Periodontal Considerations Flashcards
During Puberty:
Levels of Prevotella intermedia _____________
Occurs during age _____ to _______
Estrogen/Progesterone levels ______
Gingivitis levels _________________
INCREASE
Age 11 to 14
INCREASE
INCREASE
How to manage puberty gingivitis?
1) OHI (frequent reinforcement)
2) Scaling & polishing
3) Antimicrobial mouth rinses (CHX)
4) Local/systemic antimicrobials if severe & medical history indicates need
During Pregnancy, estrogen levels are _____________, and progesterone levels are ___________
DECREASED (estrogen)
INCREASE (progesterone)
What are the adverse pregnancy outcomes (4) ?
1) Pre-term Birth
2) Low Birth Weight
3) Preeclampsia
4) Fetal Growth Restriction & Development
Menadione is an essential nutrient for ___________
P. intermedia
Menadione =
Methyl-naphthalenedione
Progesterone =
Naphthoquione
P. intermedia can substitute naphthoquione for _____________________
methyl-naphthalenedione.
Elevated progesterone levels will facilitate ________ and _________ of ____________
Growth
colonization
P. intermedia
P. Intermedia is tissue invasive and associated with _______________ and ____________ formation
Gingival inflammation
Pyogenic granuloma formation
What are the inflammatory mediators for pregnancy?
IL1, IL 6 TNF-alpha, and PGE 2
What are the Acute Phase Responses ?
1) C-reactive protein
2) Haptoglobin
3) Fibrinogen
4) Amyloid A
What are the Periodontal pathogens associated with pregnancy?
1) P. gingivalis
2) T. forsythia
3) Campylobacter rectus
4) Provetella intermedia
5) Treponema denticola
* *Endotoxins
Periodontal disease + P. i, Fusobacterium, &
Campylobacter recta —–>
Placental invasion w/ fetal exposure to bacterium, LPS, and bacterial antigens
Periodontal disease can lead to increased levels of ?
1) Inflammatory mediators (IL 1, 6, TNF-a and PGE2)
PGE2 can lead to ____________ contraction
Pre-mature uterine
Premature uterine contraction leads to what?
Pre-term low birth weight delivery
What are the primary objectives for managing periodontal disease in pregnancy ?
1) Achieve a health oral environment
2) Maintain optimal oral hygiene (patient education)
What is the effective Dental Treatment for the 1st Trimester?
No treatment/Emergency only
What is the effective Dental Treatment for the 2nd Trimester?
Safest time frame for treatment
- control active disease
- eliminate potential problems
- postpone periodontal surgery
Last month of 3rd Trimester_________________
Selective treatment
Dental radiographs in Pregnancy?
1) Lead apron
2) High speed film
3) safety established but desirable not to have irradiation during 1st trimester
4) 2008 ADA guidelines: ONLY required to aid in establishing a definitive diagnosis
Medications in Pregnancy?
1) Consult FDA classification system
2) 1-2% of material drug dose is excreted in breast milk
Avoid which drugs during pregnancy?
1) Lidocaine
2) Bupivacaine
3) Procaine
* *Use all these with caution
4) ASPIRIN (AVOID in 3rd trimester)
5) Ibuprofen (AVOID in 3rd trimester)
6) Codeine
7) Oxycodone
8) Hydrocodone
* **AVOID PROLONGED USE
Which ABX should a pregnant woman avoid?
1) Tetracycline **
2) Clarithromycin **
3) Ciprofloxacin
4) Metronidazole
Which drugs to avoid while breast feeding?
1) Aspirin
Which ABX to avoid while breast feeding?
1) Tetracycline **
2) Ciprofloxacin
3) Metronidazole
4) Gentamicin
5) Vancomycin
6) Benzodiazepines
7) Barbiturates
What is considered a medically compromised patient?
1) hypertension
2) Ischemic heart disease
3) congestive heart disease
4) cardiac pacemakers/defibrillators
5) Infectious Endocarditis
6) Ischemic Cerebrovascular disease
Bacteremia leads to what in Atherosclerosis, Cardiovascular & Cerebrovascular disease?
Bacterial induced platelet aggregation & endothelial invasion
Immune response leads to what in Atherosclerosis, Cardiovascular & Cerebrovascular disease?
Antibodies to bacteria and cross-reactive antigens (e.g heat shock protein)
What is the effect of inflammation of the vessel wall in periodontal disease?
