perio - tutorials Flashcards
ideal outcomes of perio tx according to SDCEP (4)
- high levels of plaque control
- bleeding <10% and plaque <15%
- PPD <4mm throughout mouth
- absence of bleeding at 4mm sites
what does healing depend on
- anatomy of pocket
- immune system
- local risk factors
- anatomy of teeth at which site of pocket is
if >50% pockets healing tx is working so if less then there is an issue with instrumentation
‘engaging’ patient according to BSP
plaque levels <20% and marginal bleeding <30%
OR
>50% reduction in plaque & marginal bleeding from baseline recordings
what is a ‘non responding’ site
> 10% sites with PPD >4mm and BoP at >20% sites 1 year after active treatment
pocket depth v clinical attachment loss
pocket depth = inflammation
clinical attachment loss = bone loss
factors influencing decision for referral for perio surgery (8)
- smoking
- compliance
- OH
- systemic disease
- suitability of sites i.e. access soft & hard tissue factors
- prognosis of tooth / important of tooth
- availability of specialist tx
- pt preference
4 types of perio surgery
- access
- resective
- regenerative
- mucoginigval
access perio surgery
to gain more access to root surface in persisting pockets; inc raising full thickness mucoperiosteal flap & removal of granulose tissue
aim = improved visibility & accessibility for subgingival instrumentation of both hard & soft root surface deposits which have not been removed by non surgical means
resective perio surgery
to remove infected soft tissue of gingivae & infected bone
gingivectomy = during crown lengthening before prosthetic tx
reduction of gingival excess facilitates plaque control, restorative dentistry & improves appearance
regenerative perio surgery
indications -
1. 2 and 3 walled bony defects
2. grade II mandibular furcation defects
3. grade II buccal maxillary furcation defects
aim is to increase periodontal attachment of severely compromised teeth, a decrease in deep pockets so more maintainable range & reduction in vertical & horizontal component of furcation defects
mucogingival therapy
gingival augmentation, root coverage, gingival preservation at ectopic tooth eruption, preservation of ridge collapse associated with tooth xla
symptoms of periodontal emergency
pain
localised swelling
increased bleeding
increased mobility
ulceration
halitosis
bad taste in mouth
signs of systemic involvement i.e. fever, malaise
signs of spreading infection i.e. cellulitis, lymph node involvement
what will help diagnose perio emergency
radiographs i.e. PA
vitality testing
clinical exam
pain hx i.e. SOCRATES
location of swelling i.e. how far up root
perio exam - check pocketing in area, are they are perio pt or not
vertical bone loss more likely to be abscess in area or furcation and pocket in furcation
perio abscess v periapical abscess
for perio abscess there must be clinical attachment loss
for periapical abscess the infection has began in the pulp chamber / root canal and spread out through apices of tooth
note - the 2 can occur simultaneously in endo-perio lesion
endo perio lesion classification
- with root damage
- root # or cracking
- root canal or pulp chamber perforation
- external root resorption - without root damage
- perio pt
- non perio pt
grade 1 - narrow deep pocket in 1 tooth surface
grade 2 - wide deep pocket in 1 tooth surface
grade 3 - deep perio pocket in >1 tooth surface
sdcep mx of endo perio lesions
- consider overall prognosis of tooth & assess whether retention is possible or desirable
- if to be retained carry out endo tx of affected tooth
- following endo tx mx of perio tissues as indicated non surgically or surgically
- do not prescribe ABs unless there are signs of spreading infection or systemic involvement
when could a periodontal abscess occur
following subgingival PMPR when not all of debris is removed from base of pocket & there is healing at coronal part but not apical part so pt will present 2-3 days later with abscess
step by step of mx of perio abscess
- careful subgingival instrumentation short of base of pocket to avoid iatrogenic damage (LA likely to be required)
- if pus present in perio abscess drain by incision or through pocket
- recommend optimal analgesia i.e. paracetamol / NSAIDs
- do not prescribe ABS unless signs of spreading infection or systemic involvement
- recommend use of 10ml x2 daily 0.2% CHX MW until acute symptoms reside // H2O2 6% 15ml diluted x 3 daily
- following acute mx r/v in 10 days and carry out definitive perio instrumentation & arrange appropriate recall
if endo perio with root damage due to perforation
sectional CBCT for that area if suspecting perforation / # of roots
could:
- lift flat find perforation & treat
