Prevention of Periodontal Disease and the maintenance of health once the disease process has been controlled are the cornerstones of periodontal therapy. As plaque is the primary etiologic agent of gingivitis and periodontitis, personal plaque control is the sine qua non of dental therapy.
A patient must be able to control the etiologic agents of both caries and periodontal disease on a daily basis for therapy to be successful so as to have Prevention of Periodontal Disease. As plaque can reorganize on the teeth and subgingivally within 24 hours, daily plaque removal is essential.
What Are the Components of Personal Plaque Control in Prevention of Periodontal Disease?
Personal plaque control consists predominantly of the mechanical disruption of plaque on the facial, lingual, and interproximal surfaces of the teeth. This disruption may be achieved using a manual toothbrush, powered toothbrush, floss, interdental brush, specialized brushes, and other instruments. Antimicrobial agents such as chlorhexidine or the essential oils may be used as adjuncts to mechanical plaque removal.
What Methods of Tooth brushing May Be Recommended to a Patient?
The toothbrush can remove plaque on accessible surfaces to have Prevention of Periodontal Disease. No matter what tooth brushing method is chosen, the manual toothbrush should have soft nylon bristles and a small head, either a child’s size brush or a size 20 or the equivalent. A smaller brush head allows the brush to be properly adapted to the irregularities of tooth anatomy and arrangement. A smaller head also lessens the potential for activating the gag reflex and may reach posterior surfaces more comfortably and effectively than a larger headed brush. For use in delicate areas, the bristles may be softened by running the brush head under hot water before use.
There are many toothbrush designs available today. Each brush manufacturer presents claims why that particular brush is superior to others. In reality, brushes of many different designs will effectively remove plaque when used properly and thus Prevention of Periodontal Disease from occuring.
Bass Method for Prevention of Periodontal Disease
The bristles of the toothbrush are placed at a 45 angle to the tooth surface at the gingival margin, trying to get the bristles into the gingival sulcus. The brush is then moved in short back-and-forth motions for about 20 strokes. The brush head is then moved around the arch, both on the facial and lingual surfaces. The occlusal surfaces are cleaned by manipulating the bristle ends into the pits and fissures of the tooth crown. This is the currently preferred method of manual brushing.
Modified Stiliman Method for Prevention of Periodontal Disease
The brush bristles are resting partially on the cervical area of the teeth and partially on the gingiva pointing toward the gingival margin. Pressure is applied to the brush to cause the gingiva to blanch. The brush head is then moved in short back-and-forth strokes with the brush moving coronally at the same time. The sides of the bristles, instead of the bristle tips, are used to disrupt the plaque. This method is classified as a roll technique.
Charters’ Method for Prevention of Periodontal Disease
The brush is placed against the surface of the teeth with the bristles pointing away from the gingival margin. The back-and-forth motion is a massaging stroke for the gingiva. This method may be used for gentle plaque removal.
What Methods of Inter-proximal Cleaning May Be Recommended to a Patient?
For the patient with no or minimal attachment loss, flossing is the interproximal technique of choice. There is no clear-cut difference in effectiveness between waxed and unwaxed floss. It should be stressed to the patient that floss be used in an up-and-down motion, not in a shoeshine motion. Many patients will revert to improper technique even after proper instruction. Dental tape, basically a wider version of floss, may also be used for Prevention of Periodontal Disease.
Once attachment loss has occurred and root concavities are accessible, floss loses its effectiveness. Interproximal brushes, toothpicks, and rubber tips may be used in these circumstances. With moderate to severe attachment loss, a manual brush and an interproximal brush will outperform the manual brush and floss in plaque removal.
Interproximal brushes may be cylindrical or conical in shape. The advantage of an interproximal brush is that the bristles may be worked into root concavities and furcation areas exposed by attachment loss. The interdental brush should be used in both a back-and-forth and rotary motion to ensure maximum adaptability of the bristles. The brush should be used from both a facial and lingual or palatal approach to remove all plaque for Prevention of Periodontal Disease.
The end-tuft brush may be used on interproximal surfaces where there is no adjacent tooth and on the distal areas of the most posterior teeth. With a bend in the handle and tapered bristles, the end-tuft brush fits almost perfectly in the distal furcation of the most posterior maxillary molar.
What Role do Powered Toothbrushes Have on Personal Plaque Control?
It has been demonstrated that powered toothbrushes remove more plaque than manual tooth brushing alone for Prevention of Periodontal Disease, when both are used properly. There is no evidence to suggest that the use of a powered brush alone is as effective as appropriate manual brushing along with appropriate interproximal cleaning with floss or an interproximal brush.
Powered brushes may be useful as a motivational tool to assist patients in cleaning their teeth on a daily basis. These brushes may also assist patients with arthritis or other debilitating conditions that make holding or manipulating a manual brush difficult or impossible. While there are several distinctive designs of powered brushes, each design has its strong points and weaknesses, but all of these brushes perform at similar levels of effectiveness for Prevention of Periodontal Disease.
