Periodontal Disease

[divyanshee]

How to differentiate between various types of gingival enlargement?

        

[Anonymous]

Even there are several etiologies for gingival overgrowth; usually each etiology has its own overgrowth characteristics. For example, while genetically induced gingival overgrowth show firm, normal coloured (pink), non-inflamed gingival tissues, gingival overgrowth due to blood dyscrasias are edematous, soft, tender to touch and show tendency to bleed.

        

[Anonymous]

Drug induced gingival overgrowth

The clinical features of gingival enlargement usually presents as enlarged interdental papillae and resulting in a lobulated or nodular morphology. The effects normally limited to the attached and marginal gingivae and more frequently observed anteriorly. Histologically, in drug induced gingival overgrowth it was described as thickening of the spinous cell layer, slight to moderate hyperkeratosis, fibroblastic proliferation and fibrosis of lamina propria .

        

[sushantpatel_doc]

Rarely there can be pseudo enlargement due to underying bone overgrowth…i guess this can be diagnosed by mere palpation..

        

[shreya]

I dont think underlying bone growth can lead to gingival enlargement. Can you quote an example please.

        

[sushantpatel_doc]

There’s no example as such..the alveolus around a tooth may sometimes show idiopathic overgrowth which may be totally asymptomatic…this may give a false appearance of gingival enlargement..hence named pseudo enlargement..no particular etiology as such is present..

        

[Anonymous]

Pseudopocket formation is seen in drug induced gingival enlargement

        

[sushantpatel_doc]

Pseudo pocket is seen when there is no loss of attachment but the sulcular depth is beyond normal because of coronal growth of gingiva as in gingival enlargement mentioned above..its again a false appearance of a pocket being present..

        

[drsushant]

 LOCAL DELIVERY OF SITE-SPECIFIC ANTIMICROBIAL DRUGS 

The local delivery of antimicrobials, such as Arestin (Orapharma), offer the dentist a statistical and significant system for the treatment of periodontitis.18 The Agency for Health Care Research and Quality (the federal agency assigned to improve quality, safety, efficiency, and effectiveness of healthcare) evaluated literature on these antimicrobials in 2004.¹⁹ They concluded that scaling/root planing, when accompanied by the placement of an antimicrobial agent (Arestin) as a supplement or adjunct treatment, resulted in an improved clinical outcome in adults with chronic periodontitis. (This was compared to scaling/root planing that was done alone.) Systemic and locally placed antimicrobial drugs are therefore suggested for use when active disease is detected. They have clearly shown in the studies mentioned to be of significant help in resolving the diseased condition and restore periodontal health as quickly as possible. 

Patients usually understand medical treatment with medication. It is a natural addition to periodontal treatment, following the medical model. These drugs can be used on a routine basis as a standard of care, in successfully managing periodontal disease.

ROLE OF PROBIOTICS IN MANAGING PERIODONTAL DISEASE 
Periodontal disease may be impacted by the use of new probiotic products, such as GUM PerioBalance (Sunstar Americas) and Evora Plus (Oragenics). Probiotics consist of microorganisms in oral tablet/lozenge form that confer a health benefit to the patient. Current research has indicated that periodontal disease may be impacted by probiotics through the reduction of the body’s inflammatory mediators. Twetman et al²⁰, in 2009, using 2 strains of Lactobacillus reuteri, found that there was a reduction in bleeding on probing and the amount of cytokines present in the gingival crevicular fluid, a reduction in the periodontal inflammatory response. This may help to reduce oral disease. GUM Perio Balance is designed to be used once daily, immediately following flossing and brushing. The lozenge dissolves in the mouth in 10 minutes, and it is recommended that nothing be used in the mouth immediately after the use of the lozenge for 30 minutes (Figure 3).

 

        

[drsushant]

 

        

[drsushant]

 PAINLESS MANAGEMENT OF DISEASE

One barrier to consumer acceptance of even conservative nonsurgical periodontal treatment is still the fear of pain. Treatment must be provided painlessly, if at all possible. In order to achieve this, analgesia must be used. It has been estimated that 15% of the US population declines dental care primarily because they fear oral injections.²³ Nitrous oxide/oxygen analgesia relaxes patients and reduces their anxiety enough to allow treatment without pain. New technology allows the use of digital flow meters, such as the Porter Instrument Conscious Sedation Flowmeter. To achieve a successful result, analgesia must be available for the patients who require it. A recent innovation (developed by the author) using topical anesthetic spray (such as Hurricane [Beutlich Pharmaceutical]) and a light-cured extended contact topical fluoride varnish (such as Vanish XT [3M ESPE]), makes it possible to perform scaling/root planing without having to use injectable local anesthetics. Previously sensitive roots, which could only be instrumented after administering local anesthetic, can now be treated after a single application of Vanish XT. After being light-cured, the fluoride varnish seals the roots with a durable layer of protection, thus relieving dentinal hypersensitivity and permitting the painless instrumentation and removal of all deposits. Being able to control root sensitivity, while improving the integrity of the root of the tooth where the toxic bacteria collects, gives the dentist/hygienist the opportunity to help control the risk of disease. Reduction of this sensitivity via an extended contact topical fluoride varnish (that can last up to 6 months) can also help to improve patient compliance for performing the required at-home daily hygiene routine; thus making it easier to control the chronic disease risks and improving the future success of dental care.

