Dr.

Omar Soliman
Dr. Omar Soliman
Dr. Omar Soliman
Rationale for Periodontal Treatment

Dr. Omar Soliman

Lecturer of Oral medicine and Periodontology, South Vally
University
Dr. Omar Soliman
 OBJECTIVES OF PERIODONTAL THERAPY

• If properly performed, periodontal treatment can accomplish the following:

• Eliminate pain.
• Eliminate gingival inflammation.
• Eliminate gingival bleeding.
• Eliminate infection.
• Reduces periodontal pockets and mobility of the teeth.
• Stops pus formation.
• Arrests the destruction of soft tissue and bone.
• Establishes optimal occlusal function.
• Restores tissue destroyed by disease.
• Re-establishes the physiologic gingival contour.
• Prevent the recurrence of disease.
• Reduces tooth loss.
Dr. Omar Soliman
Dr. Omar Soliman
Dr. Omar Soliman
 OBJECTIVES OF PERIODONTAL THERAPY

• If properly performed, periodontal treatment can accomplish the following:

• Eliminate pain.
• Eliminate gingival inflammation.
• Eliminate gingival bleeding.
• Eliminate infection.
• Reduces periodontal pockets and mobility of the teeth.
• Stops pus formation.
• Arrests the destruction of soft tissue and bone.
• Establishes optimal occlusal function.
• Restores tissue destroyed by disease.
• Re-establishes the physiologic gingival contour.
• Prevent the recurrence of disease.
• Reduces tooth loss.
Dr. Omar Soliman
Dr. Omar Soliman
 Surgical Phase
Dr. Omar Soliman
(Phase II Therapy)
 Periodontal Reconstruction.
• During the healing stages of a periodontal pocket, the area is invaded by cells from four
different sources oral epithelium, gingival connective tissue, bone, and periodontal
ligament.
• The final outcome of periodontal pocket healing depends on the se︎quence of events
during the healing stages.
A. If the epithelium proliferates along the tooth surface before the other tissues reach the
area, the result will be a long junctional epithelium.
B. If the cells from the gingival connective tissue are the first to populate the area, the
result will be fibers parallel to the tooth surface and remodeling of the alveolar bone
with no attachment to the cementum.
C. If bone cells arrive first, root resorption and ankylosis may occur.
D. Finally, only when cells from the periodontal ligament proliferate coronally, there is
new formation of cementum and periodontal ligament.
• Several methods, based on different concepts and resulting in various techni︎ques, have
been recommended to improve the likelihood of gaining new attachment and increased
bone levels.
Dr. Omar Soliman
Dr. Omar Soliman
Dr. Omar Soliman
 Guided Tissue
Regeneration.

Dr. Omar Soliman

 Guided Tissue Regeneration.

- Based on that only periodontal ligament and perivascular cells have the
potential for regeneration of peridontium.

- GTR is used for the prevention of epithelial migration along the cemental wall
of the pocket and maintaining space for clot stabilization.

- GTR consists of placing barriers of different types

(membranes) to cover the bone and periodontal
ligament, separating them from the gingival epithelium
and connective tissue.

- Excluding the epithelium and the gingival

connective tissue from the root surface not only
prevents downgrowth of epithelium but also giving a
chance for repopulation of the area by cells from the
periodontal ligament and the bone.
Dr. Omar Soliman
 Regeneration

• Regeneration is the natural renewal of a structure, produced by growth

and differentiation of new cells and intercellular substances to form
new tissues or parts.
• Regeneration occurs through growth from the same type of tissue that
has been destroyed or from its precursor.
• In the periodontium, gingival epithelium is replaced by epithelium, and
the underlying connective tissue and periodontal ligament are derived
from connective tissue. Bone and cementum are replaced by connective
tissue, which is the precursor of both ︎undifferentiated connective tissue
cells develop into osteoblasts and cementoblasts, which form bone and
cementum.

Dr. Omar Soliman

 Periodontal Reconstruction.

