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Carranza's Clinical Periodontology - E-Book

Carranza's Clinical Periodontology - E-Book

Michael G. Newman | Henry Takei | Perry R. Klokkevold | Fermin A. Carranza


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Book Details


The most widely used periodontics text, Carranza's Clinical Periodontology provides both print and online access to basic procedures as well as the latest in advanced procedures and techniques in reconstructive, esthetic, and implant therapy. Not only does this book show how to do periodontal procedures, it describes how to best manage the outcomes and explains the evidence supporting each treatment. Written by leading experts Michael Newman, Henry Takei, Perry Klokkevold, and Fermin Carranza, along with a pool of international contributors, this edition also discusses the close connection between oral health and systemic disease. A new Expert Consult website includes the entire, fully searchable contents of the book, and takes learning to a whole new level with content updates, videos, a drug database, and much more.

  • Comprehensive coverage describes all aspects of periodontics in a single volume, including periodontal pathology, the etiology of periodontal diseases, the relationship between periodontal disease and systemic health, treatment of periodontal diseases, oral implantology, supportive treatment, and ethics, legal, and practical matters.
  • Problem-solving, scenario-based learning opportunities use well-documented case reports to help you learn both basic and advanced procedures and techniques.
  • 'Speed to competence' is enhanced with access to print, online, and mobile platforms.
  • A unique approach combines evidence-based decision-making, science transfer, and classification/nomenclature throughout every chapter.
  • A one-of-a-kind Genetic Factors and Periodontal Disease chapter examines the role of genetic factors in gum disease.
  • In-depth information serves as an excellent foundation in preparing for the National Board Dental Exam.
  • Coverage of the latest advances includes the emerging link between periodontal disease and systemic health.
  • Full-color illustrations depict the newest developments in surgical technology.
  • A new Multidisciplinary Approach to Dental and Periodontal Problems chapter discusses the importance of collaborative care in the practice of periodontics.
  • Etiology of Periodontal Diseases (Part 4) provides a more comprehensive background in periodontal anatomy, physiology, and pathogenesis.

Table of Contents

Section Title Page Action Price
Front cover cover
Inside front cover ifc1
Carranza's Clinical Periodontology, 12/e i
Copyright page iv
Editors v
Contributors vi
About the Book xv
About The Authors xvi
Preface xviii
Acknowledgments xix
Table of Contents xx
Introduction: 1
Chapter Outline 1
Early Civilizations 1
The Classical World 1
The Middle Ages 1
The Renaissance 1
The Eighteenth Century 3
The Nineteenth Century 3
Necrotizing Ulcerative Gingivitis 5
The Twentieth Century 5
Vienna 5
Berlin 5
The United States and Other Countries 6
Focal Infection 6
Dental Implants 6
After World War II 7
The History of This Book 8
References 8
References 8.e1
1 Biologic Basis of Periodontology 9
I Normal Periodontium 9
1 Anatomy of the Periodontium 9
Chapter Outline 9
Oral Mucosa 9
Gingiva 9
Clinical Features 9
Marginal Gingiva. 9
Gingival Sulcus. 9
Attached Gingiva. 10
Interdental Gingiva. 10
Microscopic Features 10
Gingival Epithelium 11
General Aspects of Gingival Epithelium Biology. 11
Structural and Metabolic Characteristics of Different Areas of Gingival Epithelium. 14
Oral (Outer) Epithelium. 14
Sulcular Epithelium. 14
Junctional Epithelium. 15
Development of Gingival Sulcus. 15
Renewal of Gingival Epithelium. 16
Cuticular Structures on the Tooth. 17
Gingival Fluid (Sulcular Fluid). 17
Gingival Connective Tissue. 17
Gingival Fibers. 17
Cellular Elements. 18
Repair of Gingival Connective Tissue. 18
Blood Supply, Lymphatics, and Nerves. 18
Correlation of Clinical and Microscopic Features 20
Color. 20
Physiologic Pigmentation (Melanin). 20
Size. 20
Contour. 20
Shape. 21
Consistency. 21
Surface Texture. 21
Position. 22
Continuous Tooth Eruption. 22
Periodontal Ligament 23
Periodontal Fibers 23
Cellular Elements 25
Ground Substance 25
Functions of Periodontal Ligament 26
Physical Functions. 26
Resistance to Impact of Occlusal Forces (Shock Absorption). 26
Transmission of Occlusal Forces to Bone. 26
Formative and Remodeling Function. 27
Nutritional and Sensory Functions. 27
Regulation of Periodontal Ligament Width. 28
Cementum 28
Permeability of Cementum 29
Cementoenamel Junction 29
Cementodentinal Junction 29
Thickness of Cementum 29
Cementum Resorption and Repair 30
Ankylosis. 31
Exposure of Cementum to the Oral Environment 31
Alveolar Process 31
Cells and Intercellular Matrix 33
Socket Wall 33
Bone Marrow 34
Periosteum and Endosteum 34
Interdental Septum 35
Osseous Topography 35
Fenestration and Dehiscence 36
Remodeling of Alveolar Bone 36
Development of the Attachment Apparatus 36
Cementum 37
Periodontal Ligament 37
Alveolar Bone 37
Physiologic Migration of the Teeth 37
External Forces and the Periodontium 37
Vascularization of the Supporting Structures 38
References 39
Suggested Readings 39
References 39.e1
2 Aging and the Periodontium 40
Chapter Outline 40
Effects of Aging on the Periodontium 40
Gingival Epithelium 40
Gingival Connective Tissue 40
Periodontal Ligament 42
Cementum 42
Alveolar Bone 42
Bacterial Plaque 42
Immune and Inflammatory Responses 43
Effects of Aging on the Progression of Periodontal Diseases 43
Aging and the Response to Treatment of the Periodontium 43
References 44
Suggested Readings 44
References 44.e1
II Classification and Epidemiology of Periodontal Diseases 45
3 Classification of Diseases and Conditions Affecting the Periodontium 45
Chapter Outline 45
Gingival Diseases 45
Dental-Plaque–Induced Gingival Diseases 45
Gingivitis Associated with Dental Plaque Only. 45
Gingival Diseases Modified by Systemic Factors. 45
Gingival Diseases Modified by Medications. 46
Gingival Diseases Modified by Malnutrition. 47
Non–Plaque-Induced Gingival Lesions 47
Gingival Diseases of Specific Bacterial Origin. 48
Gingival Diseases of Viral Origin. 48
Gingival Diseases of Fungal Origin. 48
Gingival Diseases of Genetic Origin. 49
Gingival Manifestations of Systemic Conditions. 49
Traumatic Lesions. 49
Foreign-Body Reactions. 50
Periodontitis 50
Chronic Periodontitis 52
