Transcript failures in periodontal therapy - some useful tips

FAILURES IN
PERIODONTAL
THERAPY
Dr shabeel pn
Contents
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Introduction
Classification of failure
Pre Therapeutic
Therapeutic
Surgical
Non surgical
• Post Therapeutic
• Summary & Conclusion
INTRODUCTION
• Dentist related failures
• Patient related failures
Dentist related failures
• Gathering data
• Improper diagnosis
• Improper investigations
• Inadequate motivation
• Improper treatment sequencing
• Incomplete treatment
• Irregular follow-ups.
Patient Related Factors
Maintenance
Smoking
Systemic Diseases.
Poor healing potential.
Psychological component – probably the least
studied and the most critical aspect in periodontics.
Classification
• Pretherapeutic
• Therapuetic
• Post Therapuetic
Pretherapeutic
Incorrect Patient Selection
• Age
• Socio-economic status and nutritional deficiencies
s
Systemic disease:
Diabetes Mellitus
Blood Dyscrasias : leukemia, Cyclic neutropenia
Immune deficiences : Neutrophil-monocytic chemotactic defects,
AIDS
Genetic disorders : Down’s syndrome, Papillion Lefevre syndrome,
hypophosphatasia , Chediak Higashi Syndrome) ;
Vitamin deficiences
Pretherapeutic
Incomplete diagnostic procedure or misdiagnosis
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Improper Clinical diagnosis
Radiological interpretations
Microbiological interpretation
Biochemical interpretation
Immunological interpretation
Inappropriate or improper dental restorations or
prosthesis
• Overhanging Class II , overextended crowns & bridges.
Failure to carry out assoc. Prosthetic-restorative
procedure
Pretherapeutic
Morphology of tooth surfaces :
Lateral accessory canals, dev. Grooves, resorption lacunae – act as
“Guide plan”for bacterial penetration…..
Habits
Occlusal corrections or teeth preparation:
TFO…prevent proper adaptive remodelling of periodontium
Therapeutic
Non-Surgical
Scaling
Root Planing
Splinting
Occlusal therapy
Local Drug Delivery
Surgical
Curettage
Gingivectomy
Abscess Drainage
Flap Surgery
Bone Grafts
GTR procedures
Root coverage procedures
Implant
Aesthetic surgeries
Scaling
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Obviously recognized by remnants of calculus
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Causes:
1. Incorrect instrumentation & Poor condition of instruments.
2. “Burnishing Calculus”.
3. “Induced Bleeding”.
4. Prescription of Gum paints.
5.Assessment of “calculus ratio”.
Root Planing
Rough root surface and persistence of
inflammation.
Inadequate RP……detection of caries.
Over instrumentation…..hypersensitivity
Presence of developmental grooves….Use of rotary
instruments to smoothen as far as possible
Splinting
Failures could be:
• Inflammation in the area
• Breaking of splint
• Increased plaque accumulation.
How to Prevent?
Diagnose whether a temporary or permanent splint
is required.
Contouring the splint
Proximal cleaning aids to be prescribed.
Should be clear of occlusal interferences.
Margins of splint should be flush with tooth surface
Occlusal therapy
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Diagnosis of occlusal abnormalities….
occlusal scheme of pt., plunger cusps,
or other occlusal Interference.
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Assessment of tooth wear and
judgement whether it can be corrected
by selective grinding or a full fledged
occlusal rehabilitation procedure is
needed.
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“Fremitus Test”.
Occlusal therapy
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Correction of worn out teeth must be done prior to
invasive periodontal surgery.
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Patients with other oral habits like tongue thrust,
occupational habits must be either advised to quit or
forced to quit before attempting any periodontal therapy.
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Gross malocclusion must be corrected following basic
therapy.
Surgical
Improper treatment sequencing :
• Role of interdisciplinary dentistry is today unquestionable
and this helps in sequencing…
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Not only the removal of primary etiological factors is
important … need to eliminate the secondary complicating
and confounding factors.
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Malocclusion, occlusal interferences, mild mobility, faulty
restorations, open contacts, etc and so on and so forth.
Improper selection of technique:
• Design of surgery or procedure, right from types of incisions to
the required modification …
• Improper selection of technique could be a primary trigger that
leads to a cascade of events precipitating in failure.
