perio Flashcards
perio classifications
BSP2017
health
plaque induced gingivitis
non plaque induced gingivitis
gingival diseases and conditions
periodontitis
necrotising periodontal diseases
periodontitis as a manifestation of systemic diseases
systemic diseases or conditions affecting periodontal tissues
periodontal abscess
perio-endo lesions
mucogingival deformities and conditions
categories of perio health
features of each
pt with intact periodontium (no BoP, no attachment loss)
pt with reduced and stable peirodontium (BoP <10%, PPD<4mm)
clinical features of healthy periodontium
knife edged
scallopped gingival margin
pink/pale
stippling
firm and flat
painless
no bleeding
clinical features of gingivitis
BPE 2 or less
no bone loss
no loss of ID papilla
inflammation
loss of stippling
halitosis
BoP
red
local and generalised
localised <30%
generalised >30%
local factors for perio
calclus
poor resotration margins/overhangs
malpositioned tooth making it hard to clean
systemmic factors for perio
diabetes (hyperglyceamia)
sex hormones (puberty, pregnancy)
smoking
poor diet
drugs - nifidipine, phenytoin, cyclosporin
systemmic factors for perio
diabetes (hyperglyceamia)
sex hormones (puberty, pregnancy)
smoking
poor diet
drugs - nifidipine, phenytoin, cyclosporin
stageing
severity
1 - early/mild (<2mm or <15%)
2 - moderate (<1/3 bone loss on root)
3 -severe (1/3-2/3 root)
4 - very severe (>2/3 bone loss)
grading
rate
A - mild rate (<0.5 when %bone loss/age)
B - moderate rate of progrssion (0.5-1)
C - rapid rate >1
currently unstable
pockets >5mm
4mm pockets with BOP
currently stable
BoP<10%
PPD < or =4mm
no BOP at 4mm sites
currently in remission
BoP >10%
PPD <4mm
no BOP at 4mm sites
types of necrotising periodontal diseases
NUG - just gingiva
NUP - with bone loss
N stomatitis - bone denudation beyond mucogingival juntion
clinical features of NUG
6
- gingivitis
- hallitosis
- loss of ID papilla (interproximal necrosis) puchned out appearance
- bleeding
- painful ulceration of ID papilla
- pseudomembrous slough
risks factors for NUG
smoking
stress
immunocompromised
poor OH
tx for NUG
OHI
smoking cessation
PMPR - under LA
CHX 0.2% mouthwash
antibiotics
* metronidazole 400mg 3xdaiy for 5days
* amoxicillin 500mg 3xdaily for 5days
periodontal abscess
definition
localised collectioon of dead and dying neutrophils
Acute exacerbation of periodontal pocket
periodontal abscess
symptoms
swelling
pain
bleeding
pus suppuration
deep pocket
TTP
periodontal abscess tx
incise and drain - through pocket or incision
OHI - CHX 0.2% mouthwash advise
subgingival PMPR short of base of pocket
review in 10 days
antibiotics if systemic symptoms - PenV 500mg 4xdaily for 5days
methods of perio-apical communication
6
apical forament
lateral canal
fractures
resorption
iatrogenic perforations
furcal canals
recession
mucogingival deformities
lack of keratinised gingval attachment
displacement of gingval soft tissue margin to ACJ resulting in root exposure
RT1
recession with no loss of interproximal attachemetn
(interproximal ACJ clinically undetectable both M and D, most of ID papilla remains)
RT2
gingival recession associated with loss of some interproximal attachement
some ID papilla remains; amount of attachemnt loss less than or = to buccal attachemnt loss
RT3
gingival recession associated with more loss of IP attachment
* no ID papilla remains
* amount of IP attachment loss is greater than buccal attachement loss
reasons for recession
5
- successful HPT
- vigorous brushing
- traumatic incisal realtionship
- iatrogenic restorative damage
- foreign body trauma
causes of tooth mobility
4
alveolar bone loss
clinical attachement loss
PDL widening
periodontal tissue disruption (due to inflammation)
effect of abnormal occlusal forces on healthy periodontium
