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BDS2 PER > Perio tutorials > Flashcards

Perio tutorials Flashcards

1
Q

Which hand should be holding the mirror?

A

Non-dominant hand

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2
Q

Why do we use correct positioning?

A

Reduce injury and fatigue

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3
Q

Describe good positioning of the dentist.

A

Back straight

Feet on floor

Thighs in a triangle, slightly slanting downwards

Patient’s mouth at the natural waist

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4
Q

What patient chin position is used when examining the upper teeth?

A

Tilted upwards

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5
Q

What patient chin position is used when examining the lower teeth?

A

Tilted downwards

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6
Q

What light position is used when examining the upper teeth?

A

Over patient’s chest, 45º

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7
Q

What light position is used when examining the lower teeth?

A

Directly over mouth

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8
Q

Describe the events of the extraoral examination.

A

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

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9
Q

What do you need to do before moving from the extraoral to the intraoral examination?

A

Change gloves! And put patient in supine position

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10
Q

Describe the events of the intraoral examination.

A

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)

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11
Q

What features of the gingiva are you looking at?

A

Colour

Size

Shape

Consistency

Position

Bleeding +/or exudate

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12
Q

How should you approach gingival inspection?

A

Choose one sextant

Look at one aspect at a time for the whole sextant

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13
Q

How will healthy attached or free gingiva feel when probed?

A

Resistant

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14
Q

What is a biofilm?

A

Complex community of micro-organisms attached to a surface and each other, in an extracellular matrix

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15
Q

What is dental plaque?

A

A biofilm growing on a hard, non-shedding surface in the oral cavity in a self-produced matrix of extracellular polymers

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16
Q

What is the main type of nutrient used in supragingival plaque?

A

Carbohydrate

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17
Q

What is the main type of nutrient used in subgingival plaque?

A

Protein

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18
Q

What are the steps of dental plaque development?

A
  1. Acquired pellicle
  2. Adhesion of primary colonisers
  3. Co-aggregation of bacteria
  4. Environment modification by bacteria
  5. Maturation
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19
Q

Describe the formation of the acquired pellicle.

A

Selective adsorption of salivary and GCF components onto the amphoteric tooth surface

(Firstly statherins, PRPs)

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20
Q

What type of bacteria are most primary colonisers?

A

Aerobic cocci

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21
Q

What does the climax community of plaque look like?

A

Lots of Gram negative bacteria

Lots of anaerobes, long rods, spirochaetes, motile species

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22
Q

What is calculus?

A

Hard mineralised deposit on hard surfaces in the mouth

Mineralised plaque

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23
Q

Why does calculus act as a plaque-retentive factor?

A

Rough surface => much increased surface area for plaque to grow

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24
Q

Name some of the different types of calcium phosphate forms you might find in calculus.

A

Brushite

Whitlockite

Dicalcium phosphate

Octacalcium phosphate

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25
Q

Describe supragingival calculus.

A

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

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26
Q

Describe subgingival calculus.

A

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

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27
Q

How does pH affect the calcium and phosphate equilibrium in the mouth?

A

High pH favours mineralisation/precipitation

Low pH favours demineralisation

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28
Q

What are the three main theories to explain calculus formation?

A

Carbon dioxide theory

Ammonia theory

Seeding theory

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29
Q

What is the carbon dioxide theory of calculus formation?

A

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

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30
Q

What is the ammonia theory of calculus formation?

A

Subgingival bacteria metabolise proteins to produce ammonia and urea

pH increases favouring precipitation of salts

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31
Q

What is the seeding theory of calculus formation?

A

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

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32
Q

What is the phosphatase theory of calculus formation?

A

Enzymes in plaque free “locked up” phosphate in organic molecules (eg proteins)

Phosphate binds to calcium in saliva

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33
Q

What procedures should be done before plaque disclosing?

A

Probing/clinical examination - dyes can alter the tissue appearance

Gross scaling - calcified deposits and overhanging margins can be misleading in recording plaque score

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34
Q

Describe O’Leary’s plaque control record.

A

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

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35
Q

Describe the procedure of plaque recording (O’Leary).

A
  1. Inform patient of why they need this done and get consent (they may not want stained lips/gums!)
  2. Tie bib on patient and lay in supine position
  3. Apply vaseline to lips with cotton wool
  4. Place saliva ejector in mouth at occlusal surface of L4 and dry teeth (3in1)
  5. Apply disclosing solution with microbrush in a sweeping motion ~30s
  6. Sit patient up and ask them to rinse carefully
  7. Dry teeth and record whether surfaces have plaque or not
  8. Calculate % plaque score and discuss results with patient with the chart and mirror
    (9. Set realistic goal/target for next time)
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36
Q

What are the advantages of O’Leary’s plaque control record?

