CONTROVERSIES

IN
PERIODONTICS

BY
K. SHIVA CHARAN YADAV
 Contents
•Introduction
•Classifying periodontal disease – a long standing dilemma
•Non inflammatory periodontal disease
•Perio endo controversy
•Animal models
•Role of stress in inflammatory disease, includng periodontal diasease.
•Perio-systemic link
•Surgical vs. non surgical treatment
•Multiple visit SRP vs. FMDT
•Bone grafts- regeneration dilemma
•Splinting- actual reality
•Curretage
•Granulation tissue- healthy vs. Infected
•Rootplaning vs Root debridement
•Root conditioning
•Periodontal dressings :- to pack or not
•Flap vs flapless implants
•First stage vs 2nd stage
•Immediate vs delayed
•Implansts in aggressive periodontics
 •Introduction
WHAT?
 A controversy is a contentious dispute, a disagreement in
opinions over which parties are actively arguing.

Critical issue : An issue which is judged severely and faults

in it are found.
•Classification Systems -Controversies
•Classification Systems -Controversies
•Grouping periodontal diseases into a widely accepted classification system has been difficult, based
primarily on disputes about the etiology and pathogenesis of a clinically disparate disease process.

•The classification systems should be viewed as dynamic works-in-progress that need to be

periodically modified.

•The development and evolution of classification systems for periodontal

diseases have been largely influenced by paradigms that reflect the
understanding of the nature of periodontal diseases during a given historical
period.
CLASSIFICATION OF PERIODONTAL DISEASES CAN BE PLACED
INTO THREE DOMINANT PARADIGMS PRIMARILY BASED ON

THE CLINICAL THE CONCEPTS OF THE INFECTIOUS

FEATURES OF THE CLASSICAL ETIOLOGY OF THE
DISEASES PATHOLOGY DISEASES
(1870–1920) (1920–1970) (1970–PRESENT).
 ‘Pyorrhea alveolaris’ , Very little known about etiology and
‘Riggs’ disease, pathogenesis, so classification based on
‘Calcic inflammation of the clinical features
peridental membrane’ , ‘Phagedenic
pericementitis’ ,
chronic suppurative pericementitis

THE CLINICAL
FEATURES OF
THE DISEASES
(1870–1920)

Debated on cause :-
local or systemic
Little or no scientific evidence was used to factors
support the opinions of the clinicians of the
time.

• It was not until the next World
Workshop, held in 1977, that
convincing arguments were
provided that there was no
scientific basis for retaining the
concept that there were non-
inflammatory or degenerative
forms of destructive periodontal
disease .
Debate :- the concept that there
were at least two forms of
destructive periodontal disease
Inflammatory
Non-inflammatory
(Degenerative/Dystrophic).
THE
CONCEPTS OF
CLASSICAL
PATHOLOGY
(1920–1970)
However, the conclusion that
some periodontal diseases were
caused by non-inflammatory or
degenerative processes was a
somewhat novel suggestion.
 Robert koch- germ theory.
W.D miller- infectious nature of periodontal
disease

The 1989 World Workshop THE

classification of periodontitis based •Loe :- eperimental
on the Infection/Host Response INFECTIOUS gingivitis( 1965-68)
paradigm was suggested.
{Depended heavily on the age of ETIOLOGY OF •Microbial specificity
the affected patients and the rates
of progression. THE DISEASES ( 1977-79)

} (1970–
PRESENT).
I, Adult Periodontitis;
II, Early Onset Periodontitis;
III, Periodontitis Associated with Systemic Disease; 1999
IV, Necrotizing Ulcerative Periodontitis; and CLASSIFICATION
V, Refractory Periodontitis
 Robert koch- germ theory.
W.D miller- infectious nature of periodontal
disease

The 1989 World Workshop THE

classification of periodontitis based •Loe :- eperimental
on the Infection/Host Response INFECTIOUS gingivitis( 1965-68)
paradigm was suggested.
{Depended heavily on the age of ETIOLOGY OF •Microbial specificity
the affected patients and the rates
of progression. THE DISEASES ( 1977-79)

} (1970–
PRESENT).
I, Adult Periodontitis;
II, Early Onset Periodontitis;
III, Periodontitis Associated with Systemic Disease; 1999
IV, Necrotizing Ulcerative Periodontitis; and CLASSIFICATION
V, Refractory Periodontitis
 American Academy of Periodontology Task Force Report on the Update to the 1999
Classification of Periodontal Diseases and Conditions-2015

• In 2014, the American Academy of Periodontology Board of Trustees charged a Task Force
to develop a clinical interpretation of the 1999 Classification of Periodontal Diseases and
Conditions to address
 Concerns expressed by the education community, the American Board of Periodontology,
• The current Classification presents challenges for the education of dental students and
implementation in clinical practice.

American Academy of Periodontology Task Force Report on the Update to the 1999 Classification of Periodontal Diseases and Conditions. J
Periodontol 2015;86(7):835-838
 • The Academy announced that an update to the 1999 Classification would
commence in 2017.

• The present focused update addresses three specific areas of concern with the
current classification:

Attachment level

Localized versus generalized periodontitis

Chronic versus aggressive periodontitis

American Academy of Periodontology Task Force Report on the Update to the 1999 Classification of Periodontal Diseases and Conditions. J
Periodontol 2015;86(7):835-838
• Non inflammatory destructive periodontal
disease (NDPD)

Clinically

Radiographically
 •Non inflammatory destructive
periodontal disease (NDPD)
Today the infectious nature of periodontitis is no longer a hypothesis
but is a universally accepted dogma.

