except for the curve blade except for the curve from the shank to the toe.from the shank to the toe.

Periodontal CurettePeriodontal Curette

is used to remove calculus, smooth is used to remove calculus, smooth root surfaces, and the soft tissue wall root surfaces, and the soft tissue wall of the pocket. A curette is used with a of the pocket. A curette is used with a pull stroke. pull stroke.

The blades must be sharp to be of any The blades must be sharp to be of any value. value.

examples are the Gracey curettes (1 examples are the Gracey curettes (1 through 14) with flexible shanks.through 14) with flexible shanks.

Gracey curettes are area Gracey curettes are area specific specific

1-2 1-2 Anterior Anterior teethteeth

3-4 Anterior 3-4 Anterior teethteeth

5-6 Anterior 5-6 Anterior and bicuspid and bicuspid teethteeth

7-8 Posterior 7-8 Posterior teeth - buccal teeth - buccal and lingual and lingual surfacessurfaces

9-10 Posterior 9-10 Posterior teeth -buccal teeth -buccal and lingual and lingual surfacessurfaces

11-12 11-12 Posterior Posterior teeth - mesial teeth - mesial surfacessurfaces

13-14 13-14 Posterior Posterior teeth - distal teeth - distal surfacessurfaces

Periodontal Hoe Periodontal Hoe

is used to remove gross is used to remove gross amounts of supragingival amounts of supragingival calculus and some calculus and some subgingival calculus in large subgingival calculus in large wide-open pockets where wide-open pockets where gingival tissues are soft and gingival tissues are soft and very easily cleaned.very easily cleaned.

used with a pull stroke. used with a pull stroke. examples of periodontal hoes examples of periodontal hoes

are the Orban 6/7 and 8/9 are the Orban 6/7 and 8/9 and Kirkland 14. and Kirkland 14.

Periodontal Hoe (HOE, PERIODONTAL). The periodontal hoe (figure 4-3) is used to remove gross amounts of supragingival calculus and some subgingival calculus in large wide-open pockets where gingival tissues are soft and very easily cleaned. The periodontal hoe is used with a pull stroke. Some examples of periodontal hoes are the Orban 6/7 and 8/9 and Kirkland 14.

Figure 4-3. Periodontal hoes.

Subgingival S and root Subgingival S and root planing using Universal or planing using Universal or

Gracey curetteGracey curette Modified Pen grasp and stable Modified Pen grasp and stable

finger rest to the toothfinger rest to the tooth Adapt cutting edge to the tooth Adapt cutting edge to the tooth

and lower shank parallel to and lower shank parallel to tooth surfacetooth surface

Insert blade under gingiva and Insert blade under gingiva and advance to base of pocket with advance to base of pocket with light exploratory strokelight exploratory stroke

At the base, 45 to 90 degrees At the base, 45 to 90 degrees working angulation is working angulation is establishedestablished

Apply lateral pressure against Apply lateral pressure against tooth surfacetooth surface

Use controlled, overlapping Use controlled, overlapping short powerful strokes using short powerful strokes using wrist –arm motion in wrist –arm motion in coronal coronal directiondirection

Confine only to Confine only to “Instrumentation zone”- “Instrumentation zone”- portions where calculus is portions where calculus is found on tooth surfacefound on tooth surface

Shank positionShank position

correct position of correct position of shank, parallel with shank, parallel with long axis of toothlong axis of tooth

engage apical or engage apical or lateral edge of lateral edge of deposit with cutting deposit with cutting edge of scaleredge of scaler

Enter facially and Enter facially and lingually with lingually with overlapping strokesoverlapping strokes

sharpening of instrunments.DAT

TOPICAL APPLICATION TOPICAL APPLICATION OF FLUORIDES AND OF FLUORIDES AND

OTHER AGENTSOTHER AGENTS Fluorides for root Fluorides for root sensitivity- fluoride sensitivity- fluoride varnish, flouride gel, varnish, flouride gel,

sealantssealants anti-microbial and/or anti-microbial and/or

anti-cariogenic anti-cariogenic agents- chlorhexidine agents- chlorhexidine / hexetidine / hexetidine mouthwash, mouthwash, toothpaste, perio toothpaste, perio chipchip

***Although mechanical ***Although mechanical plaque control is plaque control is necessary and not necessary and not replaceable by chemical replaceable by chemical plaque control- fluoride plaque control- fluoride toothpastes, topical toothpastes, topical application of fluoride application of fluoride and mouthrinse should and mouthrinse should be used as needed for be used as needed for caries control and caries control and reduction of gingivitis in reduction of gingivitis in perio patients.perio patients.

