5 - Endorsements

Question 1

What should you do if radiographs of diagnostic quality are unobtainable?

Answer 1

If radiographs of diagnostic quality are unobtainable, the dentist should confer with the parent to determine appropriate management techniques (e.g., preventive/restorative interventions, advanced behavior guidance modalities, deferral, referral), giving consideration to the relative risks and benefits of the various treatment options for the pt.

Question 2

Give examples of good radiological practices?

Answer 2

Good radiological practices (e.g., use of lead apron, thyroid collars, and high-speed film; beam collimation) are important.

Question 3

What do you have to include with the CBCT image?

Answer 3

When using CBCT, the resulting imaging is required to be supplemented with a written report placed in the patient’s records that includes full interpretation of the findings.

Question 4

For a new pt or recall pt with a primary dentition, when should you take bitewings?

Answer 4

Posterior bitewing exam taken if proximal surfaces cannot be examined visually or with a probe.

Question 5

What radiographs should be taken for periodontal disease?

Answer 5

Imaging may consist of, but is not limited to, selected bitewing and/or periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be identified clinically.

Question 6

What is the interval for posterior bitewing radiographs?

Answer 6

Recall patients with clinical caries or increased risk for caries:

1. Children and adolescents: 6-12 months
2. Adults: 6-18 months

Recall patients with no clinical caries and not at increased risk for caries:

1. Children up to transitional dentition: 12-24 months
2. Adolescents with permanent dentition: 18-36 months
3. Adults: 24-36 months

Question 7

What radiographs do you take for a new pt?

Answer 7

1. Child with primary dentition: select PAs/occlusal views and posterior BWs if proximal surfaces cannot be visualized or probed.
2. Child with transitional dentition: posterior BWs with PAN, or posterior BWs with select PAs.
3. Adolescents: posterior BWs with PAN, or posterior BWs with select PAs. An FMS is preferred when the pt has clinical evidence of generalized dental disease or a history of extensive dental treatment.

Question 8

When do the majority of traumatic dental injuries occur?

Answer 8

The majority of injuries occur before age 19.

Question 9

What are the most common types of traumatic dental injuries?

Answer 9

1. Primary dentition - luxation injuries are the most common TDIs in the primary dentition.
2. Permanent dentition - crown fractures are the most common TDIs in the permanent dentition.

Question 10

What radiographs are recommended for traumatic dental injuries?

Answer 10

Several projections and angulations are routinely recommended, but the clinician should decide which radiographs are required for the individual. The following are suggested:

1. Periapical radiograph with a 90 degree horizontal angle with central beam through the tooth in question.
2. Occlusal view.
3. Periapical radiograph with lateral angulations from the mesial or distal aspect of the tooth in question.

Question 11

What is the importance of type of splint and duration of splinting for root-fractured and luxated teeth?

Answer 11

No importance to the healing, it’s just used for comfort and improved function.
–Current evidence supports short-term, non-rigid splints of luxated, avulsed, and root-fractured teeth. While neither the specific type of splint nor the duration of splinting for root-fractured and luxated teeth are significantly related to healing outcomes, it is considered best practice to maintain the repositioned tooth in correct position, provide pt comfort and improved function.

Question 12

What are antibiotics used for in permanent teeth traumatic dental injuries?

Answer 12

1. Avulsed teeth.
2. There is limited evidence for use of systemic antibiotics in the management of luxation injuries and no evidence that antibiotic coverage improves outcomes for root-fractured teeth.
   - -Antibiotic use remains at the discretion of the clinical as TDI’s are often accompanied by soft tissue and other associated injuries, which may require other surgical intervention. In addition, the pt’s medical status may warrant antibiotic coverage.

Question 13

What is necessary to make the diagnosis of a necrotic pulp in traumatic dental injuries?

Answer 13

1. At the time of injury, sensibility tests (cold test and/or EPT) frequently give no response indicating a transient lack of pulpal response. Therefore, at least two signs and symptoms are necessary to make the diagnosis of necrotic pulp.
   - -Regular follow up controls are required to make a pulpal diagnosis.

Question 14

Pulp canal obliteration is common following what traumatic dental injuries?

Answer 14

1. PCO occurs more frequently in teeth with open apices which have suffered a severe luxation injury. It usually indicates ongoing pulpal vitality.
2. Extrusion, intrusion, and lateral luxation injuries have high rates of PCO.
3. Subluxated and crown-fractured teeth also may exhibit PCO, although with less frequency.
4. Additionally PCO is a common occurrence following root fractures.

Question 15

What is an infraction and what is the treatment?

Answer 15

1. An incomplete fracture (crack) of the enamel without loss of tooth structure.
2. In cases of marked infractions, etching and sealing with resin to prevent discoloration of the infraction lines; otherwise, no treatment is necessary.
3. No follow up is generally needed for infraction injuries unless they are associated with a luxation injury or other fracture types.

Question 16

What is a significant finding in an infraction that would affect treatment?

Answer 16

1. It should be not tender. If tenderness is observed, evaluate the tooth for possible luxation injury or a root fracture.
2. If it is symptomatic, negative response to pulp testing, signs of apical periodontitis, no continuing root development in immature teeth; than, Endodontic therapy appropriate for stage of root development is indicated.

Question 17

What is an enamel fracture and what is the treatment?

Answer 17

1. A complete fracture of the enamel. No visible sign of exposed dentin.
2. If the tooth fragment is available, it can be bonded to the tooth. Contouring or restoration with composite resin depending on the extent and location of the fracture.
3. Follow up in 6-8 weeks and 1 year.

Question 18

What is a significant finding in an infraction that would affect treatment?

Answer 18

1. It should be not tender. If tenderness is observed, evaluate the tooth for possible luxation injury or a root fracture.
2. If it is symptomatic, negative response to pulp testing, signs of apical periodontitis, no continuing root development in immature teeth; than, Endodontic therapy appropriate for stage of root development is indicated.

Question 19

What additional radiograph do you take for tooth fractures?

Answer 19

Radiograph of lip or cheek to search for tooth fragments or foreign materials.

Question 20

What is the treatment for an enamel-dentin fracture in a permanent tooth?

Answer 20

1. If a tooth fragment is available, it can be bonded to the tooth. Otherwise, perform a provisional treatment by covering the exposed dentin with glass ionomer or a more permanent restoration using a bonding agent and composite resin, or other accepted dental restorative materials.
2. If the exposed dentin is within 0.5mm of the pulp (pink, no bleeding), place a calcium hydroxide base and cover with a material such as a glass ionomer.

