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Refractory Periodontitis
- 2. Parameter on “Refractory” Periodontitis American Academy of Periodontology, J Periodontol. May 2000
- 3. Clinical examination Photos from: pocketdentistry.com
- 5. Photos from:; makeagif.com, bestanimations.com; gifhell.com; gifsoup.com; beverlyheights.comtoothclub.gov.hk,arestin.com
- 6. Refractory Periodontitis Photos from:; beverlyheights.comtoothclub.gov.hk,arestin.com; comfortdental4me.com
- 7. • A destructive periodontal disease in patients who, when longitudinally monitored, demonstrates additional attachment loss at one or more sites despite well-executed therapeutic and patient efforts to stop the progression of disease Refractory Periodontitis
- 8. Etiology: • conventional therapy failed to eliminate microbial reservoirs of infection • Emergence or superinfection of opportunistic pathogen • Unknown factors Refractory Periodontitis Photos from:; kohaladental.com; photos.com
- 9. Refractory Periodontitis Photos from: premier34.ru; dentalcompare.com; youtube.com; dentoplant.hu
- 10. Refractory Periodontitis Not applicable to patients who: 1. Have received incomplete or inadequate conventional therapy 2. Have identifiable systemic condition that increases susceptibility to infections 3. Have localized areas of rapid attachment loss related to local factors 4. Have recurrence of progressive periodontitis of many years of successful maintenance
- 11. Photos from:; www.behance.com; colorbox.com; presentermedia.com
- 12. Clinical and microbiological features of refractory periodontitis subjects Colombo et al. (1998)
- 13. Clinical and microbiological features of refractory periodontitis subjects • Aim: to compare clinical parameters and the site prevalence and levels of 40 subgingival species in successfully treated and refractory periodontitis subjects
- 14. methodology Photos from:clicker.com; tokeyclub.com; christianberdy.com; Colgate.com; clipartlord.com 94 subjects CLINICAL EXAM •Gingival redness •Suppuration •BOP •PI •PD •CAL Baseline Every 3 mo Scaling and Root planing Modified Widman + Tetracycline 250mg QID for 28 days
- 15. methodology 66 successful tx 14 28 refractory pt CAL > 3 sites, >2.5mm in 1 year Photos from:clicker.com; tokeyclub.com; www.scielo.cl;pinterest.com Checkerboard DNA- DNA hybridization Bacterial culture in blood agar plate PCR 1 2
- 17. Mean PD and CAL in subjects with refractory and successfully treated both show great variations refractory > successfully treated Results
- 18. Results Baseline BOP and gingival redness: both show great variations and overlap
- 19. Fig 3. % of sites colonized at baseline by different levels of the 40 subgingival taxa -Reject the hypothesis that periodontal pathogens were higher or more prevalent in refractory -Streptococcus constellatus: -12.6±3.6 for refractory -3.7±1.1 for successfully Results * * * * *
- 22. Results 4 3 3 4 • Great heterogeneity in subgigival microflora of refractory subjects
- 23. Results • Great heterogeneity in subgigival microflora of refractory subjects
- 24. Conclusion • Refractory subjects CANNOT BE distinguished through clinical features prior to therapy. • Refractory subjects had lower prevalence and levels of the 40 test species in their sites than subjects in the successfully treated group. • Putative perio pathogens were found in more sites of successfully treated than in refractory subjects prior to therapy. • Higher frequency of Streptococcus species in refractory. S. constellatus in refractory
- 25. Subgingival microbial profiles in refractory periodontal disease • Socransky et al. (2002)
- 26. Aim: to examine subgingival microbial profiles associated with refractory periodontitis and to seek such profiles in periodontally healthy, periodontally well- maintained elder and untreated periodontitis subjects Subgingival microbial profiles in refractory periodontal disease