CHEMOTHERAPEUTIC CHEMOTHERAPEUTIC AGENTS IN PERIO TXAGENTS IN PERIO TX

Chemotherapeutic Chemotherapeutic agents-chemical agents-chemical subs providing subs providing clinical therapeutic clinical therapeutic benefitbenefit

ANTIBIOTICS-natural ANTIBIOTICS-natural occuring, occuring, semisynthetic and semisynthetic and synthetic to destroy synthetic to destroy and inhibit growth of and inhibit growth of microorg.microorg.

ANTISEPTICS-topical ANTISEPTICS-topical application- application- mouthrinse and mouthrinse and dentrificesdentrifices

DISINFECTANTS-DISINFECTANTS-inanimate objectsinanimate objects

Topical Topical antimicrobialsantimicrobials

have emerged ashave emerged as

important adjuncts important adjuncts toto

nonsurgical nonsurgical therapy.therapy.

Chlorhexidine Chlorhexidine gluconate- gluconate- antiplaque rinse antiplaque rinse for 2 weeksfor 2 weeks

Povidone-iodine Povidone-iodine ( betadine) ( betadine) effective even in effective even in low dose in perio low dose in perio pockets even at pockets even at low conc.low conc.

CHLORHEXIDINE CHLORHEXIDINE GLUCONATEGLUCONATE

Tx for malaria in Tx for malaria in 22ndnd WW WW

Disinfectant and Disinfectant and antimicrobial in antimicrobial in very low very low concentrationsconcentrations

Rindolm Schiott Rindolm Schiott and Harald Loe, !and Harald Loe, !970’s Europe, 970’s Europe, 1986 in US1986 in US

CETYLPYRIDINIUM CETYLPYRIDINIUM CHLORIDE CPCCHLORIDE CPC

0.05 % conc results in 0.05 % conc results in immediate reduction of immediate reduction of bacterial counts which bacterial counts which is adequate to > 99%is adequate to > 99%

CPC -Active ingredient CPC -Active ingredient of oral antiseptic of oral antiseptic mouthrinsemouthrinse

Rapid bactericidal effect Rapid bactericidal effect on gm + pathogens and on gm + pathogens and fungicide effect on yeast fungicide effect on yeast ( candida albicans)( candida albicans)

Inhibits plaque and Inhibits plaque and hereby reduce hereby reduce gingivites as well gingivites as well as in treating as in treating Oropharyngeal Oropharyngeal candidiasis candidiasis

ZincZinc

Aids in wound Aids in wound healing by healing by promoting platelet promoting platelet aggregationaggregation

Zinc + CHX had a Zinc + CHX had a synergistic anti-synergistic anti-VSC effect and VSC effect and was effective for at was effective for at least 9 hours. least 9 hours. (2003 (2003 Aug. Young , Jongski, Rolla, dept Aug. Young , Jongski, Rolla, dept o Cariology, Faculty of Dent , o Cariology, Faculty of Dent , Univ. of Oslo, Norway.)Univ. of Oslo, Norway.)

DENCYTOLDENCYTOL

.05 % Chlorhexidine .05 % Chlorhexidine GluconateGluconate

CPC .05 %CPC .05 % Zinc GluconateZinc Gluconate XylitolXylitol Sodium saccharineSodium saccharine Polysorbate 20Polysorbate 20 dionized/steritized dionized/steritized

waterwater

Mode of actionMode of action

Antibacterial/ Antibacterial/ antifungal effect antifungal effect on both gram + on both gram + and gram – and gram – bacteriabacteria

Locally delivered Locally delivered antimicrobialsantimicrobialsProduct Antimicrob

ial agentFDA clearance

Dosage form

Actisite Tetracycline Yes Non resorbable fiber

Actisite fiber provides continuous release of tetracycline for 10 days. At the end of 10 days of treatment, all fibers must be removed. Fibers lost before 7 days should be replaced.

