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TARRSON FAMILY ENDOWED CHAIR IN PERIODONTICS. UCLA SCHOOL OF DENTISTRY. SECTION OF PERIODONTICS. Presents. Dr. E. Barrie Kenney Professor & Chairman Section of Periodontics. Dr. Heddie O. Sedano Professor Emeritus & Lecturer Section of Periodontics. PHASE ONE THERAPY. (INITIAL THERAPY).

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TARRSON FAMILY ENDOWED CHAIR IN PERIODONTICS

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TARRSON FAMILY ENDOWED CHAIR IN PERIODONTICS


UCLA SCHOOL OF DENTISTRY

SECTION OF PERIODONTICS


Presents

Dr. E. Barrie KenneyProfessor & ChairmanSection of Periodontics

Dr. Heddie O. Sedano

Professor Emeritus & Lecturer

Section of Periodontics


PHASE ONE THERAPY

(INITIAL THERAPY)


Comprehensive

  • Emergency Therapy

  • Examination Diagnosis and Treatment Plan

    • Phase one therapy (initial therapy)

    • Evaluation of phase one therapy

    • Phase two therapy

    • Evaluation of phase two therapy

    • Maintenance therapy


Phase two therapy

  • Periodontal surgery

  • Dental implants

  • Crown and bridge

  • Removable partial dentures


NECROTIZING

ULCERATIVE

GINGIVITIS (NUG)

EMERGENCY

THERAPY


Two weeks NUG resolved by root planning and good oral hygiene

Proceed to complete examination and diagnosis


Phase one therapy

  • Control of plaque

  • Control of diet

  • Control of systemic factors

  • Control of oral malodor and taste abnormalities

  • Control of tobacco smoking


Presence of plaque in red for 4 surfaces of each tooth

CONTROL of PLAQUE


Need to stress floss or interdental brush utilization

Presence of interproximal plaque is prominent


Plaque and bleeding scores at 4 time periods

Progressive improvement to less than 20% of surfaces with plaque


CORRELATION OF MANUAL DEXTERITY AND KNOWLEDGE WITH ORAL HYGIENE


MANUAL DEXTERITY TEST


CORRELATION COEFFICIENTS BETWEEN RIGHT HAND DEXTERITY AND BUCCO-LINGUAL PLAQUE

IN 59 ADULTS

DAY 00.41

DAY 70.38

DAY 140.33


CORRELATION COEFFICIENTS BETWEEN KNOWLEDGE AND BUCCO-LINGUAL PLAQUE

DAY 00.38

DAY 70.32

DAY 140.30


Patient with plaque induced gingivitis


Three weeks following compliance with excellent oral hygiene and plaque control


Brush is vibrated by bass technique of oral hygiene

Soft brush positioned at 45° to gingiva


Best used for interproximal plaque when interdental papillae are present

Dental Floss


Interdental brush

Tuft brush


Best used when interdental papillae are reduced

Interdental brush


Rubber interdental stimulator

Least efficient interproximal cleaner


Use of gauze to clean distal surface of teeth adjacent to edentulous areas

Gauze is most efficient for these teeth


Electric brushes used for patients with poor manual dexterity

Electric brushes can motivate some patients to improve their oral hygiene


Clinical Evaluation of the Efficiency and Safety of aNew Sonic Toothbrush

Johnson, B.D., McInnes, C.,

J. Periodontol 65:692, 1994


51 subjects got either Sonicare orhand brush. Instructed in use orModified Bass Technique withOral B 30.


Plaque scores, gingivitis scoresand sulcular bleeding scores at0, 1, 2, 4 weeks.29 subjects seen at 6 months


All subjects got timer and did notuse floss mouth rinses or otheroral hygiene aids for first 4 weeks.


Plaque Index


Sulcular Bleeding Index


Gingivitis


No increase in gingival recessionor other oral lesions associatedwith either brush at 6 months.


Comparison of an Oscillating Rotating Electric Toothbrush and a Sonic Toothbrush in Plaque Removing Ability

Van Der Weijden, S.A., Timmerman,

M.F., Van Der Velden, V.

J Clin. Periodontol 23:407, 1996


35 non dental students given aSonicare and a Braun Oral B plakcontrol brush and instructed to useeach brush every other day.


2 weeks later subjects no brushingfor 24 hours then reevaluated thenmouth brushed by an examinersplit mouth using both brushes.


Plaque IndexAfter 2 minutes Professional Brushing


They repeated this 4 weeks laterwith brushing using Zendiumtoothpaste by the students.


Plaque IndexAfter 2 minutes Panellist Brushing


At end of study they could keepone brush. 34 out of 35 keptBraun brush.


Clinical efficacy of flossing versus use of antimicrobial rinses.Zimmer. S, et al J. Periodontol. 2006 77:1380


156 patients used brush +daily rinse 0.06% chlorhexidine 0.025% fluoride or brush+ 0.1% cetylpyridiniumchloride +fluoride or brush + floss or brush alone.Evaluated at 8 weeks.


