Overview of Periodontics Overview of Periodontics for the General Practicionerfor the General Practicioner

Nashville Area Dental Continuing EducationNashville Area Dental Continuing EducationAugust 27, 2008August 27, 2008

Phillip D. Woods, DDS, MPHPhillip D. Woods, DDS, MPHCommander, USPHSCommander, USPHS

BOP National Periodontal ConsultantBOP National Periodontal ConsultantDiplomate, American Academy of PeriodontologyDiplomate, American Academy of Periodontology

Chief Dentist, MCC San DiegoChief Dentist, MCC San Diego

MCC San DiegoMCC San Diego

The Metropolitan The Metropolitan Correctional Center Correctional Center (MCC) San Diego, (MCC) San Diego, California is an California is an administrative facility administrative facility housing nearly 1000 housing nearly 1000 male and female inmatesmale and female inmates

Overview of PresentationOverview of Presentation

Pathogenesis of Periodontal DiseasesPathogenesis of Periodontal Diseases

CPITNCPITN

Current AAP Classification of Current AAP Classification of

Periodontal DiseasesPeriodontal Diseases

Sequencing of Periodontal TreatmentSequencing of Periodontal Treatment

BackgroundBackground

Oral Health in America: A Report of the Oral Health in America: A Report of the Surgeon General (2000).Surgeon General (2000).

Poor oral health is concentrated primarily among Poor oral health is concentrated primarily among lowlow--income, minority and immigrant populations.income, minority and immigrant populations.

Access to dental care is major problem for these Access to dental care is major problem for these populationspopulations

Pathogenesis of GingivitisPathogenesis of Gingivitis

Initial LesionInitial Lesion

Early LesionEarly Lesion

Established LesionEstablished Lesion

Pathogenesis of PeriodontitisPathogenesis of Periodontitis

Loss of Connective Tissue Attachment in Loss of Connective Tissue Attachment in presence of inflammationpresence of inflammationMigration of Epithelial Attachment along the Migration of Epithelial Attachment along the root surfaceroot surfaceLoss of BoneLoss of BoneHistopathology similar to established lesionHistopathology similar to established lesion

Bacterial virulenceBacterial virulenceDestruction of periodontal tissuesDestruction of periodontal tissues

Pathway to periodontal diseasePathway to periodontal disease

Presence of BacteriaPresence of BacteriaActinobacillus actinomycetemcomitansActinobacillus actinomycetemcomitansPorphyromonas gingivalisPorphyromonas gingivalisBacteroides forsythusBacteroides forsythus

Endotoxin: LipopolysaccharideEndotoxin: LipopolysaccharideReleased from gram (Released from gram (--) bacteria) bacteriaInitiates host responseInitiates host responseActs with host factors>bone resorptionActs with host factors>bone resorption

Diagnosis of Periodontal DiseasesDiagnosis of Periodontal Diseases

The diagnosis of periodontal disease is a process The diagnosis of periodontal disease is a process that involves observation and measurement of that involves observation and measurement of numerous factors and then combining one's numerous factors and then combining one's findings into a summary statement of the findings into a summary statement of the patient's oral disease status. patient's oral disease status.

CPITNCPITN

Community Periodontal Index of Community Periodontal Index of Treatment NeedsTreatment Needs

World Health OrganizationWorld Health OrganizationUseful in public health surveys and screeningUseful in public health surveys and screeningRequires use of a Periodontal ProbeRequires use of a Periodontal ProbeModified by American Academy of Modified by American Academy of Periodontology as PSR SystemPeriodontology as PSR System

WHO ProbeWHO Probe

SEXTANTSSEXTANTS

1 3

2

46

5

Third molarsdon’t count!

PROBINGPROBING

EXAMINE each toothEXAMINE each toothWALK probe around creviceWALK probe around creviceRECORD highest scoreRECORD highest score

Main Requirement of CPITNMain Requirement of CPITN

Use a Probe !!!!!!!!Use a Probe !!!!!!!!

