bleeding gums Flashcards
1
Q
What makes up the periodontium?
A
The gingival tissues
The alveolar bone (hold the teeth in the socket)
The PDL (attaches bone to root surface)
Cementum (attaches to the PDL)
2
Q
What is gingivitis?
A
Inflammatory lesion mediated by host/parasite interaction
Reversible gingival inflammation without destruction of tooth-supporting tissues
Caused by accumulation of plaque
Removal of plaque results in complete resolution of the inflammatory lesion
3
Q
What is periodontitis?
A
Chronic multifactorial inflammatory disease associated with bacterial dysbiosis
Progressive destruction of the tooth supporting structures seen
Leads to alveolar bone loss and tooth loss
4
Q
What does the junctional epithelium do?
A
Separates internal systems from external environment
Permeable to bacteria passing into connective tissues and bloodstream
Permeable to products of internal defence passing outwards
Produces gingival crevicular fluid
5
Q
What is GCF?
A
Assists the junctional epithelium to protect underlying tissues from bacterial damage
A serum transudate
During disease, many host/parasite products enter and it becomes a true exudate
6
Q
How does plaque lead to periodontal disease?
A
Plaque accumulates and alters the oral environment
Causes gingivitis by inducing an inflammatory host response
Gingival inflammation forms a pocket which allows bacteria to colonise
Low O2 levels favours anaerobic bacteria
7
Q
What bacteria are found in clinically healthy gingivae?
A
Gram positive rods and cocci which are facultatively anaerobic or aerobic
Eg - streptococci and Actinomyces
8
Q
What kind of bacteria is found in periodontitis?
A
Predominately gram negative rods and spirochetes
Eg - Aa, P. gingivalis, T. denticola and T. forsythia
9
Q
What kind of bacteria is found in gingivitis?
A
Gram positive cocci decrease and gram negative anaerobics increase
Eg - fusobacterium and actinomyces
10
Q
Which 3 bacteria make up the red complex?
A
T. denticola
T. forsythia
P. gingivalis
11
Q
Describe T. denticola and explain its virulence factor
A
Gram negative
Obligate anaerobe
Spirochete
Able to adhere to epithelial cells, releasing damaging enzymes into their ECM
12
Q
Describe T. forsythia and explain its virulence factor
A
Gram negative
Obligate anaerobe
Spirilla (spindle shaped)
Cell surface proteolytic enzymes
13
Q
Describe P. gingivalis and explain its virulence factors?
A
Gram negative
Rod shaped
Anaerobe
Produces collagenase enzyme which breaks down collagen in periodontal tissues
Degrades haemoglobin which releases iron preventing iron transport
14
Q
Describe fusobacterium nucleatum and explain its virulence factors?
A
Gram negative
Anaerobic
Non motile
Cigarette shaped bacilli with sharp pointed ends
Adhesin A - allow for other species to adhere and colonise a host tissue they otherwise couldn’t
Endotoxin
15
Q
Describe Aa and explain its virulence factors
A
Gram negative
Capnophilic
Coccobacilus
Produces leukotoxin which can kill WBCs by forming pores causing its contents to be released
16
Q
What are virulence factors?
A
Mechanisms used by pathogens to cause damage to host tissues
17
Q
How does the innate immune response act against the biofilm?
A
Intact epithelium - physical barrier
Saliva - antimicrobial effects via salivary IgA, salivary peroxidases, lysozyme and lactoferrin
GCF - washes out non-adherent bacteria
Cellular component - includes neutrophils and macrophages
18
Q
How does the adaptive immune response act against the biofilm?
A
B cells produce antibodies that neutralise bacterial toxins and tag bacteria for destruction
T-helper cells produce cytokines, assist in the differentiation of B cells to plasma cells and activate neutrophils and macrophages
19
Q
List 5 ways perio disease can present clinically in smokers
A
Any from:
- higher probing depths and more sites with deep pockets
- greater loss of alveolar bone
- 2-4 times more likely to have furcation involvement
- greater gingival recession
- fewer bleeding sites on probing
- greater calculus formation
- reduced response to tx when compared to non-smokers
20
Q
What are the steps for smoking cessation advice?
