The following are things to look for when seeing patients in our practice:

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1 DO MORE PERIO, HELP YOUR PATIENTS, HELP YOUR PRACTICE. MARTY NAGER, DMD, FICD DIPLOMATE, AMERICAN BOARD OF PERIODONTOLOGY 67 JEFFERSON BOULEVARD WARWICK, RI

2 THE PERIODONTALLY-ORIENTED RESTORATIVE PRACTICE PERIODONTAL PROGRAM GUIDELINES The following are things to look for when seeing patients in our practice: o Pocket depths equal to or greater than 5 mm. SRP with local anesthesia or pocket reduction surgery. Reevaluation 4-12 weeks later. If pocket depths still 5mm or more, or any of the following, consider referral to a periodontist. All SRP patients continue with 3 month Maintenance/Recall. o Recession with less than 1 mm of attached gingival +/- bleeding on probing. Free gingival graft, or connective tissue graft. o Mobility +/- fremitus. Occlusal analysis +/- occlusal adjustment +/- hard acrylic bite guard. o Cosmetics Including crown lengthening, connective tissue grafting (also for class V recession), post- orthodontic gingival recontouring. o Interfering frenum pull. Frenectomy. Gingival graft o Violation of biologic width, fractured tooth, deep recurrent decay, inadequate tooth structure for crown. Crown lengthening surgery. o Furcation involvement. Open cleanout surgery, SRP, local chemotherapeutics, hemisection, root amputation, extraction and dental implant. o Need for tooth extraction and bone graft for socket preservation. Surgical flap, extraction, bone graft. Anterior cosmetic tissue preservation for pontics, or implants

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4 Periodontal Diagnosis Dr. Marty Nager Diagnosis Clinical Type Treatment Gingivitis Bleeding on Probing I Scale, OHI Inflamed Tissue Mild Periodontitis 1-3 mm Pockets II SRP Moderate Periodontitis 4-6 mm Pockets III SRP Severe Periodontitis 7 mm or more Pockets IV SRP * Gingivitis implies that there is NO bone loss. Pocketing comes from coronal movement of gingival overgrowth or swelling. ** Periodontitis implies bone loss apical to the CEJ. Gingival margin may be swollen or receded. Scaling and Root Planing to be done by quadrant (or half-mouth) with local anesthesia, followed by RE-EVALUATION.

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6 Periodontal Disease: What is it? Who has it? Approximately 75% of all Americans have some form of periodontal disease, known by many as gum disease. These usually painless diseases often can go undetected until it is too late. If left untreated, gum disease can destroy the bone and tissue surrounding the teeth, causing them to become loose and, in some cases, painful. In addition, gum disease can cause bad breath and change the appearance of your smile. If the condition progresses far enough, you can lose your teeth. Common procedures include: gum surgery, bone grafts, gum graft, crown lengthening, and guided tissue regeneration. Periodontal disease (pyorrhea) is an infection that begins in the gingival tissue (gums) and then spreads under the gums into the supporting jaw bone surrounding the tooth. In health, the gum is sealed to the tooth in a fashion similar to the seal between your skin and fingernail. This area is infected daily by plaque (a combination of bacteria and saliva that exists in everyone's mouth). If plaque is allowed to remain, then bacteria breaks down the seal. The infected pocket that results is impossible to keep healthy even with scrupulous care. When the germs remain under the gums, several significant problems occur. There is frequently swelling and bleeding. These bacteria invade the root itself, changing normally glass-like smooth root surfaces to a rough "barnacle-like" one. This infects the gums even further. The plaque itself hardens into a spike-like irritant called calculus or tartar. The most important consequence of this action is further deterioration of the jaw bone around the tooth. Once this bone is lost, it cannot be replaced. Other factors which have a significant effect on the severity of this infection are smoking, diet, stress, grinding and/or clenching of the teeth, general health and resistance, medical problems and hereditary factors. The goal of periodontal treatment is to reestablish the seal of the gum to tooth, creation of a stable bite, and the establishment and maintenance of a healthy mouth. Treatment is usually in two stages. The objective of the first phase is to promote as much healing as possible by cleaning out the infection from under your gums. Before you get involved in the active treatment, we want to be sure that you can properly care for your mouth. We will, therefore, teach you a technique to remove the plaque daily by proper use of floss, brush and rubber tip. Also, we will take a special set of periodontal x-rays to accurately measure the amount of bone support that has been lost.

