Perio III 4/23/14 Final exam Flashcards
1
Q
Focal Theory of Infection
A
infections in oral cavity having an adverse effect on other organs/tissues
2
Q
Periodontitis &
Coronary Heart Disease
A
25% of those with both will die of CHD (risk esp high for men)
3
Q
Periodontitis &
cardiovascular/stroke
mechanisms
A
Perio infection -> systemic circulation -> coronary & carotid artery-> atheroma dev.
Perio infection -> production of mediators-> systemic circulation -> atheroma dev.
4
Q
Chlamydia Pneumonia Cytomegalovirus actinobacillus actinomycetemcomitans tanarella forsythensis porphyromonas gingivalis prevotella intermedia
A
bacteria ID’ed in atheromatous plaques in Hs carotid arteries
5
Q
Do well controlled diabetics need antibiotic prophylaxis?
A
not in most cases
6
Q
Does nonsurgical periodontal therapy improve glycemic control in a diabetic with periodontitis?
A
no
7
Q
What does lower glycosylated hemoglobin in a diabetic with periodontitis?
A
Combination of mechanical therapy & systemic doxycycline:
~Debridement (SRP)
~2 wks of low dose doxycycline
~Frequent maintenance
8
Q
When is the best time to give perio Tx for a diabetic?
A
before or after periods of peak insulin activity
9
Q
Periodontitis and pregnancy
A
possible risk for pre-term birth
60-70% get gingivitis
90% heart murmurs
50% inc. in CO
10
Q
when is the best time to treat a pregnant women with gingivitis?
A
2nd trimester
inform pt and maintain good OH
(estrogen/progesterone inc. partly to blame)… 0-0 anaerobic bacteria: Prevotella intermedia)
11
Q
Does perio Tx significantly alter risk of pre-term delivery?
A
no
12
Q
local antimicrobial delivery of Tetracycline hydrochloride
periodontal fiber therapy: 12.5 mg/fiber -10 days
A
Actisite
13
Q
local antimicrobial delivery of Chlorhexidine- 2.5 mg
*pockets ≥ 5mm
*broad spectrum
*gelatin = carrier, no refrigeration
*decreased pockets
~mild-moderate sensitivity during 1st week
~continue toothbrushing & regular diet
~avoid flossing for 10 days
A
Perio Chip ($16/chip... 1 tooth) provided significantly greater improvement with this adjunct when used with SRP
14
Q
local antimicrobial delivery of Doxycycline- 8.5% *pockets ≥ 5mm *controlled release for 7 days *decreased pockets, improved CAL & bop Tx chronic periodontitis
A
Atridox ($45/ syringe… 6 teeth)
significantly reduced anaerobic bacteria without dev. of antibiotic resistant bacteria.
15
Q
local antimicrobial delivery of minocycline powder (microspheres)
*25% more shift from PD 7mm to ≤5mm p 9mo
A
Arrestin
$14 per cartridge(tooth)
same contraindications as the systemic minocycline
16
Q
what local antimicrobial delivery did not consistently show more effective than just SRP alone?
A
Elyzol
- 25% Metronidazole
- for PD ≥ 5mm
- anaerobic bacteria (bacteriocidal)
Emdogain
17
Q
7 indications for controlled antimicrobial delivery
local
A
- PD ≥ 5mm
- BOP
- Where esthetics is a concern & Sx may be contraindicated (uncontrolled diabetic, elderly, …)
- Not responding to SRP
- Dental phobic pt
- Refractory Periodontitis (aka recurrent)
- Medically compromised patients (Perio Sx contraindicated)
18
Q
The only FDA approved oral, systemic Tx for chronic periodontitis that suppresses activity of destroying enzymes.
For maintenance pt with refractory/recurrent periodontitis & smokers trying to quit
A
Periostat: 20 mg capsule of doxycycline ($60/mo)
2x/day- 1 hr before meals with adequate fluids
max efficacy 9 mo… min efficacy 3 mo
19
Q
The following are oral manifestations of what?
Severe gingival inflammation
Acute gingival or periodontal abscesses
Rapidly advancing periodontal disease
A
uncontrolled diabetes mellitus
20
Q
Why re-evaluate after initial Tx?
A
Check lesion elimination (shallower pockets)
check if tissues are firmer
give time for pt education & comfort
21
Q
purpose of Phase II (surgical) Tx
A
improve Px of teeth & their replacements
Improves esthetics
22
Q
Advantages vs. disadvantages of local chemotherapeutics
A
*more concentration
*fewer side effects
*sustained delivery
*pt compliance
x More chairside time
x more expensive
x no effect on bacterial reservoirs
23
Q
side effect of pseudomonas colitis from the toxin produced by Clostridium difficile
A
Tetracyclines= doxycycline, minocycline, etc..
