Perio Flashcards
extent
<30% localised
>30% generalised
stage
severity
1 - <2mm or 15% coronal
2 - coronal third
3 - mid third
4 - apical third
grade
progression
A - slow - <0.5
B - moderate - 0.5-1.0
C - rapid - >1.0
% bone loss / age
stability
stable; BoP <10%, PPD <=4mm
remission; BoP >=10%, PDD <=4mm
unstable; PDD >=5mm or >=4mm + BoP
investigations
diet diary
MPBS
6PPC
PA radiographs
further questions for pt
pt motivation
OH techniques
smoking
MH
why could non-surgical therapy fail to eliminate bacteria from perio pockets
- deep/inaccessible pockets
- furcation lesion
- infra bony defect
- presence of virulent resistant bacteria
- poor pt compliance w OH
- systemic/host factors impairing healing
- smoking
- poorly controlled DM
- medication [phenytoin, ca channel blockers]
- immunocompromised
problems that limit usefulness of oral abx in the tx of periodontitis
- not bacterial infection but host mediated inflammatory
- abx resistance
- limited penetration of sub gingival biofilm
- disruption of normal microflora
- side effects
- need mechanical disruption
= compliance and OH needed
management of lateral periodontal abscess
reassure
incise and drain or through pocket w LA if needed
thorough supra+subgingival debridement, just short of length
occlusal adjustment if needed
analgesia
systemic PenV 2 tabs 4x day 5 days
amoxicillin 500mg tds 5 days
after acute phase - review and assess, continue pd tx
signs of improved health post periodontal abscess
reduced pocket depths
resolution of infection
decreased swelling/erythema
improved systemic conditions
bacteria involved in necrotising gingivitis
fusiform bacteria
spirochetes
clinical signs and symptoms
punched out papillae, ID, ulcers, swelling, pain
pseudomembrane formation, grey/white slough when wiped reveals bleeding underlying connective tissue
tissue destruction
halitosis
necrotising gingivitis risk factors
high stress
young
poor OH
smoking
immunocompromised
malnutrition
HIV/AIDs
outline management of necrotising gingivitis
reassure pt
superficial debridement w ultrasonic to remove soft and mineral deposits, gentle
increase depth each day 2-4
limit mechanical OH as may impair healing
chx 0.2% 2xday
abx if systemic or failing to resolve
metronidazole 400mg tds 3 days
close follow up, daily if possible
after acute phase - tx of existing condition, address risk factors
info for pt for informed consent
nature of procedure
risks vs benefits
alternatives
reason why needed
risks of nothing
costs
aftercare
crushing pain across chest and left arm
- diagnosis
- immediate management
myocardial infarcation
999
abc
oxygen 15l/min
300mg aspirin to chew
monitor vital signs, prepare for CPR
after open flap curettage
post-op instructions to minimise complications
analgesia
avoid brushing directly on area, soft brush, chx
avoid surgical site w tongue/fingers
care with hot as encourage bleeding
avoid spicy, salty, acidic
if bleeding, gentle pressure
ice to swelling
avoid strenuous activity
avoid smoking and alcohol
recognise complications and number to call back
post open flap curettage, you review at one week and all is good
when should you review next and why
4-6 weeks
healing at 1-2 weeks but takes weeks for full tissue regeneration and reattachment of PD fibres
clinical signs of improved health following non-surgical therapy
<20% plaque, <10% BoP
reduced inflammation, erythema
reduced pocket depths [ideally <=4mm]
epithelium reattachment [decreased probing depths due to long junctional epithelium]
what is SIRS
parameters
systemic inflammatory response syndrome
serious, exaggerated defence response form body causing severe inflammation throughout, due to infection/trauma/burns etc
temp <34 >36
pulse >90
resp >20
WCC <4 >12
what is a periodontal abscess
abscess from periodontal origin, usually existing pocket
accumulation of pus within gingival walls
destruction of collagen fibre attachment and alveolar bone
cause = disease exacerbation, complex morphology, changes in microbiota, increased bacterial virulence, reduced host response
signs + symptoms of periodontal abscess
ovoid elevation in gingiva along lateral root