7 The rough root surface must be smoothed to produce a glass-like surface. This is called root planing. Removal of tartar or calculus is called scaling. The inner lining of the pocket is diseased and must be removed to allow the gums to heal properly. This is called curettage. These procedures do not involve surgery and are done in one-quarter to one-half of the mouth at a time. Novocaine is used so that there is very little (if any) discomfort, usually no more than experienced with a routine filling. When these treatments are completed, the infection should be under control. After this, you can return to your normal activities, including work. We will then carefully reexamine your mouth to evaluate your healing response and determine if any damage to the bone support or gum seals exist. In areas where seals have been reestablished, no further treatment is necessary. Where they have not, they cannot be kept clean and healthy; and we will have to consider the secondary phase of therapy. The objective of this second phase of treatment is to reestablish healthy seals by minor surgical procedures. The surgery is very delicate and done in small areas at a time, in the office, using "Novocaine." You will not feel any discomfort during the procedure, but may be uncomfortable for a few days after. However, this is usually controlled by some mild pain medication that will be prescribed. The exact amount of discomfort you will experience cannot be predicted because everyone is, of course, different. However, we definitely expect that you should be able to carry out your normal activities the following day. If we jointly decide not to go ahead with pocket elimination, any seals which are still open will become reinfected, allowing the disease process and bone loss to continue. In these cases, we usually recommend that the patient return every three months, so a specially-trained hygienist can clean out these infected pockets. This is an attempt to maintain the highest level of health for what we call a "holding period" until the secondary treatment can be initiated. Since essentially we can only repair damage in your mouth and plaque returns daily, our longterm goal is prevention. MAINTENANCE becomes primarily the patient's responsibility and is THE KEY TO LONG-TERM DENTAL HEALTH AND PREVENTION OF DISEASE. No treatment will be started until you understand the problems that exist, how they should be treated and the cost involved. The fee for the initial treatment can usually be accurately predicted at the first appointment. However, because it is impossible to predict one's healing response, it is

8 impossible to predict exactly how much surgical treatment may be needed and the cost involved. This will be done before any additional treatment is initiated. Periodontal therapy can achieve a great deal in prolonging and maintaining the health of your teeth and their supporting tissues (our philosophy of treatment is to inform before we perform). Our goals are to establish health and function and help you maintain it. When your treatment is completed, your mouth should be healthy with all damage repaired. We want you to be able to prevent this sort of problem from returning and retain as many teeth a possible for the rest of your life.

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12 Local Chemotherapeutic Chart Patient Name Chart # Atri Ares Pchp Date Tooth Pocket Bleeding F/U Date Tooth Pocket Bleeding Comments.

13 Local Chemotherapeutic Chart

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15 Question 1 DENTAL EXAMINATION 101 Regular dental visits and cleanings are necessary in order to maintain your: a. teeth b. smile c. chewing d. speaking e. social life f. self image g. healthy body h. all of the above Answer: h. all of the above Untreated gum disease has been linked to heart disease, stroke, preterm low birth weight babies, and diabetes. TIME Magazine listed brushing and flossing as one of the few things you can do to maintain your overall health and live longer. Have You Seen Your Dentist Lately? Brought to you by the Rhode Island Dental Association. We promote quality dental care..ridental.

16 TEN RECOMMENDATIONS FOR PERIODONTAL TREATMENT SUCCESS Marty Nager, DMD 1. ALWAYS PROBE EVERY PATIENT, AT EVERY VISIT. 2. TAKE AN FMX (OR PAN AND BWs) ON EVERY PATIENT AT LEAST ONCE. VERTICAL BWs UPDATED YEARLY. 3. ALWAYS UPDATE AND REVIEW MEDICAL HISTORY: MEDICATIONS, ALLERGIES, HEART MURMUR, ETC. 4. POCKETS GREATER THAN 5mm NEED QUADRANT SCALING AND ROOT PLANING WITH LOCAL ANESTHESIA. 5. ALWAYS RE-EVALUATE PATIENTS PERIODONTIUM AND HOME CARE. 6. PATIENTS WHO NEED SRP NEED 3 MONTH RECALL APPOINTMENTS AND CONTINUING RE-EVALUATION. 7. POCKETING GREATER THAN 5mm MAY NEED POCKET REDUCTION SURGERY TO GAIN ACCESS TO ROOT SURFACES AND BONE. 8. INCREASING RECESSION, BLEEDING, OR FRENUM PULL NEEDS SOFT TISSUE GRAFTING. 9. TEETH WITH LESS THAN 1mm OF ATTACHED GINGIVA MAY NEED SOFT TISSUE GRAFTING. 10. RECORD AND DOCUMENT AREAS OF POCKETING, RECESSION, FURCATIONS, MOBILITY AND ATTACHED GINGIVA TO BE ABLE TO SEE CHANGES OVER TIME (DISEASE PROGRESSION).

17 The Recall/ Maintenance Visit Marty Nager, DMD Update Medical History Changes in Medications? Changes in health? Heart murmur, prosthetic hip, knee? Blood pressure check. Oral cancer screening. Probe patient and record numbers > 3 mm. Check recession and mobility. Review home care with mirror (disclosing solution as needed). Scale, RP (where needed): use topical or dentin block if needed. Polish, floss. Fluoride treatment (as needed). Vertical bitewing radiographs (as needed). Restorative exam; caries exam. Explanation of all findings to the patient by hygienist, Use mirror, models, photos etc. Doctor exam with brief overall summary by hygienist- always saying something good. Note problem areas and treatment needed. Dismiss patient and make next appointment: 6 months for healthy/ gingivitis patients. 3 months for patients who have had SRP.

