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D2 - Perio > 3 - Non-surgical Therapy > Flashcards

3 - Non-surgical Therapy Flashcards

1
Q

How much more bacteria is there on the human body than cells that comprise the body?

A

20x more

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2
Q

What is the initial therapy for soft tissue management in periodontics?

A

SRP - Scaling and Root Planing

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3
Q

In Probe Depths smaller than 3mm, why is the mean gain in Clinical Attachment Loss a negative number after SRP?

A

SRP actually tears the attachment - thereby decreasing the CAL

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4
Q

What are the mean probing depth reductions in probing depths of:

< 3 mm

4-6 mm

> 7 mm

A
  • < 3 mm - 0.03 mm
  • 4-6 mm - 1.29 mm
  • > 7 mm - 2.16 mm
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5
Q

What is the mean gain in Clinical Attachment Loss after SRP in the following probe depths:

< 3 mm

4-6 mm

> 7 mm

A
  • < 3 mm - -0.34 mm
  • 4-6 mm - 0.55 mm
  • > 7 mm - 1.19 mm
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6
Q

Regarding a 6 mm perio pocket, the following instruments are limited on how far they can reach, list them in order and how short them come from the 6 mm.

  • Traditional Ultrasonic
  • Gracey Curette
  • Ultrasonic Perio Insert
A
  1. Gracey Curette - 1.25 mm
  2. Traditional Ultrasonic - 1.13 mm
  3. Ultrasonic Perio Insert - 0.78 mm
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7
Q

What are the 6 problems of restricted access?

A
  • Probing depth
  • Furcations
  • Root proximity
  • Root flutings
  • CEJ relationships
  • Restorations
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8
Q

Why can’t lasers be used to completely treat perio problems or to do SRP?

A
  • They don’t get all the calculus off - 9 months post-laser treatment showed residual calculus and granulation tisue
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9
Q

What is the typical Clinical Protocol for perio?

A
  • OHI
    • Electric toothbrush, interpoximal cleaning, CHX rinse (twice daily)
  • SRP with local anesthesia
  • Low-dose doxycycline (20mg, #180 tabs, q12h)
    • Smokers
  • Re-eval @ 4-6 weeks post SRP
    • Re-treat residual sites of >5 mm
    • SRP, site-specific drug delivery
  • If desired response is not achieved - consider surgical treatment
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10
Q

What is considered Host Modulation?

A

Low Dose (Subantimicrobial) Doxycycline

20mg, #180 tabs, every 12 hours

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11
Q

What was Doxycycline originally marketed as?

A

Periostat

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12
Q

What is the mechanism of action of low-dose doxycycline?

A
  • At 20mg = no bacterial effect
  • Chelates calcium and other metals such as Zn and Mg.
  • Tetracycline drugs have the ability to inactivate matrix metalloproteinases - specifically the collagenases and gelatinases produced by PMNs and macrophages
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13
Q

When and where do you do SRP with Local Delivery (6 things)?

A
  • Pockets of >5 mm
  • Maintenance pts with isolated PD of 5-6 mm
  • Early stage of periodontal abscess
  • PD at the distal-facial line-angle of 2nd molars, related to 3rd molar extractions
  • Ailing implants (peri-implantitis)
  • Furcations
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14
Q

What are the site specific antimicrobials available?

A
  • PerioChip - CHX gluconate in a polymerized polylactic acid disc
  • Atradox - Doxycycline in a poly-lactide gel that polymerizes on contact with water
  • Arestin - 1 mg of minocycline micro-encapsulated in a polyglycolide-co-lactide dry powder
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15
Q

What is the main purpose of placing local antimicrobials?

A

Decrease inflammation and bleeding upon probing

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16
Q

To be effective a locally delivered antimicrobial must: (5 things)?

A
  1. Kill or inhibit the appropriate target microbes
  2. Reach the disease site
  3. Achieve adequate concentration for effectiveness
  4. Achieve appropriate duration of effect
  5. Have few side effects and/or cause no harm to the patient
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17
Q

What is the term that describes the ability of a product to bind to what it needs to (microbes)?

A

Substantivity

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18
Q

Concerning the 5 requirements of an effective locally delivered antimicrobial, what are the good ratings for Mouth Rinse?

A
  • Achieve adequate concentration
  • Does not harm the patient
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19
Q

Concerning the 5 requirements of an effective locally delivered antimicrobial, what are the good ratings for Subgingival Irrigation?

A
  • Reach the disease site
  • Achieve adequate concentration
  • Does not harm patient
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20
Q

Concerning the 5 requirements of an effective locally delivered antimicrobial, what are the good ratings for Systemic Antibiotics?

A
  • Reach the disease site
  • Kill/inhibit target microbes
21
Q

Concerning the 5 requirements of an effective locally delivered antimicrobial, what are the good ratings for Locally Delivered Antimicrobial?

A
  • Reach the disease site
  • Achieve adequate concentration
  • Achieve adequate duration of effect
  • Kill/inhibit target microbes
  • Does not harm patient

All of them!

22
Q

What is the best delivery system for treatment of chornic periodontitis?

A

Locally Delivered Antimicrobial

23
Q

Why is In Vitro Susceptibility (Arestin) so effective?

A
  • The concentration stays in the GCF for up to 28 days (10-20 milligrams)
24
Q

What microbes are susceptible to Minocycline at concentrations of 2-8 milligrams/mL?

