CDS Perio Flashcards
What are the SDCEP ideal outcomes of periodontal treatment?
Plaque scores below 15%
Bleeding scores below 10%
Probing depths 4mm or less and no bleeding at 4mm sites
What symptoms is a patient likely to have at periodontal review?
Sensitivity - tissue has shrunk because of reduced inflammation
Patients should be warned of this before step 2
How should post treatment sensitivity be handled in perio patients?
Reassurance
High fluoride toothpaste
Non responding site
A site where deep probing depths remain and have not improved (>4mm or 4mm with bleeding) after supra and subgingival instrumentation
Possible mechanisms for smoking increasing periodontal disease
- Systemically compromising the innate and adaptive immune response
- Topical reduced tissue vascularity influencing any subsequent wound healing of the affected tissues
Clinical outcomes of gingival recession
Dentine hypersensitivity
Aesthetic concerns
Plaque retention and inflammation
Tooth abrasion
Root caries
Step 1 perio treatment
Addressing risk factors
Plaque control
Supragingival scaling
Step 2 periodontal treatment
Subgingival scaling
What must all patients be warned of before commencing perio treatment?
Risk of gingival recession
Can cause aesthetic concerns, sensitivity
Predisposing factor to aesthetic concerns with gingival recession
High smile line
TIPPS
Talk
Instruct
Practice
Plan
Support
How long after step 2 treatment do you re-evaluate and why wait?
8-12 weeks
To allow healing
What else must be done if using systemic antibiotics in perio and why?
Mechanical biofilm disruption
The biofilm will have ~500 species of microbe embedded in a matrix, protecting them from antimicrobials, once this is done the bacteria in the mouth will be disorganised, then when hit with antibiotics it will be effective
Which group of people can have increased BOP with improvement in pocket depths?
Previous smokers who have quit
How might a periodontal emergency present?
Pain
Swelling
Tooth mobility
Bleeding
Pus discharge
Lymphadenopathy
Ulceration
Why is the HPC/pain history important when a periodontal emergency presents?
To help determine whether the pain is due to a pulpal cause or periodontal cause
Periodontal emergency
When an acute condition involving the periodontium causes pain, forcing the patient to seek urgent care, usually with GDP as the first port of call
May involve pain, swelling, tooth mobility, bleeding, suppuration, lymphadenopathy, ulceration
Why is timely management of periodontal emergencies necessary?
To prevent further damage to the periodontium, as well as improving the patient’s physical and psychological wellbeing, and prevent spread of infection
3 important considerations in treatment of a periodontal emergency
Partially erupted and impacted mandibular third molar
Nail biting habit - foreign body can cause gingival abscess
HPC/ pain history - try to determine whether pulpal or soft tissue origin
Investigations for periodontal emergency
- Radiographs to check whether periodontal patient
- Sensibility testing - is pulp involved
- TTP
- Clinical exam - hard or soft, is there a pocket, where is the lesion, is tooth heavily restored
Typical appearance of an endo-perio lesion radiographically
J shaped lesion
Grades of endo-perio lesions
1 - narrow deep perio pocket in one tooth surface
2 - Wide perio pocket in one tooth surface
3 - Deep perio pockets in more than one tooth surface
What must you include in an endo-perio lesion diagnosis?
Whether it is a periodontal patient or not, whether there is root damage and what, and a grade
What is the diagnosis and why
Endo perio lesion (J shape)
in periodontitis patient (bone loss) with no root damage, grade 3 (deep perio pocket affecting more than one surface)
Treatment options for endo-perio lesion
Extirpate the pulp or XLA
Debride the pocket to drain pus
Antibiotics if systemic symptoms - pen V 500mg 4x daily 4 days or if allergic 400mg metronidazole 3x daily 5 days
Recommend 0.2% chlorhexidine 10ml 2x daily one minute or 6% H2O2 for 2 minutes
What is the difference between pericoronitis and a peri-coronal abscess?
Pericoronitis is inflammation of the soft tissues surrounding the crown of a partially erupted tooth
A peri-coronal abscess is the localised accumulation of pus within the overlying gingival flap surrounding the crown of an incompletely erupted tooth
What is the difference between necrotising gingivitis and necrotising periodontitis, and how would you tell them apart?
Necrotising periodontitis includes destruction of bone
You would need a radiograph to tell them apart
What is this?
Necrotising gingivitis (or necrotising periodontitis, but this can not be diagnosed without radiographs to see whether there is bone loss)
Characteristic symptoms of necrotising gingivitis/periodontitis
Very severe pain
Punched papilla and yellowish slough appearance
Can have systemic symptoms like lymphadenopathy, malaise
What is the difference between necrotising periodontitis and necrotising stomatitis?
Necrotising stomatitis has spread away from the periodontal tissues (for example to the palate etc)
Causative factors in necrotising periodontal diseases
Commensal bacterial organisms - opportunistic infection
Underlying risk factors for necrotising periodontal diseases
Stress, compromised host immune response (HIV etc), lack of sleep, smoking, poor OH, poor nutrition
Often a healthy individual with an accumulation of lots of risk factors
Antibiotics for necrotising periodontal disease
Only when systemically unwell or the condition does not improve with debridement
400mg metronidazole 3x daily 5 days
Contraindications - warfarin, pt must not drink alcohol
How would you treat a patient with necrotising periodontal disease?
