Perio textbook Flashcards
What are the symptoms of periodontal disease?
- Bleeding gums
- Tooth sensitivity
- Tooth mobility
- Bad breath
- Loss of taste
- Pain on chewing(due to tooth mobility)
- staining of teeth (There is a roughened surface for the stain to stick to)
Discuss smoking as a risk factor
Impairs WBC function- impaired wound healing
Reduces gingival blood flow- suppressing signs and symptoms of gingivitis
Increases the production of inflamation mediating cytokines- tissue breakdown.
Discuss the general oral health of smoker?
- Lots of plaque and calculus build up.
- Higher mean probing pocket depths and more sites with deep pockets.
- Greater gingival recession
- Alveolar bone loss and furcation involvement
- No bleeding on probing
*
How do we treat smokers?
- Good daily plaque control
- Regular supra and subgingival debridement
- Avoiding hard or soft tissue grafting (due to the reduced healing capacity)
Discuss diabetes as a risk factor for periodontal disease
Diabetes causes reduced wound healing.
When it is uncontrolled, there is an increased glucose level.
The glucose needs to be used, so is used to change cell conformation.
This confuses the immune system- activating it.
This results in:
- Glycation products infiltrating the vessels resulting inflammation.
- A reduced lumen causing less blood flow
- Less oxygen and nutrients.
- Poorer wound healing
How do we treat diabetic patients in perio?
We need to check the level of glycated haemoglobin before treatment (this indicates the patients glycaemic control by showing their haemoglobin turnover over the last of 3 months)
The level should be <= 48 mmol/mol
Discuss stress as a risk factor in perio?
Stress produces cortisol
Cortisol suppresses the immune system which allows periodontal disease.
Discuss malnutrition as a risk factor in perio.
Malnutrition means the patient does not have the right nutrients, this weakens their immune system and causes more inflammation.
Discuss medications as a risk factor for perio?
Some medications have side effects that impact perio e.g. calcium channel blockers/ anti-epileptic drugs/immunosuppresants
The drug interacts with host fibroblasts causing increased deposition of connective tissue (gingival overgrowth and plaque overgrowth)
Discuss why hormones are a risk factor for periodontal disease.
A change in hormones such as pregnancy or puberty
This can cause gingival overgrowth.
Why is oestoporosis a risk factor for periodontal disease.
Osteoporosis patients have bad bone quality.
The bone resorption progresses much faster.
Discuss some local risk factors that infleunce periodontal disease?
Anatomical- e.g. malpositioned teeth/ enamel pearls.
Acquired e.g. overhangs/ orthodontic appliances/ bad restoration margins.
Occlusal Trauma- periodontal bone loss is quicker if you start with less bone.
How does periodontitis impact systemic health.
Periodontitis activates the immune system and cells which can move to other parts of the body causing systemic inflammation elsewhere.
This inflammation also compromises the barrier function of the gingival epithelium, allowing an ingress of bacteria & bacterial products into systemic circulation.
What other diseases can be caused by periodontitis?
Hypertension- Inflammation of the blood vessels, decreases the lumen thereby increasing blood pressure.
Rheumatoid Arthritis- Inflammatory cells spread to the area of arthritis and increase the inflammatory response increasing cartilage loss.
Pre-eclampsia- High blood pressure problem
Indirectly caused by periodontal bacteria activating the immune system.
Directly caused by periodontal bacteria spreading to the baby.
Alzheimers-Activation of the immune system increases the production of plaques and tangles which build up in between nerve cells (causing impairment of memory and function)
Discuss the pocket size/ black band/ observation for BPE code 0
<3.5mm- black band visible- no observations
Discuss the pocket size/ black band/ observation for BPE code 1
<3.5mm- black band visible- bleeding on probing.
Discuss the pocket size/ black band/ observation for BPE code 2
<3.5mm- black band fully visible- bleeding on probing and calculus deposits.