Experts agree that all forms of periodontitis are infectious and are characterized by
chronic inflammation, pocket formation and deepening, and loss of periodontal attachment and
alveolar bone.

Although bacteria are thought to be essential, bacteria alone are insufficient; a susceptible host is
also required, and host susceptibility is an important determinant of disease status
Page RC (2002) questioned the validity of the concept whether

• Are all forms of destructive periodontal disease

infectious?

• Are all characterized by chronic inflammation,

pocket formation and progressive deepening,
and loss of attachment and alveolar bone
NDPD has several distinct diagnostic characteristics:

fails to respond to traditional antimicrobial

treatments.
may affect all of the teeth or it may be more
severe around the posterior or the anterior teeth.

recognized most frequently in individuals in their 30s or

40s, although it may begin in patients in their 20s.

Extensive gingival recession, affecting many teeth, without

formation of deep periodontal pockets or significant clinical
manifestations or history of gingival inflammation

Resorption of alveolar bone.

Generalized loss of attachment.

•Although the mechanisms underlying NDPD have not been directly investigated, it was
suggested that they may be the same as for periodontitis except that the production of
prostaglandins and MMP, as may be initiated and perpetuated by factors other than bacterial
infection, and the mediators may be produced by cells that are normally resident in the
periodontal tissues rather than infiltrating inflammatory cells.

•Fibroblasts plus a few macrophages (histiocytes) comprise the predominant cell population
present in noninflamed gingiva (Schroeder HE 1973).
•These cells could become activated to produce, cytokines, prostaglandins and MMP by
application of abnormal forces as well as by binding of IL-l, TNF-a, or bacterial substances.

•Such forces could originate from enduring, frequently applied aggressive

oral hygiene. The resident fibroblasts could therefore serve as a source of
molecules that mediate resorption of the alveolar bone and destruction of
gingival and periodontal ligament connective tissues.
Based on the above hypothesis, have focused on the idea that
soft tissue trauma resulting from aggressive daily oral hygiene
combined with a possible genetically determined enhanced
susceptibility could account for the pathobiology of NDPD
•The Perio Endo Relationship -
Controversies
 Does Periodontal disease cause pulp necrosis?

• Many of the reports published in the early 60’s and 70’s describing pulpal changes in
Periodontally involved teeth were inaccurate & suffered from histological artifacts.

• Well framed recent studies have not found any evidence of Periodontitis causing pulp
necrosis.

Does Periodontal therapy cause pulp changes?

•Even teeth with severe Periodontitis reaching the apical third of the root were found to have
normal pulps.

•Only when the blood supply to the pulp at the apical foramen was affected. The pulp showed
changes.
Unless Periodontal disease extends all the way to the tooth apex, the weight
of evidence in the literature suggests that the dental pulp is capable of surviving significant
insults & that the effect of Periodontal disease as well as Periodontal treatment on the dental
pulp is negligible.

The relationship of Periodontal disease & pulp has been exaggerated in historical literature.
.
 Endodontically involved teeth & Periodontal health & healing

• The rate of bone destruction in teeth with Periapical lesion appeared to be statistically more
clinically marginal.

• In one study, use of DFDBA in endodontically treated teeth showed less bone fill than normal teeth.

• However well controlled studies, where Endodontic treatment was judged adequate, these teeth
responded in the same way as others.

• Well controlled studies have shown that prognosis is good even for molars treated by RCT.
 Current Position
• The Periodontal prognosis is not affected if a satisfactory, adequate Endodontic
treatment is done.

• Although there might be some statistical difference clinically Endodontically

treated teeth respond similarly to Periodontal therapy as compared to vital
teeth.
 •Role of stress in periodontal disease

“It is a state of physiological or psychological strain caused by adverse stimuli, physical, mental,
or emotional, internal or external, that tend to disturb the functioning of an organism and which
the organism naturally desires to avoid”
 •Role of stress in periodontal
disease
• In a review of psychosocial factors in inflammatory periodontal disease reported in 1995,
Monteiro da Silva et al distinguished between acute necrotizing ulcerative gingivitis and adult
periodontitis,

• They concluded that the evidence is strong for stress as a predisposing factor to acute
necrotizing ulcerative gingivitis, while the evidence for psychosocial factors as etiological agents
in periodontitis is not as substantive.

Monteiro da Silva AM, Newman HN, Oakley DA. Psychosocial factors in inflammatory periodontal diseases. A
review. J Clin Periodontol 1995: 22: 516–526.
 Genco et al 1998
Psychosocial stress
Inadequate coping Adequate coping

Activation of CNS Hypothalamus

Autonomic nervous
Chronic
Acute Pituitary ACTH

Adrenal cortex(cortisol)
Adrenal medulla

Depressed immunity(s igA, igG,PMN

Infection
Prostaglandins and proteases
IL 1,MMP

Periodontal disease
Genco RJ, Ho AW, Kopman J, Grossi SG, Dunford RG, Tedesco LA. Models to evaluate the role of stress in periodontal disease. Ann Periodontol
1998: 3: 288–302.
 Studies supporting an association between stress and
periodontal disease
Deinzer et al 1999 Severe deterioration in gingival health from baseline
levels was observed significantly more frequently in a
cohort after they had undergone a period of academic
examinations compared to a peer-control group not
experiencing such academic testing.