Aggressive Periodontitis 54
Periodontitis as a Manifestation of Systemic Disease 55
Bisphosphonate-Related Osteonecrosis of the Jaw 59
Necrotizing Periodontal Diseases 60
Necrotizing Ulcerative Gingivitis 61
Necrotizing Ulcerative Periodontitis 61
Abscesses of the Periodontium 61
Periodontitis Associated With Endodontic Lesions 61
Endodontic–Periodontal Lesions 61
Periodontal–Endodontic Lesions 62
Combined Lesions 62
Developmental or Acquired Deformities and Conditions 63
Localized Tooth-Related Factors That Modify or Predispose Individuals to Plaque-Induced Gingival Diseases or Periodontitis 63
Tooth Anatomic Factors. 63
Dental Restorations and Appliances. 63
Root Fractures. 63
Cervical Root Resorption and Cemental Tears. 63
Mucogingival Deformities and Conditions Around the Teeth 63
Mucogingival Deformities and Conditions of the Edentulous Ridges 63
Occlusal Trauma 66
References 67
Suggested Readings 66
References 67.e1
4 Fundamentals in the Methods of Periodontal Disease Epidemiology 68
Chapter Outline 68
The Need For Epidemiology 68
Measuring the Occurrence of Conditions or Diseases 68
Periodontal Conditions Typically Measured Clinically 69
Translating Periodontal Conditions into Traditional Epidemiologic Measures of Disease Occurrence 70
True and Surrogate Measures of the Periodontal Condition 70
Challenges of Obtaining Epidemiologic Measures of Periodontal Conditions and Diseases 70
Epidemiologic Study Designs 71
Randomized Controlled Trials 71
Cohort Studies 72
Case–Control Studies 72
Causes 72
Suspected Modifiable Causative Factors for Periodontal Disease 73
Tobacco Smoking. 73
Nutrition. 73
Dental Plaque. 73
The Cause of Periodontal Disease for the Patient Sitting in Your Chair 74
Diagnosis 74
Periodontal Conditions Versus Periodontal Diseases 74
Diagnostic Tests Available to Assess Periodontal Conditions 74
Translating Periodontal Diagnostic Test Results into Periodontal Disease Diagnosis 74
Normative or Arbitrary Values to Diagnose Periodontal Disease. 74
Risk-Based Reference Values to Diagnose Periodontal Disease. 74
Therapeutic Reference Values to Diagnose Periodontal Disease. 75
Periodontal Disease Diagnoses 75
References 75
Suggested Readings 75
References 75.e1
III Etiology of Periodontal Diseases 76
5 Periodontal Pathogenesis 76
Chapter Outline 76
Histopathology of Periodontal Disease 77
Clinically Healthy Gingival Tissues 77
Histopathology of Gingivitis and Periodontitis 78
The Initial Lesion. 79
The Early Lesion. 79
The Established Lesion. 80
The Advanced Lesion. 80
Inflammatory Responses in the Periodontium 81
Microbial Virulence Factors 81
Lipopolysaccharide. 81
Bacterial Enzymes and Noxious Products. 81
Microbial Invasion. 82
Fimbriae. 82
Bacterial Deoxyribonucleic Acid and Extracellular Deoxyribonucleic Acid. 82
Host-Derived Inflammatory Mediators 83
Cytokines. 83
Prostaglandins. 83
Matrix Metalloproteinases. 83
Role of Specific Inflammatory Mediators in Periodontal Disease 84
Interleukin-1 Family Cytokines. 84
Other Interleukin-1 Family Cytokines. 85
Tumor Necrosis Factor-α. 85
Interleukin-6 and Related Cytokines. 86
Prostaglandin E2. 86
Matrix Metalloproteinases. 86
Chemokines. 87
Anti-inflammatory Cytokines. 87
Linking Pathogenesis to Clinical Signs of Disease 88
Alveolar Bone Resorption 88
Receptor Activator of Nuclear Factor-κβ Ligand and Osteoprotegerin 89
Resolution of Inflammation 89
Lipoxins 89
Resolvins and Protectins 89
Immune Responses in Periodontal Pathogenesis 90
Innate Immunity 90
Saliva. 90
Epithelial Tissues. 91
Gingival Crevicular Fluid. 92
Pathogen Recognition and Activation of Cellular Innate Responses. 92
Neutrophil Function. 92
Adaptive Immunity 94
Antigen-Presenting Cells. 94
T Cells. 95
Antibodies. 97
Concept of Host Susceptibility 97
References 100
Suggested Readings 100
References 100.e1
6 Genetic Susceptibility to Periodontal Disease 101
Chapter Outline 101
Genetic and Genomic Methods of the 21st Century 102
Patterns in Populations and Pedigrees 102
Searching for Answers in the DNA 105
Inherited Variation and Risk of Periodontitis 107
Periodontitis in Genetic Syndromes and Other Diseases 107
Nonsyndromic Aggressive and Chronic Periodontitis 109
Challenges and Opportunities for the Future 112
Using Genetics for Personalized Treatment 113
Pharmacogenomics and Individualized Dentistry 113
Acknowledgments 114
References 115
Suggested Readings 114
References 115.e1
7 The Role of Dental Calculus and Other Local Predisposing Factors 116
Chapter Outline 116
Calculus 116
Supragingival and Subgingival Calculus 116
Prevalence 116
Composition 117
Inorganic Content. 117
Organic Content. 117
Attachment to the Tooth Surface 118
Formation 118
Theories Regarding the Mineralization of Calculus. 120
Role of Microorganisms in the Mineralization of Calculus. 120
Etiologic Significance 120
Materia Alba, Food Debris, and Dental Stains 121
Other Predisposing Factors 121
Iatrogenic Factors 121
Margins of Restorations. 121
Retained Cement/Periimplantitis. 122
Contours/Open Contacts. 123
Materials. 124
Design of Removable Partial Dentures. 124
Restorative Dentistry Procedures. 124
Malocclusion 124
Periodontal Complications Associated with Orthodontic Therapy 125
Plaque Retention and Composition. 126
Gingival Trauma and Alveolar Bone Height. 126
Tissue Response to Orthodontic Forces. 126
Extraction of Impacted Third Molars 127
Habits and Self-Inflicted Injuries 127
Trauma Associated with Oral Jewelry. 128
Toothbrush Trauma. 128
Chemical Irritation. 129
Smokeless Tobacco 129
Radiation Therapy 130
References 131
Suggested Readings 131
References 131.e1
8 Biofilm and Periodontal Microbiology 132
Chapter Outline 132
The Oral Cavity From a Microbe’s Perspective 135
Bacteria and Their Biofilm Mode of Living 138
Structure of a Mature Dental Plaque Biofilm 141
Accumulation of a Dental Plaque Biofilm 144
Formation of the Pellicle. 144
Initial Adhesion/Attachment of Bacteria. 144
Phase 1: Transport to the Surface. 144.e1
Phase 2: Initial Adhesion. 144.e1
Phase 3: Strong Attachment. 144.e1
Colonization and Plaque Maturation. 144
Factors That Affect Supragingival Dental Plaque Formation 145
Topography of Supragingival Plaque. 145
Surface Microroughness. 147
Individual Variables That Influence Plaque Formation. 147
Variation Within the Dentition. 148
Impact of Gingival Inflammation and Saliva. 148
Impact of Patient’s Age. 148
Spontaneous Tooth Cleaning. 148
De Novo Subgingival Plaque Formation 149
Characteristics of Biofilm Bacteria (Life in “Slime City”) 149
Metabolism of Dental Plaque Bacteria 149
