Clinical management of periodontal disease Flashcards
Goals of periodontal therapy
- Restore health/ eliminate disease
- Improve px’s quality of life
- Clinical goals
What is health?
“A complete state of physical, mental and social well being, not merely the absence of disease” - WHO 1948
What is disease?
“medically defined abnormalities in anatomical structures and/ or physiological/ biochemical processes”
What is illness?
“individuals experience or subjective perception of changes in physical, mental and social well-being”
What is oral health?
“such a state of health of the teeth,
supporting tissues, and of efficiency, as is
reasonable to safeguard general health”
Dental components of quality of life
• Functional: Chewing/Talking
• Social: Smiling without embarrassment.
• Measured by Indices such as Oral Health
Impact Profile (OHIP) Slade 1997.
Clinical goals criteria (Lang et al)
no progression. < in probing depths. no probing depth > 5mm. no bleeding on probing. no progression. no smoking plaque score < 20% surfaces
Treatment strategy
Initial treatment
Cause-related therapy
Non-surgical treatment
Surgical treatment
Principles of periodontal therapy
Structured approach
Chronic gingivitis and periodontitis: anti-infectious approach
-reduce total bacteria load
Initial treatment
Relief of pain
Diagnosis and treatment plan
Extraction of hopeless teeth
• Emergency treatment (where necessary)
• Extraction of teeth which are irrational to treat
• Px info
• Plaque control including correction of plaque retention factors
• Root surface debridement
• Initial occlusal adjustment (where necessary)
• Reassessment and monitoring
What is adequate oral hygiene?
“such a level of plaque control as is compatible
with periodontal health for an individual.”
Non-surgical treatment
• Removal of plaque retention factors (includes
scaling & correction of restoration margins)
• Root surface debridement/ disinfection where required. (>4mm pd)
• Review
• Further treatment of non-responding sites
(further RSD, antimicrobials)
Surgical treatment
• Improved access to non-healing sites • Tissue recontouring to allow better plaque control *oral hygiene must be adequate* -flap surgery: open flap debridement -gingivectomy
Reasons for maintenance and monitoring
- Re-motivation.
- Patients cannot clean subgingivally
- Re-infection issues.
- Episodic nature of disease
Monitor
- Attachment loss
- Plaque control
- Inflammation
- Mobility
- Recession
- Drifting/migration
Limitations of probing
• Inter/intra operator variance • Probe design • Patient factors • Tissue factors • BPE *Computer controlled probes: The Florida Probe (0.3-0.8mm accuracy)*
Limitations of bleeding
- Low sensitivity/specificity
- Smoking
- Medication
- Flow between sites
Limitations of absence of bleeding
Higher sensitivity/ specificity
Limitations of radiographs
- Show hard/calcified tissue only
- Inter/intra operator variance, angulation
- Processing consistency
- Px factors, tolerance/dosage
FGDP radiography guidelines
< 5mm uniform pocketing & little or no recession –
horizontal bitewings
5mm pocketing – vertical bitewings + PAs as
necessary
Irregular pocketing – bitewing (H or V) + PAs
Alternatively panoramic of optimal quality + PAs as
necessary
Risk factors
- Genetics
- Age
- Previous periodontal disease
- Smoking
- Stress
- Alcohol
- Diabetes
- Diet
Success rates, measured by percentage of teeth lost during fixed maintenance period
- Average: 13%.
- Canines: 0.2%
- Molars: 29%
- Figures for untreated teeth are not known!
Average tooth loss per year as a measure
Treated patients (good compliance): 0.1 Treated patients (poor compliance): 0.2 Untreated patients: 0.6
Toothbrushing
Lack of evidence that one specific toothbrush design is superior to another
Brushing twice daily probably optimal
Most people not effective brushers
Manual brushes on average reduce plaque scores by half
-rotation/ oscillation powered toothbrushes < plaque and gingivitis compared to manual
Single oral hygiene instruction + toothbrush demonstration + sclaing
Significant albeit small positive effect on reduction of gingival inflammation in adults with gingivitis
Toothpaste
Triclosan /zinc citrate & triclosan/copolymer toothpastes have significant albeit small +ve effects on plaque reduction & gingivitis
Toothpastes to < calculus formation also available -usually contain a pyrophosphate or zinc system
Interdental cleaning
Routine recommendation to use floss not supported by scientific evidence
-many studies show no benefit of flossing on plaque or gingivitis.
Interdental brushes < time consuming and > efficacious than floss for interdental plaque removal
Decision on which to use based on local anatomy and dexterity of individual px
-has to be sufficient space to use interdental brush
Quadrant vs full-mouth approach
Similar outcomes
Single visit full-mouth mechanical debridement (ultrasonic) may have limited additional benefit over a quadrant approach – but completed in a shorter time
No difference in incidence of recurrence of diseased periodontal pockets between full-mouth ultrasonic debridement vs traditional quadrant approach – 1 year follow up
Review at 1 month
Symptoms, risk factors and plaque scores
Review at 3 months
Plaque scores, probing depths, bleeding indices, mobility scores
RSD outcomes
Positive -< probing depths -< bleeding -no supparation -> tissue countour Negative -recession -> sensitivity -other complications
When is periodontal treatment complete?
Residual probing depths ≥ 6mm represent incomplete perio treatment, require further therapy
Residual probing depths ≥6mm & BoP ≥30% represent risk for further tooth loss
Role of systemic antibiotics
Aggressive forms of disease “Refractory” disease Necrotising forms of periodontal diseases Severe disease Abscesses
Aggressive periodontitis antibiotics
Metronidazole (400mg) and amoxicillin (500mg) both TDS, 7 days
Azithromycin 500mg daily for 3 days
caution with statins and other drugs
Locally applied antimicrobials
Metronidazole (Elyzol)
Chlorhexidine (PerioChip, Chlosite gel)
Minocycline (Dentomycin)
