Perio Flashcards
What is the likely cause of the gingival recession seen in the lower anterior sextant?
Traumatic overbite
When would mechanical root surface debridement not be successful in eliminated pocket bacteria?
* Difficulty with access (especially in furcation). * Non compliant patient. * Inadequate RSD/inexperience of clinician. * Patient is immunocompromised. * Sites inaccessible to instruments. * Failure to disrupt biofilm
When would antibiotics not be effective in periodontal disease?
* Antibiotics resisted by biofilms. * Concentration inadequate and not within the therapeutic range. * May not reach site of disease activity
How would you manage a periodontal abscess with systemic involvement?
* Incision and drainage. * Gentle sub-gingival debridement. * HSMW * Extraction of tooth if poor prognosis. * Antibiotics * Follow up HPT
What would be clinical signs of improved periodontal health?
* Reduced probing depth (<4mm). * BoP <10%. *Plaque scores <15%
*A photo showing a space between 13 and 14*
What investigations should be carried out and why?
* BPE; a screening tool for periodontal health. *PGI to assess plaque and bleeding levels. *6PPC to assess periodontal disease. * Periapicals to assess prognosis of teeth, drifting by periodontal disease. * Study models (offers a point of reference)
What bacteria are involved in ANUG?
P. Intermedia and fusobacterium as well as spirochetes such as treponema
What are the clinical signs and symptoms of ANUG?
* Blunting of interdental papilla. * Halitosis. * Grey slough that wipes off to reveal ulcerative tissue. * crater like ulcers. * Reverse gingival architecture
List 5 risk factors for ANUG
* Age (young) *Stress *Poor OH *Immunocompromised (HIV) *Smoking
Briefly outline management of ANUG
* Ultrasonic debridement *Oxygenating MW (hydrogen peroxide 3%) *OHI modified for patient *Consider Chlorhexidine *Smoking cessation if needed * ABs if systemic or immunocompromised (Metronidozole 200mg 3 x daily for 3 days)
Patient is obese and a reformed smoker, history of ischemic heart disease. Despite excellent OH he still has pockets of 6/7mm that BoP. You elect to undertake open flap curretage. What do you discuss with the patient to get informed consent?
* Risks; gingival recession, infection, pain, bleeding, swelling, bruising. *Benefits; effectively debride area with direct vision *Outcomes; possible reduction of pocket depths *Other treatment options; Repeat NSPT *Risks of no treatment; increase in pocket depth, increase in mobility, increased risk of tooth loss
A patient has just completed surgical periodontal therapy, when should the patient be reviewed and what is the rationale?
8 weeks to allow sufficient time for healing.
What are the clinical signs of improved health following HPT?
* Pocket depths <4mm *BoP <10% * Plaque score <15%
Why might antibiotics not work for chronic periodontal disease?
* Biofilms resistant to antibiotics. * Antibiotic resistance. * Antibiotics inactivated by first pass metabolism. * Poor patient adherence to regime
Describe how a modified plaque score is recorded
* Recorded for every patient
* 16, 21, 24, 36, 41, 44 (Ramfjords teeth)
* Each tooth is split into buccal/lingual.interproximal surfaces
* 2 = visible plaque
1 = Plaque revealed with probe
0 = no plaque
Describe how a modified bleeding score is recorded
* Recorded for every patient
* Measures marginal bleeding rather than BoP
* Each Ramfjords tooth has a perio probe run gently at 45 degrees around the gingival sulcus in a continuous sweepl For up to 30 seconds after probing, check for the presence or absence of bleeding.
* mesial, distal, buccal, lingual
* Score of 1 or 0
What are the four stages of periodontal disease?
Worst site of bone loss is used
Stage 1; (early/mild) <15% or <2mm from CEJ
Stage 2; (moderate) Coronal third of root
Stage 3; (severe) Mid third of root
Stage 4; (very severe) Apical third of root
How is periodontal disease graded?
% of bone loss divided by patients age
Grade A slow rate of progression, <0.5
Grade B Moderate rate of progression, 0.5-1
Grade C Rapid rate of progression >1
How do you rate the assessment of current periodontal status?
Currently stable; BoP <10%, PPD = 4mm, No BoP at 4mm sites
Currently in remission; BOP >/= 10%, PPD = 4mm, no BoP at 4mm sites
Currently unstable; PPD >/= 5mm
PPD >/= 4mm and BoP
What clinical and lab investigations can be carried out to help aid a periodontal diagnosis? (3marks)
* Thorough history including family history.
* Periodontal pocket chart
* Microbiological analysis of swab of crevicular fluid
In a patient with periodontal disease, how would you decide the prognosis for individual teeth? (3)
* Loss of attachment
* Mobility
* Furcation involvement
What are some proposed biofilm resistance mechanisms?
*Antimicrobials may fail to penetrate beyond the surface layers of the biofilm
*Antimicrobials may be trapped and destroyed by enzymes.
*Antimicrobials may not be active against non-growing microorganisms
*Expression of biofilm specific resistance genes (eg efflux pumps)
*Stress response to hostile environment conditions
Give 3 features of apical periodontitis
*Chronic poly-microbial infection
*Stimulation of host response
*Connective tissue destruction
Besides the lower anterior sextant, where else might you expect to see signs of a traumatic overbite?
Palatal gingivae of upper anteriors
Having completed a history, examined the soft tissues, charted the teeth and restorations present and examined the occlusion, list 5 other investigations you would perform.
