non-surgical management of plaque-related periodontal disease Flashcards
what percentage of patients will have periodontitis
- 50%
- 80% will have gingivitis
- 10-15% will have severe periodontitis
what is the BPE
- basic periodontal exam
- simple and rapid screening tool that is used to indicate the level of further examination needed and provide basic guidance if needed
- represent a minimum standard of care
what should the BPE be used for
- for screening only and not for diagnosis
how do you record the BPE
- dentition is split into 6 extents and highest score for each sextant is recorded
- all teeth in each sextant are examined
- for sextant to qualify must contain 2 teeth
- a WHO probe is used
- probe is walked around each tooth in each sextant
what are the sextants
- 17 to 14
- 13 to 23
- 24 to 27
- 37 to 34
- 33 to 43
- 44 to 47
what is the WHO probe like
- has a ‘ball end’ of 0.5mm in diameter and a black band from 3.5mm to 5.5mm
- light probing force should be used = enough to blanche a fingernail
how is the probe used
- all sites should be examined to ensure that the highest score in the sextant is recorded
- if a code of4 is identified in a sextant, continue to examine all sites in the sextant
- this will make sure that any furcation involvement is not missed
what does a BPE score of 0 mean
- pockets <3.5mm, no calculus, no bleeding on probing and black band completely visible
what does a BPE score of 1 means
pockets <3.5mm, no calculus/overhangs, bleeding on probing and black band completely visible
what does a BPE score of 2 mean -
pockets<3.5mm, supra or sub gingival calculus/overhangs, black band completely visible
what does a BPE score of 3 mean
- pocket depths of 3.5mm-5.5.mm black band partially visible indicating a pockets
what does a BPE score of 4 means
- probing depth of >5.5mm black band disappears indicating pocket of 6mm or more
what does a * mean on BPE chart
- furcation involvement
what do you do for patients with a BPE score of 0,1 or 2
should be recorded at every routine examination
what do you do for patients with BPE code 3 or 4
- more detailed periodontal charting is required
what must you do for BPE code 3
- initial therapy including self-care advice (oral hygiene instruction and risk factor control) then post initial therapy and record 6PPC in that sextant only after treatment
what must you do for BPE score of 4
- if score of 4 in any sextant then do a 6PPC through whole mouth
why can’t BPE be sued to monitor the reasons to periodontal therapy
- it does not provide information about how sites within a sextant change after treatment
- 6PPC must be sued to record pre and post treatment
where should BPE not be used
- around implants
what radiograph is regarded as the gold standard to be taken for scores of 3 or 4
- periapical
what level of pocket must you record for 6PPC
- only over 4mm
how do you interpret a BPE score of 0
no need for periodontal treatment
how do you interpret a BPE score of 1
oral hygiene instruction (OHI)
how do you interpret a BPE score of 2
as for code 1, plus removal of plaque retentive factors, including all supra and sub gingival calculus
how do you interpret a BPE score of 3
- as for code 2 plus RSD if required
how do you interpret a BPE score of 4
OHI, RSD and assess the need for more complex treatment, refer to specialist if need be
how do you interpret a * BPE
treat according to BPE code and assess the need for more complex treatment and referral to specialist may be indicated
what are the 2 guidelines to follow for BPE of score 3
- BSP guideline
- SDCEP
what are the BSP guidelines for a score of 3 BPE
- if a sextant scores 3, it should be revised AFTER treatment and a 6PPc completed for that sextant only after treatment
what are the SDCEP guidelines for a score of 3 BPE
- a 6PPC should be completed for that sextant BEFORE treatment and AFTER
- full period exam of all teeth ad root surface instrumentation where necessary = where code 3 is observed in only one sextant, carry out only in that sextant
what else can non surgical management known as
- cause related therapy
- hygiene phase therapy (HPT)
what is the aim of periodontal therapy
- to arrest the disease
- ideally, to regenerate lost tissue
- to maintain periodontal healthy long term
- result = keep teeth
- important patient knows why they need to come
what occurs along with periodontitis
- gum recession,
- bone loss,
- loss of attachment,
- calculus,
- plaque,
- inflamed gums
what is the treatment plan
emergency care –> disease control –> re-evaluation –> reconstruction –> supportive care
what occurs in the disease control phase of the treatment plan
- extraction of hopeless teeth
- hygiene phase therapy
- caries management
- endodontic therapy
- provisional prostheses
what can periodontal therapy do
- supra gingival plaque control - including scaling
- if get it right, can get return of health
- can get reappearance of gingiva stippling, knife edge margin return
- can remove plaque and calculus and staining
what is an effect of periodontitis
- loss of attachment and true pocket formation colonisation of the root surface
- with the presence of a pocket, you have to worry about removing the biofilm in the pocket as well
how fast will a pocket progress if not treated
1mm a year
what is removed during root surface debridement
- plaque and calculus on tooth surface stuck to root surface
- needs removed
what is done during the hygiene phase therapy stage of treatment plan
- dental health education
- oral hygiene instruction
- scaling and root surface debridement
- removal of other plaque retentive factors
what is included in dental health education