What Antimicrobial Agents Can Assist in Controlling Plaque and Gingival Inflammation?
When selecting a chemotherapeutic agent, it is important to distinguish between the ability to remove plaque and substantiated evidence of a therapeutic effect for Prevention of Periodontal Disease. Many mouth rinses can reduce the amount of plaque over rinsing with water, but without a positive therapeutic effect, the justification for recommending such an agent is minimal.
To date, two basic agents have been shown to have a significant therapeutic effect on gingivitis over a 6-month period. Chlorhexidine gluconate, 0.12%, in an alcohol-containing vehicle, now available in generic as well as brand name form, and phenolic compound/essential oil-based mouth rinses can be used to help control gingivitis. Chlorhexidine kills bacteria when used for 30 seconds twice daily. Side effects include increased calculus formation, staining of teeth and restorations, and altered taste. Caution should be taken when recommending a chlorhexidine rinse for a patient with composite resin restorations for Prevention of Periodontal Disease.
The essential oils, thymol, menthol, and eucalyptol, along with methyl salicylate for flavoring, constitute the active ingredients in most phenol-based mouth rinses. These rinses also contain between 20% to 27% alcohol in the vehicle. Discretion should be taken in recommending these rinses to recovering alcoholics.
There are other mouth rinses and mouthwashes that show a therapeutic effect for periods of time shorter than the 6 months stipulated by the U.S. Food and Drug Administration for approval as a therapeutic agent. Some agents have a detergent effect to remove plaque and contain glycerin or other compounds that leave teeth feeling smooth to the tongue. These agents have not been shown to have any significant therapeutic benefit to the patient.
What Are the Ingredients in a Dentifrice Is Periodontal Therapy Successful? (Toothpaste)
Toothpaste, in conjunction with tooth-brushing, serves to keep periodontal disease away :
• Minimize plaque buildup
• Provide an anti-caries effect
• Remove stain
• Freshen breath
The ingredients found in most toothpastes for Prevention of Periodontal Disease include:
• Polishing or abrasive agent. May be silica, calcium carbonate, alumina, or other mild abrasive. The polishing agent removes stain, stained pellicle, and plaque.
• Binder or thickener. May be the alginates or carboxymethylcellulose. These binders give the toothpaste its consistency and flowability when expressed from the tube.
• Surfactant. Detergent such as sodium lauryl sulfate that foams to aid in debris removal. Detergents may also have inherent antimicrobial properties that contribute to plaque control.
• Humectant. May be glycerin, sorbitol, or polyethylene glycol. Provides moisture to the paste and keeps it from drying out, even when left exposed for short periods of time.
• Flavoring. May be spearmint, wintergreen, or peppermint. Some patients may have allergic sensitivity reactions to certain flavoring agents, particularly those with a cinnamon base.
• Active (therapeutic) ingredient. May be fluoride for caries protection, triclosan as an antiplaque agent, pyrophosphate as an anticalculus agent, potassium nitrate as a desensitizing agent, or peroxide compounds as whitening agents.
What is the American Dental Association Seal of Acceptance?
The American Dental Association (ADA) Seal of Acceptance is earned by product manufacturers after submitting their products to rigorous testing under standards defined by the ADA. As this is a costly and lengthy process, manufacturers of consumer products more often seek approval than those of professional products. This Seal may be carried on product packaging.
How much treatment is enough for Prevention of Periodontal Disease? The answer to that question is found in an understanding of the endpoints of therapy. These endpoints must be practical and realistic for each individual patient. Once the goals of therapy have been achieved, frequent and regular re-evaluation and periodontal maintenance become integral parts of periodontal therapy. It has been well documented that patients retain more teeth for longer periods after therapy with appropriate maintenance than without that care.
This question goes to the core of periodontics as a discipline in dentistry. There are many studies that have proven that periodontal therapy, when appropriately executed and with good patient compliance to oral hygiene regimens and scheduled maintenance visits, can reduce tooth loss due to periodontal disease by up to 70%. In one group of treated patients with periodontal disease followed an average of 22 years, overall tooth loss was 7.1%. Occasionally, teeth will be lost in even the most compliant patient. Those few patients (<10% of the total) that fall into the extreme downhill group, may continue to lose attachment and subsequently lose teeth in spite of all efforts.
What Are the Goals of Periodontal Therapy?
The primary goal of periodontal therapy is the maintenance of the natural dentition in health and Prevention of Periodontal Disease, comfortable function, with pleasing aesthetics and satisfaction for the life of the patient. This goal persists even in the face of the expanding use and success of endosteal implants. Improvements in implant therapy have given the practitioner new treatment planning and decision-making challenges regarding the retention or removal of natural teeth. In spite of these successes, the overarching goal must still be the Prevention of Periodontal Disease and maintenance of the natural dentition when practically possible.
What Teeth Can Be Expected to Have the Greatest Longevity and Which Teeth Are Lost Most Frequently Due to Periodontal Disease?
