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BDS4 > Perio > Flashcards

Perio Flashcards

1
Q

Reasons for NSPT failure

A

Inc. PPD
Inc. width tooth surface
Poor access: unable to angle/adapt curette
Tenacious calculus
Root fissures/concavities/furcation
Defective restoration margins subgingival

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2
Q

Relationship between chance of calculus removal and PPD

A

Inverse
<3mm = 83%
3-5mm = 39%
>5mm = 11%

Av. depth plaque-free surface established = 3.73mm
Instrument can reach 5.52mm

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3
Q

Objectives of PD surgery

A 
Eliminate local factors 
Eliminate/red. PPD
Restore alveolar bone architecture 
Regenerate functional attachment apparatus 
Crown lengthening 
Correct mucogingival defects
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4
Q

Surgical PD therapy techniques

A 
Gingivectomy 
Flap surgery
Osteoplasty
Tunnelling
Root resection
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5
Q

Gingivectomy vs flap surgery

A

Gingivectomy

  • excision of gingiva
  • root SP then packed + PD membrane placed
  • 2ry healing
  • can’t Tx bony defect

Flap surgery

  • raise flap to level of mucogingival margin
  • allow visualisation of root for SP
  • can use to Tx bony defect
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6
Q

Discuss tunnelling and root amputation

A

Tunnelling

  • furcation 3
  • osteotomy + gingivoplasty to expose furcation
  • allows proper cleaning of furcation
  • adv: long roots, short trunk, adequate separation
  • disadv: root caries, sensitivity

Root amputation

  • furcation 2/3
  • remove 1 periodontally involved root cf whole tooth
  • req. endo
  • risk #
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7
Q

What is an infra-bony defect?

A

Occurs when base of PPD is apical to crest of alveolar bone

1 wall: only 1 wall remaining; i.e. M remaining, B+L lost
2 wall: 2 walls remaining; M+B remaining, L lost
3 wall: 3 walls remaining; defect not broken through B/L plate
Interproximal crater: bone b/w 2 teeth lost, B/L plates intact

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8
Q

Goals of periodontal therapy

A 
Infection control
PPD red./eliminated
Regeneration 
Long term success/results
Aesthetic improvement
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9
Q

Why can wound healing in OC be challenging?

A

Open system: exposed to OC via sulcus lots of bacteria -> infection
Surface healing w/ poor blood supply
- only supply through surrounding tissues + remaining PDL

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10
Q

Properties of ideal regenerative perio material

A

Promote proliferation + migration of cells from PDL
Inhibit proliferation of epithelial + gingival connective tissue into wound
Enhance space provision + wound stability

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11
Q

Examples of regenerative perio materials

A

Grafting
Enamel Matrix Protein/Derivative
Growth + Differentiation factors
Platelet rich plasma

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12
Q

Principles that success of perio regeneration is dependent on

A

PASS

1ry closure + site protection allowing for undisturbed healing
Angiogenesis: blood + undifferentiated mesenchymal cells
Space creation + maintenance for bony ingrowth
- if collapses will heal by long junctional epithelium
Stability: blood clot formation + uneventful healing

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13
Q

Requirements of regenerative perio membrane material

A

Biocompatible
Not elicit inflammatory response
Maintain barrier function
Noncollapsible; maintain space

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14
Q

Importance of enamel matrix proteins

A

EMP deposition on developing tooth root req. for cementum formation
PDL + alveolar bone formation dependent on cementum

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15
Q

Biological effects of EMD

A

Inc. attachment rate + migration of PDL cells
Inhibit epithelial down growth
Antibacterial effect on plaque
Stim. proliferation + differentiation of pre-osteoblasts
Osteopromotive w/ decalcified freeze dried bone allograft
Inc. osteogenic activity bone marrow
Inc. no gingival fibroblasts

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16
Q

Rationale for combination perio regenerative therapy

A

Enhance periodontal regeneration by GTR/GF/EMD

Provide space + enhance wound stability by means of grafting materials into defects w/ complex anatomy

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17
Q

Define furcation

A

Pathologic resorption of bone in the anatomic area of multi-rooted teeth where roots diverge

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17
Q

Horizontal and vertical classification of furcation defect

A

Horizontal: Hemp

  • 1: loss of PD support <3mm
  • 2: >3mm but not through-and-through
  • 3: through and through

