perio need to know Flashcards
when would you result in treating a patient with periodontal surgery?
- if at re-evaluation, pockets of 5mm or greater persist in the presence of excellent oral hygien
- re-evaluation should be at least 4-6 weeks after completeion of non-surgical phase
why is non-surgical therapy always carried out before surgical?
- surgery is more invasive and has more long term complications
- HPT may be all that is required to help eliminate periodontal disease
what are the disadvantages of pocket elimination?
- supporting bone may be removed
- the exposed root surface may be un-aesthetic
- the exposed root surface may be sensitive
what is ANUG?
acute necrotising ulcerative gingivitis
what are the risk factors of ANUG?
- poor oral hygiene
- smoking
- stress
- immunocompromised e.g. HIV
- malnutrition
- young adults
what pathogens are involved in ANUG?
- fusobacterium
- prevotella intermedia
how can smoking effect the periodontium?
- greater periodontitis risk
- reduced treatment response
- recurrence of disease
- tooth loss
- reduced bone height
what are the symptoms of ANUG?
- pain
- bleeding
- halitosis
what is the clinical presentation of ANUG?
- punched out
- , crater-like ulcers affecting interdental papillae, extending onto gingival margin
- ulcers covered with greyish slough which can be wiped away leaving bleeding tissue
- necrosis of gingival tissue eventually extending to PDL and bone
what is a periodontal abscess?
localised acute exacerbation of a pre-existing pocket caused by trauma or obstruction of the pocket entrance
what is a periapical abscess?
localised collection of pus around the apex of non-vital teeth as a result of pulp necrosis
what are the symptoms of a periodontal abscess?
- pain on biting
- swelling
- discharge with halitosis
what are the clinical findings of a periodontal abscess?
- swelling adjacent to periodontal pocket
- tooth may be TTP
- suppuration- discharging through sinus or pocket
- tooth mobility
- likely to have pain on lateral movement
- likely to have generalised horizontal bone loss
what is the biological width?
the natural distance between the gingival sulcus and the height of the alveolar bone
define ‘Ante’s law’
the combined periodontal area of abutment teeth should be equal to or greater than the periodontal area of the tooth/teeth being replaced
how is ANUG treated?
- debridement using an ultrasonic
- oxidising mouthwash
- chlorhexidine
- oral hygine instruction
- antibiotics;
amoxicillin 500mg for 3-5 days
metronidazole 200mg for 3-5 days
how is a periodontal abscess treated?
- drainage- incision via pocket, dialte with instrument
- gentle sub-gingival debridement
- hot saline mouthwash
- extraction of teeth with poor prognosis
- antibiotics;
amoxicilin 500mg for 5 days
metronidazole 200mg for 5 days - follow up with HPT, surgery in indicated, maintenance
what is the rationale for using antiseptics and antibiotics for perio disease?
- perio diseases have infectious aetiology
- pathogenic bacteria associated with periodontitis are susceptible to antibiotics and antiseptics
what does substantivity depend on?
- adsorption onto oral surfaces
- maintenance of antimicrobial activity
- slow neutralisation of antimicrobial activity
what are some of the problems with using antibiotics for perio disease?
- biofilms resist antibiotics
- allergic reactions
- bacterial resistance to antibiotics
what is the aim of mechanical therapy for periodontitis?
- disrupt the biofilm
- reduce bacterial load
what are the advantages of local delivery, antibiotics and antiseptics?
- high GCF concentration
- low systemic uptake
- high pt compliance
what is the periochip?
local delivary of chlorhexidine 2.5mg
biodegrades in 7-10 days
what are the 4 features of periodontitis?
- bone loss
- loss of attachment
- transforamtion of junctional epithelium to pocket epithelium
- apical migration of junctional epithelium
give examples of pulp and periodontal communication
- perforation of root canal
- facture of root
- dentinal tubules
- apical foramen
- accessory canals
what are the iatrogneic effects of restorations on the periodontium?
