Perio Flashcards
You are a GDP. A F+W 52yo male new patient presents C/O wobbly back teeth. He is a non-smoker. You perform an exam and take an OPT.
OPT provided - P67
Explain the perio Dx to the patient, the aims of initial treatment and how this will be achieved
6 mins
Introduction - name and designation
Brief Hx - what teeth how long for, noticed any progression, any other Sx (bleed when brushing, bad taste/smell/breath)
Dx - generalised periodontitis stage IV grade C currently unstable.
Show XR to pt and explain. The x-ray shows you a full view of your mouth - as if it’s ben flattened. You can see the teeth, roots, fillings, crowns and the bones. This is the level of the bone at the moment (trace line). This bone holds the teeth in This is where it started and around about where it should be (trace along ACJ). Over time, yours has disappeared and shrink back to here.
Has anyone every spoken to you about gum or periodontal disease? Periodontal disease affects the gums, bone and other supporting tissues of the teeth. This is a disease that is caused by bacteria that collects at the gum line as plaque. Normally, plaque is removed by brushing your teeth. If not removed, it causes the gums to become irritated. The gum starts to come away from the tooth, forming pockets and the plaque grows down below the gum line. Over time the bone that supports the teeth is destroyed and the gums shrink and eventually the teeth become wobbly and fall out.
Anyone can get gum disease, but some people seem to be more susceptible to it than others. Some things that put you at higher risk of getting it include diabetes, smoking, stress, a poor diet, obesity and certain medications.
Your gum disease is quite extensive - a lot of the bone has been destroyed and a lot of teeth are affected.
Unfortunately gum disease can’t be cured, only managed to slow the progression and reduce the risk of losing teeth. To manage it properly requires us to chart how deep the pockets around the teeth are now, clean away the build up above and below the gum (scaling/plaque removal), and replace any crowns or fillings that are trapping plaque and are difficult to clean around. Then in 3 months review them to see if there is any improvement. We will give you detailed instructions on what you can do to keep your teeth really clean and slow the progression. You’ll need to spend quite a bit of time brushing your teeth - probably 10-15 minutes each night and 5 minutes each morning making sure you clean them meticulously.
We’ll review you fairly frequently, every 3 months or so going forward and if the treatment doesn’t seem to be working, look to refer you to specialists in treating periodontal disease.
Does that all make sense? Do you have any questions?
Describe the components of a full mouth pocket chart and reasons for NSPT failure
6 mins
Clinical attachment loss/loss of attachment - PPD + GM (disease severity)
PPD - depth of pocket from GM of tooth (depth of inflammation. Indicates treatment difficulty)
GM - distance between GM and ACJ (recession - disease history)
Mobility (reduced prognosis)
Furcation investment (treatment difficulty)
BoP (base of pocket - measure of inflammation/disease stability)
Teeth present/absent
Resolution - pockets = 4mm or <4mm + BoP. Increased GM (recession) with reduced loss of attachment - healing
Failure - smoking, poor compliance, ineffective OH (poor dexterity, hard to reach sites), systemic factors (stress, diabetes, pregnancy, poor diet), difficult access (time limitations, pt tolerance, GDP skill), iatrogenic factors (restoration overhangs, poor margins)
You are a GDP. Mr Smith, a 30yo male emergency patient presents C/O sore gums and a metallic taste. This has only recently started. The patient is F+W and smokes 20 cigarettes per day.
Use the clinical photos provided to discuss the likely diagnosis and your proposed treatment plan to the patient
Clinical photos provided - photos 11
6 mins
Introduction - name and designation
Brief Hx - sore gums, metallic taste, anything else?
Dx - necrotising gingivitis, lymphadenopathy
Mr Smith, I’m afraid you’re suffering from an acute condition called necrotising gingivitis. This is a relatively rare condition that presents as an acute form of gum disease where the gum disease develops much faster and more severely than normal.
It is caused by certain bacteria and tends to be found in people who are medically unwell/immunocompromised, stressed, those who smoke and those who have a diet low in fruit and vegetables. It can be made worse by high plaque levels due to inadequate brushing.