Question 21

What is the treatment for an enamel-dentin-pulp fracture in a permanent tooth?

Answer 21

1. In young pts with immature, still developing teeth, it is advantageous to preserve pulp vitality by pulp capping or partial pulpotomy. Also, this treatment is the choice in young pts with completely formed teeth.
   - -Calcium hydroxide is a suitable material to be placed on the pulp wound in such procedures.
2. In pts with mature apical development, root canal treatment is usually the treatment of choice, although pulp capping or partial pulpotomy also may be selected.
3. If tooth fragment is available, it can be bonded to the tooth.
4. Future treatment for the fractured crown may be restoration with other accepted dental restorative materials.

Question 22

What is the follow up interval for fractures of teeth and alveolar bone?

Answer 22

Follow up in 6-8 weeks and 1 year.

Question 23

What is the treatment for a crown-root fracture without pulp exposure in a permanent tooth?

Answer 23

Emergency treatment:
1. As an emergency treatment, a temporary stabilization of the loose segment to adjacent teeth can be performed until a definitive treatment plan is made.

Non-emergency treatment alternatives:

1. Fragment removal only: removal of the coronal-crown-root fragment and subsequent restoration of the apical fragment exposed above the gingival level.
2. Fragment removal and gingivectomy (sometimes ostectomy): removal of the coronal crown-root segment with subsequent endodontic treatment and restoration with a post-retained crown. This procedure should be preceded by a gingivectomy, and sometimes ostectomy with osteoplasty.
3. Orthodontic extrusion of apical fragment: removal of the coronal segment with subsequent endodontic treatment and orthodontic extrusion of the remaining root\ with sufficient length after extrusion to support a post-retained crown.
4. Surgical extrusion: removal of the mobile fractured fragment with subsequent surgical repositioning of the root in a more coronal position.
5. Root submergence: implant solution is planned.
6. Extraction: extraction with immediate or delayed implant-retained crown restoration or a conventional bridge. Extraction is inevitable in crown-root fractures with a severe apical extension, the extreme being a vertical fracture.

Question 24

What is the treatment for a crown-root fracture with pulp exposure in a permanent tooth?

Answer 24

Emergency treatment:

1. As an emergency treatment, a temporary stabilization of the loose segment to adjacent teeth.
2. In pts with open apices, it is advantageous to preserve pulp vitality by a partial pulpotomy. This treatment is also the choice in young pts with completely formed teeth.
   - -Calcium hydroxide compounds are suitable pulp capping materials. In pts with mature apical development, root canal treatment can be the treatment of choice.

Non-emergency treatment alternatives:

1. Fragment removal and gingivectomy (sometimes ostectomy): removal of the coronal-crown-root fragment with subsequent endodontic treatment and restoration with a post-retained crown. This procedure should be preceded by a gingivectomy and sometimes ostectomy with osteoplasty. This treatment option is only indicated in crown-root fractures with palatal subgingival extension.
2. Orthodontic extrusion of apical fragment: removal of the coronal segment with subsequent endodontic treatment and orthodontic extrusion of the remaining root with sufficient length after extrusion to support a post-retained crown.
3. Surgical extrusion: removal of the mobile fractured fragment with subsequent surgical repositioning of the root in a more coronal position.
4. Root submergence: an implant solution is planned, the root fragment may be left in situ.
5. Extraction: extraction with immediate or delayed implant0retained crown restoration or a conventional bridge. Extraction is inevitable in very deep crown0root fractures, the extreme being a vertical fracture.

Question 25

What is the treatment for a root fracture in a permanent tooth?

Answer 25

1. Reposition, if displaced, the coronal segment of the tooth as soon as possible.
2. Check position radiographically.
3. Stabilize the tooth with a flexible splint for 4 weeks.
   - -If the root fracture is near the cervical area of the tooth, stabilization is beneficial for a longer period of time (up to 4 months).
4. It is advisable to monitor healing for at least 1 year to determine pulpal status.
5. If pulp necrosis develops, root canal treatment of the coronal tooth segment to the fracture line is indicated to preserve the tooth.

Question 26

What is the treatment for an alveolar fracture in a permanent tooth?

Answer 26

1. Reposition any displaced segment and then splint.
2. Suture gingival laceration if present.
3. Stabilize the segment for 4 weeks.

Question 27

What is the treatment for a concussion in a permanent tooth?

Answer 27

1. No treatment is needed.

2. Monitor pulpal condition for at least 1 year.

Question 28

What is the treatment for a subluxation in a permanent tooth?

Answer 28

1. Normally no treatment is needed; however, a flexible splint to stabilize the tooth for pt comfort can be used for up to 2 weeks.

Question 29

What is the treatment for an extrusive luxation in a permanent tooth?

Answer 29

1. Reposition the tooth by gently re-inserting it into the tooth socket.
2. Stabilize the tooth for 2 weeks using a flexible splint.
3. In mature teeth where pulp necrosis is anticipated or if several signs and symptoms indicate that the pulp of mature or immature teeth became necrotic, root canal treatment is indicated.

Question 30

What is the treatment for a lateral luxation in a permanent tooth?

Answer 30

1. Reposition the tooth digitally or with forceps to disengage it from its bony lock and gently reposition it into its original location.
2. Stabilize the tooth for 4 weeks using a flexible splint.
3. Monitor the pulpal condition.
4. If the pulp becomes necrotic, root canal treatment is indicated to prevent root resorption.

Question 31

What is the treatment for an intrusive in a permanent tooth?

Answer 31

Teeth with incomplete root formation:

1. Allow eruption without intervention.
2. If no movement within few weeks, initiate orthodontic repositioning.
3. If tooth is intruded more than 7mm, reposition surgically or orthodontically.

Teeth with complete root formation:

1. Allow eruption without intervention if tooth intruded less than 3 mm.
   - -If no movement after 2-4 weeks, reposition surgically or orthodontically before ankylosis can develop.
2. If tooth is intruded beyond 7mm, reposition surgically.
3. The pulp will likely become necrotic in teeth with complete root formation. Root canal therapy using a temporary filling with calcium hydroxide is recommended and treatment should begin 2-3 weeks after surgery.
4. Once an intruded tooth has been repositioned surgically or orthodontically, stabilize with a flexible splint for 4-8 weeks.