areas of intermittent pressure and tension
* areas of widened PDL until forces adequately dissipated, inc in tooth mobility
- if demand reduced - dec in tooth mobility and PDL returns to normal
normal physiological response
effect of abnormal occlusal force too great on healthy periodontium
if demand too great - PDL conts to widen until forces adequately dissipated or tooth is lost
effect of abnormal occlusal forces on healthy but reduced periodontium
tooth effefctively on alveolar bone fulcrum
hypermobile tooth
no plaque
gingival margin remains intact and perio disease will not restart
effect of abnormal occlusal forces on diseased periodontium
zone of co destruction
supra-physiological occlusal forces widen PDL width at base of pocket, hypermobile teeth
* pathological disease (inflammation) causing CAL or excessive bone loss when combined
why to intervene in occlusal trauma
3
symptomatic mobility
progressively inc mobility
assoc with deep pockets
BPE 1
pockets <3.5
BoP
no Plaque retentive factors
OHI
BPE2
pockets <3.5mm
BOP
plaque retentive factors
PMPR and OHI
BPE3
pockets 3.5-5.5mm
PMPR
OHI
6PPC after tx
BPE 4
pockets >5.5
radiographs, 6PPC that sextant
PMPR and review
BPE *
furcation involvement
furcation grades
1 - <1/3
2 - >1/3 but not through
3 - through and through
factors that affect toothmobility
height of PDL
width of PDL
presence of inflammation
nuber/shape/length of roots
tx option for tooth mobility
pros and cons
splinting
when mobilty is due to LoA, there is discomfort/chewing diffiiculties
stabilises teeth for debridement
doesnt influence rate of disease
OH difficulties for pt
causes of tooth migration
3
unfavourable occlusal forces
unfavourable soft tissue profiles
loss of attachemtn
tx options for tooth migration
tx underlying perio disease
accept and stabilise
ortho and stabilise
extract
correct occlusal relations
problems with antibiotic use for perio disease
5
- unable to penetrate biofilm - need mechanical therapy
- can be inactivated by non target organisms
- superinfection possible
- allergies
- resistance
causes of antibiotics resistance
5
- can be inactivated against non target orgaisms
- trapped and destroyed by enzymes
- expression of biofilm specific resistance genes
- may fail to penetrate beyond surface layer of biofilm
- stress reponse to hostile environment denatures AB
substantivity
persistence of action and ability to stick to target
how long agent works for
substantivity depends on
maintenance of antimicrobial aactivey and slow neutralisation of antimicrobial activity
chlorohexidine
antiseptic
bisbiguianide
dicationic action - one cation adsorbs to tooth/pellicle and other cation sticks on bacteria
in low conc causes inc cell permeability and at high conc causes cytoplasm precipitation (causing cell death)
indications for CHX
pre surgical mouthwash/aseptic technique
immunocompromised pt
limited manual dexterity/unable to perform OH
oral candidiasis
RAS
NUG
post- PMPR
post extraction/surgery
side effects of CHX
bitter taste
staining
taste disturbance
mucosal erosion
parotid swelling
successful perio features
BOP <10% - reduced
reduced probing detph - gain in clinical attachement via junctional epithelium
improve OH - reduced plaque and bleeding scores
no worsening in furcation scores
reduced or stabilised mobility
aims of perio tx
arrest disease
regenerate lost tissue
maintain longterm perio health
prevent tooth loss
improve soft tissue consistency so easier management
side effects of perio tx
recession
sensitvity
initial bleeding
components of perio tx
risk factor managenent - smoking, diet, diabetes etc
OHI
PMPR - supra and sub
removal of PRFs
re-eval
when to re-eval
8-12 weeks after PMPR
most healing occurs at 6 weeks
longer allows better healing and replacement of junction epithelium