Common symptoms include bleeding/painful gums, painful ulcers, particularly at the gum in between the teeth, bad breath, a bad/metallic taste in your mouth, increased saliva and some discomfort speaking or swallowing. The disease can also extend away from the mouth and cause swollen lymph nodes, make you feel unwell or give you a fever (high temperature).
Before I talk about what we can do to manage it, do you have any questions?
The good news is that it typically responds well to local measures. The way we treat this is by giving you some more instruction on brushing technique, such as angling the toothbrush at 45 degrees between the teeth and the gums and move the brush in a side-to-side sweeping motion and use small brushes in between the teeth to remove plaque from the areas that aren’t reached by your normal brush.
We can also numb you up using local anaesthetic and use an instrument - a scaler - to disrupt the disease and flush out the bacteria and the white/yellow material. Once we’ve scaled the teeth today, you’ll be numb for a few hours, but sore once the anaesthetic wears off. Take painkillers for the next few days, either paracetamol or ibuprofen, whatever you are able to take. Make sure you follow the instructions on the side of the packet in terms of how often to take them, but it’s never more than 2 tablets four times a day (every 4-6 hours).
Smoking has a real impact on the gums. It affects the blood vessels in the gums, reducing the ability of the gums to respond to plaque. As well as increasing your risk of getting gum disease, it also makes the disease worse more quickly, makes recovery and healing less likely and increases the risk that the gum disease will come back. I would encourage you to stop smoking or at least consider it. There are a number of groups that can help you quite smoking, including the NHS Quit Your Way scheme. If you would like more information on this I would be happy to tell you about it at the end of you appointments.
I will also give you a mouthwash away (either 6% H2O2 or 0.2% CHx). Rinse your mouth out for 2 minutes 3 times a day by diluting 15ml in half a glass of warm water.
Or rinse your mouth for 1 minute with 10ml twice a day.
If there have been any major stresses in your life recently, this may have contributed to the gum disease, so see if you’re able to reduce your stress, either by trying meditation or mindfulness or speaking to the person who may be causing the stress.
Because the disease has spread to your lymph nodes, I’ll give you some antibiotics as well to help fight of the infection (metronidazole tablets 400mg). Take 1 tablet three times a day for the next 3 days.
We’ll review you within the next 10 days to make sure everything is going in the right direction. If not, we’ll look to refer you to a specialist.
In the meantime, I would advise you to register with a dentist who will be able to provide routine treatment for you.
Does that all make sense? Do you have any questions?
You are a GDP. You are reviewing a 43yo female post-HPT. You undertake a PGI. Her plaque score is 67% and her bleeding score is 42%.
Give OHI to this patient
6 mins
Introduction - name and designation.
Discuss findings - plaque is a proxy for OH. It is easily removed from surfaces and reaccumulates within 24hrs, so it is a good indicator to see what surfaces are being missed. Do you struggle with brushing in any certain areas? What TB? Could you show me your technique?
OHI as per TIPPS
Talk - Periodontal disease affects the gums, bone and other supporting tissues of the teeth. This is a disease that is caused by bacteria that collects at the gum line as plaque. Normally, plaque is removed by brushing your teeth. If not removed, it causes the gums to become irritated. The gum starts to come away from the tooth, forming pockets and the plaque grows down below the gum line. Over time the bone that supports the teeth is destroyed and the gums shrink and eventually the teeth become wobbly and fall out.
Instruct - the best brushing technique using a manual toothbrush is called the modified bass technique. This involves angling the brush at a 45 degree angel between the teeth and the gums and brush in a side to side sweeping motion. It is important to use a methodical approach and stick to it - for example brushing all the teeth in the top right side, then top left, then bottom left, then bottom right. You need to brush the inside, biting and outside surfaces of the teeth, spending about 10 seconds per tooth. You should do this for a minimum of 2 minutes at least twice a day, including last thing at night. Replace your toothbrush every 3 months or earlier if it starts to get frayed. Use a toothpaste that contains fluoride. Spit don’t rinse
ID cleaning - small brushes can be used in between the teeth to brush the parts of the teeth that a normal brush doesn’t fit in. You should use the largest brush that fits, without the metal in the middle of the brush scraping the teeth. You simply insert the brush into the gap and move it in and out for around 10-12x per space before moving onto the next one. You might find you need different sized brushes for different spaces.
