perio Flashcards
List 5 clinical features of a healthy periodontium
- coral pink
- knife-edge scalloped margins
- firm & resilient gingiva
- complete papilla fill
- keratinised gingiva with stippling
5 clinical features of gingivitis
- gingival redness/erythematous
- enlarged, swollen & hyper plastic with rolled margins
- oedematous & spongy
- shiny
- loss of stippling
- possible ulcerations
list 5 clinical feature of periodontitis
- gingival redness & erythematous that increases in extent and intensity (become cyanotic toward MGJ)
- enlarged, swollen & hyperplastic with rolled margins
- oedematous & spongy
- loss of stippling
- possible ulcerations
- gingival recession
- drifting of teeth
- shaky teeth
why is it important to identify gingival phenotype
if thin:
- expect probing depths to be shallow
- expect recession to happen after you treat
- can pre-warn the patients of the outcome (eg. after treatment when inflammation goes down, may see black triangles)
if thick:
- less susceptible to bacterial and mechanical insult
- less likely to have gingiva recession
- but pockets will form, giving deep probing depths
what to check for medical, dental and social history
medical:
- systemic conditions: diabetes, infection endocarditis (need antibiotic prophylaxis)
- drugs: DDI, caused oral clinical presentation, allergies, pregnancy-safe medications
- MRONJ (medication-related osteonecrosis of the jaw) risk
communicable disease
- medical emergencies risk
dental & social
- oral hygiene habits (frequency, types of hygiene aids used)
- history of tooth loss (due to caries or periodontal disease?)
- history of treatment (what treatment? receptiveness to the types of dental treatment? assess attitude)
- smoker?
- job?
- diet history
why are universal precautions and infection control important
to prevent transmission of disease - from patient to clinician, from clinician to patient & within dental team (assistants receptionists, lab technicians)
protect yourself for the people you love, and protect the people that you love from you
what does PPE include
wearing sequence & things to note
HAND RUB
1. Mask
2. eye shield
- eye protection even if you are wearing glasses
3. hairnet
- cap covers forehead and ears
- ensure all fringes are tucked into the hairnet
4. gown
- ensure back portion of gown overlaps each other
- tie at the neck first, then tie at the waist
HAND RUB
5. gloves
- ensure gloves fit well. snug fit
you are the assistant. list the steps you would take to change the bib for the patient
- with gloves on - remove bib & bib holder from patients neck
- remove & dispose soiled bib into the general bin
- place bib holder onto the paper covering assistant’s cabinet top
- remove gloves & hand rub
- open the drawer WITHOUT gloves
- retrieve a new bib & drop it on the paper covering assistant’s cabinet top without touching contaminated surfaces
- close the drawer with clean ungloved hands
- hand rub and put on new pair of gloves
- attach new bib to bib holder & put on patient
7 important clinical parameters
- probing depths
- gingival recession
- furcation involvement
- BOP
- plague score
- mobility
- CAL
how to probe? what to take note while probing?
- using perio probe
- measure the vertical distance from the FGM to the base of the gingival sulcus
- perio probe should be parallel to the long axis of the tooth & closely adapted to the tooth surface
- avoid excessive probing force & pressure – damage soft tissues
- readings taken at 6 points per tooth: DB, B, MB, DP, P, MP
how to calculate gingival recession
- using perio probe
- measure the vertical distance between CEJ & FGM
- perio probe should be parallel to the long axis of the tooth and
- measured at 6 sites (same as ppd)
how to calculate CAL + its significance
CAL (clinical attachment loss) = gingival recession (CEJ to FGM) + probing depth (FGM to base of sulcus)
- using perio probe
- readings taken at 6 points per tooth: DB, B, MB, DP, P, MP
- if FGM above CEJ, gingival recession is taken to be a negative value
gives indication of the amount of tissue loses & damages around a tooth – gives a sense of prognosis + treatment plan
since it is a reproducible parameter with fixed reference points, it can be used to monitor patients condition over time
HOWEVER, it is a measure of accumulated past disease at a site rather than the current disease activity level
clinical difficulties
- cannot see CEJ
-
elaborate on mobility
- applying pressure bucco-lingually using 2 blunt ends of the instrument
class 1: able to move crown by at most 1mm horizontally
class 2: able to move crown >1mm, and able to visualise crown’s mobility
class 3: severe mobility of crown horizontally & vertically impinging tooth function
subjective measure. only vertical depression is obvious
what is fremitus? how to check
fremitus is the movement of the tooth when in function i.e. when biting in MI or moving in lateral excursive and protrusive movements
check by observing the tooth moving as the patient bites down and move jaw left , right, forwards
can use interdental contact points or saliva as a reference
elborate on furcation
- using Naber’s probe
class I: horizontal loss of periodontal support ≤ 1⁄3 tooth width
class II: horizontal loss of periodontal support > 1⁄3 tooth width, but not through the whole width of the furcation
class III: horizontal ‘through & through’ destruction of the periodontal tissues in the furcation
for maxillary molars, mesial & distal furcation should be probed from the palatal side; buccal furcation from mid buccal
for mandibular molars, buccal furcation from mid buccal; lingual furcation from mid lingual
step by step how to do plaque disclosing
- prepare vaseline & plaque disclosing agent. soak a cotton pallet in the plaque disclosing agent
- use cotton roll to apply vaseline to patient lips
- remove excess saliva in the mouth with saliva ejector, and use airjet to gently dry
- Gently dab cotton pallet onto tooth surface along the gum line for all the tooth
- ask patient to gently rinse their mouth 1-2 times
- record pink/purple stain along FGM. if stain is away from FGM, it is not charted
charting done on 4 surfaces per tooth: M, D, B, P
why is plaque disclosing important
- education for patient to see
- correlate with BOP
- for clinician to see
How to calculate plaque score
- Chart 4 sites per tooth: M, D, B, P
- plaque at FGM is charted as plaque positive regardless of size/intensity. If stain is not at FGM, it is not charted as plaque positive
%PS= (no. of sites stained/total no. of sites)x100%
significance of BOP & PS
plaque score - indicates amount of bacterial load and its location
% BOP indicates extent of inflammation in the mouth – ABSENCE indicated periodontal stability
BOP + PS – indicates patient’s susceptibility to disease
indications for PA
- assessment of periodontal status pre/post-op
- assessment of apical status for infection & inflammation
- check alveolar bone levels for implant placement
- caries status
- when planning to do invasive procedure / restoration (bridge etc)
- deep probing depth –> assess bone levels
- crown-root ratio – to make fixed pros
- assess interprox caries
- bone loss
When to take BW?
