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basic oral and dental care > clinical management of perio disease > Flashcards

clinical management of perio disease Flashcards

1
Q

What are the goals?

A

Restore health
Eliminate disease
Improve quality of life
Clinical goals

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2
Q

What is oral health?

A

A state of health of the teeth and supporting tissues and of efficiency, as is reasonable to safeguard general health
GENERAL DENTAL SERVICES REGUALTIONS

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3
Q

What is disease?

A

Medically defined abnormalities in anatomical structures +/ physiological/biochemical processes

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4
Q

What are the clinical goals?

A 
No progression
Reduction in probing depth
No probing depth >5mm
No BOP
No smoking
Plaque score <20% surfaces
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5
Q

What might affect the treatment?

A 
Susceptibility to genetic factors
Plaque control
Previous perio disease
Smoking
Stress
Some systemic diseases
Diet
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6
Q

What is our treatment strategy?

A

Initial treatment
Cause-related therapy
Non-surgical treatment
Surgical treatment

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7
Q

What is initial management?

A 
Emergency treatment 
Extraction of hopeless teeth
OHE
Plaque control
Correction of plaque retentive factors
PMPR
Initial occlusal adjustment
Reassessment and monitoring
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8
Q

What does the oral hygiene in the prevention of perio diseases study show?

A

Single OHE instruction + toothbrush demo + PMPR = +ve effect on reduction of gingival inflammation in adults w gingivitis

Lack of evidence that toothbrush designs differ

Brushing 2x daily probably optimal

Most people aren’t effective brushers

Rotation/oscillation powered- reduce plaque and gingivitis more than manual (which reduces 1/2)

Tepes quicker and more effective than floss

Special tailored advice and monitoring

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9
Q

Cochrane reviews in 2019 studies showed?

A

Floss/Tepes + tooth brushing may reduce plaque/gingivitis more than tooth brushing alone

Tepes more effective than floss?

Evidence for tooth cleaning sticks and oral irrigators- limited and inconsistent

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10
Q

What does other recent evidence show?

A

Tepes are most effective interdentally

Flossing isn’t effective

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11
Q

What does non-surgical treatment involve?

A

Remove plaque retentive factors
PMPR
PMPR of perio pockets 4+mm under LA
1 month oral health check
Review 3 months following complete treatment
Further treat of non-responding sites
Methods of delivery (quadrant v full mouth)

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12
Q

What is subgingival PMPR?

A 
Pockets 4+mm
Remove sub gingival plaque/calculus
Removal of surface toxins
Under LA
Predominantly ultrasonic
Periodontal hoes (files of needed)
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13
Q

Quadrant or full mouth approach?

A

Systemic review 2008- no difference

2005- single visit full mouth debridement may have limited additional benefit and quicker

2006 w 1 year follow up- no difference of reoccurrence of pockets

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14
Q

What are we looking for during review at 1 month?

A

Symptoms
Risk factors
Plaque score

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15
Q

What are we looking for during review at 3 months?

A 
Plaque scores
Probing depths
Bleeding indices
Mobility scores
Recession 
Furcation
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16
Q

What outcomes are we aiming for with subgingival PMPR?

A

Reduced probing depth
Less bleeding
No suppurations
Improved tissue contour

However, might have
Recession
Increased sensitivity
Other complications

17
Q

Is perio treatment effective?

A

Cobb 2002

Greatest changes in probing depths and attachment levels occur within 1-3 months post treatment

18
Q

When is perio treatment complete?

A

Residual pocket depths 6+mm represent incomplete

Residual pocket depth 6+mm and BOP 30+% represent tooth loss risk

11 years maintenance care- 2008 study

19
Q

Is perio treatment effective?

A

Published work- tooth loss during (2.4%, 5.5%, 2.2-13.2%) overall (2.3%, 16.6%, 8.4%)

Patient reported outcome measures- PROMS, questionnaires against other surgery’s eg. Hip replacement

20
Q

How is perio monitored?

A 
Probing depths
Recession 
Inflammation (bleeding)
Plaque control
Mobility
Drifting/immigration
Dentine sensitivity

Remotivate
Patients need to be able to clean sub gingivally
Think about reinfection tissues and episodic nature of disease
Risk profiles can change during

21
Q

What did Mombelli 2019 think about maintenance?