Communication Between Biofilm Bacteria 150
Interactions Between Dental Plaque Bacteria 150
Biofilms and Antimicrobial Resistance 151
Bacterial Transmission and Translocation 151
Nonbacterial Inhabitants of the Oral Cavity 152
Viruses 152
Herpesviruses. 152.e1
Papillomaviruses. 152.e1
Picornaviruses/Enteroviruses. 152.e1
Retroviruses. 152.e1
Clinical Manifestations of Oral Viral Diseases 153
Oral Ulcers. 153
Oral Tumors. 153
Other Oral Pathologies. 153
Periodontitis. 153
Yeasts 156
Protozoa 156
Archaea 157
Microbiologic Specificity of Periodontal Diseases 157
Nonspecific Plaque Hypothesis 157
Specific Plaque Hypothesis 157
Ecological Plaque Hypothesis 158
Complicating Factors 158
Criteria for the Identification of Periodontopathogens 157.e1
The Transition From Health to Disease 160
Host Susceptibility 161
Pathogenic Bacteria 161
Beneficial Species 162
Periodontal Health 162
Gingivitis 162
Chronic Periodontitis 163
Localized Aggressive Periodontitis 165
Aggressive Periodontitis 165
Necrotizing Periodontal Diseases 166
Abscesses of the Periodontium 166
Periimplantitis 167
Virulence Factors of Periodontopathogens 167
Adhesive Surface Proteins and Fibrils 167
Tissue-Destruction–Promoting Factors 167
Strategies for Evading Host Immunity 168
Future Advances in Periodontal Microbiology 168
References 169
Suggested Readings 169
References 169.e1
9 Molecular Biology of Host-Microbe Interactions 170
Chapter Outline 170
Innate Immunity in Periodontal Diseases 171
Vigilance and Tolerance 171
Defensins. 174.e1
Cell Signaling Pathways and the Expression of Biologically Active Mediators in the Innate Immune Response 174
Inflammasomes. 174.e3
Complement Systems. 174.e4
Adaptive Immunity in Periodontal Diseases 174
Activation of Adaptive Immunity in Periodontal Diseases 174
Host–Microbe Interactions in Adaptive Immunity 174.e6
Pathobiology of Periodontal Disease Progression 174
Cytokines and Mediators of Inflammation 174
Cell Signaling Events That Modulate Inflammatory Mediator Expression 176
Therapeutic Strategies for Disrupting Host-Cell Signaling in the Treatment of Periodontal Diseases 177
References 177
Suggested Readings 177
References 177.e1
10 Smoking and Periodontal Disease 178
Chapter Outline 178
The Smoking Epidemic 178
Effects of Smoking on the Prevalence and Severity of Periodontal Diseases 179
Gingivitis 179
Periodontitis 179
Effects of Smoking on the Etiology and Pathogenesis of Periodontal Disease 180
Microbiology 180
Immune–Inflammatory Responses 182
Physiology 183
Effects of Smoking on Response to Periodontal Therapy 183
Nonsurgical Therapy 183
Surgical Therapy and Implants 184
Maintenance Therapy 184
Effects of Smoking Cessation on Periodontal Treatment Outcomes 184
References 185
Suggested Readings 185
References 185.e1
IV Relationship Between Periodontal Disease and Systemic Health 186
11 Influence of Systemic Conditions 186
Chapter Outline 186
Endocrine Disorders and Hormonal Changes 186
Diabetes Mellitus 186
Oral Manifestations. 187
Bacterial Pathogens. 188
Polymorphonuclear Leukocyte Function. 188
Altered Collagen Metabolism. 189
Female Sex Hormones 189
Puberty. 189.e1
Menstruation. 189.e1
Pregnancy. 189.e1
Hormonal Contraceptives. 189.e2
Menopause. 189.e2
Hyperparathyroidism 189.e2
Hematologic Disorders and Immune Deficiencies 190
Leukocyte (Neutrophil) Disorders 191
Neutropenia. 191
Agranulocytosis. 191
Leukemia 191
The Periodontium in Leukemic Patients. 192
Leukemic Infiltration. 192
Bleeding. 192
Oral Ulceration and Infection. 194
Anemia 189.e3
Thrombocytopenia 189.e4
Antibody Deficiency Disorders 189.e4
Genetic Disorders 195
Chédiak–Higashi Syndrome 195.e1
Lazy Leukocyte Syndrome 195.e1
Leukocyte Adhesion Deficiency 195.e1
Papillon–Lefèvre Syndrome 195.e1
Down Syndrome 195.e2
Stress and Psychosomatic Disorders 195
Psychosocial Stress, Depression, and Coping 195
Stress-Induced Immunosuppression 196
Influence of Stress on Periodontal Therapy Outcomes 196
Psychiatric Influence of Self-Inflicted Injury 197
Nutritional Influences 197
Fat-Soluble Vitamin Deficiency 197.e1
Vitamin A Deficiency. 197.e1
Vitamin D Deficiency. 197.e1
Vitamin E Deficiency. 197.e1
Water-Soluble Vitamin Deficiency 197.e1
B-Complex Deficiency. 197.e1
Vitamin C (Ascorbic Acid) Deficiency. 197.e2
Possible Etiologic Factors. 197.e2
Epidemiologic Studies. 197.e2
Gingivitis. 197.e2
Periodontitis. 197.e2
Summary. 197.e3
Protein Deficiency 197.e3
Medications 197
Bisphosphonates 197
Bisphosphonates and Periodontal Bone Loss 200
Corticosteroids 200
Other Systemic Conditions 197.e3
Osteoporosis 197.e3
Congenital Heart Disease 197.e4
Tetralogy of Fallot. 197.e5
Eisenmenger’s Syndrome. 197.e5
Hypophosphatasia 197.e5
Metal Intoxication 197.e5
Bismuth Intoxication. 197.e5
Lead Intoxication. 197.e5
Mercury Intoxication. 197.e5
Other Chemicals. 197.e6
References 201
Suggested Reading 201
References 201.e1
12 Impact of Periodontal Infection on Systemic Health 202
Chapter Outline 202
Pathobiology of Periodontitis 202
Focal Infection Theory Revisited 203
Evidence-Based Clinical Practice 203
Subgingival Environment as a Reservoir for Bacteria 204
Periodontal Disease and Mortality 204
Periodontal Disease and Coronary Heart Disease/Atherosclerosis 205
Effect of Periodontal Infection 206
Ischemic Heart Disease. 206
Systemic Infections. 206
Daily Activity. 207
Thrombogenesis. 207
Atherosclerosis. 207
Role of Periodontal Disease in Myocardial or Cerebral Infarction 208
Role of Periodontal Disease in Erectile Dysfunction 209
Periodontal Disease and Stroke 209
Periodontal Infection Associated with Stroke 209
Periodontal Disease and Diabetes Mellitus 210
Periodontal Infection Associated with Glycemic Control in Diabetes 211
Periodontal Disease and Pregnancy Outcome 202.e1
Bacterial Vaginosis 202.e1
Role of Periodontitis 202.e2
Periodontal Disease and Chronic Obstructive Pulmonary Disease 202.e3
Periodontal Disease and Acute Respiratory Infections 202.e4
Periodontal Medicine in Clinical Practice 211
Periodontal Disease and Systemic Health 212
Patient Education 212
Conclusions 212
References 213
Suggested Reading 213
References 213.e1
V Gingival Pathology 214
13 Defense Mechanisms of the Gingiva 214
Chapter Outline 214
Sulcular Fluid 214
Methods of Collection 214
Permeability of Junctional and Sulcular Epithelia 214
Amount 215
Composition 215
Cellular Elements. 215
Electrolytes. 215
Organic Compounds. 215
Cellular and Humoral Activity in Gingival Crevicular Fluid 216
Clinical Significance 216
Circadian Periodicity. 216
Sex Hormones. 216