Incomplete treatment:
• Incomplete debridment…
Improper asepsis:
Improper primary closure:…delays healing
Curettage
Persistence of inflammation after procedure
Causes: 1. Diagnosis per se
2. Procedural errors;
- instrumentation
- when to stop
3. failure to irrigate…tags of
granulation tissue
4. Suture a curetted area.
Gingivectomy
Defined by recurrence of lesion either immediately
within a few weeks or by destruction of the
periodontal apparatus.
Wade (1954) outlined 15 reasons why gingivectomy fail:
1. Unsuitable case selection. Cases - underlying osseous or
intrabony defects.
2. Incorrect pocket markings
3. Incomplete pocket elimination
4. Insufficient beveling of the incision
5. Failure to remove tissue tags, resulting in excessive tissue
6. Failure to remove etiologic factors-calculus and plaque
7. Beginning or terminating the incision in a papilla
8. Failure to eliminate or control the predisposing factors
9. Inaccessible interdental spaces
10. Loose dressings
11. Lost dressings
12. Insufficient use of dressings
13. Failure to prescribe stimulators or rubber tip for
interproximal use
14. Failure to use stimulators or rubber tip
15. Failure to complete treatment
Abscess Drainage
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Defined by the recurrence of abscess/ resultant increase in
periodontal destruction.
1. Identification of source/ origin….tortousity of pocket &
complexity of the tooth .
2. Removal of entire abscess wall….remenant tags act as a
nidus….
3. Chronic abscesses tend to show more recurrence.
4. Systemic/ Local drug delivery is mandatory; if it’s a periodontal
abscess.
Flap Surgical Techniques
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Failures could be recurrence of pockets, flabby tissue, abscess
formation, gingival recession, cleft formation, loss of
interdental papilla.
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In most situations, some amount of gingival tissue recession
and loss of papilla occurs, accepted to such an extent that we
do not consider it a failure anymore.
Elimination of inflammation…Removal of deposits…improves
tissue tone & texture
Failure to remove the entire pocket lining…
Recurrence of the pocket epithelium.
Failure to correct bony ledges….improper maintenance,
periodontal infections & attachment loss
Incomplete debridement of granulation tissue and deposits.
Excessive reflection can cause increased …
postoperative surface resorption.
Regenerative Techniques
• Bone grafting Procedures
• GTR Procedures
• Growth Factor usage
Bone grafting Procedures
i.
Pre-surgical considerations….decision to
place a bone graft….
ii.
Assessment of defect morphology:
interproximal well supported 3 or 2 walled
defects & Furcation Involment.
iii. Technique of placement …increments,
compacted not condensed. Pore size or
distance between particles….significant.
iv. Maintenance of vascular continuity…..
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Alloplasts & xenografts…osteoconductive….only act as a
scaffold.
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Establishment of vascular continuity…
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Clot….should preferably arise from bone….penetrations of
cortical plate is reqd to enhance blood flow from
marrow…..trephination…aid in neovascularization.
iv. Overfilling the defect …
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lead to fibrous encapsulation
of the graft
Bone grafting Procedures
v.
“Flap margin bleed” …..persistent bleeding on flap surface
results in clot forming from the flap involving
graft….fibrous encapsulation.
vi. Postoperative infection control….antibiotics & antibacterial
mouthrinse…..
vii. Graft sterilization……most commonly overlooked aspects
viii. Primary closure with no intervening graft particles.
GTR Procedures
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Adaptation of membrane….to provide adequate space to the
periodontal ligament cells to migrate…
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Prevention of collapse…..use in conjunction with bone graft.
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Trimmed membrane…..should cover at least 2mm of
adjacent alveolar bone, no sharp edges…
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Membrane exposure…tension free flap, bacterial
accumulation..hampers healing
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Membrane suture… sling suture
Barrier-Independent Factors
• Poor plaque control
• Smoking
• Occlusal trauma
• Sub optimal tissue health (i.e. Inflammation persists)
• Mechanical habits (e.g.. Aggressive tooth brushing)
Barrier-Independent Factors
•Overlying gingival tissue
– Inadequate zone of keratinized tissues.
– Inadequate tissue thickness
•Surgical technique
– improper incision
– Traumatic flap elevation and management
– Excessive surgical time
– Inadequate closure or suturing
Barrier-Independent Factors
• Post surgical factors
- premature tissue challenge
#Plaque recolonization
#Mechanical insult
- Loss of wound stability (loose sutures, loss of fibrin
clot).
Barrier – Dependent Factors
• Inadequate root adaptation (absence of barrier effect)
• Non sterile technique
• Instability (movement) of barrier against root.