Community Index of Periodontal Community Index of Periodontal Treatment NeedsTreatment Needs

IndicatorsIndicatorsPresence or Absence of BleedingPresence or Absence of BleedingSupraSupra--gingival or Subgingival or Sub--gingival Calculusgingival CalculusPeriodontal PocketsPeriodontal Pockets

Shallow (4Shallow (4--5 mm)5 mm)Deep (6 mm or >)Deep (6 mm or >)

Community Index of Periodontal Community Index of Periodontal Treatment NeedsTreatment Needs

How to ProbeHow to Probe““SensingSensing”” Periodontal PocketsPeriodontal Pockets

Use Use < < 20 grams of force20 grams of forceAlign probe with long axis of toothAlign probe with long axis of toothExplore total extent of pocketExplore total extent of pocket

CPITN CPITN -- Code 0Code 0

CPITN CPITN –– Code 1Code 1

CPITN CPITN –– Code 2Code 2

CPITN CPITN -- Code 3Code 3

CPITN CPITN -- Code 4Code 4

CPITN Codes, Diagnostic Features & TxCPITN Codes, Diagnostic Features & Tx

CPITN ScoreCPITN Score Dx FeatureDx Feature Recommended TxRecommended Tx00 Healthy tissueHealthy tissue NoneNone11 Bleeding upon probingBleeding upon probing EducationEducation22 Calculus or overhangs Calculus or overhangs

and no PD > 3mmand no PD > 3mmEducation, ProphyEducation, Prophy

33 At least one PD 4At least one PD 4--5mm5mm Education, Prophy, Education, Prophy, ScRPScRP

44 At least one PD of At least one PD of 6mm or >6mm or >

Education, Prophy, Education, Prophy, ScRP, Surgery prnScRP, Surgery prn

XX Fewer than 2 teeth Fewer than 2 teeth function in sextantfunction in sextant

Exclude from Exclude from needs assessmentneeds assessment

North Carolina ProbeNorth Carolina Probe

Detecting FurcationsDetecting Furcations

Nabors ProbeNabors Probe

ReviewReview

4242--11

The Comprehensive Periodontal The Comprehensive Periodontal ExaminationExamination

Circumferential probing depthsCircumferential probing depthsAreas of recessionAreas of recessionAreas of food impactionAreas of food impactionBleeding on probingBleeding on probingTooth mobilityTooth mobilityRadiographsRadiographsTooth vitalityTooth vitality

Former Periodontal DiagnosesFormer Periodontal Diagnoses1. Adult1. Adult2. Early2. Early--OnsetOnsetPrepubertal (localized and generalized)Prepubertal (localized and generalized)

Juvenile (localized and generalized)Juvenile (localized and generalized)Rapidly ProgressiveRapidly Progressive

3. Periodontitis Associated with Systemic 3. Periodontitis Associated with Systemic DiseaseDisease4. Necrotizing Ulcerative4. Necrotizing Ulcerative5. Refractory5. Refractory

Current Periodontal DiagnosesCurrent Periodontal Diagnoses

Summary of the 1999 International Summary of the 1999 International Workshop for a Classification of Periodontal Workshop for a Classification of Periodontal Diseases and ConditionsDiseases and Conditions

(Armitage, GC. (Armitage, GC. Ann PeriodontolAnn Periodontol 1999; 4:11999; 4:1--4)4)

Current Periodontal DiagnosesCurrent Periodontal Diagnoses

I. Gingival Diseases I. Gingival Diseases A. Dental Plaque A. Dental Plaque -- InducedInducedB. NonB. Non--Plaque Plaque –– InducedInduced

II. Chronic PeriodontitisII. Chronic PeriodontitisA. LocalizedA. LocalizedB. GeneralizedB. Generalized

Current Periodontal Diagnoses, cont.Current Periodontal Diagnoses, cont.

III. Aggressive PeriodontitisIII. Aggressive PeriodontitisA. LocalizedA. LocalizedB. GeneralizedB. Generalized

IV. Periodontitis as Manifestation of Systemic DZIV. Periodontitis as Manifestation of Systemic DZAcquired NeutropeniaAcquired NeutropeniaLeukemiasLeukemiasOtherOther

Periodontal DiseasesPeriodontal Diseases

Gingival DiseasesGingival DiseasesChronic PeriodontitisChronic PeriodontitisAggressive PeriodontitisAggressive PeriodontitisPeriodontitis as a Periodontitis as a manifestation of systemic manifestation of systemic diseasedisease

Necrotizing Periodontal Necrotizing Periodontal diseasediseaseAbscesses of the Abscesses of the periodontiumperiodontiumPerioPerio--Endo LesionsEndo LesionsDevelopmental or Developmental or Acquired deformities and Acquired deformities and conditionsconditions