If you can’t fit a brush, you should floss. To do this, take a length of floss and wrap it around your two middle fingers and use your index fingers to stabilise it. Carefully pull the floss down it the space, shape it around one of the teeth and gently floss back and forth as you work your way up the tooth. Repeat this for the other tooth that meets the gap and then move space, remembering to use a new piece of the floss length each time.
You can use a STTB on you last standing teeth or around lone staining teeth. Simply place the brush head on the junction between the tooth and the gum and brush around it like a paintbrush.
You can use F MW once a day, at another time from brushing - for example after lunch.
You shouldn’t eat or drink for 30mins after you brush your teeth or use mouthwash
You can use disclosing tablets if you want as well. You crush these up in between your teeth and they stain plaque purple. You can do this after brushing to find the sites you miss and then remove the plaque from these areas. You don’t have to use them everyday.
Practise - ask pt to demo and then correct them (can use disclosing tablet)
Plan - when to, keep a log if this helps
Support - at each follow up visit, we’ll repeat the plaque chart and look to have the scores less than 20% to show you’re doing well. We can also use it to find certain areas that you might struggle with and give more focussed instructions on reaching these sites.
Does that all make sense? Do you have any questions?
You area GDP. A 14yo male new patient attends complaining of movement of his upper front teeth.
You complete an examination. The patient has reasonable OH and pocketing around his upper 1s and 6s.
Discuss the diagnosis with the patient and how you plan to proceed
You do not need to take a history.
6 mins
Introduction - name and designation
Dx - molar-incisor pattern periodontitis stage IV grade C currently unstable.
Has anyone every spoken to you about gum or periodontal disease? Periodontal disease affects the gums, bone and other supporting tissues of the teeth. This is a disease that is caused by bacteria that collects at the gum line as plaque. Normally, plaque is removed by brushing your teeth. If not removed, it causes the gums to become irritated. The gum starts to come away from the tooth, forming pockets and the plaque grows down below the gum line. Over time the bone that supports the teeth is destroyed and the gums shrink and eventually the teeth become wobbly and fall out.
Anyone can get gum disease, but some people seem to be more susceptible to it than others. This specific type of disease is rare but is more common in young people. We think there is a link with genetics and family history, so we will speak to your parents and examine them and screen any siblings you have as well. Some things that put you at higher risk of getting it include diabetes, smoking, stress, a poor diet, obesity and certain medications.
Unfortunately gum disease can’t be cured, only managed to slow the progression and reduce the risk of losing teeth. To manage it properly requires us to take x-rays of your teeth, chart how deep the pockets around the teeth are now, clean away the build up above and below the gum (scaling/plaque removal), and replace any crowns or fillings that are trapping plaque and are difficult to clean around. We’ll also make contact with a specialist to see if they have any advice for us or if they want to examine you as well.
Then in 3 months review them to see if there is any improvement. We will give you detailed instructions on what you can do to keep your teeth really clean and slow the progression. You’ll need to spend quite a bit of time brushing your teeth - probably 10-15 minutes each night and 5 minutes each morning making sure you clean them meticulously.
We’ll review you fairly frequently, every 3 months or so going forward and once we have managed to stabilise the disease, we can speak to the orthodontic team and ask if you could be considered to get braces to straighten the teeth and move align your front teeth.
We’ll look to start the gum treatment very soon, which will improve the chance of success.
Does that all make sense? Do you have any questions?
You are a GDP. A 26yo female presents C/O bleeding gums. She is F+W and is 24 weeks pregnant.
Discuss the diagnosis with the patient, including other problems that may occur in the mouth during pregnancy, and your proposed plan.
6 mins
Introduction - name and designation
Ask - how are you keeping? How far along are you? All fine with the baby?
Dx - pregnancy gingivitis.
During pregnancy, your body has to adapt to allow a baby to grow inside you. Your body is good at recognising things that aren’t normal and fighting against this. You don’t normally have a baby inside you so your body has to adapt to make sure it doesn’t fight against the baby, by calming down your immune system slightly, stopping it from attacking the baby.
