ICP L28: Management of patients with gingivitis and periodontitis

Question 1

Outline the pathogenesis of periodontal disease

Answer 1

It is exaggerated and poorly effective non-resolving inflammation of the connective tissues supporting teeth leading to tooth destruction which is mediated by an inflammatory immune response to bacteria in the oral biofilm

Question 2

What factors can make the host more susceptible to periodontitis

Answer 2

Genetics - congenital detects in immunity, age
Systemic disease - DM, obesity, CVD, immunodeficiency
Environmental - smoking, diet, stress

Question 3

Outline the signs and symptoms of gingivitis

Answer 3

Inflammation of the gums due to plaque accumulation characterised by: erythema, oedema, tenderness, enlargement, swelling, redness and some complain of halitosis, altered taste, difficulty eating and reduced QoL

There is bleeding on probing with no bone loss (therefore it is reversible) - X-rays do not aid diagnosis

Question 4

Define a case of periodontitis

Answer 4

1. Interdental attachment loss is detectable at >=2 non-adjacent teeth or
2. Buccal/ oral attachment loss >=3mm with pocketing >=3mm is detectable at >=2 teeth

Question 5

What causes other then periodontitis can CAL be a result of

Answer 5

Clinical attachment loss can occur due to

• Gingival recession of traumatic origin
• Dental caries extending into cervical area of tooth
• Presence of CAL on distal aspect of second molar associated with malposition/extraction of third molar
• Endodontic lesion draining through the marginal periodontium
• Vertical root fracture

Question 6

Outline the signs and symptoms of periodontitis

Answer 6

• Supra/sub gingival plaque/calculus accumulation
• Erythema, oedema, tenderness, enlargement, swelling, redness, suppuration (pus out of sulcus), gum recession, halitosis
• Pocket formation, bleeding on probing and suppuration
• Loss of periodontal attachment
• Irreversible loss

Question 7

Describe probing on health teeth

Answer 7

In health the tooth is surrounded by a sulcus - the JE forms the base of the sulcus by attaching to the enamel of the crown near the CEJ

Depth = 1-3mm

Question 8

Describe probing on a diseased tooth

Answer 8

A periodontal pocket (deepened gingival sulcus) due to disease - the JE forms the base of the pocket by attaching to the root surface apical to CEJ

Depth = >3mm

Question 9

Define PPD

Answer 9

Probing pocket depth = distance from gingival margin to tip of probe (cannot be sure if probe reaches base of sulcus)

Question 10

Define PAL/CAL

Answer 10

Probing/Clinical attachment loss = distance from CEJ to tip of probe this needs measurement between free gingival margin and CEJ :

PAL/CAL = [ PPD - (CEJ-FGM) ]

Question 11

Define gingival recession

Answer 11

Distance from gingival margin to CEJ, when gingival margin is apical to CEJ = negative, when gingival margin is coronal to CEJ = positive (due to pseudo pocket - gingival overgrowth)

Question 12

What are the therapeutic objectives of gingivitis

Answer 12

• Control risk factors
• Improve patients compliance and effectiveness of oral hygiene by motivating patient to achieve successful removal of supra gingival dental biofilm (FMPS <20%)
• Reduce/eliminate gingival inflammation (FMBS <10%)

Question 13

What are the therapeutic objectives of periodontitis

Answer 13

• FMPS <20%
• FMBS <10%
• Stop periodontitis progression and reduce PPD - the aim is to reach closed pockets (no PPD>4mm and BoP)

Question 14

Outline the step wise approach for periodontitis treatment (each new stage includes the previous one)

Answer 14

1. Behavioural change by motivating patient to remove supra gingival biofilm and control risk factors
2. Control sub gingival biofilm and calculus (sub gingival instrumentation)
3. Treat >=4mm PPD with BoP/deep pockets >=6mm to gain further access to sub gingival instrumentation/ aim at regeneration or resecting the residual lesions
4. Supportive periodontal care aimed at maintaining periodontal stability by combining preventative and therapeutic interventions

Question 15

Outline step 1 of periodontitis therapy

Answer 15

• supra gingival biofilm control : mechanical and chemical
• interventions to improve effectiveness of oral hygiene
• adjunctive therapies for gingival inflammation
• professional mechanical plaque removal (hygienists using a scaler, curette and sonic/ultrasonic instruments)
• risk factor control

= foundation for optimal treatment response and long-term stable outcomes

Question 16

Outline step 2 of periodontitis therapy

Answer 16

Eliminate/reduce sub gingival biofilm and calculus using

• physical/chemical agents
• host modulating agents
• sub gingival antimicrobials
• systemic antimicrobials
• debridement, scaling and root planing to reduce plaque levels, inflammation and PPD and gain attachment level and recession

Question 17

What is debridement

Answer 17

Removal of soft sub gingival deposits

Question 18

What is scaling

Answer 18

Removal of hard calcified deposits

Question 19

What is debridement

Answer 19

Removal of soft sub gingival deposits (laser + air polishing)

Question 20

What is scaling

Answer 20

Removal of hard calcified deposits (ultrasonics)

Question 21

What is root planing

Answer 21

Removal of pathological cement through the reshaping of the root surface (curette)

Question 22

Outline healing after sub gingival instrumentation

Answer 22

Debridement, scaling, root planing

PPD reduction due to recession of marginal tissues (depending on phenotype and oedema - more evident when there is less KT) and clinical attachment level gain (due to long JE and reduction of oedema)

Question 23

Why is the formation of long junctional epithelium beneficial in periodontitis patients

Answer 23

Because it creates a more shallow pocket that is easier for the patient to clean - the destruction of bone, cementum and PDL loss remains