Preventive Periodontics – Prof
Like Infection Control and like whatever, like, ya know, and like whatever, ya know?
Definitions
• Sterilization – destruction of all microbial forms
• Disinfection – destruction of Pathogenic microorganisms
• Asepsis – exclusion of microorganisms
• Aseptic Chain – don’t touch contaminated things, i.e. hair, face, cart, glasses
Patient Screening
• High risk pts are impossible to identify
• Treat all pts as if they were infected with an incurable disease
• Standard Precautions – every pt treated as if they were a disease carrier
• Special Precautions for HIV pt – none
Gloves
• Gloved hands may be weakest like to infection control program
• Not a substitute for hand washing
• Latex Allergy
o 8-17% of healthcare workers are at risk
o Exposure by direct contact or inhalation
o No commercial reagent
o Large variation in latex levels btw brands
o Causes Contact Dermatitis, Asthmatic Attack, Anaphylaxis
Masks
• Should filter 95% of 3.5 micron-sized particles
• Change btw pts and every hour with heavy aerosol
Instrument Management
• Utility gloves for scrubbing
• Ultrasonic Cleaners – 16 times more effective than hand scrubbing
• Do not store instruments in open trays in drawers
• Autoclave
o 250( at 15psi for 20 min
o Air stratification may be problem
o May rust instruments
• Chemiclave
o 270( at 20psi for 20 min
o Chemical soln of Formaldehyde and Ethanol
o Does not rust or corrode instruments
o No air pockets
• Dry Heat Sterilization
o 120( for 2 hours
o May rust instruments
o Air stratification may be problem
o Not practical for use in dental offices
• Ethylene Oxide
o 140( for 2-6 hours plus aeration time
o Useful for low heat items
o Potential Carcinogen
o Not practical for use in dental offices
• Flash Sterilizers
o Stem sterilizers
o 270( at 30 psi for 3-10 min
o Not intended for use as primary sterilization
• 2% Gluteraldehydes Gluteraldehyde
o 6-10 hours – sterilize
o 30 min – disinfect
o Corrosive, Toxic and Irritating
• Quaternary Ammonium Compounds
o Do Not Sterilize
o Serve no purpose in dental offices
o Often called “Cold Sterilization”
o ADA recommends this not be used in dentistry
• Guidelines
o Do not Disinfect if you can Sterilize
• Biologic Monitoring
o Spore testing
o Should be performed on a regular basis
o Bacillus stearothermophilus Spores
• Process Indicators – do not insure complete sterility
Surface Disinfection
• Alcohol
o Unacceptable as an instrument or surface disinfectant
o Ineffective against spores and activity diminishes in presence of blood and saliva
o NOT acceptable for use in dental offices
• Phenols
o Acceptable for use in dental offices
o Broad Antimicrobial action
o Tuberculocidal
o Can irritate skin and corrode metal
• Iodophors
o Acceptable for use in dental offices
o Residual Antimicrobial effect
o Tuberculocidal
o Contains Iodine, so leaves stain residue
• Sodium Hypochlorite
o Acceptable for use in dental offices
o Corrosive
o Use 1:10 ratio with water
o Should be mixed daily
• Synergized Quaternary Ammonium Compounds
o Mixture of quaternary Ammonium and Alcohols
o Tuberculocidal
o Non-corrosive and non-staining
o Acceptable for use in dental offices
Standards
• Hospital level, Tuberculocidal Disinfectant should be used
• Cubicle prep in two steps – Clean and Disinfect
Parts of Periodontium
• Gingiva
• Periodontal Ligament
• Cementum
• Alveolar Bone
Marginal (Free) Gingiva
• Portion surrounding neck of tooth – no directly attached to the tooth
• Interdental papilla is part of Free Gingiva
• Keratinized
Attached Gingiva
• Portion of gingival that extends apically from Free Gingiva to Mucogingival Junction
• Bound tightly to underlying bone
• Keratinized
Free Gingival Groove
• Shallow depression btw Free and Attached Gingiva
• Present in approx 50%
Gingival Sulcus
• Healthy is 1-3 mm
• Non-Keratinized and more prone to disease
Junctional Epithelium
• Collar-like band of non-keratinizing epithelium at base of Sulcus/Pocket
Gingival Col
