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The New periodontal Disease : The New periodontal Disease : Inflammatory and RiskyInflammatory and Risky

S LS LSam LowSam Lowslow@dental.ufl.eduslow@dental.ufl.edu

GingivitisGingivitis

•• Condition is reversible Condition is reversible

•• But, if left untreated But, if left untreated maymay progress to progress to periodontitis with loss of attachment ofperiodontitis with loss of attachment ofperiodontitis with loss of attachment of periodontitis with loss of attachment of connective tissue and eventual loss of connective tissue and eventual loss of supporting bone.supporting bone.

PeriodontitisPeriodontitis

•• Disease of tooth supporting structureDisease of tooth supporting structure

•• Exhibits pathologic changes in the Exhibits pathologic changes in the periodontium ( irreversible)periodontium ( irreversible)periodontium ( irreversible)periodontium ( irreversible)

•• Caused by bacterial plaqueCaused by bacterial plaque

•• Usually develops from preUsually develops from pre--existing existing gingivitisgingivitis

PeriodontitisPeriodontitis

•• ChronicChronic

•• AggressiveAggressive

Chronic PeriodontitisChronic Periodontitis

•• Adult periodontitisAdult periodontitis

•• Umbrella term for a number of disease Umbrella term for a number of disease syndromessyndromessyndromessyndromes

•• 25 to 50% of the population25 to 50% of the population

•• Rapid or slow with periods of exacerbation Rapid or slow with periods of exacerbation and remissionand remission

•• Variety of microbial floraVariety of microbial flora

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Aggressive PeriodontitisAggressive Periodontitis

•• Generalized or localized juvenile Generalized or localized juvenile periodontitisperiodontitis

•• PrePre--puberty periodontitspuberty periodontitsPrePre puberty periodontitspuberty periodontits

•• Rapidly advancing periodontitisRapidly advancing periodontitis

•• Refractory periodontitisRefractory periodontitis

Refractory or Recurrent ??Refractory or Recurrent ??

The Choice is yours !!!The Choice is yours !!!

RefractoryRefractory

•• Hard to ManageHard to Manage

•• ObstinateObstinate•• ObstinateObstinate

•• Not yielding to treatment, as a diseaseNot yielding to treatment, as a disease

Factors Which Contribute to Factors Which Contribute to Refractory PeriodontitisRefractory Periodontitis

•• Pretreatment conditionPretreatment condition

•• Patient Plaque ControlPatient Plaque Control

•• Treatment techniqueTreatment technique•• Treatment techniqueTreatment technique

•• Recall complianceRecall compliance

•• Local FactorsLocal Factors

•• * Immunologic response* Immunologic response

•• * Microbial Flora* Microbial Flora

The True Refractory PatientThe True Refractory Patient

•• Post surgical depth < 3mm.Post surgical depth < 3mm.

•• Plaque Assessment > 70% efficiencyPlaque Assessment > 70% efficiency

•• Maintenance recare 2Maintenance recare 2 3 months3 months•• Maintenance recare 2Maintenance recare 2--3 months3 months

•• Competent recare therapyCompetent recare therapy

•• No local or systemic factorsNo local or systemic factors

•• Progressive attachment lossProgressive attachment loss

•• Progressive osseous resorptionProgressive osseous resorption

Contagious or Transmissible?Families

• Periodontitis aggregates within families

• Significant relationship among siblings for spirochetes on tongue and in pockets Otherspirochetes on tongue and in pockets. Other organisms on gingivae and in saliva

Van der Velden, 1993

• P. gingivalis and A.A. organisms transmitted between parents and their children

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Contagious or Transmissible?Spouses

• P. gingivalis can be transmitted between spouses

• P gingivalis isolated from saliva, tongue, tonsilar area

• 10 of 18 severe periodontal patients had spouses with same10 of 18 severe periodontal patients had spouses with same organism

Van Steenbergen, 1993

• Spouses of patients with advanced periodontitis have a higher prevalence of periodontal pathogens and worse

periodontal status than spouses of healthy subjects

Asikainer, 1995

Periodontal disease is a common, chronic, and persistent infection

• Periodontal disease is:– A persistent infection that can spread rapidly

throughout the periodontium1

– The most common chronic bacterial infection in adults

– A problem that affects more than 35.7 million Americans

– The #1 cause of adult tooth loss in the US

• Three out of 4 American adults develop a periodontal infection

Current Concepts of PeriodontitisCurrent Concepts of Periodontitis

2. Sites

1. Biofilms 3. Episodic

‘Latest’ Paradigm: Biofilm Management

• Ecological paradigm

– Biofilm is needed for health & low levels of pathogens are normal

16

– Key is maintaining balance to sustain a ‘healthy’ biofilm

Marsh (2006)