A
  • Porphyromonas gingivalis
  • Prevotella intermedia
  • Fusobacterium nucleatum
  • Eikenella corrodens
  • A.a.
25
Q

Where does Low Dose Doxycycline work in the pathogenesis of periodontal disease?

A
  • Cytokines
  • Prostanoids
  • MMPs
  • Connective tissue and bone metabolism
26
Q

Where does Local Antimicrobial work in the pathogenesis of periodontal disease?

A
  • Microbial challenge
  • Antigens
  • LPS
  • Other virulence factors
27
Q

Where does Local Antibiotics + Low Dose Doxycycline work in the pathogenesis of periodontal disease?

A
  • Microbial challenge
    • Antigens, LPS, other virulence factors
  • Host Immuno-inflammatory Response
    • Cytokines, Prostanoids, MMPs
  • Connective Tissue and Bone Metabolism
28
Q

What are the realistic clinical expectations for non-surgical management of periodontitis of the following pocket depths able to be reduced to?

5 mm

6 mm

7 mm

A
  • 5 mm –> 3 mm
  • 6 mm –> 3 mm (possible) 4 mm
  • 7 mm –> 4 mm (possible) 5 mm
29
Q

What is the average reduction in Probe Depth and Change in CAL for periodontal therapies (4-6 mm)?

A
  • Reduction in PD - 1.23 mm
  • Change in CAL - 0.81 mm
30
Q

What periodontal therapy gives the greatest reduction in PD and change in CAL?

A

Open Flap Debridement

  • Reduction in PD - 3.00 mm
  • Change in CAL - 1.50 mm
31
Q

What are the common systemic antibiotics used as adjuncts in the treatment of aggressive periodontitis?

A
  • Amoxicillin
  • Metronidazole (strong, metallic after taste, no alcohol)
  • Tetracycline HCl
  • Doxycycline
  • Clindamycin
  • Amoxicillin + Clavulanic Acid (Augmentin)
  • Azithromycin (has become ineffective in period)
32
Q

What are the advantages of the use of systemic antibiotics in the treatment of chronic perio?

A
  • Affects bacterial reservoirs
  • Targets multiple sites of infection
  • Reduces chair time required to treat pts
  • Absorb into soft tissues adjacent to infected site
  • Penetrates to base of infected pocket
  • Wide choice of different antibiotics
33
Q

What are the disadvantages of the use of systemic antibiotics in the treatment of chronic perio?

A
  • Allergy
  • GI intolerance
  • Patient compliance ***
  • Potential for drug interactions
  • Cost to patient
  • Inabilit to penetrate an intact biofilm
34
Q

What are the common side effects of systemic antibiotics?

A
  • GI problems
  • Nausea
  • Photosensitivity
  • Bacterial Resistance
  • Esophagitis
  • Candidiasis (Tetracycline HCl, Doxycycline, Minocycline, Amoxicillin)
35
Q

For majority of studies, systemically administered antibiotics exhibited a more positive effect on what than the control group?

And what antibiotic had a significant effect on attachment level?

A

Clinical Attachment Loss

Amoxicillin + Metronidazole (CAL + 0.4 mm)

36
Q

Should systemic antibiotics be used in most patients with periodontitis?

A

NO! - consider in specific patient groups or defined conditions (aggressive perio or severe and progressive chronic perio)

37
Q

When inidcated as part of a perio therapy, systemic antibiotics should be used in conjunction with what?

And when should they be treated for optimal outcomes?

A

SRP

Antibiotics should be used at the time of SRP and all treatment should be carried out within 7 days

38
Q

What are the reasons for failure of systemic therapy?

A
  • Patient non-compliance
  • Inability to penetrate infection
  • Inability to eradicate source of infection
  • Cost to patient
  • Inability to pentrate an intact biofilm
39
Q

Treatment of chronic perio with what results in significant decreases in levels of serum hsCRP and IL-6?

A

SRP + Arestin

40
Q

Treatment of chronic perio with what results in significant decreases in levels of GCF-MMPs (8 &9), hsCRP, HDL and APO-A?

A

SRP + Sub-antimicrobial dose doxycycline

41
Q

What phase of treatment is the significant and decisive phase of perio therapy and most changes in the treatment plan happen?

A

Re-Evaluation

42
Q

What are the Re-Eval decisions?

A
  • If pt has improved to a level where the disease is stable - Maintenance Phase
  • If there has been no improvement or disease is not stable - Personalized Re-Treatment
43
Q

What are your options for personalized Re-treatment?

A
  • Antimicrobial therapy (Systemic or local)
  • Surgery
  • Combination
44
Q

What is the most critical phase of successful perio therapy?

A

Maintenance Phase

45
Q

What are the treatment decisions based on in the maintenance phase?

A
  • Changes in probe depths
  • Presence of bleeding/plaque
  • Progressive loss of clinical attachment
46
Q

For maintenance visits - what do you do if: probing depths are stable, no BOP?

A
  • Routine treatment, review OHI
  • Same recall interval
47
Q

For maintenance visits - what do you do if: Probing depths stable, but positive BOP?

A
  • Review OHI
  • Re-scale and root plane bleeding sites
  • Consider local delivery of antimicrobials
  • Consider shortening recall interval
48
Q

For maintenance visits - what do you do if: both probing depths and BOP increase?

A
  • Review OHI
  • Re-scale and root plane
  • Consider adjunctive therapy
    • Locally delivered or systemic
  • Referral to periodontist
49
Q

What is the time needed for pockets to re-infect, providing the interval for periodontal maintenance appointments?

A

3 months

9-11 weeks

D2 - Perio (5 decks)

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