TIME TRAVEL

THROUGH
PERIODONTICS
Dr. Sandip Ladani
 What is Periodontics?

• Periodontics is a specialization of dentistry dealing

with the study of tooth supporting structures:
– Gingiva
– Cementum
– Periodontal Ligament
– Supporting Alveolar Bone
Understanding Of
Etiology

–“Pituita” or
Hippocr Calculus.
at es
Hippocrates

•“The doctrine of
calculus”
•Extensive formation
of tartar on the teeth
and related this to
toothache Paracelcus
Hippocrates Paracelcus

Anton van Leeuwenhoek

Hippocrates Paracelcus
Anton van Leeuwenhoek

First individual to identify bacteria as

the cause of periodontal disease.

Adolph Witzel
Hippocrates Paracelcus
Anton van Leeuwenhoek Adolph Witzel

Considered the role of predisposing factors,

irritational factors and bacteria in etiology.

Willoughby D. Miller
Plaque
 Plaque
Hypotheses

Ecological
Non- Specific
Plaque
Hypothesis
Specific
Loe H, Theilade F, Jensen SB. Experimental gingivitis in man. J Periodontology 1965:36:177-187.
 P. gingivalis in News Again
• HIV – 1
– P. gingivalis strongly facilitated the reactivation of HIV-1 by high production of butyric acid.
– P. gingivalis could act as a risk factor for HIV-1 in latently infected individuals (1).

• Smoking
– In smokers the cigarette smoke is found to alter some of the genes of P.gingivalis
associated with its virulence, detoxification, DNA repair, and oxidative stress mechanism.
– This results in changes with protein expression in the cell membrane, which affects the
bacterial cell characteristics and how immune system recognizes it.
– These results could possibly explain why smokers are resistant to periodontal treatment
and are more susceptible to oral disease caused by P. gingivalis. (2)
References:
1.IADR2009, abstract #1703, "Reactivation of Latent HIV-1 by Porphyromonas gingivalis Involves Histone Modifcation", by K. Ochiai et al., of Nihon
University, Tokyo, Japan
2. Tobacco-induced alterations to Porphyromonas gingivalis–host interactions http://www3.interscience.wiley.com/journal/121659253/abstract
PERIODONTAL Disease
PROGRESSION
 DIAGNOS
• is IS defined as
chronological
organization and
critical evaluation of
dental-treatment1.jpg

information obtained
from patients history,
laboratory and
radiological
examination.
Periodontal Disease
 Traditional Diagnostic
Techniques
(Gold Standards)

• Clinical: Periodontal Probing

• Radiographic: Conventional radiographs
• Microbiological: Characterizing the composition of
the subgingival microflora.
 PERIODONTAL
PROBING

• Indicator of the primary consequence of periodontal

disease i.e., the loss of periodontal attachment.
 Radiographic
• Dental radiographs are the traditional method used to assess the
destruction of alveolar bone associated with periodontitis.

• They provide useful information on interproximal bone levels.

• Numerous cross-section and longitudinal epidemiological studies

have used radiographs as the principal method of determining the
presence or absence of periodontal destruction.
 Microbiologi
cal Cultures
• The subgingival microbiota, particularly gram-
negative anaerobes, are the major etiologic factors
of chronic and aggressive periodontitis.

• The nature of investigation rarely helps chair side

use and this has contributed to their limited
application.
Advances in Diagnosis
• Recent research in periodontal diagnosis
is aimed at identification of the disease
process that, if unaltered, will result in
future periodontal breakdown.

• Hence, accurate diagnosis is always

essential for a successful therapy.
Advanced
Third Generation (Automated/ Computer linked electronic
constant pressure) Probes

Thermal Periodontal Probe

system: Periotemp
Computer Assisted Densitometric Image
Analysis: (CADIA)
 Halimeter ®

• Within seconds, the Halimeter®

can confirm the typical finding of
•VSC —
•Hydrogen sulfide,
•Methyl mercaptan,
•dimethyl sulfide)
in the breath, produced by
anaerobic bacteria on the
tongue.
T-Scan ®
 PerioTest ®
Clinical degree of Periotest value
loosening