• Intervention

– Restore the balance: interfere with environmental factors that favor selection and growth of pathogens

Periodontal bacteria form dense biofilms

• The bacteria associated with periodontal disease reside within biofilms above and below the gingival margin1-3

Bi fil d i f• Biofilms are dense mixtures of organisms resistant to natural antibodies and proteins that the body uses to fight infection1

Model of Risk FactorInteraction in

Human Periodontal Disease

Environmental

Challenge

Host

Response

Unique Periodontal

Anatomy

Periodontal

destruction

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The perio/systemic interfaceThe perio/systemic interface

•• Perio disease modestly associated with Perio disease modestly associated with atherosclerosis, MI and CVDatherosclerosis, MI and CVD

•• Periodontal disease may be a risk factor forPeriodontal disease may be a risk factor forPeriodontal disease may be a risk factor for Periodontal disease may be a risk factor for preterm/low birth weightpreterm/low birth weight

•• A variety of oral interventions improving A variety of oral interventions improving oral hygiene reduce pneumonia by 40%oral hygiene reduce pneumonia by 40%

2003 Contemporary workshop

Interaction of Risk Factors for Periodontal Disease

HOST

BacteriaBacteria Behavioral Risk Factors

Oral HygieneOral Hygiene

SmokingSmoking

Systemic DiseasesSystemic Diseases

Biologic Risk Factors

Metabolic ChangesMetabolic Changes

Anatomic ChangesAnatomic Changes

StressStressPSTPST

kimball genetics

Association between Cigarette Smoking, Bacterial Pathogens, and

Periodontal Status

• 615 adults, 28 to 73 years old

Odd i f k d h 3 5• Odds ratio of pocket depth > 3.5 mm was 5.3

• Bacteria not different

Stoltenberg, et al

J Periodontol, 1993

Nicotine ingestion as a risk factor for periodontal disease…

• Effects neutrophils and monocytes

• Increased oxidative burst

• Impaired phagocytosis and chemotaxis• Impaired phagocytosis and chemotaxis

• Prostaglandins, Tissue necrosing factor, collagenase, and elastase increase

Periodontal Disease inNon-Insulin-Dependent

Diabetes Mellitus

• 1,342 subjects, 15 years and older

• 19% ith diabetes / 12% impaired gl cose tolerance• 19% with diabetes / 12% impaired glucose tolerance

• Odds ratio of 2.8 times for periodontal disease

Emrich et al

J Periodontol

Vol 62, 1991

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Diabetes as a risk factor in periodontal diseases..

• Altered neutrophil and monocyte function

• Increased oxidative stress

• Impaired chemotactic and phagocytic• Impaired chemotactic and phagocytic function

• Neutrophils are primed

• Periodontal infections compromise glycemic control

Occlusion as a Contributing FactorOcclusion as a Contributing Factor

Occlusion must be stabilized in Occlusion must be stabilized in Aggressive Periodontitis !Aggressive Periodontitis !

•• Initial or progressive mobility is major factorInitial or progressive mobility is major factor

•• Primary occlusal traumaPrimary occlusal trauma–– Occlusal adjustmentOcclusal adjustment

–– Occlusal guardOcclusal guard

•• Secondary occlusal traumaSecondary occlusal trauma–– Occlusal adjustmentOcclusal adjustment–– no fremitusno fremitus

–– Occlusal guardOcclusal guard

–– Splint !Splint !

