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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
Where does Low Dose Doxycycline work in the pathogenesis of periodontal disease?
* Cytokines * Prostanoids * MMPs * Connective tissue and bone metabolism
26
## Footnote Where does Local Antimicrobial work in the pathogenesis of periodontal disease?
* Microbial challenge * Antigens * LPS * Other virulence factors
27
## Footnote Where does Local Antibiotics + Low Dose Doxycycline work in the pathogenesis of periodontal disease?
* Microbial challenge * Antigens, LPS, other virulence factors * Host Immuno-inflammatory Response * Cytokines, Prostanoids, MMPs * Connective Tissue and Bone Metabolism
28
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
* 5 mm --\> 3 mm * 6 mm --\> 3 mm (possible) 4 mm * 7 mm --\> 4 mm (possible) 5 mm
29
What is the average reduction in Probe Depth and Change in CAL for periodontal therapies (4-6 mm)?
* Reduction in PD - 1.23 mm * Change in CAL - 0.81 mm
30
What periodontal therapy gives the greatest reduction in PD and change in CAL?
Open Flap Debridement * Reduction in PD - 3.00 mm * Change in CAL - 1.50 mm
31
What are the common systemic antibiotics used as adjuncts in the treatment of aggressive periodontitis?
* Amoxicillin * Metronidazole (strong, metallic after taste, no alcohol) * Tetracycline HCl * Doxycycline * Clindamycin * Amoxicillin + Clavulanic Acid (Augmentin) * Azithromycin (has become ineffective in period)
32
What are the advantages of the use of systemic antibiotics in the treatment of chronic perio?
* 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
## Footnote What are the disadvantages of the use of systemic antibiotics in the treatment of chronic perio?
* Allergy * GI intolerance * Patient compliance \*\*\* * Potential for drug interactions * Cost to patient * Inabilit to penetrate an intact biofilm
34
What are the common side effects of systemic antibiotics?
* GI problems * Nausea * Photosensitivity * Bacterial Resistance * Esophagitis * Candidiasis (Tetracycline HCl, Doxycycline, Minocycline, Amoxicillin)
35
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?
Clinical Attachment Loss Amoxicillin + Metronidazole (CAL + 0.4 mm)
36
Should systemic antibiotics be used in most patients with periodontitis?
NO! - consider in specific patient groups or defined conditions (aggressive perio or severe and progressive chronic perio)
37
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?
SRP Antibiotics should be used at the time of SRP and all treatment should be carried out within 7 days
38
What are the reasons for failure of systemic therapy?
* Patient non-compliance * Inability to penetrate infection * Inability to eradicate source of infection * Cost to patient * Inability to pentrate an intact biofilm
39
Treatment of chronic perio with what results in significant decreases in levels of serum hsCRP and IL-6?
SRP + Arestin
40
## Footnote Treatment of chronic perio with what results in significant decreases in levels of GCF-MMPs (8 &9), hsCRP, HDL and APO-A?
SRP + Sub-antimicrobial dose doxycycline
41
What phase of treatment is the significant and decisive phase of perio therapy and most changes in the treatment plan happen?
Re-Evaluation
42
What are the Re-Eval decisions?
* 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
What are your options for personalized Re-treatment?
* Antimicrobial therapy (Systemic or local) * Surgery * Combination
44
What is the most critical phase of successful perio therapy?
Maintenance Phase
45
What are the treatment decisions based on in the maintenance phase?
* Changes in probe depths * Presence of bleeding/plaque * Progressive loss of clinical attachment
46
For maintenance visits - what do you do if: probing depths are stable, no BOP?
* Routine treatment, review OHI * Same recall interval
47
## Footnote For maintenance visits - what do you do if: Probing depths stable, but positive BOP?
* Review OHI * Re-scale and root plane bleeding sites * Consider local delivery of antimicrobials * Consider shortening recall interval
48
## Footnote For maintenance visits - what do you do if: both probing depths and BOP increase?
* Review OHI * Re-scale and root plane * Consider adjunctive therapy * Locally delivered or systemic * **Referral to periodontist**
49
What is the time needed for pockets to re-infect, providing the interval for periodontal maintenance appointments?
3 months 9-11 weeks

D2 - Perio (5 decks)

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