Discuss the pocket size/ black band/ observation for BPE code 3
3.5mm-5.5mm/ partially visible black band
Discuss the pocket size/ black band/ observation for BPE code 4
>5.5mm- black band not visible
What does the * mean in a BPE
There is furcation involvement.
Compare your next step in periodontal testing for a BPE code 3 compared to a code 4.
Compare the BSP & SDCEP GUIDELINES.
code 3 in 1 sextant- a 6 point pocket chart for that sextant.
code 3 in more than 1 sextant- 6 point pocket chart for the full mouth.
code 4- a 6 point pocket chart for the whole mouth.
BSP- After initial treatment
SDCEP- before and after initial treatment.
List Ramfjords teeth?
16
21
24
36
41
44
What is the function of the modified plaque and bleeding score?
These are used to determine patient engagement and decide if the patient can advance to formal periodontal treatments (pocket charting and root surface debridement)
What scores are we aiming for in the modified plaque and bleeding scores and when?
To show patient engagement and progress with treatment (PMPR) we want:
<30% plaque score
<35% marginal bleeding score
or <50% improvement in both.
These mean our patient has the ability to maintain a high oral hygiene level. (we need this high level for periodontal treatment to be successful)
Whereas our aim for the end of treatment is:
<10% bleeding score
<15% plaque score.
No pockets >4mm- would be too large for the patient to be able to clean.
Discuss the score options for modified plaque scores?
2- plaque is visible
1- plaque is found when probing
0- no plaque
Discuss the score options for modifed bleeding scores.
1-bleeding
0-no bleeding.
what is different about a full mouth bleeding and plaque chart?
This does not grade the plaque level. It just notes if plaque is present or not.
How do we measure the gingival margin related to the ACJ?
We look at the distance from the gingiva margin to the ACJ.
Look for the change in colour.
Inflammation is written as a negative value.
How do we measure the pocket probing depth?
Measure the distance from the gingival margin to the base of the pocket.
How do we measure loss of attachment
LOA= Gingival margin + Probing depth
How do we measure bleeding on probing?
+ means there is bleeding
- means there is no bleeding
How do we measure furcation regions?
We grade them
Grade 1- loss of bone < 1/3 tooth width
Grade 2- loss of bone > 1/3 tooth width
grade 3- The probe can pass through the entire furcation.
How do we measure mobility?
grade 0= 0.1-0.2mm movement horizontally
grade 1= <1mm movement horizontally
Grade 2= >1mm movement horizontally
Grade 3= movement horizontally and vertically.
When do we use an abbreviated 6 point pocket chart?
For patient reviews to highlight areas requiring further treatment.
What do you record on an abreviated 6 point pocket chart?
Pockets of >4mm
Sites with Bleeding on probing
Furcation involvement
Mobility
What is the disadvantage of an abreviated 6 point pocket chart ?
6 point pocket charts don’t measure periodontal attachment loss.
What does this radiograph show and what does it indicate?
This shows a loss of lamina dura (the white line around the tooth)
which shows that there is active disease
What is highlighted in this radiograph and what does it indicate?
This shows an apical lucency.
This shows there is inflammation. Decomposition of the pulp causes chemicals to spread into the other tissues causing damage. (the apical lucency)
What should you include in your radiographic report about bone loss. ?
Distribution- is it localised <30% or generalised >30% of teeth
Shape- is it horizontal or vertical
severity
mild (<30% root length) Moderate (30-50%) Severe (>50%)
What will happen if a patient does not control peridontal disease?
- Inflammation
- Tooth mobility
- Tooth loss.
What will happen if the patient succesfully controls periodontal disease?
- less bleeding
- Less swelling- causing black triangles
- Gums colour will change from red to pink
- Gum recession- as the root is exposed
- Increased sensitivity due to exposed root.
- Mobility (if calculus was holding the teeth in place)
*
Compare the treatment options for periodontal disease?
Do nothing- inadvisable as teeth will fall out.
Periodontal treatment- remove bacteiral deposits from the tooth and root.