Arestin Minocycline No Biodegrable powder in syrinque

A minocycline hyclate powder is placed into the diseased pocket, where it will dissolve in 7-10 days.

Atridox Doxyclycline

yes Biodegradable mixture in syringe(gel)

A doxycycline hyclate gel is placed into the diseased pocket, where it will dissolve in 7-10 days.

Perio cline Minocycline no Biodegradable device in syringe

Periochip Chlorhexidine

Yes Diodegradable device( gelatin matrix)

A chlorhexidine gluconate gelatin disk is placed into the diseased pocket, where it

will dissolve in 7-10 days.5-8mm in 7-10 days, w/ 2 mm depth reduction

Actisite® periodontal fiber Actisite® periodontal fiber for periodontal pocket for periodontal pocket placement consists of a 23 cm placement consists of a 23 cm (9 inch) monofilament of (9 inch) monofilament of ethylene/vinyl acetate ethylene/vinyl acetate copolymer, 0.5 mm in copolymer, 0.5 mm in diameter, containing 12.7 mg diameter, containing 12.7 mg of evenly dispersed of evenly dispersed tetracycline hydrochloride, tetracycline hydrochloride, USP.Actisite® fiber provides USP.Actisite® fiber provides continuous release of continuous release of tetracycline for 10 days. tetracycline for 10 days.

Actisite is an antibiotic Actisite is an antibiotic originally isolated from originally isolated from Streptomyces aureofaciensStreptomyces aureofaciens. .

The length of fiber used will vary The length of fiber used will vary with pocket depth and contour. with pocket depth and contour. The fiber should be placed to The fiber should be placed to closely approximate the pocket closely approximate the pocket anatomy and should be in contact anatomy and should be in contact with the base of the pocket. An with the base of the pocket. An appropriate cyanoacrylate appropriate cyanoacrylate adhesive should be used to help adhesive should be used to help secure the fiber in the pocket. secure the fiber in the pocket.

When placed within a periodontal When placed within a periodontal pocket, Actisite fiber provides pocket, Actisite fiber provides continuous release of tetracycline continuous release of tetracycline for 10 days. At the end of 10 days for 10 days. At the end of 10 days of treatment, all fibers must be of treatment, all fibers must be removed. Fibers lost before 7 days removed. Fibers lost before 7 days should be replaced. should be replaced.

SEE ARESTIN IN SEE ARESTIN IN ACTIONACTION

http://http://www.arestin.com/www.arestin.com/for-professionals-for-professionals-mode-action.jspmode-action.jsp

ARESTIN®ARESTIN® Microspheres are a bioadhesive, Microspheres are a bioadhesive,

bioresorbable polymer in powder form bioresorbable polymer in powder form produced by a microencapsulation produced by a microencapsulation process. Once ARESTIN® is process. Once ARESTIN® is administered, it immediately adheres administered, it immediately adheres to the periodontal pocket.to the periodontal pocket.

Crevicular fluid hydrolyzes the Crevicular fluid hydrolyzes the polymer causing water-filled channels polymer causing water-filled channels to form inside the Microspheres. These to form inside the Microspheres. These holes provide "escape routes" for the holes provide "escape routes" for the encapsulated antibiotic for sustained encapsulated antibiotic for sustained release. The active drug dissolves and release. The active drug dissolves and diffuses out of the Microspheres diffuses out of the Microspheres through the channels into the through the channels into the surrounding tissue. Eventually, the surrounding tissue. Eventually, the Microspheres themselves are Microspheres themselves are fragmented through polymer fragmented through polymer hydrolysis and are completely hydrolysis and are completely bioresorbed.bioresorbed.

