non-surgical periodontal treatment Flashcards
what are the 2 periodontal diseases?
plaque induced gingivitis
periodontitis
what kind of conditions are periodontal diseases?
inflammatory
what are periodontal diseases caused by?
formation and persistence of biofilm
describe paque
biofilm-sticky colourless deposit
forms in stages
microbial composition changes from health to disease
what can plaque bacteria attach to?
tooth surfaces, periodontal tissues, connective tissues
what is calculus?
calcified deposits found attached to the surfaces of teeth and other solid structures- often pale yellow/brown
always covered by plaque biofilm
can be supra and subgingival
detected by direct vision, probing or on radiographs
plaque retentive factor
how is periodontitis resisted?
genetic factors:
innate immune response
adaptive immune response
inflammation
what are the risk factors for periodontitis?
environmental: smoking dental plaque accumulation socioeconomic status host-specific: genetic factors overall inflammatory burden
what are the clinical manifestations of ginigvitis?
change in colour of gingivae
marginal gingival swelling
loss of countour (blunting) of interdental papilla
bleeding from gingival margin on probing/brushing
plaque present at gingival margin
no clinical attachment loss or alveolar bone loss
gingival sulcus 3mm or less from gingival margin to base of junctional epithelium at CEJ
what are the clinical manifestations of periodontitis?
loss of periodontal connective tissue attachment
gingival sulcus >3mm from gingival margin to base of junctional epithelium
junctional epithelium migrated apically with formation of true periodontal pocket
alveolar bone loss
what are the stages of periodontal management?
screening
assessment
treatment (as part of overall tx)
monitoring
what is involved in screening?
BPE
what are treatment outcomes affected by?
early diagnosis, prevention and promp intervention
what is the key to early diagnosis?
screening with BPE
what is a BPE?
walking a probe around each teeth, and recording the worst score
describe a WHO probe
ball end 0.5mm diameter
black band 3.5-5.5mm
second black band 8.5-11.5mm
describe an UNC probe
15mm long
markings at each mm and colour coding at 5th, 10th, 15th mm
how is a probe used?
light probing force (20-25g)
nail
incline probe at distal and mesial aspect
what are the requirements for the sextants in BPE?
at least 2 teeth to qualify
3rd molar used if 1 & 2 absent
how are sextants used?
probe walked around sulcus/pockets in each sextant and highest score recorded
what is a score of 0?
pockets <3.5mm, first black band on probe visible
what is a score of 1?
pockets <3.5mm, first black band visible, bop
what is a score of 2?
pockets <3.5mm. first black band visible possible bop, calculus present
what is a score of 3?
probing depth 3.5-5.5mm, first black band partially visible, possible bop, possible calculus
what is a score of 4?
probing depth>5.5mm first black band disappears, possible bop, possible calculus
what does an asterisk mean? *
furcation involvement
-identified in addition to score
what should be done if there is obvious interdental recession?
BPE
full periodontal assessment
what are the possible interpretations of BPE scores?
no need for perio tx
OHI
OHI & removal of plaque retentive factors & calculus
OHI & root surface debridement
OHI, RSD, assess need for more complex tx, referal to specialist
what is BPE screening used for?
assists in reaching a diagnosis- gingivitis/periodontitis
assists in formulation of tx plan or decision to refer
determines if detailed perio charting indicated, or radiographs
what are the options with a BPE code 3?
review after tx and 6 point pocket chart for that sextant
6 point chart before tx and after. full perio exam of all teeth and root surface instrumentation where necessary- only in sextant code 3
why are radiographs taken in perio?
aid diagnosis and helps w/ staging/grading of disease
helps determine progonisis of teeth
assessment of morphology of affected teeth
pattern and degree of alveolar bone loss
monitoring long-term stability of perio health
which radiographs are used?
horizontal & vertical bitewings
periapicals
dental panoramic tomographs
why are horizontal bitewings used?
as long as alveolar crest is visible might show early localised bone loss
presence of poorly contoured rest.
subgingival calculus
why are vertical bitewings used?
provides non distorted views of bone levels in relation to CEJ
can provide better visualisation of bone level than horizontal
difficult to position accurately
why are periapicals preferred?