        

[Drsumitra]

  new type of fluorescent labeling technology determined that microbe biofilm can interact with other bacteria when located on a tooth.

It was determined that a single image can demonstrate some type of cooperation between the various forms of microbe biofilm.

The information was revealed during a presentation at the American Society for Cell Biology meeting in Denver.

The specific types of bacteria that interacted were Prevotella and Actinomyces. The study to figure out the roles bacteria play in the mouth was conducted by a research team from the Marine Biological Laboratory.

Prevotella is the bacteria often associated with periodontal disease. There have also been cases in which the bacteria were present in anaerobic lung infections.

This new technology will lead to several other new findings involving bacteria. It could be pivotal to research involving tooth decay or any other dental problem related to bacteria

        

[Drsumitra]

 

        

[drmithila]

 A primary aim of periodontal probing is to locate the most coronal level of the connective-tissue attachment. However, this generally is not attainable, as penetration of the probe tip in the pocket or the lining soft tissues correlates with periodontal health.^7,8 It has been established that the extent of probe penetration is influenced by the inflammatory status of the tissues.^7,9-12 In most instances when healthy tissues are examined, the probe tip stops coronal to the apical termination of the junctional epithelium (Figure 1), whereas at inflamed sites the probe tip frequently passes apical to this point (Figure 2). The depth of probe penetration partially depends on the extent to which the gingival connective tissue has been lysed or infiltrated by inflammatory cells. In other words, intact connective tissue underlying the crevicular epithelium is an important factor resisting probe penetration. Spray et al¹³ suggested that the state of health of the underlying connective-tissue fibers influences probing measurements. There is a “hammock effect” in health, where healthy fibers act as a barrier and prevent apical movement of the instrument, while inflamed connective tissue offers less resistance to penetration. With reduction in inflammation, an accurate estimate of the sulcus depth is more likely to be obtained. The probe penetration is significantly greater in the presence of visible inflammation, but not where there was bleeding after probing.⁸ These results suggest that the location of the inflamed connective tissue may be a critical factor. Anderson et al¹⁴ determined the correlation between clinical and histologic inflammation and probe-tip penetration of the pocket tissues in dogs. A strong correlation was found between probe penetration and degree of inflammation, and the difference in mean inflammation scores between sites where probes were located coronal or apical to the epithelium was statistically significant.

Anatomically, the gingival sulcus is defined as the distance from the gingival margin to the coronal extension of the junctional epithelium.¹⁵ However, the ability of the periodontal probe to measure this distance accurately is questionable. Results of human studies performed by Sivertson and Burgett¹⁶ indicate that the periodontal probe routinely penetrates to the coronal level of the connective tissue attachment of untreated periodontal pockets. Armitage et al⁷ found that, in healthy specimens, the probe failed to reach the apical termination of the junctional epithelium. In cases with experimental gingivitis, however, most probes came closer to the apical termination of the junctional epithelium, but on the average still fell short. In periodontitis specimens, the probes consistently went past the most apical cells of the junctional epithelium. A significant relationship between the degree of inflammation and level of probe penetration was found. Saglie et al¹⁷ noted that probing depths measured in the laboratory were always shallower than those recorded clinically. The authors attributed this discrepancy to the presence of a zone of completely and partially destroyed periodontal fibers, which allowed the probe to extend apically to the coronal level of connective-tissue attachment. The results of these studies illustrate that periodontal probes do not precisely measure, and often overestimate, the true histologic sulcus depth, and that inflammation has a significant influence on probe penetration. This has important implications regarding how measurements taken with periodontal probes are interpreted. Because probes rarely stop at the exact location of the most apical cells of the junctional epithelium, probing measurements are clearly not precise assessments of the actual level of connective-tissue attachment. PPD measurements overestimate connective-tissue attachment loss at inflamed sites and underestimate it at noninflamed sites. An increased probing depth is a sign of reduced tissue resistance to probing, which in turn can be interpreted as an indication of the presence of an inflammatory cell infiltrate in the gingival tissue.¹¹Most research has shown that the tendency for penetration of the probe into the tissues at the base of pocket resulting in an overestimate of probing depth is greater at inflamed sites^7,10,11 and in nonsmokers

        

[drmithila]

 

Periodontal Probes

The periodontal probe continues to be one of the more useful diagnostic tools to determine the presence and severity of periodontal lesions. An ideal periodontal probe should possess specific characteristics:

1. It should be tissue-friendly and not traumatize periodontal tissues during probing.

2. It should be suitable as a measuring instrument.

3. It should be standardized to ensure reproducibility, particularly with respect to recommended pressure.

4. It should be suitable both for use in the clinical setting where precise data documentation is required on an individual patient basis, and for screening purposes, as in epidemiology.

