Riassunto esame Parodontologia 2, Prof. Discepoli Nicola, libro consigliato Clinical Periodontology and Implant Dentistry, Lindhe

Periodontics II 05/10/2021

Periodontics II, lesson 1 - Clinical guidelines

This is an introductory lecture about clinical guidelines.

Two years ago the European federation of Periodontology developed a series of clinical guidelines by which they tried to resume every treatment that can be done in periodontics under a multilevel approach.

Every phase of the sequential treatment that we can perform on patients was basically classified in 4 steps:

• Clinical guidelines.
• Clinical and radiographic diagnosis.
• Periodontal prognosis.
• Step 1.
• Step 2.
• Re-evaluation.
• Step 3 surgical approach → conservative surgery, resective surgery, reconstructive surgery, regenerative periodontal therapy, periodontal plastic procedures.
• Or Step 4 supportive periodontal therapy → previously termed.

Anamnesis and medical history

The first step to detect the probability of a patient to be a periodontal patient when approaching a new patient is anamnesis and medical history.

The informations that we want to gather include:

• Positive history of periodontitis because in every chronic disease a positive previous history of disease is the most important predictor or risk indicator for future relapse.
• If a patient has already been diagnosed for PD, the patient will be at an high risk of PDs independently of his behaviours.
• Smoking habits.

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• Comorbidities such as CVDs and diabetes, mainly the latter due to the fact that metabolic disorders are tightly linked with PDs.
• Familiarity e.g. if the patient has a parent who lost teeth at a young age.
• Oral hygiene habits questioning the patient in terms of number of times he brushes teeth, the use of inter-proximal devices and use of mouthwashes.

Patients usually use a lot of mouthwashes because many dentists give mouthwashes thinking that they are able to eliminate biofilm.

However biofilm cannot be chemically removed, it has to be eliminated mechanically either by tooth brushing and using inter-proximal devices or by professional mechanical plaque removal.

• Pain absence.

We don’t expect patients to feel acute pain, which can be felt only in periodontal abscess and necrotising periodontitis.

Many times patients refer to feel tenderness, like something strange running across their gums. In the vast majority of patients they feel nothing at all.

• Occurrence of spontaneous bleeding.

We can ask the patient if in the morning they see blood spots on the pillow.

Regarding signs and symptoms we can see tenderness, bleeding, mobility and food impaction.

Following anamnesis, we can go through specific questions regarding patient’s relationship with the dentist.

Important questions that we can ask are:

• How often did you do mechanical plaque removal in the last year?
• How many times did you do a visit with the dentist in the last year?
• How many times did you receive a professional prophylaxis?

Clinical and radiographic diagnosis

Following anamnesis we can start the diagnostic phase where the first step is the screening whose aim is to define and divide patients in healthy and diseased ones.

Screening is performed by using a periodontal probe making a walk through the patients’ sulcus allowing us to understand if the patients need a full periodontal chart.

Screening is similar to CPITN, however CPITN is only used in epidemiology so we divide patient mouth in sextants giving a score depending on plaque, bleeding, CAL. The sextant will take the score of the worst site. This is called periodontal screening record (PSR).

If there are two or more non adjacent sites with attachment loss we can define the patient as a periodontitis patient therefore we have to proceed with a full mouth periodontal chart, six sites for each teeth checking PPD, recession, loss of attachment, CAL, mobility, and furcation involvement.

Afterwards we can examine previous radiographic exams or perform a periapical radiography to better observe the area of interest.

Merging clinical and radiographic informations we develop a specific diagnosis according to the 2018 classification.

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Periodontal prognosis

Once clinical diagnosis has been done, we need to develop prognosis which indicates how the disease will progress in the future and how it will affect the patient in that specific tooth and that specific site.

Prognosis is dependent on professional experience, clinical diagnosis and patient's compliance.

Sequence of treatment of periodontitis

After proper diagnosis and prognosis we can step into the sequence of treatment of periodontitis:

• Step 1 → previously named systemic phase.

In this step we must encourage the patient towards behavioural changes and we should undertake removal of supragingival biofilm from professional and a patient’s standpoint and control the risk factors (quit smoking, dietary counselling, suggest physical activity).

Once the patient is motivated and he’s aware about his condition we can move forward.

• Step 2 → The most important clinical act to treat periodontitis nowadays.

It consists in the use of subgingival instrumentation (e.g. curette, scaler, ultrasonic devices) going as deep as possible to remove biofilm and calculus from the tooth surface.

The aim is to re-establish a balanced condition (on the surface) between immune system and biofilm. This is performed by professional mechanical plaque removal and sub-gingival instrumentation.

• Reevaluation.

After the last appointment of sub-gingival instrumentation we allow the patient to properly heal for about 2-3 months, after this period patient is recalled to re-evaluate the variables through a periodontal chart (PPD, furcation, mobility, CAL, BOP).

All this clinical information will allow us to understand how much treatment was effective.