0 -08 to +09

I +10 to +19

II +20 to +29

III +30 to +50

 DetecTar ®
• DetecTar: “The optical probe offers the possibility of
subgingival calculus detection and may, therefore, be suited
to determine the endpoint of root surface instrumentation
during non-surgical periodontal therapy. ” (J Periodontol
2005;76:1202-1206)
• Non surgical periodontal • Surgical periodontal
therapy therapy
– Scaling & Root Planing – Curettage
– Oral hygiene maintenance – Gingivectomy
– Antibiotics – Flap surgery
• Systemic
• Local
– Resective
– Host Modulation Therapy – Regenerative
– Full mouth Disinfection – Perioestheic Surgery
Consensus Report Discussion Section 11, Proceedings of the World Workshop in
Clinical Periodontics, 1989: 11: 13-20.
 Milestones in
Periodontal Therapy
Glimpses of the
Past
• “Materia Medica” for
oral and periodontal
diseases.
• Rarely resorted to
surgery.
• Abu’l Qasim
(Albucasis) (936-
1013 AD), described
the technique of
scaling the teeth,
using a set of
instruments that he
developed.
• “Libellus de Dentibus”
(A Little Treatise on the Teeth).
• He advised scaling of
calculus and curettage of
granulation tissue so that
actual reattachment of the
gingival and periodontal
tissue could take place.
• Gingivectomy for
hyperplastic gingival
tissues.

Ambroise Paré
• First specialist in
Periodontics
• Conservative approach to
periodontal
• Oral prophylaxis and
prevention, advocating
cleanliness of the mouth
and opposing surgery. John W. Riggs
• “Riggs’ Disease”
• Developed a surgical technique
consisting of a scalloped, continuous
gingivectomy excision, exposing the
marginal bone for subsequent curettage
and remodeling.
Salomon Robicsek
 Changing trends in
Periodontal Management
• Three major concepts in Periodontal therapy which changed with
the course of history are:

– the concept of bone and its involvement in Periodontitis,

– the true nature of soft tissue to tooth attachment,
– the pocket elimination philosophy.

“Its better to have LONGER TEETH than

TEETH NO LONGER….!!!!”
?? Root Biomodification ??
Rationale :
 Root debridement generates a smear layer.
 An agent to remove this smear layer
 Expose the collagen fibers is an important factor to obtain
biologically acceptable tooth surfaces.

Various Chemical Agents Used For Root

Biomodification :
 Citric Acid

 Tetracycline

 Fibronectin

 EDTA-(Ethylene Diamine Tetra Acetic Acid.)

 Sodium Deoxycholate

 Human Plasma Fraction (COHN IV)

 Enzyme Lysosome

 PDGF-Platelet Derieved Growth Factor

 ?? Root Biomodification ??
•Animal studies demonstrated new connective tissue attachment following acid
demineralization

•Histologic evaluation in human clinical trials demonstrated limited connective

tissue attachment and limited regeneration following citric acid demineralization

•Results from clinical trials using any type of root conditioning agent indicate
no additional improvement in clinical conditions [1].

•A recent meta-analysis systematic review confirmed that the use of citric acid,
tetracycline, or EDTA to modify the root surface provides no clinically
significant benefit of regeneration in patients with chronic periodontitis [2].

Ref:
[1] Handelsman M, Davarpanah M, Celletti R. Guided tissue regeneration with and without citric acid treatment in
vertical osseous defects. Int J Periodontics Restorative Dent 1991; 11(5):350–63.
[2] MariottA. Efficacy of clinical root surfacemodifiers in the treatment of periodontal disease. A systematic
review. Ann Periodontol 2003;8:205–26.
 Non-Surgical
Therapy
Current Concept-
Full Mouth
Disinfection

Ref: Quirynen M, Mongardini C,

Pauwels M, Bollen ML C, Van Eldere J, van
Steenberghe D,. One Stage Full- Versus
Partial-Mouth Disinfection in the
Treatment of Chronic Adult or Generalized
Early-Onset Periodontits. II. Long-Term
Impact on Microbial Load. J
Periodontology 1999;70:646-656.
 Periodontal Microsurgery
• Periodontal microsurgery is the natural transition
from conventional surgical principles to a surgical
ethic in which the microscope is employed to permit
more accurate & atraumatic handling tissues to
enhance wound healing.

Compound Loupe

Eyeglass Mounted Prism Loupe

Simple Loupe
 Lasers
• Pocket debridement and reattachment-without traditional surgery,
we can induce the pocket to “zip up.”

• Hard and Soft Tissue Recontouring

• Guided Tissue Regeneration –to make the root biocompatible and

seal accessory canals in the furcation.