Smooth muscle cells + Vascular endothelium–> collagen elastin, Upregulation of ICAM -1 and V CAM-1–> PMNs , macrophages and Foam cells—> Atheroma formation (Coronary vascular disease)
Increased CRP in the liver does what?
Binds to epitopes on lipid membranes of damaged cells leading to CRP– C’ activation leads to PMN chemotatix and phagocyte activation causing tissue damage
Increased SAA in the liver causes what ?
Promotes lipid deposition in atheroma –> Atheroma formation (coronary vascular disease)
_________ + ___________ activates the C’ cascade via the classical pathway
CRP + C1 q
Increased Fibrinogen in the liver in perio disease causes what?
Thrombus fomation–> Atheroma formation (coronary vascular disease)
Hypertension is present in ________ american adults.
Systolic BP > or equal to _______ Hg
Diastolic BP > or equal to _______Hg
> 20%
140 mm Hg
90 mm Hg
When measuring BP take _______ readings, _____ reading, ______ minutes apart at a min of ______ office visits
multiple
2
10
2
Normal BP = _____
Pre-hypertention = _______
What is stage 1 hypertension?
What should you do?
- 140-159/ 90-99)
- inform patent and routine medical consult
- Monitor BP @ each appointment
- Minimize stress
- No changes in dental Tx
What is stage 2 hypertension?
What should you do?
> or equal to 160/ > or equal to 100
- inform patent and routine medical consult
- Monitor BP @ each appointment
- Minimize stress
- Selective dental care when BP is or equal to 180 or diastolic > or equal to 100 IMMEDIATE MEDICAL ATTENTION ONLY DO EMERGENCY CARE
What are the dental consideration or hypertension?
1) DONT treat if not under MD
2) Local anesthesia w/ epi 1: 100,000 or without
3) Ensure profound local anesthesia
4) review medication/drug interaction
If you have unstable angina _______ treatment ONLY
Emergency
If stable angina:
Pt brings _________
Local anesthesia w/ _________ for _____ patients
Carefully ____ during treatment
Nitroglycerin
Epi
Hypertensive
Monitor
How long should patient wait after MI or STROKE to have TX?
6 MONTHS
Note: Then treat as stable angina & BEST to obtain medical consult prior to TX
Congestive Heart Failure:
_________ problem- inadequate ____ to tissue
consult with _______________
Review _______________
Treat in ___________ postion
__________ appointments /_______ reduction
Pump O2 Physician Medications/drug interaction Upright Short Stress
All pacemakers places in the last _______ are shielded
10 yrs
With defibrillators, patients may exhibit _________ movement.
Consider using a _______ during Tx
Sudden
Bite-block
In Infectious (Bacterial endocarditis):
Microbes colonize ________ or _________
___________ strep is most common
Periodontal bugs involved are _______, _______ , and ______
- Endocardium
- heart valves
- Alpha hemolytic
- Eikenella corodens
- A.a
- Capnocytophaga spp
How can a dental procedure lead to infectious endocarditis?
Dental procedure–> Bleeding–> Transient bacteremia–>Possible Infectious Endocarditis
In Infectious (Bacterial endocarditis):
Identify level of patient _________
Provide oral hygiene __________
Educate patient about importance of ___________
Treatment should include__________, ____________, __________ , _____________
- Risk
- instructions
- maintaining perio health w/ respect to transient bacteria
- Pre- treatment with CHX
- DECREASE # of visits
- 7 + days between appoints (10-14 days)
- Regular recall/perio maintenance
MOST patients ________ antibiotics before dental procedures to prevent infective endocarditis (prophylaxis)
DO NOT NEED
Which cases are worth the risks for dental prophylaxis?
1) artificial heart valve
2) history of having IE
3) certain specific, serious congenital heart conditions
Which type of cases have taken prophylactic ABX in the past but NO LONGER need them?
1) Mitral valve prolapse
2) Rheumatic heart disease
3) bicuspid valve disease
4) calcified aortic stenosis
5) Congenital heart conditions (septal defect, atrial defect, hypertrophic cardiomyopathy)
CVA =
Wait how long to do perio Tx?
Stroke
-6 months
Ischemic =
Atherosclerosis
Hemorrhagic =
Hypertension
What are the TX considerations for Cerebrovascular Accident ?
