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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