FAILURES IN PERIODONTAL THERAPY

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FAILURES IN PERIODONTAL THERAPY

• Dr shabeel pn

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Contents

• Introduction
• Classification of failure
• Pre Therapeutic
• Therapeutic
• Post Therapeutic
• Summary Conclusion

Surgical
Non surgical
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INTRODUCTION
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• Dentist related failures
• Patient related failures

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Dentist related failures

• Gathering data
• Improper diagnosis
• Improper investigations
• Inadequate motivation
• Improper treatment sequencing
• Incomplete treatment
• Irregular follow-ups.

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Patient Related Factors

• Maintenance
• Smoking
• Systemic Diseases.
• Poor healing potential.
• Psychological component probably the least
  studied and the most critical aspect in
  periodontics.

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Classification

• Pretherapeutic
• Therapuetic
• Post Therapuetic

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Pretherapeutic

• Incorrect Patient Selection
• Age
• Socio-economic status and nutritional
  deficiencies

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s

• Systemic disease
• Diabetes Mellitus
• Blood Dyscrasias leukemia, Cyclic neutropenia
• Immune deficiences Neutrophil-monocytic
  chemotactic defects,
• AIDS
• Genetic disorders Downs syndrome, Papillion
  Lefevre syndrome,
• hypophosphatasia ,
  Chediak Higashi Syndrome)
• Vitamin deficiences

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Pretherapeutic

• Incomplete diagnostic procedure or misdiagnosis
• 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

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Pretherapeutic

• Morphology of tooth surfaces
• Lateral accessory canals, dev. Grooves,
  resorption lacunae act as Guide planfor
  bacterial penetration..
• Habits
• Occlusal corrections or teeth preparation
  TFOprevent proper adaptive remodelling of
  periodontium

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Therapeutic
Surgical
Non-Surgical
Curettage Gingivectomy Abscess Drainage Flap
Surgery Bone Grafts GTR procedures Root coverage
procedures Implant Aesthetic surgeries
Scaling Root Planing Splinting Occlusal
therapy Local Drug Delivery
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Scaling

• Obviously recognized by remnants of calculus
• Causes
• 1. Incorrect instrumentation Poor
  condition of instruments.
• 2. Burnishing Calculus.
• 3. Induced Bleeding.
• 4. Prescription of Gum paints.
• 5.Assessment of calculus ratio.

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Root Planing

• Rough root surface and persistence of
  inflammation.
• Inadequate RPdetection of caries.
• Over instrumentation..hypersensitivity
• Presence of developmental grooves.Use of rotary
  instruments to smoothen as far as possible

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Splinting

• Failures could be
• Inflammation in the area
• Breaking of splint
• Increased plaque accumulation.

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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

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Occlusal therapy

• Diagnosis of occlusal abnormalities. occlusal
  scheme of pt., plunger cusps, or other occlusal
  Interference.
• Assessment of tooth wear and judgement whether it
  can be corrected by selective grinding or a full
  fledged occlusal rehabilitation procedure is
  needed.
• Fremitus Test.

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Occlusal therapy

• Correction of worn out teeth must be done prior
  to invasive periodontal surgery.
• 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.
• Gross malocclusion must be corrected following
  basic therapy.

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Surgical

• Improper treatment sequencing
• Role of interdisciplinary dentistry is today
  unquestionable and this helps in sequencing
• Not only the removal of primary etiological
  factors is important need to eliminate the
  secondary complicating and confounding factors.
• Malocclusion, occlusal interferences, mild
  mobility, faulty restorations, open contacts, etc
  and so on and so forth.

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• 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 closuredelays healing

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Curettage
Persistence of inflammation after
procedure Causes 1. Diagnosis per se 2.
Procedural errors - instrumentation
- when to stop 3. failure to
irrigatetags of granulation
tissue
4. Suture a curetted area.
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Gingivectomy
Defined by recurrence of lesion either
immediately within a few weeks or by destruction
of the periodontal apparatus.
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• 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

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• 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

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Abscess Drainage

• 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 its a periodontal abscess.

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Flap Surgical Techniques

• Failures could be recurrence of pockets, flabby
  tissue, abscess formation, gingival recession,
  cleft formation, loss of interdental papilla.
• 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.

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Elimination of inflammationRemoval of
depositsimproves 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.
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Regenerative Techniques

• Bone grafting Procedures
• GTR Procedures
• Growth Factor usage

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Bone grafting Procedures

1. Pre-surgical considerations.decision to place a
   bone graft.
2. Assessment of defect morphology interproximal
   well supported 3 or 2 walled defects Furcation
   Involment.
3. Technique of placement increments, compacted not
   condensed. Pore size or distance between
   particles.significant.