A

Objective measure

Paediatric motivation and engagement

Visual and educational tool

Allows longitudinal monitoring

Allows tailoring of OHA

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37
Q

What are the disadvantages of O’Leary’s plaque control record?

A

Stains calculus, overhangs => misleading

Time-consuming

Stains soft tissues, esp tongue

Doesn’t distinguish the amount of plaque present

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38
Q

Describe the Silness-Loe plaque index.

A

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

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39
Q

What are Ramfjord’s teeth?

A

6 index teeth used for partial mouth recording:

UR6, UL1, UL4, LL6, LR1, LR4

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40
Q

Describe the oral hygiene index.

A

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)
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41
Q

What is the main technique to mechanically remove plaque?

A

Tooth brushing

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42
Q

Describe the ideal toothbrush.

A

MAX 2.5cm for adults, 1.5cm for children

Flat trim

Medium texture

Round-ended nylon filaments

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43
Q

What type of grasp should you hold a toothbrush with?

A

Palm grasp

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44
Q

Describe the modified Bass technique.

A

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

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45
Q

Why is the scrub technique not recommended?

A

Abrasive and traumatic, may cause gum recession

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46
Q

What is double brushing?

A

When you use an electric toothbrush like a manual brush (moving in circles rather than holding it in place)

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47
Q

What are the general rules of tooth brushing?

A

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

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48
Q

What are the advantages of an electric toothbrush?

A

Timer

Pressure sensor

Motivational for some people

Good for those with poor manual dexterity

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49
Q

What are the disadvantages of an electric toothbrush?

A

Expensive

Requires charging

Some may brush for a shorter time (misconceptions)

Loud and weird feeling in the mouth

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50
Q

Why do we limit the number of interdental brushes prescribed to 2/3?

A

Avoids confusion

Increases compliance

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51
Q

How should a patient use interdental brushes?

A

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

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52
Q

How much floss do you need for one session?

A

30-40cm/forearm’s length

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53
Q

Describe how to use floss.

A

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

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54
Q

What are the disadvantages of using floss?

A

Requires excellent manual dexterity

Time consuming

Difficult to master

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55
Q

Describe superfloss.

A

Used for crowns, orthodontic appliances, bridgework

Stiffened ends for threading

Spongy section to brush

Normal floss for flossing

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56
Q

When may you use an interspace brush?

A

Malaligned teeth

Lone teeth

Very distal surfaces

Furcation areas

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57
Q

How do you use an interspace brush?

A

Splayed action with bristles penetrating gingival crevice

Small circles

58
Q

What is chlorhexidine gluconate used for?

A

Mouthwash or gel as an adjunct to treat acute inflammation

59
Q

Which compound found in many toothpastes interferes with the action of chlorhexidine gluconate?

A

Sodium lauryl sulphate

60
Q

Why do we not use chlorhexidine gluconate for long periods?

A

Can cause staining and loss of taste

61
Q

Describe the brief intervention you would take for a patient that smokes.

A

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

62
Q

What three factors are necessary for a patient to adhere to advice according to the Philip Ley Motivation Model?

A

Memory of info given

Understanding of info given

Satisfaction of interaction with dental team

63
Q

What are the classes of mobility?

A

Class I <1mm horizontal mobility

Class II >1mm horizontal mobility

Class III >1mm horizontal and vertical mobility

64
Q

Which type of radiograph is considered the “gold standard” for assessing periodontal tissues?

A

Periapical (paralleling technique)

65
Q

Give the different parts of a periodontitis diagnosis.

A

Extent - localised/generalised

“Periodontitis”

Stage (severity)

Grade (rate of progression)

Stability

Risk factors

66
Q

What are the signs and symptoms of acute necrotising ulcerative periodontal disease?

A

Systemic symptoms like fever

Ulceration of dental papillae

Red painful gingivae with bleeding on probing

Halitosis

Bad taste in the mouth

Necrotic fibrinous slough

67
Q

How do you differentiate between a lateral periodontal abscess and an endodontic abscess?

A

Sensibility/vitality tests

Vital = more likely to be periodontal

68
Q

What HbA1c level indicates well-controlled diabetes?