Moss 1996 Provided evidence for the role of environmental

stressors as factors in periodontal disease

Genco 1999 Indicated a significant role for financial strain in relation

to greater alveolar bone and periodontal attachment
loss, after adjusting not only for age and gender, but also
for smoking.
 • With a few notable exceptions, workers have been critical of studies investigating the
relationship between psychosocial stress and periodontal disease.

• Many of the reports in this area are identified as ‘exploratory’ or ‘preliminary’ investigations
and use small sample sizes.

• In addition, the use of different major dependent variables across studies – dental plaque
levels, attachment loss, loss of alveolar bone, etc. – makes comparisons across studies
difficult and limits the ability to generalize about the specificity of the relationship between
psychosocial stress and periodontal disease.

Leresche L,Dworkin S. The role of stress in inflammatory disease, including periodontal disease: review of concepts and current findings. Periodontology 2000
2002;30:91–103
 Direct association between periodontal disease and stress remains to be
proven, which is partly due to lack of an adequate animal models and
difficulty to quantifying the amount and duration of stress.

The available scientific evidence thus, does not definitively support a

casual relationship between psychosocial factors and inflammatory
periodontal diseases.

Goyal, et al.: Stress and periodontal disease: The link and logic!! Industrial Psychiatry Journal .2013;22(1):1-11
 •USE OF ANIMAL MODELS

Problem in relating finding from

animal research to the human
dentition

33
 Animals As Models
• Small and inexpensive
rodents:
– Mice
– Rats
– Hamsters
– Minks

• Larger animals:
– Dogs
– Sheep.
• Non-human primates:
– Baboon
– Macaque
– Chimpanzee
– Gorilla

• Various other species include:

−Suricates.
– Apes. −Wolves.
– Cats. −Foxes.
– Horses. −Racoons.
– Guinea pigs. −Rabbits.
−Coatis.
– Hedge hogs.
−Ferret.
– Pigs. −The Mongolian gerbil.
– Lemurs. −The least shrew
– Mongooses. −Cattle.
•If a high crown on tooth of a dog or monkey, the tooth will intrude and recognize a new position
while human tooth gets progressively mobile.

• Para functional habit is a major factor in human occlusal trauma, monkeys and dogs not known
to have such persistent habits

• Periodontal disease naturally occurs in humans.

• In the animals models the lesion of periodontal is induced artificially.

• With treatment these artificially treated lesion repair more predictably than naturally occurring
lesions
Non surgical vs. Surgical therapy- Controversies

Vs
 •Non surgical vs. Surgical therapy-
Controversies
 “Critical probing depth value for scaling and root planing was significantly smaller than the
corresponding value for scaling and root planing used in combination with modified Widman
flap surgery (2.9 vs 4.2 mm).
(Lindhe et al, J Clin Periodontol 1982)

In addition, the surgical modality of therapy resulted in more attachment loss than the non-surgical
approach when used in sites with initially shallow pockets.

 On the other hand, in sites with initial probing depths above the critical probing depth value more
gain of clinical attachment occurred following Widman flap surgery than following scaling and root
planing.
When sites with initial PPD 1–3mm were involved in treatment by open flap debridement, there
was significantly more CAL loss than with treatment by scaling and root planing (WMD –0.51 mm;
95% CI –0.74, –0.29).

When sites with initial PPD 4–6mm were treated by open flap debridement, there was
significantly less CAL gain than with the scaling and root planing procedure (WMD–0.37mm; 95%
CI –0.49, –0.26).

When sites with initial PPD <6mm were treated with open flap debridement, there was
significantly more CAL gain than with scaling and root planing (WMD0.19mm; 95%CI 0.04,0.35).
(Haitz Mayfield J Clin Periodontol 2002)
 Surgical Versus Non-surgical Methods Of Treatment For Periodontal Disease

• A meta analysis was performed comparing surgical & non-surgical treatment methods

• ..at the end of one year follow up modified widman flap reduced pocket depth more than SRP
or curettage with anesthesia

• attachment levels showed better results for nonsurgical treatment group , although significant
differences disappeared after 5 years

• The choice of outcome measure influences the choice of therapy, with

surgical therapy providing greater benefit for probing depth and non-surgical
therapy providing greater benefit for attachment level.

Joshipura K, Burdick E, J Clin Periodontol 1993; 20(4): 259-68

41
Effects of surgical periodontal therapy as compared to non surgical
therapy
 More probing depth reduction.
 Greater loss of CAL in shallow pockets.
 More gain of CAL in deeper pockets.
 More gingival recession initially but no difference later.
 Loss of crestal bone.
 Variable gingival morphology.
 Variable esthetic outcome.
Decision making for surgical and non surgical
treatment of chronic periodontitis
Multiple visits SRP vs. Single stage Full Mouth Disinfection
therapy

Vs
 •Scaling & Root Planing – Multiple
visits vs. Single stage Full Mouth
Disinfection therapy
 Supragingival plaque plays a significant role in the subgingival recolonization of periodontal
pockets.
 As such, bacteria in the saliva or on the tongue, tonsils or oral mucosa can have an impact on
the subgingival recolonization of pockets after periodontal therapy.
 The aim of the full-mouth disinfection approach was to eradicate, or at least suppress, all
periodontal pathogens in a very short time span, not only from the periodontal pockets but
from the entire oropharyngeal cavity (mucous membranes, tongue, tonsils and saliva).
Quirnyen et al 1995)
 The impact of a one-stage, full-mouth disinfection procedure as compared to multiple visits
quadrant wise scaling was explored in four prospective studies

All four studies reported significantly greater improvements of

clinical outcomes in the test group, including:
A significant additional reduction in probing
A significant additional gain in clinical attachment level and
 A significantly greater reduction in bleeding upon probing.