Vertical: Tarnow + Fletcher

  • A: bone loss <3mm
  • B: 4-6mm
  • C: >7mm
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18
Q

Dx of furcation defect

A

X-ray

  • indicate existing furcation involvement
  • can’t provide Dx of classification

Clinical: Naber’s probe

  • B+L: good reproducibility + validity
  • MP: less reliable
  • DP: most difficult, poor reproducibility
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19
Q

Tx of F1

A

OH
NSPT: consider odontoplasty
PD supportive therapy

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20
Q

Management of single mandibular F2

A

Regeneration
NSPT + odontoplasty
Surgical: OFD, apically positioned flap, osteoplasty

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21
Q

Tx of combined mandibular F2 defect

A

2 + 1

  • regeneration
  • NSPT + odontoplasty
  • surgical

2 + 2

  • tunnelling
  • NSPT + odontoplasty
  • resection/hemisection
  • surgical
  • regeneration
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22
Q

What does successful perio regeneration req.?

A

PDL cells

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23
Q

Factors affecting healing following PD surgery

A 
Pt: OH, smoking
Tooth
Gingiva: recession, biotype
Initial PPD
Membrane exposure/infection
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24
Q

Factors affecting outcome of PD surgery

A 
Defect
- size
— 2x2mm predictable; 5x4mm unpredictable 
- morphology
- angle
Soft tissue management/flap recession
Space maintenance 
Tooth
- endo condition
- mobility
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25
Q

Tx of single maxillary F2 defect

A

Buccal

  • regeneration
  • NSPT + odontoplasty
  • SPT

Interproximal

  • NSPT + odontoplasty
  • SPT
  • regeneration
  • resection
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26
Q

Tx of combined maxillary F2 defect

A

Interproximal

  • SPT
  • NSPT + odontoplasty
  • resection/root separation
  • tunnelling

Buccal + Interproximal

  • SPT
  • resection/separation
  • tunnelling
  • NSPT + odontoplasty
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27
Q

Tx of F3 defects

A

L

  • tunnelling
  • root separation
  • NSPT
  • root resection
  • XLA

U

  • root resection
  • NSPT
  • tunnelling
  • root separation
  • XLA
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28
Q

When should perio re-evaluation be carried out?

A

Following SRP
- junctional epithelium reestablish: 1-2/52
- connective tissue repair: 4-8/52
8/52 too long

Ideal: 4-8/52

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29
Q

What is supportive periodontal therapy?

A

Procedures performed at selected intervals to assist PD pt maintain OH

30
Q

Objectives of SPT

A

Min. recurrence + progression of PD/implant disease
Red. incidence tooth/implant loss
Inc. probability of locating + Txing other oral disease/condition

31
Q

Compare trial and compromised SPT

A

Trial: maintain borderline PD conditions over period to further assess need for corrective therapy while maintaining PD health on balance throughout mouth

  • inadequate gingiva
  • gingiva architectural defects
  • borderline pockets
  • furcation defects

Compromised: slow progression of PD disease in pt corrective therapy indicated cannot be provided due to:

  • health
  • economics
  • poor OH
  • recalcitrant defects post-corrective therapy
32
Q

Rationale for SPT

A

PD biofilm rebounds 2/52 following SRP (Wennstrom, 2011)
Clinical success w/ regular maintenance (Becker, 2001)
Residual bleeding PPD >4mm inc. risk progression + tooth loss
Limit incidence + freq. tooth loss
Limit CAL

33
Q

When should alternatives to locally delivered antimicrobials be considered in perio?

A

Multiple PPD>4mm in 1 Q
LDAs failed to control PD
Anatomical defects; infrabony defect

34
Q

Criteria for perio referral

A

Aggressive/severe PD

  • PPD >6mm
  • excellent plaque: <20%
  • failed respond RSD w/ LA

Acute: desquamative gingivitis, necrotising PD
Drug induced gingival conditions + localised gingival swelling
Localised significant root exposure in otherwise stable pt

35
Q

Rationale behind new perio classification

A

Pts exhibit different disease progression
Little evidence aggressive + chronic perio different states and req. different Tx
Evidence multiple factors influence outcome
System based on severity fails to comprehend; complexity + risk factors

36
Q

Why did BSP introduce modified WWP guidelines?