18 TRUTHS OF GUM DISEASE Gum disease is a silent disease-you can have it and not even know it. It occurs when bacteria get below the gum line, beyond where your toothbrush can reach. If you have gum disease, you can brush and floss all you want, but it will not go away until a dentist or hygienist removes the bacteria from under the gum line. Gum disease is an infection which can be transferable. Risk factors (including smoking and diabetes) make some people more susceptible to gum disease than others. You can clean your teeth twice a day and see your dentist twice a year and still have gum disease. Twice yearly cleanings may remove only the bacteria above the gum line. If you have gum disease, bacteria is getting into your blood stream and traveling throughout your body. Gum disease can double your risk of having a heart attack and other health problems. When you eliminate gum disease, you lower your risk for heart disease, stroke and other health problems.

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20 WHY DO I NEED GUM TREATMENT? During our years of practice experience, we have found it to be in the best interest of our patients if they thoroughly understand their periodontal (gum) problems, treatment and the fees involved. Similar to high blood pressure and high cholesterol, gum disease does not hurt, but needs to be treated. We want you to understand clearly what is involved in the treatment of your problem. Periodontal disease (pyorrhea) is an infection that begins in the gum tissue and then spreads under the gums into the supporting jaw bone surrounding the tooth. Without gum treatment there is continued deterioration of the jaw bone around the teeth. Once this bone is lost, it cannot be replaced. The teeth eventually loosen and will be lost. In health, the gum is sealed to the tooth in a fashion similar to the seal between your skin and fingernail. This area is infected daily by plaque (a combination of bacteria and saliva that exists in everyone's mouth). If plaque is allowed to remain, then bacteria breaks down the seal. The infected pocket that results is too deep and is impossible to keep healthy, even with excellent daily care and regular dental cleanings. We have recommended a series of scaling and root planning appointments (deep cleanings) to try and control your gum disease. This treatment is necessary in order to get below the gum tissue and remove the plaque. These procedures do not involve surgery and are done in one-quarter to one-half of the mouth at a time. Novocain is used so that there is no discomfort, usually no more than experienced with a routine filling. Once the deep cleanings have been completed, you must maintain excellent daily homecare and make a commitment to have your teeth cleaned every 3 months. This is necessary to try to maintain your gums in a healthy manner and have the gum disease not continue to progress. If you choose not to have the deep cleanings, your gum disease will get worse, possibly leading to gum surgery and or tooth loss. Untreated GUM DISEASE has been linked to many diseases in the body including heart attack, stroke, diabetes, low birth weight babies, lung infection, stomach ulcer reinfections and prostate cancer in men. Gum disease does not hurt. You can have it and not even know it. Only a dentist or hygienist can tell if you have gum disease.

21 Local Chemotherapeutic Products There are some new products on the market for the "treatment" of periodontal disease. These products are being heavily marketed by a number of large companies. Many of our patients will be asking about these products. Although we are excited that there is new technology being developed for the treatment of periodontal disease, the majority of research show a small but statistically significant improvement. Although this is may be statistically significant for research, it "may not be clinically significant. Clinically, we can't measure tenths of a millimeter with the probe. Only time will tell how these products will help to maintain the progression of periodontal disease. Actisite is a tetracycline fiber that is placed under the gun tissue to release a high concentration of antibiotic to the specific site. The fiber is used for localized pocketing in isolated areas, usually after gum treatment has been performed and the area is compromised. The fiber is placed around the tooth, held in place with cyanoacrylate and removed seven to ten days later. PerioChip is a resorbable chip that is placed in localized pocketing in isolated areas. It contains chlorhexidine (same as Peridex) which is released over a week's time as the chip dissolves, treating one specific sight (or tooth surface). Atridox is a gel that contains doxycycline (a type of tetracycline). This is squirted into a pocket, and this dissolves over a week s time releasing the antibiotic to the specific site, multiple tooth surfaces, or multiple teeth. Arestin is a Minocycline (a type of tetracycline) powder in the form of microspheres. It is injected into the pocket. This antibiotic treats one specific sight (or tooth surface), and dissolves. Periostat is a pill that is taken twice a day for at least three months, (sometimes six or nine months). This is taken in conjunction with SRP. This pill contains a subantimicrobial dose of Doxycycline, which inhibits collagenase and other enzymes involved with tissue breakdown. It is only 1/5 th the strength of doxycycline and is does not work as an antibiotic. This is available only by prescription. We are trying all of these products in certain patients to see how they work first hand, but unfortunately, a fiber, a gel, a chip, and a pill will not cure periodontal disease. Better yet... try the products yourself and follow-up on how they work in your office. An office study sheet follows.