4th year Flashcards
4 components of a full periodontal charting
Periodontal pocket depths
Bleeding on probing
Plaque index
Mobility
Define BPE and describe how it is conducted
Screening tool for periodontal disease
Conducted by using light probing force (20-25grams) WHO probe (‘ball end’ 0.5mm in diameter and a black band from 3.5mm to 5.5mm) to assess pocket depths in sextants
3 things that must be included in the record when managing a periodontal condition
Condition of the periodontal tissues
Risk factors
Periodontal advice and treatment
Define periodontal health
Clinical gingival health on an intact or reduced periodontium
Define periodontitis
Chronic inflammation of the supporting tissues around the teeth
6 investigations to stage periodontal disease
Assessment of greatest site of clinical attachment loss
Assessment of radiographic bone loss
Assessment of tooth loss due to periodontitis
Maximum pocket depth
Furcation involvement
Occlusal trauma
4 step approach to periodontal treatment
Step 0: Prerequisite to therapy
Step 1: Risk factor control
Step 2: Intervene
Step 3: Check/review
Step 4: Exit, plan longer-term care
Describe the 4 components of step 0 in the S3 treatment guidelines for periodontitis
Educate
Diagnose
Risk assess
Plan
Describe the 3 components of step 1 in the S3 treatment guidelines for periodontitis
OHI
PMPR
Supra-gingival scaling
Describe the 2 components of step 2 in the S3 treatment guidelines for periodontitis
Sub-gingival biofilm, calculus removal
Adjunct therapy
Describe the 2 components of step 3 in the S3 treatment guidelines for periodontitis
Periodontal pocket chart
Re-treatment of non-responder sites
Describe the 2 components of step 4 in the S3 treatment guidelines for periodontitis
Plan longer-term, supportive care
Rehabilitation
Define an engaging patient
Favourable improvement in OH
Reduce plaque and bleeding scores by 50%
Plaque scores ≤ 20% and bleeding scores ≤ 30%
Progresses to step 2
Describe the management of a non-engaging patient
Remain in step 1 until engaged
Describe the evidence-based recommendations for the choice of toothbrush
The use of a powered toothbrush may be considered as an alternative to manual tooth brushing for patients in supportive periodontal care
Describe the evidence-based recommendations for interdental cleaning
Recommend that tooth brushing should be supplemented by the use of interdental brushes (where anatomically possible) for patients in supportive periodontal care
Describe the evidence-based recommendations for the use of floss
Do not suggest the use of floss as the first-choice method of interdental cleaning for patients in supportive periodontal care
Describe the evidence-based recommendations for the use of other interdental cleaning devices
Suggest the use of other interdental cleaning devices in interdental areas, not reachable by interdental brushes, for patients in supportive periodontal care
Describe the evidence-based recommendations for the use of adjunctive locally administered antiseptics
Locally administered sustained-release chlorhexidine may be considered as an adjunct to sub-gingival instrumentation in patients with periodontitis
Describe the evidence-based recommendations for the timing of delivery of sub-gingival root
instrumentation
Supportive periodontal care should be scheduled for intervals of 3 to a maximum of 12 months, with the frequency determined by the patient’s risk profile and periodontal status after active therapy
Epidemiology of periodontitis
8-12% of population
Define a risk factor
Factor that is biologically linked to the disease that can be modified
6 risk factors for periodontal disease
Smoking
Diabetes
Stress
Drugs
Systemic diseases
Nutrition
6 systemic diseases that can have an effect on periodontal health
Ehlers Danlos Syndrome
Hypophosphatasia
Down syndrome
Chediak higashi syndrome
Papillion-Lefevre syndrome
Leucocyte adhesion deficiency
1 mechanisms behind why Down syndrome increases risk of periodontal disease
Underlying neutrophil disorder
1 mechanisms behind why Papillon-Lefevre syndrome increases risk of periodontal disease
Mutation in cathepsin C gene and enzyme required for activation neutrophil-derived antimicrobial peptide
6 effects of smoking on periodontal status
Increases risk of developing periodontal disease
Greater frequency of diseased sites
Greater reduction of periodontal bone height
Poorer response to periodontal therapy
Increased risk of continuing loss of attachment
More prone to gingival recession/furcation defects
4 mechanisms behind why smoking increases risk of periodontal disease
Impaired PMN function
Reduced gingival blood flow
Impaired healing
Effects plaque microbial flora
Effect of age on periodontal status
Prevalence of periodontitis increases with age
Effect of diabetes on periodontal status
Increases risk of developing periodontal disease
4 mechanisms behind why diabetes increases risk of periodontal disease