maintains therapeutic drug maintains therapeutic drug concentrations for up to 21 days.concentrations for up to 21 days.

http://www.arestin.com/for-professionals-mode-action.jsp

PeriochipPeriochip

http://http://www.periochip.cowww.periochip.com/Index.asp?m/Index.asp?CategoryID=123CategoryID=123

Chlorhexidine Chip – the Chlorhexidine Chip – the only bacteriocidal only bacteriocidal subgingival therapysubgingival therapy

PerioChip® is the only PerioChip® is the only antiseptic bacteriocidal antiseptic bacteriocidal adjucnt therapy to SRP, adjucnt therapy to SRP, indicated for Periodontitisindicated for Periodontitis

A Dexcel Pharma product, PerioChip® is a small, orange brown, rectangular chip (rounded at one end) for insertion into periodontal pockets that are at least 5mm deep.PerioChip® is composed of 2.5 mg Chlorhexidine D-gluconate in a biodegradable matrix of hydrolyzed gelatin, cross linked with glutaraldehyde. Chlorhexidine is the leading standard, broad - spectrum antimicrobial agent. In the form of a chip, PerioChip® is the only antiseptic locally applied agent to treat Periodontitis.

http://http://www.periochip.cowww.periochip.com/Index.asp?m/Index.asp?CategoryID=123CategoryID=123

Systemic Use of AntibioticsSystemic Use of AntibioticsIndications :Indications : Multiple sites unresponsive to mechanical Multiple sites unresponsive to mechanical

debridementdebridement Acute periodontal infections and ongoing Acute periodontal infections and ongoing

disease progression associated with disease progression associated with systemic manifestationssystemic manifestations

Presence of tissue invasive organismsPresence of tissue invasive organisms prophylaxis in medically compromised prophylaxis in medically compromised

patients,patients, as an adjunct to surgical and non-surgical as an adjunct to surgical and non-surgical

periodontalperiodontal therapy.therapy.

Slots J, van Winkelhoff AJ. Antimicrobial Slots J, van Winkelhoff AJ. Antimicrobial therapy in periodontics. therapy in periodontics. J Calif Dent Assoc J Calif Dent Assoc 1993;21(Nov.):51-561993;21(Nov.):51-56

COMMON ANTIBIOTIC REGIMEN in COMMON ANTIBIOTIC REGIMEN in treating Periodontal diseases treating Periodontal diseases Jorgenson MG , Jorgenson MG , Slots, J Practical antimicrobial periodontal therapy, Compend Slots, J Practical antimicrobial periodontal therapy, Compend

Contin Educ Dent 2000; 21:111Contin Educ Dent 2000; 21:111

SINGLE AGENT

Metronidazole 250-500mg tid 8 days

Ciprofloxacin 500mg bid 8 days

Clindamycin 300mg bid 8 days

COMBINATION THERAPY

Metronidazole/ amoxicillin

250mg of each tid.

8 days

Metronidazole. Ciprofloxacin

500mg of each bid-mixed anaerobic-enteric rod infections.

8 days

Guidelines for use of Guidelines for use of antibiotics in perioantibiotics in perio

Clinical diagnosisClinical diagnosis _> 5 mm pockets that _> 5 mm pockets that

bleed on probing bleed on probing microbial composition microbial composition

of plaque, medical of plaque, medical status and current status and current medsmeds

Microbiologic sampling Microbiologic sampling before instrumentationbefore instrumentation

May not undergo perio May not undergo perio surgery for chronic surgery for chronic periodontitisperiodontitis

Not use as Not use as monotherapymonotherapy

But must be part of But must be part of comprehensive tx comprehensive tx planplan

Use antibiotics 1 to 2 Use antibiotics 1 to 2 days before surgery days before surgery for a total of 8 days.for a total of 8 days.( for regenerative ( for regenerative wound healing) wound healing) SLOTS, SLOTS,

PRACTICAL ANTIMICROBIAL PERIODONTAL THERAY, PRACTICAL ANTIMICROBIAL PERIODONTAL THERAY, COMPEND CONTIN EDUC DENT 2000, 21:111COMPEND CONTIN EDUC DENT 2000, 21:111

Cost can be a Cost can be a determinant in selecting determinant in selecting

antimicrobialantimicrobiallower costlower cost TetracyclinesTetracyclines amoxicillin,amoxicillin, metronidazole.metronidazole.