• Saddle-like depression interproximal of posterior teeth
• Non-Keratinized
• Where Gingivitis usually begins from lack of flossing
Alveolar Mucosa
• Freely movable, not bound to underlying bone
• Non-Keratinized; not designed to withstand mastication forces
Mucogingival Junction
• Scalloped line dividing Keratinized Gingival from Alveolar Mucosa
Measuring Keratinized Gingiva
• Measure Gingival Margin to Mucogingival Junction
Measuring Attached Gingiva
• Measure amount of Keratinized Gingiva
• Subtract Sulcus/Pocket depth
• Should be at least 1mm; varies btw 1 and 9 mm
• Greatest amount
o Lingual of mandibular molars
o Facial maxillary anteriors
• Least amount
o Mandibular first premolars
Cementum
• Inorganic contact is 40-50%
• Anchors tooth to bone by PDL
• Cellular at Apical 1/3
• Acellular at Coronal 2/3
PDL
• Supportive – anchors tooth
• Formative – maintains biological activity
• Nutritive – supplies nutrients and removes waste
• Sensory – transmits tactile and pain sensation
Alveolar Process
• Alveolar Bone Proper
o Surrounds root and gives PDL attachment
o “Lamina Dura” radiographically
o also “Cribriform Plate”
• Supporting Alveolar Bone
o Surrounds Alveolar Bone Proper and gives support to sockets
Healthy Gingiva
• Color – Coral Pink
o Influenced by Inflammation, Vascularity, Keratinization, Pigmentation
• Contour – scalloped line around each tooth, knife-edged, fills embrasure
• Consistency – firm and resilient
• Surface Texture – stippling may or may not be present; least reliable
Unhealthy Gingiva
• Color – bright red to bluish red
• Contour – rounded, rolled, blunted, flattened, cratered, bulbous
• Consistency – spongy, edematous to fibrotic
Gingival Descriptions
• Location – Generalized or Localized
• Severity – Slight, Moderate, Severe
• Location – Papillary, Marginalized, Diffuse
• Contour – Knife-edged, Enlarged, Bulbous, Cratered
• Consistency – Firm and Resilient, Edematous, Fibrotic
• WNL is not acceptable
• Description Examples
o Generalized moderate diffuse redness. Consistency is fibrotic; papilla are blunted
o Generalized slight marginal redness and enlargement with localized moderate redness and enlargement facial lower anteriors
o Generalized coral pink; firm and resilient consistency with localized slight marginal redness on linguals of mandibular posteriors
Dental Deposits
• Non-Mineralized
o Acquired pellicle
o Bacterial plaque
o Materia Alba
o Food Debris
• Mineralized
o Calculus
• Acquired Pellicle
o Derived from saliva or Crevicular Fluid
o If removed, begins to reform immediately
o Bacteria use pellicle as nutrient (Nidus)
o Mode of attachment for Calculus
• Bacterial Plaque
o Non-calcified, Organized mass of bacterial colonies
o Mechanical removal
o Availability of nutrients effect build-up
o Initial plaque formation may take 2 hours
o 2 days to double in mass
o Initial Colonizers – gram positive aerobic and facultative anaerobes
o Secondary Colonizers – shift to gram negative and anaerobic
o Intracellular Plaque Matrix
▪ Inorganic and Organic components
▪ Major component – Polysaccharides
▪ Minor component – Glycoproteins
o Dental Plaque Metabolism
▪ Sucrose is energy source; bacteria produce
• Acid
• Intracellular and Extracellular Polysaccharides
o Dextrans – sticky anchor for plaque mass – 20%
o Levans – energy source for bacteria – 10%
o Bacteria – 70-80%
o Plaque cannot be removed by water spray
o Anaerobic Glycolosis drops pH to below 4.5 for demineralization
• Materia Alba
o Unorganized soft mixture of Salivary Protein, Bacteria and desquamated Epithelial cells
o May be removed with water spray
• Dental Calculus
o Plays major role in inflammatory periodontal diseases; prevents plaque removal
o Supragingival Calculus
▪ 30% mineralized
▪ Common on lower anteriors and Buccal maxillary molars b/c of Sublingual and Stenson Ducts
o Subgingival Calculus
▪ 60% mineralized
Theories of Mineralization
• ppt of Calcium and Phosphate in saliva or GCF leads to mineralization
