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7/18/2012
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The New periodontal Disease : The New periodontal Disease : Inflammatory and RiskyInflammatory and Risky
S LS LSam LowSam [email protected]@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