perio - step 3 Flashcards
SDCEP BPE 3
- assess extent of BoP
- assess modifiable risk factors i.e. smoking / suboptimal diabetes
- make preliminary perio diagnosis based on pt presentation
- at post tx review carry out full periodontal assessment inc 6PPC at involved sextants to determine if probing depths have reduced and to confirm perio diagnosis
SDCEP BPE 4
- full perio assessment inc 6PPC of whole dentition
- assess extent of BoP
- assess modifiable risk factors
how long after BSP step 2 do you do step 3
12 weeks
what is BSP step 3
management of non responding sites:
- reinforce OH / risk factor control / behaviour change
- moderate 4-5mm residual PPD reperform sub gingival PMPR
- deep residual pockets >6mm consider alternative causes
- consider referral for pocket mx / regenerative surgery
- if referral not possible reperform subgingival instrumentation
pt factors to consider prior to surgery
- OH <20% plaque & <10% bleeding
- quality of maintenance available & pt access to it
- ability of pt to tolerate procedure
- likely pt compliance to maintenance post surgery
- cost & pt acceptance
- aesthetics of site & potential for post op recession
tooth factors to consider prior to surgery
- access to non responding sites
- shape of defect
- pros / endo considerations
- tooth position / anatomy (tilting, overeruption, proximity to adjacent roots, enamel pearls, ridges / root grooves)
systemic / medical factors to consider prior to surgery
- smoking
- unstable angina / uncontrolled hypertension / stroke or MI within 6mths prior
- poorly controlled diabetes
- immunosuppressed pts
- anticoags
all must be controlled prior to surgery
options inc in step 3 (4)
- repeated subgingival instrumentation
- access flap surgery
- resective flap surgery
- regenerative flap surgery
local antimicrobials
e.g. CHX
locally delivered ABs
adjuncts to PMPR
may be indicated in unresponsive sites where surgery is contraindicated / not desired
BSP / SDCEP say not for routine care
egs of local antimicrobials
periochip - biodegradable gelatin matrix (2.5mg CHX) insert into pocket, slow release over 7 day period
dentomycin gel - 2% minocycline gel, 3-4 applications every 12 days
systemic antibiotics
antibiotic stewardship
BSP / SDCEP does NOT recommend routine use of systemic antibiotics as an adjunct to PMPR
consent process
- reason for providing surgical tx
- other options for managing area inc no tx
- consequences of no surgery
- nature of surgical procedure
- post op consequences i.e. the usual plus sensitivity, failure, mobility, non vitality, recession
- requirement for ongoing post op maintenance
- cost
aims of access surgery / open flap debridement
- access to areas of continued inflammation / infection
- usually for PPD >6mm
- to allow access for surgical debridement
why will pocket depth decrease
- increase in clinical attachment resulting from
- formation of long junctional epithelium
- increase in tissue tone which produces resistance to probing - decreased oedema leading to gingival recession
aim follow access surgery
- healing by repair
- long epithelial reattachment to root surface
what and why for regenerative perio surgery
tissue regeneration inc bone & functional PDL formation
indicated when
- intrabony defects >3mm or deeper as assessed radiographically (note this is not PD)
- class II or class III furcation defect
guided tissue regeneration (GTR)
barrier membranes +/- addition of bone derived grafts
membrane prevents gingival epithelium / CT from entering bone defect & to induce osteogenesis & pdl regeneration
creates space to acts as scaffold for vascularisation and cell ingrowth from base of defect
emdogain (enamel matrix derivative)
tissue healing agent derived from porcine tooth germ
forms matrix on root surface that mediates production of cementum by modulating wound healing process
induce regeneration of functional attachment
why tx furcation lesions
- clinical relevance
- economic considerations - tooth retention following perio surgery more cost effective than xla & replacement with pros
- pt preference
4 options for furcation surgery
- regenerative
- root resection
- root separation
- tunnelling
when do you use regenerative surgery for furcations (3)
- mandibular class II
- maxillary class II buccal
- maxillary class III (ID)
grade 1 furcation SDCEP
initial furcation involvement
furcation opening can be felt on probing but involvement is <1/3 tooth width
grade 2 furcation SDCEP
partial furcation involvement
loss of support >1/3 tooth width but does not inc total width of furcation
grade 3 furcation SDCEP
through & through involvement
probe can pass through entire furcation
root resection / root separation
class 3 or multiple class 2 furcation lesions in same tooth
good quality endo needed
good root separated as assessed radiographically; not possible on fused roots
remaining roots should not be hypermobile
remaining tooth structure should be restorable
motivated pt, good OH, low caries rate
tunnelling
mandibular class 3
bone & soft tissue recontoured to allow insertion of ID brush
risk = root hypersensitivity & root caries
regenerative surgery
aims to promote regeneration of periodontal tissues that have been lost inc use of membranes / grafts / application of biologic agents
indications for regenerative / mucogingival surgery
- perio lesions required reconstructive / regenerative tx inc around implants
- mucogingival deformities & poor aesthetics
- short clinical crowns where increase in crown height is required prior to restorative
- removal of aberrant frena
- creation of more favourable soft tissue bed pre implant surgery
3 most common regenerative procedures
- free gingival graft
- pedicle graft
- connective tissue graft
full thickness v split thickness flap
full = full mucoperiosteal flap
split = leaving behind CT & periosteum that covers bone
free gingival graft
split thickness flap to generate CT bed to receive graft
harvest graft from palate
not carrying blood supply so some graft may die
pedicle graft
prepare base to receive via epithelial removal STF and move laterally to cover site
still attached at base so good blood supply
CT graft
papillae sparing
helps thicken tissue
raise coronal flap
pull CT down over tooth
pull whole thing coronally then suture in place
guided bone regeneration
for 1 2 3 walled defects
3 wall better propensity for healing as osteoblasts coming from all sides
autograft
from same person
allograft
different person
alloplast
synthetic material
xenoplast
from animal
healing from grafting procedures
new connective tissue attachments
gingival recession and why do we treat it
apical migration of gingival margin from CEJ
indications for tx:
1. poor aesthetics
2. difficult plaque control
3. sensitivity
aetiology of gingival recession
localised:
- excessive brushing / incorrect technique
- traumatic incisor relationship
- habits
- anatomical i.e. frenal pull
generalised:
ongoing perio or following resolution of inflammation after successful tx
localised / generalised:
complication of ortho tx
cairo 2012 gingival recession classification
recession type 1 - no IP tissue loss
RT2 - IP loss from CEJ to base of pocket, not as significant as mid buccal
RT3 - recession associated with loss of IP attachment, IP tissue loss from CEJ to base of pocket worse than mid buccal - FULL ROOT COVERAGE NOT POSSIBLE
tx of gingival recession
- baseline recession readings via clinical photos / study models
- eliminate aetiological factors i.e. habits or piercings
- OH & single tufted brushes
- topical desensitising agents & FV
- gingival veneer to cover exposed roots / embrasure spaces
- crowns
- mucogingival surgery
what is crown lengthening
aims to apically reposition the entire periodontal attachment including alveolar bone
indications of crown lengthening
- increase clinical crown height to give adequate retention for restorations
- expose enough clinical crown to allow restorative ferrule to be achieved
- exposure subgingival restoration margins / 2ndary caries / #
- correction of uneven gingival contour compromising aesthetics inc excessive gingival display
procedure & risks of crown lengthening
4mm of bone removal
risks = root damage
to help prevent move onto hand instruments e.g. enamel chisel to prevent