More expensive More expensive azithromycin,azithromycin, clarithromycin,clarithromycin, ciprofloxacin,ciprofloxacin, amoxicillinamoxicillin Clavulanic acid,Clavulanic acid, clindamycin.clindamycin.

MetronidazoleMetronidazole Recalcitrant periodontitis with Recalcitrant periodontitis with

P.Gingivalis and/or P.IntermediaP.Gingivalis and/or P.Intermedia   Effective antibacterial concentrations Effective antibacterial concentrations

in gingival tissue and crevicular fluidin gingival tissue and crevicular fluid Cleared by hepatic metabolism with a Cleared by hepatic metabolism with a

half-life of 6-14 hours and prolonged half-life of 6-14 hours and prolonged by hepatic function impairment by hepatic function impairment 

Interaction with warfarin Interaction with warfarin 

ClindamycinClindamycin Recurrent periodontitis with Recurrent periodontitis with

Peptostreptococcus, Peptostreptococcus, ββ-streptococci -streptococci and various oral and various oral Gram(-) anaerobic Gram(-) anaerobic rodsrods  

Pseudomembranous colitis may result Pseudomembranous colitis may result due to overgrowth of due to overgrowth of C. difficileC. difficile

  

TetracyclinesTetracyclines For For A.actinomycetemcomitansA.actinomycetemcomitans species species Inhibit gingival collagenasesInhibit gingival collagenases Doxycycline - highest protein binding Doxycycline - highest protein binding

capacity, longest half-lifecapacity, longest half-life

Minocycline – best absorption, and tissue Minocycline – best absorption, and tissue penetrationpenetration

Adverse effect to teeth and bonesAdverse effect to teeth and bones Not for pregnant women, <8years of age Not for pregnant women, <8years of age

  

Fluoroquinolones (Ciprofloxacin)Fluoroquinolones (Ciprofloxacin) For For enteric rods, pseudomonads, enteric rods, pseudomonads,

staphylococci, A.actinomycetemcomitansstaphylococci, A.actinomycetemcomitans Penetrate readily into the periodontium Penetrate readily into the periodontium

and reach a high concentration and reach a high concentration  May induce tendinopathy May induce tendinopathy  Strenuous exercise should be avoided Strenuous exercise should be avoided

during therapyduring therapy

  

Food does not influence the Food does not influence the bioavailability of mostbioavailability of most

oral antibioticsoral antibiotics except except tetracyclines,tetracyclines, fluoroquinolones,fluoroquinolones, azithromycin. azithromycin.

These three groupsThese three groups

of antibiotics should of antibiotics should be taken 1 hour be taken 1 hour before before

or 2 hours after or 2 hours after food intake.food intake.

AzithromycinAzithromycin Also highly active against Also highly active against

many periodontal pathogensmany periodontal pathogens Excellent penetration into Excellent penetration into

both normal and pathological both normal and pathological periodontal tissuesperiodontal tissues

  

Metronidazole + AmoxicillinMetronidazole + Amoxicillin Predictable eradication of Predictable eradication of

A.actinomycetemcomitansA.actinomycetemcomitans and marked suppression of and marked suppression of P. P. gingivalisgingivalis in aggressive forms in aggressive forms of adolescent periodontitis of adolescent periodontitis and in recalcitrant adult and in recalcitrant adult periodontitisperiodontitis

Metronidazole + CiprofloxacinMetronidazole + Ciprofloxacin Substitute for Metronidazole Substitute for Metronidazole

+ Amoxicillin for those who + Amoxicillin for those who are allergic to are allergic to ββ-lactam drugs-lactam drugs

At least 18 years of ageAt least 18 years of age

ReevaluationReevaluation

Every 4 weeks Every 4 weeks after completion of after completion of scaling and root scaling and root planing proceduresplaning procedures