Abscesses of the PeriodontiumAbscesses of the Periodontium

Gingival AbscessGingival Abscess

Periodontal AbscessPeriodontal Abscess

Pericoronal AbscessPericoronal Abscess

Gingival AbscessGingival Abscess

A localized purulent infection that A localized purulent infection that involves the marginal gingiva or involves the marginal gingiva or interdental papillainterdental papilla

Gingival AbscessGingival Abscess

Gingival AbscessGingival Abscess

EtiologyEtiologyAcute inflammatory response to foreign substances Acute inflammatory response to foreign substances forced into the gingivaforced into the gingiva

Clinical FeaturesClinical FeaturesLocalized swelling of marginal gingiva or papillaLocalized swelling of marginal gingiva or papillaA red, smooth, shiny surfaceA red, smooth, shiny surfaceMay be painful and appear pointedMay be painful and appear pointedPurulent exudate may be presentPurulent exudate may be presentNo previous periodontal diseaseNo previous periodontal disease

Gingival AbscessGingival Abscess

TreatmentTreatmentElimination of foreign objectElimination of foreign object

Drainage through sulcus with probe or light scalingDrainage through sulcus with probe or light scaling

FollowFollow--up after 24up after 24--48 hours48 hours

Periodontal AbscessPeriodontal Abscess

A localized purulent infection within the tissues A localized purulent infection within the tissues adjacent to the periodontal pocket that may lead adjacent to the periodontal pocket that may lead to the destruction of periodontal ligament and to the destruction of periodontal ligament and alveolar bonealveolar bone

Periodontal AbscessPeriodontal Abscess

Periodontal AbscessPeriodontal Abscess

Usually preUsually pre--existing chronic periodontitis present!!!existing chronic periodontitis present!!!

Factors associated with abscess developmentFactors associated with abscess developmentOcclusion of pocket orifice Occlusion of pocket orifice (by healing of marginal gingiva following (by healing of marginal gingiva following supragingival scaling)supragingival scaling)

Furcation involvementFurcation involvementSystemic antibiotic therapy Systemic antibiotic therapy (allowing overgrowth of resistant bacteria)(allowing overgrowth of resistant bacteria)

Diabetes MellitusDiabetes Mellitus

Periodontal AbscessPeriodontal Abscess

Clinical FeaturesClinical FeaturesSmooth, shiny swelling of the gingivaSmooth, shiny swelling of the gingivaPainful, tender to palpationPainful, tender to palpationPurulent exudatePurulent exudateIncreased probing depthIncreased probing depthMobile and/or percussion sensitiveMobile and/or percussion sensitiveTooth usually vitalTooth usually vital

Periodontal Vs. Periapical AbscessPeriodontal Vs. Periapical Abscess

Periodontal AbscessPeriodontal AbscessVital toothVital toothNo cariesNo cariesPocketPocketLateral radiolucencyLateral radiolucencyMobilityMobilityPercussion sensitivity variablePercussion sensitivity variableSinus tract opens via Sinus tract opens via keratinized gingivakeratinized gingiva

Periapical AbscessPeriapical AbscessNonNon--vital toothvital toothCariesCariesNo pocketNo pocketApical radiolucencyApical radiolucencyNo or minimal mobilityNo or minimal mobilityPercussion sensitivityPercussion sensitivitySinus tract opens via Sinus tract opens via alveolar mucosaalveolar mucosa

Periodontal AbscessPeriodontal Abscess

TreatmentTreatmentAnesthesiaAnesthesiaEstablish drainageEstablish drainage

Via sulcus is the preferred methodVia sulcus is the preferred methodSurgical access for debridementSurgical access for debridementIncision and drainageIncision and drainageExtractionExtraction

Periodontal AbscessPeriodontal Abscess

Other Treatment Considerations:Other Treatment Considerations:

Limited occlusal adjustmentLimited occlusal adjustmentAntimicrobialsAntimicrobialsCulture and sensitivityCulture and sensitivity

A periodontal evaluation following resolution of acute symptoms is essential!!!