Dysregulation of PMNs function
Altered collagen metabolism
Micro vascular damage
Describe the relationship between periodontal disease and diabetic control
Significant periodontal disease increases risk of worsening glycaemic control
Effect of psychological stress on periodontal status
Increases risk of developing periodontal disease
Effect of scurvy on periodontal status
Increases gingivitis and loss of attachment leading to tooth loss
1 mechanism behind why scurvy increases risk of periodontal disease
Lack of vitamin C affects formation of collagen fibres
Effect of pregnancy on periodontal status
Increased gingival inflammation progressively during pregnancy
Effect of IL-1 gene polymorphisms on periodontal status
Associated with advanced periodontal disease
3 drugs associated with drug induced gingival overgrowth
Phenytoin
Cyclosporin
Calcium channel blocker amlodipine
5 tooth related risk factors for periodontal disease
Anatomical risk factors
Tooth position
Iatrogenic risk factors
Xerostomia
Occlusal trauma
Incompetent lip posture
Describe a risk assessment tool for periodontal disease
PreViser uses smoking history, diabetic status and clinical findings to assess a patients risk of developing periodontal disease
4 properties of chlorhexidine
Anti-plaque
Anti-microbial
Substantivity
Highly effective
Describe the substantivity property of chlorhexidine
Ability to bind to soft and hard tissues, increasing working time
Concentration of standard chlorhexidine mouthwash UK
0.2% chlorhexidine gluconate, 10ml rinse (20mg)
Concentration of Corsodyl Daily Defence mouthwash
0.06% Chlorhexidine Digluconate
3 indications for the use of chlorhexidine mouthwash
Post-scaling and root instrumentation
Post periodontal surgery
Acute gingival infections
4 disadvantages of chlorhexidine mouthwash
Interacts with sodium lauryl sulphate in toothpaste decreasing chlorohexidine activity
Brown/black staining of teeth
Altered taste sensation
Potential to cause parotid swelling
Indication for use of Corsodyl Daily Defence mouthwash
Part of a maintenance program to limit staining
Indication for use of chlorhexidine gel
Patients with localised gingivitis associated with mouthbreathing
1 reason antibiotics are used in periodontal therapy
Facilitate removal of sub-gingival bacteria
4 reasons against of the use of antibiotics in periodontal therapy
No penetration of antibiotics without mechanical disruption of the plaque biofilm
Potential systemic upset
Potential bacterial resistance
Non-surgical periodontal therapy is successful without antibiotics
6 topical antimicrobials
Dentomycin
Atridox
Actisite
Arestin
Elyzol
Periochip
4 advantages of topical antimicrobials
Direct to site of action
Low dosage required
No systemic upset
Reduced risk of resistance
5 indications for the use of topical antimicrobials
Localised disease
Sites showing poor response to mechanical treatment in otherwise stable patients
Localised molar/incisor periodontitis
Chronic, recurrent periodontal abscesses
Adjunctive to debridement in deep or recurrent periodontal sites
Describe Periochip
Slow release 2.5mg chlorhexidine from bovine gelatin carrier
Designed to be used in periodontal pockets ≥5mm
4 properties of Periochip
Delivers peak concentration at 2 hours
Continued release over 10 days
Self-retentive in pocket
No bacterial resistance
3 indications for use of systemic microbials
Generalised disease
Adjunctive to excellent mechanical debridement
For access to periodontal and other oral sites
6 stages in the treatment of generalised advanced chronic or aggressive periodontitis
Extraction of hopeless teeth
Endodontic therapy
Non-surgical periodontal therapy
Systemic antibiotic therapy
Periodontal surgery
Maintenance
2 systemic microbials used in periodontal therapy
Amoxycillin 250mg tid 5-7 days + Metronidazole 200mg tid 5-7 days
Tetracycline 250mg qid 7 days
Describe Periostat
Low-dose doxycyclineused as part of maintenance programme for patients with generalised, aggressive periodontitis
4 features of Periostat
Sub-MIC levels
Anti-collagenase effect
Single dose daily over 9 months
No bacterial resistance problems
4 features of localised molar-incisor periodontitis in young adults
Affects younger age group (<35 years)
Rapid attachment loss and bone destruction
Patients otherwise healthy
Microbial and plaque deposits inconsistent with levels of destruction
1 risk determinant for periodontitis in young adults
Family history
1 causative bacteria linked to periodontitis in young adults
Aggregatibacter actinomycetemcomitans
5 mechanisms of Aggregatibacter actinomycetemcomitans leading to periodontitis in young adults
Releases lethal leucotoxin directed against neutrophils and monocytes
LPS induces bone resorption
Produces enzymes such as collagenase
Chemotactic inhibition factors
Resists phagocytosis
5 stages in the treatment of periodontitis in young adults
OHI, plaque control, smoking cessation advice