• Premature exposure of barrier to oral environment and
microbes.
• Premature loss or degradation of barrier.
Growth factor usage
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Method of draw… various techniques …blood bank draw
technique..superior viable platelet conc.
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Shelf life….24 hours, chair side equipment.
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Use of thrombin; and its ratio…released during surgery is
enough, ratio 1:7
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Aspiration technique…platelets fragile
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When used alone will invariably fail to show desired results.
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Prevent standing of PRP….premature bursting
Root Coverage Procedures
• Rotated flaps
• Soft tissue grafts
Root Coverage Procedures
Presurgical considerations…. depends on the position of the
tooth, the extent of malocclusion if present, the thickness of
the gingiva present in the adjacent area
The etiology of the recession must be corrected.
Depth of the vestibule , width of attached gingiva .
Graft handling could be one of the reasons for failure….
Squeezing of the graft leads to leakage of the plasmatic fluid
…..dessication
Size of the graft should be adequate…. ideal size should be
1.25-1.5 mm
The presence of clot between the graft and root surface….
Compression of graft against root surface
Root conditioning is a must; esp in soft tissue graft
procedures
Rotated flaps
Intra-surgical considerations:
• Horizontal incision; mandatory to maintain viability of papilla.
• Cut-back incision; prevents tissue ledges.
• Partial thickness is desired as this may prevent donor site
recession.
Rotated flaps
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Coronally displaced flaps fail most often because
they are either secured in tension and are not
stable; thus vertical incisions play a critical role in
success of this procedure.
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These procedures show limited success if interproximal recession is also present.
Laterally positioned flap
• Common reasons for failure
– Tension…. Distal incision
– Pedicle too narrow
– Exposure of bone at radicular surface
– Poor stabilization
Double papilla flap
• Common reasons for failure
– Non union of component flaps
– Full tickness flap…..Dehiscence or fenestrations
– Inadequate attached gingiva in the papillary area
– Proper placement of the flap on periosteal bed
– Adequate fixation of the flap to prevent shifting
Free Soft tissue grafts
• Epithelialized grafts
• Sub-epithelial Connective Tissue Grafts
Epithelialized grafts
• The sutured graft should always be either at the level or
higher than the level of adjacent recipient bed but never
below; this leads to graft rejection (Chiranjeevi 1989).
• Recipient bed preparation should be beveled and broader at
the base.
Sub epithelial Connective Tissue
• 2 techniques of procurement; separation of full thickness
yields more C.T. and easier.
• Grafts have to be trimmed and the lipid layer has to be
removed.
• Tunnel technique gives only marginal recession coverage as
opposed to pouch technique
• Reasons for failure…. Langer &
Langer 1992
– Recipient bed too small
– Flap perforation
– Inadequate graft size
– Inadequate coronal
positioning of flap
– Too thick a CT graft
– Poor root preparation
– Poor papillary bed
preparation
Implants
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Inadequate union of bone and implant at the time of
surgical insertion.
Improper biomaterials
a) Use of dissimilar materials
b) Bio-incompatible materials
Contamination of the implant surface & infection
Surgical overheating of bone
Structural design that does not transmit forces evenly to the
bone
Premature loading with occlusal forces prior to healing
phase
Increased periodontal pocket activity
Post Therapeutic
Instruction & Motivation
• Preservation of the periodontal health … requires as positive
programme
• If periodontist follows a very good therapeutic procedures…..pt
does not maintain or not under proper recall visits….signs of
PD,tooth loss etc.
failure- bone loss
• Motivation + reinforcement of OHI.
• Failure to continue with treatment…conscious or unconscious
decision
Unsupervised healing: Absence of supervision…
• Professional cleaning of supragingival area periodically
• Failure to assess OH status…
• Inbility to monitor nutritional status…
Persistent or reintroduction of certain microorganisms
• Failure to eliminate certain
microorganisms..A.a….persistence or recurrence.
• Some remain in the DEJ…resistant to
antibiotics…recurrence.
• Reintroduction…..
New Disease:
Refractory Periodontitis: “a disease in multiple sites in
patients which continue to demonstrate attachment loss after
appropriate therapy”
Ability or skill of the operator:
CONCLUSION
References
• Dr.Ramaswamy. Causes of failure of periodontal treatment.
JISP 1995; 19:23-24.
• Gerald Kramer. Dental failures associated with periodontal
surgery. DCNA 1972;16:13-31.
