clinical management of perio disease Flashcards
What are the goals?
Restore health
Eliminate disease
Improve quality of life
Clinical goals
What is oral health?
A state of health of the teeth and supporting tissues and of efficiency, as is reasonable to safeguard general health
GENERAL DENTAL SERVICES REGUALTIONS
What is disease?
Medically defined abnormalities in anatomical structures +/ physiological/biochemical processes
What are the clinical goals?
No progression Reduction in probing depth No probing depth >5mm No BOP No smoking Plaque score <20% surfaces
What might affect the treatment?
Susceptibility to genetic factors Plaque control Previous perio disease Smoking Stress Some systemic diseases Diet
What is our treatment strategy?
Initial treatment
Cause-related therapy
Non-surgical treatment
Surgical treatment
What is initial management?
Emergency treatment Extraction of hopeless teeth OHE Plaque control Correction of plaque retentive factors PMPR Initial occlusal adjustment Reassessment and monitoring
What does the oral hygiene in the prevention of perio diseases study show?
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
Cochrane reviews in 2019 studies showed?
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
What does other recent evidence show?
Tepes are most effective interdentally
Flossing isn’t effective
What does non-surgical treatment involve?
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)
What is subgingival PMPR?
Pockets 4+mm Remove sub gingival plaque/calculus Removal of surface toxins Under LA Predominantly ultrasonic Periodontal hoes (files of needed)
Quadrant or full mouth approach?
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
What are we looking for during review at 1 month?
Symptoms
Risk factors
Plaque score
What are we looking for during review at 3 months?
Plaque scores Probing depths Bleeding indices Mobility scores Recession Furcation
What outcomes are we aiming for with subgingival PMPR?
Reduced probing depth
Less bleeding
No suppurations
Improved tissue contour
However, might have
Recession
Increased sensitivity
Other complications
Is perio treatment effective?
Cobb 2002
Greatest changes in probing depths and attachment levels occur within 1-3 months post treatment
When is perio treatment complete?
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
Is perio treatment effective?
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
How is perio monitored?
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
What did Mombelli 2019 think about maintenance?
Mandatory for long term success
Patient and dental team need to work closely together
Combine efforts for plaque control and risk control
What did Echeverría 2019 think about maintenance?
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
What are some limitations of clinical measurements and radiographs?
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
What are BSP guidelines on antimicrobials?
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
What is the role of systemic antibiotics?
Severe rapidly progressive forms of disease
Refractory disease
Necrotising forms of perio
Abscesses
What antibiotics can be prescribed for severe rapidly progressing perio?
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
What is the role of locally applied antibiotics?
Metronidazole (Elyzol)
Chlorhexidine (PerioChip)
Minocycline (Dentomycin)
Often in gel form
Few sites? Poor response to debridement? Deep site? Repeat applications?
Limited evidence, minimal benefit
What is the role of perio surgery?
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
What guidelines do we follow?
EFP S3 lvl clinical practice 2020
BSP implementation of European S3 lvl treatment 2021
What are the steps of the BSP guidelines?
- Building foundations for optimal treatment outcomes (behavioural change and risk factor control)
- Subgingival instrumentation
- Managing non-responding sites
- Maintenance (supportive perio care)
How can foundations be built for optimal treatment outcomes?
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
How do we reevaluate the patient?
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
How is subgingival instrumentation implemented?
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
How do we manage non-responding sites?
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
How do we do maintenance?
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
What is the supportive care phase?
Aim to prevent reinfection/reoccurrence of disease
Successfully treated patients remain at high risk for reoccurrence or progression
What must recall visits include?
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