To permit time for To permit time for epithelial and epithelial and connective tissue connective tissue healing and time to healing and time to assess oral hygiene assess oral hygiene skills of Pxskills of Px

Response to non-surgical Response to non-surgical treatment- guidelines treatment- guidelines

IDEAL SATISFACTORY UNSATISFACTORY

Plaque score <15 % >15-40% >40%

Probing depths 1-3mm Most 1-4 few 4-6mm

Many >6mm

Furcation involvement

None Early grade/incipient

Grade II/III

Bleeeding score for non smokers

<10% >10% < 40% depending on susceptibility

>40%

Future treatment options

Simple maintenance

1. Maintenance with subgingival removal from residual pockets and

re-evaluation in 1 year

2. Surgery if plaque scores are low.

1. Improve plaque scores and re treat.

2. Extract untreatable teeth

3. Maintain as best as possible.

PPERIOSCOPY

ERIOSCOPY

Perioscopy makes use of a Perioscopy makes use of a

technology similar to the technology similar to the

orthoscopic and endoscopic procedures orthoscopic and endoscopic procedures used in medicine for many years.used in medicine for many years.

If perioscopy is properly paired with regenerative If perioscopy is properly paired with regenerative proteins, and anti-inflammatory medication, proteins, and anti-inflammatory medication, bone loss damage can be reversed.  This unique bone loss damage can be reversed.  This unique synergistic protocol is known as synergistic protocol is known as RPERPE - - Regenerative Periodontal Endoscopy.Regenerative Periodontal Endoscopy.

1 meter in length 1 meter in length and .99 mm in and .99 mm in diameter. It is made diameter. It is made up of 10,000 optical up of 10,000 optical and 19 illumination and 19 illumination elements.elements.

RPE: Regenerative RPE: Regenerative Periodontal Endoscopy.Periodontal Endoscopy.

Non-surgical periodontal disease Non-surgical periodontal disease treatment treatment

RPERPE is an advanced is an advanced non-invasive periodontal procedurenon-invasive periodontal procedure combining fiber optic microscope technology with regenerative combining fiber optic microscope technology with regenerative proteins. This unique synergistic approach is an exciting proteins. This unique synergistic approach is an exciting breakthrough in non-surgical periodontal therapy, providing breakthrough in non-surgical periodontal therapy, providing your patients with a definitive new option in non-surgical your patients with a definitive new option in non-surgical periodontal disease treatment. periodontal disease treatment.

RPE is a conservative treatment program which emphasizes the RPE is a conservative treatment program which emphasizes the preservation of the teeth, gums, and bone. RPE can dramatically preservation of the teeth, gums, and bone. RPE can dramatically reduce or even eliminate the need for aggressive periodontal reduce or even eliminate the need for aggressive periodontal surgery, as well as the need for multiple rounds of antibiotics surgery, as well as the need for multiple rounds of antibiotics and deep cleanings. In addition, all dental disease conditions and deep cleanings. In addition, all dental disease conditions can be pinpointed much earlier, preventing further problems.can be pinpointed much earlier, preventing further problems.

Subgingival endoscopy is a miniature Subgingival endoscopy is a miniature fiberoptic camera that provides real-time fiberoptic camera that provides real-time visualization of subgingival anatomy visualization of subgingival anatomy enhanced by intense illumination and 24-enhanced by intense illumination and 24-48x magnification. 48x magnification.

The DV2 Perioscopy System integrates a The DV2 Perioscopy System integrates a miniature camera, light, water irrigation, a miniature camera, light, water irrigation, a digital processor, and a flat panel video digital processor, and a flat panel video monitor that captures the real-time monitor that captures the real-time images. images.

The illumination and water are controlled The illumination and water are controlled by a foot-activated control system. by a foot-activated control system.

The Perioscopy camera magnifies root The Perioscopy camera magnifies root surfaces, furcations, and soft tissue in the surfaces, furcations, and soft tissue in the pocket. pocket.

