Perio tutorials Flashcards
Which hand should be holding the mirror?
Non-dominant hand
Why do we use correct positioning?
Reduce injury and fatigue
Describe good positioning of the dentist.
Back straight
Feet on floor
Thighs in a triangle, slightly slanting downwards
Patient’s mouth at the natural waist
What patient chin position is used when examining the upper teeth?
Tilted upwards
What patient chin position is used when examining the lower teeth?
Tilted downwards
What light position is used when examining the upper teeth?
Over patient’s chest, 45º
What light position is used when examining the lower teeth?
Directly over mouth
Describe the events of the extraoral examination.
Overall appraisal of head, neck, face and skin - facial symmetry, inspect scalp and ears
Palpation of lymph nodes - cervical and supraclavicular, submental and submandibular, pre and post auricular
Salivary glands and TMJ
Visual inspection of vermillion border and lips
What do you need to do before moving from the extraoral to the intraoral examination?
Change gloves! And put patient in supine position
Describe the events of the intraoral examination.
Inspect and palpate mucosa with index and thumb - buccal and labial
Inspect and palpate floor of mouth (may move tongue to touch palate)
Examine salivary gland ducts
Inspect tongue surfaces and palpate (may hold with some gauze)
Visual inspection and palpation of soft and hard palate, inspect tonsils and oropharynx (say ahhh)
What features of the gingiva are you looking at?
Colour
Size
Shape
Consistency
Position
Bleeding +/or exudate
How should you approach gingival inspection?
Choose one sextant
Look at one aspect at a time for the whole sextant
How will healthy attached or free gingiva feel when probed?
Resistant
What is a biofilm?
Complex community of micro-organisms attached to a surface and each other, in an extracellular matrix
What is dental plaque?
A biofilm growing on a hard, non-shedding surface in the oral cavity in a self-produced matrix of extracellular polymers
What is the main type of nutrient used in supragingival plaque?
Carbohydrate
What is the main type of nutrient used in subgingival plaque?
Protein
What are the steps of dental plaque development?
- Acquired pellicle
- Adhesion of primary colonisers
- Co-aggregation of bacteria
- Environment modification by bacteria
- Maturation
Describe the formation of the acquired pellicle.
Selective adsorption of salivary and GCF components onto the amphoteric tooth surface
(Firstly statherins, PRPs)
What type of bacteria are most primary colonisers?
Aerobic cocci
What does the climax community of plaque look like?
Lots of Gram negative bacteria
Lots of anaerobes, long rods, spirochaetes, motile species
What is calculus?
Hard mineralised deposit on hard surfaces in the mouth
Mineralised plaque
Why does calculus act as a plaque-retentive factor?
Rough surface => much increased surface area for plaque to grow
Name some of the different types of calcium phosphate forms you might find in calculus.
Brushite
Whitlockite
Dicalcium phosphate
Octacalcium phosphate
Describe supragingival calculus.
Precipitate of salivary mineral salts, 37% mineral content
Commonly near salivary gland duct openings (lingual of lower incisors, buccal of upper 6/7s)
Creamy yellow-brown depending on staining
Fairly soft to moderately hard - easily removed by clinician
Describe subgingival calculus.
Detected clinically as roughness on the root surface
Darker brown-black - precipitate from blood/GCF
Harder and adheres more firmly => more difficult to remove by clinician
How does pH affect the calcium and phosphate equilibrium in the mouth?
High pH favours mineralisation/precipitation
Low pH favours demineralisation
What are the three main theories to explain calculus formation?
Carbon dioxide theory
Ammonia theory
Seeding theory
What is the carbon dioxide theory of calculus formation?
Freshly secreted saliva full of bicarbonate
Bicarbonate reacts with any H+ in the mouth to form carbon dioxide
Carbon dioxide breathed out of the mouth so more H+ is used => pH increases favouring precipitation of salts
What is the ammonia theory of calculus formation?
Subgingival bacteria metabolise proteins to produce ammonia and urea
pH increases favouring precipitation of salts
What is the seeding theory of calculus formation?
Bacteria act as a seed and attract calcium ions
High calcium ion concentration attracts negative phosphate ions
Concentrated ions precipitate out as a solid deposit
What is the phosphatase theory of calculus formation?
