Perio-Prostho Literature Review Summary
Perio-Prostho Literature Review Summary
Perio-Prostho Literature Review Summary
Periodontal Diseases:
Advances in Periodontal Disease Ø Adult periodontitis (Affects patients 35 years or older; microbial deposits; no systemic illness)
Diagnosis Ø Juvenile periodontitis (Circumpubertal; neutrophil dysfunction; affects first molars & incisors)
Ø Pre-pubertal periodontitis (Generalized; neutrophil dysfunction; affects deciduous dentition)
Greenstein - 1990 - IJRD Ø Rapid progressive periodontitis (Young adults; rapid, progressive; neutrophil dysfunction)
Ø Refractory periodontitis (Does not respond to conventional therapy)
Ø Gingivitis (Isolated or generalized; endemic; redness, bleeding upon probing)
Ø ANUG (Necrosed papilla; gingival pain)
Probing depth assessment used to determine the need for therapy can be misleading (because it is
possible to have healthy deep sulci). Increasing probing depth reflect progressive periodontitis unless
they can be attributed to coronal migration of the gingiva or measurement error
Clinical attachment levels are the most accurate way to monitor patients
Contemporary Interpretation of
Probing Depth Assessments:
Reproducibility of Probing Depth Assessments:
Diagnostic and Therapeutic
Prior to therapy, assessment of deep probing depths was associated with increased measurement error
Implications. A Literature Review
After therapy, probing depths were more reproducible (resolution of inflammation & reduced probing
depths after treatment)
Greenstein - 1997 - J Periodotol
Relationship Between Bleeding Upon Probing and Probing Depth:
Direct relationship between the prevalence of bleeding upon probing & increased probing depth
Deep probing depth bleed more frequently upon probing than shallow site
The two most commonly used parameters to characterize a patient as having Periodontitis:
Measurements of probing depth & clinical attachment loss
Meticulous oral hygiene can influence subgingival microflora in shallow & moderately deep pocket but
were not altered in deep pockets >5mm
Scaling & root planning of periodontitis lesion usually result in probing depth reduction due to either
gain of clinical attachment or recession
Probing Reproducibility:
Varies between patients & for different sites within patients
Differing probing forces lead to different amounts of penetration of the probe tip into the tissues
Gold standard - clinical and Tendency for examiners to round off readings to nearest millimeter is a source for magnification & errors
radiographical assessment of disease Angulation of probing is a source of eproducibility error
activity
Radiographic Method:
Claffey - 1997 - J Periodotol Cannot reflect bony morphology buccally & Iingually
Can provide information on interproximal bone levels
Lang et al - 1997 Any force greater than 0.25 N may evoke bleeding in healthy sites with an intact periodontium
Attstrom & Van der Velden - 1994 Classified Periodontal Conditions to:
I. Gingivitis II. Adult periodontitis III. Early onset periodontitis IV. Necrotizing periodontitis
DEFINITIONS:
Determinants “Risk factors that cannot be modified”
Risk factor “Risk factors that can be modified”
Risk indicator “A possible factor associated with a disease”
Risk marker “Predictive risk factor associated with an increased probability of disease in the future”
DETERMINANTS:
Current View of Risk Factors for
1. Age (More periodontal disease in older age groups)
Periodontal Diseases
2. Race (No differences between African-American & whites)
3. Gender (Male gender is associated with more severe periodontal disease)
Genco - 1996 - J Periodontol 4. Socioeconomic status (No relation between Socioeconomic status & periodontal disease)
McGuire - 1991 - J Periodontol Only the good prognosis category stayed relatively stable over time
Fair & poor categories improved
Questionable category generally got better, but a significant number of teeth were lost
Hopeless teeth either improved or were lost (never retained a questionable prognosis)
Mandibular molars & mandibular 2nd premolar tended to maintain worse than expected
Maxillary cuspid & mandibular teeth from 1st bicuspid to 1st bicusbid maintained better than expected
Maxillary lateral incisor performing worse while maxillary central incisor performing better
Results of maxillary arch were almost a mirror image of the results of the mandibular arch
Accurate prognosis was more difficult to make for teeth with an initial less than good prognosis