• As previously discussed, the term perio︎ontal reconstruction refers to the

process of regeneration of cells and fibers and remodeling of the lost
periodontal structures that results in (1) gain of attachment level, (2) formation
of new periodontal ligament fibers, and (3) a level of alveolar bone
significantly coronal to that present before treatment.
• A techniq︎ue to attain these ideal results has been a constant but elusive goal of
periodontal therapy for centuries.
• Regeneration of the periodontal ligament is the key to periodontal
reconstruction because it ︎provides continuity between the alveolar bone and the
cementum and also because it contains cells that can synthesize and remodel
the three connective tissues of the alveolar part of the periodontium.︎

Dr. Omar Soliman

 Repair

• Repair simply restores the continuity of the diseased marginal gingiva and
reestablishes a normal gingival sulcus at the same level on the root as the base
of the preexisting periodontal pocket. This process, called healing by︎ scar︎,
arrests bone destruction but does not result in gain of gingival attachment
or bone height. This return of the destroyed periodontium to health involves
regeneration and mobilization of epithelial and connective tissue cells into the
damaged area and increased local mitotic divisions to provide sufficient
numbers of cells.
• For the diseased gingiva and attachment apparatus to regain (totally or
partially) their level on the root, therapy must include special materials and
techni︎ques. If these are not used or are not successful, tissues under go repair
only, which involves regeneration of tissue to remodel the attachment
apparatus but does not include regaining attachment level or new bone height.
For this reason, we prefer to use the term reconstruction of︎ the perio︎dontium to
refer to the crucial therapeutic techniq︎ues that seek to rebuild the periodontium
and result in a significant gain of attachment and bone height.
Dr. Omar Soliman
 New Attachment

•New attachment is the embedding of new periodontal ligament fibers into new
cementum and the attachment of the gingival epithelium to a tooth surface previously
denuded by disease.
•The critical phrase in this definition is ︎tooth surface previously denuded by disease︎.
The attachment of the gingiva or the periodontal ligament to areas of the tooth from
which they have been removed in the course of treatment (or during preparation of
teeth for restorations) represents simple healing or reattachment of the periodontium,
not new attachment.
•The term reattachment refers to repair in areas of the root not previously exposed to
the pocket such as after surgical detachment of the tissues or following traumatic
tears in the cementum, tooth fractures, or the treatment of periapical lesions.
•Epithelial ad︎aptation differs from new attachment in that it is the close apposition of
the gingival epithelium to the tooth surface, with no gain in height of gingival fiber
attachment. The pocket is not completely obliterated, although it may not permit
passage of a probe.
Dr. Omar Soliman
Dr. Omar Soliman
Dr. Omar Soliman
Dr. Omar Soliman
 Local Therapy

• The cause of periodontitis and gingivitis is bacterial pla︎que accumulation on the

tooth surface close to the gingival tissue. The accumulation of plaq︎ue can be
favored by a variety of local factors, such as calculus, overhanging margins of
restorations, and food impaction, the removal of︎ plaq︎ue can︎ all of︎ the ︎factors that
f︎avor its accumulation is the primar︎y goal in local therapy.︎︎
• It should be remembered that total pla︎que elimination as obtained in experimental
studies may not be possible in human subjects.
• Abnormal forces on the tooth can increase tooth mobility. The thorough
elimination of pla︎que and the prevention of its formation can help maintain
periodontal health, even if traumatic forces are allowed to persist.
• However, the elimination of trauma may increase the chances for bone
regeneration and the gain of attachment. Although this point is not widely
accepted, it appears that creating occlusal relationships that are more tolerable to
the periodontal tissues increases the margin of safety of the periodontium to the
buildup of pla︎que, in addition to reducing tooth mobility.
Dr. Omar Soliman
 The Systemic Therapy

•Systemic therapy may be employed as an adjunct to local measures for specific

purposes such as controlling systemic complications from acute infections or
chemotherapy and preventing harmful effects of post treatment bacteremia. The
control of systemic diseases that aggravate the patient’s periodontal condition is
always a consideration so proper precautions can be instituted during therapy .
•Systemic therapy for treatment of the periodontal condition in conjunction with
local therapy is indicated in patients with aggressive periodontitis. In these
diseases, systemic antibiotics are used to eliminate the bacteria that invade
the gingival tissues and can repopulate the pocket after scaling and root
planing.
•In addition, periodontal manifestations of systemic diseases are treated primarily
by other local measures.

