hey it's dr amanda with straight smile solutions straightsmilesolutions.com and
this is just another one of those faqs that keeps coming up um in my personal orthodontic
consulting business straight smile solutions we probably get one mega period patient every
day and the doctors are all confused why things aren't going as predicted or why the treatment
plan maybe can't be done a certain way so if you want to watch my other videos i have
on periodontal disease and orthodontic treatment or periodontal disease and invisalign treatment
you can just go into my youtube channel to get to my youtube channel go to your youtube channel put
in the search bar straight smile solutions that'll take you to my youtube channel which has a green
banner from there there's a little magnifying glass in the top right not the corner just top
right it's super tiny you have to look for it if you don't know where it is let me know and
i'll show you where it is and you can put in any keyword that's how you search things so i would
just put in the word perio and that should pull up any period videos that i have which is there's
a few there's a handful but this one is going to tie it all together so let's talk about that so
first of all listen i'm an orthodontist so whenever i had a perio patient
um of course i'm looking for a peri release to be signed okay so that's just how it is i'm
not managing the period during treatment i'm just moving teeth it's a little bit different if you're
a general dentist and you happen to have a perio patient who you're doing invisalign on you might
be managing the perio you might be outsourcing the period treatment of course i'm always in support
of our fellow specialists like periodontists i have a lot of friends that are periodontists
they're great people i'm personally undergoing perio treatment not for perio proper but for
um a tongue tie release but i had to go through the whole perio exam
i've had period surgery before for other things that were not related to disease but anyways
um blah blah so look up my other videos but i do think that if you have a perio patient
where you have concerns about attachment loss and the predictability of tooth movement tooth loss
you should definitely refer to perio i don't care if you're a general dentist you manage the period
on your own if the patient has complications and if you did not refer to perio you may be
liable this may be below standard of care and i think patients would have a ground to complain
i'm just saying no i'm not gonna get involved in that but i'm just saying you're not a periodontist
yes you can do some period treatment in your office maybe you can do lots of period treatment
but you need to put on your periodontal shoes and say yeah you know this tooth may not
survive maybe this tooth needs grafting surgery first maybe you know we need to do a bone graft
before middle or after maybe we need to do a soft tissue graft before middle or after if you're not
comfortable making those decisions then you shouldn't be releasing the perio you should
refer to perial let them do the release in writing say this patient is and there
should be you should have a document like a perio clearance slash cavity clearance
where the third party where the periodontist specialist will sign off if a periodontist will
not sign off for treatment you shouldn't be doing it you know because most periodontists will and
they'll say yeah i'll sign off as long as i can manage their period during treatment fine you can
have the patient during treatment i think that's a great idea and i think i'd love for you to do that
so just think about that um because that seems to be a bit of a stumbling block i know y'all are in
a hurry to get treated but if your patient's tooth falls out during or shortly after treatment your
patient's not going to be too happy and i realize that that is kind of in the informed consent the
invisalign informed consent and or your standard braces inform consent which i hope you're having
your patients sign that is your responsibility to have them sign it it's lightly in there but
if you had a patient that had a tooth like i don't know i'm just poking at this but let's say
this tooth or this tooth these lower sevens and you were trying to upright them and you clearly
got some vertical you know defects and horizontal defects and things like that um you know
that tooth might fall out you may make the attachment loss
worse depending on the treatment how you're moving teeth things like that so unless your
patient is aware in writing that they may lose some teeth that they spend a lot of money to fix
you might get yourself in trouble so anyways that's the main thing i just want to let you know
please please please talk to your periodontist but let's talk about also
different types of movements and how moving teeth in a periodontally compromised
patient is different right so let's talk about crowding how do we normally fix crowding so
i mean got a crowning patient here we've got a spacing patient here two different things right
if i've got crowding the ways i can get crowdings fixed are the following we can do expansion and if
you don't know what arch expansion is hopefully you're not having perio situations in a kid who
needs palatal expansion so that's out but arch expansion which means widening the arch moving
it more buckly you can have proclination which means tipping the front teeth forward okay you
can have distalization which can't happen if you have third molars but if they're out you