Enzymes in plaque free “locked up” phosphate in organic molecules (eg proteins)
Phosphate binds to calcium in saliva
What procedures should be done before plaque disclosing?
Probing/clinical examination - dyes can alter the tissue appearance
Gross scaling - calcified deposits and overhanging margins can be misleading in recording plaque score
Describe O’Leary’s plaque control record.
Uses plaque disclosing agents
Records presence or absence of plaque on 4 sites of every tooth = MB, B, DB, L/P
Percentage plaque score calculated
Describe the procedure of plaque recording (O’Leary).
- Inform patient of why they need this done and get consent (they may not want stained lips/gums!)
- Tie bib on patient and lay in supine position
- Apply vaseline to lips with cotton wool
- Place saliva ejector in mouth at occlusal surface of L4 and dry teeth (3in1)
- Apply disclosing solution with microbrush in a sweeping motion ~30s
- Sit patient up and ask them to rinse carefully
- Dry teeth and record whether surfaces have plaque or not
- Calculate % plaque score and discuss results with patient with the chart and mirror
(9. Set realistic goal/target for next time)
What are the advantages of O’Leary’s plaque control record?
Objective measure
Paediatric motivation and engagement
Visual and educational tool
Allows longitudinal monitoring
Allows tailoring of OHA
What are the disadvantages of O’Leary’s plaque control record?
Stains calculus, overhangs => misleading
Time-consuming
Stains soft tissues, esp tongue
Doesn’t distinguish the amount of plaque present
Describe the Silness-Loe plaque index.
Examine all four surfaces of UR6, UR2, UL4, LL6, LL2, LR4 for plaque
0 = none
1 = film of plaque at gingival margin
2 = moderate accumulation of plaque, seen with naked eye
3 = abundance of plaque
Sum of 4 surfaces / 4 = tooth plaque index
All teeth indices / 6 = plaque index for patient
What are Ramfjord’s teeth?
6 index teeth used for partial mouth recording:
UR6, UL1, UL4, LL6, LR1, LR4
Describe the oral hygiene index.
Sum of debris and calculus index
Debris and calculus indices = sum of scores / number of scores respectively
0 = no debris or calculus 1 = soft debris or supragingival calculus covering <1/3 of tooth 2 = soft debris or supragingival calculus covering >1/3 and <2/3 of tooth 3 = soft debris or supragingival calculus covering >2/3 of tooth (or continuous heavy band of subgingival calculus cervically)
What is the main technique to mechanically remove plaque?
Tooth brushing
Describe the ideal toothbrush.
MAX 2.5cm for adults, 1.5cm for children
Flat trim
Medium texture
Round-ended nylon filaments
What type of grasp should you hold a toothbrush with?
Palm grasp
Describe the modified Bass technique.
Brush 45º towards gumline
Small circles ~3 per tooth
Start with most distal surface of last molar
Hold brush vertically for lingual/palatal surface of anteriors
Why is the scrub technique not recommended?
Abrasive and traumatic, may cause gum recession
What is double brushing?
When you use an electric toothbrush like a manual brush (moving in circles rather than holding it in place)
What are the general rules of tooth brushing?
Brush twice a day, right before bed and one other time
At least 2 minutes
Always use a systematic/methodical order
Spit don’t rinse (fluoride toothpaste)
Change brush(head) every 3 months or earlier if bristles splay
What are the advantages of an electric toothbrush?
Timer
Pressure sensor
Motivational for some people
Good for those with poor manual dexterity
What are the disadvantages of an electric toothbrush?
Expensive
Requires charging
Some may brush for a shorter time (misconceptions)
Loud and weird feeling in the mouth
Why do we limit the number of interdental brushes prescribed to 2/3?
Avoids confusion
Increases compliance
How should a patient use interdental brushes?
Use where there is space to do so
Place horizontally at the top of the papilla and move back and forth to clean proximal surfaces
Once a day, before brushing
How much floss do you need for one session?
30-40cm/forearm’s length
Describe how to use floss.
Wrap floss around middle fingers until ~5cm between fingers remains
Use thumb and index to guide floss gently between contact point
Tuck gently against one tooth under gumline in a c-shape
Move floss up and down to clean tooth surface and repeat on adjacent tooth
Remove from interdental space, move to a clean section of floss and repeat with next interdental space
What are the disadvantages of using floss?