Clindamycin (cleocin)
Penicillins = penicillin VK, amoxicillin, augmentin
24
Q
Bacteriostatic via protein synthesis -> G+/- 2 types of this drug's absorption may be lowered by: -antacids (NaHCO3) -laxatives (Mg, Ca, Al) -antidiarrhea -food/diary -Fe, Zn Other 1 Tx refractory periodontitis x pseudomonas colitis side effect
A
Tetracycline & minocycline
Doxycycline
25
Bacteriostatic (some -cidal) -> G +/- anaerobes
Tx refractory periodontitis
x pseudomonas colitis side effect
x diarrhea, abdominal pain, blood in stools
Clindamyacin
26
```
Bacteriocidal via DNA syn -> obligate anaerobes
Tx periodontitis/AIDS
x GIT
x inc. anticoagulant effect
x disulfuran-like rxn
```
Metronidazol (flagyl)
27
Bacteriocidal via CW syn -> rapidly growing bacteria
Tx perio abscess
x pseudomembranous colitis
x allergic rxn
Penicillins (pen VK, amoxillin, augmentin)
28
Amoxicillin advantage over penicillin VK
```
better absorbed (95% vs. 65%)
longer serum 1/2 life (0.7-1.4 vs. 0.5)
may take with food
```
29
Bacteriocidal via protein synthesis
Stays in the tissue 9-10 days after finishing regimen
x 1 causes upset stomach/nausea more common
The other is the alt Tx for periodontal abscess due to its better anaerobic coverage, long serum 1/2 life (1 dose/day), & pregnant category B
Erythromycin (1)
azithromycin (other)
clarithromycin
30
These systemic drugs cause...:
Dilatin
Cyclosporine
Calcium channel blockers
hyperplastic gingiva
31
2 important antibiotic regimens
Amoxicillin & metronidazole
| Doxycycline
32
Guidelines for antibiotics:
| Are they necessary for most gingivitis or periodontitis?
No
33
Guidelines for antibiotics:
May be necessary for refractory periodontal disease which doesn't respond to conventional therapy. What should be given? (give 4 regimens)
1. Doxycycline 100 mg; 21 tabs, 2 for day 1 and then 1/day
2. Amoxicillin & Metronidazole (500mg & 250 mg)
3. (if allergic to penicillin) Ciprofloxacin & Metronidazole (250 mg each)
4. (refractory & generalized aggressive periodontitis) Clindamycin 150 mg
34
Guidelines for antibiotics:
| Tx for locally aggressive (juvenile) periodontitis
Doxycycline
| Amoxicillin & Metronidazole (500mg & 250 mg) 22 tabs each- 2 tabs each, then 1 q 6 hrs
35
Guidelines for antibiotics:
| List (10) systemic diseases that influences severity of periodontal disease
1. Chediak-Higashi Syndrome
2. Down's Syndrome
3. Papillon LeFevre Syndrome
4. DIabetes
5. AIDS
6. Cancer
7. Leukemia
8. Neutropenia
9. Hypophosphatasia
10. Leukocyte Adhesion Deficiency
36
Guidelines for antibiotics:
| Tx with Papillon LeFevre Syndrome
Augmentin (amoxicillin 500 mg, clavulonic acid 125 mg)
37
Guidelines for antibiotics:
| Tx for AIDS & gingivitis
Chlorhexidine rinse
38
Guidelines for antibiotics:
| Tx for AIDS & periodontitis (NUG, NUP)
Chlorhexidine rinse & Metronidazole
39
Guidelines for antibiotics:
for pregnant women with periodontitis
(avoid 3, safe 4, yes 2)
No: tetracyclines, clarithromycin, & ciprofloxacin
Safe to use: Penicillin (amoxicillin), cephalosporins, erthromycin base, azithromycin
Yes: Clindamycin, metronidazole
40
Guidelines for antibiotics:
What should be given to pt with periodontal abscess that doesn't respond to conventional therapy and have systemic involvement.
Must see pt and will want to curette the pocket involved
| Penicillins & Erythromycin
41
Guidelines for antibiotics:
| Sign for when infection becomes systemic
1. Fever
2. Increased vital signs
3. Lymphadenopathy
4. Malaise
5. Increased WBC count
Local infection: pain, redness, edema, pus, fistula.
42
Guidelines for antibiotics:
| Pt with NUG/NUP who have systemic involvement
doxycycline, metronidazole
43
3 advantages & 2 disadvantages of LASERS in perio therapy
*greater hemostasis
*greater bactericidal effects
*minimal wound contraction
x precautions of eyes & other tissues
x reflected beam (Diodes don't have this pbm)
(limited evidence that lasers may provide an additional benefit when used as adjunct to SRP)
44
Applications of LASERS in perio therapy
Gingival troughing- for impression taking
Fibroma removal
Frenectomy
Gingivectomy (removes epithelial lining...)