Extract the teeth- common if the gum disease is severe
Periodontal surgery
What is emergency periodontal care?
Treating:
- Pericoronitis
- periodontal Abcesses
- Acute Ulcerative necrotising gingivitis
What is the intital periodontal treatment?
Risk factors- give advice to reduce risk factors (smoking cessation)
Treatment:
- Extraction of hopeless teeth
- Hygiene phase therapy- Management of plaque retentive factors, showing patients how to control plaque and motivating them.
- Caries treatment
- Endodontic treatment.
- Provisional prosthesis.
What is the first re-evaluation stage after treatment for?
Assessing the patient’s oral hygiene compliance
If they are engaging- PPD >3mm with plaque and bleeding scores reduced by 50%.- patient can move to step 2 (Subgingival PMPR)
If patient is not engaging we need to repeat step 1.
What is the maintenance program for periodontal treatment?
This is also known as supportive periodontal therapy.
Patient moves onto this when the end point has been achieved (PPD <4mm without BoP)
This is preventing new or recurrent periodontitis lesions by:
Recalling the patient every 3 months
Supragingival and subgingival PMPR.
Reinstrumenting the active pockets.
Continuous monitoring of local and systemic factors.
Measuring the 6 point pocket chart and comparing it.
What are we checking when we re-evaluate a patient?
Their:
- compliance with OHI.
- Standard of Oral hygiene (using a plaque chart)
- Residual pockets and inflammation (using a 6 point pocket chart)
What are the goals for periodontal treatment?
<10% bleeding score
<15% plaque score.
No pockets >4mm- would be too large for the patient to be able to clean.
How long do we wait before re-evaluating a patient and why?
8 weeks.
Because pocket charting often reveals decreased pocket depth due to:
Decreased oedema causing the gingival recession.
Increased gingival attachment (because of a formation of long junctional epithelium and an increase in tissue tone- producing resistance to probing)
Compare the 3 clinical situations at periodontal re-evaluation?
No improvement- Oral hygiene is inadequate with persistent inflammation.
Partial improvement- OH is good but there are persistent deep pockets with evidence of inflammation.
Complete improvement- Goals have been achieved in all teeth. OH is good and there is no inflammation.
What are the next steps if our patient shows no improvement at re-evaluation?
Decide if further treatment is appropriate?
Is the patient engaging? - what barriers are there to good OH
What does the patient think?
Is their OH likely to improve?
If continuing- Repeat cause related therapy (full debridment/ OHI/ motivation to reduce plaque levels)
If not continuing treatment- place them on the maintenance program.
What are our next steps if the patient shows partial improvement when re-evaluated?
Targeted debridement of the active pockets and then re-evaluate.
What are the next steps if there is complete improvement?
Place on the periodontal maintenance program and proceed with any restorative reconstructive treatment.
Discuss some reasons for no improvement?
- Necrotic pulp-no matter how many times you clean the pocket it will just get re-infected.
- Blind PMPR due to deep pockets- so may not remove all of the calculus.
- Furcation involvement- more resistant to PMPR.
What is surgical Periodontal treatment?
This is when we surgically gain access to deep pockets for debridement when the pockets are resitant to non-surgical therapy.
How can we tell clinically if a patient has previously had periodontal disease?
Look at the loss of attachment- this tells us the patient’s bone loss.
Where can you find false pocketing in the mixed dentition?
Around erupting permanent teeth.
Compare a simplified BPE to a normal BPE
A simplified BPE is used in children aged 7-11. This only grades from 0-2.
Only carried out on 16,11,26,36,31,46.
A normal BPE is used in 12 and over. This grades from 0-4. carried out on all teeth.
What are the SDCEP plaque scores?
10/10 no plaque present
8/10- line of plaque present around the cervical margin.
6/10- cervical 1/3 of crown covered with plaque
4/10- middle 1/3 of the crown covered with plaque.
How do you treat a child with a BPE of 2?
OHI
Prevention
PMPR
Removal of plaque retentive factors.