• Mineralization begins extracellularly btw 1-14 days after plaque formation
Indices
• Index – places a numerical value on an observation; standardized
• Dental Indices – Bleeding, Plaque
• Plaque Index
o Total Teeth Present x 6 = Total Surfaces
o Total Surfaces x 100 = ___% = Plaque Index
Periodontal Probing
• Single most important way to diagnose periodontal disease
• Calibrated Periodontal Probe
o Measures pocket depth
o Measures width of attached gingiva
o Assess bleeding points
o Measure size of oral lesions and gingival recession
• Nabors Probe – used to detect and measure furcation involvement
• Basic Instrumentation Principles
o Use modified pen grasp
o Fulcrum close to tooth
o Tip of probe should contact tooth at all times
o Working end is parallel to long axis
o Use 10-15 grams of pressure
o Healthy Gingiva – probe stops at Junctional Epithelium
o Disease – probe into CT
o Keep probe subgingival, walking circumference of tooth
o Angle into Col
o 6 measurements per tooth
• Perio Measurements
o Pocket Depth – base of pocket to gingival margin
o Attachment Level – CEJ to base of pocket (Pocket Depth – Attachment Loss)
o Attachment Loss
▪ If Pocket Depth = 2mm
▪ And Recession = 3mm
▪ Then Attachment Loss = 5mm
Anterior Sickle Scaler
• Used to remove Supragingival Calculus in Anterior Region
• Straight, Rigid shank for Heavy Calc removal
• Not good Subgingivally, unless tissue is distended
o 2 cutting edges on each end
o Pointed tip
• Cross-section shape
o Triangular with a pointed back
o Tip/Toe – last 2mm used for calculus removal
• Terminal Shank (and Handle) parallel to long axis of tooth
• Angulation
o Proper angulation is 45-90(
o >90( will burnish calculus and Lacerate tissue
o 50% Bone Loss
o Attachment loss of >7 mm
o Furcation involvement
o Mobility likely
o Supparation
o Pain possible in later stages
• Case Type V
o Refractory Periodontitis – does not respond to therapy
o Uncommon Diseases
▪ Periodontal Disease
▪ ANUG
▪ LJP
▪ RAP
Periodontal Disease Etiology
• Primary – Plaque
• Secondary: Local and Systemic
o Local
▪ Overhangs
▪ Calculus
▪ Crowded teeth
▪ Large caries
▪ Poor Crown Margins
▪ Xerostomia
▪ Furcations
▪ Orthodontics
▪ Food Impaction
o Systemic
▪ Smoking
▪ Diabetes
▪ Aging
▪ Stress
▪ Nutritional deficiencies
▪ Medications
Classification of Pockets
• Gingival Pocket (Pseudo-pocket, False pocket)
o Caused by Hyperplasia – gingiva moving coronally
o No apical migration of Junctional Epithelium
o No Bone Loss
• Periodontal Pockets (True pocket)
o Caused by bone loss associated with apical migration of Junctional Epithelium
▪ Suprabony – bottom of pocket is Coronal to the crest of Alveolar Bone
▪ Infrabody – bottom of pocket is Apical to the crest of Alveolar Bone
Bone Loss
• Horizontal Bone Loss
o More generalized
• Vertical Bone Loss
Periodontal Explorer
• Detection of:
o Calculus
o Necrotic Cementum
o Defective Margins
o Tooth Surface Irregularities
o Decalcified areas/Caries
• Detection of Calculus is essential to its removal
o Assesses amount of Calculus prior to its removal
o Evaluates following Calculus removal
• Tactile Sensitivity
o Ability to distinguish smoothness and roughness
o Evaluation of tmt
• EXD 11/12 Explorer
o Modified pen grasp
o Light grasp to increase sensitivity
o Roll instrument btw thumb and forefinger to keep tip adapted
o Posterior Use
▪ Working end – curves toward Mesial of tooth
▪ Once working end is determined, Offset toward Distal surface
▪ NOT flipped in posterior – same end for both Mesial and Distal surfaces
▪ Terminal Shank is parallel with long-axis of tooth
▪ Short, overlapping strokes into Interproximal
▪ Begin at Distal angle and work into Interproximal
▪ Again, Begin at Distal line angle and work toward Mesial surface
o Anterior Use
▪ Right Handed – 8:00 for surfaces toward, 11:00 for surfaces away
▪ Begin at midline
▪ Handle is parallel to long axis
▪ Flip instrument for opposite Interproximal surfaces
Universal Curets and like whatever, ya know?