Question 32

What home care instructions should be given to pts with traumatic dental injuries?

Answer 32

Both pts and parents of young pts should be advised regarding:

1. Care of the injured tooth/teeth for optimal healing.
2. Prevention of further injury by avoidance of participation in contact sports
3. Meticulous oral hygiene, and rinsing with an antibacterial such as chlorhexidine gluconate 0.1% alcohol free for 1-2 weeks.

Question 33

In what cases is reimplantation of an avulsed permanent tooth not indicated?

Answer 33

1. Severe caries or periodontal disease
2. Non-cooperating patient
3. Severe medical conditions (e.g., immunosuppression and severe cardiac conditions)

Question 34

What is the first aid for avulsed teeth at the place of accident?

Answer 34

1. Immediate replantation is the best treatment at the place of accident. If for some reason this cannot be carried out, there are alternatives, such as using various storage media.
   - -If a tooth is avulsed, make sure it is a permanent tooth (primary teeth should not be replanted).
2. Instructions:
   - -Keep the pt calm.
   - -Find the tooth and pick it up b the crown (the white part). Avoid touching the root.
   - -If the tooth is dirty, wash it briefly (max 10 s) under cold running water and reposition it. Try to encourage the pt/guardian to replant the tooth. Once the tooth is back in place, bite on a handkerchief to hold it in position.
   - -If this is not possible, or for other reasons when replantation of the avulsed tooth is not possible (e.g., an unconscious patient), place the tooth in a glass of milk or another suitable storage medium and bring with the pt to the emergency clinic. The tooth can also be transported in the mouth, keeping it inside the lip or cheek if the pt is unconscious. If the pt is very young, he/she could swallow the tooth - therefore it is advisable to get the pt to spit in a container and place the tooth in it. Avoid storage in water!
   - -If there is access at the place of accident to special storage or transport media (e.g., tissue culture/transport medium, Hanks balanced storage medium (HBSS or saline) such media can preferably be used.
   - -Seek emergency dental treatment immediately.

Question 35

Why is the time out of the mouth important in avulsions?

Answer 35

The condition of the cells is depending on the storage medium and the time out of the mouth, especially the dry time is critical for survival of the cells. After a dry time of 60 min or more, all periodontal ligament (PDL) cells are nonviable.

Question 36

Give some examples of osmolality balanced media?

Answer 36

1. HBSS
2. Saline
3. Milk

*Saliva is not osmolality balanced, but can be used.

Question 37

Why is delayed replantation of an avulsed tooth bad?

Answer 37

1. Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and not expected to heal.
2. The goal in delayed replantation is, in addition to restoring the tooth for esthetic, functional and psychological reasons, to maintain alveolar bone contour.
   - -However, the expected eventual outcome is ankylosis and resorption of the root and the tooth will be lost eventually.

Question 38

What can you do to help prevent ankylosis in an avulsion with a high extra-oral dry time?

Answer 38

To slow down osseous replacement of the tooth, treatment of the root surface with fluoride prior to replantation has been suggested (2% sodium fluoride solution for 20 min) but it should not be seen as an absolute recommendation.

Question 39

When do you use topical anesthetics in avulsions and why?

Answer 39

1. For an avulsed tooth with an extra-oral dry time

Question 40

For an avulsion of a permanent tooth, how do you remove the coagulum in the socket for replantation?

Answer 40

Remove the coagulum from the socket with a stream of saline.

Question 41

What is the treatment guideline for an avulsion of a permanent tooth that has been replanted before the pt’s arrival at the clinic?

Answer 41

1. Leave the tooth in place.
2. Clean the area with water spray, saline, or chlorhexidine.
3. Suture gingival lacerations, if present.
4. Verify normal position of the replanted tooth both clinically and radiographically.
5. Apply a flexible splint for up to 2 weeks.
6. Administer systemic antibiotics.
7. Check tetanus protection.
8. Give pt instructions.
9. Initiate root canal treatment 7-10 days after replantation and before splint removal.

• -The difference between a closed apex and open apex tooth is that:
  1. For an open apex tooth, root canal treatment is not initiated and the tooth is allowed for possible revascularization. If that does not occur, root canal treatment is recommended.

Question 42

What is the treatment guideline for an avulsion of a permanent tooth that has an extra-oral dry time

Answer 42

1. Clean the root surface and apical foramen with a stream of saline and soak the tooth in saline thereby removing contamination and dead cells from the root surface.
2. Administer local anesthesia.
3. Irrigate the socket with saline.
4. Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
5. Replant the tooth slowly with slight digital pressure. Do not use force.
6. Suture gingival lacerations, if present.
7. Verify normal position of the replanted tooth both clinically adn radiographically.
8. Apply a flexible splint for up to 2 weeks, keep away from the gingiva.
9. Administer systemic antibiotics.
10. Check tetanus protection.
11. Give pt instructions.
12. Initiate root canal treatment 7-10 days after replantation and before splint removal.

• -The difference between a closed apex and open apex tooth is that:
  1. For an open apex tooth, root canal treatment is not initiated and the tooth is allowed for possible revascularization. If that does not occur, root canal treatment is recommended.
  2. For an open apex tooth, after cleaning the tooth with saline, topical antibiotics is applied to enhance chances for revascularization of the pulp and can be considered if available.

Question 43

What is the treatment guideline for an avulsion of a permanent tooth that has an extra-oral dry time >60 min?

Answer 43

1. Remove attached non-viable soft tissue carefully, for example, with gauze. The best way to do this has not yet been decided.
2. Root canal treatment to the tooth can be carried out prior to replantation or later.
   - -In cases of delayed replantation, root canal treatment should be either carried out on the tooth prior to replantation or it can be carried out 7-10 days later like in other replantation situations.
3. Administer local anesthesia.
4. Irrigate the socket with saline. Remove the coagulum from the socket with a stream of saline.
5. Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
6. Replant the tooth slowly with slight digital pressure.
7. Suture gingival lacerations, if present.
8. Verify normal position of the replanted tooth clinically and radiographically.
9. Stabilize the tooth for 4 weeks using a flexible splint.
10. Administer systemic antibiotics.
11. Check tetanus protection.
12. Give pt instructions.
    - -To slow down osseous replacement of the tooth, treatment of the root surface with fluoride prior to replantation (2% sodium fluoride solution for 20 min) has been suggested but it should not be seen as an absolute recommendation.