can you scooting the teeth back and it depends on the bone and and tuberosities and things like
that so obviously you have to look at a panel in terms of the proclination what i use to see if
that's possible is coarse asaf and cef numbers if you don't have if you have a perio patient
a hard barrier patient you better have a cef and you better have ceph numbers and you better have
a panel don't try to do things with inadequate records have your records up to standard of care
dot your eyes cross your t's do things right like an orthodontist would do refer out to perio
for that release for that clearance explain why you're asking for it you know and i do have some
additional clearance forms that you can purchase at my store street smile solutions website
go to store and you'll see them in there they're twenty dollars a pop if you're one of our vip or
concierge doctors you get as many as you want for free if you're a matter if you're a member
of dsn dental success network mark costas we do give three pieces of paperwork for free to
anyone who's a member to in order to prove you're a member you need to message us on dsn workspace
um but that's the only freebies i got there so yeah so you get the idea we've got proclination
expansion distalization another option would be ipr which is interproximal reduction which is
kind of sawing and removing microscopic amounts of tooth structure in between each tooth
you can get up to about five millimeters per arch assuming you don't have restorations or
interproximal fillings or things like that that that helps out so the combination of
you know all those will help you with crowding however when you have perio you might not be
able to do some of these things so what should you probably not be doing well i probably wouldn't be
doing doing too much transverse expansion because that's tipping the teeth we're not doing palatal
skeletal expansion because this is not a kiddo so we're tipping the teeth and in doing so it might
compromise the perio breakdown a little bit more i certainly wouldn't be doing if i had the pano
and it looked like the teeth were at all flared i certainly you could always use a cbct as well
i certainly wouldn't be proclaiming the teeth so those are off the table for the most part
in a healthy patient those are on the table right so we have more options for crowding
we do have a distillation option which is scooting teeth back you can do a couple millimeters on
top and maybe one to one and a half on the lower depending on the ridge but the third molars have
to be out and gone and that you know the bone should be healed a little bit so there's that
and you can do the ipr of course you have perio which is definitely kind of my go-to way to
get crowding fixed because usually along with parallel we have black triangles that's how that
is it may not be too noticeable when the teeth are crooked but it becomes quite noticeable when the
teeth are straight so ipr is usually a good way but you're not going to fully get rid of all the
black triangles that's just part of perio if you don't like it you can have restorations later yes
that can get expensive sorry there's also the options of doing gum fillers gumdrop technique
um things like that again this is all cosmetic it usually probably won't be covered by insurance it
can get very expensive so um again a periodontal compromised patient can make things much much
more compromised so coordinate with your local periodontist support your local periodontist
and communicate well with your patient everyone's always in a hurry to get straight teeth but they
don't realize the risks i can tell you personal experience i did have a family member who did
get i won't mention who she is but um she did get braces this was before invisalign um in her 50s
could have been 40s um and she had some periodontal issues and she did lose some
lower incisors but she knew that like she was not surprised going in the doctor said
very likely you're going to lose some lauren sizes very likely you're going to need an implant
that's just how it's going to be you know we're going to straighten teeth
and probably going to lose some teeth so she got implants not a big deal but she was prepared right
and it was in writing and she knew and she knew it was gonna be an additional expense
she knew it wasn't gonna be covered by insurance so but i do always prefer invisalign hands down
over braces on any perio patient i know a lot of european patients out there really really want
to have braces you're like oh i'm not going to be compliant i'm not going to wear my invisalign i'm
sorry but invisalign sources are just slower and lower and they are the slowest lowest and their
trim is the healthiest out of any aligner company out there it's just the best i mean i'm not at
all working for invisalign or align technology i hate saying something is the best but for perio
it is the best it is the only one i would do now if i was a healthy younger patient
yeah there could be lots of options you can do braces you can do other aligner companies
you can do a sure smile you can do clear correct you can do white labor but for perio
invisalign hands down i would not do anything else and i certainly wouldn't do clear correct because
their trim line is too high not good for perio and the material is too thick i've seen crazy things
happen with clear correct and perio patients so anyways hopefully that is helpful thank you