Perio Flashcards
28 y/o fit and well, FM PAs showing bone loss on multiple teeth
diagnosis?
why? (5)
investigations?
generalised aggressive periodontitis
bone loss affecting 3 or more other teeth inc 6s and incisors age of pt rapid progression of bone loss vertical bony defects pt otherwise fit and well
thorough history (including family)
6ppc
swab of crevicular fluid -
How would you decide prognosis of individual teeth in cases of periodontitis?
loss of attachment
mobility
furcation involvement
give reasons for only partial removal of pocket bacteria during scaling? (5)
poor operator technique failure to disrupt biofilm poor pt OH pt immunocompromised difficulty accessing prevents removal
Why do antibiotics fail in aiding pocket bacteria removal?
-
- not in therapeutic range - inadequate concentration
- lack of vision - antibiotics do not reach site of disease activity
How would you manage a periodontal abscess with systemic involvement?
incise and drain gentle subgingival debridement hot salty MW advise optimal analgesia XLA if tooth poor prognosis Antibiotics (amoxycillin and metronidazole) follow up hpt
What would be clinical signs of improved periodontal health?
probing depth reduction to <4mm
BOP to <10%
plaque scores of <15%
Space between 13 and 14
Investigations and why?
impediment with implant placement here?
SI: BPE- screening tool PGI - plaque and bleeding record 6PPC - perio disease chart PA rads: path detection study models
implant :
periodontal disease
inadequate bone levels
inadequate space <7mm
What bacteria are involved with ANUG
p. intermedia
fusobacterium
spirochetes - treponema
Clinical signs and symptoms of ANUG
- blunted interdental papilla
- grey slough which when wiped reveals ulcerated tissue
- halitosis
- crater like ulcers
- reverse gingival architecture
5 risk factors for ANUG
smoking young age poor OH immunocompromised stress
Mgmt for ANUG
ultrasonic debridement oxygenating MW e.g 3% H202 CHX OHI Smoking cessation if needed Antibiotics if systemic/immunocompromsied - metronidazole 400mg tds/3days
What would you need to say for informed consent for open flap curettage
- Risks- gingival recession + normal oral surgery risks (bleeding, swelling, pain, infection)
- Other tx options - continue NSPT
- Risks of no tx- increased mobility, increased pocket depths, increased likelihood of losing teeth
- Benefits of tx- can effectively debride with DIRECT VISION
- Outcome- possible reduction in probing depth
- Recommendation
Pt feels central crushing pain during surgery. What do you think it is?
immediate mgmt?
Myocardial Infarction
GTN spray - 2 sublingual actuations
oxygen 15L/min
Aspirin chewed 300mg
In what forms would you deliver post surgical advice? and what would you say- for open flap curettage?
written and spoken
avoid smoking for min. 1 week
avoid rinsing for 1 day- after 1 day can rinse with CHX MW(2%, bid) or hot salty
avoid exercise, just rest
do not probe area
Review appt timeframe for open flap curettage?
8 weeks
to allow sufficient healing
Bacteria that cause periodontal disease
gram negative anaeobic
A. a
P.gingivalis
B.forsythia
T.denticola
What patients might benefit from antibiotics along side hygiene phase therapy?
- pt who is not responding favourably to scaling and debridement therapy/ HPT, with continuing clinical attachment loss
- pt who test positive for P.ging or A.a in subgingival biofilm - as can invade epithelium of periodontal pockets
- pt with severe chronic periodontitis and generalised deep pocket depths
Why might antibiotics not aid in reduction in bacteria numbers in perio cases?
- cannot kill bacteria in biofilm .:.
- biofilm not successfully disrupted during Scale and debridement
- not therapeutic range - not correct dose
- poor pt compliance to regime
- antibiotic resistance
- antibiotics inactivated by 1st pass metabolism
Why is it that azithromycin and tetracycline are perhaps considered more successful for perio tx than amoxycilin and metronidazole?
azi &tet- actively taken up and concentrated by cells
amo&met- enter cells by passive diffusion
What is SIRS
Criteria
systemic inflammatory response syndrome
any 2 or more of:
- tachycardia- HR >90bpm
- tachypnoea - RR >20breaths/pm
- leukopenia or bandemia or leukocytosis
<4000 cells/mm3 or >10% or >12000 cells/mm3
- fever or hypothermia - >38 degrees celcius or <36
Pt presents with suppurating abscess - How would you diagnosis
-sensibility test - if tooth vital then is perio abscess. if non-vital is endo abscess.
- if TTP laterally is perio lesion, if TTP vertically is endo lesion.
use gutta percha and PA to trace sinus tract to identify origin of lesion
What is a periodontal abscess?
localised collection of pus within tissues of periodontium
acute exacerbating of an existing periodontal pocket
caused by: untreated perio/ inadequate RSD/ food packing
Signs and symptoms of perio abscess
pain on biting/spontaneous TTP (laterally) swelling pus pocketing at swelling mobility
How do you manage occlusal trauma in a pt with perio?