Requires excellent manual dexterity
Time consuming
Difficult to master
Describe superfloss.
Used for crowns, orthodontic appliances, bridgework
Stiffened ends for threading
Spongy section to brush
Normal floss for flossing
When may you use an interspace brush?
Malaligned teeth
Lone teeth
Very distal surfaces
Furcation areas
How do you use an interspace brush?
Splayed action with bristles penetrating gingival crevice
Small circles
What is chlorhexidine gluconate used for?
Mouthwash or gel as an adjunct to treat acute inflammation
Which compound found in many toothpastes interferes with the action of chlorhexidine gluconate?
Sodium lauryl sulphate
Why do we not use chlorhexidine gluconate for long periods?
Can cause staining and loss of taste
Describe the brief intervention you would take for a patient that smokes.
Ask if they smoke routinely, record smoking habits in notes
Advise current smokers of the adverse effects and benefits of quitting
Assess any interest in quitting or perhaps lowering frequency of smoking
Arrange for follow up/referrals to specialists with their consent
What three factors are necessary for a patient to adhere to advice according to the Philip Ley Motivation Model?
Memory of info given
Understanding of info given
Satisfaction of interaction with dental team
What are the classes of mobility?
Class I <1mm horizontal mobility
Class II >1mm horizontal mobility
Class III >1mm horizontal and vertical mobility
Which type of radiograph is considered the “gold standard” for assessing periodontal tissues?
Periapical (paralleling technique)
Give the different parts of a periodontitis diagnosis.
Extent - localised/generalised
“Periodontitis”
Stage (severity)
Grade (rate of progression)
Stability
Risk factors
What are the signs and symptoms of acute necrotising ulcerative periodontal disease?
Systemic symptoms like fever
Ulceration of dental papillae
Red painful gingivae with bleeding on probing
Halitosis
Bad taste in the mouth
Necrotic fibrinous slough
How do you differentiate between a lateral periodontal abscess and an endodontic abscess?
Sensibility/vitality tests
Vital = more likely to be periodontal
What HbA1c level indicates well-controlled diabetes?
<6.5%
Which drugs may cause drug-induced gingival overgrowth?
Phenytoin (anticonvulsant for epilepsy)
Calcium channel blockers like nifedipine (for hypertension)
Ciclosporin (immunosuppressive for eg. transplants)
What is a pregnancy epulis?
Swelling on the gingiva, usually anterior
Caused by increased vascularity and plaque
How should you treat a pregnancy epulis?
Wait until after pregnancy to remove as there is an increased chance of regrowth and risk of bleeding when pregnant
Emphasise good oral hygiene and regular visits
Which hormone causes the increased gingival blood flow seen during pregnancy?
Progesterone
What impact does smoking have on periodontal disease?
Increased risk of periodontitis as well as more severe disease/bone loss/tooth loss
Masks disease due to low levels of inflammation (vasoconstriction)
Reduces response to treatment
Which genetic conditions are most detrimental when it comes to periodontal disease susceptibility?
Hereditary neutropenic conditions
Describe the initial lesion of the Page and Schroeder model.
24-48hrs of plaque accumulation
Localised to gingival sulcus and subadjacent tissue
Local vasodilatation and increased vascular permeability
More IgG, complement, fibrin, neutrophils, GCF (dilutes toxins)
Describe the early lesion of the Page and Schroeder model.
4-7days of plaque accumulation
Junctional and sulcular epithelium proliferate
Increased vasodilatation and vascular permeability
Even more GCF and neutrophils
Local accumulation of T lymphocytes
Beginning of collagen and fibroblast degradation
Describe the established lesion of the Page and Schroeder model.
2-3wks of plaque accumulation, can persist for many years
Junctional and sulcular epithelium proliferate - may be replaced by pocket epithelium
T lymphocytes dominate the lesion
Some collagen loss
New vessel formation and plasma cells present, mainly IgG and IgA
Describe the advanced lesion of the Page and Schroeder model.
Pocket formation and apical migration/attachment loss (collagen and bone loss)
Imbalance in host-microbial interaction
Reparative fibrotic response
New vessel formation, plasma cells, more IgM
Dense infiltrate of lymphocytes, macrophages, plasma cells causing breakdown of epithelial barrier
Name some mechanisms of direct damage by bacteria.