Mechanical Stimulation. 216
Smoking. 216
Periodontal Therapy. 216
Drugs in Gingival Crevicular Fluid 216
Leukocytes in the Dentogingival Area 216
Saliva 217
Antibacterial Factors 217
Salivary Antibodies 217
Enzymes 217
Salivary Buffers and Coagulation Factors 218
Leukocytes 218
Role in Periodontal Pathology 218
References 218
Suggested Readings 218
References 218.e1
14 Gingival Inflammation 219
Chapter Outline 219
Stage I Gingival Inflammation: The Initial Lesion 219
Stage II Gingival Inflammation: The Early Lesion 220
Stage III Gingival Inflammation: The Established Lesion 220
Stage IV Gingival Inflammation: The Advanced Lesion 223
References 223
Suggested Readings 223
References 223.e1
15 Clinical Features of Gingivitis 224
Chapter Outline 224
Course and Duration 224
Description 224
Clinical Findings 224
Gingival Bleeding on Probing 225
Gingival Bleeding Caused by Local Factors 226
Chronic and Recurrent Bleeding. 226
Gingival Bleeding Associated with Systemic Changes 227
Color Changes in the Gingiva 227
Color Changes with Gingivitis. 227
Metallic Pigmentation. 227
Color Changes Associated with Systemic Factors 228
Changes in the Consistency of the Gingiva 228
Calcified Masses in the Gingiva. 228
Toothbrushing. 229
Changes in the Surface Texture of the Gingiva 229
Changes in the Position of the Gingiva 229
Traumatic Lesions. 229
Gingival Recession. 229
Positions of the Gingiva. 229
Clinical Significance. 230
Changes in Gingival Contour 230
References 231
Suggested Readings 230
References 231.e1
16 Gingival Enlargement 232
Chapter Outline 232
Inflammatory Enlargement 232
Chronic Inflammatory Enlargement 232
Clinical Features. 232
2 Clinical Periodontics 357
I Diagnosis, Prognosis, and Treatment Plan 357
29 Clinical Diagnosis 357
Chapter Outline 357
First Visit 357
Overall Appraisal of the Patient 357
Medical History 357
Dental History 358
Current Illness. 358
Intraoral Radiographic Survey 361
Casts 361
Clinical Photographs 362
Review of the Initial Examination 362
Second Visit 362
Oral Examination 362
Oral Hygiene. 362
Oral Malodor. 362
Examination of the Oral Cavity. 362
Examination of the Lymph Nodes. 362
Examination of the Teeth and Implants 362
Wasting Disease of the Teeth. 362
Dental Stains. 363
Hypersensitivity. 363
Proximal Contact Relations. 363
Tooth Mobility. 364
Trauma from Occlusion. 365
Pathologic Migration of the Teeth. 365
Sensitivity to Percussion. 365
Dentition With the Jaws Closed. 365
Functional Occlusal Relationships. 366
Examination of the Periodontium 366
Plaque and Calculus. 366
Gingiva. 366
Use of Clinical Indices in Dental Practice. 366
Periodontal Pockets. 366
Signs and Symptoms. 366
Detection of Pockets. 366
Pocket Probing. 366
Probing Technique. 369
Level of Attachment Versus Pocket Depth. 370
Determining the Level of Attachment. 370
Bleeding on Probing. 370
When to Probe. 370
Probing Around Implants. 370
Automatic and Electronic Periodontal Probing. 370
Probing Force. 370
Probe Angulation. 370
Determination of Disease Activity. 371
Amount of Attached Gingiva. 371
Degree of Gingival Recession. 372
Alveolar Bone Loss. 372
Palpation. 373
Suppuration. 373
Periodontal Abscess. 373
Periodontal Abscess and Gingival Abscess. 374
Periodontal Abscess and Periapical Abscess. 374
Laboratory Aids to Clinical Diagnosis 374
References 374
Suggested Readings 374
References 374.e1
30 Significance of Clinical and Biologic Information 375
Chapter Outline 375
Tangible versus Intangible Benefits 375
Size of the Treatment Effect 375
Defining Four Levels of Clinical Significance 376
Clinical Significance Level 1 376
Clinical Significance Level 2 376
Clinical Significance Level 3 377
Clinical Significance Level 4 377
Conclusion 377
References 377
Suggested Readings 377
References 377.e1
31 Radiographic Aids in the Diagnosis of Periodontal Disease 378
Chapter Outline 378
Normal Interdental Bone 378
Radiographic Techniques 378
Bone Destruction in Periodontal Disease 378
Bone Loss 379
Amount. 379
Distribution. 379
Pattern of Bone Destruction 379
Radiographic Appearance of Periodontal Disease 380
Periodontitis 380
Interdental Craters 382
Furcation Involvement 383
Periodontal Abscess 383
Clinical Probing 383
Localized Aggressive Periodontitis 385
Trauma from Occlusion 385
Digital Intraoral Radiography 386
Advanced Imaging Modalities 387
Conclusion 387
References 390
Suggested Readings 390
References 390.e1
32 Clinical Risk Assessment 391
Chapter Outline 391
Definitions 391
Risk Factors for Periodontal Disease 391
Tobacco Smoking 391
Diabetes 391
Pathogenic Bacteria and Microbial Tooth Deposits 391
Risk Determinants/Background Characteristics for Periodontal Disease 392
Genetic Factors 392
Age 392
Gender 392
Socioeconomic Status 393
Stress 393
Risk Indicators for Periodontal Disease 393.e1
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome 393.e1
Osteoporosis 393.e1
Infrequent Dental Visits 393.e1
Risk Markers/Predictors for Periodontal Disease 393.e1
Previous History of Periodontal Disease 393.e1
Bleeding on Probing 393.e1
Clinical Risk Assessment for Periodontal Disease 393.e1
Conclusion 393
References 393
Suggested Readings 393
References 393.e4
33 Determination of Prognosis 394
Chapter Outline 394
Definitions 394
Types of Prognosis 394
Overall Versus Individual Tooth Prognosis 395
Factors in Determination of Prognosis 395
Overall Clinical Factors 395
Patient Age. 395
Disease Severity. 395
Plaque Control. 396
Patient Compliance and Cooperation. 396
Systemic and Environmental Factors 396
Smoking. 396
Systemic Disease or Condition. 396
Genetic Factors. 397
Stress. 398
Local Factors 398
Plaque and Calculus. 398
Subgingival Restorations. 398
Anatomic Factors. 398
Tooth Mobility. 400
Prosthetic and Restorative Factors 400
Caries, Nonvital Teeth, and Root Resorption. 401
Relationship Between Diagnosis and Prognosis 401
Prognosis for Patients with Gingival Disease 401
Dental Plaque–Induced Gingival Diseases 401
Gingivitis Associated with Dental Plaque Only. 401
Plaque-Induced Gingival Diseases Modified by Systemic Factors. 401
Plaque-Induced Gingival Diseases Modified by Medications. 401
Gingival Diseases Modified by Malnutrition. 401
Non–Plaque-Induced Gingival Lesions. 401
Prognosis for Patients with Periodontitis 401
Chronic Periodontitis. 401
Aggressive Periodontitis. 402
Periodontitis as Manifestation of Systemic Diseases. 402
Necrotizing Periodontal Diseases. 402
Reevaluation of Prognosis After Phase I Therapy 403
References 403
Suggested Readings 403
References 403.e1
34 Rationale for Periodontal Treatment 404