A

<6.5%

69
Q

Which drugs may cause drug-induced gingival overgrowth?

A

Phenytoin (anticonvulsant for epilepsy)

Calcium channel blockers like nifedipine (for hypertension)

Ciclosporin (immunosuppressive for eg. transplants)

70
Q

What is a pregnancy epulis?

A

Swelling on the gingiva, usually anterior

Caused by increased vascularity and plaque

71
Q

How should you treat a pregnancy epulis?

A

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

72
Q

Which hormone causes the increased gingival blood flow seen during pregnancy?

A

Progesterone

73
Q

What impact does smoking have on periodontal disease?

A

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

74
Q

Which genetic conditions are most detrimental when it comes to periodontal disease susceptibility?

A

Hereditary neutropenic conditions

75
Q

Describe the initial lesion of the Page and Schroeder model.

A

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)

76
Q

Describe the early lesion of the Page and Schroeder model.

A

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

77
Q

Describe the established lesion of the Page and Schroeder model.

A

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

78
Q

Describe the advanced lesion of the Page and Schroeder model.

A

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

79
Q

Name some mechanisms of direct damage by bacteria.

A

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

80
Q

Name some mechanisms of indirect damage by the host.

A

Release of tissue destructive enzymes and MMPs

Polyclonal activation of B cells preventing useful/specific antibody production (LPS)

Cytokine release causing bone resorption

81
Q

What probe is used for the BPE?

A

WHO probe

82
Q

Which probe is used to measure furcation involvement?

A

Nabers probe

83
Q

Which probes could be used for a 6PPC?

A

William’s probe

UNC15 probe

84
Q

Why are third molars usually not included in a BPE?

A

Partially erupted

False pockets

Erupt at angles

85
Q

Describe the position of the probe when taking a BPE.

A

Parallel to long axis of tooth (angulation)

Always in contact with tooth surface (adaptation)

86
Q

Which teeth are probed for a BPE in a child under 11 years old?

A

UR6, UR1, UL6

LR6, LL1, LL6

87
Q

What factors affect the accuracy of probing?

A

Angulation

Pressure

Calculus

Site

Inflammation

Operator variation

88
Q

What types of furcation involvement are seen in lower teeth?

A

Buccal/lingual

89
Q

What types of furcation involvement are seen in upper teeth?

A

Distal/mesial

90
Q

What would you do if you recorded a code 3 in a BPE?

A

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

91
Q

What would you do if you recorded a code 3 in a BPE?

A

6PPC of entire dentition and appropriate radiographs (periapical) to stage and grade

92
Q

What are the parameters of the 6PPC?

A

Periodontal probing depths (mm)

Bleeding

Suppuration

Recession

Mobility

Furcation involvement

93
Q

What instruments are present in the American Eagle periodontal kits?

A

Sickle scaler 311-312

Scandette

Gracey 7-8

Gracey 11-12

Gracey 13-14

Explorer 11/12

94
Q

What is a periodontal probe?

A

Slender assessment tool used to evaluate periodontal health

95
Q

Generally describe the shape of a periodontal probe used for 6PPC.

A

Blunt, rod-shaped end

Circular cross section

mm markings (calibrated)

96
Q

What is an explorer?

A

Assessment instrument with a fine, wire-like working end

97
Q

Which periodontal instrument gives the best tactile feedback?

A

Explorer

98
Q

What is an explorer used for?

A

Locate:

  • calculus deposits
  • tooth surface irregularities
  • defective restoration margins
  • decalcified areas
  • carious lesions
99
Q

What are the three main parts of a periodontal instrument?

A

Handle

Shank

Working end

100
Q

Describe the features of the handle of a periodontal instrument.

A

Metal, silicone or resin

Large diameter = less fatigue and more control

Hollow or solid (hollow allows better tactile feedback)

Serrations prevent slipping

101
Q

What may a longer shank indicate about an instrument?

A

Used for posterior teeth or deep pockets

102
Q

What may a shorter shank indicate about an instrument?

A

Used for anterior teeth or supragingival areas

103
Q

What are the two ways that a working end can terminate?

A

As a rounded toe or a sharp tip

104
Q

What is the function of a sickle scaler?

A

Removal of supragingival calculus

105
Q

Why is a sickle scaler not used subgingivally?

A

May scratch or gouge the root surface unnecessarily

106
Q

Describe the shape of a sickle scaler.

A

Triangular cross-section - pointed back with 2 cutting edges

Sharp tip at the end

Face perpendicular to terminal shank

107
Q

What are the advantages of the pointed tip of a sickle scaler?