- 27. Methodology REFRACTORY N=36 PERIODONTALLY HEALTHY N=27 WELL- MAINTAINED N=35 UNTREATED PERIO N=115 •TX = SRP + MWF + Tetracycline •Showed full mouth mean CAL or >3 sites w/ >2.5mm after therapy •No PPD or CAL > 4mm •≥ 66 yrs old •Regular perio maintenance q 3-6 mo for an average of 14.2 years after perio therapy •Atleast 4 sites w/ PD >4mm and / or CAL >4mm
- 28. Demographics of 4 groups
- 29. results Mean prevalence and level of taxa differed sig. for 4 groups
- 30. results • Perio & refractory – red and orange complex; purple and actinomyces
- 31. Results •ratio of counts of actinoymces sp and counts of red complex between groups. •Proportions of taxa of actinomyces and red complex
- 32. results • Clustered analysis showed heterogeneity in the 4 clusters of refractory group with 8 outlier subjects
- 33. results I - streptococcus species of yellow complex II – low prevalence of all taxa; orange III – wider distribution; A. naeslundii and V. parvula IV- red and orange complex; B. forysthus strep constellatus in all group
- 34. results Clusters seen in refractory can also be seen in other groups
- 35. Conclusion • Refractory perio, on average, have similar microbiota to that seen in untreated perio • Refractory perio have heterogenous subgingival microbiota • Microbial profiles of refractory is seen in perio subjects as well as some healthy and some well maintained
- 36. Conclusion • prevalence of Streptococcus species is not seen in refractory groups • Detection of different microbial profiles design individual treatment for each patient
- 37. Comparison of subgingival microbial profiles of refractory periodontitis, severe periodontitis, and Periodontal Health using the Human Oral Microbe Identification Microarray• Colombo et al. (2009)
- 38. Comparison of subgingival microbial profiles of RP, GRs,PH using the HOMIM • Aim: to compare subgingival microbiota of subjects with refractory (RP), treatable periodontitis (GRs= good responders) or periodontal health (PH) using the human oral microbe identification microarray
- 39. methodology Photos from:clicker.com; tokeyclub.com; christianberdy.com; Colgate.com; clipartlord.com CLINICAL EXAM •Gingival redness •Suppuration •BOP •PI •PD •CAL Baseline Every 3 mo Scaling and Root planing Modified Widman + Amox 500mg + Metro 250mg TID for 14 days PERIODONTALLY HEALTHY N=20 •No PPD > 3mm or CAL > 2mm PERIO N=47 •Atleast 5 sites with PD and CAL ≥6mm
- 40. methodology Photos from:clicker.com; tokeyclub.com; christianberdy.com; Colgate.com; clipartlord.com PERIODONTALLY HEALTHY N=20 PERIO N=47 Good Responders N= 30 Refractory Perio N=17 •Show mean attachment loss and/or > 3 sites w/ ≥ 2.5mm HOMIM
- 43. RESULTS •All clinical parameters (except suppuration) were sig. in perio group vs control •RP showed mean CAL than GRs
- 44. Microbiologic profiles of 3 groups at baseline: Prevalence of Streptococcus species Most species were seen in perio pt 28% of all species/genera/ clones is not seen in PH perio pathogen in RP
- 45. Results Species detected higher in periodontally healthy subjects
- 46. Comparison of microbiota in sites that lost attachment vs healthy/gained attachment • S. intermedius/ constellatus, S. anginosus, P. micra, Selenomonas spp, etc are higher in sites losing attachment
- 47. Conclusion • Role of species that play in the initiation and /or progression of RP, the effect of periodontal therapy on this unusual microbiota and the interaction between these species and oral microorganism are unknown
- 48. Conclusion • Abx may be effective against pathogenic bacteria but may not be effective against unusual species overgrowth continuous perio destruction • More studies are needed
- 49. DETECTION OF ENTEROCOCCUS FAECALIS IN SUBGINGVIVAL BIOFILM OF PATIENT WITH CHRONIC REFRACTORY PERIODONTITIS • Gajan et al. (2010)
- 50. DETECTION OF ENTEROCOCCUS FAECALIS IN SUBGINGVIVAL BIOFILM OF PATIENT WITH CHRONIC REFRACTORY PERIODONTITIS • Aim: to investigate the presence of E. faecalis in subgingival biofilm of patients with chronic refractory periodontal diseases