* BPE
* Full periodontal chart as indicated
* Clinical photographs
* Plaque and bleeding indices
* Radiographs
* Study models
* Mobility scores
* Sensibility testing
List two generatl approaches to this patients initial treatment
* Hygiene phase therapy
* A bite raising appliance
At a re-evaluation appointment there are no deep pockets and the patients oral hygiene is excellent. But the lower incisors are still mobile and causing the patient concern, what further treatment would you offer to manage the mobility?
A lingual bonded splint. This would only be indicated if the patients oral hygiene is very good as in this case
Give four indications for the use of chlorhexidine mouthwash?
Pre surgery
Post surgery
Denture induced stomatitis
Medically impared (case selective)
Acute necrotising ulcerative gingivitis
Treatment in dry socket
Endo irrigant
High caries risk (individual dependent)
What 3 features on a PA would lead you to a diagnosis of Generalised Aggressive Periodontitis?
* Bone loss affecting at least 3 teeth
* Age of the patient
* Patient otherwise fit and well
* Vertical bony defects
* Rapid progression of bone loss
What clinical and lab investigations could you carry out for a pt with periodontitis?
Thorough history inc family history
Periodontal pocket chart
Microbiological analysis of sample (swab of crevicular fluid)
In a patient with periodontal disease, how would you decide the prognosis of each tooth?
Loss of attachment
Mobility
Furcation involvement
In what ways would you provide post perio surgery advice for a patient, and what would you like them to know to avoid post op complications?
* Verbal and written
* Avoid smoking for one week if possible
* Avoid rinsing for that day, can rinse from the following day
* Avoid strenuous exercise
* Rinse with CHX mw 2 x daily 0.2% 10ml
How do you manage a perio abscess with sytemic involvement?
* May require LA
* Achieve drainage via pocket or incision
* Gentle RSI short of the base of the pocket to avoid trauma
* Advise on analgesic use
* Give OHI including use of CHX mw until acute symptoms subside
* Provide antibiotics due to systemic involvement 500mg amoxicillin or 400mg metronidazole both 3 x daily for 5 days
* Review in ten days
What is a periodontal abscess?
Acute exacerbation of an existing periodontal pocket eg trauma or obstruction. Caused by food packing or inadequate RSD
What are some signs and symptoms of a periodontal abscess?
Pain on biting or spontaneously
TTP
Swelling
Pus
Pocketing at swelling
Mobility
How is a periodontal abscess differentiated from a periapical abscess?
Sensibility testing vital vs non vital
Also consider perio status of the rest of the mouth
How do you manage occlusal trauma in a patient with periodontal disease?
Address the cause; ease high restorations, address parafunction
Bit raising appliance for night time wear
HPT
What factors can influence localised mobility?
* Existing periodontal disease
* Occlusal trauma causing widening of PDL
* Morphology and length of roots
* Alveolar bone loss
* Resorption/trauma
When might splinting be advised in a periodontitis patient?
Mobility due to advanced loss of attachment
Mobility is causing discomfort or difficulty eating
To facilitate RSD
Why is there a decease in mobility following perio treatment?
Increased tissue tone and long junctional epithelial attachment
What can be done if the PDL is still widened after successful treatment?
Reduce occlusal contacts
How are localised and generalised aggressive periodontitis different?
Local - localised LOA, 6s, incisors, initially occurs around puberty, robust antibody response
General - Generalised LOA 6s, incisors and 3 + other teeth Onset usually under 30 years Poor serum antibody response
Episodic nature
What bacteria is involved in aggressive periodontitis?
AA
Porphymonas gingivalis
How is aggressive periodontitis initially managed?
Non surgical sub gingival PMPR.
2 weeks CHX mw and spray
ABs (amoxicillin or metronidazole)
Refer to specialise within 6-8 weeks
In periodontitis, what features would indicate a tooth had poor prognosis and why?
Mobility - reduced bone support
Furcation involvement - more difficult to keep clean
LOA - less supporting structures for tooth
Loss of vitality
Diagnose
Angular bone loss
Besides clinically and radiographic, what other two pieces of information are needed before determining prognosis of teeth?
Smoking history
Drug history
Systemic disease
How is localised angular periodontitis caused?
When pathway of inflammation travels directly into PDL space, localised plaque retentive facors
How does a healthy periodontium react to occlusal trauma?
PDL widening - mobility
No LOA or inflammation
Will resolve when occlusion addressed
What category of drug is chlorhexidine?
Bisbiguanide antiseptic
What is the substantivity of CHX
12 hours
Give two commonly prescribed doses of chlorhexidine
- 2% 10ml/ 20mg 2 x daily
- 12% 15ml/18mg 2 x daily
Name four side effects of CHX
Staining
Taste disturbance
Salivary gland enlargement
Anaphylaxis
Interacts with SLS
List 8 uses for chlorhexidine
Surgical pre op rinse
What is TIPPS?
Delivery method of OHI
Talk, instruct, practice, plan, support
What 7 things are recorded on a periodontal pocket chart?
Missing teeth
Gingival margin
Pocket depth
LOA
Mobility
Furfaction
BOP
Give two disadvantages of a pocket chart
Assumes all patients have same root length so may appear worse than it is
Pobing depths are subjective/variation between clinicians
What are the local factors for gingival recession?
Periodontal disease
Habits
Traumatic tooth brushing
Abraisive toothpaste
High frenal attachment
Crowding
Traumatic overbite
Orthodontic treatment
Poor marginal fit restorations
How can localised recession be managed?
Atraumatic toothbrushing technique
Minimise other risk factors
Monitor
Treat sensitivity
Free/pedicle soft tissue graft
Coronal advancement flap
