AAP Classification of Periodontal Diseases and Conditions (1999)

Gingival Diseases Dental plaque-induced gingival diseases Non-plaque induced gingival lesions Chronic Periodontitis (Slight: 1-2mm CAL; moderate: 3-4mm CAL; severe: >5mm CAL) Localized Generalized (>30% of sites are involved) Aggressive Periodontitis (Slight: 1-2mm CAL; moderate: 3-4mm CAL; severe: >5mm CAL) Localized Generalized (>30% of sites are involved)

AAP Classification of Periodontal Diseases and Conditions (1999)

Periodontitis as a Manifestation of Systemic Diseases Associated with hematological disorders Associated with genetic disorders Not otherwise specified Necrotizing Periodontal Diseases Necrotizing ulcerative gingivitis Necrotizing ulcerative periodontitis Abscesses of the Periodontium Gingival abscess Periodontal abscess Pericoronal abscess

AAP Classification of Periodontal Diseases and Conditions (1999)

Periodontitis Associated with Endodontic Lesions Combined periodontic-endodontic lesions Developmental or Acquired Deformities and Conditions Localized tooth-related factors that modify or predispose to plaque-induced gingival diseases periodontitis Mucogingical deformities and conditions around teeth Mucogingival deformities and conditions on edentulous ridges Occlusal trauma
The Periodontal Disease Classification System of the American Academy of Periodontology - An Update, Journal of Canadian Dental Association, 2002; 66:549-7

Crystal S. Baik

What is Refractory Periodontal Disease

Refractory periodontal disease refers to destructive periodontal diseases in patients who demonstrate continued attachment loss in spite of adequate treatment and proper oral hygiene. Contributing factors include:type of therapy provided, furcation involvement, microflora, and smoking history.
Journal of Canadian Dental Association, December 2000 Elizabeth Black

Periodontal Disease and Diabetes

The diabetic state is associated with: Decreased collagen synthesis Increased collagenase activity Altered neutrophil function Elevated blood sugar levels suppress the hosts immune response and results in: Poor wound healing Susceptibility to recurrent infections Periodontal disease is often considered the 6th complication of diabetes and may place the individual at risk for future diabetic complications
*From The Amer Acad of Periodontology, pamphlet "Diabetes

Periodontal Disease & Diabetes

BRITTLE DIABETICS: More susceptible to gingivitis, gingival hyperplasias and periodontitis More harmful proteins (cytokines) in their gingival tissues Decreased beneficial proteins (growth factors) interferes with the healing response Increased levels of serum triglycerides may be related to greater probing depths and attachment loss
*From Fedi, The Periodontic Syllabus, 4th ed., 2000

Periodontal Disease and Diabetes

TREATMENT: Closely monitor blood glucose levels Maintenance of meticulous oral hygiene and strict recall appointments Short appointments in relaxed, nonstressful environment Have source of oral glucose available Effective treatment of periodontal infection and reduction of periodontal inflammation are associated with a reduction in the level of glycosylated hemoglobin the marker of diabetic control
*From Little & Falace, Dental Management of the Medically

Periodontal Treatment and Diabetes

-The diabetic patient requires special precautions prior to
periodontal treatment -treatment in the uncontrolled diabetic is contraindicated
-treatment in the brittle diabetic requires prophylactic antibiotics, started 2 days preoperatively (Penicillin VK) and continuing through the immediate post-op period -treatment of the well-controlled diabetic may the same as an ordinary patient

Periodontal Treatment and Diabetes

Protocol for Treatment:
Clinician should make sure that prescribed insulin has been taken, followed by a meal Morning appointments are appropriate because of optimal insulin levels Monitor vitals, including blood glucose prior to treatment Procedures performed may alter the patients ability to maintain caloric intake, therefore post-op insulin doses should be altered accordingly Tissues should be handled as atraumatically and minimally as possible (less than 2 hrs) Epinephrine should not be used in concentration greater than 1:100,000 due to epinephrine effects on insulin Diet recommendations should be made to maintain proper glucose balance Frequent recall and fastidious home oral care should be stressed