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• Maintenance of vascular continuity..
• Alloplasts xenograftsosteoconductive.only act
  as a scaffold.
• Establishment of vascular continuity
• Clot.should preferably arise from
  bone.penetrations of cortical plate is reqd to
  enhance blood flow from marrow..trephinationaid
  in neovascularization.
• Overfilling the defect
• lead to fibrous encapsulation
• of the graft

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Bone grafting Procedures

• Flap margin bleed ..persistent bleeding on
  flap surface results in clot forming from the
  flap involving graft.fibrous encapsulation.
• Postoperative infection control.antibiotics
  antibacterial mouthrinse..
• Graft sterilizationmost commonly overlooked
  aspects
• Primary closure with no intervening graft
  particles.

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GTR Procedures

• Adaptation of membrane.to provide adequate space
  to the periodontal ligament cells to migrate
• Prevention of collapse..use in conjunction with
  bone graft.
• Trimmed membrane..should cover at least 2mm of
  adjacent alveolar bone, no sharp edges
• Membrane exposuretension free flap, bacterial
  accumulation..hampers healing
• Membrane suture sling suture

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Barrier-Independent Factors

• Poor plaque control
• Smoking
• Occlusal trauma
• Sub optimal tissue health (i.e. Inflammation
  persists)
• Mechanical habits (e.g.. Aggressive tooth
  brushing)

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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

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Barrier-Independent Factors

• Post surgical factors
• - premature tissue challenge
• Plaque recolonization
• Mechanical insult
• - Loss of wound stability (loose sutures, loss
  of fibrin clot).

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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.

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Growth factor usage

• Method of draw various techniques blood bank
  draw technique..superior viable platelet conc.
• Shelf life.24 hours, chair side equipment.
• Use of thrombin and its ratioreleased during
  surgery is enough, ratio 17
• Aspiration techniqueplatelets fragile
• When used alone will invariably fail to show
  desired results.
• Prevent standing of PRP.premature bursting

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Root Coverage Procedures

• Rotated flaps
• Soft tissue grafts

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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 .

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• 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

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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.

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Rotated flaps

• 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.
• These procedures show limited success if
  inter-proximal recession is also present.

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Laterally positioned flap

• Common reasons for failure
• Tension. Distal incision
• Pedicle too narrow
• Exposure of bone at radicular surface
• Poor stabilization

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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
  

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Free Soft tissue grafts

• Epithelialized grafts
• Sub-epithelial Connective Tissue Grafts

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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.

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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

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• 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

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Implants

• Inadequate union of bone and implant at the time
  of surgical insertion.
• Improper biomaterials
• Use of dissimilar materials
• 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

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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 failure- bone loss
  
• Motivation reinforcement of OHI.
• Failure to continue with treatmentconscious or
  unconscious decision

PD,tooth loss etc.
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• 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 DEJresistant to
  antibioticsrecurrence.
• Reintroduction..

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• 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

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CONCLUSION
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References

• Dr.Ramaswamy. Causes of failure of periodontal
  treatment. JISP 1995 1923-24.
• Gerald Kramer. Dental failures associated with
  periodontal surgery. DCNA 19721613-31.
• Leon Lefer. Failures in motivation of dental home
  care. DCNA 1972161pg3.
• Bradley RE. Periodontal Failures related to
  improper prognosis treatment planning.DCNA
  197261pg33-43.
• Wang HL, MacNeil RL. GTR. DCNA1998 42509.

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• Recent advances

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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 patients 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

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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 patients 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 patients
  own tissue, in a fashion similar to the bodys
  natural tissue attrition and replacement process.

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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 200576(11)1814-1822.

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• Application of Regenerative Tissue Matrix

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Root Coverage
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Soft Tissue Ridge Augmentation
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Soft Tissue Augmentation Around Dental Implants
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Guided Bone Regeneration
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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 200576(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, DArchivio D, Lisanti L, Di Luccio A
  and Perinetti G. J Periodontol 200273(11)1299-13
  07.
• 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
  200172(8)998-1005.

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• 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 200172(5)571-582.
• Surgical therapies for the treatment of gingival
  recession. A systematic review. Oates TW,
  Robinson M and Gunsolley JC. Ann Periodontol
  20038303-320.
• 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 2002731405-1411.
• 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
  20047544-56.

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Platelet rich Fibrin
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