2-dimensional picture of bone levels in relation to both CEJ’s and total root length
identifies furcation involvement, possible endodontic complications
why would OPT be used?
quicker
less uncomfortable
useful assessment of other pathologies
can distort esp. anteriors
what is the basic perio tx plan/
immediate/emergency care initial/disease control re-evaluation (periodontal surgery) reconstructive maintenance/supportive care
what is disease control?
extraction of hopeless teeth hygiene phase therapy caries management endodontic therapy -dressing & temporisation provisional prostheses
what is hygiene phase therapy?
nonsurgical management dental health education OHI scaling & root surface debridement removal of other plaque retention factors -defective restoration margins, overhangs, crown margins -dentures -orthodontic retainers re-evaluation
what is the aim of hygiene phase therapy?
arrest disease process
regenerate lost tissue
maintain periodontal health long term
how do you complete dental health education?
educate the px modifiable risk factors plaque control behavioural change -risk factor management -effective plaque removal -professional mechanical plaque removal
what is the soler pneumonic? (communication)
Square on to px Open posture, no crossed arms Lean forward, look interested Eye contact Relaxed demeanor
how do you explain the disease to px?
pictures/diagrams
radiographs- extend of disease- bone loss
disclose plaque and show areas px missing
show sites of disease-inflamed, bleeding gingivae and health in motion
see and modify toothbrush technique using face miror, show and advise what interdental cleaning aids are required
check understanding
what history is important for risk factor intervention?
medical issues:
- diabetes, controlled?
- dental attendance- hygienist, why?
- smoking- how long, when stop, cessation
- holistic- lifestyle factors: stress, poor diet
what is a modified plaque and bleeding score?
partial mouth recording system rather than full mouth plaque and bleeding score
standardised and reproducible method to assess px engagement
how are the teeth recorded for a plaque & bleeding score?
ramfjord
6 index teeth
distributed to best reflect condition of the whole mouth
what is a modified plaque score?
an index to measure status of oral hygiene by measuring plaque
tangible feedback
provide targets and a quantifiable measure of how the px should be performing
how is plaque detected on a plaque score?
visualisation of plaque on three surfaces of each ramfjord tooth
probe used to detect presence of plaque
what does a plaque score of 0 mean?
no plaque visible, even when probe used
what does a plaque score of 1 mean?
some plaque visible only when probe used to skim tooth surface
what does a plaque score of 2 mean?
visible amount of plaque which can be seen without used of a probe
what does a plaque score of N mean?
no measurement could be made of this surface/tooth
what are the 3 surfaces on ramfjord teeth?
interproximal
buccal
palatal/lingual
how is the total plaque score found?
scores for each surface are added to get a total
then divided by total number
what is a modified bleeding score?
measures marginal bleeding rather than bleeding on probing
marginal bleeding reflects how well px can carry out effective plaque control daily
how do you carry out a modified bleeding score?
periodontal probe is run gently at 45 degrees around the gingival sulcus in a continuous sweep
check presence or absence of bleeding for up to 30s after probing
what are the 4 surfaces of ramfjord teeth for a modified bleeding score?
mesial
distal
buccal
palatal/lingual
what is a bleeding score of 0?
absence of bleeding on probing
what is a bleeding score of 1?
presence of bleeding on probing
how is the total bleeding score found?
scores for each surface added to get a total score
divided by max bleeding score possible
max=24
what do you do if one of ramfjord’s teeth missing?
code N used
max changes
how does a modified plaque/bleeding score indicate an engaged px?
less than 35% bleeding score
less than 30% plaque score
greater than 50% improvement in both
which score is more important in nonsmokers?
bleeding
which score is more important in smokers?
should be interpreted together
what happens to the tx plan if the px is non-engaging?
root surface debridement should be delayed
px informed
identify any barriers
continue w/ oral health education, motivation and behavioural change
what does periodontal charting investigate?
probing depth recession- works out attachment level bleeding on probing- disease activity mobility furcation
what does grade 1 furcation involvement mean?