Instruments
• Columbia 13/14
o Shorter shank, better in shallow pockets
• McCall’s 17/18
o Shorter shank, better in shallow pockets
• 4R/4L
o Long shank, better in deeper pockets
Shape – Universal Curets curet
• Two cutting edges
• Triangle shape with rounded back
• Can be used on all surfaces of all teeth – both Supra and Subgingivally
Design Features
• Ends are mirror images of each other
• Two cutting edges per end
• Posterior Teeth - Same end used for the entire aspect
• Anterior Teeth – both ends used, instrument flipped, for opposite Interproximal surfaces
Usage
• Insert at 0(, then open to 45( working angle
• >90( - burnished calculus and damaged tissue
• 9000ppm – they form Ca Fluoride
o Fluorosis is a Hypomineralization
o Fluorohydroxyapatite is most desireable form of Fluoride in Enamel
▪ Ca Fluoride serves as Fluoride source for Re-mineralization
▪ Ca Fluoride deposits are dissolved by acids and become available as a Re-mineralization source
o Topical Fluoride related to number of Tmts
▪ Fluoride does not benefit sound enamel
• Benefits of Fluoride
o Re-mineralization – forms Fluorohydroxyapatite
o Interfere with Bacterial Metabolism – inhibits Glycolosis
o Prevention of Caries – by formation of Fluorohydroxyapatite
• Professional Topical Fluoride
o 8% Stannous Fluoride
▪ Rarely used
▪ Acidic, tastes bitter, stains
o 2% Neutral Sodium Fluoride
▪ Forms Fluoroapatite and CaF
▪ Gels and Foams
▪ Does not stain teeth or irritate tissues
• Good for use with Composites
• Use with Porcelain – crowns, veneers…
• Use on Exposed Root Surfaces
• Use with Glass Ionomers
▪ 9000 ppm
▪ pH 7.0
▪ Slow uptake
▪ 4 minute application
o 1.23% Acidulated Phosphate
▪ Forms Fluoroapatite and CaF
▪ Gels and Foams
▪ Thixotropic Gels – thicker and will liquefy in heat of mouth
▪ 12,000 ppm
▪ pH 3.5
▪ 4 minute application
• Topical Fluoride Indications
o High caries activity – 2 or more new lesions
o Sensitive or exposed roots
o Deteriorating restorations
o Overdentures
o History of head/neck trauma
o Xerostomia
o Newly erupted teeth
• Importance of Topical for Children
o 40% caries reduction in children
o 50% reduction in demineralization in Ortho pts
• Fluoride Foams
o Uptake is comparable to gels
o Less material is used
o Tastes better
• Fluoride Toxicity
o Based upon body weight – Probable Toxic Dose is 5mg/kg
▪ < 5mg/kg – office use of available Al or Mg products
▪ > 5mg/kg – same as above, plus hospitalization
▪ >15mg/kg – call 911
o Emergency Tmt – milk and eggs bind Fluoride and prevent chemical burn
o Signs/Symptoms of overdose
▪ Nausea
▪ Abdominal Cramps
▪ Vominting
▪ Incrased Salivation/Dedration
• Post-Op – pt should not eat or drink for frist 30 op
• Fluoridated Prophy Paste
o Polishing removes fluoride lost by abrasive
• Home Fluoride
o OTC – 0.4% Stannous – STOP, Gel Kam
• OTC Fluoride Mouthrinse
o OTC – 225ppm NaF – ACT, Fluorigard
o Intended for daily use
• Rx Fluoridated Dentrifice
o Paste – Prevident 5000 Plus
o Designed to replace Dentrifice
o Use at least once per day
• Rx Fluoride Gels
o 5000 ppm
o 1.1% NaF
▪ Gel – Prevident
▪ Gel – NeutraCare
o No abrasive system
o Not intended to be used instead of regular toothpaste
o 7.0 pH
o Brush on following brushing
• Non-Rx Fluoridated Gels
o 1000 ppm – 0.4% Stannous Fluoride
o does not replace toothpaste
• Caries reduction Protocol – home and office
o Pts in Medium to High Risk category
▪ CHX – 1/day for two weeks, every three months
▪ CHX in morning and Fluoride in evening
o Pts in low risk category – consider OTC Fluoride rise
o Perio tmt with CHX is BID
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