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Periodontology

Assessing New Attachment in Periodontal Therapy

Assessing new attachment following periodontal therapy is crucial for evaluating treatment outcomes and understanding the healing process. However, various methods of assessment have limitations that must be considered.

1. Periodontal Probing

  • Assessment Method: Periodontal probing is commonly used to measure probing depth and attachment levels before and after therapy.

  • Limitations:

    • Coronal Positioning of Probe Tip: After therapy, when the inflammatory lesion is resolved, the probe tip may stop coronal to the apical termination of the epithelium. This can lead to misleading interpretations of attachment gain.
    • Infrabony Defects: Following treatment of infrabony defects, new bone may form so close to the tooth surface that the probe cannot penetrate. This can result in a false impression of improved attachment levels.
    • Interpretation of Results: A gain in probing attachment level does not necessarily indicate a true gain of connective tissue attachment. Instead, it may reflect improved health of the surrounding tissues, which increases resistance to probe penetration.

2. Radiographic Analysis and Reentry Operations

  • Assessment Method: Radiographic analysis involves comparing radiographs taken before and after therapy to evaluate changes in bone levels. Reentry operations allow for direct inspection of the treated area.

  • Limitations:

    • Bone Fill vs. New Attachment: While radiographs can provide evidence of new bone formation (bone fill), they do not document the formation of new root cementum or a new periodontal ligament. Therefore, radiographic evidence alone cannot confirm the establishment of new attachment.

3. Histologic Methods

  • Assessment Method: Histologic analysis involves examining tissue samples under a microscope to assess the formation of new attachment, including new cementum and periodontal ligament.

  • Advantages:

    • Validity: Histologic methods are considered the only valid approach to assess the formation of new attachment accurately.

  • Limitations:

    • Pre-Therapy Assessment: Accurate assessment of the attachment level prior to therapy is essential for histologic analysis. If the initial attachment level cannot be determined with certainty, it may compromise the validity of the findings.

Keratinized Gingiva and Attached Gingiva

The gingiva is an essential component of the periodontal tissues, providing support and protection for the teeth. Understanding the characteristics of keratinized gingiva, particularly attached gingiva, is crucial for assessing periodontal health.

Keratinized Gingiva

  1. Definition:

    • Keratinized gingiva refers to the gingival tissue that is covered by a layer of keratinized epithelium, providing a protective barrier against mechanical and microbial insults.

  2. Areas of Keratinized Gingiva:

    • Attached Gingiva:
      • Extends from the gingival groove to the mucogingival junction.
    • Marginal Gingiva:
      • The free gingival margin that surrounds the teeth.
    • Hard Palate:
      • The roof of the mouth, which is also covered by keratinized tissue.

Attached Gingiva

  1. Location:

    • The attached gingiva is the portion of the gingiva that is firmly bound to the underlying alveolar bone.

  2. Width of Attached Gingiva:

    • The width of attached gingiva varies based on location and can increase with age and in cases of supraerupted teeth.

  3. Measurements:

    • Greatest Width:
      • Found in the incisor region:
        • Maxilla: 3.5 mm - 4.5 mm
        • Mandible: 3.3 mm - 3.9 mm
    • Narrowest Width:
      • Found in the posterior region:
        • Maxillary First Premolar: 1.9 mm
        • Mandibular First Premolar: 1.8 mm

Clinical Significance

  • Importance of Attached Gingiva:

    • The width of attached gingiva is important for periodontal health, as it provides a buffer zone against mechanical forces and helps maintain the integrity of the periodontal attachment.
    • Insufficient attached gingiva may lead to increased susceptibility to periodontal disease and gingival recession.

  • Assessment:

    • Regular assessment of the width of attached gingiva is essential during periodontal examinations to identify potential areas of concern and to plan appropriate treatment strategies.

  • Mobility Tests: Perio test, Fremitus test.
  • Bone Evaluation: Transgingival probing.
  • Halitosis Detection: Gold standard = Organoleptic analysis.
  • Indices:
    • PMA Index: Gingival disease.
    • Ramfjord Index Teeth: 16, 21, 24, 36, 41, 44.
    • Merin’s Classification: Patient recall.
    • Surrogate Endpoint: Reduction in probing depth.

Laser Classifications

Hard Tissue Lasers

  • Er:YAG and Er:YSGG: Highest water absorption coefficients
  • Applications: Calculus removal, root surface modification, bone surgery

Soft Tissue Applications

  • CO2 Laser: Excellent for soft tissue procedures
  • Diode Lasers: Hemostasis and bacterial reduction

Microsurgery Principles

Wound Approximation

  • Technique: Butt joint approximation for optimal healing
  • Instrumentation: Instruments weighing ≤15-20g for precision

  • Attached Gingiva Width:
    • Maxillary incisors: 3.5 – 4.5 mm
    • Mandibular incisors: 3.3 – 3.9 mm
    • Least in premolars (~1.8 – 1.9 mm)
  • Cementum:
    • Thickest in apical third and furcation (150 – 200 µm)
    • Acellular cementum: cervical third
    • Cellular cementum: forms after occlusal contact
  • PDL Fibres:
    • Principal: Type I collagen
    • Reticular: Type III collagen
    • Oblique fibres: Largest group, resist vertical forces
    • Transseptal fibres: Reconstructed post bone loss
    • Alveolar crest fibres: Prevent extrusion

Systemic Antibiotics

  • Most photosensitizing: Doxycycline
  • Only one causing tooth discoloration: Minocycline

Local Drug Delivery

  • Atridox: Doxycycline
  • Arestin: Minocycline
  • Elyzol: Metronidazole
  • Periochip: Chlorhexidine
  • Actisite: Tetracycline

Host Modulation

  • SDD (Sub – antimicrobial Dose Doxycycline): Only FDA – approved host modulating agent

🔁 Pulse Patterns

Pulse Type Condition
Slow rising pulse Aortic stenosis (AS)
Pulsus alternans CHF
Pulsus bigeminus Digoxin therapy
Pulsus paradoxus Tamponade, pericarditis, asthma
Water hammer pulse Aortic regurgitation
Pulsus bisferiens Best felt in radial artery

🔊 Heart Sounds

  • Loud S1: Short PR interval, tachycardia, mitral stenosis
  • Fourth Heart Sound (S4): Heard during ventricular filling
  • Opening snap: High-pitched, diastolic sound
MDS SUBJECTS

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