Perio Flashcards
Reasons for NSPT failure
Inc. PPD
Inc. width tooth surface
Poor access: unable to angle/adapt curette
Tenacious calculus
Root fissures/concavities/furcation
Defective restoration margins subgingival
Relationship between chance of calculus removal and PPD
Inverse
<3mm = 83%
3-5mm = 39%
>5mm = 11%
Av. depth plaque-free surface established = 3.73mm
Instrument can reach 5.52mm
Objectives of PD surgery
Eliminate local factors Eliminate/red. PPD Restore alveolar bone architecture Regenerate functional attachment apparatus Crown lengthening Correct mucogingival defects
Surgical PD therapy techniques
Gingivectomy Flap surgery Osteoplasty Tunnelling Root resection
Gingivectomy vs flap surgery
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
Discuss tunnelling and root amputation
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 #
What is an infra-bony defect?
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
Goals of periodontal therapy
Infection control PPD red./eliminated Regeneration Long term success/results Aesthetic improvement
Why can wound healing in OC be challenging?
Open system: exposed to OC via sulcus lots of bacteria -> infection
Surface healing w/ poor blood supply
- only supply through surrounding tissues + remaining PDL
Properties of ideal regenerative perio material
Promote proliferation + migration of cells from PDL
Inhibit proliferation of epithelial + gingival connective tissue into wound
Enhance space provision + wound stability
Examples of regenerative perio materials
Grafting
Enamel Matrix Protein/Derivative
Growth + Differentiation factors
Platelet rich plasma
Principles that success of perio regeneration is dependent on
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
Requirements of regenerative perio membrane material
Biocompatible
Not elicit inflammatory response
Maintain barrier function
Noncollapsible; maintain space
Importance of enamel matrix proteins
EMP deposition on developing tooth root req. for cementum formation
PDL + alveolar bone formation dependent on cementum
Biological effects of EMD
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
Rationale for combination perio regenerative therapy
Enhance periodontal regeneration by GTR/GF/EMD
Provide space + enhance wound stability by means of grafting materials into defects w/ complex anatomy
Define furcation
Pathologic resorption of bone in the anatomic area of multi-rooted teeth where roots diverge
Horizontal and vertical classification of furcation defect
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
Dx of furcation defect
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
Tx of F1
OH
NSPT: consider odontoplasty
PD supportive therapy
Management of single mandibular F2
Regeneration
NSPT + odontoplasty
Surgical: OFD, apically positioned flap, osteoplasty
Tx of combined mandibular F2 defect
2 + 1
- regeneration
- NSPT + odontoplasty
- surgical
2 + 2
- tunnelling
- NSPT + odontoplasty
- resection/hemisection
- surgical
- regeneration
What does successful perio regeneration req.?
PDL cells
Factors affecting healing following PD surgery
Pt: OH, smoking Tooth Gingiva: recession, biotype Initial PPD Membrane exposure/infection
Factors affecting outcome of PD surgery
Defect - size — 2x2mm predictable; 5x4mm unpredictable - morphology - angle Soft tissue management/flap recession Space maintenance Tooth - endo condition - mobility
Tx of single maxillary F2 defect
Buccal
- regeneration
- NSPT + odontoplasty
- SPT
Interproximal
- NSPT + odontoplasty
- SPT
- regeneration
- resection
Tx of combined maxillary F2 defect
Interproximal
- SPT
- NSPT + odontoplasty
- resection/root separation
- tunnelling
Buccal + Interproximal
- SPT
- resection/separation
- tunnelling
- NSPT + odontoplasty
Tx of F3 defects
L
- tunnelling
- root separation
- NSPT
- root resection
- XLA
U
- root resection
- NSPT
- tunnelling
- root separation
- XLA
When should perio re-evaluation be carried out?
Following SRP
- junctional epithelium reestablish: 1-2/52
- connective tissue repair: 4-8/52
8/52 too long
Ideal: 4-8/52
What is supportive periodontal therapy?
Procedures performed at selected intervals to assist PD pt maintain OH
Objectives of SPT
Min. recurrence + progression of PD/implant disease
Red. incidence tooth/implant loss
Inc. probability of locating + Txing other oral disease/condition
Compare trial and compromised SPT
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
Rationale for SPT
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
When should alternatives to locally delivered antimicrobials be considered in perio?