Some women get swollen and sore gums, which may bleed, during pregnancy. Bleeding gums are caused by a build-up of plaque on the teeth. Hormonal changes during pregnancy can make your gums more vulnerable to plaque, leading to inflammation and bleeding. This is called pregnancy gingivitis. During pregnancy, because your immune system is altered, it can be extra sensitive to plaque, so can make existing gum disease worse, or over-react to small amounts of plaque.
The way we manage this is by removing the plaque and cleaning the teeth and giving you advice on meticulously keeping your teeth clean - brushing for at least 2 mins a minimum of twice a day using a toothpaste that contains fluoride and using small brushes in between the teeth to clean the surfaces a normal brush can’t. If you want, you can swill a salty mouthwash round your mouth (1tsp in cup of water) once a day to help reduce inflammation.
We can review you regularly and clean the teeth to help reduce the effect of pregnancy gingivitis as well.
There’s also a chance you might get something called a pregnancy pulls or a pyogenic granuloma. This is a small swelling that might occur on the gums/in the mouth. Usually we manage this by keeping an eye on it and it tends to disappear after you’ve had the baby. If it doesn’t, we can talk about removing it once you’ve had your baby.
Does that all make sense? Do you have any questions?
You are a GDP. A 50-year-old male patient attended for HPT with the hygienist 3 months ago. His 35 is tender, has a swelling around the tooth and has 8mm pocket on the distal aspect as well as suppuration.
The patient is systemically well and has a normal body temperature.
Provide your diagnosis to the patient and discuss how you would like to investigate the matter further.
Indicate to the examiner when you wish to receive the results of the special investigations (EPT vital, ECl +ve. XR - PAP and distal bone loss)
6 mins
VOSCE
Introduction - name and designation
Pt concerns and expectations
There’s some swelling around the tooth, so it looks like an abscess. I need to do a few more tests to check the health of the tooth before I can tell you which type and how we will manage it.
EPT vital, ECl +ve. XR - PAP and distal bone loss
From the x-ray it looks like a periodontal abscess. This is an acute condition that is caused when bacteria get in a gap between the tooth and the gum called a pocket, and then can’t get out again, so the cells that fight the infection move into the area, the gum swells up and turns into an abscess.
To treat this, we’ll numb you up and flush out the area using saline. We can also use an instrument to scale the tooth, helping to remove any bacteria that is there. It’s important to keep your teeth clean and use small brushes in between your teeth to reach the areas that your brush can’t and help reduce the chance of this happening again. You should use CHx MW for the next week or so - rinse your mouth with 10ml twice a day for a minute at a time.
Once we’ve scaled the teeth today, you’ll be numb for a few hours, but sore once the anaesthetic wears off. Take painkillers for the next few days, either paracetamol or ibuprofen, whatever you are able to take. Make sure you follow the instructions on the side of the packet in terms of how often to take them, but it’s never more than 2 tablets four times a day (every 4-6 hours).
Because there’s no signs of systemic infection - like a fever or swollen lymph nodes, you don’t need any antibiotics. We’ll see you again in a week to review you.
Does that all make sense? Do you have any questions?
Describe the S3 treatment guidelines
6 mins
Dx - perio and extent (generalised/localised/MI), stage, grade, activity (stable/unstable/in remission), RFs
Step I - DHE, OHI, PMPR (supragingival), remove PRFs, smoking cessation, diabetic control interventions, set recall interval
If non-engaging - repeat
If engaging - step 2
Engaging - OH better by 50% or more, plaque score <20%, bleeding score <30%, pt met individual targets
Step 2 - reinforce OH, RF control, behaviour change, root PMPR ± systemic antimicrobials (CHx - ABx for specialists)
Re-evaluate after 3/12. If unstable - step 3. If stable - step 4
Step 3 - reinforce OH, re-perform root PMPR on moderate (4-5mm) pockets, consider alternative causes if deep (>6mm) pockets persist, refer for pocket Mx/regenerative surgery
Step 4 - supportive periodontal therapy. Reinforce OH, regular targeted PMPR to reduce the risk of tooth loss, consider adjunctive TP (Duraphat) or MW (CHx, infrequent use) to control gingival inflammation
