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Current approach in periodontal care, Rashidah Ayob, periodontal care, dentistry, Malaysian association of dental public health conference
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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.