A
Ask
Advise
Assess
Assist
Arrange
21
Q
What is a normal HbA1C?
A
Below 42mmol/mol or below 6%
22
Q
What is the HbA1c for prediabetes?
A
42-47mmol/mol or 6-6.4%
23
Q
What is the HbA1c for diabetes?
A
48mmol/mol or over, or 6.5% or over
24
Q
How does diabetes affect periodontitis?
A
Bi-directional relationship (NSTx can improve glycaemic control)
Poor glycaemic control = greater periodontal tissue destruction
Reduced chemotaxis of neutrophils
Decreased collagen synthesis so poor tx response
Diabetes complicates wound healing
25
Name 3 risk factors for gingival inflammation and enlargement
Pregnancy - pregnancy epulis and increased oestrogen and progesterone
Puberty - increased inflammatory response to plaque
Medications
26
Name 4 drugs that can cause gingival enlargement
Calcium channel blockers eg - amlodipine for hypertension
Phenytoin for epilepsy
Ciclosporin - anti-rejection drug
Oral contraceptive pill
27
Name 5 other systemic risk factors for periodontal disease?
Any from:
- family history of periodontal disease
- stress
- diet - increased glucose and lipid uptake
- age - increases with age
- obesity
- osteoporosis
- rheumatoid arthritis
28
What is the role of the plaque biofilm?
Acts as a shield protecting the microorganisms against inflammatory and immune systems as well as from chemical agents
29
Give 5 examples of plaque retentive factors
Calculus
Crowding
Overhanging restorations
Poorly designed RPDs
Root furcation
30
How much weight should be used when recording a BPE?
20-25g
31
When should a simplified BPE be used and what does it record?
Ages 7-11
Codes 0-2 to screen for bleeding and presence of local plaque retentive factors
32
Describe tx for BPE 0,1 or 2
0 and 1 - OHI and toothbrushing instruction
2 - OHI and supragingival PMPR
Risk factor modification
33
Describe tx for a code 3 BPE
Supra and sub gingival PMPR
OHI
6 point pocket chart in that sextant only
Risk factor modification
Radiographs as required
34
Describe tx for a code 4 BPE
Full mouth 6PPC, then begin periodontal therapy, then repeat pocket chart 3/12
Radiographs visualising alveolar bone crest
35
What is the difference between marginal bleeding and bleeding from the base of the pocket?
Gingival margin is linked to inadequate OH
Base of the pocket indicates presence of active periodontal disease
36
Why is plaque and marginal bleeding monitored regularly?
Allows understanding of initial level of plaque control and inflammation
Enables response to tx to be objectively monitored and can be helpful for motivation
Determines if pt is periodontal stable and if engaging
37
What is probing depth?
Distance from gingival margin to the base of the pocket
38
What is gingival recession?
When the gingival margin becomes apical to the CEJ
39
What is clinical attachment loss and how is it calculated?
Combines pocket depth and gingival recession to give an overall indication of where the periodontal tissues attach to the root surface
The pocket depth is added to the position of the gingival margin
40
What are the bands on a Naber’s probe?
3-6mm
9-12mm
41
What are the furcation involvement grades?
1 - involvement less than 1/3 of tooth width
2 - loss of support exceeds 1/3 but not the total width of the furcation
3 - probe can pass through the entire furcation
42
What are the grades of mobility?
0 - 0.1-0.2mm, normal physiological mobility
1 - up to 1mm movement in horizontal direction
2 - between 1-2mm movement in a horizontal direction
3 - >2mm horizontal, and vertical mobility, rotation, impinges on function
43
What should be assessed on radiographs for periodontal disease?
Root length and morphology
Level of alveolar bone and remaining bone support
PDL space and periapical region
Furcation involvement of multi-rooted teeth
Restorations, decay and calculus
44
What radiographs should be taken for BPE 3?
If generalised 4-5mm pocketing and little/no recession - horizontal BWs
Can be supplemented with PAs for anterior teeth only if it’s likely to change pt management
45
What radiographs should be taken for BPE 4?