Predicting Periodontal Predicting Periodontal PrognosisPrognosis

1.1. Increasing pocket depthIncreasing pocket depth2.2. Furcation involvementFurcation involvement3.3. MobilityMobility4.4. Crown root ratioCrown root ratio5.5. SmokingSmoking6.6. Restorative dentistryRestorative dentistry

McGuire, 1995McGuire, 1995

+ Local Factors

Age

(subgingival calculus, plaque)

+ PeriodontitisPeriodontitis(attachment loss, bone loss)

“Resistance”“Resistance”

+

Age

(subgingival calculus, plaque)+

Local Factorsp q )

Periodontitis(attachment loss, radiographic bone loss)

“Susceptibility”“Susceptibility”

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Susceptible Resistant

high moderate average moderate high

Validity and accuracy of a risk Validity and accuracy of a risk indicator in predicting periodontal indicator in predicting periodontal

diseasedisease•• PRC: score 1 to 5PRC: score 1 to 5

•• Routine data collection as age,smoking, Routine data collection as age,smoking, diabetes pocket depth furcations anddiabetes pocket depth furcations anddiabetes,pocket depth,furcations and diabetes,pocket depth,furcations and vertical bone lesionsvertical bone lesions

•• 15 year analysis of bone and tooth loss15 year analysis of bone and tooth loss

•• Reliable risk assessment toolReliable risk assessment tool»» Page,et alPage,et al

JADA May 2002 JADA May 2002

www.PreViser.com

PST® Genetic Test: Prevention and Management

of Periodontal Disease

kimball genetics

Periodontal Disease andPeriodontal Disease andCardiovascular DiseaseCardiovascular Disease

•• 1818--year study of 1,147 subjectsyear study of 1,147 subjects

•• Probing and bone loss are significant risk Probing and bone loss are significant risk factors for coronary heart diseasefactors for coronary heart disease

•• Odds ratio of 2.1 fold for CHD controlling Odds ratio of 2.1 fold for CHD controlling all other factorsall other factors

•• Chronic systemic exposure to bacteria, Chronic systemic exposure to bacteria, endotoxin, and cytokinesendotoxin, and cytokines

Beck, et alBeck, et al

J PeriodontolJ Periodontol

Vol 67 No 10, 1996Vol 67 No 10, 1996

Periodontal Infection as a Possible Periodontal Infection as a Possible Risk Factor for Preterm Low Birth Risk Factor for Preterm Low Birth

WeightWeight•• Case control study of 124 pregnant or post partum Case control study of 124 pregnant or post partum

mothersmothers

•• Parameter of clinical attachment levelsParameter of clinical attachment levels

•• 18.2% of all preterm low birth weight attributable 18.2% of all preterm low birth weight attributable to periodontal diseaseto periodontal disease

•• Pregnant mothers with severe periodontal disease Pregnant mothers with severe periodontal disease have a 7.9 fold increased risk for preterm LBWhave a 7.9 fold increased risk for preterm LBW

Offenbacher S, et alOffenbacher S, et al

J PeriodontolJ Periodontol

Vol 67, No 10, 1996Vol 67, No 10, 1996

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The perio/systemic interfaceThe perio/systemic interface

•• Perio disease modestly associated with Perio disease modestly associated with atherosclerosis, MI and CVDatherosclerosis, MI and CVD

•• Periodontal disease may be a risk factor forPeriodontal disease may be a risk factor forPeriodontal disease may be a risk factor for Periodontal disease may be a risk factor for preterm/low birth weightpreterm/low birth weight

•• A variety of oral interventions improving A variety of oral interventions improving oral hygiene reduce pneumonia by 40%oral hygiene reduce pneumonia by 40%

2003 Contemporary workshop

World Workshop of Periodontology, 1996

1. Wide variations of inflammatory response Wide variations of inflammatory response among subjects.among subjects.

2.2. Microbial parameters explain a small amount Microbial parameters explain a small amount of disease incidence or prevalence.of disease incidence or prevalence.

3.3. Half the variability in periodontal disease Half the variability in periodontal disease expression is controlled by genetic not expression is controlled by genetic not microbial factors.microbial factors.

AETNA launches Dental/Medical Integration Program that includes Specialized Pregnancy

Benefits

• Members who are pregnant, diabetes, coronary artery disease, or CVS (stroke)

• Reimburses for and increases the frequencyReimburses for and increases the frequency of recare

• High risk members who seek early dental care lower their medical risk

Dental History is Critical in Formulating a Patient’s

Periodontal Status

• Familial history

• Medical statusMedical status

• Smoking habit

• Stress activity

• Parafunctional symptoms

Data CollectionData Collection

DiagnosisDiagnosis

EtiologyEtiology

DiagnosisDiagnosis

PrognosisPrognosis

Treatment PlanTreatment Plan

Data CollectionData Collection

Radiographic ExamRadiographic Exam

ProbingProbing

Tissue CharacteristicsTissue Characteristics

MobilityMobility

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Vertical BitewingsVertical Bitewings