Prognosis Versus Actual Outcome The overall accuracy for teeth with less than "good" initial prognoses:
II. The Effectiveness of Clinical was 43% at 5 years & 35% at 8 years
Parameters in Developing an
Accurate Prognosis care Clinical Factors Related to Worse Prognoses:
1. Smoking 2. Probing depth 3. Furcation involvement 4. Root form 5. Malposition
McGuire - 1996 - J Periodontol 6. Diabetes 7. Parafunctional habit 8. Percent bone loss 9. Endodontic involvement
Teeth with poor prognoses initially were 7 ½ times as likely to improve compared with fair prognoses
Teeth with questionable prognoses initially were 12 times as likely to improve when compared to fair
Hirschfeld & Wasserman - 1978 - J The total number of teeth were lost was 2.6% in the WM group, 22.7% in the D group & 55.4% in the
Periodontol ED group with higher percentages of non-questionable teeth lost
There was variation in pattern of tooth loss in different positions in the arch & bilateral symmetry
In all groups, 4 times as many repeated surgical procedures were done in mandibular arch as in maxilla
Questionable maxillary incisors were more resistant to loss (8.2% lost) than mandibular incisors (17.2%)
The greatest inflammation was found about Mandibular central incisors, lateral incisors & cuspids
The most resistant to loss that had greater survival after surgery were mand cuspids & 1st bicuspids
Maxillary 2nd molars had the highest frequency of tooth loss between examinations
Mandibular 2nd molars were lost slightly less frequently
Maxillary & mandibular canines & mandibular central incisors had the lowest loss rate
The Long-Term Evaluation of Molars had the highest mean probing scores at the first examination
Periodontal Treatment and Anterior teeth had the lowest first examination scores
Maintenance in 95 Patients
FACTORS IN DETERMINING A PROGNOSIS:
Becker et al - 1984 - J Perio Rest Dent 1. Remaining supporting bone 2. Crown-root ratio 3. Root proximity
4. Health of adjacent teeth 5. Mobility 6. Restorative treatment plans
Periodontal therapy & maintenance are successful in reducing moderate to deep pockets with minimal
long-term bone loss
The average periodontal tooth loss rate was 0.29 teeth per patient over an average 12.9 year period
Tooth Type:
Majority of periodontally involved teeth lost were maxillary molars (63.7%). Followed by mandibular
molars (20.0%) & maxillary premolars (7.3%)
COMPARED PERIODONTAL THERAPIES
Surgical therapy produced greater & retained probing depth reduction than non-surgical therapy
A Review of Longitudinal Studies
That Compared Periodontal Plaque control alone either produced no change or a minimal reduction in clinical inflammation
Therapies Root planning with plaque control produced a much greater reduction
SCALING:
“Removal of plaque, calculus & stain from crown & root surfaces”
ROOT PLANNING:
Removal of cementum or surface dentin that is rough or impregnated with calculus, toxins,
or microorganisms”
Greenstein Assessment of changes in probing depths & clinical attachment levels should be made 3 to 4 weeks after
scaling & root planning
Ultrasonic debridement was more effective than hand scaling in Class II & III furcation at reducing
spirochetes & motile rods
if signs of inflammation persist after non-surgical care then surgical access may be necessary
Non-surgical therapy frequently was sufficient to resolve inflammation & arrest Periodontitis
it is often difficult to remove plaque & calculus when probing depths exceed 5 mm
Dimensional Alteration of the Compared baseline & six-month examinations of probing attachment levels:
Periodontal Tissues Following Sites with initially shallow < 4 mm pockets tended to lose on between 1 & 2 mm of attachment
Therapy Sites with 4 to 6 mm pocket depth, gained probing attachment between 0.5 & 1.2 mm
Sites with initially deep pocket > 6 mm, gained probing attachment between 1.8 & 2.8 mm
Lindhe - 1987 - Int J Perio Rest Dent
Treatment of deep and shallow With GTR, most of the sites gained 2 mm or more of attachment with no attachment loss observed in any
intarbony defects. A multicenter of the treated cases
randomized controlled clinical trial
Clinical attachment level gains & probing pocket depth reductions in GTR with bioresorbable barrier
Cortellini - 1998 - J Clin Periodontal membranes treated sites were greater than those observed in sites treated with the access flap alone
CRATERS TYPES:
I. Shallow 1mm to 2mm deep II. Medium 3mm to 4mm deep III. Deep 5mm or more