pain, localised swelling, associated pus
bite may feel high
bleeding, tenderness of probing
increased mobility
TTP
suppuration through root spontaneous or w pressure
differentiate periodontal abscess and periapical abscess
sensibility =
PD normal, PA not respond as necrosis
probing =
PD deep pocket, PA normal
radiograph =
PD vertical bone loss, PA radiolucency/widened PDL
management of occlusal trauma in pt w periodontal disease
address perio - non-surgical
correct occlusal stability - smooth premature contacts, reduce high cusps, ortho, occlusal adjust to distribute forces more evenly
parafunctional habits - splint, relaxation, CBT etc
splinting - temp stabilise if excessively mobile, or for debridement
doesn’t affect rare of PD destruction, can worsen OH
what factors influence localised mobility
periodontal - inflammation, attachment loss, height/width of PDL
teeth - number, shape, length of roots
PD abscess
occlusal - trauma, bruxism, tooth migration
endo - pathology, RR
trauma
iatrogenic - high rests causing excessive forces, ortho forces
medications - bisphosphonates
when may splinting be advised
advanced mobility due to loss of attachment - discomfort, difficulty eating
stabilisation for tx
post-trauma
why is there a decrease in mobility post-perio tx
reduced inflammation
improved attachment level
reorganisation and reattachment of PDL
improved occlusal stability
bone healing
long junctional epithelium
what could you do if PDL is still widened post perio tx
in occlusal trauma pt
reassess perio health - plaque, bleeding, probing, occlusal trauma
splinting
management parafunction
what bacteria is implicated in periodontitis
P.gingivalis
T.denticola
T.forsythia
how is angular bone loss caused
vertical osseous defect, occurs when bone loss progresses down the root of the tooth
bone destruction occurs at an angle, not uniformly around a tooth
“V” shaped pattern
how do you classify angular defects/infrabony
based on number of walls remaining
1 wall
2 wall
3 wall
what is the limitation of treatment for angular bone loss
limited access of non-surgical therapy
root surface debridement may not be successful and effectively access these deep defects
alternative tx for angular defects, beside non-surgical
periodontal surgery = access surgery/open flap debridement
regenerative periodontal surgery = guided tissue regeneration, enamel matrix derivative
what is the difference between horizontal and angular bone loss
horizontal =
more generalised, uniform loss of bone height across alveolar ridge, parallel plane
angular =
infrabony, localised bone loss non-uniformly, unevenly, creating a “V” shape
define localised and generalised bone loss
localised = <30% of teeth
generalised = >30% of teeth
define mild, moderate and severe bone loss
mild = <15% or 2mm of root
mod = coronal third
severe = mid third
very severe = apical third
how does healthy periodontium react to traumatic occlusion
PDL widening until forces adequately dissipated
should then stabilise
may cause mobility as a result
RETURN TO NORMAL
how does healthy but reduced periodontium react to traumatic occlusion
PDL widening until forces adequately dissipated
less resilient
less able to adapt and recover
tooth more vulnerable, increase mobility, further degradation of periodontal health
how does periodontitis respond to traumatic occlusion
worsening of periodontitis
increased mobility
progressive attachment loss
increased bone loss
exacerbation of inflammation
gingival recession
root resorption
risk tooth loss
what is chlorhexidine
biguanide gluconate
broad spectrum antimicrobial
topical antiseptic
chlorhexidine mode of action
membrane disruption =
disrupts cell membrane, binds and causes leakage of cell causing death
bactericidal effect =
bactericidal action against wide range bacteria
inhibition of bacterial adhesion =
prevents bacteria adhering to oral surfaces
define substantivity
ability of substance to bind to tissues/surfaces and maintain antimicrobial action over time
what is chlorhexidine substantivity
good
remains active for several hours
up to 12hrs of residual effect
give 2 common doses of chlorhexidine