reasons why PMPR may fail
- inadequate operator technique
- blunt instrument
- pt not engaging with OHI regime
- no correction of risk factors - smoking, poorly controlled diabetes
- not debriding enitre pocket anatomy - unable to access
- poor visiualisation of pocket meaning unable to assess when successful cleared pocket - not enough suction
aims of periodontal surgery
2
arrest disease by gaining access to complete PMPR
regenerate loss perio tissues
contraindications for perio surgery
non engaing pt
e.g. poor OH, smoking
types of perio surgery
3
access - OFC
regenerative - GTR, GBR
mucogingival
features of healing post OF PMPR
organisation of blood clot
replacement by collagenous connective tissue
attachement via long junctional epithelium
reduciton in probing depths (gain in clinical attachement and recession)
aims of gingivectomy
facilitate pt OH
improve aesthetics
facilitate restorative dentistry
indications for gingivectomy
4
gingival overgrowth/hyperplasia
areas with difficult acces
pseudopockets
idiopathic gingival fibromatosis
shallow suprabony pocket
drugs that can cause gingival hyperplasia
anticonvuslants - phenytoin
immunosuppressants - cyclosporin m
Ca channel blockers - nifedipine
inidications for GBR
2 or 3 walled proximal defetc
indications for elimination perio surgery
types of
grade II furcation defects in mandible
grade II buccal furcation defects maxilla
tunnel prep and furcation plasty (make through and through)
hemisection or separation
indications for XLA
non functional tooth
gross mobility
little remaining attachement and recurrent symtpms
key perio pathogens
p gingivalis
t denticola
t forsythia
pathophysiology of gingivitis
inc PRR stimulation
inc production of pro inflammatory mediators
inflammation
inc vasodilation and immune cell migration
amlification of healthy immune resopnse
pathophysiologi of perio
biofilm extends into pocket and adaptive immune response predominates
further amplification of pro inflammatory processes
Connective tissue destruction - MMPs
Alveolar bone resorption - RANKL - due to exacerbated uncontrolled immune response
perio biofilm formation
conditioning film - organisms ATTACHES to enamel and growth from supra to deep gingival crevice
* more harmful bacteria furhter in = anaerobic, Red Sockranskys
coaggregation of bacteria = dense biofilm formation
chronic inflammation but P.ging subverts immune response
* dysbiosis of biofilm
complement activated
* bone destruction and PDL loss
bacteria in gingivitis and NUG
p.intermedia
anaerobic
-ve rod
black
w
red sokranskys organisms
t.denticola
t.forsythia
p.gingivalis
p.gingivalis
virulence
- gingipains - nutrients to self, degrade host immune response
- tissue toxic byproducts
- endotoxic LPS
- capcular polysaccharides
- proteases
- frimbriae - adherence and invasion
smoking and perio
Acidic favours p.ging
Delayed wond healing
Vasocontriction
Impacted chemotaxis
Cytokine production dec
Enzyme catalase dec
diabetes and perio
Healing delayed (dec collagen)
Inc chemotaxis by macrophages IL6 and TNF alpha
advanced Glycerin end products due to abnormal glucose
Heightened inflammatory reponse and dec neutrophils
HbA1c - ideal 48mmol/mol (below 6.5%)
birelational
endo perio lesions with root damage
3
root fracture or cracking
root canal or pulp chamber perforation
external root resoprtion
endo perio lesiosn without root damage
in periodontitis pts
3
grade 1 - narrow deep perio pocket in 1 tooth surface
grade 2 - wide deep pocket in one tooth surface
grade 3 - deep pocket in more than 1 tooth surface
endo perio lesion in non perio pt
3
grade 1 - narrow deep pocket in 1 tooth surface
grade 2 - wide deep perio pocket in 1 tooth surface
grade 3 - deep pocket in more than 1 tooth surface
