Locally Delivered Antimicrobial Adjuncts To Subgingival PMPR Flashcards
Evidence for microbial aetiology
Periodontal disease has a microbiological aetiology
Koch’s postulate modified by Socransky (1979) for criteria for the evidence of microbiological basis to periodontal disease
Mechanical debridement limitations
Poorer treatment outcomes for sites with furcation involvement compared to molar flat surfaces and non molar teeth
In 600 patients maintained for an average of 22 years, the majority of teeth lost were molars with furcation involvement
Mechanical therapy may fail to remove periodontal pathogens
Microorganisms may remain in which oral tissues despite thorough mechanical debridement?
Microorganisms may remain in the following oral tissues despite thorough mechanical debridement.
•Sub epithelial gingival tissue
•Crevicular epithelial cells
•Located in the connective tissue
•Altered cementum and dentinal tubules
•Sub gingival calculus
•Anatomical features
•Colonisation of dorsum of tongue, tonsils and oral mucosa
Microorganisms may remain in the following oral tissues despite thorough mechanical debridement, therefore what do we use to target the residual bacteria?
Adjunctive agents
What is the host response to bacterial invasion and what is the consequences of this?
The host response to bacterial invasion is by mounting an inflammatory response which acts as a double edge sword by causing further periodontal destruction.
Why is the use of adjunctive agents important in treatment outcomes?
Adjunctive agents target the inflammatory response of the host and this would benefit the treatment outcomes because an inflammatory response causes further periodontal destruction
Potential Adjuncts to Professional Mechanical Plaque Removal
What is available?
Potential Adjuncts to Professional Mechanical Plaque Removal
Are they effective: what’s the evidence?
What is the UKS3 guidelines?
S3 level methodology - combined the assesment of formal evidence from 15 systemic reviews with a representative group
- it accounts for health equality, environmental factors and clinical effectiveness
- it encompasses 62 clinical recommendations for the treatment of stage 1-3 periodontitis based on a. Step wise process mapped to the 2017 classification
Clinical significance of the S3-level guidelines
To combine the evaluation of formal evidence, grading and synthesis with the clinical expertise of a broad range of stakeholders to form clinical recommendations
It is implemented for direct applicability in the uk healthcare system
Who was the S3-level guidelines developed by
European federation of periodontology (EFP)
Define periodontitis
Periodontitis is characterized by progressive destruction of the tooth- supporting apparatus.
Primary features of periodontitis
Its primary features include the loss of peri- odontal tissue support manifest through clinical attachment loss (CAL) and radiographically assessed alveolar bone loss, presence of peri- odontal pocketing and gingival bleeding
Pathophysiology of periodontitis
Periodontitis is a chronic multifactorial inflammatory disease asso- ciated with dysbiotic dental plaque biofilms.
A case of clinical periodontal health is defined by
A case of clinical periodontal health is defined by the absence of inflammation [measured as presence of bleeding on probing (BOP) at less than 10 % sites] and the absence of attachment and bone loss arising from previous periodontitis.
A case of clinical gingivitis case is defined by
A gingivitis case is defined by the presence of gingival inflammation, as assessed by BOP at ≥10 % sites and absence of detectable attachment loss due to previous periodontitis.
Localised gingivitis is defined as 10 %-30 % bleeding sites, whilst generalized gingivitis is defined a >30 % bleeding sites
A periodontitis case is defined by
A periodontitis case is defined by the loss of periodontal tissue support, which is commonly assessed by radiographic bone loss or interproximal loss of clinical attachment measured by probing.
Other meaningful descriptions of periodontitis include:
the number and proportions of teeth with probing pocket depth over certain thresholds (commonly ≥4 mm with BOP and ≥6 mm), the number of teeth lost due to periodontitis, the number of teeth with intrabony lesions and the number of teeth with furcation lesions.
An individual case of periodontitis should be further characterized using a matrix that describes the .. and … of the disease.
stage and grade
Stage is largely dependent upon the … of disease at presentation, as well as on the anticipated complexity of … … , and further includes a description of … and … of the disease in the dentition.
Severity
case management
extent and distribution
Grade provides supplemental information about … of the disease including a history-based analysis of the … of periodontitis progression; assessment of the … for further progression; analysis of possible poor outcomes of treatment; and assessment of the risk that the disease or its treatment may negatively affect the general health of the patient.
Biological features
Rate
Risk
The staging, which is dependent on the … of the disease and the anticipated complexity of case management, should be the basis for the patient’s … based on the scientific evidence of the different therapeutic interventions
Severity
treatment plan
The grade, since it provides supplemental information on the patient’s … and rate of progression, should be the basis for individual planning of care
risk factors
Criteria for defining stages of periodontitis
Criteria for defining grades of periodontitis
After completion of periodontal therapy, a stable periodontitis patient has been defined by gingival health on a reduced periodontium
What would be BOP
(bleeding on probing in <10 % of the sites; shallow probing depths of 4 mm or less and no 4 mm sites with bleeding on probing).