Damage to sulcular epithelium
Leukocyte killing via leukotoxin
Impairment of PMN function
Dysregulation of cytokine networks
Degradation of Ig
Degradation of fibrin
Increased mucosal permeability and disaggregation of proteoglycans
Proteolytic enzyme degradation
Bone resorption by LPS or lipoteichoic acid
Name some mechanisms of indirect damage by the host.
Release of tissue destructive enzymes and MMPs
Polyclonal activation of B cells preventing useful/specific antibody production (LPS)
Cytokine release causing bone resorption
What probe is used for the BPE?
WHO probe
Which probe is used to measure furcation involvement?
Nabers probe
Which probes could be used for a 6PPC?
William’s probe
UNC15 probe
Why are third molars usually not included in a BPE?
Partially erupted
False pockets
Erupt at angles
Describe the position of the probe when taking a BPE.
Parallel to long axis of tooth (angulation)
Always in contact with tooth surface (adaptation)
Which teeth are probed for a BPE in a child under 11 years old?
UR6, UR1, UL6
LR6, LL1, LL6
What factors affect the accuracy of probing?
Angulation
Pressure
Calculus
Site
Inflammation
Operator variation
What types of furcation involvement are seen in lower teeth?
Buccal/lingual
What types of furcation involvement are seen in upper teeth?
Distal/mesial
What would you do if you recorded a code 3 in a BPE?
Initial perio therapy = OHI and removal of secondary local factors such as calculus and overhangs
Recall in 3 months and conduct a 6PPC in that sextant
What would you do if you recorded a code 3 in a BPE?
6PPC of entire dentition and appropriate radiographs (periapical) to stage and grade
What are the parameters of the 6PPC?
Periodontal probing depths (mm)
Bleeding
Suppuration
Recession
Mobility
Furcation involvement
What instruments are present in the American Eagle periodontal kits?
Sickle scaler 311-312
Scandette
Gracey 7-8
Gracey 11-12
Gracey 13-14
Explorer 11/12
What is a periodontal probe?
Slender assessment tool used to evaluate periodontal health
Generally describe the shape of a periodontal probe used for 6PPC.
Blunt, rod-shaped end
Circular cross section
mm markings (calibrated)
What is an explorer?
Assessment instrument with a fine, wire-like working end
Which periodontal instrument gives the best tactile feedback?
Explorer
What is an explorer used for?
Locate:
- calculus deposits
- tooth surface irregularities
- defective restoration margins
- decalcified areas
- carious lesions
What are the three main parts of a periodontal instrument?
Handle
Shank
Working end
Describe the features of the handle of a periodontal instrument.
Metal, silicone or resin
Large diameter = less fatigue and more control
Hollow or solid (hollow allows better tactile feedback)
Serrations prevent slipping
What may a longer shank indicate about an instrument?
Used for posterior teeth or deep pockets
What may a shorter shank indicate about an instrument?
Used for anterior teeth or supragingival areas
What are the two ways that a working end can terminate?
As a rounded toe or a sharp tip
What is the function of a sickle scaler?
Removal of supragingival calculus
Why is a sickle scaler not used subgingivally?
May scratch or gouge the root surface unnecessarily
Describe the shape of a sickle scaler.
Triangular cross-section - pointed back with 2 cutting edges
Sharp tip at the end
Face perpendicular to terminal shank
What are the advantages of the pointed tip of a sickle scaler?
Able to get beneath calculus and scoop it off
Good access to interproximal areas
What do universal and site-specific mean?
Universal = 2 cutting edges so can be used on all teeth
Site-specific = 1 cutting edge so can only be used for specific teeth
Describe the shape of a scandette.
2 cutting edges with a semicircular cross section
Face perpendicular to terminal shank
Rounded back and rounded toe (less damage to pocket/sulcus soft tissues)
What is a scandette used for?
Removal of light-moderate subgingival calculus deposits (can be used supragingivally)
What is the advantage of using a site-specific debridement instrument?
One cutting edge so less traumatic to the soft tissues of the pocket
Describe the shape of a site-specific curette (Graceys).
Rounded back and rounded toe
Semicircle cross section
Lower cutting edge at 70º to terminal shank
How do you identify the cutting edge of a site-specific curette?
Hold instrument so you are looking at the toe
Angle instrument until terminal shank is perpendicular to floor
Look for lower cutting edge
How do you hold a periodontal instrument?