Periodontal AbscessPeriodontal Abscess

Antibiotics Antibiotics (if indicated due to fever, malaise, (if indicated due to fever, malaise, lymphadenopathy, or inability to obtain drainage)lymphadenopathy, or inability to obtain drainage)

Without penicillin allergyWithout penicillin allergyPenicillinPenicillin

With penicillin allergyWith penicillin allergyAzithromycinAzithromycinClindamycinClindamycin

Alter therapy if indicated by culture/sensitivityAlter therapy if indicated by culture/sensitivity

Pericoronal AbscessPericoronal Abscess

A localized purulent infection within the tissue A localized purulent infection within the tissue surrounding the crown of a partially erupted surrounding the crown of a partially erupted tooth.tooth.Most common adjacent to mandibular third Most common adjacent to mandibular third molars in young adults; usually caused by molars in young adults; usually caused by impaction of debris under the soft tissue flapimpaction of debris under the soft tissue flap

Pericoronal AbscessPericoronal Abscess

Pericoronal AbscessPericoronal Abscess

Clinical FeaturesClinical FeaturesOperculum (soft tissue flap)Operculum (soft tissue flap)Localized red, swollen tissueLocalized red, swollen tissueArea painful to touchArea painful to touchTissue trauma from opposing tooth commonTissue trauma from opposing tooth commonPurulent exudate, trismus, lymphadenopathy, fever, Purulent exudate, trismus, lymphadenopathy, fever, and malaise may be presentand malaise may be present

Pericoronal AbscessPericoronal Abscess

Treatment OptionsTreatment OptionsDebride/irrigate under pericoronal flapDebride/irrigate under pericoronal flapTissue recontouring Tissue recontouring (removing tissue flap)(removing tissue flap)

Extraction of involved and/or opposing toothExtraction of involved and/or opposing toothAntimicrobials Antimicrobials (local and/or systemic as needed)(local and/or systemic as needed)

Culture and sensitivityCulture and sensitivityFollowFollow--upup

Necrotizing Periodontal DiseasesNecrotizing Periodontal Diseases

Necrotizing Ulcerative Gingivitis (NUG)Necrotizing Ulcerative Gingivitis (NUG)

Necrotizing Ulcerative Periodontitis (NUP)Necrotizing Ulcerative Periodontitis (NUP)

Necrotizing Ulcerative GingivitisNecrotizing Ulcerative Gingivitis

An infection characterized by gingival necrosis An infection characterized by gingival necrosis presenting as presenting as ““punchedpunched--outout”” papillae, with papillae, with gingival bleeding and paingingival bleeding and pain

Necrotizing Ulcerative GingivitisNecrotizing Ulcerative Gingivitis

Necrotizing Ulcerative GingivitisNecrotizing Ulcerative Gingivitis

Necrosis limited to gingival tissuesNecrosis limited to gingival tissuesEstimated prevalence 0.6% in general populationEstimated prevalence 0.6% in general populationYoung adults (mean age 23 years)Young adults (mean age 23 years)More common in CaucasiansMore common in CaucasiansBacterial floraBacterial flora

Spirochetes (Spirochetes (Treponema Treponema sp.)sp.)Prevotella intermediaPrevotella intermediaFusiform bacteriaFusiform bacteria

Necrotizing Ulcerative GingivitisNecrotizing Ulcerative Gingivitis

Clinical FeaturesClinical FeaturesGingival necrosis, especially tips of papillaeGingival necrosis, especially tips of papillaeGingival bleedingGingival bleedingPainPainFetid breathFetid breathPseudomembrane formationPseudomembrane formation

Necrotizing Ulcerative GingivitisNecrotizing Ulcerative Gingivitis

Necrotizing Ulcerative Necrotizing Ulcerative PeriodontitisPeriodontitis

An infection characterized by necrosis of An infection characterized by necrosis of gingival tissues, periodontal ligament, and gingival tissues, periodontal ligament, and alveolar bonealveolar bone

Necrotizing Ulcerative Periodontitis

Necrotizing Ulcerative Necrotizing Ulcerative PeriodontitisPeriodontitis

Clinical FeaturesClinical FeaturesClinical appearance of NUGClinical appearance of NUGSevere deep aching painSevere deep aching painVery rapid rate of bone destruction Very rapid rate of bone destruction Deep pocket formation not evidentDeep pocket formation not evident

Necrotizing Ulcerative Periodontitis

Necrotizing Periodontal DiseasesNecrotizing Periodontal Diseases

TreatmentTreatmentLocal debridementLocal debridementOral hygiene instructionsOral hygiene instructionsOral rinsesOral rinsesPain controlPain controlAntibioticsAntibioticsModify predisposing factorsModify predisposing factorsProper followProper follow--upup