–There is no difference between the replantation treatment for an closed apex and open apex tooth.

Question 44

What is the concern regarding anesthetics in replantation of an avulsed tooth?

Answer 44

1. Concern is sometimes raised whether there are risks of compromising healing by using vasoconstrictor in the anesthesia.
2. Evidence is weak for omitting vasoconstrictor in the oral and maxillofacial region and must be further documented before any recommendations against the use of it can be given.

Question 45

What antibiotics are given in dental avulsions?

Answer 45

1. For systemic administration, tetracycline is the first choice in appropriate dose for pt age and weight the first week after replantation.
   - -The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young pts.
   - -In many countries, tetracycline is not recommended for pts under 12 years of age. A penicillin phenoxymethylpenicillin (Pen V) or amoxycillin, in an appropriate dose for age and weight the first week, can be given as alternative to tetracycline.
2. Topical antibiotics (minocycline or doxycycline, 1 mg per 20 ml of saline for 5 min soak) appear experimentally to have a beneficial effect in increasing the chances of pulpal space revascularization and periodontal healing and may be considered in immature teeth.

Question 46

Should a pt have a tetanus booster for an avulsion?

Answer 46

Refer the pt to a physician for evaluation of need for a tetanus booster if the avulsed tooth has contacted soil or tetanus coverage is uncertain.

Question 47

What kind of splinting is best for healing after an avulsion?

Answer 47

Current evidence supports short-term, flexible splints for splinting of replanted teeth.
–Studies have shown that periodontal and pulpal healing is promoted if the replanted tooth is given a chance for slight motion and the splinting time is not too long.

Question 48

Where should the splint be placed and why?

Answer 48

The splint should be placed on the buccal surfaces of the maxillary teeth to enable lingual access for endodontic procedures and to avoid occlusal interference.

Question 49

How long are avulsed teeth splinted for?

Answer 49

1. If the tooth is replanted before the pt’s arrival to the clinic or the extra-oral dry time 60 min, splint for 4 weeks.

Question 50

What are the pt instructions following an avulsion of a permanent tooth?

Answer 50

1. Avoid participation in contact sports.
2. Soft diet for up to 2 weeks. Thereafter normal function as soon as possible.
3. Brush teeth with a soft toothbrush after each meal.
4. Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.

Question 51

How is endodontic therapy completed on an avulsed permanent tooth?

Answer 51

1. if root canal treatment is indicated, the ideal time to begin treatment is 7-10 days post-replantation.
2. Calcium hydroxide is recommended as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material.
3. Alternatively if an antibiotic-corticosteroid paste is chosen to be used as an anti-inflammatory, anti-clastic intra-canal medicament, it may be placed immediately or shortly following replantation and left for at least 2 weeks.
   - -If the antibiotic in the paste is dechlortetracycline, there is a risk of tooth discoloration and care should be taken to confine the paste to the root canal and avoid contact of the paste with the pulp chamber walls.
4. if the tooth has been dry for more than 60 min before replantation. The root canal treatment may be carried out extra-orally prior to replantation.

Question 52

What is the follow-up interval for replanted teeth?

Answer 52

4 weeks, 3 months, 6 months, 1 year and yearly thereafter.

Question 53

What are the signs of a favorable outcome after replantation of an avulsed permanent tooth?

Answer 53

1. Closed apex: normal mobility, normal percussion sound. No radiographic evidence of resorption or periradicular osteitis: the lamina dura should appear normal.
2. Open apex: asymptomatic, normal mobility, normal percussion sound. Radiographic evidence of arrested or continued root formation and eruption. Pulp canal obliteration is to be expected.

Question 54

What the signs of an unfavorable outcome after replantation of an avulsed permanent tooth?

Answer 54

1. For both closed apex and open apex: symptomatic, excessive mobility or no mobility (ankylosis) with high-pitched percussion sound. Radiographic evidence of resorption (inflammatory, infection-related resorption, or ankylosis-related replacement resorption).
   - -When ankylosis occurs in a growing pt, infraposition of the tooth is highly likely leading to disturbance in alveolar and facial growth over the short, medium and long term.

Question 55

Following a failed replantation of an avulsed permanent tooth and the tooth is lost, what are the treatment options?

Answer 55

Appropriate treatment options may include:

1. Decoronation
2. Autotransplantation
3. Resin retained bridge
4. Denture
5. Orthodontic space closure with composite modification and sectional osteotomy.

–After growth is completed, implant treatment can also be considered.

Question 56

What is the most common sequelae following intrusion and avulsion of primary teeth in children?

Answer 56

1. White or yellow-brown discoloration of crown and hypoplasia of permanent incisors are the most common sequelae following intrusion and avulsion of primary teeth in children during the ages of 1-3 years.
   - -It is therefore not recommended, for instance, to replant an avulsed primary incisor.

Question 57

What is the treatment for an enamel fracture in a primary tooth?

Answer 57

Smooth sharp edges.

Question 58

What is the treatment for an enamel dentin fracture in a primary tooth?

Answer 58

1. If possible, seal completely the involved dentin with glass ionomer to prevent microleakage.
2. In case of large lost tooth structure, the tooth can be restored with composite.

Question 59

What is the treatment for a crown fracture with exposed pulp in a primary tooth?

Answer 59

1. If possible, preserve pulp vitality by partial pulpotomy.
   - -Calcium hydroxide is a suitable material for such procedures. A well-condensed layer of pure calcium hydroxide paste can be applied over the pulp, covered with a lining such as reinforced glass ionomer. Restore the tooth with composite.
2. The treatment is depending on the child’s maturity and ability to cope. Extraction is usually the alternative option.

Question 60

What is the treatment for a crown-root fracture in a primary tooth?

Answer 60

Depending on the clinical findings, two treatment scenarios may be considered:

1. Fragment removal only if the fracture involves only a small part of the root and the stable fragment is large enough to allow coronal restoration.
2. Extraction in all other instances.

Question 61

What is the treatment for a root fracture in a primary tooth?

Answer 61

1. If the coronal fragment is not displaced, no treatment is required.
2. If the coronal fragment is displaced, repositioning and splinting might be considered. Otherwise, extract only that fragment. The apical fragment should be left to be resorbed.

Question 62

What is the treatment for an alveolar fracture in a primary tooth?