Periapicals
46
What should be assessed on radiographs for periodontal disease?
Bone levels
Intra-bony defects
Furcation involvement
Overhangs and sub-gingival calculus
Pathology - dental infections, cysts or tumours
47
According to BSP 2017, what are the different conditions of periodontal health, gingival disease and conditions?
Periodontal health (intact periodontium)
Periodontal health (reduced periodontium)
Gingivitis: dental biofilm-induced (intact periodontium)
Gingivitis: dental biofilm-induced (reduced periodontium
Gingival disease and conditions: non biofilm-induced
48
According to BSP 2017, what are the different conditions of periodontitis?
Periodontitis
Necrotising periodontal disease
Periodontitis as a manifestation of systemic disease
49
According to BSP 2017, what are the other conditions affecting the periodontium?
Systemic diseases or conditions affecting the periodontal supporting tissues
Periodontal abscesses and endontic-periodontal lesions
Mucogingival deformities and conditions
Traumatic occlusal forces
Tooth and prosthesis related factors
50
How is the extend of periodontal disease established?
<30% sites affected = localised
>30% sites affected = generalised
Molar-incisor pattern
51
How is the stage of periodontal disease established?
Severity
Worse site of interproximal bone loss using PA or OPG
Stage 1 - early/mild, <15% bone loss
Stage 2 - moderate, coronal third of root
Stage 3 - severe, mid third of root
Stage 4 - very severe, apical third of root
52
How is grade of periodontitis established?
Rate of progesssion
% bone loss/patient age
A - <0.5
B - 0.5-1.0
C - >1.0
53
How is currrent periodontal disease status calculated?
Stable - BoP <10% and PPD≤4mm, no BoP at 4mm sites
Remission - BoP≥10% and PPD ≤4mm, no BoP at 4mm sites
Unstable - PPD≥5mm or PPD≥4mm with BoP
54
What is periodontal health and what characterises it?
Absence of bleeding on probing, erythema, oedema and patient symptoms with no attachment loss or bone loss
<10% BoP and all sites with probing depths ≤3mm
55
List the clinical features of gingivitis
Erythema - inc blood flow
Oedema - inc leakiness of bvs
Loss of gingival contour and stippling
Possible false pocketing - due to gingival swelling, junctional epithelium remains at CEJ
BoP - due to microulceration of sulcularnepithelium
Bad taste - esp in morning due to stagnation in gingival crevice overnight
Halitosis
56
List the clinical features of periodontitis
Increase in pocket probing depth - due to apical migration of junctional epithelium and loss of underlying connective tissue
Increased tooth mobility - due to loss of periodontal support
Interproximal recession
Suppuration
Drifting of teeth - due to loss of underlying bone and forces from tongue and lips
57
How are risk factors controlled with non-surgical periodontal therapy
Monitor plaque and bleeding
OHI and diet advice
PMPR - supra and sub gingival
6PPC if indicated
Liaise with GP if indicated - diabetes and to control meds
58
What adjuncts can be used in non-surgical periodontal therapy and how?
CHX - antibacterial agent to reduce bacterial count in the mouth, max of 7 days, may result in a metallic taste and staining
Antibiotics - metronidazole
59
When should pts be reviewed after non-surgical periodontal therapy?
6-8 weeks - time required for re-adaptation of long-junctional epithelium, recession and reduced PPD
60
List 5 aims of periodontal tx?
Control patients symptoms
Reduce inflammation
Provide advice on risk factor control to reduce risk of ongoing or future disease
Stabilise disease
Support the pt after tx is complete to either limit further tissue loss or avoid recurrence of disease
61
Shorty summarise the different BSP steps
1 - building foundations for optimum tx
2 - subgingival instrumentation
3 - managing non-responding sites
4 - maintenance
62
What happens in step 1 tx?
Confirm diagnosis - indices carried out - BPE, MPBS, appropriate radiographs
Explain disease, risk factors, risks and benefits including no tx
Give detailed, tailored OHI
Risk factor modification eg - smoking cessation
Supragingival PMPR
Correct plaque retentive factors eg - overhangs
Next appointment - assess response to step 1 - move onto step 2 if pt is engaged, if not then repeat step 1
63
What are the aims of sub gingival PMPR?