Extraction of hopeless teeth
Sub-gingival scaling and root instrumentation
Local delivery of Dentomycin, Atridox
Periodontal surgery
Maintenance, follow-up
Describe dentomycin
2% minocycline hydrochloride local anti-microbial with anti-collagenase activity
Describe atridox
10% doxycycline hyclate local anti-microbial with anti-collagenase activity
Liquid polymer, hardens on contact with fluid
4 acute gingival conditions
Periodontal abscesses
Necrotising gingivitis
Necrotising periodontitis
Acute herpetic gingivostomatitis
Define acute periodontal abscesses
Sudden build up of pus within a pocket that will track until it is able to drain either through pocket or gingival tissues
4 signs of an acute periodontal abscess
Well localised pain to a vital tooth
Tooth ’elevated’ in its socket
Redness / swelling around gingiva
Pointing on gingiva
Management of an acute periodontal abscess
Drainage through the pocket by thorough subgingival debridement with LA or lanced with a scalpel to allow pus drainage
Follow-up
Define chronic periodontal abscesses
Long-standing suppurating pocket
3 potential causes of traumatic gingival lesions
Toothbrushing
Flossing
Toothpicks
1 sign of trauma from toothbrushing
Elongated superficial lesions predominantly found buccally
1 sign of trauma from flossing
Interdental lesion with linear cleft on buccal or lingual gingiva
Management of traumatic gingival lesions
Removal of the offending agent and symptomatic therapy
Define necrotising gingivitis
Opportunistic infection commonly affecting interdental papillae
3 predisposing factors to necrotising gingivitis
Smoking
Stress
Immuno-compromised
Bacterial aetiology of necrotising gingivitis
Anaerobic bacteria
Gram -ve motile rods
Spirochaetes
4 signs of necrotising gingivitis
Acute pain in gingivae
Punched out ulceration of tips of interdental papillae
Gingival ulcers bleed spontaneously/readily
Foetor oris
Define necrotising periodontitis
Infection characterised by necrosis of gingival tissues, PDL and alveolar bone
2 signs of necrotising periodontitis
Deep interproximal craters with denudation of alveolar bone
Sequestration of interdental or buccal/lingual bone
Management of necrotising gingivitis and periodontitis
Initial debridement under LA
Prescribe chlorhexidine mouthwash, symptomatic management
Severe cases 3 day course 200mg metronidazole x3 daily or amoxycillin 250 mg x3 daily for 5 days
Follow-up
Define acute herpetic gingivostomatitis
Infection of the oral cavity which is caused by the herpes simplex virus (HSV)
2 signs of acute herpetic gingivostomatitis
Multiple lesiosn with rupture to form ulcers (<5mm) over gingivae and oral mucosa with erythematous margin
Swollen gingivae
Management of acute herpetic gingivostomatitis
Supportive and symptomatic management as condition is self-limiting over 7 days
Define gingival recession
Apical migration of the gingival margin below the cement-enamel junction leading to exposure of the root surface accompanied with osseous/bone recessions
Prevelance of gingival recession
20-60% of the population
4 anatomical predispositions to gingival recession
Bone dehiscence
Bone fenestration
Thin gingival biotype
High frenal attachment
Define bone dehiscence
Defect that results in lowering of the crestal bone margin to expose the root surface
Common site of bone dehiscence
Labial/buccal aspect of maxillary canines and mandibular anterior teeth
Define bone fenestration
Window of bone loss on the lingual/buccal aspect of a tooth that exposes root surface
Describe the assessment of periodontal phenotype
Periodontal probe inserted into the sulcus:
Probe visible: thin (≤1 mm)
Probe not visible: thick (> 1 mm)
Describe the relationship between high frenal attachment and gingival recession
High frenal attachment can cause an apical pull of gingival tissues and gingival recession
5 acquired factors linked to gingival recession
Aggressive toothbrushing
Occlusion, parafunctional habits
Orthodontic treatment
Trauma
Restorations impinging on the biologic width
Describe the relationship between occlusion and parafunctional habits and gingival recession
Repeated gingival trauma due to occlusion or parafunctional activity may lead to gingival recession
Describe the relationship between orthodontic treatment and gingival recession
Tooth/root movements through bony envelope may lead to dehiscence and risk of recession
Define biological width
The distance from the junctional epithelium and connective tissue attachment to the root surface of a tooth (2mm)
4 consequences of crown margin impinging on biologic width
Gingival inflammation
Pain
Gingival recession
Underlying bone resorption
3 aquired pathological factors linked to gingival recession
Periodontal disease
Periodontal treatment
Factitious trauma
Describe the relationship between periodontal treatment and gingival recession