- address issue - parafunction/ high restorations
- bite raising appliance worn at least at night
- hpt as necessary
What factors can influence localised mobility?
occlusal trauma - increasing pdl width
resorption/trauma
When would you advise splinting of mobile teeth?
to assist in rsd
when mobility causes discomfort
difficulty eating
Why is there a decrease in mobility after perio tx?
growth of junctional epithelium
What can you do to manage pt with widened pdl after rx?
Reduce contact in occlusion
What is the role of occlusion in periodontal disease?
occlusal trauma itself cannot cause loss of attachment but can exacerbate existing periodontal pockets
What is occlusal trauma?
signs and symptoms?
injury to the periodontium
resulting from occlusal forces
that exceed the reparative capacity
of the attachment apparatus
severe attrition
exposed dentine
increased sensitivity
mobility
fremitus?
vibration or movement of the tooth in functional occlusion
types of occlusal trauma?
primary and secondary
primary- where excessive loads are placed on teeth with normal periodontal tissues
secondary- where normal loads become excessive due to loss of attachment
What findings would indicate aggressive periodontitis?
severe periodontal destruction inconsistent with OH findings
familial aggregation
early onset
pt otherwise fit and well
Differences between localised and generalised aggressive periodontitis?
localised:
- localised CAL
- 6s and incisors
- circumpubertal age
- robust antibody response
generalised:
- generalised CAL
- 6s and incisors and at least 3 other teeth
- onset before 30 y/o
- poor serum antibody response
- episodic in nature
bacteria indicated in aggressive periodontitis?
A.a
P.gingivalis
Mgmt of aggressive periodontitis
start with NSPT - RSD
2 week CHX MW and SPRAY
Refer to specialist within 6/8 weeks
define gingivitis
inflammation of the gingiva, characterised by red, swollen tissues which bleed on probing or brushing
define chronic periodontitis
disease characterised by destruction of junctional epithelium and connective tissue attachment of the tooth, with bone destruction and formation of periodontal pockets
What perio features could make a tooth have a poor prognosis? (3)
and if so, what parts of history needed to determine if teeth poor prognosis or not?
mobility - less bone support
loss of attachment - less tissue support
furcation involvement- difficulty cleaning
non vitality
smoking, drug history, systemic disease
International 1999 Classification of Periodontal disease? (7)
gingivitis chronic periodontitis aggressive periodontitis Periodontitis with systemic disease necrotising ulcerative gingivitis periodontal abscess perio-endo lesion gingival enlargement developmental or acquired deformities
Causes of gingival recession
- chronic periodontal disease
- inadequate toothbrushing technique
- occlusal trauma
- high frenal attachments
- orthodontics
- poor fit restorations
- habits
- abrasive toothpaste
Generalised gingival recession - always chronic inflammatory periodontal disease
localised-
- if v shaped localised - occlusal trauma
- if u shaped localised -
- inadequate tooth brushing,
- chronic inflammatory periodontal disease
- high frenal attachment
Disease to cause vertical defects in bone?
how does it cause this?
Localised angular periodontitis
Localised aggressive periodontitis/
radius of destruction of plaque is 2mm. .:. depends where plaque are situated. if interproximal bone is >2mm bony defect will be vertical/angular
how to classify degree of bone loss?
Mild <30%
Mod 30-50%
Severe >50%
difference in bacteria between localised and generalised aggressive?
localised only has A.a
generalised has both A.a and P. ging
Management aggressive periodontitis
OHI Complete Scaling and debridement Antibiotic therapy- amoxycillin and metronidazole CHX MW OHI
Clinical signs of periodontal healing
Gingival recession
Reduction in BOP
Reduction in probing depth
How does each react to traumatic occlusion?
a) healthy periodontium
b) reduced periodontium
c) periodontium with periodontitis
a) widening of pdl .:. slight mobility. no LOA, will return to normal if trauma removed
b) widen of pdl but less pdl there. .:. increased mobility
c) loss of attachment when pdl widens, as pdl then breaks
What is CHX?