Modified pen grasp
Where can the finger rest/fulcrum be during debridement?
Same arch as tooth, on a stable tooth close by
Across the arch
Opposite arch
External soft tissues overlying bone (eg chin)
Edentulous ridges
What is the function of the fulcrum?
Stabilises hand and controls stroke
Provides leverage for stroke production and power for instrumentation
Tactile feedback
What can the mirror be used for?
Tissue retraction (no finger rest)
Indirect vision (finger rest)
Illumination
Stabilisation/balance
Describe the position of a debridement instrument when in use.
Terminal shank should be parallel to the long axis of tooth/surface
What is the 12 o’clock position used for?
Anterior sextants
What is the 11 o’clock position used for?
Right posterior palatal or lingual surfaces
What is the 10 o’clock position used for?
Left posterior surfaces
Right posterior buccal surfaces
What are the exploratory and working strokes?
Exploratory stroke = determines size and location of deposit
Working stroke = removes deposit (apical to coronal), 2/3 per deposit
What are the two types of ultrasonic scalers?
Piezo-electric scalers
Magnetostrictive scalers
How does a piezo-electric scaler work?
Tip vibrations created by a piezo-electric crystal system with piezoceramic discs that vibrate on a titanium shaft when high frequency electric currents (32-35kHz) are applied
How does a magnetostrictive scaler work?
Elliptical tip vibrations created by a resonating stack of ferromagnetic metal strips on the back of the insert
Initiated by an oscillating magnetic field within a coiled electric current
What type of ultrasonic scaler requires more coolant?
Magnetostrictive scalers (produce more heat)
What are the 4 modes of action of an ultrasonic scaler?
Acoustic turbulence (micro-streaming)
Cavitational effect
Mechanical action
Fluid lavage
Describe acoustic turbulence.
Pressure produced within a confined space (periodontal pocket) by a continuous stream of fluid flowing over the vibrating instrument tip
Antimicrobial effect by disrupting and destroying subgingival pathogens
Describe the cavitational effect.
Tip of USS produces a spray containing millions of bubbles which collapse, releasing energy
Energy destroys bacterial cell walls and removes endotoxin from root surface
Describe mechanical action.
Action of vibrating tip removes calculus (no need for lateral pressure)
Describe fluid lavage.
Flushing ability created by continuous fluid stream within pocket
Washes debris, bacteria and unattached plaque from pocket
Improves vision
What are the two strokes that can be carried out with an ultrasonic scaler?
Tapping motion
Sweeping motion
Describe the tapping stroke with an USS.
Point of instrument positioned at most coronal edge of calculus
Tip directed against deposit in a light tapping motion
Vertical or oblique strokes
Describe the sweeping stroke with an USS.
Tip used in an eraser-like motion for deplaquing (coronal to apical)
Overlapping strokes to cover entire root surface
Light pressure and grasp
Vertical, horizontal and oblique strokes
What are the indications for USSs?
Supra or subgingival calculus
Plaque removal
Heavy staining
Overhangs
Residual orthodontic cement
Maintenance appointments (faster)
Acute necrotising ulcerative gingivitis patients
Patient preference
What are the contraindications for USSs?
Known infectious diseases (aerosols)
Pacemakers (avoid magnetostrictive)
Hearing aids (sound)
Implants (may damage surface)
Gold or porcelain restorations
Decalcification (sensitivity)
What are the advantages of using ultrasonic scalers over hand instrumentation?
Less time for supragingival calculus removal
Less tissue trauma, conservation of cementum
Healing of soft tissues is slightly faster
Ergonomic - less pressure required so less operator fatigue
Effective with ANUG patients and furcation involvement
Improved stain removal, can remove orthodontic cement and overhangs
Can destroy bacteria from a distance
360º action from tip and no sharpening required
What are the possible hazards of USSs?
Thermal damage if water stops flowing
AGP - infectious disease transmission
Electromagnetic fields may disrupt pacemakers
Auditory damage
What is root surface debridement?
Instrumentation of root surface to remove calculus, bacterial plaque and its byproducts
Produces a smooth root surface whilst conserving cementum
Removal of diseased/infected tissue (eg ANUG)
What does “blended approach” mean?
Use of both hand instrumentation and ultrasonic scalers