Answer 62

1. Reposition any displaced segment and then splint.
2. General anesthesia is often indicated.
3. Stabilize the segment for 4 weeks.
4. Monitor teeth in fracture line.

Question 63

What is the treatment for a concussion in a primary tooth?

Answer 63

1. No treatment is needed. Observation.

Question 64

What is the treatment for a subluxation in a primary tooth?

Answer 64

1. No treatment is needed. Observation.
2. Brushing with a soft brush and use of alcohol-free 0.12% chlorhexidine topically on the affected area with cotton swabs twice a day for 1 week.

Question 65

What is the treatment for extrusive luxation in a primary tooth?

Answer 65

1. Treatment decisions are based on the degree of displacement, mobility, root formation, and the ability of the child to cope with the emergency situation.
2. For minor extrusion (

Question 66

What is the treatment for lateral luxation in a primary tooth?

Answer 66

1. If there is no occlusal interference, as is often the case in anterior open bite, the tooth is allowed to reposition spontaneously.
2. In case of minor occlusal interference, slight grinding is indicated.
3. When there is more severe occlusal interference, the tooth can be gently repositioned by combined labial and palatal pressure after the use of local anesthesia.
4. In severe displacement, when the crown is dislocated in a labial direction, extraction is the treatment of choice.

Question 67

What is the treatment for intrusion in a primary tooth?

Answer 67

1. If the apex is displaced toward or through the labial bone plate, the tooth is left for spontaneous repositioning.
2. If the apex is displaced into the developing tooth germ, extract.

Question 68

What is the treatment for an avulsion in a primary tooth?

Answer 68

1. It is not recommended to replant avulsed primary teeth.
2. At the initial examination make sure that all avulsed teeth are accounted for. If not it is highly recommended to make a radiographic examination in order to ensure that the missing tooth is not a case of complete intrusion or root fracture with loss of the coronal fragment. If the avulsed tooth has not been found refer the child to the pediatrician to exclude aspiration.

Question 69

When should child abuse be suspected in traumatic dental injuries?

Answer 69

1. The possibility of child abuse should be considered when assessing children under the age of 5 years who present with intra-oral trauma affecting the lips, gums, tongue, palate, and severe tooth injuries.

Question 70

What is an extra-oral lateral view radiograph used for in traumatic dental injuries?

Answer 70

Extra-oral lateral view of the tooth in question may reveal the relationship between the apex of the displaced tooth and the permanent tooth germ as well as the direction of dislocation (size 2 film, vertical view), but is seldom indicated as it rarely adds extra information.

Question 71

When is splinting done in traumatic dental injuries of primary teeth?

Answer 71

Splinting is used only for alveolar bone fractures and possibly for intra-alveolar root fractures.

Question 72

What tests are not reliable in primary teeth?

Answer 72

Sensibility and percussion tests are not reliable in primary teeth bc of the inconsistent results.

Question 73

What do you do when there is discoloration after traumatic dental injury to a primary tooth?

Answer 73

1. Discoloration is a common complication after luxation injuries.
2. Such discoloration may fade, and the tooth may regain its original shade.
   - -Teeth with persisting dark discoloration may remain asymptomatic clinically and radiographically or they may develop apical periodontitis.
   - -There is an association between crown discoloration and pulp necrosis in traumatized primary teeth. Unless associated infection exists, root canal treatment is not indicated.

Question 74

What home care instructions can you give to help prevent accumulation of plaque and debris after traumatic dental injury to a primary tooth?

Answer 74

1. Brushing with a soft brush.
2. Use of alcohol-free 0.1% chlorhexidine gluconate topically on the affected area wihth cotton swabs twice a day for 1 week are recommended to prevent accumulation of plaque and debris.

Question 75

What are the principles critical to optimal cleft/craniofacial care?

Answer 75

1. Management of pts with craniofacial anomalies is best provided by an interdisciplinary team of specialists.
2. Optimal care for pts with craniofacial anomalies is provided by teams that see sufficient numbers of these pts each year to maintain clinical expertise in diagnosis and treatment.
3. The optimal time for the first evaluation is within the first few weeks of life and, whenever possible, within the first few days. However, referral for team evaluation and management is appropriate for pts of any age.
4. From the time of first contact with the child and family, every effort must be made to assist the family in adjusting to the birth of a child with a craniofacial anomaly and the consequent demands and stress placed upon that family.
5. Parents/caregivers must be given information about recommended treatment procedures, options, risk factors, benefits, and costs to assist them in (1) making informed decisions on the child’s behalf, and (2) preparing the child and themselves for all recommended procedures.
6. Treatment plans should be developed and implemented on the basis of team recommendations.
7. Care should be coordinated by the team, but should be provided at the local level whenever possible; however, complex diagnostic or surgical procedures should be restricted to major centers with appropriate treatment facilities and experienced care providers.
8. It is the responsibility of each team to be sensitive to linguistic, cultural, ethnic, psychosocial, economic, and physical factors that affect the dynamic relationship between the team, the pt, and his/her family.
9. It is the responsibility of the team to monitor both shrot-term and long-term outcomes. Thus, longitudinal follow up of pts, including appropriate documentation and record-keeping is essential.
10. Evaluation of treatment outcomes must take into account the satisfaction and psychosocial well-being of the pt, as well as effects on growth, function, and appearance.

Question 76

For pts with cleft lip/palate and other craniofacial anomalies, what prosthetic appliances may help to close a fistula or aid in speech?

Answer 76

Prosthetic appliances such as an obturator may help to close a fistula or aid in speech.

Question 77

At what age does the incidence of periodontal attachment and supporting loss increases?

Answer 77

Loss of periodontal attachment and supporting bone is relatively uncommon in the young but the incidence increases in adolescents aged 12-17 when compared to children aged 5-11.

Question 78

What periodontal diseases affect young individuals?

Answer 78

1. Dental plaque-induced gingival diseases
2. Chronic periodontitis
3. Aggressive periodontitis
4. Periodontitis as a manifestation of systemic disease
5. Necrotizing periodontal diseases

Question 79

What bacterial species are important in the etiology and pathogenesis of gingivitis?

Answer 79

Although the microbiology of this disease has not been completely characterized, when comparing gingivitis in children as opposed to adults, there is increased subgingival levels of:

1. Actinomyces sp.
2. Capnocytophaga sp.
3. Leptotrichia sp.
4. Selenomas sp.

Question 80

What can modify the gingival inflammatory response to dental plaque in gingivitis?