Treatment may induce gingival recession as healthy gingival tissues migrate to sit 2-3mm above bone or recession becomes more noticeable as gingival swelling decreases
Describe the relationship between factitious trauma and gingival recession
Self-induced injury of the periodontal tissues as a result of repeated voluntary trauma to localised areas may lead to gingival recession
Describe Miller’s classification of gingival recession
Presence of interdental papilla is the most important factor for determining root coverage
Define Miller’s I classification
Recession short of muco-gingival junction, normal papillary height, no periodontal bone loss in the interdental area, 100% root coverage
Define Miller’s II classification
Recession at or apical to mucogingival junction, normal papillary height, no periodontal loss in the interdental area, 100% root coverage
Define Miller’s III classification
Recession at or apical to mucogingival junction, some reduction in papillary height, bone or soft tissue loss in the interdental area or malpositioning of the teeth preventing 100% root coverage
Define Miller’s IV classification
Recession at or apical to mucogingival junction; significant loss of papillary height to a level apical to marginal soft tissue recession
4 consequences of gingival recession
Root caries
Abrasion cavities
Dental hypersensitivity
Poor aesthetics
Describe level 1 management of gingival recession
Prevention: OHI, atraumatic toothbrushing technique, scaling and root debridement
Describe level 2 management of gingival recession
Surgical correction if indicated
Describe level 3 management of gingival recession
Maintenance and monitoring
6 factors improving success of surgical treatment
Gingival margin is on the CEJ (class I,II)
PPD<3mm
No BOP
Highly motivated patients with excellent plaque control
Adequate width of attached gingiva
Thick gingival biotype
4 treatment options for gingival recession
Maintain current gingival position and prevent progression
Composite additions to teeth
Gingival veneer
Mucogingival surgery
Describe 3 features of free gingival graft tissue
Generally from firm keratinised tissue of the palate
Includes epithelium and underlying connective tissue lamina propria
Should be 1-2mm thick
Describe 3 features of a connect tissue graft
Underlying connective tissue lamina propria only
Healing is improved, heals by primary intention
Improved aesthetic outcome
Describe 3 features of a coronal advancement flap
One surgical site
Improved vascularisation and colour match
Predictable only in shallow recessions
Describe 4 features of periodontal surgery with repositioning
Flap surgery with apically repositioned flap
Allows access for bone removal
Preserves keratinised gingival tissue
Heals more rapidly than Gingivectomy
Give an alternative to grafts
Synthetic materials
3 examples of synthetic materials
Mucograft
Mucoderm
Aloederm
2 features of synthetic materials
Increase thickness of keratinised tissue
Can be used where there is no suitable donor site to harvest material
Describe Brannstrom’s theory of dentine sensitivity
Fluid movement in dentinal tubules stimulates nerve endings and causes short, sharp pain which resolves immediately on removal of stimulus
Level of sensitivity related to number of exposed dentinal tubules
3 symptomatic treatments for dentine hypersensitivity
Topical fluoride
Unfilled resin eg Seal and Protect
Restoration with GI or composite
5 indications for flap surgery
Access for root surface instrumentation
Modification of osseous furcation defects
Apical repositioning of gingival tissues/crown lengthening
Periodontal regeneration
Root resection/hemisection
3 indications for excisional surgery
Management of drug-induced gingival overgrowth
Tissue biopsy
Crown lengthening
1 indication for mucogingival surgery
Management of recession
3 indications for crown lengthing
Aesthetic reasons
Complications with existing restorative work
Toothwear
5 features to consider when selecting patients suitable for periodontal flap surgery
Good compliance and response but some residual pockets ≥5mm and bleeding
Re-instrumentation unsuccessful
Bleeding on probing (from bottom of pockets) Residual deep periodontal pocketing
Non-smoker
4 stages of the surgical flap procedure
Crevicular incision that splits periosteum using firm pressure from scalpel
Careful mucoperiosteal flap elevation
Scaling and root planning
Suturing
2 important features in surgical flap design
Ensure broad base of flap so as to allow good vascular supply to tissue
Include papilla in flap
2 options for surgical flap design
Envelope flap
Relieving incisions
3 features of post-operative care after periodontal flap surgery
Chlorhexidine mouthwash start next day
Use soft brush
Review in 1 week for suture removal
3 potential responses to periodontal flap surgery
Gingival recession
Exposed root surface
Minimal residual pocketing
Describe 3 stages of Modified Widman approach internal bevel incision
Initial incision splits the periosteum
Crevicular incision