•• Alveolar Crest HeightAlveolar Crest Height

•• Pattern of Bone LossPattern of Bone Loss

•• CEJCEJ

•• Dentition Related PathologyDentition Related Pathology

D0180 Comprehensive periodontal evaluation

• New or established patients

• Can be proceeded by D0150 (PSR)

• Evaluation of periodontal condition:• Evaluation of periodontal condition:– Probing and charting

– Dental and medical history

– Overall health assessment

Periodontal ProbingPeriodontal Probing

2N Nabors2N NaborsFurcation ProbeFurcation Probe

PQOWPQOWPeriodontal Periodontal

ProbeProbe

Automated Probing

Which club…….

• Green Dot Club: Gingivitis

67 %67 %

• Red Dot Club: Periodontitis

33 %33 %

“Risk factors”Risk factors”

Patient characteristics associated with the development Patient characteristics associated with the development of the diseaseof the disease

“P ti f t ”“P ti f t ”“Prognostic factors”“Prognostic factors”

Patient characteristics that may predict the outcome Patient characteristics that may predict the outcome once the disease is present, but do not actually cause it.once the disease is present, but do not actually cause it.

Laupacis, et. al.Laupacis, et. al.

JAMA, 1994JAMA, 1994

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Refractory Periodontitis Associated with Abnormal Refractory Periodontitis Associated with Abnormal Polymorphonuclear Leukocyte Phagocytosis and Polymorphonuclear Leukocyte Phagocytosis and Cigarette SmokingCigarette Smoking

MacFarlane, et. al.MacFarlane, et. al.

J. Periodontol., Nov. 1992J. Periodontol., Nov. 1992

31 refractory patients31 refractory patients

12 controls12 controls

•• No chemotactic defects noted, but phagocytosis impairedNo chemotactic defects noted, but phagocytosis impaired

•• 90 % of refractory patients were smokers90 % of refractory patients were smokers

•• Strong association between peripheral blood PMN defect and Strong association between peripheral blood PMN defect and refractory refractory

periodontitisperiodontitis

Refractory Periodontitis: Critical Questions in Refractory Periodontitis: Critical Questions in Clinical ManagementClinical Management

KornmanKornman

J. Clinical Periodontol, 1996J. Clinical Periodontol, 1996

•• Condition describes patient characteristic not siteCondition describes patient characteristic not site

•• Two types of refractoryTwo types of refractory

a. localized nona. localized non--responsive sitesresponsive sitespp

b. generalized nonb. generalized non--responsive patientsresponsive patients

•• Clinical characteristicsClinical characteristics

a. multiple sites show clinically detectable disease progressiona. multiple sites show clinically detectable disease progression

b. progression occurs even in sites of minimal or no previous b. progression occurs even in sites of minimal or no previous diseasedisease

c. disease progression not stopped by conventional treatmentc. disease progression not stopped by conventional treatment

Prognosis versus Actual Outcome IIPrognosis versus Actual Outcome II

The Effectiveness of Clinical Parameters in Developing an Accurate The Effectiveness of Clinical Parameters in Developing an Accurate PrognosisPrognosis

McGuire and NunnMcGuire and Nunn

J. Periodontol., 1996J. Periodontol., 1996

Predictive Factors in Determining a Poor Prognosis…Predictive Factors in Determining a Poor Prognosis…

•• Increased probing depthIncreased probing depth•• Increased probing depthIncreased probing depth

•• Severe furcation involvementSevere furcation involvement

•• Greater mobilityGreater mobility

•• Poor crown/root ratioPoor crown/root ratio

•• Malposed teethMalposed teeth

•• SmokingSmoking

•• Teeth used as fixed abutmentsTeeth used as fixed abutments

Periodontal RecarePeriodontal Recare

•• Medical HistoryMedical History

•• Plaque Control PASS SCORE____% EPlaque Control PASS SCORE____% ERecommendations:Recommendations:–– Recommendations:Recommendations:

•• Areas of ConcernAreas of Concern

•• Therapy TodayTherapy Today

•• Next recare/ CommentsNext recare/ Comments

Supportive Periodontal Supportive Periodontal MaintenanceMaintenance

HostHostResistanceResistance SusceptibilitySusceptibility

RadiographsRadiographs 3636 monthsmonths 1818 monthsmonthsRadiographsRadiographs 36 36 monthsmonths 18 18 monthsmonths

ComprehensiveComprehensive 3636 monthsmonths 1818 monthsmonthsExamExam

Increase Frequency..............Increase Frequency..............