The one-stage, full-mouth disinfection procedure resulted in statistically significant additional

reductions in the prevalence of periodontopathogens, especially subgingivally, and to a lesser
extent in the other intra-oral niches,
 The latter especially during the period when the patients were rinsing with chlorhexidine
 Facts:
 Full mouth disinfection protocol proves better than quadrant scaling because-
1. Complete debridement in single visit preventing cross contamination
2. Adjunct use of chemical plaque control agent (irrigation and mouthrinsing)
 But certain studies have found no significant differences in these two protocols ( Jervoe-strom
2003 and Koshy 2005)

 In the systematic review by Eberhard et al., the comparison of full-mouth

instrumentation vs. quadrant-wise scaling and root planing revealed no
statistically significant differences with regard to mean probing pocket depth
reduction or clinical attachment level change.
 Future Challenges

 The new concept has no disadvantages and ⁄ or risks for the patient. The clinician and the patient
therefore can only gain via a better outcome of the mechanical debridement, reduced need for
surgery, and more efficient treatment and time management,
 More research is needed to explore in greater detail the potential of the one stage, full-mouth
disinfection, protocol
 Latest 2015 systematic review conclusions

The inclusion of five additional RCTs in this updated review comparing the clinical effects of conventional
mechanical treatment with FMS and FMD approaches for the treatment of chronic periodontitis has not
changed the conclusions of the original review.

From the twelve included trials there is no clear evidence that FMS or FMD provide additional benefit
compared to conventional scaling and root planing.
Eberhard J, Jepsen S, Jervøe-Storm PM, Needleman I, Worthington HV. Full-mouth treatment modalities (within 24 hours) for chronic periodontitis in adults. Cochrane Database Syst
Rev. 2015 Apr 17;4:CD004622 . 
Controversy around complete
removal of
granulation tissue

Vs
 •Controversy around complete
removal of
granulation tissue
Removal of pocket granulation tissue during periodontal flap surgery procedures was
developed with the aim to improve the conditions for wound healing and new attachment
formation.

Nevertheless, later studies indicated that removal of this tissue in conjunction with flap
surgery is not critical for establishing conductive conditions for the efficient healing of the
periodontal tissues (Lindhe & Nyman 1985).
Hence, the implications of the removal of this granulation tissue on the repair and/or
regeneration process of the periodontium have been interpreted in different ways over time.

The fact that granulation tissues formed after tooth extraction can differentiate into bone,
filling up the empty socket, indicates that some precursor cells are present (Steiner et al.
2008, Trombelli et al. 2008)
Recently Ronay et al (2012) found that Infected periodontal granulation tissue contains cells
expressing embryonic stem cell markers, implying that surgical removal of granulation tissue
inevitably results in removal of pluripotent stem cells that might potentially contribute to the
healing of the tissue, once the infection is controlled.

This knowledge needs to be considered further in treatment approaches that aim in optimal
periodontal wound healing and attaining periodontal regeneration.
•Root planing vs. Root surface
debridement
 •Root planing vs. Root surface
debridement
 Kieser et al, proposed that pocket ⁄ root instrumentation should be performed as three
separate stages of treatment (debridement, scaling, root planing), which have objectives
pursued in an orderly sequence, in preference to the traditionally practiced combination of
scaling and root.

The objectives:
 Subgingival debridement is defined as the removal or the disruption of microbial biofilms,
 Scaling is defined as the removal of calcified accretions and
 Root planing is defined as the removal of diseased or contaminated root cementum.
 planing.
The rationale for performing root planing was originally based on the concept that bacterial
endotoxins penetrate into the cementum (Aleo 1971, Hatfield 1974)

Concept that was later disproved by data from experimental studies showing that the endotoxins
were only loosely adherent to the surface and did not penetrate into the cementum (Caffey 2003,
Cafesse 2006)
)
Hence, intentional removal of tooth structures by root planing during pocket ⁄ root
instrumentation is not considered a prerequisite for periodontal healing (Nyman et al 2003).

Another factor to consider in relation to root planing and the removal of the cementum layer is
the potential risk of inducing increased root sensitivity,(Wennstrom et al 2005
•Bone graft vs OFD
 •Bone graft vs OFD
The use of bone grafts for reconstructing osseous defects produced by periodontal disease
dates back to Hegedus in 1923 and was revived by Nabers & O’Leary in 1965.
"Osseous grafting therapy has been shown to be clinically successful for time intervals
exceeding 20 years when encompassed in a comprehensive care program based on effective
daily plaque control by the patient and a professionally supervised periodontal maintenance
program"0).
Others believe that the use of bone grafts to enhance regeneration of the periodontium is
unacceptable.
'Not one of the human studies has provided the type of experimental model that clearly
demonstrates new attachment formation.
From the standpoint of scientific documentation, the value (of regenerative procedures) is not
clear. Spectacular results of "bone fill" in intrabony pockets have been reported with or without
bone implantation (Ramfjord, 1984).
Still others are convinced that bone grafts are detrimental. "Ignorance of the contribution
of the various tissue components in periodontal wound healing may explain the widespread
use of bone transplants in the treatment of intrabony pockets" (Karing et aL, 1984).