5. It should be easy and simple to use and read.

Over the years, the shape, design, and function of probes have changed to enhance accuracy and reproducibility. Three generations of probes have been suggested by Philström¹⁹: first generation—conventional handheld instruments; second generation—force application during measurement; third generation—force application using automated measurement and computerized data capture. The conventional handheld probes most commonly are preferred for their ease and simplicity in application. However, the use of second- and third-generation probes also is common, especially in the field of research where variables such as pressure or force on probing, reproducibility, and accuracy are investigated. Various studies considering these different probes and their characteristics also are found in the literature. Samuel et al²⁰ have published an in vitro study testing the accuracy and reproducibility of automated and conventional probes. In that study automated probes were reported to offer increased accuracy over conventional probes, and the reproducibility of both Florida pocket-depth and disk probes was found to be comparable with that of the conventional probes. Buduneli et al²¹ in an in vitro model investigated the accuracy and reproducibility of two manual probes and concluded that overall accuracy was higher with the WHO probe compared with the Williams probe. This study also revealed better reproducibility percentages for the WHO probe in comparison with the Williams probe.

Probe Characteristics

Characteristics of the probe, such as its diameter at the tip and the calibration, can influence PPD measurement. Different probes, such as Michigan, Williams, Marquis, Goldman-Fox, and Nabers probes, have different dimensions and a different diameter at the tip. The tip diameters range from 0.28 mm for the Michigan “O” probe to 0.7 mm for the Williams probe. Moreover, the widths of probe markings in the painted bands differ by as much as 0.7 mm between probes because of manufacturing errors. Figure 3 illustrates different manual probes. Van der Zee et al⁵ evaluated the accuracy of probe markings in a variety of probes and noted that probes from the same batch from the same production line could differ by more than 0.5 mm in calibration and the mean tip diameter ranged from 0.28 mm to 0.7 mm. They concluded that probe-tip diameter and calibration should be considered in addition to other variables of periodontal probing. Standardization of tine characteristics and avoidance of the use of different types or batches in a single study should enhance the accuracy and reproducibility of periodontal probe-dependent measurements.

Atassi et al²² compared a parallel-sided probe to a tapered probe (Figure 4). Results indicated that the parallel-sided tine tended to yield a deeper reading when a difference occurred. Garnick and Silverstein²³reviewed the effect of the probe-tip diameter on accurate probe placement and recommended a probe-tip diameter of 0.6 mm and a 20-g force to measure a reduction in the clinical probing depth after therapy. Quirynen et al²⁴ found interexaminer variability was dependent upon probe type. The study compared a conventional periodontal probe with an automatic, computerized, constant-force, electronic probe in vivo and found that PPD measurements recorded with the manual probe were consistently deeper than those recorded with the electronic probe. Wang et al⁴ evaluated intra- and interexaminer reproducibility for conventional and electronic probes and found that reproducibility may not necessarily be higher with an electronic, force-controlled periodontal probe than with a conventional manual probe. In an attempt to overcome some of the technical challenges associated with conventional manual periodontal probes, numerous electronic periodontal probes have been developed that permit probe insertion with a controlled force.⁹

The controlled-force probe that has achieved the most widespread use is the Florida Probe^® (Florida Probe Corp, Gainesville, FL) (Figure 5A and Figure 5B). This computer-linked device has in vitro resolution of 0.1 mm and is capable of recording probing depths and relative attachment levels.^25-31 Clinical measurements obtained with conventional manual probes are consistently greater than those obtained with controlled-force probes.^24,32-37 One of the possible reasons for this is reduced tactile sensitivity associated with the use of controlled-force probes. This is especially true in patients with untreated periodontitis for whom the presence of subgingival calculus can interfere with probe insertion. With conventional probes, it generally is easier for the operator to manipulate the probe tip past subgingival calculus deposits. A definite advantage of computer-linked probes is that they can record probe readings automatically. Some systems allow voice-activated data entry.³⁸ The usefulness of controlled-force probes in day-to-day clinical practice has not yet been demonstrated.⁹

One possible reason for the lack of widespread acceptance of controlled-force electronic probes by practitioners might be increased patient discomfort when these devices are used, particularly around the anterior teeth. During probing with conventional manual probes, the operator can decrease the insertion force rapidly if the patient shows any early signs of discomfort. With controlled-force probes, this patient–dentist feedback is not possible because the probe is inserted into the pocket in one motion and with fixed or predetermined force

        

[Author]

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