- xla
- refer to specialist
if no apical area no need to re endo
mta used to restore perforation
if remove post warn pt of risk of # and risk increases with increasing length of post
what ABs to use
pen V 500mg x 4 daily for 5 days
metronidazole 400mg TID for 5 days
MUST be used in conjunction with mechanical therapy to reduce bacterial load and disrupt the biofilm
NG/NP symptoms
severe pain
punched out papilla (can end up with a lot of recession following tx)
yellow / grey sloughing
halitosis
bleeding readily provoked
risk factors of NG/NP
stress (suppresses immune system)
smoking
immunocompromised
severe malnutrition
key factor about NG/NP
OPPORTUNISTIC INFECTION - bacteria already there but they thrive in this environment
tx of NG/NP
1st visit - LA as very painful, supra gingival debridement to encourage healing, prescribe CHX MW / H2O2 MW, identify & address risk factors
2nd visit (3-5 days later) - r/v, subgingival debridement
if continuation of symptoms consider referral to specialist in primary or secondary care
if systemic involvement / spreading infection prescribe 400mg metronidazole TID for 3 days
chemical burn symptoms
pain, TTP, bad taste
tx chemical burn
not much tx
avoid brushing that specific area for a few days to allow to heal
antimicrobial MW
likely to have gingival recession so cover it
PHG presentation & tx
presentation - severe red & inflamed gingiva, vesicles that rupture and can form ulcers on gingiva, buccal, palatal, labial mucosa
cause - HSV1
tx - self limiting, lasts 10-14 days, analgesia & fluids
if severe / immunocompromised pt then aciclovir 200mg x 5 daily for 5 days
recurrent 2ndary herpes
redness, swelling, heat, pain itching, fluid filled blisters
water, analgesia, more local and therefore painful
analgesia & wait for it to resolve by itself, can prescribe CHX MW as pt will not want to brush area & we don’t want accumulation of plaque
usually lips / palate
leukaemia
infiltration of lymphocytes, OH compromised due to gingival appearance, swollen, spontaneous bleeding & palor?
urgent referral to GMP
in meantime regular fluid intake & analgesia
how often 6PPC in supportive care
x1 yearly
why is 4mm threshold
pt has influence on environment of pocket via home methods in pockets up to 4mm but anything >4mm is impossible for pt to reach and maintain
why HbA1c
interested in glycation because of advanced glycation end products which trigger inflammation in the body i.e. vessel causing microangiopathy & neuropathy leading to CV disease & leading to diabetic outflow
measure HbA1c as it measures process of glycation over 3mths (lifespan of RBC)
intervals in step 4
tailored to patient !
shortest recall is 3/12
key to this is risk factors i.e. behavioural / lifestyle / systemic / local plaque retentive factors / root grooves / furcation / crowding / overhanging restorations
what can be an adjunct to determine periodontal risk
online tools such as periodontal risk assessment (spider diagram)
members of the team that can take care of pt who requires periodontal tx
GDP
hygiene therapist
perio specialist
dental students in secondary care
hygienist & local anaesthetic
following PGD directive so can give anaesthetic but needs to be under prescription from dentist
same with radiographs; hygienist can take radiographs but dentist must report them
how to prescribe LA
type of anaesthesia
max dosage
frequency
route of administration i.e. via injection
when should periodontitis pts be referred
level 2 complexity (stage II/III/IV & residual true pocketing 6mm+) after initial non surgical tx step 1 and 2 accepted in specific situations
level 3 complexity (grade C or stage IV & true pocketing of 6mm+) should be referred once lifestyle / behavioural factors have been addressed & appropriate non surgical step 1 and 2 are undertaken in general practice
what is involved in step 4 tx
continuous visits ongoing for life
OH / risk factors at every appt
supra & sub gingival PMPR if residual pockets
prescription will need reviewed yearly
can use perio tools to decide recall interval as this must be tailored to pt
(furcation / risk factors / residual pocketing will all decrease recall period)
6PPC should be carried out yearly (modified pocket chart just for r/v)
what should be contained on referral letter
referrer details
address of referring practice
email address of referring practive
date
telephone no
pt details i.e. address, DoB, CHI, contact details
GMP details - address, telephone, email
MH - current meds
SH - smoking, family hx of perio
clinical indo
diagnosis and classification
reason for referral
details of prev perio tx carried out inc OH demonstration & PMPR
relevant radiographs & perio charts
clinical images if available