Dr. Omar Soliman

 The Systemic Therapy

In the late twentieth century, the concept of host mo︎dulation was introduced as a
medical approach to periodontal treatment. it was possible to block periodontal
bone loss in animals with the aspirin-like drug indomethacin. Evidence was then
presented that some nonsteroi︎al antiinfl︎ammatory︎ d︎rugs (NSAIDs), such as
︎urbiprofen and ibuprofen, can reduce the development of experimental gingivitis,
as well as the loss of alveolar bone in periodontitis. These drugs are propionic
acid derivatives and act by inhibiting the cyclooxygenase pathway of arachidonic
acid metabolism, thereby reducing prostaglandin formation. These NSAIDs can
be administered by mouth or applied topically.
Another drug that has a strong inhibitory effect on bone resorption is
alendronate, a bisphosphonate︎ which is currently used to treat metabolic
diseases in humans, such as Paget disease or hypercalcemia of malignancy, which
result in bone resorption. Experimental studies in monkeys have shown that
alendronate reduced the bone loss associated with periodontitis.
Dr. Omar Soliman
 Factors That Affect Healing.

In the periodontium, as elsewhere in the body, healing is affected by local and

systemic factors.
Local Factors
Systemic conditions that impair healing may reduce the effectiveness of local
periodontal treatment and should be corrected before or during local procedures.
However, local factors, particularly plaq︎ue microorganisms, are the most common
deterrents to healing after periodontal treatment.
Healing is also delayed by
(1)excessive tissue manipulation during treatment,
(2)trauma to the tissues,
(3)the presence of foreign bodies, and
(4)repetitive treatment procedures that disrupt the orderly cellular activity in the
healing process.
Dr. Omar Soliman
In the periodontium, as elsewhere in the body, healing is affected by local and
systemic factors.
Local Factors
An ade︎quate blood supply is needed for the increased cellular activity during
healing. If the blood supply is impaired or insufficient, areas of necrosis will develop
and delay the healing process.
Healing is improved by debridement (removal of degenerated and necrotic tissue),
immobilization of the healing area, and pressure on the wound.

Dr. Omar Soliman

Systemic Factors
Healing capacity diminishes with age, probably because of the atherosclerotic
vascular changes common in aging and the resulting reduction in blood
circulation. Healing is delayed in patients with generalized infections and in those
with diabetes and other debilitating diseases.
Healing is impaired by insufficient food intake︎ bodily conditions that interfere
with the use of nutrients︎ and deficiencies in vitamin C, proteins, and other
nutrients. However, the nutrient req︎uirements of the healing tissues in minor
wounds, such as those created by periodontal surgical procedures, are usually
satisfied by a well-balanced diet.
Healing is also affected by hormones. Systemically administered glucocorticoids
such as cortisone hinder repair by depressing the in︎flammatory reaction or by
inhibiting the growth of fibroblasts, the production of collagen, and the formation
of endothelial cells.
Systemic stress, thyroidectomy, testosterone, adrenocorticotropic hormone
(ACTH), and large doses of estrogen suppress the formation of granulation tissue
and impair healing. Progesterone increases and accelerates the vascularization of
immature granulation tissue and appears to increase the susceptibility of the
gingiva to mechanical injury by causing dilation of the marginal vessels.
BONE DESTRUCTION CAUSED
BY SYSTEMIC DISORDERS.

bone loss initiated by local inflammatory processes may be

magnified by systemic influence on the response of alveolar
bone.

This is termed . The bone factor concept .