Screen these children again after 6 months.
How do you treat a child with a BPE of 3/4/*?
Full periodontal assessment
radiographs (to establish if pocketing is true or false)
PMPR/ OHI + prevention
If score is 4 or * consider referal to a specialist.
You should review these patients after 3 moths.
What is the purpose of mechanical disruption?
To reduce the bacterial challenge (OHI) through supra and subgingival plaque control (PMPR)
When do we use systemic antibiotics or local antimicrobials?
After first line of treatment (Decreased plaque and HPT)
If infection is still not gone away despite HPT and excellent oral hygiene (highlighting that the type of bacteria is the issue)
In combination with mechanical disruption (we need to remove the protection given to bacteria by the matrix)
What are the advantages of local antimicrobials.
You insert it into specific sites (i.e. the deepest pockets)
Reduced systemic dose as you don’t need to worry about the metabolism.
High local concentration.
When do we use local antimicrobial perio-chip?
On targeted treatment after HPT:
- On persisting pockets >5mm
- Only in isolated pockets
- After evacuation of pus and RSD in periodontal abscesses.
- Always used with root surface debridement.
When would systemic antibiotics be better suited than local antibiotics?
For multiple deep pockets in one area.
Why is supportive periodontal care important?
To prevent new or recurrent periodontitis. It will recurr if they are not seen regularily.
How is the frequency of supportive periodontal care decided?
Based on the patient’s risk. A stable patient can have longer intervals between appointments.
Summarise the supportive periodontal care.
General examination- we are looking to see if anything has changed since the last appointment.
Treatment- dependent on the general examination findings.
Then take your notes and schedule the next appointment
If a patient on maintenance has a BPE of 4, what 6 point pocket chart do we complete anually?
Full 6 point pocket chart.
If a patient on maintenance has a BPE of 3 in >1 sextant. What 6 point pocket chart do we complete anually?
Full 6 point pocket chart.
If a patient on maintenance has a BPE of 3 in 1 sextant, what 6 point pocket chart do we complete anually?
6 point pocket chart in that sextant.
How do we treat sites with >4mm subgingival deposits?
Subgingival PMPR
How do we treat sites which bleed on probing?
Subgingival PMPR
How do we treat sites with <4mm where subgingival deposits are present?
Subgingival PMPR.
How do we treat sites <4mm without calculus present.
Leave the pocket alone. As unneccesary instrumentation would cause significant attachment loss.
Discuss some of the reasons for recurrence of periodontal disease?
- Inadequate plaque control from the patient or failure to comply with supportive treatments. (i.e. not attending)
- Failure of treatment to remove all the potential factors favouring plaque accumulation
- Incomplete calculus removal in areas of difficult access.
- Inadequate restorations placed after periodontal treatment was completed.
- Presence of systemic diseases can affect the host resistance to previously acceptable levels of plaque.
What does this radiograph show and what does this indicate?
This shows a black space between the roots indicating there has been bone loss at the furcation of the root- this is a sign of periodontal disease.
Compare the two types of maintenance for a dental patient?
Supportive dental care- this is for patients who have previously had periodontal disease and successfully responded to treatment.
Dental prophylaxis- for patients without a history of periodontal disease.
What is PMPR?
Professional mechanical plaque removal.
This is the new term and can be supragingival or subgingival.
We have decided that systemic antibiotics are neccesary for the treatment of this patient. What should you prescribe
1st choice:
500mg amoxicillin AND 400mg metrondiazole 3 times daily for 7 days.
If allergic or on warfarin.
100mg doxycycline for 21 days with 200mg loading dose.
Give examples of the local antibiotics we can use for periodontal treatment?
Arestin (1mg minocycline HCL microspheres)
Atridox (Doxycycline hyclate 10%)
Elyzol (25% metronidazole)
Explain the use of access therapy for treatment of periodontal disease?
To improve visibility and access for sub-gingival instrumentation of both soft and hard root surface deposits that cannot be removed by non-surgical means.