Implants **
45
3 purported benefits of lasers in SRP
1. curretage by laser (curretage has no added benefit over SRP)
2. reduction of sub-G bacteria (unpredictable & inconsistent)
3. SRP (Er:YAG laser show greatest potential for effective SRP... but potential for root or bone damage)
46
An electronic device that generates ultrasonic microvibrations at variable frequencies... doesn't cut soft tissue in sinus surgery
Piezoelectric Surgery
47
3 goals of physiologic occlusion
(no signs of dysfunction or disease)
Stable endpoint of Mn closure
Bilateral distribution of occlusal forces
Axial loading of teeth
48
excess occlusal force on a normal dentition is considered as ..."
primary occlusal trauma
49
normal force on a periodontally compromised dentition
secondary occlusal trauma
50
Therapeutic priority is to control inflammation: what's addressed 1st? 2nd?
1. Control inflammation
| 2. Address residual mobility
51
* Tooth mobility, inc. displacement, stable pattern-adaptation
* tooth migration
* tooth pain on percussion
* PDL widening apical resorption on vital tooth
* TMJ dysfunction
* xs wear facets or fractures
* fremitus
Clinical features of occlusal trauma
| *Evaluate pulpal vitality & parafunctional habits
52
```
Occlusal adjustment
Splinting
Stents
Orthodontic tooth movement
Occlusal reconstruction
Extraction
```
Treatment options for traumatic occlusion
53
May eliminate need for osseous resection entirely
No loss of interproximal papillae
No postoperative sensitivity
Orthodontic extrusion
fast= 2-3mm /wk will bring ST mov, but not bone
slow= 2-3mm/mo will allow bone to reform with the tooth & ST mov.
54
Concerns associated with orthodontic extrusion
harder to achieve a good emergence profile fo the final prosthesis, complicating OH
Tooth may be difficult to restore & maintain due to root form
55
When used with orthodontic extrusion, this helps prevent rotation relapse... its done every 1-2 wks during the extursion and under LA
Circumcrestal fiberotomy
| -severing supercrestal gingival fibers
56
Why is bracket placement important in extrusive orthodontics?
need certain distance to get th eextrusive force
57
Orthodontic extrusion can be done alone or in combination with properly timed...?
Traditional orthodontics
Palatal implants
Periodontal Sx- "Wickodontics"
58
Goals of Orthodontics
| to use the PDL & alveolar bone
Force to maximize movement
Without pain
Without root resorption
Maintains healthy of PDL thru-out the movement.
59
Tooth Movement Fundamentals:
| Trailing side vs. Leading side
Trailing side: tension, bone deposition, collagen fibers stretched
Leading: pressure, bone resorption, collagen fibers compressed
60
Theory of Traditional Orthodontics
```
Molars anchor teeth
Move teeth 1 at a time
Big root surafce area vs. small
Pit many teeth against few
Slow process...
```
61
Theory of palatal implants
Absolute (no relative) anchorage
Movement all at once!
Simultaneous, not segmental movements
Any tooth movement
62
- access
- angle of implant
- midline suture
- avoid nasal floor perforation
- Later... explanation of the implant
Site determination for Sx for palatal implants.
63
Burst of localized remodeling and healing following surgical wounding of cortical bone- basically recruiting osteoclasts & osteoblasts in the presence of damage to bone... peaks 1-3 mo
Corticotomies: cut cortical bone -> elevate flap -> "lines & dots" -> marrow space
Wickodontics ...aka
POAA= periodontally accelerated osteogenic orthodontics
RAP= Regional Accelerated Phenomenon
64
Root morphology (concavit, enamel pearl, etc...)
Platform switching
Injection material stuck in pocket
Impingement on biological width
Subgingival restorations or defects (pontic must be ≥2 mm from bone)
Iatrogenic causes of periodontal pathology
65
What has no lasting adverse effect on the periodontium when used correctly?
Retraction cord
66
Broadly, interproximal restorations & caries are associated with an increased risk for...
CAL or bone loss & gingival inflammation
67
What's associated with food impaction & are damaging to the periodontium (typically causing loss of attachment on both proximal surfaces)
narrow open contacts
68
What will cause BOP from 0% -> 100% p 22 wks?