A

Mandatory for long term success
Patient and dental team need to work closely together
Combine efforts for plaque control and risk control

22
Q

What did Echeverría 2019 think about maintenance?

A

Perio can be treated but not eradicated
Personal maintenance- continuous removal of bacteria at gingiva level + professional assistance
Patient compliance, adherence and persistence for long term success

23
Q

What are some limitations of clinical measurements and radiographs?

A

Errors in probing depth measures
BOP (low sensitivity, smoking, medication, flow between sites)
Absence of bleeding (higher sensitivity)

Radiographs show hard calcified tissue only
Inter/intra operator variance and angulation
Patient factors and tolerance

24
Q

What are BSP guidelines on antimicrobials?

A

Little place in routine treatment
Antibiotic resistance increasing
Limit unless clear evidence base
Drainage of infection and removal of cause still pertinent
Few times where systemic/locally applied agents appropriate

25
Q

What is the role of systemic antibiotics?

A

Severe rapidly progressive forms of disease
Refractory disease
Necrotising forms of perio
Abscesses

26
Q

What antibiotics can be prescribed for severe rapidly progressing perio?

A 
Metronidazole 400mg (not to be had w alcohol or pregnant or warfarin) +
amoxicillin 500mg- both TDS 7 days

Azithromycin 500mg daily 3 days
~increased risk abnormal heart rhythm

Caution w statins and other drugs

27
Q

What is the role of locally applied antibiotics?

A

Metronidazole (Elyzol)

Chlorhexidine (PerioChip)

Minocycline (Dentomycin)

Often in gel form

Few sites? Poor response to debridement? Deep site? Repeat applications?

Limited evidence, minimal benefit

28
Q

What is the role of perio surgery?

A

Non responsive sites
Access for effective instrumentation
Improve gingival/tooth morphology for cleaning
Regenerate lost perio attachment

Flap surgery- open flap debridement
Gingivectomy- cut back tissues

29
Q

What guidelines do we follow?

A

EFP S3 lvl clinical practice 2020

BSP implementation of European S3 lvl treatment 2021

30
Q

What are the steps of the BSP guidelines?

A
  1. Building foundations for optimal treatment outcomes (behavioural change and risk factor control)
  2. Subgingival instrumentation
  3. Managing non-responding sites
  4. Maintenance (supportive perio care)
31
Q

How can foundations be built for optimal treatment outcomes?

A

Explain disease, risk factors, alternatives, pros and cons and no treatment
OHE importance
Reduce risk factors (plaque retentive features, smoking cessation, diabetes control)
Tailored OHE (interdental cleaning, PMPR etc)
Select recall period based on guidance and risk factors

32
Q

How do we reevaluate the patient?

A

Non engaging patient= return to step 1

Engaging patient= plaque scores 20% or less, bleeding 30% or less (or 50% improvement) OR meet personal care plan

33
Q

How is subgingival instrumentation implemented?

A

Reinforce OHE, risk factor control, behaviour change
Hand +/ powered PMPR
Use of systemic antimicrobials if needed

1 month review after this to reinforce OHE plus plaque score, review Tepe sizes and any post-op complications

Review after 3 months- full perio assessment
If unstable= step 3
If stable= step 4

34
Q

How do we manage non-responding sites?

A 
Reinforce OHE, risk factor control, behaviour change
If moderate (4-5mm) pockets, reperform PMPR
If deep (6+mm) pockets, consider alternative causes
Consider referral or reperform sub PMPR
35
Q

How do we do maintenance?

A

Reinforce OHE, risk factor control, behaviour change
Regular targeted PMPR to limit tooth loss
Consider toothpaste/mouth wash to control inflammation

Recall 3-12 months
Need to maintain stability
If recurrent disease- re assess

36
Q

What is the supportive care phase?

A

Aim to prevent reinfection/reoccurrence of disease

Successfully treated patients remain at high risk for reoccurrence or progression

37
Q

What must recall visits include?

A 
Med and smoking history update
Oral hygiene assessment
Full perio charting
Sensibility testing of suspecting teeth
OHE
PMPR
Fluoride on exposed roots
Assess prostheses
Radiographic evaluation
3-12 month recalls

basic oral and dental care (49 decks)

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