It pinpoints residual calculus remaining It pinpoints residual calculus remaining after traditional instrumentation andafter traditional instrumentation and

allows for more thorough removal of allows for more thorough removal of tenacious depositstenacious deposits

Perioscope techniquePerioscope technique

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Subgingival micro ultrasonic Subgingival micro ultrasonic endoscopic periodontal endoscopic periodontal debridementdebridement

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Why is RPE - Regenerative Periodontal Why is RPE - Regenerative Periodontal Endoscopy - a better method than Endoscopy - a better method than

surgery for treating Periodontal Disease?surgery for treating Periodontal Disease? EffectivenessEffectiveness - using the dental endoscope, skilled clinicians are able to - using the dental endoscope, skilled clinicians are able to see below the gum line to find and treat areas of plaque and calculus that see below the gum line to find and treat areas of plaque and calculus that would go undetected in traditional treatment methods. RPE - Regenerative would go undetected in traditional treatment methods. RPE - Regenerative Periodontal Endoscopy - is a unique and very specific protocol aimed at Periodontal Endoscopy - is a unique and very specific protocol aimed at arresting disease and regenerating lost bone around the teeth.arresting disease and regenerating lost bone around the teeth.

Freedom from painFreedom from pain - because the instruments are so tiny and so - because the instruments are so tiny and so accurate, RPE treatments are almost completely painless.accurate, RPE treatments are almost completely painless.

Long Term ResultsLong Term Results - because RPE addresses all aspects of - because RPE addresses all aspects of the periodontal disease process, and not just merely the removal of the the periodontal disease process, and not just merely the removal of the calculus trapped under the gums, we observe long term periodontal health.calculus trapped under the gums, we observe long term periodontal health.

CostCost - RPE costs much less than periodontal surgery - the real savings is in - RPE costs much less than periodontal surgery - the real savings is in prevention of tooth loss and the enormous costs associated with tooth prevention of tooth loss and the enormous costs associated with tooth replacement. replacement. 

CosmeticsCosmetics - RPE treatments do not cause the gum disfigurement that - RPE treatments do not cause the gum disfigurement that sometimes results from osseous periodontal surgery.sometimes results from osseous periodontal surgery.

PreventionPrevention -  undiagnosed dental problems-such as decay or failing -  undiagnosed dental problems-such as decay or failing restorations-can be detected early with RPE, preventing larger problems. restorations-can be detected early with RPE, preventing larger problems.

What are the benefits to What are the benefits to the patient?the patient?

less traumatic procedure with less less traumatic procedure with less discomfort, faster discomfort, faster healing time, no healing time, no post-operative visits, and less post-operative visits, and less gingival recession than after gingival recession than after surgery. surgery.

Benefits of Dental Benefits of Dental Endoscopy to the General Endoscopy to the General

DentistDentist   Effective Diagnostic SupportEffective Diagnostic Support Seeing subgingivally aids in determining the Seeing subgingivally aids in determining the

cause of undisclosed pain due to root cause of undisclosed pain due to root fractures, subgingival caries, root resorption, fractures, subgingival caries, root resorption, post perforations, even extruded gutta perchapost perforations, even extruded gutta percha

Endoscopic vision gives you “clinical Endoscopic vision gives you “clinical restorative peace of mind”restorative peace of mind”

The dentist can deliver cosmetic and crown & The dentist can deliver cosmetic and crown & bridge cases with the confidence that a hidden bridge cases with the confidence that a hidden root problem won’t lead to a failed foundation root problem won’t lead to a failed foundation and a costly remakeand a costly remake

Benefits of Dental Benefits of Dental Endoscopy to the General Endoscopy to the General

DentistDentist Accurately determine whether a crown margin is Accurately determine whether a crown margin is

open or decayed, as well as visualize residual cement open or decayed, as well as visualize residual cement that can lead to soft tissue inflammationthat can lead to soft tissue inflammation

Subgingival sight immediately allows a practitioner Subgingival sight immediately allows a practitioner to become a better root diagnosticianto become a better root diagnostician