Incision to remove wedge of gingival tissue
2 types of resective gingival surgery
Gingivectomy
Gingivoplasty
Define gingivectomy
Surgical excision of gingival tissue to eliminate soft tissue pockets
Define gingivoplasty
Surgical re-contouring or reshaping of gingival tissue
Describe 2 stages of external bevel incision
Blade at 45 degree angle to gingival tissue, use Blake’s or Kirkland scapel
Recontour the gum or to excise areas of gingival overgrowth
Describe 1 feature of excisional surgery
Leaves a broad wound which requires a dressing to allow healing by primary intention
4 indications for resective gingival surgery
To eliminate supra bony pockets after completion of non surgical treatment
To improve the aesthetics
Crown lengthening to facilitate restorative procedures
Management of drug-induced gingival overgrowth
1 feature of post-operative care after resective gingival surgery
Coe-pak for 5 days following surgery
Define occlusal trauma
Injury to the periodontium occurring as a result of occlusal forces in excess of the reparative or adaptive capacity of periodontium
Does occlusal trauma commonly occur with or independently of periodontal disease
Commonly with periodontal disease
Define primary occlusal trauma
Due to excessive occlusal forces applied to teeth with normal periodontal support, periodontally healthy teeth
Define secondary occlusal trauma
Due to normal or excessive forces applied to teeth with reduced periodontal support
Define grade I mobility
Tooth movement less than 1mm in buccal-lingual direction
Define grade II mobility
Tooth movement greater than 1mm in buccal-lingual direction
Define grade III mobility
Tooth movement greater than 1mm in buccal-lingual direction and can be depressed in the socket
Give a primary indicator of occlusal trauma
Tooth mobility
Describe the relationship between secondary occlusal trauma and tooth mobility
In secondary occlusal trauma a smaller non-axial force causes the same horizontal movement because the position of fulcrum is lower due to reduced supporting bone
4 stages in pathogenesis of occlusal trauma
Increased occlusal forces overwhelm the physical limitations of the PDL
PDL vessels undergo haemorrhage, thrombosis oedema and increased vascular permeability
Periodontal fibres become disorganised and collagen destruction follows
Increased osteoclastic activity and cemental resorption leads to bone resorption in pressure zones
Define fremitus
Tooth displacement caused by the patients own occlusal forces
Describe how to assess fremitus
Place a finger on the buccal aspect of the maxillary teeth
Ask the patient to tap the teeth together in inter-cuspal position and lateral and protrusive contacts
Palpate and visualise for displacement
Describe 3 common clinical signs of traumatic occlusion
Class II incisor relationships and with deep overbites
Stripping of upper incisor palatal gingiva or lower incisor buccal gingiva
Increased probing depths on the palatal aspect of upper incisors
Describe 4 common radiographic signs of traumatic occlusion
Alveolar bone loss due to periodontitis
Widening of PDL
Funneling of periodontal ligament
Reduced crown - root ratio
Describe the relationship between stress and periodontal disease
Increased risk for progressive periodontitis in adults with psychological traits of stress
Describe the relationship between stress and bruxism
Increased stress is associated with clenching/grinding causing increased occlusal load and subsequent PDL lidening
3 managements of occlusal trauma
Grind teeth out of occlusion
Splint if mobility persists despite resolution of pocketing
Restore missing posterior support with RPD to reduce occlusal load
Describe aTwistflex wire splint
Passive wire splint cemented in place with flowable composite
Describe a fibre splint
Fibre mesh placed on teeth and cemented with composite
Describe a composite only splint
Composite flowed around teeth, rigid splint
2 disadvantages of a composite only splint
Bulky and interferes with cleaning
Rigid, high chance of fracture
Describe a cast metal resin-retained splint
Specific lab made metal splint
1 disadvantages of cast metal resin-retained splint
Rigid, very high chance of debond
4 considerations for occlusal splinting
Must provide with an occlusal splint
Preferable for splint to incorporate stable canines
Must be be sufficient enamel for etching, crowns not suitable
Not suitable for teeth with Class III mobility
Define natural pontics
Use crown of compromised tooth as bridge pontic
Indication for natural pontics
Technique used for mobile teeth with very poor prognosis
5 stages of natural pontic provision
Compromised tooth extracted and root sectioned off at previous level of gingiva + 2mm
Extirpate pulp through apical foramen and clean pulp chamber with sodium hypochlorite
Seal apical portion of crown with composite
Splint cemented onto remaining teeth
Crown of extracted tooth cemented onto splint