- overhangs can cause plaque accumulation at the gingival margin, leading to inflammation
- irritants which are poorly placed during restorations can initiate or add to exisitng inflammation
- subgingivally placed restorations or crowns can impinge on the biologic width - this promotes inflammation and loss of clinical attachment
what is the composition of dental plaque?
- primarily composed of micro-organisms (1g of wet weight plaque contains 10x11 bacteria)
- microorganisms exist within intracellular matrix that also contains epithelial cells, macrophages and leukocytes
- intracellular matrix consists of organic (polysaccharides, proteins and lipids) and inorganic (calcium and phosphorus) materials derived from saliva, gingival crevicular fluid and bacterial products
what are the effects of uncontrolled diabetes mellitus on the periodontium?
- tendancy towrds enlarged gingivae, abscess formation, periodontitis, mobile teeth
- reduction in defence mechanisms and increased susceptibility leads to destructive periodontal disease
- severe ginigval inflammation, deep periodontal pockets and rapid bone loss appear in diabetic patients with poor oral hygiene
- diabetes mellitus alters the response of periodontal tissues to local factors, delaying post surgical healing
what drugs are responsible for agranulocytosis?
- benzene ring derivatives
- amino pyrine
- arsenical agents
- gold salts
give local causes of hyperpigmentation of the gingiva
- chronic gingivitis
- ANUG
- herpetic gingivostomatitis
- chemical irritation
- metallic pigmentation in the areas of pre-existant inflammation e.g. mercury intoxication
- amalgam tattoo
give systemic factors which can cause hyperpigmentation of the gingivae
- increased melanin e.g. addisons disease
- increased billirubin e.g. jaundice
- increased iron e.g. pregnancy/diabetes
what is papillon-Lefe’vre syndrome?
- inherited- follows autosomal recessive pattern
- hyperkeratotic skin lesions
- severe destruction of periodontium
- calcification of dura
- signs usually appear together before age 4
- skin lesions consist of hyperkeratosis and ichthyosis of localised areas on palms, soles, knees, elbows
- periodontal involvement consists of early inflammatory changes that lead to bone loss and exfoliation of teeth
what are the characteristics of papillon-Lefe’vre syndrome?
- primary teeth lost by age 5-6
- permanent dentition erupts normally but are lost within a few years due to destructive periodontal disease
- pt usually edentulous apart from third molars by age 15
- third molars lost within a few years of eruption
how is papillon-Lefe’vre syndrome managed?
- extraction of primary teeth with poor prognosis allows for safer environment for eruption of permanent dentition
- etretinate, isotretinoin and acitretin can be used to reduce chronic inflammation of gingivae
name drugs which can cause gingival enlargment
- anticonvulsants e.g. phenytoin
- immunosuppressants
- calcium channel blockers e.g. nifedipine
how is drug induced gingival enlargement treated?
- strict plaque control
- substitution of drug by physician
- gingivectomy
- flap procedures
a 5 year old presents with diffuse redness of oral mucosa including gingiva proceeded by vesicles. what is the most likely diagnosis?
acute herpetic gingivostomatitis
what are the immunologic factors of localised aggressive periodontitis?
- human leukocyte antigens
- functional defects of PMNs and/or monocytes
- autoimmunity
- altered helper or suppressor T-cell function
- polycolonal activation of B-cells
- genetic predisposition
define infrabony and suprabony periodontal pockets
- suprabony pocket-base of pocket coronal to alveolar crest
- infrabony pocket- base of pocket apical to alveolar crest
give classifications of periodontal pocket
- false pocket
- true pocket (suprabony or infrabony)
- simple
- compound
- complex
outline management of periodontal pockets
- strict plaque control
- oral hygiene instruction
- root surface debridement
- gingivectomy for suprabony pockets
- periodontal flap procedures
what are the different methods of mechanical plaque control?
- tooth brush
- dental floss
- interdental cleaning
what are the indications of a gingivectomy?
- gingival enlargment
- suprabony periodontal pocket
- suprabony periodontal abscess
what are the contraindications of a gingivectomy?