Medium Craters:
Cannot be managed by palatal approach alone and will require buccal osseous procedures
MAXILLARY PREMOLARS:
Maxillary 1st premolar is a challenging tooth to manage than 2nd premolar
(Proximity of mesial furcation to the CEJ & frequently bifurcated)
Positive Architecture:
“Scalloped architecture of interdental bone height coronal to the radicular bone”
Reversed Architecture:
“Existed when interdental papilla is apical to the buccal & lingual marginal gingiva”
Vertical Grooving:
Gradual diminishing of interdental bone height as the transition is made from anterior to posterior
Grant et al Divided Furcation Into 3 Parts: 1. Root trunk 2. Furcation roof or dome 3. Root separation
ROOT TRUNK:
“Part of the root that extends from CEJ to the area of root separation”
Long root trunk & short root anatomy has a more favorable prognosis during early furcation
involvement (if the furcation becomes diseased, the prognosis is often poor)
Multi-rooted teeth with short root trunks have the highest furcation involvement 75%, but are the best
Anatomic Considerations in the candidates for respective procedures (longer root)
Etiology and 01 Maxillary and
Mandibular Molars with Furcation Distal furcation have a higher incidence of furcation involvements than mesial furcation in maxillary
Involvement molars (although more apically located, is more prone to earlier invasions than the mesial because of its
position directly beneath the interproximal contacting area)
Mardom-Bey et al - 1991 - Int J Perio
Rest Dent THREE CATEGORIES OF CERVICAL ENAMEL PROJECTION (CEP):
Grade I: Showing a change in the CEJ with enamel projecting toward the bifurcation
Grade II: Approaching the furcation, but not actually making contact with it
Grade III: Extending into the furcation
Grade I & Grade III projections were the most often observed
There are more CEPs in mandibular molars than in maxillary molars
Cervical enamel projections seem to be more prevalent in maxillary & mandibular 2nd molars
Bifurcation Ridge:
The incidence of bifurcation ridges has been found to vary from 70% to 73% in mandibular molars
A retrospective analysis of the Evaluated a group of patients with teeth treated by hemisection and/or root amputation:
periodontal-prosthetic treatment of The main reasons for failure was other than periodontal disease (Endodontic reasons & caries)
molars with interradicular lesions It was possible to maintain good oral hygiene in patients with root amputations & hemisections
Carnevale - 1991 - IJPRD The inflammation resolved
Prognosis and mortality of root- Compared Tooth Mortality of Root-Resected Molars with that of Root-Filled Single Rooted Teeth:
resected molars Survival rates were 68% for root-resected molars & 77% for root-filled single rooted teeth over 10-year
(Not statistically significant) Prognosis of root-resection is not poorer than prognosis of single rooted
Biofilm et al - 1997 - IJPRD teeth if endodontic conditions & maintenance care are optimal
Class I:
Incipient horizontal involvement just into the intraradicular area
No intraradicular horizontal bone loss
Class IA:
The Restoration of the Approximately the first one half of the initial one third of the buccolingual tooth dimension
Sectioned Molar Early intraradicular horizontal bone loss
Class IIA:
Horizontal involvement into middle one third of the tooth but not beyond one half of the tooth dimension
Intraradicular vertical & horizontal bone loss; almost always a crater
Class III:
Horizontal involvement beyond one half of the buccolingual tooth dimension
Intraradicular vertical & horizontal bone loss; a more severe combination type of defect
Combined Therapy for Teeth With Therapeutic Possibilities According to the Degree of Furcation Involvement:
Furcation Involvement Used as Degree 1: Scaling, root planning, odontoplasty
Abutments for Fixed Restorations Degree 2: Periodontal surgery
Degree 3: Endodontocs, periodontics & fixed prosthodontics (integrated tx have shown a higher long-
Hurzeler - 1990 - Int J Pros term success rate than that obtained using other modalities)
INDICATIONS OF GTR:
1. Class II furcation defects
Current status of guided periodontal 2. Two or three wall vertical interproximal
tissue regeneration 3. Circumferential intrabony osseous defects
Quistones - 1995 - JOP GTR is based on the type of healing resulting after periodontal surgery is determined by the tissues that