A

Simplify; aid implementation into general practice
Speed up Dx
Continue use of BPE; used universally

37
Q

Discuss distribution of PD

A

Molar-incisor pattern
Localised: <30%
Generalised: >30%

38
Q

Discuss staging of PD

A

Indication of disease severity + complexity of Tx
Measurement: % radiographic bone loss
- single worst site in mouth

39
Q

PD stages

A

Root divided into 1/3 starting 2mm apical from CEJ

1: initial; <15%/>2mm
2: mod.; coronal 1/3
3: severe w/ potential for tooth loss; mid 1/3
4: severe w/ potential for loss of dentition; apical 1/3

40
Q

Discuss PD grading

A

% bone loss/Age

A: slow; <0.5
B: mod; 0.6-1.0
C: rapid; >1.0

41
Q

Discuss current activity of PD

A

Stable

  • PPD <4mm
  • BOP <10%
  • no BOP in PPD=4mm

Remission

  • PPD <4mm
  • BOP >10%
  • no BOP in PPD=4mm

Unstable

  • PPD >4mm
  • BOP >10%
42
Q

Discuss risk factor profile of PD

A 
Smoking 
Uncontrolled DM
Stress
Immunosuppression 
Genetics
43
Q

Dx summary for PD

A 
Distribution 
PD
Stage
Grade
Current activity 
Risk factors

Generalised Perio Stage 3 Grade B currently in Remission. Risk; smoking 15/d

44
Q

Osteoplasty vs ostectomy

A

Osteoplasty

  • reshape bone to guide gingiva
  • don’t remove supporting bone
  • furcation 1

Ostectomy
- removal of supporting bone to even out surface

45
Q

Resection vs regeneration

A

Resection

  • removal of hard tissue
  • create flat osseous architecture to facilitate better adaptation of soft tissue
  • red. PPD, inc. recession

Regeneration: addition of regenerative/grafting material to rebuild lost apparatus

46
Q

General Tx for infrabony defects and favourability to regeneration/resection

A

Greater no. walls remaining, inc. favourability to regeneration
- except 4 wall defect
Less walls req. resection

Deep defects

  • narrow: most favourable
  • wide: regeneration

Shallow: req. resective Tx

47
Q

List localised-tooth related factors that predispose to PD

A 
Accumulations 
Morphology 
Enamel pearls
Cervical enamel projections 
Bifurcation ridges
Root #s
Root proximity 
Accessory canals 
Cervical root resorption + Cemental tears
Occlusion/Trauma
Malocclusion 
Post-XLA defect
Habits
Altered passive eruption
48
Q

Discuss development of calculus

A

Calcification of plaque starts within 4-8h

Mineralised: 50% 2d, 60-90% 12d

49
Q

Significance of calculus accumulations

A

Incidence calculus, gingivitis + perio inc. w/ age

Calculus doesn’t directly cause gingival inflammation
Provides niche for plaque accumulation

50
Q

Significance of dental staining re PD

A

Inc. surface roughness -> inc. plaque accumulation

51
Q

Define: fornix, entrance, trunk, degree of separation, divergence of roots

A

Fornix: roof of furcation
Entrance: area b/w non/separated parts of roots
Trunk: body of root before roots diverge
Degree of separation: angle b/w separating roots
Divergence: distance b/w roots

52
Q

Effect of root morphology on PD

A

Furcations, grooves, concavities make more difficult to clean thus allow for inc. plaque retention

53
Q

Discuss enamel pearls + cervical enamel projections

A

Enamel pearls

  • developmental deviation; 1.1-9.7%
  • S: U7/8s
  • usually at furcation area
  • may contain dentine + pulp tissue
  • prevent connective tissue attachment

Cervical enamel projection

  • developmental deviation
  • S: B LMs
  • apical projections of enamel
  • prevent connective tissue attachment
54
Q

Effect of root #s + root proximity on PD

A

s

  • significant inc. PPD
  • usually only 1 site

Proximity

  • closer together = inc. risk
  • little interproximal space, less bone thickness
55
Q

What is altered passive eruption?