1) Short appointments
2) Ensure profound anesthesia
3) concentration of epi in local anesthetic no greater than 1: 100,000
4) consider using light conscious sedation
5) Obtain MD consult (INR)
6) Monitor BP during TX
What is the Pathobiology of Diabetes (Type I)
Depletion of Beta cells–> lack of insulin–>hyperglycemia–>cellular starvation–> (retinopathy, nephropathy, angiopathy, neuropathy, delayed wound healing, periodontitis)–> increased lipolysis–> increase in FFA–> Elevated Ketone levels–>KETOACIDOSIS–> DEATH or pathology
What is the Pathobiology of Diabetes (Type II)
Diet & Obesity–> elevated FFA–> Lipocyte secretion of TNF alpha–> insulin resistance–> DIABETES –> (retinopathy, nephropathy, angiopathy, neuropathy, delayed wound healing, periodontitis)
What can lead to ELEVATED synthesis of Inflammatory cytokines (TNF alpha, IL-1, IL 6 and PGE2)?
(keep in mind this later leads to chronic disease like diabetes)
1) Obesity
2) Periodontitis (bacterial factors)– can be genetic or environmental [smoking]
BMI of _______ is overweight
BMI of _______ is obese
25-29.9
>30
Obesity has been suggested to be associated with an INCREASED susceptibility to ____________
Bacterial infection (perio disease)
Study that analyzed Body weight & perio infection suggested that response association of BMI with __________ in ___________
- Increase
- Periodontal pockets
Normal HbA1c assay _________
Good diabetes control _______
Moderate diabetes control_____
poor_________
4-6%
8%
Diabetes Alert:
1) Family history
2) Age > 40
3) Classic symptoms (3 P’s)
4) Perio abscesses (multiple & recurrent)
5) Rapid alveolar bone loss
6) poor response to Tx
Signs and symptoms of Diabetes
1) Xerostomia
2) burning of mouth
3) Perio abscesses
4) Dental caries
5) Candidiasis
What are the periodontal considerations for diabetes?
1) Impaired wound healing
2) increased plaque activity (xerostomia)
3) Increased bone resorption
4) Altered PMN chemotaxis
5) Periodontal Abscesses
What are the intrinsic changes of the aging periodontium?
1) DECREASED epithelial turnover rates with age
2) DECREASED progenitor cell reserves
3) Oral epithelium becomes thin
4) Reduced keratinization
What are the Stochastic(RANDOM) changes of the aging periodontium?
1) Changes within cells result in morphologic and physiologic changes
2) Structures become stiffer
3) Loss of elasticity
What are the Physiologic changes of the aging periodontium?
1) PDL LOSS of elasticity
2) DECREASED in vascularity
3) DECREASE in bone density
4) INCREASE in bone resorption
5) INCREASE in cementum thickness
What are the Functional changes of the aging periodontium?
1) REDUCED mitotic activity
2) REDUCED metabolic rate
3) REDUCTION in healing capacity & rate
4) Inflammation develops more rapidly and more severely
Risk factors for older adults and perio disease are the ________ for any age
Same
The older adults and perio disease have ________ numbers with advanced disease
fewer (problem teeth removed?)
When treatment planning for older adults what should we do?
1) Carefully review medical status
2) Assessment for PD, CAL, Mobility, radiographic bone loss of remaining teeth
3) Diagnosis
4) Initial Therapy- Non-surgical
5) Re-evaluation
6) Restorative/ implants OK
7) Maintenance
Oral Bisphosphonates are used for the treatment of __________ and it is associated with _____________
-Bone cancer, other diseases
-Avascular bone necrosis of the jaws
(BIONJ) Biphospho induced osteonecrosis of the jaw
Intravenous Bisphosphonates =
1) Aredia
2) Zometa
Individual taking oral Bisphosphonates (Fosamax, Aconel and Boniva) for > 3 years may be at a __________ risk for loss of newly placed ____________ and ___________ following tooth ________ or periodontal surgery involving bone exposure.
- GREATER
- implants
- BIONJ
- Extractions
What are the Treatments for Sjogrens syndrome and diabetes ?
1) Salivary substitues (Salivart)
2) Salivary Stimulation (Sugarless candy–lemon drop, Sugarless gum)
In the Elderly patient what are the special considerations for root caries?
1) Susceptibility due to gingival recession
2) Recurrent carries around old restoration & crowns
In the Elderly patient what are the special considerations ?
1) Mental capacity (Senile Dementia, Alzheimers)
2) Depression
3) Nutrition
4) Neuromuscular Control (Parkinsonian Tremor)