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During re-evaluation we want to check if patient reached a level of autonomy in terms of home care and most importantly we want to assess if the patient full mouth plaque score reached a balance.

The full-mouth plaque score should be <25% to be considered clinically stable.

The full-mouth bleeding score should be <10% to be considered healthy in absence of loss of attachment, otherwise we have gingivitis.

These threshold can be considered reliable in the vast majority of the cases.

• Step 3 re-treatment.

If we observe some unresponding sites we must undergo mainly with sub-gingival instrumentation (step 2) otherwise go through surgery.

Let’s see the steps in details:

Step 1

• Supragingival dental biofilm control → we cannot eliminate biofilm, we can only control it.
• Oral hygiene instructions.
• Adjunctive therapies for gingival inflammation.
• Professional mechanic plaque removal (PMPR) → first therapeutic approach performed in patient’s mouth with ultrasounds usually.
• Risk factor control → smoking, metabolic control of diabetes, dietary counselling.

Step 2

We do not usually divide supragingival and subgingival treatment, by starting with PMPR and subgingival instrumentation trying to go as deep as possible within the sulcus/pockets. If needed we can make two sessions or three sessions according to the severity.

Even though the vast majority of treatment is done with ultrasounds we still use curettes because they are really refined tools that enable us to obtain more consistent sub gingival calculus removal although they are more biologically aggressive in comparison to ultrasound.

• Use of adjunctive physical or chemical agents.
• Use of adjunctive host-modulating agents.
• Use of adjunctive subgingival locally delivered antimicrobials.
• Use of adjunctive systemic antimicrobials.

Are we supposed to give therapeutic antibiotics to patient?

Antibiotic systemic resistance suggest us not to give antibiotics for PDs, we should only treat it with mechanical approach.

According to scientific evidence even in highly severe patients (stage 3) the attachment gain is really small (0,5mm of attachment gain) which is not sustainable.

We usually do not give antibiotics except in very specific and rare cases.

Same is for locally derived antibiotics such as chlorexidine since the clearance of the sulcus is so rapid that they are not so effective. So no local antimicrobials.

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Step 3 - In case of non responding sites

• Repeat subgingival treatment with or without adjunctive therapies.
• Access flap periodontal surgery.
• Resective periodontal surgery.
• Regenerative periodontal surgery.

The aim is to regenerate what was lost for periodontal disease, so bone, periodontal ligament and cementum.

Step 4 supportive periodontal care

• This is in which we must maintain periodontal stability in all patients checked at regular intervals for their whole life. We need a new periodontal chart after a couple of months.
• Any patient might need a re-treatment.
• We must do a proper diagnosis and a new treatment plan in case of new relapse.
• We must maintain patient's compliance and promote healthy lifestyles.

Case presentation

Patient, Ana, is a 45 years old housewife complaining about teeth mobility and not liking her smile, so there is also an aesthetic issue. Chief complain.

The most important thing to ask to patient is this because we have to merge scientific evidence, our perspective and patient perspective.

House classification

One of the most important tool is the House classification (1), a way to classify the patient from a psychological perspective.

We usually ask patient to place in order of importance aesthetic, health and function.

According to the order we can define different personalities, in this case due to the fact the patient seems to be very collaborative and to have high treatment expectation and placed aesthetic at the first step she was defined as a philosophic patient, which is a category of this classification.

General medical history

Then we start then with the general medical history.

She is a type 1 patient (ASA), she smokes 20 cigarettes/day from 15 years, she has no parafunctions, previous disease history, no disease currently and no specific drugs. Her father has type 2 diabetes.

The two most important informations that we can gather from medical history are that she’s a smoker and that father has diabetes.

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Dental history

Then we proceed with dental history.

Last prophylaxis was one year ago (many times there is a direct relationship between the severity and the time passed from the last prophylaxis), she has fillings and endodontic treatments and also a fixed partial prosthesis.

This means that she was aware of her need of a dentist, but no one told her she was a periodontal patient.

She does not use interproximal devices and does not properly clean her teeth.

She refers gum bleeding, halitosis (due to food impaction), gingival recessions and teeth mobility.

There is a tight relation between halitosis and periodontitis.

Gram- anaerobic bacteria produce more volatile sulphur compounds from saliva and food that might determine halitosis.

One of the main treatments for halitosis are step1 and step2.

Screening

Full periodontal chart

This is a scheme which sums up all the informations obtained from patient’s mouth.

Ana is stage 3 grade C, not stage 4 because she lost just one tooth.

From the full periodontal chart it emerges that full-mouth plaque score is 70% and full-mouth bleeding score is 33%.

The second line of numbers (e.g. 666, 334 etc.) is the PPD.

In black recession, in red PPD (together..), pink dot is plaque, the red rhombus is BOP, mobility is indicated with roman numbers, furcation are indicated with triangle (1, 2 or 3).