Remove all sub gingival plaque, calculus and other PRFs
Remove all cementum associated with endotoxin
Produce biologically inert root surface capable of regeneration of PDL/bone and capable of accepting LJE attachment coronary
Facilitate resolution of gingival inflammation - epithelial re-attachment (1-2 weeks), inflammation reduction - up to 3 weeks, cross-linking and remodelling of collagen - 3 months
64
What is the difference between long junctional epithelium and junctional epithelium?
LJE extends deeper into the pocket
65
How do you assess if a pt is engaging?
Plaque levels ≤20% and marginal bleeding ≤30% or
≥50% reduction in plaque and marginal bleeding from baseline measurements
Patient has met their personal self-care targets
66
What toothbrushing advice should be given?
Brush 2x a day for at least 2 minutes
Either manual toothbrush or electric with effective technique
Most appropriate type of brush based on pt ability, needs, preference and dexterity
Spit don’t rinse
Leave at least 30 minutes between acidic foods/drinks and toothbrushing - minimise risk of enamel loss
Advise pts with gingival inflammation, periodontitis, ortho appliances and/or complex restorations effective brushing likely to take longer than 2 minutes
Bleeding on brushing is a sign of gingival/periodontal inflammation and shouldn’t stop if their gums bleed
If bleeding was present, resolution of this signifies a reduction in inflammation
67
What interdental cleaning advice should be given?
If perio diagnosis - clean interdentally at least once a day
Appropriately sized ID brushes where interdental space allows, with floss in spaces too small
ID brush should fit snugly into ID space without wire rubbing against tooth
Different sized brushes may be required for different spaces
Demo technique to pt in surgery and get them to show it back - modify where required
Gingival inflammation - advise pt to clean ID as required to control inflammation - floss or ID brushes
68
What is included in step 2?
Subgingival PMPR at sites of ≥4mm PPD
Reinforce OHI, risk factor control and behaviour change
Can use adjunctive systemic antimicrobials
Post-op instructions - may notice black triangles, surface recession and sensitivity
Next appointment - re-evaluate after 3 months
Where residual disease present - discuss further options:
- if unstable move onto step 3 - managing non-responding sites
- if stable - step 4 maintenance
69
How do you re-evaluate and assess response to non-surgical periodontal therapy?
6PPC recorded pre- and post-tx
Cannot use BPE
70
Describe step 3
If unstable - need to manage non-responding sites
Reinforce OHI, risk factor control and behaviour change
For moderate 4-5mm residual pockets - re-perform subgingival instrumentation
For deep residual pocketing (≥6mm) can re-subgingival PMPR or consider alt causes
Consider referral for pocket management or regenerative surgery
If referral not possible, re-perform subgingival PMPR
If all sites are stable after step 3 - proceed to step 4
71
Describe step 4
Continue supportive periodontal therapy for maintenance
Reinforce OHI, risk factor control and behaviour change
Regular, targeted PMPR as required to limit tooth loss
Consider evidence based adjunctive efficacious toothpaste and mouthwash to control inflammation
72
What are the characteristics of successful periodontal therapy?
Reduction in bleeding on probing and brushing/flossing
Reduction in probing pocket depths and achieving stability
Change in gingival contour
73
What is the purpose of supportive periodontal therapy?
To avoid further attachment loss
To maintain the therapeutic benefits
To provide long-term monitoring and maintenance for patients
74
What should a maintenance appointment include?
Re-evaluation of plaque control
Assessment of bleeding on probing
Inspection for pus and furcation lesions
Radiographic evaluation if necessary
Tx of persisting bleeding pockets
PMPR - biofilm disruption/removal
75
What should the frequency of maintenance visits be?
Individually tailored from 3-12 months
Depends on various factors such as plaque control, bleeding on probing and alveolar bone levels
Annual full mouth 6PPC
76
How is grade C periodontitis managed?