- 51. Enterococcus Faecalis Photo from: microbiologyinpictures.com
- 52. Enterococcus Faecalis • Normal human commensals adapted to nutrient- rich, oxygen-depleted and ecologically complex environments • 1 of the top 3 nosocomial bacterial pathogen • strain resistant to antibiotics • Found in 60% of school children with high caries and 75% of pt w/ endodontic infection • Most commonly isolated or detected species from oral infection
- 53. methodology Photos from:clicker.com; tokeyclub.com; christianberdy.com; Colgate.com; clipartlord.com 100 non-smoking Chronic periodontitis subjects CLINICAL EXAM •Gingival redness •Suppuration •BOP •PI •PD •CAL Baseline Every 3 mo Scaling and Root planing Modified Widman + Tetracycline 250mg QID for 28 days
- 54. methodology Photos from:clicker.com; tokeyclub.com; christianberdy.com; Colgate.com; clipartlord.com 100 non-smoking Chronic periodontitis subjects 73 successful 27 Refractory
- 55. methodology Photos from:clicker.com; tokeyclub.com; christianberdy.com; Colgate.com; clipartlord.com 73 successful get 27 27 Refractory •Mean attachment level gain •No sites w/ CAL >2.5mm after 1 yr of perio therapy •Mean attachment loss and/or >3 sites w/ CAL > 2.5mm after perio therapy culture in blood agar plate to determine presence of E. faecalis
- 56. Result Successfully Treated Refractory Periodontitis Age 41.25±1.7 42.45±2.9 Presence of E. faecalis * 11.1% 51.8% * p<0.05
- 57. Conclusion • Within the limitations of this study, detection of E. faecalis in refractory sites seem to have a role in pathogenesis of refractory periodontitis • Sound knowledge of pathogen can help develop effective treatment strategies • Patients with refractory are candidates for bacterial culturing
- 58. How do We Proceed with Treatment? Photos from: picgif.com
- 59. 1. Arrest the disease 2. Slow the progression of disease • Control may not be possible in all instances just slow the progression Therapeutic Goals
- 60. 1. Collection of subgingival microbial samples 2. Selection and administration of an appropriate antibiotic regimen 3. antimicrobial regimen + conventional therapies may be used Treatment Considerations
- 61. 4. Re-evaluation with microbiological testing as indicated 5. Identification and attempt to control risk factors (ex. Smoking) 6. Intensified periodontal maintenance program shorter intervals between appointment with microbiologic testing if indicated Treatment Considerations
- 62. 1. Desired outcome is to arrest or control the disease 2. If control is not possible, the treatment objective is to slow the progression of the disease Outcome Assessment
- 63. THANK YOU
Hinweis der Redaktion
- This isa 40 year old patient who came to your office with a chief complaint of bleeding gums when brushing his teeth. Patient claims to be systemically healthy. Clinical exam revealed clinicall attachment loss of 4-6mm
- Radiographic exam revealed patient has fairly good amount of one remaining with bone support generally ranging from 60-80%. You gave this patient a diagnosis of generalized moderate with localized severe chornic periodontitis.
- After clinical and radiographic
- However, despite your attempts to control the infection with conventional periodontal therapy, Additional clinical attachment loss occurred. So you begin to think did I miss out anything?
- Superinfection - infection occurring after or on top of an earlier infection, especially following treatment with broad-spectrum antibiotics.
- Not applicable to patients who: Have received incomplete or inadequate conventional therapy Have identifiable systemic condition that increases susceptibility to infections Have localized areas of rapid attachment loss related to local factors Have recurrence of progressive periodontitis of many years of successful maintenance
- 1st phase: all underwent Checkerboard to compare microbiotia before tx 2nd phase: from 14 refractory, do another checkerboard, bacterial culture and PCR