So we can observe inter-proximal loss of attachment lot of recession and plaque. There is some mobility and furcation involvement.

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Radiographic examination (OPT in this case)

We can observe: several endodontics treatments (quite incongruent??), extensive bone loss, acquired diastema due to periodontal drifting, fixed prosthesis with incongruent margins (we should pay attention to this because biofilm accumulation could occur there), malposition, rotation, furcation involvement, supra bony lesions and several fillings.

The site with the worst prognosis is the 3.5 where we can observe a infrabony angular bone defect (probably 3 walls).

This is confirmed by the periapical x-rays (above).

There is a periodontal ligament space widening due to trauma, which can be identified as space between lamina dura dentis and roots.

Several teeth are traumatised, the signs of which clinically is the mobility which is the main concern of the patient.

We refer to secondary occlusal trauma since in a periodontal patient muscles will work normally acting on a reduced periodontium determining eventually the trauma of the area.

How many definition of mobility do we have?

In case of periodontal ligament reduction, so loss of attachment there is physiological mobility since the tooth is not under trauma. In this case, if patient doesn’t feel any pain

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or discomfort, we should do nothing.

In presence of trauma we have a pathological mobility since it is a progressive mobility and in this case you have to act instead.

Patient also has several decays, friction involvements and angular bony defects (23, 25, 37, 35, 32, 46).

In the intra-oral image we can observe a generalised interproximal loss of attachment as every time there is a recession and we can see a CEJ interproximally this means that there is loss of attachment.

There is plaque accumulation almost everywhere especially on the fifth sextant.

We can observe generalised gingival erythema. Brown spots on gingiva are present due to smoking habits.

We can also see incongruent restoration (hard to clean), malposition, extrusion, recession, mucogingival line (we have quite well represented band of attached gingiva except around the lower 3rd premolar which also has a frenum pull + mucosa), non-cervical carious lesion associated with brushing trauma (circled in the image). This must be identified at the very beginning to properly modify the oral hygiene behaviour.

Now we move to labial analysis where we ask the patient to forcibly smile in order to trace important reference point landmarks such as the labial line.

How many mm of gingiva we are expected to be exposed by a patient during a forced smile? About 1mm, if the patient displays more than 1,5 mm we are dealing with an high smile line.

Patient displays from 16 to 26 with buccal corridors are completely occupied (they are not evident).

The relationship between the cusp margin and the central incisor should be on the same line and the central incisor zenith should be 1mm below.

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Treatment plan

How can we manage this patient?

Treatment plan has specific steps:

• The first thing that we want to do is reduce and keep out the infection (decay and periodontal disease). We eliminate caries and start with:

Step 1 → systemic phase (smoke counselling) and non-surgical periodontal therapy (PMPR, and oral hygiene instructions giving particular attention to the use of the interproximal toothbrush).

Step 2 → scaling and root planing aka sub-gingival instrumentation.

• Re-evaluation after 2 months.

PI is 24% and BOP is 23%.

BOP is so low because she is a smoker.

PPD is still quite important.

Furcation involvement is not improved since step1 and step2 are usually not able to improve furcation grade.

We reduce PPD by inducing a recession with our subgingival instrumentation.

We can gain some mm depending on the initial PPD. The deeper the PPD the more recession we will have following sub gingival instrumentation.

• Since patient is still clinically unstable and since there are still unresponding sites we proceed with step 3 therefore surgical periodontal treatment.

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We perform an osteo-resorptive approach on the first sextant with osteoplasty and some inter proximal remodeling.

We suture and let heal.

There is a disto-buccal root amputation to improve the patient's cleaning.

Angular bony defects can be treated through regenerative therapy (bone graft).

Patient had 4 surgical treatments in the end due to the presence of residual PPD in every quadrant: 3 osteo-resorptive surgery and 1 regenerative.

• Re-evaluation after 2 months of healing.

PI is 9% and BOP is 11%.

The patient's condition is highly improved.

Furcations are still present but we have no PPD more than 5 mm that are bleeding.

Now the patient is stable even if patient continues to smoke.

• Once the patient is stable we proceed with an orthodontic therapy to improve her smile. Are we able to move a tooth with 60% loss of attachment without risk? There is no more PPD or BOP so we can try and apply orthodontic forces to improve her smile.

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Periodontics - Lesson 2

Clinical diagnosis

The first step of diagnostic process is clinical diagnosis which is followed by radiographic diagnosis as a confirmatory exam.

The informations gathered from these steps are then merged into a classification.

Following diagnosis we go through prognosis.

Sequence of treatment of periodontitis

• Step I → Behaviour changes by motivating the patient and removal of supra-gingival dental biofilm and risk factor control; The core of STEP 1 is to control the supra gingival dental biofilm and to give proper oral hygiene instructions.

After giving instruction to the patient we start with the so called professional mechanical plaque removal (PMPR).

All PDs risk factors deals with low grade inflammation.

Periodontal disease