"Since granulation tissue derived from bone has the potential to induce root resorption
and ankylosis, the rationale of favoring bone growth with the use of bone transplants is
highly questionable" (Karring et al, 1980).
 Delineating grafting options for intrabony
regeneration based on evidence

 The only materials with human histological evidence to substantiate their regenerative use are
autogenous bone grafts of intraoral or extraoral sources and demineralized freeze-dried bone
allograft.

With respect to the treatment of intrabony defects:-

 bone grafts increase bone level, reduce crestal bone loss, increase clinical attachment level,
and reduce probing depth compared to open flap debridement (OFD) procedures;
 No differences in clinical outcome measures emerge between particulate bone allograft and
calcium phosphate (hydroxyapatite) ceramic grafts; and
 Bone grafts in combination with barrier membranes increase clinical attachment level and
reduce probing depth compared to graft alone.
The results of this systematic review indicate that bone replacement
grafts provide demonstrable clinical improvements in periodontal
osseous defects compared to surgical debridement alone
 •To pack or not to pack:
the current status of periodontal
dressings

Vs
 •To pack or not to pack:
the current status of periodontal
dressings
 Clinical trials supporting the use of periodontal
dressings
Ariaudo and Tyrell et al
 Protection of wound from mechanical trauma, stability of the surgical site during healing
process
Prichard et al
 Patient comfort during healing, good adaptation to underlying gingival and bony tissue,
prevention of postoperative hemorrhage or infection, decreasing tooth hypersensitivity,
protecting the clot from forces applied during speaking or chewing, preventing gingival
detachment from the root surface
Wikesjo et al
 Prevention of flap displacement in apically repositioned flaps, additional support in free
gingival grafting procedures
Sigusch et al
 Periodontal wound dressing has a positive effect on clinical long-term results
 Clinical trials not in favor of use of periodontal
dressings

Stahl et al
 Dressing accumulates plaque
Greensmith et al
 No differences in healing
Kidd and Wade et al
 Greater pain experience Plaque accumulation Subsequent microbial
invasion Nonpack areas showed better wound healing Lesser pain scores
Jones and Cassingham et al
 Irritates healthy tissue increases chances of infection
 Systematic review -2015 Monie et al

Placement of periodontal dressing after non surgical mechanical therapy can be beneficial in
improving overall short term clinical outcomes, although more controlled studies are needed to
validate this finding.
Monie A, Kramp A, Criado E, Suarez F, Wang HL.Effect of periodontal dressing on non surgical periodontal treatment outcomes:A systematic review. Int J Dent Hyg
2015
Splinting mobile teeth- Controversies
 •Splinting mobile teeth-
Controversies
 In the past, the use of splinting of periodontally compromised teeth was
contentious.
 The presumption was that the use of splints to control tooth mobility was required
to control gingivitis, periodontitis, and pocket formation.
 It was assumed that mobility had a direct relationship to attachment loss and
vertical osseous defect formation
In other study, it was reported that there is no correlation between splinting and reduced tooth
mobility during initial periodontal therapy (Kegel et al. 1979).
 Control of tooth mobility with splinting after osseous surgery did not reduce mobility of the
individual teeth (Kegel et al. 1979)
However, other studies report that tooth mobility can be controlled and managed with splinting
and will improve periodontal prognosis.
(Pollack 1999; Laudenbach et al. 1977; Amsterdam 1974).
Splinting periodontally affected teeth helps in faster healing and regeneration.
There is no doubt that splinting does reduce tooth mobility while the splint is in place (Serio 1999;
McGuire and Nunn 1996).
 Further, regenerative procedures using membranes and bone graft have greater predictability if
tooth movement is eliminated (Cortellini et al. 2001).
 Clinical rationale for splinting (Pollack 1999; Serio 1999;
Siegel et al. 1999; Ramfjord and Ash 1981; Lemmerman 1976):

 Stabilization of mobile teeth during surgical, especially regenerative

therapy. Friedman believed that unless splinted, mobile teeth may not
respond as well to reattachment procedures (Friedman 1953; Ferencz
1987).
 Prevention of the supra-eruption of an unopposed tooth to eliminate the
potential for the development of periodontal problems (Hirschfield 1937).
 Stabilization of periodontally compromised tooth when more definitive
treatment is not possible.
 Stabilization of loose teeth to restore the patient’s psychological and
physical well-being.
 Splinting duration and periodontal outcomes for replanted avulsed teeth:
a systematic review.

The evidence for an association between short-term splinting and an increased

likelihood of functional periodontal healing, acceptable healing, or decreased
development of replacement resorption, appears inconclusive. 
Hinckfuss SE, Messer LB. Splinting duration and periodontal outcomes for replanted avulsed teeth:a systematic review. Dent Traumatol. 2009 Apr;25(2):150-7. 
Gingival Curettage – Controversies :-
Gingival Curettage – Controversies :-

•Should gingival curettage as a separate procedure be considered obsolete?