1. Poor plaque control performance.1. Poor plaque control performance.

2. Increasing pocket depth, bleeding,2. Increasing pocket depth, bleeding,suppuration.suppuration.

3. Radiographic increase of bone loss.3. Radiographic increase of bone loss.

4. Increasing furcation involvement.4. Increasing furcation involvement.

5. Complex restorative cases.5. Complex restorative cases.

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Systemic Antimicrobial TherapySystemic Antimicrobial Therapy

Indications for Systemic Antiobiotics

•• Juvenile PeriodontitisJuvenile Periodontitis–– Localized vs. GeneralizedLocalized vs. Generalized

•• Rapidly Advancing PeriodontitisRapidly Advancing Periodontitis

•• Refractory PeriodontitisRefractory Periodontitis

The Fundamentals of Ultrasonics in Periodontal Therapy

Exam - PSR (0150)

(0, 1, 2)

FMX

Gross Debridment

(4355) P10 Prophylaxis

Oral Hygiene OHI P50

(01110)

Prophylaxis

OHI P50

(01110)

Periodic Maintenance

(01110) P50

( 6 month intervals)

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Exam - PSR (0150)

(3, 4)

FMX

Gross Debridment(4355) P10,P50 Periodontal Exam

(0160)

Oral Hygiene

Periodontal ExamPeriodontal Exam

(0160)

Root Planing

(4341) P50,P100,Curettes

4 Quads

2 - 4 appointments

Revaluation (Phase I)

(0170) (4910) P50,P100,Curettes

Instrumentation ProtocolInstrumentation Protocol

•• DebridementDebridement (Gross)(Gross)–– Ultrasonic : PUltrasonic : P--10 P10 P--5050

•• DebridementDebridement (Gingivitis)(Gingivitis)•• DebridementDebridement (Gingivitis)(Gingivitis)–– Ultrasonic : P Ultrasonic : P -- 50 (option P 10)50 (option P 10)

–– PolishPolish

•• DebridementDebridement (Periodontitis)(Periodontitis)–– Ultrasonic : P Ultrasonic : P -- 50 P 50 P -- 100 (option P 10)100 (option P 10)

–– Gracey Curettes : thinGracey Curettes : thin

–– PolishPolish

Sulcular IrrigationSulcular Irrigation

•• UltrasonicUltrasonic–– 9 : 1 ratio 9 : 1 ratio -------- water to Betadinewater to Betadine

•• ManualManual•• Manual Manual –– 2 : 1 ratio 2 : 1 ratio ------ water to Betadinewater to Betadine

Slots, JorgensenJADA, 9-2000

Local Delivery AntibioticsLocal Delivery Antibiotics

•• User User -- friendlyfriendly

•• Stays in placeStays in place•• Stays in placeStays in place

•• Requires no removalRequires no removal

•• Enhances the effect of debridmentEnhances the effect of debridment

Depress Handle to Depress Handle to

Express Arestin Express Arestin

How to UseHow to Use

from the Cartridgefrom the Cartridge

Indications for “SDA” TherapyIndications for “SDA” Therapy

•• Generalized sites !!!Generalized sites !!!

•• Limited on frequency of applicationLimited on frequency of application

•• Recurrent or RefractoryRecurrent or Refractory•• Recurrent or RefractoryRecurrent or Refractory

•• NonNon--surgical options after Phase Isurgical options after Phase I–– Marginal plaque controlMarginal plaque control

–– Medical complicationsMedical complications

–– Financial implicationsFinancial implications

–– Anatomical concerns with surgeryAnatomical concerns with surgery

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Indications for “LDA” TherapyIndications for “LDA” Therapy

•• Localized sites !!!Localized sites !!!