MPBS, 6PPC
Appropriate radiographs with crestal bone visible
Non-surgical subgingival PMPR of all sites >4mm and >3mm with BoP
Tailored OHI
Can use systemic antibiotics
77
What are the antibiotic options for periodontal tx? - check this with SDCEP
Amoxicillin 500mg TDS - 7 days
Metronidazole 400mg TDS - 7 days
If penicillin allergy:
- doxycycline, day 1 - 200mg loading dose, then 100mg for 21 days
78
When should antibiotics be administered for perio and why?
Begin cycle on last day of subgingival PMPR
Antibiotics work to remove any bacteria left after RSD
Cannot reach bacteria in plaque biofilm within pocket
Antibiotics remove bacteria in tissues surrounding pockets
79
Who can we prescribe adult systemic antibiotics to? - check with SDCEP
Stage 2-4 grade C w/ MI pattern
Stage 2-4 grade c with 2 other criteria:
- age <35
- family history - 1st degree relative
- vertical bone loss pattern
- systemically healthy and never smoked
Necrotising perio diseases
80
List 4 risk factors for necrotising periodontal diseases
Smokers
Immunodeficiency patients eg - HIV
High stress
Poor OH
81
What are the clinical findings of necrotising periodontal diseases?
Grey, pseudomembranous slough covering gingival margin
Painful, ulcerated gingival margins
Papillae have punched out appearance
Can have loss of crestal bone
Bad breath/halitosis
Metallic taste
82
How are necrotising periodontal diseases treated? - check SDCEP
LA and debride - remove supra and subgingival deposits as much as tolerable
Pain relief - paracetamol and ibuprofen
Antibiotics - metronidazole 400mg - 1 tablet TDS for 3 days - pt should avoid alcohol, don’t prescribe if on warfarin
Or amoxicillin 500mg - 1 tablet TDS for 3 days
Review in 1 weeks
83
What causes necrotising periodontal diseases?
Spirochaetal and fusiform bacteria
84
What advice should be given to a pt with a necrotising periodontal disease?
Stop smoking
Use soft toothbrush gently - will be very sore
Fluoridated toothpaste and ID cleaning daily
0.2% chlorhexidine 10ml in half a cup of water TDS
Benzydamine spray prior to cleaning helps with pain
85
What are the clinical findings of a periodontal abscess?
Pt most likely presents with periodontitis clinically
Loss of alveolar crest may be seen radiogrpahically
Tooth usually mobile and TTP laterally
Abscess usually adjacent to perio pocket
Pus may be draining from pocket or sinus
Tooth usually vital
Possible systemic involvement - fever/malaise
86
What can you do if unsure of the source of an infection?
Place a GP cone into the associated sinus tract and then take a PA radiograph
87
How are periodontal abscesses managed? - check SDCEP
Administer LA and carry out debridement
Explain cause to pt and discuss OH improvements that can be made
Antibiotics only if systemic involvement:
- metronidazole 400mg TDS for 5 days
- or amoxicillin 500mg TDS for 5 days
Review in 1 week - ensure infection cleared and plan for future periodontal care
88
What are perio-endo lesions?
Occur when tooth has clinical attachment loss as well as necrotic, or partially necrotic pulp
Irrespective of primary origin of pathology
89
List 6 ways that periodontal tissues communicate with dental pulp
Apical foramen
Dentinal tubules
Lateral canals
Furcation canals
Cracks and fracture lines
Perforation by dental instruments
90
How are perio-endo lesions diagnosed?
May be no clear history with chronic, symptomless lesions
Clinical exam- isolated extensive pocketing may be present esp in furcation areas
Special tests:
- radiographs - loss of lamina dura, PDL widening, J shaped lesion, apical radiolucency and furcation involvement
- sensibility testing
- TTP
91
How are perio-endo lesions managed?