A

Developmental condition w/ abnormal dento-alveolar relationships

Gingival margin (sometimes bone) more coronal

  • > pseudopockets
  • > aesthetic concerns
56
Q

Localised dental prosthesis-related factors predisposing to PD

A 
Poor/invasive margins
Overhangs
Contours
Decay
Open/loose contacts 
DM + Procedures 
Removable prostheses
Ortho appliances
57
Q

Discuss effect of poor restorative margins on PD

A

Never good -> microleakage -> 2ry caries + PD breakdown
Follow anatomy of tooth, not encroach further than req.

Subgingival

  • deeper = higher chance inflammation
  • inc. PPD
  • inc. CAL
  • more bacteria
  • encroach on supracrestal tissue attachment -> pathological inflammation
58
Q

Discuss contour of restorations effect on PD

A

Over-contoured

  • accumulate plaque
  • handicap OH
  • prevent self-cleaning mechanisms of cheek, lips, tongue

Flat B/L contours

  • follow cervical contours
  • doesn’t accentuate cervical bulge
59
Q

Discuss open contacts + overhangs effect on PD

A

Open contacts

  • forceful food wedging due to O forces
  • some move due to movement; can’t fix due to over-contouring
  • over T -> PD breakdown as difficult to clean

Overhangs
- inc. bone loss w/ med./L overhangs
— small (<25%) less detrimental
- removal improve status thus replace restorations

60
Q

Side effects of dentures and ortho appliances (perio)

A

Dentures

  • plaque accumulation if poor OH
  • gingival inflammation/pressure
  • traumatic O forces

Ortho

  • plaque accumulation
  • change plaque composition
  • gingival inflammation + enlargement
  • gingival recession
  • trauma: bands, elastics
  • bone loss
  • root resorption
61
Q

Criteria for PD Dx

A

Interdental CAL >1mm at 2/+ nonadjacent sites
OR
Buccal CAL>3mm w/ PPD>4mm at 2/+ teeth

62
Q

1ry features of aggressive PD

A

Familial tendency
Otherwise healthy
Rapid bone/attachment loss

63
Q

2ry features of aggressive PD

A

Calculus deposits inconsistent w/ destruction
Progression poss. self arresting
Localised or generalised

64
Q

Differentiate b/w localised + generalised aggressive PD

A

Localised

  • circumpubertal onset
  • 6s, Is
  • freq. A.a.
  • neutrophil function abnormalities
  • robust serum Ab response

Generalised

  • <30y
  • at least 3 other teeth than 6s + Is
  • freq. A.a. + P.g.
  • neutrophil function abnormalities
  • poor serum Ab response
65
Q

Evidence of aggressive vs chronic PD

A

No evidence of specific pathophysiology that enables differentiation
Little consistent evidence different diseases

66
Q

Goals of aggressive PD Tx

A

Arrest disease progression
Regenerate tissues (if feasible)
Achieve: comfort, aesthetics, function
Prevent recurrence

67
Q

Why is regenerative/reconstructive surgery usually favourable in aggressive PD pt?

A

Young
Good OH
2/3 wall defects

68
Q

Evidence for adjunct systemic antimicrobial therapy for Tx aggressive PD

A

Amoxicillin + metronidazole
Significant benefit + attachment gain for PPD >6mm
More beneficial @ initial phase cf reTx

69
Q

Factors to consider re Tx furcations

A 
Degree of involvement
C:R + root length 
Root anatomy/morphology 
Root separation 
Strategic value
Tooth mobility 
Req. RCT?
Pros req.?
PD condition adjacent teeth
OH maintenance?
Bone quality 
Cost
Long term prognosis
70
Q

Contra/indications for root resection

A

Indications

  • advanced caries
  • severe recession on 1 root
  • too close root proximity for prosthetic restorations
  • RCT failure
  • root resorption/#/perforation
  • severe vertical bone loss w/ 1 root

Contra

  • poor C:R
  • red. supportive structure w/ RRs
  • unsuccessful RCT
  • long root trunk
  • fused roots
  • poor surgical access
71
Q

What are the clinical endpoints for furcation Tx?

A 
Complete closure (20%)
Conversion to F1 (horizontal)
Conversion to class A (vertical)
72
Q

When should XLA be considered in furcation cases?

A

F3 + >75% bone loss
Bone loss >50% + complete X-ray loss of bone in furcation
Loss >70% bone height
Bone loss to apex
Terminal + unopposed tooth in arch
Solitary D abutment w/ inc. mobility
Affecting PD status adjacent teeth may serve as abutments
Preservation may inc. complexity future implant procedures

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