Necrotizing Periodontal DiseasesNecrotizing Periodontal Diseases

TreatmentTreatmentLocal debridementLocal debridement

Most cases adequately treated by debridement and Most cases adequately treated by debridement and sc/rpsc/rpAnesthetics as neededAnesthetics as neededConsider avoiding ultrasonic instrumentation due to Consider avoiding ultrasonic instrumentation due to risk of HIV transmissionrisk of HIV transmission

Oral hygiene instructionsOral hygiene instructions

Necrotizing Periodontal DiseasesNecrotizing Periodontal Diseases

TreatmentTreatmentOral rinses Oral rinses –– ((frequent, at least until pain subsides frequent, at least until pain subsides allowing effective OH)allowing effective OH)

Chlorhexidine gluconate 0.12%; 1/2 oz 2 x dailyChlorhexidine gluconate 0.12%; 1/2 oz 2 x dailyHydrogen peroxide/waterHydrogen peroxide/waterPovidone iodinePovidone iodine

Pain controlPain control

Necrotizing Periodontal DiseasesNecrotizing Periodontal Diseases

TreatmentTreatmentAntibiotics (systemic or severe involvement)Antibiotics (systemic or severe involvement)

MetronidazoleMetronidazoleAvoid broad spectrum antibiotics in AIDS patientsAvoid broad spectrum antibiotics in AIDS patients

Modify predisposing factorsModify predisposing factorsFollowFollow--upup

Frequent until resolution of symptomsFrequent until resolution of symptomsComprehensive periodontal evaluation following Comprehensive periodontal evaluation following acute phase!!!!acute phase!!!!

Gingival Diseases of Gingival Diseases of Viral OriginViral Origin

Acute manifestations of viral infections of the Acute manifestations of viral infections of the oral mucosa, characterized by redness and oral mucosa, characterized by redness and multiple vesicles that easily rupture to form multiple vesicles that easily rupture to form painful ulcers affecting the gingiva.painful ulcers affecting the gingiva.

Primary Herpetic Primary Herpetic GingivostomatitisGingivostomatitis

Classic initial infection of herpes simplex type 1Classic initial infection of herpes simplex type 1

Mainly in young children Mainly in young children

90% of primary oral infections are asymptomatic90% of primary oral infections are asymptomatic

Primary Herpetic Gingivostomatitis

Phases of Periodontal TherapyPhases of Periodontal Therapy

Preliminary Phase Preliminary Phase Treatment of emergenciesTreatment of emergencies

Etiotropic Phase (Phase I Therapy) Etiotropic Phase (Phase I Therapy) Plaque control and patient educationPlaque control and patient education

Evaluation of response to Etiotropic TherapyEvaluation of response to Etiotropic TherapySurgical Phase (Phase II Therapy)Surgical Phase (Phase II Therapy)Restorative Phase (Phase III Therapy)Restorative Phase (Phase III Therapy)Maintenance Phase (Phase IV Therapy)Maintenance Phase (Phase IV Therapy)

Preferred Sequence of Preferred Sequence of Periodontal Therapy Periodontal Therapy

1.1. Emergency PhaseEmergency Phase

2.2. Etiotrophic PhaseEtiotrophic Phase

3.3. Maintenance PhaseMaintenance Phase

4.4. Surgical Phase Surgical Phase -- -- -- -- -- Restorative PhaseRestorative Phase

Reference TextReference Text

Carranza's Clinical Periodontology, 9Carranza's Clinical Periodontology, 9thth Ed. Ed. Michael Newman, Henry Takei, Michael Newman, Henry Takei,

Fermin Carranza and Perry KokkevoldFermin Carranza and Perry Kokkevold

SpecialSpecial ThanksThanks

CAPT Nick Makrides, Chief Dentist, BOPCAPT Nick Makrides, Chief Dentist, BOPCAPT Tim Ricks, IHS Nashville Area DirectorCAPT Tim Ricks, IHS Nashville Area DirectorCAPT Todd Smith, IHS National ConsultantCAPT Todd Smith, IHS National ConsultantCAPT Bill Stenberg, CG PeriodontistCAPT Bill Stenberg, CG Periodontist