Chapter Outline 404
What Does Periodontal Therapy Accomplish? 404
Local Therapy 404
Systemic Therapy 404
Factors That Affect Healing 404
Local Factors 404
Systemic Factors 405
Healing After Periodontal Therapy 405
Regeneration 406
Repair 406
New Attachment 406
Periodontal Reconstruction 407
References 407
Suggested Readings 407
References 407.e1
35 The Treatment Plan 408
Chapter Outline 408
Master Plan for Total Treatment 408
Extracting or Preserving a Tooth 408
Sequence of Therapeutic Procedures 409
Explaining Treatment Plan to the Patient 410
II Management of Patients with Special Needs 411
36 Conscious Sedation 411
Chapter Outline 411
Rationale for Sedation During Periodontal and Implant Surgical Procedures 411
ADA Policy Statement and Guidelines for Conscious Sedation 411
ADA Policy Statement: The Use of Sedation and General Anesthesia by Dentists 411
ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists 412
Definitions and Levels of Sedation 412
Pediatric Sedation 412
Adult Sedation 412
Minimal Sedation. 412
Maximum Recommended Dose. 413
Incremental Dosing. 413
Supplemental Dosing. 413
Moderate Sedation. 413
Titration. 414
Deep Sedation. 414
General Anesthesia. 414
Clinical Guidelines for Minimal and Moderate Sedation 414
Patient Evaluation. 414
Preoperative Preparation. 414
Personnel and Equipment. 415
Monitoring. 415
Documentation. 418
Recovery and Discharge. 418
Mild Sedation/Anxiolysis 411.e1
Oral Sedation 411.e1
Guidelines for Mild Sedation with Oral Medications. 411.e1
Inhalation Sedation 411.e4
Induction Phase. 411.e4
Treatment Phase. 411.e4
Recovery Phase. 411.e4
Moderate (Conscious) Sedation 411.e5
Oral Sedation 411.e5
Combined Oral and Inhalation Sedation 411.e5
Intravenous Sedation 411.e5
Single Benzodiazepine Intravenous Sedation Techniques 411.e5
Midazolam Technique. 411.e5
Diazepam Technique. 411.e5
Combination Intravenous Sedation. 411.e6
Meperidine Combined with Diazepam or Midazolam. 411.e6
Fentanyl Combined with Midazolam. 411.e6
Combined Oral and Intravenous Sedation 411.e6
Rationale for Technique. 411.e6
Sedation Failures 418
Emergency Preparedness 419
Conclusion 419
References 419
Suggested Readings 419
References 419.e1
37 Periodontal Treatment of Medically Compromised Patients 420
Chapter Outline 420
Cardiovascular Diseases 420
Hypertension 420
Ischemic Heart Diseases 422
Congestive Heart Failure 423
Cardiac Pacemakers and Implantable Cardioverter-Defibrillators 423
Infective Endocarditis 423
Cerebrovascular Accident 425
Endocrine Disorders 425
Diabetes 425
Thyroid and Parathyroid Disorders 420.e1
Adrenal Insufficiency 420.e1
Hemorrhagic Disorders 428
Coagulation Disorders 428
Anticoagulant Medications. 430
Antiplatelet Medications. 430
Thrombocytopenic Purpuras 420.e2
Nonthrombocytopenic Purpuras 420.e2
Blood Dyscrasias 420.e2
Leukemia 431
Agranulocytosis 431
Renal Diseases 420.e2
Liver Diseases 420.e3
Pulmonary Diseases 420.e3
Medications and Cancer Therapies 431
Bisphosphonates 431
Anticoagulant/Antiplatelet Therapy 432
Corticosteroids 432
Immunosuppression and Chemotherapy 433
Radiation Therapy 433
Prosthetic Joint Replacement 435
Recommendation 1. 435
Recommendation 2. 435
Recommendation 3. 435
Pregnancy 420.e3
Infectious Diseases 420.e4
Hepatitis 420.e4
HIV and AIDS 420.e5
Tuberculosis 420.e6
References 436
Suggested Readings 436
References 436.e1
38 Periodontal Therapy in the Female Patient 437
Chapter Outline 437
Puberty 437
Management 437
Menses 438
Periodontal Manifestations 438
Management 439
Pregnancy 439
Periodontal Manifestations 439
Role of Pregnancy Hormones 440
Subgingival Plaque Composition. 440
Periodontal Disease and Preterm, Low-Birth-Weight Infant. 440
Preeclampsia. 441
Maternal Immunoresponse 441
Other Oral Manifestations of Pregnancy 442
Clinical Management 442
Plaque Control. 442
Prenatal Fluoride. 442
Treatment 442
Elective Dental Treatment. 442
Dental Radiographs. 442
Medications. 443
Breastfeeding. 443
Oral Contraceptives 445
Management 445
Menopause 437.e1
Oral Changes 437.e1
Clinical Management 437.e1
Conclusion 445
References 446
Suggested Readings 446
References 446.e1
39 Periodontal Treatment for Older Adults 447
Chapter Outline 447
The Aging Periodontium 447
Intrinsic Changes 447
Stochastic Changes 447
Physiologic Changes 447
Functional Changes 448
Clinical Changes 448
Demographics 447.e1
Population Distribution 447.e1
Health Status 447.e1
Functional Status 447.e2
Nutritional Status 447.e2
Psychosocial Factors 447.e3
Dentate Status 447.e4
Periodontal Status 447.e5
Caries Status 447.e5
Dental Visits 447.e6
Xerostomia 447.e7
Candidiasis 447.e7
Dental and Medical Assessments 447.e7
Review of Dental History 447.e7
Review of Medical History 447.e7
Review of Medication Use 447.e8
Extraoral and Intraoral Examinations 447.e8
Assessment of Risk 447.e9
Quality of Life 447.e9
Periodontal Diseases in Older Adults 448
Etiology 448
Relationship to Systemic Disease 448
Periodontal Treatment Planning 449
Prevention of Periodontal Disease and Maintenance of Periodontal Health in Older Adults 449
Chemotherapeutic Agents 449
Antiplaque Agents. 449
Fluoride. 450
Saliva Substitutes. 450
Risk Reduction 450.e1
Conclusion 450
References 450
Suggested Readings 450
References 450.e2
40 Treatment of Aggressive and Atypical Forms of Periodontitis 451
Chapter Outline 451
Aggressive Periodontitis 451
Therapeutic Modalities 451
Conventional Periodontal Therapy. 452
Surgical Resective Therapy. 452
Regenerative Therapy. 452
Antimicrobial Therapy. 452
Microbial Testing. 456
Local Delivery. 457
Full-Mouth Disinfection. 457
Host Modulation. 458
Treatment Planning and Restorative Considerations 458
Use of Dental Implants. 458
Clinical Consideration. 458
Periodontal Maintenance 458
Periodontitis Refractory to Treatment 459.e1
Necrotizing Ulcerative Periodontitis 459
References 459
Suggested Readings 459
References 459.e3
III Diagnosis and Treatment of Periodontal Emergencies 460
41 Treatment of Acute Gingival Disease 460
Chapter Outline 460
Acute Necrotizing Ulcerative Gingivitis 460
First Visit 460
Instructions to the Patient. 461
Second Visit 461
Third Visit 461
Gingival Changes with Healing 462
Additional Treatment Considerations 462
Contouring of Gingiva as Adjunctive Procedure. 462
Role of Drugs. 462
Persistent or Recurrent Cases 462
Acute Pericoronitis 463
Acute Herpetic Gingivostomatitis 463
References 464
Suggested Readings 464
References 464.e1
42 Treatment of Periodontal Abscess 465
Chapter Outline 465
Classification of Abscesses 465
Periodontal Abscess 465
Gingival Abscess 465