•Does it have any advantage over SRP?
•Does ENAP remain in vogue?
•Does the long term results of Curettage hold any indication of it?
 Gingival Curettage – The Facts

•Short & long term clinical trials have confirmed that gingival curettage provides no additional
benefits compared to SRP alone.
•The pocket epithelium is neither removed completely not the procedure provides increased root
surface access.
No new attachment is gained following Curettage.
Employment of LASER showed no increased advantage either by way of reduced bacterial count
or better results.
Gingival Curettage – The Position

• It is a procedure of historical interest.

 AAP STATEMENT REGARDING GINGIVAL CURETTAGE
• Gingival curettage is a distinct procedure that may be performed in conjunction with, or
subsequent to, SRP.

• The actual result obtained with curettage is most often a long junctional epithelium, which is
the same result obtained with SRP alone.

• Also, it is a blind procedure ..does not afford the improved root surface access and visibility
gained with flap surgery that is mandatory to achieve complete mechanical removal of biofilm
and accretions.

• Short term and long term clinical trials have confirmed that SRP alone produces results that
are clinically equivalent to curettage + SRP

• There is no evidence that gingival curettage has any therapeutic benefit in the treatment of
chronic periodontitis
ADA , in its guidelines for periodontal therapy, did not include curettage as a method of
82
treatment
 •Systemic Antimicrobials in
Periodontal therapy - Controversies
 •Systemic Antimicrobials in
Periodontal therapy - Controversies
• Which are the periodontal conditions requiring systemic antimicrobials?
• Who are the patients requiring such therapy?
• When such therapy is recommended?
• What is the regimen to be followed?
• Can periodontal surgery be avoided if antimicrobials are used?
 Systemic antimicrobials – Problems
• Periodontal infections are different from other microbial infections – Polymicrobial
• Complex microbial population.
• Neither identity of the causative organism/s nor microbial susceptibility are readily
available in day to day practice.
• Literature is replete with conflicting reports.
Rationale for use of Systemic antimicrobials in Periodontics

• Many micro organisms are tissue invasive.

• Mechanical therapy does not eliminate pathogens completely particularly from
inaccessible areas.
• Aggressive type of periodontal conditions require strong counter attack.
• Refractory cases require multifaceted approach.
 Systemic antimicrobials – The Facts
• Acute condition with systemic involvement.
• Gingivitis – NUG
• Periodontitis – Aggressive and Refractive
• Not as Mono therapy
• Selection of an antibiotic is empirical.
• There is no overwhelming evidence that antimicrobials reduce the need for surgery.
 Post surgical Antimicrobial medication
• Should antimicrobials be prescribed regularly in every case after periodontal surgery?
• If antimicrobials are prescribed, then which one/combination?
• Do antimicrobials affect surgical outcome?
• Do regenerative procedures benefit by antimicrobial medication?
The Use Of Systemic Antibiotics In Periodontal Therapy

Concluded: it should be adjunctive to mechanical debridement and

suggested that antibiotic intake should start on the day of debridement completion;
debridement should be completed within a short time (preferably 1 week) and with an
adequate quality, to optimize the results
(Herrera et al 2002)

Concluded: the use of systemically administered adjunctive antibiotics with and

without SRP and/or surgery appeared to provide a greater clinical improvement
in AL than therapies not employing these agents.
The data supported similar effect sizes for the majority of the antibiotics;
therefore, the selection for an individual patient has to be made based on other
factors.
(Haffajee, A.D, 2003)

89
 Effectiveness of systemic amoxicillin ⁄ metronidazole as adjunctive therapy to scaling
and root planing in the treatment of chronic periodontitis periodontitis: a systematic
review and meta-analysis.-2012

The findings of this meta-analysis seem to support the effectiveness of SRP + AMX/MET; however,

future studies are needed to confirm these results.

Sgolastra F, Gatto R, Petrucci A, Monaco A. Effectiveness of systemic amoxicillin ⁄ metronidazole as adjunctive therapy to scaling and root planing in the treatment of
chronic periodontitis: a systematic review and meta-analysis. J Periodontol 2012: 10: 1257–1269.
 Antibiotic of choice in aggressive periodontitis? 2015 systematic review

SRP plus systemic antibiotics led to an additional clinical effect compared with SRP alone in the
treatment of AgP. Of the antibiotic protocols available for inclusion into the Bayesian network
meta-analysis, Mtz and Mtz/Amx provided to the most beneficial outcomes.
Root conditioning
 Root conditioning
•An exposed root surface undergoes substantial alteration and may no longer serve as an
appropriate substrate for cell attachment.
•There is loss of collagen fiber insertion, contamination of root surface by bacteria and
alteration in mineral density.

•Root surface also lacks chemotactic stimuli for migration of cells capable of producing
periodontal regeneration.
•Apical migration of junctional epithelium along the root surface over connective tissue
following surgical therapy also appears to inhibit regeneration
Scaling and root planing is effective in removing bacterial deposits as well as removing
endotoxins from exposed root surface.

However it results in formation of smear layer which is thought to serve as a physical barrier
between periodontal tissues and the root surface, and may inhibit formation of new connective
tissue attachment to root surface.
,

Root conditioning of periodontally involved root surfaces

will also expose

will will
eliminate and enlarge the
demineralize demineralize
cytotoxic opening of
the planed root the inter
materials dentinal
surface tubular dentin.
tubules.
 •Exposed collagen matrix of dentin is chemotactic for PMNs,
macrophages and fibroblasts.

