2 - Step 3 Flashcards
What is the aim of step 3?
- treat areas of dentition that are not responding to step 2 therapy
- gaining further access for sub gingival instrumentation, regenerating or resecting lesions
What are the step 3 options?
- treatment adjuncts
- access surgery
- regenerative options
- furcation treatment options
What are examples of local adjuncts?
- local antimicrobials
- periochip
- dentomycin
What is periochip?
- biodegradable gelatin matrix with chlorhexidine
- inserted into pocket following PMPR
- suitable in angular defects or furcations
- chlorhexidine is released slowly over 7 days
Is periochip effective?
- shown to have short term improvements in probing depth
- improvements are small and no significant differences in CAL
What is dentomycin?
- 2% minocycline gel
- syringed into pocket following PMPR
- 3-4 applications every 2 weeks
- treatment not repeated within 6 months
- reduces bacterial load in pocket
Is dentomycin effective?
- shown to have short term improvements in probing depth and CAL
- long term benefits not proven
What are examples of systemic adjuncts?
- systemic antibiotics
- host modulation therapy
- sub-antimicrobial dose doxycycline
- statins, bisphophonates, probiotics, NSAID
What is an example of the indication for systemic adjuncts?
Periodontitis grade C in younger patients
What is periostat?
- sub-antimicrobial dose doxycycline
- no association with antimicrobial resistance
- host modulation of collagenase
Is periostat effective?
Significant improvements to patient outcomes versus PMPR alone
When is periodontal surgery indicated?
- non-responding sites where good quality PMPR has been carried out
- periodontal pocketing of >/= 6mm
- suitable patient with suitable tooth and defect factors
What consent is required for periodontal surgery?
- reason for providing treatment
- options available including no treatment
- consequences of no treatment
- nature of procedure
- post-op complications
- post-op maintenance
- cost
What post-op complications are associated with periodontal surgery?
- pain, swelling, bruising, bleeding, infection
- potential time off work
- failure to resolve
- tooth mobility
- tooth non-vitality
- recession
What is access surgery?
- access to areas of continued inflammation or infection
- areas of PPD >/= 6mm
- allow for surgical debridement
What are the steps of access surgery?
- examination and identification of deep non-responding site despite good OH
- full thickness flap raised
- defect granulation tissue removed, root surface curettage
- suture with primary closure (monofilament)
- SPT
How does access surgery heal pockets?
- heals by repair, not by regeneration
- long epithelial reattachment to root surface
What are the indications for regenerative surgery?
- infrabony defects 3mm or deeper on radiograph
- class 2 or 3 furcation defect
What is GTR?
- guided tissue regeneration
- barrier membrane and bone-derived grafts are used to create scaffold for vascularisation and cell ingrowth from base of defect
What is EMD?
- enamel matrix derivative (emdogain)
- derived from porcine tooth germ
- injected into defect, forms matrix on root that mediates production of cementum
- induces preservation of functional attachment
- suitable in narrow defects, so does not wash away
Why are furcation lesions treated?
- class 2 furcations survive much better than class 3 (class 1 respond to PMPR)
- tooth retention is more cost effective than extraction and prosthesis
- patients prefer to retain their own teeth
What are the treatment options for furcation surgery?
- regenerative surgery
- root resection
- root separation
- tunnelling
What furcations are amenable to regenerative surgery?
- mandibular class 2
- maxillary class 2 (buccal)
- maxillary class 2 (interdental)
What furcations are amenable to root resection or separation surgery?
- class 3 lesions
- multiple class 2 lesions in same tooth
- teeth should be endodontically treated, not mobile and remaining structure restorable
- roots cannot be fused
What furcations are amenable to tunnelling?
Mandibular class 3 lesions
What is tunnelling?
Bone and soft tissue recontoured to allow insertion of interdental brush
What risks are associated with tunnelling?
- root hypersensitivity
- root caries