Pericoronal Abscess 465
Acute Versus Chronic Abscess 465
Periodontal Versus Pulpal Abscess 465
Specific Treatment Approaches 465
Acute Abscess 465
Drainage through Periodontal Pocket. 465
Drainage through External Incision. 467
Chronic Abscess 468
Gingival Abscess 468
Pericoronal Abscess 468
References 469
Suggested Readings 469
References 469.e1
43 Diagnosis and Management of Endodontic-Periodontic Lesions 470
Chapter Outline 470
Anatomic Considerations of the Pulpal and Periodontal Continuum 470
Factors Initiating Pulpal and Apical Diseases 472
Classification of Pulpal and Apical Diseases 472
Biologic Effects of Pulpal Infection on Periodontal Tissues 472
Biologic Effects of Periodontal Infection on the Dental Pulp 475
Differential Diagnosis of Pulpal and Periodontal Infection 475
Patients’ Subjective Symptoms 476
Coronal Integrity 476
Radiographic Appearance 477
Vitality 477
Treatment Considerations of Endodontic-Periodontic Lesions 477
Effect on the Periodontium of Endodontic Procedural Complications and Dental Anomalies 478
Perforations 478.e1
Tooth Fractures 478.e1
Crown-Root Fractures. 478.e1
Horizontal Root Fractures. 478.e2
Horizontal Fractures in the Coronal Area. 478.e2
Horizontal Fractures in the Midroot Area. 478.e2
Horizontal Fractures in the Apical Area. 478.e3
Vertical Root Fractures. 478.e3
Definition. 478.e3
Incidence. 478.e3
Clinical Findings. 478.e4
Sodium Hypochlorite Accident 478.e5
Resorptive Defects 478.e5
Dental Anomalies 478.e6
Dens Invaginatus. 478.e6
Dens Evaginatus. 478.e7
Lingual Groove. 478.e7
Ultrasonic Devices 478.e7
Conclusion 479
References 479
Suggested Readings 479
References 479.e1
IV Non-Surgical Treatment 480
44 Phase I Periodontal Therapy 480
Chapter Outline 480
Rationale 480
Treatment Sessions 480
Sequence of Procedures 481
Step 1: Plaque Biofilm Control Instruction. 481
Step 2. Removal of Supragingival and Subgingival Plaque Biofilm and Calculus. 481
Step 3. Recontouring Defective Restorations and Crowns. 482
Step 4. Management of Carious Lesions. 482
Step 5. Tissue Reevaluation. 482
Results 482
Healing 482
Decision to Refer for Specialist Treatment 482
Conclusion 483
References 484
Suggested Readings 484
References 484.e1
45 Plaque Biofilm Control for the Periodontal Patient 485
Chapter Outline 485
The Toothbrush 485
Toothbrush Design 486
3 Oral Implantology 684
I Biology, Diagnosis, Biomechanics and Treatment Plan 684
71 Periimplant Anatomy, Biology, and Function 684
Chapter Outline 684
Implant Geometry (Macrodesign) 684
Endosseous Implants 684.e1
Blade Implants. 684.e1
Pins. 684.e1
Disk Implants. 684.e1
Root Form (Cylindrical) Implants 684.e1
Transmandibular Implants 684.e2
Subperiosteal Implants 684.e2
Implant Surface Characteristics (Microdesign) 684.e2
Additive Processes 684.e3
Subtractive Processes 684.e4
Implant Surface Chemical Composition 684.e4
Implant Surface Free Energy and Micro-Roughness 684.e5
Hard Tissue Interface 685
Initial Bone Healing 685
Bone Remodeling and Function 686
Soft Tissue Interface 686
Epithelium 687
Connective Tissue 689
Keratinized Tissue 689
Vascular Supply and Inflammation 690
Clinical Comparison of Teeth and Implants 691
Conclusion 692
References 692
Suggested Readings 692
References 692.e1
72 Clinical Evaluation of the Implant Patient 693
Chapter Outline 693
Case Types and Indications 693
Edentulous Patients 693
Partially Edentulous Patients 694
Multiple Teeth. 694
Single Tooth. 696
Esthetic Considerations. 696
Pretreatment Evaluation 696
Chief Complaint 697
Medical History 697
Dental History 697
Intraoral Examination 698
Diagnostic Study Models. 698
Hard Tissue Evaluation. 698
Radiographic Examination. 699
Soft Tissue Evaluation. 699
Risk Factors and Contraindications 699
Medical and Systemic Health–Related Issues 699
Diabetes Mellitus. 699
Bone Metabolic Disease. 699
Medications. 701
Immune Compromise and Immune Suppression. 703
Radiation Therapy. 703
Psychologic and Mental Conditions 704
Habits and Behavioral Considerations 704
Smoking and Tobacco Use. 704
Parafunctional Habits. 704
Substance Abuse. 704
Posttreatment Evaluation 704
Conclusion 704
References 705
Suggested Readings 704
References 705.e1
73 Diagnostic Imaging for the Implant Patient 706
Chapter Outline 706
Standard Projections 706
Periapical Radiographs 706
Occlusal Radiographs 706
Panoramic Radiographs 707
Lateral Cephalometric Radiographs 708
Cross-Sectional Imaging 708
Multislice Computed Tomography 708
Cone-Beam Computed Tomography 709
Interactive “Simulation” Software Programs 710
Patient Evaluation 710
Exclude Pathology 710
Identify Anatomic Structures 710
Assess Bone Quantity, Quality, and Volume 710
Evaluate Relation of Alveolar Ridge with Existing Teeth and Desired Implant Position 717
Clinical Selection of Diagnostic Imaging 719
Clinical Examination 719
Screening Radiographs 719
Fabrication of Radiographic and Surgical Guides 719
Cross-Sectional Tomography 719
Intraoperative and Postoperative Radiographic Assessment 719
Conclusion 720
References 722
Suggested Reading 722
References 722.e1
74 Biomechanics, Prosthetic Considerations, and Treatment Planning 723
Chapter Outline 723
Biomechanical Considerations 723
Load-Bearing Capacity 723
Angulation and Arrangement 724
Treatment Planning With Dental Implants 726
Edentulous Maxilla 726.e1
Edentulous Mandible 726.e2
Partially Edentulous Patients 726
Multiple-Tooth Sites. 726
Single-Tooth Sites. 726
Strategies to Avoid Implant Overload 728
Occlusal Design 728
Cantilevers 728
Connecting Implants to Teeth 728
Conclusion 728
References 729
Suggested Readings 728
References 729.e1
II Surgical Procedures 730
75 Basic Implant Surgical Procedures 730
Chapter Outline 730
General Principles of Implant Surgery 730
Patient Preparation 730
Implant Site Preparation 730
One-Stage Versus Two-Stage Implant Placement Surgery 731
Two-Stage “Submerged” Implant Placement 731
Flap Design, Incisions, and Elevation 731
Implant Site Preparation 732
Round Bur. 732
The 2-mm Twist Drill. 732
Pilot Drill. 732
The 3-mm Twist Drill. 732
Countersink Drill (Optional). 732
Bone Tap (Optional). 733
Implant Placement. 735
Flap Closure and Suturing 735
Postoperative Care 735
Second-Stage Exposure Surgery 736
Simple Circular “Punch” or Crestal Incision. 736
Partial-Thickness Repositioned Flap. 736
Postoperative Care. 737
One-Stage “Nonsubmerged” Implant Placement 737
Flap Design, Incisions, and Elevation 737
Implant Site Preparation 738
Flap Closure and Suturing 738
Postoperative Care 738
Conclusion 738
References 738
Suggested Readings 738