When, after completion of periodontal treatment, these criteria are met but bleeding on probing is present at >10 % of sites, then the patient is diagnosed as a stable periodontitis patient with gingival inflamma- tion.
Sites with persistent probing depths ≥4 mm which exhibit BOP are likely to be … and require …
It should be recognized that successfully treated and stable periodontitis patients will remain at … of recurrent periodontitis, and hence if gingival inflammation is present adequate measures for … should be implemented to prevent … periodontitis.
unstable
further treatment.
increased risk
inflammation control
recurrent
A proposed algorithm has been used by the EFP to assist clinicians with this periodontal diagnosis process when examining a new patient.
It consists of 4 sequential steps:
1) Identifying a patient suspected of having Periodontitis
2) Confirming the diagnosis of Periodontitis
3) Staging the Periodontitis Case
4) Grading the Periodontitis
Sequence for the treatment of periodontitis stages I, II and III
Patients, once diagnosed, should be treated according to a pre- established … to therapy that, depending on the dis- ease stage, should be incremental, each including different interventions.
stepwise approach
The first step in therapy is aimed at … by motivating the patient to undertake successful … and risk factor control
guiding behaviour change
removal of supra- gingival dental biofilm
The first step in therapy may include the following interventions:
- Supragingival dental biofilm control
- Interventions to improve the effectiveness of oral hygiene [motiva-
tion, instructions (oral hygiene instructions, OHI)] - Adjunctive therapies for gingival inflammation
- Professional Mechanical Plaque Removal (PMPR), which includes
the professional interventions aimed at removing supragingival plaque and calculus, as well as possible plaque-retentive factors that impair oral hygiene practices. - Risk factor control, which includes all the health behavioural change interventions eliminating/mitigating the recognized risk factors for periodontitis onset and progression (smoking cessation, improved metabolic control of diabetes, and perhaps physical exercise, dietary counselling and weight loss).
This first step of therapy should be implemented in who?
all periodontitis patients, irrespective of the stage of their disease, and should be re- evaluated frequently
Why should the first step of therapy be re- evaluated frequently?
- Continue to build motivation and adherence, or explore other alternatives to overcome the barriers
- Develop skills in dental biofilm removal and modify as require
- Allow for the appropriate response of the ensuing steps of therapy
Second step of therapy know as?
cause-related therapy
The second step of therapy (cause-related therapy) is aimed at?
The second step of therapy (cause-related therapy) is aimed at controlling (reducing/eliminating) the subgingival biofilm and cal- culus (subgingival instrumentation).
The second step of therapy (cause-related therapy) is aimed at controlling (reducing/eliminating) the subgingival biofilm and cal- culus (subgingival instrumentation).
In addition to this. the following interventions may be included:
- Use of adjunctive physical or chemical agents
- Use of adjunctive host-modulating agents (local or systemic)
- Use of adjunctive subgingival locally delivered antimicrobials
- Use of adjunctive systemic antimicrobials
This second step of therapy should be used for who?
This second step of therapy should be used for
- all periodontitis patients, irrespective of their disease stage, - only in teeth with loss of periodontal support and/or periodontal pocket formation
The individual response to the second step of therapy should be assessed when?
The individual response to the second step of therapy should be assessed once the periodontal tissues have healed (periodontal re- evaluation).
When should we consider the third step of therapy?
If the endpoints of therapy (no periodontal pockets ≥4 mm with bleeding on probing) have not been achieved and there are still deep periodontal pockets (≥6 mm) the third step of therapy should be considered.
If the treatment has been successful in achieving the end- points of therapy, what do we do?
If the treatment has been successful in achieving the end- points of therapy, patients should be placed in a supportive periodontal care (SPC) program.
The third step of therapy is aimed at?
The third step of therapy is aimed at treating those areas of the dentition not responding adequately to the second step of therapy (presence of pockets ≥4 mm with bleeding on probing or presence of deep periodontal pockets (≥6 mm)), with the purpose of gaining further access to subgingival instrumentation, or aiming at regenerating or resecting those lesions that add complexity in the man- agement of periodontitis (intra-bony and furcation lesions).
The third step of therapy may include the following interventions:
- Repeated subgingival instrumentation with or without adjunctive therapies
- Access Flap Periodontal Surgery
- Resective Periodontal Surgery
- Regenerative Periodontal Surgery
What should be taken into consideration before surgical intervention in the third step of therapy?
When there is indication for surgical interventions, these should be subject to additional patient consent and specific evaluation of risk factors or medical contra-indications should be considered.
What should occur after completion of the third step of therapy?
The individual response to the third step of therapy should be re- assessed (periodontal re-evaluation) and ideally the endpoints of therapy should be achieved, and patients should be placed in supportive periodontal care, although these endpoints of therapy may not be achievable in all teeth in severe stage III periodontitis patients.
Supportive periodontal care is aimed at?
Supportive periodontal care is aimed at maintaining periodontal stability in all treated periodontitis patients combining preventive and therapeutic interventions defined in the first and second steps of therapy, depending on the gingival and periodontal status of the patient’s dentition.
How often should supportive periodontal care occur?