•It can also support the attachment and migration of fibroblasts.

•Root surface demineralization also enhances healing.

A study was taken up by the College of Dentistry, Columbia, to assess the efficacy of root surface
biomodification by tetracycline, citric acid or EDTA, in patients with chronic periodontitis.

Thirty-four studies incorporating a total patient population of 575 were analyzed- 26 for citric
acid, 5 for tetracycline and 3 for EDTA treatment.
Four of eight human histological studies represented regeneration with use of citric acid and only
1 of 18 clinical studies reported attachment gain. Of 5 studies using tetracycline, 1 histological
study and 1 clinical study reported attachment gain.

No regeneration was reported in the 3 studies evaluating the use of EDTA.

Evidence suggests that the use of citric acid, tetracycline and EDTA to modify root surfaces
provides no benefit of clinical significance to regeneration in patients with chronic periodontitis.
Selvig et al. examined wound healing in experimental fenestration defects following
conditioning of defects walls with either saline or citric acid.

Post surgically after 14 days, healing appeared to be delayed in the citric acid treated site as
compared to the control.
•Periodontitis - systemic disease
association
•Periodontitis - systemic disease
association
The term ‘Periodontal Medicine’, as first suggested by Offenbacher, to be a broad term that
defines a rapidly emerging branch of periodontology focusing on the wealth of new data
establishing a strong relationship between periodontal health or disease and systemic health
or disease.

Evidence emerging has shed light on the converse side of the relationship between systemic
health and oral health.
 This field of periodontal medicine addresses the
following important questions :

Can bacterial infection of the periodontium, have an effect remote

from the oral cavity?

Is periodontal infection a risk factor for systemic diseases or

conditions that affect human health?
 Periodontitis and systemic diseases: a record of discussions of working group
4 of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases 2013

The group was unanimous in their opinion that the reported

associations do not imply causality, and establishment of causality will
require new studies

Because of the relative immaturity of the body of evidence for each

of the purported relationships, the field is wide open and the gaps in
knowledge are large.

Linden GJ, Herzberg MC and on behalf of working group 4 of the joint EFP/AAP workshop. Periodontitis and systemic diseases: a record of discussions of working group
4 of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Periodontol 2013;84(4 Suppl.):S20-S23
 Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases 2013
There is consistent and strong epidemiologic evidence that
periodontitis imparts increased risk for future CVD

The impact of periodontitis on ACVD is biologically plausible: translocated circulating oral microbiota
may directly or indirectly induce systemic inflammation that impacts the pathogenesis of
atherothrombogenesis

in vitro, animal and clinical studies do support the interaction and biological
mechanism, intervention trials to date are not adequate to draw further conclusions

Tonetti MS, Van Dyke TE and on behalf of working group 1 of the joint EFP/ AAP workshop. Periodontitis and atherosclerotic cardiovascular disease: consensus
report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Clin Periodontol 2013; 40 (Suppl. 14): S24–S29.
 Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on
Periodontitis and Systemic Diseases- 2013

There is a direct and dose-dependent relationship between

periodontitis severity and diabetes complications in diabetes patients

Emerging evidence that severe periodontitis may predispose to the

development of diabetes.

Severe periodontitis adversely effects diabetes control (HbA1C)

Chapple ILC, Genco R, and on behalf of working group 2 of the joint EFP/AAP workshop. Diabetes and periodontal diseases: consensus report of the Joint EFP/ AAP
Workshop on Periodontitis and Systemic Diseases. J Periodontol 2013;84(4 Suppl.):S106-S112
 Periodontitis and adverse pregnancy outcomes: consensus report of the Joint
EFP/AAPWorkshop on Periodontitis and Systemic Diseases
Working committee was of the opinion that observational studies provide evidence for impact of
periodontal disease on adverse pregnancy outcome.

Two major pathways have been identified, One direct, in which oral microorganisms and/or their
components reach the foetal–placental unit

Indirect, in which Inflammatory mediators circulate and impact the foetal placental unit

Although periodontal therapy has been shown to be safe and lead to improve periodontal conditions in
pregnant women. It doesn’t reduce overall rate of pre term birth and low birth weight.

Sanz M, Kornman K, and on behalf of working group 3 of the joint EFP/AAP workshop. Periodontitis and adverse pregnancy outcomes: consensus report of the
JointEFP/AAP Workshop on Periodontitis and Systemic Diseases. J Periodontol 2013;84(4 Suppl.):S164-S169
 Periodontal Disease and Risk of Chronic Obstructive Pulmonary Disease: A Meta-Analysis of
Observational Studies 2012

Based on current evidence, PD is a significant and independent risk factor of

COPD.

However, whether a causal relationship exists, remains unclear.

Moreover, the authors suggest performing randomized controlled trails to explore whether
periodontal interventions are beneficial in regulating COPD pathogenesis and progression.

Xian-Tao Zeng,Ming-Li Tu,Dong-Yan Liu, Dong , Zheng, Jing Zhang, Wei Dong Leng .2012.plus one
 Periodontitis and systemic diseases: a record of discussions of working group 4 of the
Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases

Rehumatoid arthritis
Reports of an epidemiological association with periodontal disease,
including the NHANES data set and case-control studies, are inconsistent.