- difficult to see areas, especially for detection and monitoring of caries
- assessment of existing restorations
- assessment of periodontal status
What type of toothbrush would you recommend
small compact head
- can turn tooth brush around corners easily such as the DB/DL line angles of the last tooth
soft tapered fine tip bristles
- fine tip to go into the gingival sulcus
- bristles soft will not hurt gums; doesnt fan out too easily but can last for at least 3 months
base of toothbrush white preferred
- can see if dirty (food stuck) – patient can remove it and prevent fungi growth
bigger handles for patients with dexterity issues
- esp elderly or children
- easier to hold
what tooth paste would you recommend
fluoridated toothpaste, 1450ppm
identify the types of floss & technique to use them
- floss
- floss pick / floss holder
- superfloss
- floss threader
2 differences between universal
universal has 2 cutting edges while Gracey’s has 1 cutting edge
Universal has no offset, face of blade beveled at 90degrees to shank. Gracey’s has offset blade, face of blade bevelled at 70degrees
cutting edge of grace: when terminal shank is vertical, cutting edge is position lower
10 key points of root debridement
- locate calculus - visual or tactile
- choose the right instrument
- hold instrument with modified pen grasp
- position dental chair, patient’s head and your body in a comfortable position
- firm & stable finger rest
- adaptation of cutting edge against the tooth surface with terminal shank parallel to the long axis of the tooth and the first 1-2mm of the cutting edge is in close contact to the root surface
- angulation for insertion - tilt face towards the tooth (insertion angle <40 – CLOSED angle), go into pocket, all the way to the base of the sulcus
- angulation for calculus removal – tilt the blade out slightly (WORKING angle – 70-80deg) so that cutting edge “cuts” into the root surface
- apply firm lateral pressure and deliver short forceful vertical strokes in an overlapping manner
- use forearm strength (not just wrist/fingers)
ways to locate calculus
- visual
- 1-2s jets of air directed at FGM
- look for a shadow/ a bright light - tactile
- sharp explorer (straight explorer or perio explorer 11/12)
- perio explorer 11/12 thinner – more sensitive(?) to roughness
which gracey curette to use
anterior: #1/2, #3/4, #5/6
B & L: #7/8, #9/10
M: #11/12, #15/16
D: #13/14, #17/18
modified pen grasp
- thumb & index finger at the junction of the handle and shank
- middle finger on shank
- handle rests against the flesh of the hand
challenges of scaling & root debridement
- essentially a BLIND procedure; highly dependent on tactile sensitivity and familiarity to root anatomy
- visualisation is challenging because it can be obscured by bleeding
- subgingival calculus are typically locked into the root concavities and therefore are more tenacious and difficult to reach
- subginigval calculus are dark brown in colour due to the accumulation of heme within the pores of the calculus. As it is within an enclosed space underneath the gingiva, it is all DARK and thus hard to see
how to overcome these challenges
- PRACTICE
- try out different positions of the patients head & operator position
- give LA
- use mouth prop
- good illumination
- clear view - remove blood, debris, saliva, with metal suction tip
- perform root debridement in a systematic manner
how to sharpen hand instrument
- use Arkansas sharpening stone with lubricant (oil/dry). this prevents metal remnants from dull instrument from being incorporated and deposited into stone
- identify cutting edge esp for Gracey curettes
- hold stone at 45degree angle
- ensure that the entire blade is flat on sharpening stone so as to not create 2 planes on the blade
- hold flat surface of curette firmly against the stone, leaving no gaps between the stone and blade
- firm downwards long sharpening strokes in one direction
- right hand finger against side of stone to guide and maintain curette position
how to tell if instrument is sharp
- glare test
- sharp edge will not reflect light; dull edge will reflect light
- acrylic stick test
- place cutting edge at 80-90degrees to long axis of tooth
- push cutting edge gently in toward stick
- if cutting edge bites into stick, it is sharp; if dull, cutting edge slides across stick
max speed for ultrasonic scaler? why must we not go above this speed?
not more than 30. usual range 10-20
- don’t go more than 30 because scaler tip may break
cap ultrasonic scaler when not in use
cap the ultrasonic scaler when it is not in use
- prevent sharps injury
- reduce the risk of instrument fracture if the instrument is dropped onto the floor
do not invert the ultrasonic scaler when keeping it on the dental panel, as the bottom surface is not cleaned
if your pumice slurry on a dampen dish is too watery
remove excess water using a gauze
how to control speed of high speed/slow speed handpiece
With the speed foot control, the intensity of the is modified by pressure on the foot pedal. Step harder to increase speed of instrument to the one that you have set. Step halfway and more gently to reduce the speed.
etiological agent of periodontitis
BACTERIA in a susceptible host
connect tissues of the periodontium
mainly type 1 collagen
5 types: circular, alveolo-gingival, dento-gingival, dento-periosteal, trans-septal fibres