This step should be rendered at regular intervals according to the patient’s needs and, at any of these recall visits, a patient may need re-treatment if recurrent disease is detected.
During supportive care, a patient may need re-treatment if recurrent disease is detected. - what do we do in these situations?
In these situations, a proper diagnosis and treatment plan should be reinstituted.
Compliance with the recommended oral hygiene regimens and healthy lifestyles are part of supportive periodontal care.
In any stage of therapy, what can occur for hopeless teeth?
In any of the steps of therapy, tooth extraction may be considered if the affected teeth have a hopeless prognosis.
Bps classifications staging and grading
Clinical recommendations: first step of therapy
Providing the periodontitis pt with adequate preventive / health promotion tools to facilitate adherence with the prescribed therapy and the assurance of adequate outcomes.
- implementation of patient motivation strategies
- behavioural changes to achieve adequate self-performed oral hygiene practices
- control of local and systemic modifiable risk factors that significantly influence this disease.
What 3 steps entail first step of therapy
- educational and preventive interventions aimed to control gingival inflammation
- professional mechanical removal of supragingival plaque and calculus
- elimination of local plaque retentive factors.
this first step of therapy represents the foundation for optimal treatment response and long-term stable outcomes.
What are the adequate oral hygiene practices of periodontitis patients in the different steps of periodontitis therapy?
- interdental brushes
- dental floss
- oral irrigators, wood sticks, etc.
As adjuncts to mechanical plaque control
- antiseptic agents, delivered in different formats, such as dentifrices and mouth rinses
other agents aimed to reduce gingival inflammation have also been used adjunctively to mechanical biofilm control, such as probiotics, anti-inflammatory agents and antioxidant micronutrients.
When gingival inflammation is present what do we teach the pt?
When gingival inflammation is present, inter-dental cleaning, preferably with interdental brushes (IDBs) should be professionally taught to patients.
Clinicians may suggest other inter-dental cleaning devices/methods when the use of IDBs is not appropriate.
In general, what is the efficacy of risk factor control in peri- odontitistherapy?
Smoking and diabetes are two proven risk factors in the etiopathogenesis of periodontitis and therefore, their control should be an integral component in the treatment of these patients.
In- terventions for risk factor control have aimed to educate and advise patients to make behavioural changes to reduce the effect of risk factors and in specific cases to refer patients for specialist medical therapy.
Other relevant factors associated with healthy lifestyles (stress reduc- tion, dietary counselling, weight loss or increased physical activities) may also be part of the overall strategy for reducing patients’ risk factors
Clinical recommendations: second step of therapy
The second step of therapy (also known as cause-related therapy) is aimed at the elimination (reduction) of the sub-gingival biofilm and calculus and may be associated with removal of endotoxin-associated root surface (cementum).
Define sub-gingival instrumentation
for all non-surgical procedures per- formed by hand (i.e. curettes) or power-driven (i.e. sonic/ultrasonic devices) instruments that are specifically designed to gain access to the root surfaces in the sub-gingival environment to remove sub-gingival biofilm and calculus.
As a prerequisite, the second step of therapy re- quires the successful implementation of the measures described in the first step of therapy.
Furthermore, sub-gingival instrumentation may be supplemented with the following adjunctive interventions
• Use of adjunctive physical or chemical agents.
• Use of adjunctive host-modulating agents (local or systemic).
• Use of adjunctive sub-gingival locally delivered antimicrobials. • Use of adjunctive systemic antimicrobials.
Does the adjunctive use of local statins improve the clinical outcome of sub-gingival instrumentation?
No
Does the adjunctive use of probiotics improve the clinical outcome of sub-gingival instrumentation?
No
Does the adjunctive use of systemic sub- antimicrobial doxycycline (SDD) to sub-gingival instrumentation improve clinical outcomes?
No
Does the adjunctive use of adjunctive chemotherapeutics (antiseptics) improve the clinical outcome of sub- gingival instrumentation?
Adjunctive antiseptics may be considered, specifically chlorhexidine mouth rinses for a limited period time, in periodontitis therapy, as adjuncts to mechanical debridement in specific cases
BSP implementations - chlorhexidine
Do adjunctive locally administered antibiotics improve the clinical outcome of sub-gingival instrumentation?1
Yes depending on the situation
Do adjunctive systemically administered antibiotics improve the clinical outcome of sub-gingival instrumentation?
The patient’s response to the second step of therapy should be assessed after …
an adequate healing period (periodontal re-evaluation)
The rationale for the third step of therapy is to …
The rationale for the third step of therapy is to treat those sites that do not respond adequately to the second step of therapy.
The purpose of the third step is to access non-responding sites and to regenerate or eliminate those lesions that add complexity to the management of periodontitis (intrabony and furcation lesions).
It may include the following interventions:
- Repeated subgingival instrumentation with or without adjunctive therapies
- Access Flap Periodontal Surgery [113]
- Resective Periodontal Surgery
- Regenerative Periodontal Surgery
How effective are access flaps as compared to repeated subgingival instrumentation?
How effective are access flaps as compared to repeated subgingival instrumentation?