CHX NaF 1.58 CPC/NaF 1.54 FLOSS 2.10 BRUSH 2.00 /

MODIFIED PROXIMAL PLAQUE INDEX


Papilla Bleeding Index

CHX /NaF 0.67 CPC/NaF 0.75 FLOSS 0.77 BRUSH 0.89


Additional effect of dentifrices on the instant efficacy of tooth brushing.Paraskevas S .et al J. Periodontol.2006 77:1522


3 toothpastes used in 40 patients each after 48 hours plaque accumulation.Split mouth hand brush with or without paste.


Tooth paste gave average of 3% more plaque than brush alone.More abrasive pastes no more effective.


CONTROL OF DIET

More benefit comes from reduction of sucrose in diet so less caries and less plaque minimal effect on gingival inflammation from other dietary modifications


CONTROL OF SYSTEMIC FACTORSCONSULT WITH PATIENT’S M.D.

Control of Hemostasis

Control of Bacteremia

Control of Diabetes

Control of Medications


CONTROL OF ORAL MALODORAND TASTE ABNORMALITIES

Plaque control is most predictable way to reduce oral malodor together with daily tongue scarping to reduce bacterial load of oral cavity.


CONTROL OF TOBACCO SMOKING

Elimination of smoking significantly improves tissue response to initial therapy.


PHASE ONE THERAPY

Removal of pathologic tissue for biopsy

Removal of caries-endodontic therapy

Removal of hopeless teeth

Removal of calculus


Biopsy should be done immediately in initial therapy

Clinical diagnosis of possible malignant ulceration


Immediate biopsy result diagnosis of squamous cell carcinoma

Exophitic growth from area previously diagnosed as lichen planus


Non ulcerated lesion present for at least 3 years


Tissue removed includes periphery of normal tissue

Diagnosed as benign hemangioma


Biopsy site sutured


Furcal bone loss resolved after endodontic treatment carried out before any periodontal care

Removal of caries

Endodontic therapy


Tooth # 3 has 8 mm pockets and grade 3 mobility

Removal of hopeless teeth


Radiograph confirms hopeless prognosis for tooth # 3

Recommend extract tooth # 3 during initial therapy


Deep pockets seen of distal of tooth # 4


Tooth # 4 shows periodontal remodeling after extracting tooth # 3

Pocket depth improved on distal of tooth # 4


REMOVAL OF CALCULUS

Root Planing


Photomicrograph of calculus embedded in cementum

Root planing is needed to remove embedded calculus


Universal curets for root planing


Gracey curet 5/6

Triangular shaped scaler for small interproximal spaces


Explorers are used to confirm completion of root planing

Root surfaces should be glassy smooth and free of calculus


Prior to root planing with curetes

Root surface magnified


S.EM of new sharp curete

Note surface notches on cutting edge


Root surface magnified after root planing with curet

Note smooth surface with very slight striations


Magneto strictive effect results in high frequency complex movement of tip

Ultrasonic scalers


Root surface magnified after ultrasonic instrumentation

Large ripples seen that can be detected with explorer


MEAN TOOTH SURFACESROUGHNESS SCORES


Remove large deposits with ultrassonic scaler then root plane with curets

Gross amounts of calculus and plaque


Needs root planing with curets

Radiographic evidence of calculus


Sublingual calculus with acute inflammation of gingiva

Root planing done with curets and oral hygiene optimized


Normal healthy gingiva. No bleeding on proving

Four weeks after initial therapy


No need for further periodontal therapy

Pocket reduction


Gingival inflammation is combination of acute and chronic changes

Interproximal pockets are 6 mm with attachment loss and bone loss


Residual pockets and bone loss require phase two periodontal surgery

Root planing with curete has resolved acute inflammation


PHASE ONE THERAPY

Occlusal correction

Occlusal splints

Provisional splinting of teeth

Orthodontic movement


Occlusal Adjustment

  • Correction of Centric

    • Stable centric relation

    • No interferences between CR and CO

  • Correction of lateral excurtions

    • Balancing interferences

    • Working interferences

    • Balancing interferences

  • Correction of protrusive excursions

    • Straight protrusive

    • Protrusolateral

  • Correction of centric occlusion


OCCLUSAL SPLINTS

(ORTHOTICS)


PROVISIONAL SPLINTS


PHASE ONE THERAPY

Restorative corrections

Open contacts

Overhangs

Poor margins

Poor contours


PHASE ONE THERAPY

Correction of inadequate

removable partial dentures


Change in Alveolar Bone 4 Years After Partial Dentures as Percentage of Lengths of the Teeth


Pocket depth

Plaque score

Bleeding on probing

Caries

Occlusal stability

Mobility, fremitus

Mucosal health status

Mucogingival status

Systemic status

Radiographic evaluation

Oral malodor and taste

Esthetics

Modification of phase two treatment plans

PHASE ONE EVALUATION


SECTION OF PERIODONTICS UCLA

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