initial furcation involvement
furcation opening can be felt on probing but the involvement is less than 1/3 of the tooth width
what does grade 2 furcation involvement mean?
partial furcation involvement
loss of support exceeds one third of the tooth width but does not include the total width of the furcation
what does grade 3 furcation involvement mean?
through-and-through involvement
probe can pass through the entire furcation
what does grade 0 tooth mobility mean?
mobility measured at crown level
tooth mobile w/i alveolus to approx. 0.1-0.2mm in a horizontal direction
what does grade 1 tooth mobility mean?
increased mobility of the crown of the tooth to at the most 1mm in a horizontal direction
what does grade 2 tooth mobility mean?
visuallt increased mobility of the crown of the tooth exceeding 1mm in a horizontal direction
what does grade 3 tooth mobility mean?
severe mobility of the crown of the tooth in both horizontal and vertical directions impinging on the function of the tooth
in full periodontal charting what might manual probing measurements be influenced by?
resistance of the tissues
size, shape and tip diameter of the probe
site and angle of probe insertion
pressure applied
presence of obstructions such as calculus
px discomfort
how would you perform OHI?
as px to bring current dental hygiene aids
ask how often they are used and replaced in non judgemental way
discuss
-toothbrushes
-dental floss and tape
-interdental sticks
-interdental brushes
ask px to demonstrate + modify technique and practice using a face mirror
use disclosing tablets to identify areas px missing and coach for better plaque control
carry out modified plaque and bleeding scores
how do you coach toothbrushing?
manual- bass technique
bristles directed into the gingival sulcus at 45* angle to the long axid of the teeth
brush activated with short back and forth vibrating motions
warn against vigorous toothbrushing- may cause gingival abrasion, gingival recession, tooth abrasion
medium soft filament brush, wait 30min after eating prior to brushing
what are single tufted brushes used for?
to clean maligned teeth
to clean distal surfaces of last molar teeth
teeth affected by localised gingival recession
what are interdental brushes used for?
any primal attachment loss
range of sizes based on interdental space
snug fit w/o wire rubbing
8-10 back and forth strokes in each space
why is chlorhexidine the most effective mouthwash?
possesses the property of adsorption to oral surfaces, notably enamel
long substantivity
fairly broad antimicrobial spectrum
interferes w/ taste, discolours teeth
what are the problems that can arise from alcohol in mouthwash?
dry mouth
oral cancer
when should you prescribe an anti-plaque mouthwash eg 0.2% chlorhexidine?
for px where pain limits mechanical plaque removal
eg following sub-gingival instrumentation or for px with acute contitions
how would you try to change a behaviour?
when modifiable risk factor identified, px should be informed about the effect of the risk foactor on periodontium and negative impact on tx
offer advice and support
ask -> advise -> refer
elaborate on: explain, obtain, ask, make, to cause a behaviour change
explain -explain coaching is essential for plaque control obtain -consent -demonstrate plaque removal in px mouth -tailor to each px ask -to clean teeth and modify technique as necessary make -a plan w/ ox -goal setting, planning, self monitoring
why is making a plan with the px important?
periodontitis may require up to 20 mins once/twice a day of oral hygiene procedures
- to achieve high levels of plaque control to achieve periodontal stability
- px needs to understand time commitment
- plan how they will allocate this time
what is included in a patient agreement form?
diagnosis
self care plan
agreement statement
what is on a consent form?
info about perio tx
risks of perio tx
diagnostic statement
consent form- signed by px and clinician
what is scaling and root surface debridement?
part of overall prevention
removal of both supra gingival and subgingival plaque and calculus deposits
create a root surface compatible w/ biological reattachment
describe scaling
supragingival calculus easily identifiable when present in large deposits
sometimes superficial deposits of subgingival calculus can also be seen
deeply located deposits are identified by probing fine pointed probe or ball-ended probe
supragingival instrumentation facilitates px plaque control
at following visit inflammation should be apparent if good plaque control
when is subgingival root surface instrumentation used?
once px has adequate plaque control-engaged
more time consuming than supragingival scaling
what is root surface debridement?