References 738.e1
76 Localized Bone Augmentation and Implant Site Development 739
Chapter Outline 739
Guided Bone Regeneration 739.e1
Barrier Membranes 739.e1
Nonresorbable Barrier Membranes. 739.e1
Resorbable Barrier Membranes. 739.e2
Bone Graft Materials 739.e2
Autogenous Bone 739.e2
Localized Ridge Augmentation 739
Flap Management 739
Horizontal Bone Augmentation 740
Particulate Bone Graft. 740
Monocortical Block Graft. 740
Procedure. 740
Simultaneous Implant Placement 743
Complications 746
Alveolar Ridge Preservation/Management of Extractions 746
Delayed Implant Placement 746
Staged Implant Placement 747
Delayed Versus Staged Technique 747
Immediate Implant Placement 747
Conclusion 749
References 749
Suggested Readings 749
References 749.e1
77 Advanced Implant Surgical Procedures 750
Chapter Outline 750
Maxillary Sinus Elevation and Bone Augmentation 750
Indications and Contraindications 750
Surgical Procedures for Sinus Elevation 751
Presurgical Evaluation of Maxillary Sinus. 751
Simultaneous Implant Placement. 751
Bone Graft Materials. 751
Crestal Osteotomy Technique. 754
Procedure. 754
Lateral Window Technique. 755
Risks and Complications 756
Supracrestal/Vertical Bone Augmentation 756
Guided Bone Regeneration and Augmentation 756
Distraction Osteogenesis 758
Growth Factors in Bone Augmentation 758
Bone Morphogenetic Proteins 758
Autologous Platelet Concentration 762
Conclusion 762
References 763
Suggested Readings 763
References 763.e1
78 Esthetic Management of Difficult Cases (Minimally Invasive Approach) 764
Chapter Outline 764
Surgical Strategy for Predictable Esthetics 765
Determine the Level of Surgical Esthetic Goal 765.e1
Visualize the Final Outcome 765.e1
Preserve Existing Tissues Important for Esthetics 765.e1
Always Overbuild Bone and Soft Tissue in Augmentation Surgeries 765.e1
Immediate Implant Placement for Predictability and Esthetics 765
Surgical Management of Difficult Cases (Minimally Invasive Approach) 766
Components of Esthetic Examination 766
Case Presentation 1 766
Patient Dental History and Chief Complaint. 766
Examination and Diagnosis. 767
Treatment Objectives. 767
Treatment Options. 767
Surgical Strategy for Predictable Esthetics. 767
Treatment Plan and Rationale. 769
Treatment Sequence. 769
Surgical Procedure. 769
Results. 769
Case Presentation 769.e1
Dental History and Chief Complaint. 769.e1
Examination and Diagnosis. 769.e1
Treatment Objectives. 769.e2
Treatment Options 769.e2
Surgical Strategy for Predictable Esthetics. 769.e3
Treatment Plan and Rationale. 769.e3
Treatment Sequence. 769.e3
Surgical Procedure. 769.e3
Results. 769.e4
Case Presentation 3 769.e4
Dental History and Chief Complaint. 769.e4
Examination and Diagnosis. 769.e4
Treatment Objectives. 769.e6
Treatment Options 769.e6
Treatment Plan and Rationale. 769.e6
Treatment Sequence. 769.e6
Surgical Procedure. 769.e6
Results. 769.e6
Conclusion 769
References 769
Suggested Readings 769
References 769.e8
79 Technologic Advances in Implant Surgery: 770
Chapter Outline 770
Implant Microsurgery 770
Microsurgical Tooth Extraction 770
Implant Drilling in the Extraction Site 770
Bone Grafting 771
Buccal Gingival Grafting 772
Immediate Provisional Fabrication 772
Immediate Implant Occlusion 773
Custom Impression Transfer Coping 773
Final Implant Restoration 773
Conclusion 774
References 775
Suggested Readings 775
References 775.e1
80 Technologic Advances in Implant Surgery: 776
Chapter Outline 776
Clinical Characteristics of Ultrasonic Cutting 776
Microprecision 776
Selective Cutting 777
Maximum Visibility 777
Excellent Healing 777
Clinical Applications 777
Periodontal Surgery 777
Crown Lengthening 777
Tooth Extraction Techniques 779
Simplified Tooth Extraction. 781
Implant Site Preparation 781
Advanced Clinical Applications 776.e1
Sinus Lift 776.e1
Ridge Expansion 776.e1
Bone Harvesting 776.e1
Particulate Bone Chip Harvesting Technique. 776.e1
Clinical Note. 776.e3
Block Harvesting Technique. 776.e3
Conclusion 784
References 785
Suggested Readings 785
References 785.e1
81 Technologic Advances in Implant Surgery: 786
Chapter Outline 786
Computer-Assisted Implant Surgery 786
Uses and Requirements 786
Sequence of Steps 787
Data Acquisition 787
CAIS CT-Based Technology. 787
CAIS Immediate Mapping. 787
Identification and Registration 787
Navigation and Positional Tracking 788
External Viewer, Augmented Reality, and 3D Projection Screens 788
Advantages and Disadvantages 790
Conclusion 790
References 791
Suggested Readings 791
References 791.e1
III Complications 792
82 Implant-Related Complications and Failures 792
Chapter Outline 792
Definition of Implant Survival and Implant Success 792
Types and Prevalence of Implant Complications 793
Different Types of Dental Implants 794
Surgical Complications 794
Hemorrhage and Hematoma 795
Neurosensory Disturbances 795
Implant Malposition 796
Biologic Complications 798
Inflammation and Proliferation 798
Dehiscence and Recession 798
Periimplantitis and Bone Loss 799
Implant Loss or Failure 800
Complications Related to Augmentation Procedures 792.e1
Autogenous Bone Harvesting and Grafting 792.e1
Guided Bone Regeneration 792.e1
Sinus Bone Augmentation 792.e2
Lateral Window Sinus Lift. 792.e2
Crestal (Osteotome) Sinus Lift. 792.e2
Complications Related to Placement and Loading Protocols 792.e3
Immediate Implant Placement 792.e3
Immediate Loading after Implant Placement 792.e3
Implant Placement Using a Flapless Approach 792.e4
Prosthetic or Mechanical Complications 801
Screw Loosening and Fracture 801
Implant Fracture 801
Fracture of Restorative Materials 802
Esthetic and Phonetic Complications 802
Esthetic Complications 802
Phonetic Problems 803
Conclusion 803
References 804
Suggested Readings 804
References 804.e1
IV Supportive Care and Results of Implant Treatment 805
83 Supportive Implant Treatment 805
Chapter Outline 805
Rationale for Supportive Implant Treatment 805
Examination of Implant(s) 805
Periimplant Probing 806
Microbial Testing 807
Stability Measures 807
Implant Percussion 807
Radiographic Examination 807
Assessment of Periimplant Health 808
Evaluation of Plaque (Biofilm) Control 808
Evaluation of Periimplant Health and Disease 808
Evaluation of Implant Osseointegration 809
Evaluation of Implant Restorations 809
Implant Maintenance 809
Methods for Patient Oral Hygiene 809
Methods for Professional Recall Maintenance 810
Treatment of Periimplant Diseases 810
Periimplant Mucositis 811
Periimplantitis 811
Referral of Patients to the Periodontist 811
References 812