A

Able to get beneath calculus and scoop it off

Good access to interproximal areas

108
Q

What do universal and site-specific mean?

A

Universal = 2 cutting edges so can be used on all teeth

Site-specific = 1 cutting edge so can only be used for specific teeth

109
Q

Describe the shape of a scandette.

A

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)

110
Q

What is a scandette used for?

A

Removal of light-moderate subgingival calculus deposits (can be used supragingivally)

111
Q

What is the advantage of using a site-specific debridement instrument?

A

One cutting edge so less traumatic to the soft tissues of the pocket

112
Q

Describe the shape of a site-specific curette (Graceys).

A

Rounded back and rounded toe

Semicircle cross section

Lower cutting edge at 70º to terminal shank

113
Q

How do you identify the cutting edge of a site-specific curette?

A

Hold instrument so you are looking at the toe

Angle instrument until terminal shank is perpendicular to floor

Look for lower cutting edge

114
Q

How do you hold a periodontal instrument?

A

Modified pen grasp

115
Q

Where can the finger rest/fulcrum be during debridement?

A

Same arch as tooth, on a stable tooth close by

Across the arch

Opposite arch

External soft tissues overlying bone (eg chin)

Edentulous ridges

116
Q

What is the function of the fulcrum?

A

Stabilises hand and controls stroke

Provides leverage for stroke production and power for instrumentation

Tactile feedback

117
Q

What can the mirror be used for?

A

Tissue retraction (no finger rest)

Indirect vision (finger rest)

Illumination

Stabilisation/balance

118
Q

Describe the position of a debridement instrument when in use.

A

Terminal shank should be parallel to the long axis of tooth/surface

119
Q

What is the 12 o’clock position used for?

A

Anterior sextants

120
Q

What is the 11 o’clock position used for?

A

Right posterior palatal or lingual surfaces

121
Q

What is the 10 o’clock position used for?

A

Left posterior surfaces

Right posterior buccal surfaces

122
Q

What are the exploratory and working strokes?

A

Exploratory stroke = determines size and location of deposit

Working stroke = removes deposit (apical to coronal), 2/3 per deposit

123
Q

What are the two types of ultrasonic scalers?

A

Piezo-electric scalers

Magnetostrictive scalers

124
Q

How does a piezo-electric scaler work?

A

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

125
Q

How does a magnetostrictive scaler work?

A

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

126
Q

What type of ultrasonic scaler requires more coolant?

A

Magnetostrictive scalers (produce more heat)

127
Q

What are the 4 modes of action of an ultrasonic scaler?

A

Acoustic turbulence (micro-streaming)

Cavitational effect

Mechanical action

Fluid lavage

128
Q

Describe acoustic turbulence.

A

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

129
Q

Describe the cavitational effect.

A

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

130
Q

Describe mechanical action.

A

Action of vibrating tip removes calculus (no need for lateral pressure)

131
Q

Describe fluid lavage.

A

Flushing ability created by continuous fluid stream within pocket

Washes debris, bacteria and unattached plaque from pocket

Improves vision

132
Q

What are the two strokes that can be carried out with an ultrasonic scaler?

A

Tapping motion

Sweeping motion

133
Q

Describe the tapping stroke with an USS.

A

Point of instrument positioned at most coronal edge of calculus

Tip directed against deposit in a light tapping motion

Vertical or oblique strokes

134
Q

Describe the sweeping stroke with an USS.

A

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

135
Q

What are the indications for USSs?

A

Supra or subgingival calculus

Plaque removal

Heavy staining

Overhangs

Residual orthodontic cement

Maintenance appointments (faster)

Acute necrotising ulcerative gingivitis patients

Patient preference

136
Q

What are the contraindications for USSs?

A

Known infectious diseases (aerosols)

Pacemakers (avoid magnetostrictive)

Hearing aids (sound)

Implants (may damage surface)

Gold or porcelain restorations

Decalcification (sensitivity)

137
Q

What are the advantages of using ultrasonic scalers over hand instrumentation?

A

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

138
Q

What are the possible hazards of USSs?

A

Thermal damage if water stops flowing

AGP - infectious disease transmission

Electromagnetic fields may disrupt pacemakers

Auditory damage

139
Q

What is root surface debridement?

A

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)

140
Q

What does “blended approach” mean?

A

Use of both hand instrumentation and ultrasonic scalers

BDS2 PER (4 decks)

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