0.12% - general oral hygiene, 10-15ml 30secs 2x day
0.2% - antibacterial purpose, tx, 10-15ml 30secs 2x day
side effects of chlorhexidine
staining
taste alteration
mucosal irritation
xerostomia
sore throat
parotid gland swelling
uses of chlorhexidine
OH adjunct
post-surgical care [xla, perio surgery]
oral infections - necrotising, RAS
peri-implantitis management
pericoronitis
denture stomatitis
primary herpetic gingivostomatitis
osteonecrosis
what is TIPPS
behavioural change theory, aim to make pt more confident in ability to perform effective plaque biofilm removal, plan how and when to look after oral
TALK
INSTRUCT
PRACTICE
PLAN
SUPPORT
what 7 things are recorded on periodontal pocket chart
teeth present/not present
pocket depths
gingival margin
clinical attachment level
furcation
mobility
bleeding
disadvantages of pocket charting
time consuming
uncomfortable for pt
subjective
based on operator technique
doesn’t give comprehensive view on bone loss
limited predictive value
local factors for gingival recession
restoration overhangs
poor IP contact points
plaque/biofilm accumulation
toothbrushing trauma
poor OH
traumatic incisor relationship
abrasive TP
frenum
misaligned teeth
ortho tx
piercings
how can you measure gingival recession
CPITN probe relative to CEJ
cairo classification
how is localised recession managed
record magnitude clinically/study models to monitor progression
alter habits - TB, TP, single tuft
improve OH
remove plaque + retentive factors
desensitising agents
if bad
gingival veneers
crowns
mucogingival surgery
tooth 15 has been root treated, has 9mm pocket and vertical body defect radiographically
give 3 differential diagnosis
what special investigations
endo-perio lesion, periodontal abscess, subgingival root fracture
PA radiograph, percussion/palpation test, transillumination, BPE, 6PPC if indicated, sensibility tests
pt wants implant
what would you look for?
good compliance
good OH
quality of remaining bone
height/width of bone
proximity to roots/anatomcial structures
MH
smoking status
age
gingival biotype
2 interventions for inadequate bone level pre-implant
autograft - same
allograft - cadaver
xenograft - animal
alloplast - synthetic
indications for regenerative periodontal surgery
infrabony defects >=3mm
class 2/3 furcation defect
deep pockets >=6mm
no medical contraindications
reasonable tooth prognosis
non-resolved pockets following good quality non-surgical tx
if regenerative periodontal surgery fails, how else can this root be managed
resective surgery
root resection
root separation
xla
why is diabetes a risk factor in periodontal disease
impaired/altered immune response
impaired wound healing
overproduction of pro-inflammatory cytokines
hyperglycaemia leads to AGE, which makes connective tissue more susceptible to destruction and damages collagen/connective tissue
tests for diabetes
normal vs diabetic values
HbA1c =
normal <42mmol/L, <5.7%
diabetic >48mmol/L >5.6%
fasting blood sugar test =
normal <100mg/dL
diabetes >126mg/dL
glucose tolerance test =
normal <139mg/dL
diabetes >200mg/dL
how does smoking affect periodontal tissues
vasoconstriction
increased keratinisation
impaired antibody production
decreased Th lymphocytes
increased pro-inflammatory cytokines
impaired wound healing
what is interleukin-1
cytokine involved in regulation of immune and inflammatory responses
pro-inflammatory cytokine mediatior
promotes tissue destruction via MMP
induces bone resorption via activating osteoclasts
name 3 oral conditions associated with inflamed gingiva extending beyond mucogingival junction
periodontitis
acute necrotising periodontitis
desquamative gingivitis
medications associated with gingival hyperplasia
phenytoin
cyclosporin
amlodipine
how do you manage gingival hyperplasia
identify cause
improve OH
surgical management if needed - gingivectomy/gingivoplasty
describe BPE values
0 - <3.5mm, no calculus/BoP
1 - <3.5mm, BoP
2 - <3.5mm, calculus
3 - 3.5-5mm
4 - >5mm
* - furcation
how is mobility graded
0 - 0.1-0.2mm
1 - 1mm
2 - >1mm
3 - horizontal + vertical movement
how is furcation graded
1 - <1/3 tooth width
2 - >1/3 tooth width
3 - through through