bisbiguanide antiseptic
Mode of action of CHX
dicationic
one cation adheres to pellicle
one cation disrupts bacterial membrane
bacteriocytic and -static
Substantivity of CHX
12 hours
Common doses of CHX
- 2% 10/20ml bid
0. 15% 15/18ml bid
4 side effects of CHX
staining taste disturbance salivary gland enlargement anaphylaxis sls interaction
8 uses of CHX
pre op rinse post intraoral surgery ANUG denture stomatitis tx of dry socket medically compromised pt high caries risk pt pt post jaw fixation for OH Endo irrigant Recurrent Oral Ulceration
What is included in HPT
NSPT non surgical periodontal therapy
Scale and RSD
Removal of plaque retentive factors
OHI
Method of proper OHI
TIPPS talk instruct practice plan support
7 parts to record on periodontal chart
teeth missing gingival margin probing depth loss of attachment BOP mobility furcation
2 disadvantages of perio chart
- doesnt take into account root length - .:. severity misleading
- probing depths are SUBJECTIVE and can vary greatly
How can you measure recession
photos w/ probe
pocket chart
study models
Mgmt of localised gingival recession
atraumatic tooth brushing technique minimise other risk factors monitor treat sensitivity free soft tissue graft (palatal) coronal advancement flap
Tx for multirooted teeth with furcation involvement (3)
guided tissue regeneration
tunnel preparation
hemisection
Previously root treated tooth with 9mm probing depth pocket and vertical bony defect. Dx?
initial tx?
perio-endo lesion
endo-perio lesion
true combined lesion
re-rct
implant factors?
pt motivation smoking bone quality and quantity smoking MH (bisphosphonates) restorative options
How can bony defects be classified?
horizontal or vertical
by number of walls 1/2/3
2&3 have better prognosis
indications for regenerative periodontal therapy?
2&3 walled defects
grade 2 furcation in mandibular molars
grade 2 buccal furcation in maxillary molars
Why is diabetes a risk factor in perio disease?
WIPA
- delayed WOUND healing
- both are pro INFLAMMATORY diseases
- immunosuppression- impaired PMN neutrophil function
- ADVANCED glycation end (AGE) products increase tissue destruction
2 tests for diabetes diagnosis?
and expected values?
RPG random plasma glucose <11.1mmol/L normal, above diabetics.
FPG fasting plasma glucose <7 mmol/L
both need 2 separate OCCASIONS
Test for diabetic control
normal value?
Hb1ac
<7%
4 ways in which smoking affects periodontal tissues
CCEB
CHEMOTAXIS and phagocytosis impaired
CYTOKINE production affected
ENZYME catalyse affected
BLOOD flow restricted
name the cytokine important in tissue destruction?
what does it do
interleukin-1
pro-inflammatory cytokine
stimulates release of enzymes and osteoclasts .:. increasing tissue destruction
pt attends with inflamed gingiva extending beyond mucogingival junction. clinical description?
signs?
3 oral conditions that could cause this?
2 risk factors?
2 tx?
desquamative gingivitis - clinical description not a condition
erythematous, glazed, friable, haemorrhagic gingiva +/- pain
oral lichen planus OLP
pemphigus vulgaris PV
mucous membrane pemphigoid MMP
risk: smoking, plaque
tx:
- enhanced OHI
- scaling to remove supra and subgingival plaque
- removal of intraoral restorations/ prostheses
- topical or systemic corticosteroids:
- >local lesions: beclamethasone inhaler
- > generalised: betamethasone tablet dissolved as MW
Name the 3 meds associated with gingival hyperplasia?
phenytoin - antiepileptic
cyclosporin - immunosuppressant
nifedipine - calcium channel blocker
How do you manage gingival hyperplasia?
plaque still main causation .:. OHI and RSD then if not responding- surgery liaise with GP re: changing medication
Values for BPE
0 → black band showing completely, no BOP or plaque retentive factors – No Rx/OHI.
1 → band visible, BOP, no plaque retentive factors – Rx – OHI.
2 → band visible, BOP, supra/sub calc or plaque retentive factors. Rx – OHI, remove PRFs, S&P/RSI.
3 → band partly visible → 3.5-5.5mm – Rx – 6PPC sextant of full mouth if >2 grade 3 measured. OHI, RSI, remove
plaque retentive factors.
4 → band not visible → >5.5mm. Rx – 6PPC full mouth, RSI, remove plaque retentive factors, consider referral. * →
furcation involvement.
How is mobility graded?
0 - physiological movement (0-0.2mm)
1 - <1mm movement
2 - 1-2mm movement
2 - >2mm movement and vertical movements - rotations and depressions
How is furcation graded?
0- <3mm horizontal
1 - >3mm horizontal but not through and through
2 - through and through
How is gingival recession graded?
Miller’s classification
How would you decide the prognosis of individual teeth in a pt with aggressive perio? (7)
symptoms bone levels angular defects mobility furcation involvement is pt maintenance possible? short tapered roots
5 signs and symptoms of periodontal disease
signs- mobility furcation involvement increased probing depth LOA BOP gingival recession
symptoms- tooth "loose" tooth movement bleeding food packing "long in tooth"
localised risk factors for periodontal disease
overhanging restorations defective margins partial dentures oral appliances calculus OH tooth malposition