the removal of contaminated material, leaving root surface smooth and hard
what hand instruments are used for scaling? (scalers)
chisel-push scaler sickle scaler - designed primarily for supragingival plaque and calculus removal hoe curettes -universal -site specific jacquettes
why should sharp instruments be used?
improve efficiency
more likely to remove deposits than burnish them
reduces the amount of force used- reduced fatigue
how are powered instruments used?
less angulation
inserts activated prior to insertion
adapt surface that best conforms to anatomy of tx site
strokes initiate at gingival margin
overlapping strokes along root surface
tapping stroke w/ point of the tip for tenacious supragingival deposits
light grasp
keep tip moving and maintain contact
fulcrum only to stabilize instrument not for leverage
what are the differences with a powered vs hand instrument?
powered leaves a rougher, grittier surface,
produces aerosols
water coolant causes cavitation and coolant acts to flush out pocket,
better access to furcations
less unwanted tooth tissue removal
what is full mouth disinfection?
prevent treated pockets being re-colonised by intra-oral translocation of bacteria
full mouth RSD at one or more sittings on the same day
used of chlorhexidine for subgingival irrigation, tongue brushing and mouth rinsing
what is the effect of scaling and root surface debridement on the microflora?
significantly reduces the levels and prevalence of pathogenic species
complete elimination of these species is unrealistic
what is the effect of scaling and root surface debridement on the hard and soft tissues?
decrease in gingival inflammation
shrinkage of the gingival tissues leads to recession
increase in collagen fibres in the CT beneath the pocket and formation of long junctional epithelial attachment
-decrease pocket depth -increase attachment level
little change in bone height at sites w/ horizontal bone loss
vertical defects display some infill and gain in bone height
how does healing occur following RSD?
gain in attachment due to long junctional epithelium formation and improved tissue tone
-inflammatory infiltrate replaced by collagen
what is the timeline for RSD healing?
gradual repair and maturation of tissues over 9-12 months
how can restorations be plaque retentive factors?
overhanging margins
marginal discrepancies
subgingival margins
over contoured crowns
how can RPD’s be plaque retentive factors?
gingival coverage
direct trauma
uncontrolled loads
how can orthodontic appliances be plaque retentive factors?
access to interdental cleaning may be compromised
bands can lie close to gingival margin
how is success measured?
inflammation
-bleeding on probing indices
reduction in probing depth
gain in probing attachment level
what is probing depth?
indicated the difficulty of tx and the likelihood of recurrence
what are attachment levels?
a measure of tissue destruction (pre-tx) and the extent of repair (post-tx)
what are the effects of RSD with supragingival plaque control?
decreased gingival inflammation
reduction in probing depth
gain in probing attachment level
marked changes in the subgingival microbial flora
what is done on re-evaluation?
repeating indices taken at baseline and compared: probing depths bleeding score plaque score attachment levels tooth mobility furcation
what is considered successful at re-evaluation?
good oral hygiene no bleeding on probing no pockets >4mm no increasing tooth mobility a functional and comfortable dentition
why does tx fail?
inadequate px plaque control -lack of compliance -lack of dexterity systemic risk factors -smoking -uncontrolled diabetes residual subgingival deposits -deep pockets -furcation lesions, concavities and root grooves -inexperienced operator/ not enough time spent on RSD
what is the purpose of supportive periodontal therapy?
prevents recurrence of disease
stabilises periodontal condition
maintains optimum periodontal health
intervals approx. 3 months
what is supportive periodontal therapy?
plaque control reinforces- remotivate/re-educate px
examine for signs of recurrent disesae
retreat any recurrence/ new disease
-scaling, RSD, polishing
arrange recall to review px and monitor perio status
what do you do if on re-evaluation the px presents with poor OH?
if there is reason to think OH will improve
-offer 1 further appointment and recheck plaque chart
if not
-discharge to GDP for supportive care
what should you do if on re-evaluation the px has good OH but has detectable subgingival calculus?
remove calculus and review
what should you do if on re-evaluation the px has good, OH, and no detectable subgingival calculus?
discus with consultant if site suitable for surgery
if consultant says no discharge to GDP for supportive care