• Leon Lefer. Failures in motivation of dental home care. DCNA
1972;16:1:pg3.
• Bradley RE. Periodontal Failures related to improper
prognosis & treatment planning.DCNA 19726:1:pg33-43.
• Wang HL, MacNeil RL. GTR. DCNA1998; 42:509.
Recent advances
What is AlloDerm Regenerative Tissue Matrix?
• AlloDerm is an acellular dermal matrix derived
from donated human skin that undergoes a
multi-step proprietary process that removes both
the epidermis and the cells that can lead to tissue
rejection.
• AlloDerm has been used in a wide variety of soft
tissue grafting procedures such as root coverage, soft
tissue augmentation and guided bone regeneration
with a consistent record of excellent results.1-7
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Advantages compared to the connective tissue
autograft from the patient’s palate:
Eliminates the need for palatal surgery
Removes palatal harvesting limitations from treatment
planning considerations
Reduces patient reluctance to follow through with surgical
treatment
Consistent quality
Provided in multiple convenient sizes
Available in two thickness ranges for use in different
procedures:
0.9 to 1.6 mm - AlloDerm for root coverage, soft tissue ridge
augmentation, etc.
0.5 to 0.8 mm - AlloDerm GBR for guided bone regeneration
and barrier membrane function
How does AlloDerm work?
• AlloDerm provides a matrix consisting of collagens, elastin,
vascular channels, and proteins that support
revascularization, cell repopulation and tissue remodeling.
• After placement, the patient’s blood infiltrates the AlloDerm
graft through retained vascular channels, bringing host cells
that adhere to proteins in the matrix.
• Significant revascularization can begin as early as one week
after implantation.
• The host cells respond to the local environment and the
matrix is remodeled into the patient’s own tissue, in a fashion
similar to the body’s natural tissue attrition and replacement
process.
Documented equivalence to autogenous
connective tissue
• Multiple, randomized clinical trials (RCT) have shown root
coverage results with AlloDerm to be equivalent to
autogenous connective tissue, and concluded that the
procedure was predictable and practical.
• A meta-analysis of eight RCTs showed no statistically
significant differences between the two groups for measured
outcomes: recession coverage, keratinized tissue formation,
probing depth and clinical attachment levels.
Acellular Dermal Matrix for Mucogingival Surgery: A Meta-Analysis.
Gapski R, Parks CA and Wang HL. J Periodontol 2005;76(11):1814-1822.
Application of Regenerative
Tissue Matrix
Root Coverage
Soft Tissue Ridge Augmentation
Soft Tissue Augmentation Around Dental Implants
Guided Bone Regeneration
References
• Management of Gingival Recession by the Use of a Acellular Dermal Graft Material: A
12-Case Series. Santos A, Goumenos G and Pascual A. J Periodontal 2005;76(11):1982-
1990.
• Subpedicle Acellular Dermal Matrix Graft and Autogenous Connective Tissue Graft in
the Treatment of Gingival Recessions: A Comparative 1-Year Clinical Study. Paolantonio
M, Dolci M, Esposito P, D’Archivio D, Lisanti L, Di Luccio A and Perinetti G. J
Periodontol 2002;73(11):1299-1307.
• Clinical Evaluation of Acellular Allograft Dermis for the Treatment of Human Gingival
Recession. Aichelmann-Reidy ME, Yukna RA, Evans GH, Nasr HF and Mayer ET. J
Periodontol 2001;72(8):998-1005.
• Predictable Multiple Site Root Coverage Using an Acellular Dermal Matrix Allograft.
Henderson RD, Greenwell H, Drisko C, Regennitter FJ, Lamb JW, Mehlbauer MJ,
Goldsmith LJ and Rebitski G. J Periodontol 2001;72(5):571-582.
• Surgical therapies for the treatment of gingival recession. A systematic review. Oates
TW, Robinson M and Gunsolley JC. Ann Periodontol 2003;8:303-320.
• Root coverage of advanced gingival recession: A comparative study between acellular
dermal matrix allograft and subepithelial connective tissue grafts. Tal H, Moses O, Zohar
R, et al. J Periodontol 2002;73:1405-1411.
• The clinical effect of acellular dermal matrix on gingival thickness and root coverage
compared to coronally positioned flap alone. Woodyard JG, Greenwell H, Hill M, et al. J
Periodontol 2004;75:44-56.
Platelet rich Fibrin