Excluding third molars, maxillary second molars are lost most often to periodontal disease. This would be expected both due to complex root anatomy and the difficulty in performing effective oral hygiene because of the tooth location. Mandibular canines and first premolars are the teeth most likely to be retained.
What Clinical Parameters May Be Used to Judge the Success of Periodontal Therapy?
There are several clinical and radiographic parameters that may be used to judge the success of periodontal therapy, including:
Reduction or absence of bleeding on probing
Bleeding on gentle probing (25 g of force) is still the best prognostic indicator of the potential for future attachment loss. Absence of bleeding on probing is a 98% negative predictor that the site will lose attachment in the future. Conversely, approximately 30% of sites that bleed at consecutive maintenance visits over one year are at risk for future attachment loss. Since it is impossible to predict exactly which site will lose attachment, the thrust of therapy is to control inflammation at all sites for Prevention of Periodontal Disease.
Reduction of probing depth and gains in periodontal attachment
Periodontal therapy is focused on the removal of etiologic agents and contributing factors and the subsequent maintenance of health. One way to improve this possibility for both the patient and practitioner is to reduce probing depths. Greater success is achieved in creating and maintaining a plaque-free environment with shallow pockets compared to pockets greater than 5 mm in depth. Persistence of periodontal pathogens and progressive loss of attachment is associated with deeper pockets. Pocket depth may be reduced by inflammatory control achieved with initial therapy, respective surgery (eg, gingivectomy, apically positioned flap with osseous surgery), or by repair or regeneration of lost periodontal attachment.
Positive radiographic changes
Positive radio-graphic changes related to the success of periodontal therapy include the reappearance of a crestal lamina dura at the interproximal osseous crests, evidence of bone fill in areas of regenerative therapy, narrowing of the periodontal ligament space in teeth subject to occlusal trauma, and the absence of calculus on coronal and root surfaces. While radio-graphs made in clinical practice are not standardized, valuable comparisons may still be made between pretreatment and post-treatment films.
Tooth mobility is caused by the presence of edema in the gingival and periodontal tissues, loss of attachment, and the effects of occlusal forces on the attachment apparatus. After inflammatory control is completed, teeth often exhibit decreased mobility. This is due to the elimination of edema and the reformation of the supragingival connective tissue fibers that contribute to tooth stability, particularly when there has been attachment loss. Judicious occlusal adjustment by selective grinding to relieve fremitus may also contribute to increased tooth stability. Mobile teeth may be successfully maintained in a state of health. Increasing mobility or hypermobility are indicators that an occlusion remains unstable even after therapeutic intervention. Targeted occlusal therapy for Prevention of Periodontal Disease, removable or fixed splints, may be indicated in this case.
What Are the Limitations of Periodontal Therapy?
There may be significant limitations to what periodontal therapy can accomplish. First and foremost, the patient must be dedicated to a daily ritual of personal plaque control. Without this, successful treatment becomes an uphill battle. There may be limitations due to the amount of attachment loss, root anatomy, uncorrectable local or systemic factors, uncontrollable occlusal forces, mobility, and last but not least, the diagnostic acumen and skill of the clinician.
What Can Be Done for the Patient Who Fails to Respond to Periodontal Therapy?
It is important to identify those factors that may contribute to a patients continued attachment loss. Failures in therapy may be related to either diagnostic or therapeutic shortcomings. Even with accurate diagnoses and flawless treatment, the occasional patient will continue to lose attachment.
Diagnostic deficiencies in Prevention of Periodontal Disease:
• Related to health history: Undetected diabetes, immune compromise, or other systemic disorder
• Improper use, or nonuse, of the periodontal and furcation probe
• Improper radiographic examination: Particularly the use of bitewing films of less than a diagnostic quality to detect interproximal bone loss; vertical bitewing films are recommended to adequately visualize posterior interproximal bone height
• Abnormal anatomy rendering complete root detoxification impossible
• Unidentified microbes not eradicated by conventional mechanical therapy
• Undetected traumatic occlusion
• Pulpal pathosis
Therapeutic deficiencies, failure to:
• Instruct the patient adequately in plaque control
• Formulate a comprehensive treatment plan
• Control the etiological agents
• Identify and correct local contributing factors
• Treatment failures related to diagnostic deficiencies
• Select proper of therapeutic modalities
• Execute proper initial therapy with adequate follow-up
• Provide adequate surgical techniques
• Utilize an effective maintenance program
How is Prognosis Determined?
Patients are extremely interested in whether or not the proposed treatment is going to be effective, It would be beneficial for clinicians to give their patients a reasonably accurate prediction of treatment success. Unfortunately, prognostic acumen is limited. Except for those teeth that originally have a good prognosis, projections were ineffective at projecting the fate of teeth, accuracy in predicting was in about the 40% range. Initial mobility, increasing mobility, and smoking were seen as factors negatively affecting prognosis.
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