Answer 80

Conditions that can increase inflammatory response to plaque:

1. Changes in gonadotrophic hormone levels during the onset of puberty.
2. Alterations in insulin levels in pts with diabetes.

Question 81

How can the gingival condition improve in gingivitis?

Answer 81

The gingival condition usually responds to thorough removal of bacterial deposits and improved daily oral hygiene.

Question 82

What type of periodontitis is common in children?

Answer 82

1. Children and adolescents can have any of the several forms of periodontitis (aggressive periodontitis, chronic periodontitis and periodontitis as a manifestation of systemic diseases).
2. However, chronic periodontitis is more common in adults, while aggressive periodontitis may be more common in children and adolescents.

Question 83

What are the features of aggressive periodontitis?

Answer 83

Primary features of aggressive periodontitis:
1. History of rapid attachment and bone loss with familial aggregation.

Secondary features of aggressive periodontitis:

1. Phagocyte abnormalities
2. Hyperresponsive macrophage phenotype

Question 84

What is the difference between localized and generalized aggressive periodontitis?

Answer 84

Localized aggressive periodontitis:

• Occurs in children and adolescents without clinical evidence of systemic disease and is characterized by the severe loss of alveolar bone around permanent teeth.
  1. Interproximal attachment loss on at least two permanent first molars and incisors.
  2. Attachment loss on no more than two teeth other than first molars and incisors.

Generalized aggressive periodontitis:

• Often considered to be a disease of adolescents and young adults, can begin at any age and often affects the entire dentition.
  1. Generalized interproximal attachment loss including at least three teeth that are not first molars and incisors.

Question 85

When does aggressive periodontitis begin in children?

Answer 85

In young individuals, the onset of these diseases is often circumpubertal.

Question 86

What is the prognosis of localized aggressive periodontitis (LAgP)?

Answer 86

1. Some investigators have found that the localized form appears to be self-limiting, while others suggest that it is not.
2. Some pts initially diagnosed as having LAgP were found to have GAgP or to be periodontally healthy at a 6-year follow up exam.

Question 87

What are the signs of localized aggressive periodontitis in the primary dentition?

Answer 87

Bone loss around primary teeth can be an early finding in localized aggressive periodontitis.

Question 88

What are the genetics of localized aggressive periodontitis?

Answer 88

1. Linkage studies of the Brandywine population (a segregated group of people in Maryland that represents a relatively closed gene pool) have found a gene conferring increased risk for LAgP on choromosome 4.
   - -Subsequent linkage studies of African American and Caucasian families did not confirm linkage to this locus, suggesting that there may be genetic and/or etiologic heterogeneity for aggressive periodontitis.

Question 89

What are the differences in plaque and calculus between LAgP and GAgP?

Answer 89

Localized Aggressive Periodontitis:
1. Many reports suggest that pts with LAgP generally form very little supragingival dental plaque or calculus. In contrast, other investigators find plaque and calculus at levels similar to other periodontal diseases.

Generalized Aggressive Periodontitis:
1. Individuals with GAgP exhibit marked periodontal inflammation and have heavy accumulations of plaque and calculus.

Question 90

What type of bacteria are in LAgP and GAgP?

Answer 90

Localized Aggressive Periodontitis:

1. Actinobacillus actinomycetemcomitans in combination with Bacteroides-like species.
2. In some populations, Eubacterium sp. have been associated with the presence of LAgP.
3. To date, however, no single species is found in all cases of LAgP.

Generalized Aggressive Periodontitis:

1. Subgingival sites from affected teeth harbor high percentages of non=motile, facultatively anaerobic, Gram-negative rods including Porphyromonas gingivalis.
2. In one report, the levels of P. gingivalis and Treponema denticola were significantly higher in GAgP and LAgP pts compared to matched controls with GAgP pts having the highest levels.

Question 91

What neutrophil problems are present in LAgP and GAgP?

Answer 91

Localized Aggressive Periodontitis:
1. Functional defects include anomalies of chemotaxis, phagocytosis, bactericidal activity, superoxide production, FcgIIIB (CD16) expression, leukotriene B4 generation, and Ca2+ channel and second messenger activation.

Generalized Aggressive Periodontitis:
1. Neutrophils from pts with GAgP frequently exhibit suppressed chemotaxis as observed in LAgP with a concomitant reduction in GP-110. This suggests a relationship between the two variants of aggressive periodontitis.

Question 92

What is the protective antibody against A. actinomycetemcomitans?

Answer 92

1. Most of the antibody reactive with A. actinomycetemcomitans is specific for high molecular weight lipopolysaccharide and is of the IgG2 subclass.
   - -This antibody response appears to be protective, as early-onset periodontitis pts having high concentrations of antibody reactive with A. actinomycetemcomitans lipopolysaccharide have significantly less attachment loss than pts who lack this antibody.
2. The protective antibody response afforded by IgG2, as well as the clinical manifestations of aggressive periodontitis, is modified by patients’ genetic background as well as environmental factors such as smoking and bacterial infection.

Question 93

What is important for the successful treatment of aggressive periodontitis?

Answer 93

Successful treatment of aggressive periodontitis depends on:

1. Early diagnosis.
2. Directing therapy against the infecting microorganisms.
3. Providing an environment for healing that is free of infection.

Question 94

What is the treatment for LAgP?

Answer 94

1. While there is some disagreement among individual studies regarding treatment of LAgP, most authors recommend a combination of surgical or non-surgical root debridement in conjunction with antimicrobial (antibiotic) therapy.
   - -These findings are supported by other work in which meticulous and repeated mechanical therapy with antibiotics proved to be sufficient to arrest most cases of LAgP.
2. However, surgical treatment may be effective in eliminating A. actinomycetemcomitans without the use of antibiotics.

Question 95

What are the most successful antibiotics used to treat LAgP?

Answer 95

1. The most successful antibiotics reported are the tetracyclines, sometimes prescribed sequentially with metronidazole.
   - -Metronidazole in combination with amoxicillin has also been utilized, especially where tetracycline-resistant A. actinomycetemcomitans are present.

Question 96

What is the treatment for GAgP?