- explain nature of disease, use diagrams, photos etc
- discuss findings of examination
- use language patient understands
what is the oral hygiene instruction
- tooth brushing - modified Bass technique
- interdental cleaning = floss and tape, interdental sticks
- disclosing agents
how do you know if the interdental brush is the correct size
- should displace the bristles but tooth shouldn’t rub on wire
what is scaling
the removal of plaque and calculus from tooth surfaces
what is the definition of debridement
- the act of removing dead, contaminated or adherent tissue, or foreign material
what else if RSD called
- RSI
- root surface instrumentation
what does scaling and root surface debridement include
- scaling and root planing and removal of supra gingival calculus
what is root planing
- the removal of contaminated cementum, leaving the root surface smooth and hard
- but with root planing will experience pain and sensitivity = so don’t need to remove the calculus if right next to biofilm to prevent sensitivity
what are scaling instruments
- hand instruments
- powered instruments
what is the difference between powered and hand instruments
- no difference in plaque/calculus removal or healing response
- ultrasonic/sonic tip designs may allow better access to furcations
- powered instruments may be faster and less demanding on the operator = only in the right hands
- ultrasonic may results in less unwanted tooth tissue removal
- water coolant - cavitation and flushing effect in ultrasonic
- powered produces aerosols
- powered leave rougher surface
- greater tactile with hand instruments
what is the usual cause of plaque retention factors
- usually caused by dentists
- defective restoration margins
what can be problems with restorations
- restoration margins = location, adaptation
- restoration contour = can create plaque trap
- partial dentures = gingival cover, direct trauma
what must you look at at the re-evaluation stage
- patient plaque control
- bleeding on probing
- residual probing depths and attachment levels
- tooth mobility
what would be success of therapy
- good oral hygiene
- no bleeding on probing
- no pockets >4mm
- no increasing tooth mobility
- a functional and comfortable dentition
what are the 3 categories patient will fall into after re-evaluation
- poor OH = persistent inflammation
- good Oh = inflammation resolved
- good OH = persistent deep pockets wit BOP
what can you offer if situation not getting any better
supportive treatment
what are the next moves for each of the 3 branches after re-evaluation
- poor OH = identify resin for poor OH and then supportive care or repeat cause-related therapy
- good OH inflammation resolved = supportive care and proceed with treatment plan
- good OH persistent pockets = surgical access or repeat RSD then re-evaluate
why does treatment fail
- poor compliance
- inadequate debridement
what are the limitations of non-surgical therapy
- root morphology
- furcation involvement
- deep pockets
- skill level
- time
what is supportive periodontal care
- maintain periodontal health
- detect and treat recurrence
- maintain an accepted level of disease
- manage tooth loss
- intervals of approximately 3 months are appropriate for most patients
- OH must be reinforced
- examine for signs of recurrent disease
- scaling, RSD, polishing and other treatments as necessary
how do you work out the attachment loss
- record gingival margin and pocket probing depth then with these will know the attachment loss
what do probing depths indicate
- difficulty of treatment and recurrence of disease
what are attachment levels an indication of
- measure of tissue destruction and the extent of repair
what can manual probing measurements influenced by
- resistance of tissues
- size, shape and tip diameter of the probe
- site and angle of probe insertion
- pressure applied
- presence of obstructions such as calculus
- patient discomfort
what is the effect of supra gingival plaque control alone
- decreased gingival inflammation
- limited effect on probing depths
- no change in attachment levels
- no alteration in sub gingival microflora in deep pockets (>6mm)
what is the effect of RSD without supragingival plaque control
- initially reduction in inflammation and pocket depth
- pockets are re-colonised by bacteria from supra gingival plaque
- disease recurs
effects of RSD with supra gingival plaque control
- decreased gingival inflammation
- reduction in probing depths
- gain in probing attachment levels
- marked changes in the sub gingival microbial flora
how is gain of attachment got
- due to long junctional epithelium formation and improved tissue tone
- inflammatory infiltrate is replaced by collagen
when is the greatest changes noted during treatment
- observed 4-6 weeks after therapy
- gradual repair and maturation of tissues over 9-12 months
how should treatment be organised
- quadrant approach or full mouth disinfection
what is the full mouth disinfection approach for treatment
- objective = prevent treated pockets being re-colonised by intra-oral translocation or bacteria
- full mouth RSD at one or more sittings on the same day
- use of chlorohexidine for subgingival irritation, tongue brushing and mouth rinsing
what are the effects of RSD
- reduces microbial challenge = decreased inflammation
- inoculation with plaque organisms = boosts immune response
summary of non-surgical management of plaque related periodontal disease
- must be incorporated into overall treatment plan
- starts with hygiene phase therapy
- success requires both operator and patient involvement
- requires careful re-evaluation
- requires careful maintenance following treatment