 Recent Studies: -Effective treatment of periodontal infection and reduction of periodontal inflammation are associated with a reduction in the level of glycated hemoglobin -Increased serum triglyceride levels in uncontrolled diabetics have been shown to be related to greater attachment loss and probing depths

Periodontal Treatment and Diabetes

-ThereforeControl of periodontal disease should be an important part of the overall management of the diabetic patient
Sources: Carranza and Newman, Clinical Periodontology, 8th ed. Grossi, et al. Treatment of Periodontal Disease in Diabetics Reduces Glycated Hemoglobin. Journal of Periodontology, Vol. 68, No. 8 Chris VanDeven

Smoking and Periodontal Disease

Smoking is a major cause of periodontal disease. Smokers are 4x as likely to develop periodontitis as non-smokers. Smoking may be responsible for more than half of the periodontal disease among adults in the U.S. Up to 90% of refractory periodontitis patients are smokers.
References: 1) Tomar, S., Asma, S. ; J Periodontol 2000;71:743-751 2) Johnson GK. Slach NA. Impact of tobacco use on periodontal status. [Review] Journal of Dental Education. 65(4):313-21, 2001 Apr.

Graham Smith

Smoking and Periodontal Disease

Smoking may increase levels of certain periodontal pathogens. Smoking has a negative effect on host response, such as neutrophil function and antibody production. Smoking has been shown to have a cytotoxic effect on gingival fibroblasts and could slow down wound healing.
References:
3) Rota MT.; Tobacco smoke in the development and therapy of periodontal disease: progress and questions. [Review] Bulletin du Groupement International Pour la Recherche Scientifique en Stomatologie et Odontologie. 41(4):116-22, 1999 Oct-Dec. 2) Johnson GK. Slach NA. Impact of tobacco use on periodontal status. [Review] Journal of Dental Education. 65(4):313-21, 2001 Apr. Graham Smith

Smoking and Periodontal Disease

Smoking may be one parameter to use in deciding to treat refractory periodontitis in smokers with a systemic antibiotic therapy directed against smoking-associated periodontal bacteria. Smoking cessation seems to have a beneficial effect on periodontal health.
References:
4) Lie MA. [Smoking as a risk factor for periodontitis]. [Review] [Dutch] Nederlands Tijdschrift voor Tandheelkunde. 106(11):419-23, 1999 Nov. 5) van Winkelhoff AJ. Bosch-Tijhof CJ. Winkel EG. van der Reijden WA. Smoking affects the subgingival microflora in periodontitis. Journal of Periodontology. 72(5):666-71, 2001 May. Graham Smith

What is Periostat?
Doxycycline Hyclate- inhibits collagenase activity and reduces the collagenase activity in gingival crevicular fluid of patients with adult periodontitis Indicated for use as an adjunct to scaling and root planing to promote attachment level gain and to reduce pocket depths Periostat is available as a tablet(20mg) to be taken orally two times a day (about an hour before, or two hours after meals). Should be taken with plenty of fluids. Typical treatments range from 3months to 12months.
www.Periostat.com R.Macnowski

What is Periostat?
Clinical studies have shown that the use of Periostat, along with SC/RP is more effective at regaining attachment level, than treatment with SC/RP alone Periostat is the first and only therapeutic agent designed to modulate the host response and helps to slow the progression of periodontal disease. Periostat should be used when traditional SC/RP treatments alone are ineffective, but before surgery is indicated.
www.Periostat.com R. Macnowski

What is Periostat?
Periostat is not an antibiotic- the low dosages of periostat have no detectable effect on bacteria. Periostat should not be used with children, expecting mothers, nursing mothers, or anyone with a tetracycline hypersensitivity. Periostat may cause hypersensitivity to sunlight No reports of tooth staining May reduce the effect of BCPs
www.periostat.com R.Macnowski