Answer 96

1. While the use of antibiotics in conjunction with surgical or non-surgical root debridement appears to be quite effective for the treatment of LAgP, GAgP does not always respond well to conventional mechanical therapy or to antibiotics commonly used to treat periodontitis.
   - -Alternative antibiotics may be required, based upon the character of the pathogenic flora.
2. In GAgP pts who have failed to respond to standard periodontal therapy, laboratory tests of plaque samples may identify periodontal pathogens that are resistant to antibiotics typically used to treat periodontitis.
   - -It has been suggested that follow-up tests after additional antibiotic or other therapy is provided may be helpful in confirming elimination of targeted pathogenic organisms.

Question 97

What is chronic periodontitis characterized?

Answer 97

1. Localized (less than 30% of the dentition affected) or generalized (greater than 30% of the dentition affected).
2. Slow to moderate rate of progression that may include periods of rapid destruction.
3. The severity of disease can be mild (1 to 2 mm clinical attachment loss), or severe (≥5 mm clinical attachment loss).

Question 98

What is periodontitis as a manifestation of systemic disease?

Answer 98

In pts with one of several systemic diseases that predispose to highly destructive disease of the primary teeth, the diagnosis is periodontitis as a manifestation of systemic disease.

Question 99

What are some examples of systemic diseases that are associated with periodontitis?

Answer 99

1. Papillon-Lefevre syndrome
2. Cyclic neutropenia
3. Agranulocytosis
4. Down syndrome
5. Hypophosphatasia
6. Leukocyte adherence deficiency

Question 100

What causes the increased susceptibility to periodontitis and other infections in periodontitis as a manifestation of systemic disease?

Answer 100

1. It is probable that defects in neutrophil and immune cell function associated with these diseases play an important role in increased susceptibility to periodontitis and other infections.
   - -In Down syndrome, for example, the amount of periodontal destruction has been shown to be positively correlated with the severity of the neutrophil chemotaxis defect.
   - -Neutrophils from some children with a clinical diagnosis of periodontitis as a manifestation of systemic disease have abnormalities in a cell surface glycoprotein (LFA-1, leukocyte functional antigen-1, also known as CD11, and Mac-1).
   - -The neutrophils in these pts having LAD (leukocyte adhesion deficiency) are likely to have a decreased ability to move from the circulation to sites of inflammation and infection.
2. In some cases, specific genes have been associated with these diseases.
   - -Examples include the cathepsin C gene and Papillon-Lefevre syndrome and the tissue non-specific alkaline phosphatase gene and hypophosphatasia.

Question 101

Why is diabetes-associated periodontitis excluded as a specific form of periodontitis associated with systemic disease?

Answer 101

Diabetes is a significant modifier of all forms of periodontitis.

Question 102

When does periodontitis as a manifestation of systemic disease begin in children?

Answer 102

Begins between the time of eruption of the primary teeth up to the age of 4 or 5.

Question 103

Compare the clinical differences seen in the localized and generalized forms of periodontitis as a manifestation of systemic disease?

Answer 103

1. Localized form - affected sites exhibit rapid bone loss and minimal gingival inflammation.
2. Generalized form - there is rapid bone loss around nearly all teeth and marked gingival inflammation.

Question 104

What bacteria are associated with periodontitis as a manifestation of systemic disease?

Answer 104

1. A. actinomycetemcomitans
2. Prevotella intermedia
3. Eikenella corrodens
4. Capnocytophaga sputigena

Question 105

What is the treatment for periodontitis as a manifestation of systemic disease?

Answer 105

1. Treatment of periodontitis as a manifestation of systemic disease in children is similar to the treatment of localized and generalized aggressive periodontitis int he permanent dentition and has been reported to include surgical or non-surgical mechanical debridement and antimicrobial therapy.
   - -Localized lesions have been treated successfully with this approach, but the degree of predictable success in managing generalized periodontitis is low when systemic diseases are contributing factors. In many cases, the affected teeth had to be extracted.

Question 106

What are the most significant findings used in the diagnosis of necrotizing periodontal diseases?

Answer 106

The two most significant findings used in the diagnosis of NPD are:

1. The presence of interproximal necrosis and ulceration.
2. The rapid onset of gingival pain.

-Pts with NPD can often be febrile.

Question 107

What bacteria are associated with necrotizing periodontal diseases?

Answer 107

Necrotizing ulcerative gingivitis/periodontitis sites harbor high levels of spirochetes and P. intermedia, and invasion of the tissues by spirochetes has been shown to occur.

Question 108

What factors predispose children to necrotizing periodontal diseases?

Answer 108

1. Viral infections (including HIV)
2. Malnutrition
3. Emotional stress
4. Lack of sleep
5. Variety of systemic diseases

Question 109

What is the treatment for necrotizing periodontal diseases?

Answer 109

NUG:

1. NUG usually responds rapidly to the reduction of oral bacteria by a combination of personal plaque control and professional debridement.
   - -Debridement with ultrasonics has been shown to be particularly effective and results in a rapid decrease in symptoms.
2. The use of chemotherapeutic rinses by the pt may be beneficial during the initial treatment stages.
   - -After the acute inflammation of the NUG lesion is resolved, additional intervention may be indicated to prevent disease recurrence or to correct resultant soft tissue deformities.
3. If the pt has lymphadenopathy or is febrile, antibiotics may be an important adjunct to therapy.
   - -Metronidazole and penicillin have been suggested as drugs of choice.

NUP:
1. Management of NUP involves debridement which may be combined with irrigation with antiseptics (e.g., providone iodine), antimicrobial mouth rinses (e.g., chlorhexidine), and administration of systemic antibiotics.

Question 110

What are the signs of a healthy periodontium?

Answer 110

Currently accepted clinical signs of a healthy periodontium include:

1. The absence of inflammatory signs of disease such as redness, swelling, suppuration and bleeding on probing.
2. Maintenance of a functional periodontal attachment level.
3. Minimal or no recession in the absence of interproximal bone loss.
4. Functional dental implants.

Question 111

What are the prominent risk factors for development of chronic periodontitis?

Answer 111

Prominent risk factors for development of chronic periodontitis include:

1. Presence of specific subgingival bacteria
2. Tobacco use
3. Diabetes
4. Age
5. Male gender

• Furthermore, there is evidence that other factors can contribute to periodontal disease pathogenesis:
  1. Environmental
  2. Genetic
  3. Systemic (e.g., diabetes)

Question 112

What is the requirement to be accepted by the ADA Council on Dental Therapeutics as an effective agent for the treatment of gingivitis?