Multiple PPD>4mm in 1 Q
LDAs failed to control PD
Anatomical defects; infrabony defect
Criteria for perio referral
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
Rationale behind new perio classification
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
Why did BSP introduce modified WWP guidelines?
Simplify; aid implementation into general practice
Speed up Dx
Continue use of BPE; used universally
Discuss distribution of PD
Molar-incisor pattern
Localised: <30%
Generalised: >30%
Discuss staging of PD
Indication of disease severity + complexity of Tx
Measurement: % radiographic bone loss
- single worst site in mouth
PD stages
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
Discuss PD grading
% bone loss/Age
A: slow; <0.5
B: mod; 0.6-1.0
C: rapid; >1.0
Discuss current activity of PD
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%
Discuss risk factor profile of PD
Smoking Uncontrolled DM Stress Immunosuppression Genetics
Dx summary for PD
Distribution PD Stage Grade Current activity Risk factors
Generalised Perio Stage 3 Grade B currently in Remission. Risk; smoking 15/d
Osteoplasty vs ostectomy
Osteoplasty
- reshape bone to guide gingiva
- don’t remove supporting bone
- furcation 1
Ostectomy
- removal of supporting bone to even out surface
Resection vs regeneration
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
General Tx for infrabony defects and favourability to regeneration/resection
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
List localised-tooth related factors that predispose to PD
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
Discuss development of calculus
Calcification of plaque starts within 4-8h
Mineralised: 50% 2d, 60-90% 12d
Significance of calculus accumulations
Incidence calculus, gingivitis + perio inc. w/ age
Calculus doesn’t directly cause gingival inflammation
Provides niche for plaque accumulation
Significance of dental staining re PD
Inc. surface roughness -> inc. plaque accumulation
Define: fornix, entrance, trunk, degree of separation, divergence of roots
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
Effect of root morphology on PD
Furcations, grooves, concavities make more difficult to clean thus allow for inc. plaque retention
Discuss enamel pearls + cervical enamel projections
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
Effect of root #s + root proximity on PD
s
- significant inc. PPD
- usually only 1 site
Proximity
- closer together = inc. risk
- little interproximal space, less bone thickness
What is altered passive eruption?
Developmental condition w/ abnormal dento-alveolar relationships
Gingival margin (sometimes bone) more coronal
- > pseudopockets
- > aesthetic concerns
Localised dental prosthesis-related factors predisposing to PD
Poor/invasive margins Overhangs Contours Decay Open/loose contacts DM + Procedures Removable prostheses Ortho appliances
Discuss effect of poor restorative margins on PD
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
Discuss contour of restorations effect on PD
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
Discuss open contacts + overhangs effect on PD
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
Side effects of dentures and ortho appliances (perio)
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
Criteria for PD Dx
Interdental CAL >1mm at 2/+ nonadjacent sites
OR
Buccal CAL>3mm w/ PPD>4mm at 2/+ teeth
1ry features of aggressive PD
Familial tendency
Otherwise healthy
Rapid bone/attachment loss
2ry features of aggressive PD
Calculus deposits inconsistent w/ destruction
Progression poss. self arresting
Localised or generalised
Differentiate b/w localised + generalised aggressive PD
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
Evidence of aggressive vs chronic PD
No evidence of specific pathophysiology that enables differentiation
Little consistent evidence different diseases
Goals of aggressive PD Tx
Arrest disease progression
Regenerate tissues (if feasible)
Achieve: comfort, aesthetics, function
Prevent recurrence
Why is regenerative/reconstructive surgery usually favourable in aggressive PD pt?
Young
Good OH
2/3 wall defects
Evidence for adjunct systemic antimicrobial therapy for Tx aggressive PD
Amoxicillin + metronidazole
Significant benefit + attachment gain for PPD >6mm
More beneficial @ initial phase cf reTx
Factors to consider re Tx furcations
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
Contra/indications for root resection
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
What are the clinical endpoints for furcation Tx?
Complete closure (20%) Conversion to F1 (horizontal) Conversion to class A (vertical)
When should XLA be considered in furcation cases?
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