- need for bone surgery
- situation in which the bottom of the pocket is apical to the mucogingival junction
- aesthetic considerations - especially anterior maxilla
name the different types of gingivectomy
- surgical gingivectomy
- gingivectomy by electro surgery
- gingivecomty by chemo surgery
- laser gingivectomy
how does healing after a gingivectomy take place?
- formation of protective surface clot
- underlying tissue acutely inflamed with some necrosis
- clot replaced by granulation tissue
- 24 hours- increase in angioblasts beneath inflamed and necrotic area
- 72 hours- increase young fibroblasts in area
- 2 weeks- vessels of periodontium connect with gingival vessels
- complete connective tissue repair takes 7 weeks
classify periodontal flaps
bone exposure after flap reflection:
* full thickness
* partial thickness
placement of flap after surgery:
* undiplaced
* displaced
management of papilla:
* conventional
* papilla preservation
what are the 2 basic incisions of periodontal flaps?
- horizontal
- vertical
describe horizontal periodontal flaps
- directed along margin of gingivae in mesial or distal direction
3 types; - internal bevel incision
- crevicular incision
- interdental incision
describe internal bevel incisions
- horizontal incision
- basic to most periodontal flap procedures
- incision from hwich flap is reflected to expose underlying bone and root
- aka first incision
- # 11 or #15 surgical scalpel used
describe crevicular incisions
- a horizontal incision
- starts at the bottom of the pocket and is directed towards the bone margin
- beak shaped #12D blade usually used
describe interdental incisions
- horizontal incision
- performed after the flap is elevated
- orban knife used
describe vertical incisions
- can be used on one or both ends of the horizontal incision- depends on design and purpose of flap
- vertical incisions at both ends are necessart if the flap is apically displaced
- must extend beyond mucogingival line to alveolar mucosa to allow for release of flap to be displaced
- avoided on lingual and palatal surfaces
- incision should be made at line angles of tooth
how many classifications of furcation involvement are there?
4
define a grade I furcation involvement
- incipient, early stage
- pocket is suprabony and affects soft tissues
- early bone loss with increased probing depth
- no radiographic change
define a grade II furcation involvement
- cul-de-sac with definite horizontal component
- vertical bone loss may be present
- radiograph may/may not depict changes
define a grade III furcation involvement
- bone not attached to the dome of furcation
- in early stage may be filled with soft tisse and not visible
- radiograph will show a radiolucent area
define a grade IV furcation involvement
- interradicular bone is detroyed
- soft tissue have receded apically so opening is clinically visible
outline treatment for class IV furcation involvement in a mandibular first molar
- nonsurgical inaffective because ability to instrument tooth surface adequately is compromised
- periodontal therapy, endodontic therapy and restoration may be required
what are the 2 types of periapical abscess?
chronic
acute
what are the characterisitics of a chronic periapical abscess?
- gradual onset
- little or no discomfort
- intermittent discharge of pus through an associated sinus tract
how do chronic periapical abscesses appear radiographically?
signs of osseous destruction
radiolucency at the apex
what are the characteristics of acute periapical abscesses?
- rapid onset
- spontaneous pain
- extreme tenderness of tooth to pressure
- pus formation and swelling of associated tissues
- systemic signs of malaise, fever and lymphadenopathy
- may not show radiographically
what are the risk factors of chronic gingivitis?
- pregnancy
- leukaemia
- puberty related
- poor OH
what is the treatment for chronic gingivitis?
- OHI
- HPT is required for removal of plaque and calculus
*
what are the indications for periodontal surgery?
- Pockets 5mm or greater 4-6 weeks after non-surgical treatment in the presence of excellent oral hygiene
what are the aims of periodontal surgery?
to arrest disease by gaining access to complete root surface debridement and to regenerate lost periodontal tissues
what should a GDP check for when reviewing a patient with previous surgical root surface debridement?
- poor oral hygiene with persistent inflammation
- good oral hygiene with inflammation resolved
- good oral hygiene with persistent deep pockets with bleeding on probing
what treatment would you carry out at a follow up appointment for a patient who smokes and presents with ANUG?
debridement with LA
smoking cessation advice
OHI