first repopulate the root surface by placing a physical barrier between the gingival flap & the root surface
during surgery (to exclude gingival epithelium & CT from the root surface & creates an area into which
progenitor cells from the periodontal ligament & the alveolar bone can migrate)
Root surface conditioning with citric acid had minimal or no effect in furcation defects
GTR used alone or in combination with bone replacement grafts, had the highest overall ranking
The treatment of choice for Class II furcation defects is GTR with bone replacement grafting or alone
Low-level radiation (less than or equal to 2.5 Gy) does not affect bone regeneration
Jacobsson et al - 1985 Higher doses of irradiation (5 Gy or more), resulted in significant reduction in bone regeneration
Metzler et al - 1991 Reported better results in buccal defects than in interproximal furcation defects due to better accessibility
2 & 3 wall intrabony defects have a significantly better response to GTR procedures (82% to 91% defect
Cortellini et al - 1993 fill) than do 1 wall defects (39% defect fill)
Caton et al - 1992 Most of the healing following GTR is completed within 3 months
CT Attachment:
Dimensions and Relations of the “The distance from the base of the epithelial attachment to the crest of the alveolar bone”
Dentogingival Junction in Humans The most constant (1.07 mm mean average length)
Biologic Width:
Considered to have a constant dimension of 2 mm
Used as a unit of measure for locating restorative margins with respect to the alveolar crest
Restorative margins and periodontal
health: A new look at an old Junctional Epithelium:
perspective The normal length of a junctional epithelium is 1 mm or less
Block - 1987 - JPD Oral epithelium proliferates & forms a new junctional epithelium in approximately 5 days
Gargiulo et al The average length of the junctional epithelium was 0.97 mm & average sulcus depth was 0.69 mm
Youngblood et al Manual brush was effective to a depth of only 0.7 mm
Electric brush could reach plaque 1.4 mm below the gingival margin
BIOLOGIC WIDTH:
“The combined dimension of CT attachment & junctional epithelium averages 2.04 mm”
De Wall - 1993 - Int J Periodontol When restorative margins extend into BW, one of four pathologic alterations will develop:
1) Crestal bone loss resulting in a localized infrabony pocket
2) Gingival recession and localized bone loss
3) Localized gingival hyperplasia with minimal bone loss
4) Combinations of all
Biologic width of the molars was significantly greater than that of the anterior teeth & premolars
The concept of BW requires a minimum of 2.04 mm of sound tooth structure above the osseous crest
Base of the Sulcus:
The single most important factor determining the gingival response to restorative dentistry
Define the cervical limitation of tooth preparation & the intracrevicular margin location
Altering Gingival Levels: The
Restorative Connection. Part I: Osseous Crest:
Biologic Variables For determining gingival levels
Kios - 1994 - J Esthet Dent COMPONENTS OF DENTO-GINGIVAL COMPLEX (DGC):
1. Connective tissue fibrous attachment
2. Junctional epithelium or epithelial attachment
3. Sulcus
The desired distance from margin to bone on facial & interproximal is 2.5 mm
CROWN LENGTHENING
The minimal distance from alveolar crest to coronal extent of sound tooth structure should be 4 mm
(2 mm bracing on sound tooth structure & 2 mm biologic width)
The maxillary canine is the tooth with the most favorable prognosis for successful treatment
The poorest candidate is the maxillary central incisor
Surgical lengthening of clinical crown Creating a distance of 3 mm from the alveolar crest to the future reconstruction margin during surgical
Bragger - 1992 - JCP CL leads to stable periodontal tissue levels over a period of 6 months
The greatest amount of both mean bone removal & biologic width was found on the mid-facial surface
Clinical comparison of desired versus & the least amount at distal-lingual surface
actual amount of surgical crown
lengthening The proposed minimum desired 3 mm biologic width was not routinely achieved in this study
(Clinicians may need to be more aggressive during surgical CL procedures to achieve the proposed goal
Herrero et al - 1995 - J Periodontol of 3 mm biologic width)
Periodontal and dental When restoration margins are placed intra-crevicularly, they should be no deeper than 0.5 mm & parallel
considerations in clinical crown to the gingival margin
extension- a rational basis for