• Biostimulation-
– increase soft tissue healing six-fold.
– enhances bone healing
– induces blood vessels to grow.
LANAP
LANAP
Antibiotics and periodontal therapy:

When?
 Systemic Antibiotics
What?
• Tetracyclines Aggressive, Rapidly advancing
severe, adult case
• Metronidazole Severe Adult Case
• Augmentin Refractory, Aggressive
• Amoxicillin + metronidazole Aggressive,
• Augmentin + metronidazole refractory,
rapidly advancing
 New in Antibiotics
• Prof Brogden from Univ of Iowa says:
"We are developing an antibiotic that can target and kill a
particular pathogen without harming or altering the composition
of the normal, more beneficial bacteria in the body. Such a
product would provide a variety of new treatments for oral
diseases as well as a means of prevention.”
• Attached a broad spectrum antibiotic to a protein that targets
the specific receptor on the cell wall of the bacteria.
• When this narrow spectrum antibiotic was tried on a mix of
bacteria, it only killed P. gingivalis, while leaving the other to
bacteria as it is.

Adapted from Scientific Daily ( from http://www.sciencedaily.com- /releases/2009/04/090401200431.htm)

Locally Delivered Antibiotics
• Goodson et al in 1979
• Requirement of treating periodontal disease
include
1. Controlled release of drug
2. Maintained localized concentration of
drug at infection site for optimum time
3. Minimal side effect
 Locally Delivered Antibiotics

• 12.7 mg Tetracycline –HCl fiber (Actisite®)

• 10% Doxycycline hyclate gel (Atridox®)
• 2.5mg Chlorhexidine chip (Periochip®)
• Minocycline-HCl 1 mg microspheres (Arestin®)
• 25% Metronidazole (Elyzol®)
 Actisite®
Tetracycline Fibers
• non-resorbable
• 25% tetracycline powder
• 7 to 10 days before being removed.
• Technique sensitive application of the fiber.
• A foreign body tissue response.
 Atridox®

•Biodegradable gel system

•Doxycycline (10%) in syringe able gel system
 ARESTIN ®
• Minocycline HCl 1mg
• Slowly resorbed microspheres.
• A 0.36mm increased pocket
depth reduction.
 ELYZOL ®
• An oil based Metronidazole 25% dental gel

• Applied in viscous consistency to the pocket where is

liquidized by body heat and hard again contact with
water

• Preparation contain Metronidazole benzoate,

which is converted into active substance by
esterase in GCF .
 PerioChip ®
• Bioabsorbable
• 34% CHX in a gelatin matrix.
• 5 x 5 x 1 mm
• The drawback
cumbersome application
does not always fit every size pocket.
 Comparison of
Local Delivery Systems
3

2
 Inspektor TC
This was created by a team at University of Liverpool. This is what
Professor Sue Higham Unversity's School of Dental Sciences has to say

"It is extremely difficult to get rid of all plaque in the mouth.

Left undisturbed it becomes what we call ‘mature’ plaque and
gets thicker. This is what leads to gingivitis, or bleeding
gums, and decay.”

Sources: University of Liverpool Press Release, Liverpool Daily Post

Neutrophil Research:
The Future of Periodontal Diagnosis &
Treatment
• A 30 second oral rinse
that is collected from the
patient.

• A biochemical agent is
added that results in a colour
change that reports the
number of oral neutrophil
present.

Ref: Bender, J.S., H. Thang, and M. Glogauer. 2006. Novel rinse assay for the quantification of oral neutrophils
and the monitoring of chronic periodontal disease. J Periodontal Res. 41:214-20.
 Ozone Therapy &
Periodontics
•Nagayoshi et al
•The ozonated water strongly inhibited the formation of dental plaque
in vitro.
•These results suggest ozonated water may be useful in reducing
infections caused by microorganisms present in dental plaque. (1)

•Huth et al.
•In an in vitro study evaluated whether gaseous or aqueous ozone has
any toxic effect on human oral epithelial and gingival fibroblast cells in
comparison with established antiseptics.
•The investigators found ozone gas to be toxic to the cell lines and
aqueous ozone was more biocompatible than gaseous ozone. (2)

Ref: 1. Nagayoshi M, Kitamura C, Fukuzumi T, Nishihara T, Terashita M. Efficacy of ozone on survival and
permeability of oral microorganisms. Oral Microbiology and Immunology 2004; 19:240-6.
2. Huth KC, Jacob FM, Saugel B, Cappello C, Paschos E, Hollweck R, Hickel R, Brand K. Effect of ozone on oral
cells compared with established antimicrobials. European Journal of Oral Sciences 2006; 114:435-440.
 Photodisinfection
The Future of Periodontal Therapy
Blue Light = Calculus

Green Light = Tooth Surface

 Nanodentistry

• Nanorobotic dentifrice [dentifrobots]

• Bone replacement materials
– Hydroxyapatite nanoparticles used to treat
bone defects are
• Ostim® (Osartis GmbH, Germany) HA
• VITOSSO (Orthovita, Inc, USA) HA +TCP
• NanOSSTM (Angstrom Medica, USA) HA
Your patient may not always care how much
you know, but will always want to know how
much you care.