Animal studies provide biological plausibility.

Linden GJ, Herzberg MC and on behalf of working group 4 of the joint EFP/AAP workshop. Periodontitis and systemic diseases: a record of discussions of
working group 4 of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Periodontol 2013;84(4 Suppl.):S20-S23
 Periodontitis and chronic kidney disease: a systematic review of the association of
diseases and the effect of periodontal treatment on estimated glomerular filtration
rate- 2013
Despite of the number of studies included and the nature of the study
designs, there is quite secure evidence to support the positive association
between periodontitis and CKD

Periodontal treatment did not significantly improve the -GFR levels.

Chambrone L, Foz AM, Guglielmetti MR, Pannuti CM, Artese HPC, Feres M,Romito GA. Periodontitis and chronic kidney disease: a systematic review of the association
of diseases and the effect of periodontal treatment on estimatedglomerular filtration rate. J Clin Periodontol 2013; 40: 443–456.
 Periodontitis and systemic diseases: a record of discussions of working group 4 of
the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases

The association between chronic kidney disease (CKD) and

periodontitis in several studies is statistically significant and consistent.

Studies of the effects of periodontal interventions on the emergence of

CKD in patients with type 2 diabetes would be useful, particularly to adjust
for confounding of diabetes with this condition.

Linden GJ, Herzberg MC and on behalf of working group 4 of the joint EFP/AAP workshop. Periodontitis and systemic diseases: a record of discussions of working
group 4 of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Periodontol 2013;84(4 Suppl.):S20-S23
DENTAL IMPLANTS
 •Flap v/s flapless implants
"Flapless" implant placement into extraction sockets did not result in the prevention of alveolar bone
resorption and did not affect the dimensional changes of the alveolar process following tooth extraction
when compared with the usual placement of implants raising mucoperiosteal flaps.
(Caneva M,2010)

The flapless technique revealed more marginal bone resorption compared with the flap technique. Extra
care should be taken in the flapless approach with respect to the inclusion criteria and difficulty of the
surgery.
(Malo P,2008)
Human clinical trials with data on comparison of SR and changes in MBL between the flapless and
conventional flap procedures, with at least five implants in each study group and a follow-up
period of at least 6 months, were included in this systematic review revealed that the SRs and
radiographic marginal bone loss of flapless intervention were comparable with the flap surgery
approach.(Guo-Hau Lin,2014)
 •One stage v/s two- stage implant
placement
The one-stage approach might be preferable in partially edentulous patients since it avoids one surgical
intervention and shortens treatment times, while a two-stage submerged approach could be indicated when
an implant has not obtained an optimal primary stability, when barriers are used for guided tissue
regeneration or when it is expected that removable temporary prostheses could transmit excessive forces on
the penetrating abutments, especially in fully edentulous patients.(EspositoM,2009)
If these preliminary results will be confirmed by more robust trials, a 1-stage procedure might be preferable
since it avoids one minor surgical intervention and shortens the waiting time to provide the final restoration.

There might be specific situations though, such as when optimal implant stability is not obtained at
placement or when barriers are used in conjunction with implants, in which a 2-stage approach might be
preferable.
(Cochrane Database Sys Rev,2007)
•Immediate versus delayed loading
•Primary stability is one determinant of osseointegration.
•Placement of implants immediately after extraction is challenging because, in the case of a
large socket, part of the implant will show exposed surfaces that will need to be covered with
bone during healing.

Primary stability can be influenced by

by reducing the
placing the implant
diameter of the by using wider
in as much cortical
osteotomy related implants
bone as possible
to the implant
Some authors claim that immediate implant placement will counteract resorption following
extraction. However, available data are not conclusive and the method is still controversial.

The secondary stability depends on the bone tissue response during healing, and stability seems to
increase with time for implants with low primary stability.
If a certain degree of primary stability is achieved, such implants may be candidates for immediate ⁄ early
loading protocols.

It seems to be the general opinion that surface-modified implants are preferred for early loading because of
their rapid integration.

In a meta-analysis of 13 prospective trials, early implant loading was not associated with worse outcomes
compared to conventional loading.
•Implants in patients with aggressive
periodontitis
•Al-Zahrani conducted a systematic review, which included nine articles, four of which were
case reports.

•These publications demonstrated there was good short-term survival of implants placed in
patients treated for aggressive periodontitis that subsequently were periodontally
maintained.

•The data indicated, however, that bone loss occurred around implants in patients with a
history of aggressive periodontitis more often than around implants in patients with history
of chronic periodontitis or periodontally healthy individuals.
•Periodontal diseases should be controlled before placement of implants.

•Individuals with aggressive periodontitis may be susceptible to additional periods of disease

progression. At present, however, no recommendations can be made to define a time period that
should elapse before initiating implant therapy.

•There are a limited number of studies addressing the survival rate in patients with aggressive
periodontitis.

•It is unknown what effect retention of questionable teeth in these patients will have on the
success rate of implants in individuals who had aggressive periodontitis
 Conclusion
• In reviewing past and present concepts and treatment modalities that
are available, it has becomes evident that there are no completely
accepted principles and techniques

• Further studies are needed to guide clinician for rendering better

treatment care…….

When a thing ceases to be a matter of controversy, it ceases to be a

matter of interest.

120
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Thank
You…..