Presence of overhangs
| -cause rapid changes in the subG microbiota and are associated with attachment loss
69
5 Major steps for periodontal maintenance & supportive therapy
1. update medical, dental, & social Hx
2. detailed exam, clinically & radiographically
3. update Dx & Px
4. review OH & compliance
5. perform supra & sub G instrumentation
70
objectives of periodontal therapy
establish & preserve health
| restore fxn
71
Tooth loss according to maintenance frequency
1. Tx + maintenance
2. Tx - maintenance
3. no Tx
1. 0.11 teeth/yr
2. 0.22 teeth/yr
3. 0.36 teeth/yr
72
Best predictors of attachment loss over 5 yrs
52% had PD > 7mm had CAL
| plaque & bleeding aren't very predictive
73
```
negative aggression & immaturity
passivity dependence & depression
emotion-focused coping
external focus of control & poor coping abilities
low emotional intelligence
neuroticism
```
are linked with Non-Compliance
74
```
Older pt
non-smokers
female
those who spend longer in active Tx
Those with shorter recall itnervals
```
are more likely to be compliers
75
3 mo recall interval for...
1st yr pt for routine therapy & uneventful healing
76
1-2 mo recall interval for...
1st yr pt with difficult case:
| complicated prosthesis, furcation involvement, poor crown-to-root ratios, questionable pt cooperation
77
1-3 mo recall interval for..
generally poor results after periodontal therapy and/or several negative factors:
1-inconsistent or poor OH
2-heavy calculus formation
3-systemic disease that predisposes to periodontal bkdn
4-many remaining pockets
5-occlusal pbms
6-recurrent caries
7-complicated prosthesis
8-perio Sx indicated but can't be performed or condition too advanced 2b Sx correctable
9.- many teeth with <50% alv bone support
10.smoking
11. Positive family Hx
12 BOP> 20%
78
3-4 mo recall interval
```
generally good results maintained for at least a yr, but pt displays some of these negative factors:
1-inconsistent or poor OH
2-heavy calculus formation
3-systemic disease that predisposes to periodontal bkdn
4-some remaining pockets
5-occlusal pbms
6-ongoing ortho
7-complicated prosthesis
8-recurrent caries
9.- some teeth with <50% alv bone support
10.smoking
11. Positive family Hx
12 BOP> 20%
```
79
An adjunct that hasn't led to significant improvement
Emdogain & Elyzol
80
SRP + photodynamic therapy
soaking bacteria with a dye (methylene blue) & zapping them with a diode at a specific wavelength... very good results, but diode is expensive
81
Tooth loss clusters are common.
false... will likely only find certain individuals
82
Surgical or non-surgical procedures result in greater PD redn?
sugrical
83
Open flap debridement or regenerative procedures produce greater improvement in infrabony pockets?
regenerative procedures
84
From dental insurances:
| What're the most common perio Tx?
36% SRP
21% ST grafts & crown lengthening
17% perio maintenance
17% osseous Sx
85
From dental insurances:
| most common dental coverages
```
26% restorative dentistry
21.5% fixed pros
13.5% preventive care
11.5% Dx
7.5% endo
7.5% ortho
7.5% OMS
6% Perio... 1/2 is performed by non-periodontist
```
86
GP feels incompetent in the required procedure. A suggested guide to making the decision to refer is this: if the practitioner would not preform the procedure being on one of his or her own family members, the pt should be referred to someone more competent in the procedure. Usually in such cases, the generalist hasn’t had education in or experience with the procedure under consideration
GP should refer to dental specialist
87
GP doesn’t have the interest in accomplishing the required procedure. Many dentists don’t enjoy accomplishing certain areas of dentistry, and they haven’t developed their abilities beyond the dental school level in those areas.
GP should refer to dental specialist
88
The pt has experienced numerous failed attempts in achieving an acceptable result with a procedure as performed by a general dentist & would feel more comfortable and be more cooperative if treated by a specialist.
GP should refer to dental specialist
89
The procedure is among the most difficult techniques within each specialty that’re considered to be primarily in the realm of practitioners in the respective specialty. In other words, few general dentists accomplish the procedure.
GP should refer to dental specialist
90
The pt has had specialist treatment in the past & prefers to have the therapy accomplished by a specialist
GP should refer to dental specialist
91
Pt has a rare or relatively unknown condition that’s best treated by a specialist who has seen & has treated these types of cases
GP should refer to dental specialist
92
50% of perio pt are how old?
26-45 yo ...GP Tx more early to moderate perio
| Older pt will have more advanced perio
93
Dental team involvement: dental team & practice style analysis
dental team: desire & motivation to make the transformation, and the role of each team member
practice style: willingness to critically analyze existing practice & commitment to invest time, energy & funds
94
Legal standard of care
dentist should know general Tx responses
95
- female gender
- practicing with one other dentist (vs solo or grp)
- employing 2+ hygienists more hygienists refer pt to perio
- being more than miles from the nearest periodontist
4 significant positive influence on the # of referrals/mo from a GP to a periodontist