treatment Whenever possible, the finish line should be determined prior to surgery (or should be anticipated if it is
not possible)
Smukier & Chaibi - 1997 – IJPRD
Cohen - 1902 Defined Biologic Width as “junctional epithelial & connective tissue elements of the dento-gingival
continuum that occupy the space between the base of the gingival crevice & the alveolar crest”
Dimension of biologic width vicinity 2.04 mm (made up of junctional epithelial dimension of 0.97 mm
Gargiulo et al plus 1.07 mm of connective tissue attachment in a coronal-apical direction)
The sulcular depth was estimated to be in the vicinity of 0.69 mm
TOOTH PREPARATION:
Should be performed 4 to 6 weeks after surgical CL for a supragingival finish line and 8 weeks after
crown lengthening if the margins are to be placed in the sulcus
Interproximal Periodontal Disease - The most frequent lesion noted occurs where there is damage to the bone under the contact point
The Embrasure as an Etiologic Factor The most complicated area to take an impression with retraction cord is interproximal of upper centrals
Nevins - 1982 - IJRD The alveolar housing for the roots of anterior teeth is narrower than that for posterior teeth
The Effect of the Distance from the Variables that may contribute to presence or absence of the papilla:
Contact Point to the Crest of Bone on 1. Degree of inflammation 2. Pocket depth of adjacent teeth
the Presence or Absence of the 3. Fibrous or edematous nature of tissue 4. Anterior versus posterior teeth
Interproximal Dental Papilla 5. Presence of proximal restorations 6. History of previous non-surgical & surgical therapy
7. Mesio-distal distance between the 2 teeth 8. Total volume of the embrasure space
Tarnow et al - 1992 - J Periodontol DISTANCE FROM BASE OF THE CONTACT POINT TO THE CREST OF BONE:
5 mm or less --- inter-proximal papilla Almost always present (100% of the time)
6 mm --- Present more than half of the time (56% of the time)
7 mm or more --- Missing most of the time(27% of the time or less was present)
Mucogingival Surgery:
Mucogingival surgery “Plastic surgical procedures designed to correct defects in the morphology, position and/or amount of
gingivae surrounding the teeth”
Wennstrom - 1994 - Quint Publ
The possibility of achieving a new CT attachment in the apical portion of the defect seems to be
considerably better in narrow gingival recessions than in wider one
Class III:
Marginal tissue recession extends to or beyond the mucogingival junction
Loss of interdental bone
Interdental soft tissue is apical to CEJ, but coronal to the apical extent of the marginal tissue recession
Class IV:
Marginal tissue recession extends beyond the mucogingival junction
Loss of interdental bone & soft tissue to a level corresponding to apical extent of marginal tissue
Undercontouring of the clinical crown will cause deflection of masticated food onto the gingival margin,
forcing it into the sulcus, thus initiating gingivitis
Current theories of crown contour,
margin placement, and pontic design A normal tooth at the bucco-cervical bulge is usually equal or less than 0.5 mm wider than the CEJ
Becker & Kaldahl - 1981 - JPD Interproximal space that is slightly larger than normal (Open embrasure) may be desirable since it
provides adequate room for the gingival papilla and is a more accessible area to clean
Few incidences of new caries associated with supragingival margins have been reported because of
improved access for plaque control
Subgingival margins should be avoided except for the following specific situations:
1. Esthetic demands 2. Caries removal 3. Subgingival tooth fracture
4. To gain crown length 5. Existing subgingival restorations 6. Provide favorable crown contour
PONTIC DESIGN:
The modified ridge-lap design in posterior region & ridge-lap facing design in the anterior region offer
minimal tissue contact, acceptable cosmetic value, proper cheek support & accessibility for adequate OH
(design of the pontic may be the most important factor in preventing inflammatory reactions, not the
material used in the pontic)
Overcontouring prevents the normal cleansing action of the musculature and allows food to stagnate in
Morris
the overprotected sulcus
Townsend Even with grossly undercontoured, open embrasure spaces, lateral food impaction rarely occurs as long
as interproximal tooth contacts are properly maintained
Supragingival margins increase the potential for achieving optimal gingival health around restored teeth