Doesn’t matter what came first - options:
1. Extraction - when poor long-term prognosis OR
2. Drain abscess +/- antibiotics if acute infection with systemic involvement
3. Then RCT first and subgingival PMPR after 3/12 if residual pocket remains
Leave 3 months between RCT and PMPR for healing potential of endo lesion to be assessed first
After RCT, lesion may heal without persistent periodontal pocket so adjunctive perio therapy would be inappropriate
92
List 3 anatomical problems in furcation involvement
Majority of multi-rooted teeth are positioned posteriorly making access difficult
Posterior teeth have broader contact areas that are less amenable to plaque control
Root surface concativies complicate plaque control interdentally
93
What are the aims of treating furcation defects?
Elimination of microbial plaque from exposed root complex
Facilitation of adequate self-performed plaque control
94
List 6 methods of treatment for furcations
Non-surgical periodontal therapy - PMPR and tailored OH
Furcation plasty - muco-periosteal flap to allow PMPR, removal of tooth structure to allow widened entrance for healing
Root resection or hemisection
Tunnelling surgery
Resective surgery
Regenerative surgery
95
What is tunnelling surgery and when is it indicated?
Re-contouring the furcation to facilitate cleaning with ID brush
Entire furcation area exposed
High risk of post op caries and sensitivity
Indicated in class III furcations
96
What is resective surgery and when is it indicated?
Gingival and bone contouring to shift the gingival margins apically and produce a healthy sulcus depth
Aims to reduce PPD and improve OH, recession has to be accepted to achieve a healthier periodontal state
Indicated in single wall defects or degree I furcations
97
What is regenerative surgery and when is it indicated?
Regeneration of soft and hard tissues
Techniques include guided tissue regeneration (GTR), bone grafting and use of enamel matrix derivatives
Indicated in two or three sided wall defects and degree II furcations
98
What is occlusal trauma?
Excessive or imbalanced forces applied to the teeth during biting and chewing in which occlusal forces exceed the physiological limit of the periodontal tissues
99
What’s the difference between primary and secondary occlusal trauma?
Primary - trauma in the absence of periodontal disease, localised remodelling with widening of PDL space occurs, no periodontal disease present and PDL fibres are overloaded
Secondary - trauma in the presence of periodontitis, may act as co-factor, increased rate of periodontal disease progression, treat periodontal disease first
100
List 4 radiographic features of occlusal trauma
Any from:
- widening of PDL space
- crescent is bone loss and angular bony defects in secondary
- funnel shaped defect coronally with primary
- hypercementosis
- root resorption (greater in primary)
- tertiary dentine formation in pulp chamber
101
What are the clinical features of occlusal trauma?
E/O - TMJ pain, TMJ click, tender MoM, masseter hypertrophy
I/O - mobility, drifting, pain when chewing, wear facets, enamel or restoration fractures, occlusal interferences, soft tissue changes, tongue scalloping, linea alba
102
How is tooth mobility treated?
Diagnosis and tx of periodontal disease
Occlusal adjustment if mobility persists as a direct result of occlusal trauma - only after perio tx
If mobility is due to lack of alveolar bone support this is not necessarily an indication for splinting
103
When is splinting indicated in occlusal trauma management?
A tooth with a health but reduced periodontium where mobility is progressive
A tooth with increased mobility that the pt finds uncomfortable during functioni
104
What should be considered when splinting?
Plaque retention - design splints that pt can clean
What technique and material will be used
105
What is peri-implant mucositis?
Inflammation of the periodontal tissues around an implant that is caused by plaque formation - reversible
106
What is peri-implantitis?
An extension of peri-implant mucositis that spreads to the supporting tissues of the implant
It results in bone loss, increasing probing depths and can cause crater-like defects in the bone around the implant seen on radiographs
In advanced cases it leads to implant mobility
107
What is the difference between peri-implant mucositis and peri-implantitis?
Peri-implantitis is the spread of inflammation from the periodontal tissues to the supporting tissues which can lead to bone loss and increased probing depths
Peri-implant mucositis is the initial stage of inflammation of the periodontal tissues and is reversible
108
How is a failing implant treated?
Range of periodontal therapies including local antibiotics and bone-supplemented GTR
Tissue transformation using bone morphogenetic protein may be useful in the future
109
What should be used to scale implants?
Plastic or carbon fibre scaling instruments - implants can be easily damaged