Debridement of necrotic tissue with local anaesthetic daily, deeper/more as the patient builds up a tolerance
Advise chlorhexidine 0.2ml 2x daily
Describe the clinical presentation
Erosive lesion on the attached gingiva
Mixed red and white appearance with yellow fibrin layer
Chemical burn (this is from phosphoric acid)
Treatment of chemical burn
Eliminate the initiating factor if required, analgesia, usually heal without intervention
Surgery to cover recession if aesthetic zone
Avoid brushing the area for a few days
What blood test would you carry out to determine how well controlled someone’s diabetes is? What score would denote that it is well controlled?
Hba1c
<48mmol/mol
What information can be gained from Hba1c test?
Haemoglobin glycation over a period of 3 months - because this is the life span of a red blood cell
Why is Hba1c useful in diabetics?
It gives us an indication as to how much haemoglobin glycation has occurred over the past 3 months and therefore the levels of AGEs, which are thought to be the major causes of diabetic complications
This tells us how well controlled someone’s diabetes is
What is the fourth step of periodontal therapy?
Supportive periodontal care
A specific SPC programme will be designed considering the patient’s individual factors
What are three key considerations when designing a SPC plan?
Interview
Assessment
Evaluation
What is relevant when interviewing a patient to plan a SPC regime?
elicit information on periodontal health symptoms, MH and SH, risk factors, plaque control regime and patient motivation, and treatment carried out
What is relevant when assessing a patient in order to design a SPC regime?
Plaque and calculus deposits, periodontal health including inflammation, PPDs and bleeding pockets
What is relevant when evaluating a patient in order to design a SPC plan?
Evaluate intervention needs including risk factor management, oral hygiene and re-treatment
Potential practical intervention aspects of an SPC plan
Oral hygiene coaching
Instrumentation of supra and sub-gingival plaque and calculus
Treatment of sites with recurrence or residual periodontitis
Planning aspects of an SPC regime?
Interval before next visit and which member of the dental team should undertake this visit
Ideal Hba1c for diabetics
48mmol/mol 6.5% or below
Normal range for HbA1c in non diabetics
4%-5.6%
How do AGEs act on the body
Causing intracellular damage and apoptosis
Roughly how often would you 6ppc in a stable periodontal patient having SPC?
Annually
Why is 4mm decided as the pocket depth for stability?
Up to 4mm, the patient has influence on the environment in this pocket with their home oral hygiene practices
Anything more than 4mm in impossible to maintain at home - you are leaving anaerobic bacteria in anaerobic environment for months between visits
A Insertion of perio probe
B Top of pocket
C Probing depth
D Attachment level
E Gingiva
F Alveolar bone
G Root surface
H Periodontal ligament
I Base of pocket
J Pocket
K Cement-enamel junction
L Enamel
What is the likely cause of localised severe recession of the lower labial gingivae?
Traumatic overbite
Why are lower incisors more at risk of gingival recession with a traumatic overbite?
Thin gingival biotype
Thin buccal plate
What symptoms might a patient be concerned about in gingival recession caused by a traumatic overbite?
Dentine hypersensitivity
Poor aesthetics
Root caries
What does a diagnosis of peri-implant health require?
Absence of clinical signs of inflammation
Absence of bleeding or suppuration on gentle probing
No increase in pocket depth compared to previous examinations
Absence of bone loss beyond crestal bone level changed from initial bone remodelling
No more than a single bleeding spot - not a line of bleeding around the collar
Peri implant mucositis
Presence of bleeding and/or suppuration on gentle probing with or without increased PD compared to previous examinations
Absence of bone beyond crestal bone level changes resulting from initial bone remodelling
Peri implantitis
Peri implant biofilm associated pathological condition occurring in tissues around dental implants, and characterised by inflammation in peri-implant mucosa and subsequent progressive loss of supporting bone
Clinical presentation of peri implantitis
Inflammation
BOP
Suppuration
Increasing probing depths
Recession of the mucosal margin
Routing periodontal exam of implants
NOT BPE
6ppc of all implants - in health or disease
% of implant patients with peri implantitis
22
(43% with peri implant mucositis)
Predisposing systemic factors to peri- implant disease
History of severe periodontitis
Poor plaque control
No regular supportive peri implant care
Smoking
Diabetes
Local factors that predispose to peri-implant diseases
Submucosal cement
Positioning of implants limiting access to oral hygiene and maintenance
Absence of peri-implant keratinised mucosa
Occlusal overload
Presence of titanium particles within peri-implant tissues
Bone compression necrosis, overheating, micromotion or biocorrosion
How to assess a dental implant and its restoration
Look for inflammation or infection
Check oral hygiene
Probe around the implant restoration
Check the restoration for signs of cracks, loosening, cleansability
