perio scenarios

Question 1

A 50 year old man attends complaining of painful gums and a metallic taste. OE he has poor OH with yellow-white ulcers on his interdental papilla.

How would you manage this patient? What is the likely diagnosis?

Answer 1

Necrotising Ulcerative Gingivitis

1. Introduce yourself and take a brief history of the complaint.
2. Determine if there are any associated risk factors (spirochaetal infection, smoking, stress, HIV).
3. Explain you would usually examine the pt.
4. Give OHI although the pt may not be able to brush due to pain.
   - full mouth PMPR.
   - chemical plaque control with CHLORHEXIDINE.
   - metronidazole 200-400mg 3x a day for 3 days.
5. Give advice on managing risk factors (OHI, smoking cessation, stress management).
6. Consider referral.

Question 2

A pt presents with pain in the LR5 and radiographs show PA pathology and bone loss.

What would indicate that this is a periodontal lesion?

Answer 2

PERIODONTAL:

• no toothache
• lateral TTP ++
• perio pocketing present
• probing the sinus may lead to pocket.
• discharge will come through the pocket.
• swelling will be present in the attached gingiva.
• positive to vitality testing.
• radiographs show vertical bone loss.

Question 3

A pt presents with pain in the LR5 and radiographs show PA pathology and bone loss.

What would indicate that this is a PA lesion?

Answer 3

PA Lesion:

• pt has toothache.
• Vertical TTP ++
• no pocketing present.
• probing may lead to apex.
• discharge may be present over the apex.
• swelling present at the apex.
• vitality testing NEGATIVE.

Question 4

Describe Grade I furcation.

Answer 4

Horizontal bone loss not exceeding 1/3 of the tooth width.

Question 5

Describe Grade II Furcation.

Answer 5

Horizontal bone loss greater than 1/3 of the tooth width but NOT extending over the total width.

Question 6

Describe Grade III Furcation.

Answer 6

Horizontal bone loss extending the full width of the furcation area.

Question 7

A 14 year old girl attends as a new patient. OE, she has reasonable OH but there are pockets around her central incisors and first molars with drifting of the incisors.

What disease could she have and how would you manage it?

Answer 7

Localised Aggressive Periodontitis

Management includes:
- OHI
- supra and sub PMPR
- consider antibiotics such as doxycycline, oxytetracycline, metronidazole or dentomycin gel.

Question 8

A 14 year old girl attends as a new patient. OE, she has reasonable OH but there are pockets around her central incisors and first molars with drifting of the incisors.

What possible complications could there be for the management of this condition?

Answer 8

Tetracyclines should be avoided in developing teeth as they deposit, causing staining and hypoplasia.

• avoid in children under 12 and in pregnancy *

Question 9

Describe Localised Aggressive Periodontitis.

Answer 9

• Occurs in childhood and adolescence.
• Usually localised to incisors and first molars.
• Gingivae may look normal despite presence of pocketing.
• Degree of periodontal destruction is out of proportion to the deposits of plaque and calculus.

Question 10

What do Tetracyclines do in the management of localised aggressive periodontitis?

Answer 10

1. Active against Aa and other periodontal pathogens.
2. Reduce host neutrophil collagenases and bone loss.
3. Antibacterial action.

Question 11

What would a BPE Code 0 indicate?

Answer 11

No disease, clinical gingival health.

Question 12

What would a BPE Code 1 Indicate?

Answer 12

No pockets greater than 3.5mm but bleeding on probing present.

Question 13

What would a BPE Code 1 indicate?

Answer 13

No pockets greater than 3.5mm, BoP present.

Question 14

What treatment would be indicated for a BPE Code 1?

Answer 14

OHI

Question 15

What would a BPE Code 2 indicate?

Answer 15

No pockets over 3.5mm with supragingival calculus present.

Question 16

What would be the treatment indicated for a BPE Code 2?

Answer 16

OHI, supragingival PMPR and management of contributing factors.

Question 17

What would a BPE Code 3 indicate?

Answer 17

Pockets between 3.5-5.5mm present.

• black band partially visible *

Question 18

What treatment would be indicated for a BPE Code 3?

Answer 18

OHI, Supra and Sub PMPR.

Question 19

What would a BPE Code 4 indicate?

Answer 19

Pockets present over 5.5mm.

• black band not visible *

Question 20

What treatment would be indicated for a BPE Code 4?

Answer 20

OHI, supra and sub PMPR, surgery if required.

Question 21

A 24 year old woman presents at your practice complaining of bleeding gums. She is in her second trimester of pregnancy but is otherwise fit and healthy.

How would you manage her problem?

Answer 21

1. Explain that gingival inflammation and bleeding is caused by accumulation of plaque/bacteria.
2. This is exacerbated during pregnancy, especially in the 2nd and 3rd trimesters.
3. Management would include supragingival PMPR, improving ONI and regular supportive care.

Question 22

A 24 year old woman presents at your practice complaining of bleeding gums. She is in her second trimester of pregnancy but is otherwise fit and healthy.

What other problems may she develop and how would these be managed?

Answer 22

1. Pyogenic Granuloma - pedunculated fibrogranulomatous lesion occurring in the anterior maxillary interdental papillae.
   - bleeds easily on touching.
   - managed by careful OHI and debridement.
2. Marked pregnancy gingivitis.
3. Worsening of any existing periodontitis/tooth mobility/
4. Gestational Diabetes.
5. Vitamin Deficiency.

Question 23

Why would a patient with uncontrolled diabetes not be suitable for an implant?

Answer 23

Pts with uncontrolled diabetes tend to have more extensive periodontitis and although implants don’t have a PDL, bone loss and inflammation may occur around the implant leading to failure.