33% of the people, gingival aspect of their most visible anterior teeth did not show during a normal smile
& 16% during an exaggerated smile
Shoulder finish line can be established subgingivally while keeping the entire rotary instrument diameter
Gingival Esthetics within peripheral tooth contours where there is less chance of gingival contact
Chamfers & beveled shoulders requires that part of the rotary instrument diameter be located outside
Goodacre - 1990 - JPD peripheral tooth contours, with greater potential for gingival trauma
Provisional restorations are in position for as little time as possible preferably no more than 2 to 3 weeks
Factors deserve consideration in using retraction cord & attempting to minimize soft tissue trauma:
1) Time (Should not exceed 15 to 20 minutes)
2) Size & number (Too large a retraction cord or too many cords can cause excessive trauma)
3) Pressure of Placing retraction cord (excessive pressure can produce tissue blanching & recession)
Subgingival crown margins result in less favorable periodontal condition than margins at gingival crest or
above
A new epithelium will proliferate to cover the exposed connective tissue wound and complete healing
Maintaining and enhancing gingival will normally take place within 8 to 14 days
architecture in fixed prosthodontics
Typical extension into the gingival sulcus should not exceed 0.5 to 1 mm, (depending upon the depth of
Ferencz - 1991 - JPD the sulcus)
The average depths of the healthy cervice vary between 1 to 1.5 mm on the facial aspect of the maxillary
anterior region (The recommended subgingival margin level for a crown is half of this value and should
Impression Considerations in the be no deeper than 0.5 mm to 0.7 mm)
Maxillary Anterior Region
Two methods to minimize the potential for penetration beyond the base of the crevice by the bur:
Chiche - Compend Contin Edu Dent 1) Prepacking gingival tissue with a thin, non-impregnated cord
2) Probing the crevice depth during tooth preparation (when the crevice tissues is less than l-mm deep)
A minimum waiting period of 3 months after surgery is recommend before initiating the final restoration
Tarnow et al Marginal tissue recession resulting from violation of BW rapidly stabilize within 2 weeks
post-surgery with no further apical migration
Guidelines for the Use Of 0.12% Chlorhexidine Gluconate Mouthrinse in Fixed Prosthodontics:
1) Assess gingival health
Gingival enhancement in fixed (patient's oral hygiene abilities, pocket depths, plaque levels & presence of bleeding upon probing)
prosthodontics. Part I: Clinical Patient with pocket depths greater than 4 mm should first be treated or referred to a periodontist
findings
2) Prophylaxis on initial appointment & regimen of CHX 15 ml h.i.d. at least 2 weeks before fixed
Sorensen et al - 1991 - JPD prosthodontic procedures
3) If the patient has no bleeding sites, minimal plaque levels, or gingivitis, the use of chlorhexidine is
probably not indicated (with a gingival index much less than 1, limited benefit would be observed)
Gingival enhancement in fixed Chlorhexidine has been shown to be the most efficacious agent in reducing supra-gingival plaque &
prosthodontics. Part II: Microbiologic gingivitis when compared with other antimicrobial agents (Rinsing twice daily with 0.12%
findings
chlorhexidine resulted in significantly greater reduction of perio pathogens)
Flemmig et al - 1991 - JPD
Chlorhexidine’s Action:
The positively charged chlorhexidine molecule binds to negatively charged regions on the bacterial cell
wall leading to rupture & cell death
Gingival enhancement in fixed
prosthodontics. Part III: Anamnestic Chlorhexidine’s Side Effects:
findings 1. Development of brown pellicle discolorations (most in interproximal aspect of mandibular anterior teeth)
2. Altered taste sensation
Sorensen et al - 1991 - JPD 3. Discoloration of the tongue & mucosa
4. Gingival irritation
Of the reported side effect, taste alteration was more objectionable side effect than staining
Patient perceived gingival health benefits were more important than patient perception of the side effects
Clinical evaluation of patients eight to There was no significant difference in caries incidence, change in sulcus depth, tooth mobility or alveolar
nine years after placement of bone loss between those who wore the dentures & those who didn’t
removable partial dentures
There were increased levels of inflammation in areas covered by RPDs & areas bellow clasp arms
Chantler - 1984 - JPD