•• Recurrent or RefractoryRecurrent or Refractory

•• NonNon surgical options after Phase Isurgical options after Phase I•• NonNon--surgical options after Phase Isurgical options after Phase I–– Marginal plaque controlMarginal plaque control

–– Medical complicationsMedical complications

–– Financial implicationsFinancial implications

–– Anatomical concerns with surgeryAnatomical concerns with surgery

•• Restorative site at riskRestorative site at risk

Lasers and Periodontal therapy…

• Carbon Dioxide

• Er:YAG

• ErCR:YSGG• ErCR:YSGG

• Nd:YAG

• Diode

• Ar

Potential laser applications for periodontal therapy……

UV Visible IR

HA H O2

tion,

a

Nd YAG

Tm:YAG2.09um

Ho:YAG2.12um

Er:YAG2.94um

CO10.6um

2

H O2

Nd YAG

Er:YAG2.940 nm

Er,Chr:YSSG2.780 nm

CO2

10.600 nm

Different Absorption Characteristics:Blue: Water Red: Hydroxyapatite

HA

0.1 0.2 0.3 0.5 0.8 1 2 3 5 10 (um)

Wavelength (microns)

Rela

tive E

xtinct Nd:YAG

1.06umNd:YAG1.064 nm

Diode810 or 980 nm

Advantages of Lasers in Surgical Procedures

Laser Cut More Visible To Eye / Dry Field

Laser Sterilizes Wound As It Cuts

Decreased Post Operative Pain And EdemaDecreased Post Operative Pain And Edema

Decreased Post Operative Infection The theory of “Sealing” and “Sterilizing” the wound?

Less Wound Contraction And Scarring

Pocket Sterilization

• De-epitheliaze by using tip in up/down diagonal manner

• Blanch outer 5 mm. of epithelium

i i d il k• Patient returns in 7 days to repeat until pocket is 3 mm.

• Subtract 3 from intial pocket depth=number of treatments needed

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Assessing SuccessAssessing Success

•• RadiographsRadiographs

•• Pocket depthsPocket depths

•• RentryRentry•• RentryRentry

•• HistologyHistology

Progression of Disease

Surgical Curettage Flap Surgery

Tooth Loss in Maintenance Patients in a Tooth Loss in Maintenance Patients in a Private Periodontal Practice, Private Periodontal Practice,

Wilson….1986Wilson….1986

•• 162 patients minimum of 5 years162 patients minimum of 5 years

•• 36% compliant36% compliant

–– No teeth lostNo teeth lost

•• 64% erratic compliance64% erratic compliance

–– 60 teeth lost60 teeth lost

•• Teeth lost:Teeth lost:

–– Maxillary molarsMaxillary molars

–– Mandibular molarsMandibular molars

Compliance with Maintenance therapy in a Compliance with Maintenance therapy in a Private Practice…Wilson et al, 1984Private Practice…Wilson et al, 1984

961 patients over 8 years961 patients over 8 years

16% complied with recommended maintenance16% complied with recommended maintenance

Erratic compliance in 49%Erratic compliance in 49%

34% Never reported for maintenance after active 34% Never reported for maintenance after active treatmenttreatment

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Compliance with Supportive Periodontal Compliance with Supportive Periodontal Therapy Part I and II: Risk of noncompliance in Therapy Part I and II: Risk of noncompliance in

a ten year period, Novaes..2001a ten year period, Novaes..2001

•• Factors of gender, age, surgery vs. non surgeryFactors of gender, age, surgery vs. non surgery

•• 43.9% noncompliant in surgery43.9% noncompliant in surgery

•• 53.2% noncompliant in non surgery53.2% noncompliant in non surgery

•• Highest risk for noncompliance:Highest risk for noncompliance:

–– FemaleFemale

–– Under 30 years ageUnder 30 years age

–– Over 51 years of ageOver 51 years of age

–– Underwent nonUnderwent non--surgical caresurgical care

Effecting the “Host”Effecting the “Host”

ConclusionsConclusions

1. Past dental history and plaque control are critical in establishing 1. Past dental history and plaque control are critical in establishing the diagnosis of refractory periodontal diseasethe diagnosis of refractory periodontal disease

2. New patients with a history of previous periodontal surgery should2. New patients with a history of previous periodontal surgery shouldbe monitored for at least one year prior to additional surgerybe monitored for at least one year prior to additional surgerybe monitored for at least one year prior to additional surgery.be monitored for at least one year prior to additional surgery.

3. Adjunctive antibiotic therapy may be necessary only after culture 3. Adjunctive antibiotic therapy may be necessary only after culture and sensitivity.and sensitivity.

4. The frequency of recare and the competency of debridement4. The frequency of recare and the competency of debridementare crucial to stabilizationare crucial to stabilization

5. Occlusal stability is a necessity5. Occlusal stability is a necessity