Explain the process of Access therapy in surgical periodontal treatment?
- Intra-cervical incision through the base of the gingival pocket and entire gingivae.
- Muco-periosteal full thickness flap is lifted.
- Removal of granulose tissue and PMPR of root surface.
- Flap is then sutured back into place.
What post operative care advice should be given to a patient after undergoing periodontal surgery.
Reinforce mechanical plaque control
Post-operative soft toothbrush for cleaning the area.
Chlorohexidine mouthwash for 1-2 weeks.
Analgesics for 2-3days.
Sutures should be removed after a week.
Antibiotics- if complications with healing
What is a gingivectomy?
excision of excess gingival tissue to cause it to heal by secondary intention. But we need to have dealt with the cause of the gingival enlargement before surgical treatment.
This is completed to facilitate plaque removal, restorations and improve appearance.
What are the indications for a gingivectomy?
Gingival enlargement or overgrowth.
Idiopathic gingival fibromatosis
Falls pocket (enlargement of the gingivae but no change to the apical migration of the junctional epithelium)
Minor corrective procedures.
During crown lengthening during prosthetic treatment.
What is regenerative periodontal surgery?
to obtain shallow maintainable pockets by reconstructing the destroyed attachment apparatus and so also limits the recession of the gingival margin
Compare horizontal and vertical bone loss
Horizontal bone loss is when the base of the pocket is located coronally to the alveolar crest.
Vertical bone loss is when the apical end of the pocket is located below the alveolar crest,
Define a crater periodontal pocket?
Where the bone loss involves two adjacent teeth
Define an intrabony defect?
Where the bone loss only affects the root surface of only 1 tooth.
How are intrabony defects classified?
- 1 wall
- 2 wall
- 3 wall
How do we manage intrabony defects?
Closed/open PMPR
Regnerative techniques
What is emdogain and what is it’s function?
An enamel matrix protein derived from the porcine tooth germ. This forms a matrix on the root surface that mediates the production of cementum.
Give examples of different ways we can use augmentation to treat bony defects due to periodontal disease?
Bone graft
Emdogain
Tissue guided regeneration.
What is tissue guided regeneration?
Placing a barrier between the gingival epithelium and the tooth. This encourages the repopulation of PDL & bone cells cells in the area instead of the immigration of epithelial cells.
What needs to be done to the area before placing a bone graft for the treatment of periodontal disease?
PMPR
What are the treatment options for teeth with furcation involvement?
Palative
Repair
Regeneration.
Eliminate furcation
Extract
Explain the palliative treatment of teeth with furcation involvement.
When do we choose this option?
Treatment with non surgical PMPR and maintenance of plaque control.
Only with class I furcations.
When the furcation is asymptomatic & Functional and pt will attend for routine debridement.
Explain how we repair a tooth with furcation involvement?
Supra and subgingival PMPR (for small furcations) or open flap debridement for larger ones.
In what situations would we try and regenerate a tooth with furcation involvement and how do we do this.
For furcations with:
- two and 3 walled proximal defects
- Grade II mandibular furcation involvement
- Grade II buccal maxillary furcation involvement.
Use of Emdogain.
Explain the elimination of a furcation as a treatment option for furcated teeth.
Resective treatment to get rid of the furcation and make the area easier to clean.
The tunnel preparation- making the furcation space large enough for cleaning with an interdental brush.
Root resection- Splitting the tooth in half and extracting one half.
What teeth with furcation involvement would be suitable for elimination of the furcation?
Successfully endodontically treated teeth.
Feasable root separation and removal.
Restorable remaining root structure.
Where the remaining roots are not hypermobile.
Motivated patients.
In which teeth with furcation involvement would we extract the tooth?
Recurrent symptoms.
Little remaining attachment
Gross mobility
Non-functional.
Why do the BSP guidelines recommend doing the 6 point pocket chart after initial treatment?
As some large pockets may be related to inflammation so we let them die down before taking the 6PPC.