Suggested Readings 811
References 812.e1
84 Results of Implant Treatment 813
Chapter Outline 813
Defining Implant Outcomes 813
Factors That Influence Implant Outcomes 815
Anatomic Location 815
Implant Design 815
Placement and Loading Protocols 816
Immediate Implant Placement. 816
Immediate Occlusal Loading. 816
Bone Augmentation 816
Risk Factors 816
Smoking. 817
Diabetes. 817
Periodontitis. 817
Esthetic Results and Patient Satisfaction 817
Conclusion 818
References 818
Suggested Readings 818
References 818.e1
4 Supplementary Topics (Online-Only) e9
85 Atlas of Periodontal Diseases e9
Suggested Readings e71
Plaque-Induced Gingival Diseases e10
Clinical Features of Gingivitis e10
Melanin Pigmentation e12
Etiology of Periodontal Diseases e13
Gingival Diseases Modified by Systemic Factors e20
Gingival Diseases Associated with Blood Dyscrasias e23
Leukemia e23
Anemia e23
Drug-Induced Gingival Diseases e25
Non–Plaque-Induced Gingival Lesions e26
Streptococcus Species e26
Herpes Virus Infections e27
Gingival Diseases of Fungal Origin e28
Gingival Lesions of Genetic Origin e30
Hereditary Gingival Fibromatosis e30
Gingival Manifestations of Systemic Conditions e32
Mucocutaneous Lesions e32
Other Systemic Diseases e35
Allergies e39
Traumatic Lesions (Factitious, Iatrogenic, and Accidental) e40
Cysts and Tumors e44
Chronic Periodontitis e46
Chronic Periodontitis Modified by Systemic Factors e49
Diabetes Mellitus e49
Aggressive Periodontitis e53
Periodontitis as a Manifestation of Systemic Diseases e58
Leukemias e58
Genetic Disorders e60
Necrotizing Periodontal Diseases e65
Bisphosphonates e67
Abscesses of Periodontium e69
Endodontic-Periodontal Lesions e71
86 Introduction to Evidence-Based Decision Making e72
Chapter Outline e72
Background and Definition e72
Principles of Evidence-Based Decision Making e72
Evidence-Based Dentistry e72
Evidence-Based Decision-Making Process and Skills e73
Asking Good Questions: The PICO Process e73
Becoming a Competent Consumer of the Evidence e73
Sources of Evidence. e75
Levels of Evidence. e76
Searching for and Acquiring the Evidence e77
Appraising the Evidence e78
Common Ways Used to Report Results. e78
Applying the Evidence: Evidence-Based Dentistry in Action e79
Evaluating the Outcomes e79
Conclusion e80
Suggested Readings e80
References e80
87 Assessing Evidence e82
Chapter Outline e82
Twelve Tools for Assessing Evidence e82
Be Skeptical e82
Don’t Trust Biologic Plausibility e83
What Level of Controlled Evidence Is Available? e83
Did the Cause Precede the Effect? e83
No Betting on the Horse After the Race Is Over e84
What Is a Clinically Relevant Pretrial Hypothesis? e84
Clinically Relevant Endpoint. e85
Common and Relevant Comparisons. e85
Representative Study Sample. e85
Small Type I and Type II Error Rates. e86
Size Does Matter e86
Is There a Better Alternative Explanation e87
Was the Study Properly Randomized? e88
When to Rely on Nonrandomized Evidence? e88
Did the Investigators Take into Account the Placebo/Nocebo Effects? e89
Was There Protection Against Conflict of Interest? e89
Conclusion e90
References e90
88 Electronic Dental Records and Decision Support Systems e92
Chapter Outline e92
Functionalities and Components Available in Electronic Dental Records e92
Patient Registration e92
Periodontal Chart e92
Electronic Dental Record Use in Dental Practices e92
Commonly Used Electronic Dental Records e94
Barriers to Using Electronic Dental Records e94
Limited Functionality for Communication and Collaboration. e94
Suboptimal Usability and Steep Learning Curve. e95
Insufficient Reliability of Electronic Dental Records and Infection Control Issues. e95
Challenges to Realizing the Full Potential of Electronic Dental Records e95
Standards for Information Content of Electronic Dental Records. e95
Data Representation and Interoperability. e95
Benefits of Using Electronic Dental Records e95
Reusing Electronic Dental Records Data for Research Purposes. e95
Clinical Decision Support Systems e95
Decision Support System Types. e95
Risk-Based Decision Support Systems for Periodontal Disease. e96
Barriers to the Adoption of Clinical Decision Support Systems. e96
Factors That Improve the Adoption of Clinical Decision Support Systems. e96
Future of Electronic Dental Records and Decision Support Systems in Dentistry e96
Suggested Readings e96
References e96
89 Locally Delivered, Controlled-Release Antimicrobials e98
Chapter Outline e98
Background and Objectives e98
Currently Available Agents (U.S.) e98
Chlorhexidine Chip. e98
Doxycycline Gel. e99
Minocycline Microspheres. e99
Rationale for Local Delivery and Controlled-Release e101
Pharmacokinetics e102
Chlorhexidine Chip. e102
Doxycycline Gel. e102
Minocycline Microspheres. e103
Drug Development and Registration e103
Locally Delivered, Controlled-Release Antimicrobials: Magnitude of the Effect e103
Statistical Versus Clinical Significance e115
Clinical Use e116
Costs and Outcomes e116
Tobacco Smoking e118
Potential New Indications e118
Currently Available Agents (Non-U.S.) e118
Conclusion e118
Key Points e119
Suggested Readings e120
References e120
90 Locally Delivered, Controlled-Release Antimicrobials: e123
Chapter Outline e123
Drug Development and Registration e123
Phases of Drug Development e123
Evaluating Safety and Efficacy e123
Informed Consent and Legal Considerations e123
Clinical Trial Evidence e124
Trial Design Considerations e124
Trial I Error Rate Control. e124
Clear Statement of the Objectives, Proposed and Actual. e124
Methods of Analysis in the Protocol, Statistical Plan, and Reports. e124
Methods of Adequate Assurance of Patient Selections. e125
Patient Assignments That Minimize Bias, Group Comparability. e125
Methods to Minimize Bias for All Parties: Patients, Investigators, and Data Analysts. e125
Endpoints Well Defined and Addressing the Primary Hypothesis. e125
Analysis of Results Allows for the Interpretability of the Effects of the Study Drug. e125
Clinical Use e126
Combination Adjunctive Therapy e126
Surgical Therapy e126
Periimplantitis e126
Adverse Effects and Cautions for Use e127
Currently Available Agents (Non-U.S.) e127
Chlorhexidine-Based Products e127
PerioCol-CG. e127
Chlo-Site. e127
Tetracycline-Based Products e128
PerioCol-TC. e128
Periodontal Plus AB. e128
Clinical Studies e128
Considerations for Future Research e128
Key Points e134
References e134
Index 819
A 819
B 823
C 825
D 830
E 833
F 835
G 837
H 841
I 842
J 845
K 846
L 846
M 848
N 852
O 853
P 856
Q 866
R 866
S 867
T 871
U 874
V 875
W 875
X 875
Y 875
Z 875