Effective Minimally Invasive Periodontal Effective Minimally Invasive Periodontal TherapyTherapy

Finally a way to treat the hundreds of perio patients Finally a way to treat the hundreds of perio patients in your practice with 4+ mm pocketsin your practice with 4+ mm pockets

Scaling under direct visualization gives Scaling under direct visualization gives clinicians the ability to provide definitive root clinicians the ability to provide definitive root debridementdebridement

Benefits of Dental Benefits of Dental Endoscopy to the General Endoscopy to the General

DentistDentist High Patient AcceptanceHigh Patient Acceptance Perioscopy is a comfortable and well-tolerated Perioscopy is a comfortable and well-tolerated

minimally-invasive procedureminimally-invasive procedure Most patients who are aware they are Most patients who are aware they are

periodontally-involved are compelled by a way periodontally-involved are compelled by a way to save their teeth that can possibly avoid to save their teeth that can possibly avoid surgerysurgery

The dental endoscopy option gives your The dental endoscopy option gives your patients the choice to be treated in the setting patients the choice to be treated in the setting where they are most comfortable – your officewhere they are most comfortable – your office

Advanced perio patients especially are Advanced perio patients especially are thrilled to have a viable option other than thrilled to have a viable option other than surgery (particularly those who have surgery (particularly those who have already experienced flap surgery)already experienced flap surgery)

Of course, patients with severe localized Of course, patients with severe localized or aaggressive periodontal disease will or aaggressive periodontal disease will often still benefit clinically from being often still benefit clinically from being appropriate specialty referralappropriate specialty referral

Pleased patients will enthusiastically tell Pleased patients will enthusiastically tell family members, coworkers and friendsfamily members, coworkers and friends

Benefits of Perioscopy™ Benefits of Perioscopy™ to the Periodontistto the Periodontist

   Reach Patients You Have Not Been Reach Patients You Have Not Been

TreatingTreating Those patients who come to your office Those patients who come to your office

but fear or refuse surgery now become but fear or refuse surgery now become prime candidates for Perioscopyprime candidates for Perioscopy

Periodontist has the option to use Periodontist has the option to use Perioscopy exclusively for minimally-Perioscopy exclusively for minimally-invasive treatment, as an adjunct to flap invasive treatment, as an adjunct to flap surgery, or bothsurgery, or both

Patients referred by a general dentist Patients referred by a general dentist who tells his/her patients you offer a who tells his/her patients you offer a less-invasive solution are more likely less-invasive solution are more likely to actually walk into your officeto actually walk into your office

Patients are likely to proceed with Patients are likely to proceed with Perioscopy treatment when they Perioscopy treatment when they literally see the calculus, furcation or literally see the calculus, furcation or root fracture on the monitor in front root fracture on the monitor in front of them during an examof them during an exam

Strengthen Relationships between the Strengthen Relationships between the Periodontist and Referring DentistsPeriodontist and Referring Dentists

Dentists will preferentially refer cases to Dentists will preferentially refer cases to the periodontist in their community known the periodontist in their community known to give their patients the best available to give their patients the best available and least-invasive treatmentand least-invasive treatment

Referring docs will increasingly send their Referring docs will increasingly send their best patients and biggest perio cases to best patients and biggest perio cases to the leading-edge periodontist who has the leading-edge periodontist who has embraced Perioscopy embraced Perioscopy

Clinical Treatment Results and User Clinical Treatment Results and User Skills Will ImproveSkills Will Improve

Periodontist is able to see exactly where Periodontist is able to see exactly where other non-invasive therapies are being other non-invasive therapies are being applied and better monitor how they are applied and better monitor how they are progressingprogressing

Superclean Perioscopy root surfaces are Superclean Perioscopy root surfaces are highly likely to reduce or stop tissue highly likely to reduce or stop tissue inflammationinflammation

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Results of phase I therapy and maintenanceCase : Severe Chronic periodontitis after 3 weeks and 18 monthsWith non surgical perio dontal treatment- scaling, root planing and plaque control therapy

p. 607 Clinical Perio, Carranza