2 - Step 3

Question 1

What is the aim of step 3?

Answer 1

• treat areas of dentition that are not responding to step 2 therapy
• gaining further access for sub gingival instrumentation, regenerating or resecting lesions

Question 2

What are the step 3 options?

Answer 2

• treatment adjuncts
• access surgery
• regenerative options
• furcation treatment options

Question 3

What are examples of local adjuncts?

Answer 3

• local antimicrobials
• periochip
• dentomycin

Question 4

What is periochip?

Answer 4

• biodegradable gelatin matrix with chlorhexidine
• inserted into pocket following PMPR
• suitable in angular defects or furcations
• chlorhexidine is released slowly over 7 days

Question 5

Is periochip effective?

Answer 5

• shown to have short term improvements in probing depth
• improvements are small and no significant differences in CAL

Question 6

What is dentomycin?

Answer 6

• 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

Question 7

Is dentomycin effective?

Answer 7

• shown to have short term improvements in probing depth and CAL
• long term benefits not proven

Question 8

What are examples of systemic adjuncts?

Answer 8

• systemic antibiotics
• host modulation therapy
  
  • sub-antimicrobial dose doxycycline
• statins, bisphophonates, probiotics, NSAID

Question 9

systemic antimicrobials cons

Answer 9

• antibiotic stewardship - bacteria resistance
• side effects - GI disturbance (alteration of gut microbiome)

Question 10

What is an example of the indication for systemic adjuncts?

Answer 10

Periodontitis grade C in younger patients

Question 11

What is periostat?

Answer 11

• sub-antimicrobial dose doxycycline
• no association with antimicrobial resistance
• host modulation therapy of collagenase

Question 12

Is periostat effective?

Answer 12

Significant improvements to patient outcomes versus PMPR alone

Question 13

When is periodontal surgery indicated?

Answer 13

• non-responding sites where good quality PMPR has been carried out
• periodontal pocketing of >/= 6mm
• suitable patient with suitable tooth and defect factors

Question 14

What consent is required for periodontal surgery?

Answer 14

• reason for providing treatment
• options available including no treatment
• consequences of no treatment
• nature of procedure
• post-op complications
• post-op maintenance
• cost

Question 15

What post-op complications & risks are associated with periodontal surgery?

Answer 15

• pain, swelling, bruising, bleeding, infection
• potential time off work
• failure to resolve
• tooth mobility
• tooth non-vitality
• recession

Question 16

what factor to consider in MH for periodontal surgery

Answer 16

• smoking (impaired wound healing/ response）
• unstable angina/ uncontrolled hypertension / MI or stroke within 6 mo
• poorly controlled diabetes
• immunocompromised
• anticoagulants
  
  • DOAC
  • vit K antagonist
  • antiplatelet

Question 17

what factor to consider of the tooth for periodontal surgery

Answer 17

• access
• shape of defect
• tilting
• ridges/ root grooves
• overeruption
• enamel pearls
• proximity to adjacent tooth

Question 18

What is access surgery?

Answer 18

• access to areas of continued inflammation or infection
• areas of PPD >/= 6mm
• allow for surgical debridement

Question 19

What are the steps of access surgery?

Answer 19

• 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

Question 20

How does access surgery heal pockets?

Answer 20

• heals by repair, not by regeneration
• long junctional epithelial reattachment to root surface

Question 21

What are the indications for regenerative surgery?

Answer 21

• infrabony / angular defects 3mm or deeper on radiograph
• class 2 or 3 furcation defect

Question 22

What is GTR?

Answer 22

• guided tissue regeneration
• barrier membrane and bone-derived grafts
• prevents rapidly proliferating gingival epithelium / con tis entering bone defect
• to allow osteogenesis and PDL regeneration (slower)
• are used to create scaffold for vascularisation and cell ingrowth from base of defect

Question 23

What is EMD?

Answer 23

• enamel matrix derivative (emdogain)
• derived from porcine tooth germ
• injected into defect, forms matrix on root that mediates production of cementum
• induces regeneration of functional attachment
• suitable in narrow defects, so does not wash away

Question 24

Why are furcation lesions treated?

Answer 24

• resonable survival rates - 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

Question 25

What are the treatment options for furcation surgery?

Answer 25

- regenerative surgery - root resection - root separation - tunnelling

Question 26

What furcations are amenable to regenerative surgery?

Answer 26

- mandibular class 2 - maxillary class 2 (buccal) - maxillary class 2 (interdental)

Question 27

What furcations are amenable to root resection or separation surgery?

Answer 27

- **class 3 lesions** - multiple class 2 lesions in same tooth - teeth should be **endodontically treated**, - remaining root not mobile and remaining structure restorable - roots cannot be **fused** - pt motivated / good OH

Question 28

What furcations are amenable to tunnelling?

Answer 28

Mandibular class 3 lesions

Question 29

What is tunnelling?

Answer 29

Bone and soft tissue **recontoured** to allow insertion of **interdental brush**

Question 30

What risks are associated with tunnelling?

Answer 30

- root hypersensitivity - root caries