Answer 112

A product must reduce plaque and demonstrate effective reduction of gingival inflammation over a period of at least 6 months.
–The agent must also be safe and not induce adverse side effects.

Question 113

What medicaments have been given the ADA Seal of Acceptance for the control of gingivitis?

Answer 113

1. The active ingredients of one product are thymol, menthol, eucalyptol, and methyl salicylate.
2. The active ingredients in the other two are chlorhexidine digluconate and triclosan.

Question 114

How are topical anti-plaque agents useful in reducing gingivitis?

Answer 114

Penetration of topically applied agents into teh gingival crevice is minimal. Therefore, these agents are sueful for the control of supragingival, but not subgingival plaque.

Question 115

How can supragingival irrigation reduce gingival inflammation beyond that normally achieved by toothbrushing alone?

Answer 115

1. Among individuals who do not perform excellent oral hygiene, supragingival irrigation with and without medicaments is capable of reducing gingival inflammation beyond that normally achieved by toothbrushing alone.
   - -This effect is likely due to the flushing out of subgingival bacteria.

Question 116

What do you do if gingivitis remains following the removal of plaque and other contributing local factors?

Answer 116

Do a thorough evaluation of systemic factors (e.g., diabetes, pregnancy, etc.).
–If such conditions are present, gingival health may be attained once the systemic problem is resolved and plaque control is maintained.

Question 117

What is the difference between NUG and NUP?

Answer 117

1. NUG is associated with specific bacterial accumulations occurring in individuals with lowered host resistance.
2. NUP manifests as rapid necrosis and destruction of the gingiva and periodontal attachment apparatus. It may initiate gingival bleeding and pain, and it usually represents an extension of necrotizing ulcerative gingivitis in individuals with lowered host resistance.

Question 118

What periodontal disease is seen in individuals with HIV?

Answer 118

1. Severe loss of periodontal attachment that does not necessarily present clinically as an ulcerative lesion. Not an acute disease.
2. Linear gingival erythema (LGE) occurs in some HIV-infected individuals and does not appear to respond to conventional scaling, root planing and plaque control.
   - -Antibiotic therapy should be used in HIV-positive pts with caution due to the possibility of inducing opportunistic infections.

Question 119

What is the treatment for herpetic gingivitis?

Answer 119

1. In otherwise healthy pts, treatment for herpetic gingivitis consists of palliative therapy.
   - -The infection is self-limiting and usually resolves in 7-10 days.
   - -Systemic antiviral therapy with acyclovir is appropriate for immunocompromised pts with herpetic gingivitis.

Question 120

What drugs can cause overgrowth of gingiva?

Answer 120

1. Anticonvolusants (phenytoin)
2. Immunosuppressant (cyclosporine)
3. Calcium channel blockers (nifedipine)

Question 121

What is the treatment for gingival overgrowth?

Answer 121

1. Among individuals taking phenytoin, gingival overgrowth may be minimized with appropriate personal oral hygiene and professional maintenance.
   - -However, root debridement in pts with gingival overgrowth often does not return the periodontium to normal contour. The residual overgrowth may not only complicate the pt’s ability to adequately clean the dentition, but it may also present esthetic and functional problems.
2. The modification of tissue topography by surgical recontouring may be undertaken to create a maintainable oral environment.
   - -The benefits of surgical reduction may be lost due to rapid proliferation of the tissues during the post-therapy phase. Recurrence is common in many pts with drug-induced gingival overgrowth.
3. Consultation with the pt’s physician is advisable to determine if it is possible to use an alternative drug therapy that does not induce gingival overgrowth. If not, then repeated surgical and/or non-surgical intervention may be required.

Question 122

What factors may limit the success of treatment by root planing?

Answer 122

1. Root anatomy (e.g., concavities, furrows, etc.)
2. Furcations
3. Deep probling depths

Question 123

When should systemic antibiotics be administered for treatment of chronic periodontitis?

Answer 123

The adjunctive use of systemically delivered antibiotics may be indicated in the following situations:

1. Pts with multiple sites unresponsive to mechanical debridement.
2. Acute infections.
3. Medically compromised pts.
4. Presence of tissue-invasive organisms.
5. Ongoing disease progression.

Question 124

Systemic application of what host modulating agents may improve periodontal status?

Answer 124

1. NSAIDs
2. Subantimicrobial dose doxycycline
   - -The US FDA approved the use of a systemically delivered collagenase inhibitor consisting of a 20-mg capsule of doxycycline hyclate as an adjunct to scaling and root planing for the treatment of periodontitis.
   - -Subantimicrobial dose doxycycline as an adjunct to scaling and root planing provides defined but limited improvement in periodontal status.

-In general, since pts with chronic periodontitis respond to conventional therapy, it is unnecessary to routinely administer systemic medications such as antibiotics, NSAIDs, or subantimicrobial dosing with doxycycline.

Question 125

What local drug therapies are approved by the FDA to improve periodontal status?

Answer 125

1. The FDA has approved the use of an ethylene vinyl acetate fiber that contains tetracycline, a gelatin chip that contains chlorhexidine, and a minocycline polymer formulation as adjuncts to scaling and root planing.
2. The FDA has also approved the use of doxycycline hyclate in a bioabsorbable polymer gel as a stand-alone therapy for the reduction of probing depths, bleeding upon probing, and gain of clinical attachment.

Question 126

What is the healing for root debridement and surgical debridement and does it regenerate lost tissues?

Answer 126

1. While root debridement in combination with plaque control has demonstrated efficacy in resolving inflammation and arresting periodontitis, healing typically results in the formation of a long junctional epithelium with remodeling of the alveolus.
2. Similarly, surgical debridement alone does not induce significant amounts of new connective tissue attachment. However, some bone fill may occur in selected sites.

• Chemical agents that modify the root surface, while promoting new attachment, have shown variable results when used in humans.
• Bone grafting and guided tissue regeneration (GTR) techniques, with or without bone replacement grafts, may be successful when used at selected sites with advanced attachment loss.
• The use of biologically engineered tissue inductive proteins (e.g., growth factors, extracellular matrix proteins, and bone morphogenic proteins) to stimulate periodontal or osseous regeneration has also shown promise.

Question 127

What is the maintenance interval for managing chronic periodontitis?

Answer 127

In-office periodontal maintenance at 3 to 4 month intervals can be effective in maintaining most pts.