Periodontal disease- tx planning and therapy Flashcards
what types of scalers are there?
USS and Sonic scaler- both operate at high frequencies and use water to cool heated tip
what is the sonic scaler?
- operates at 5-10kHz
- CONNECTS TO AIR TURBINE (same as high speed handpiece)
what is the USS?
- operates at 20kHz
- high frequency
- POWERED BY ELECTRICAL CURRENT
what are the types of USS?
- magnetostrictive
- piezoelectric
how does magentostrictive USS work?
ELECTRICAL ENERGY FLOWS THROUGH COIL OF WIRE IN HANDPIECE WHICH CAUSES RAPID EXPANSION AND CONTRACTIONS OF METAL STACKS WHICH causes vibrations
- use all sides of tip
how does piezoelectric USS work?
electrical energy is used to activate crystals within the handpiece which cause vibrations
- use 2 sides of tip
what are the modes of action for USS?
mechanical- movement of vibratory tip breaks deposits from the tooth surface
cavitational- vibratory tip causes minute air bubbles within water implode causing shock waves which break deposits from surface and bubbles release O2 which kills anaerobic bacteria
acoustic- water from vibratory tip flushes pocket and debris from the tooth surface and disrupts biofilm
what are the indications of using an USS?
- supra scale
- sub scale
- RSD
- cavitational effect only (NUG)
- remove staining
- REMOVE AMALGAM LEDGES
what are the contraindications of using USS?
- dentine hypersensitivity- exposed dentine recession
- anxious patients
- IMPLANTS - CAN DAMAGE TITANIUM IMPLANT
- pacemaker- high frequency may interfere with pacemaker
- PORCELAIN CROWNS
- DECALCIFICATION- CAN CAPITATE LESIONS- IRREVERSIBLE damage
- patients with contagious diseases e.g tb
what are the properties of calculus?
- sterile
- crystalline structure
- inert
- unmineralised layer of plaque on top
- porous- can withhold bacterial endotoxins
- supra and sub
- impedes normal OH
- must be removed by professional
- prone to staining- diet or smoking
- rough surface
- local risk factor for periodontitis
advantages of USS
- fine tip- can be used in furcations
- efficient
- use supra and sub
- USED IN NARROW POCKETS
- cavitational effect
disadvantages of USS
- CONTRAINDICATIONS
- MAY NOT TOLERATE WATER/SUCTION
- CAN DAMAGE TOOTH IF NOT USED CORRECTLY
- EXPENSIVE
- CREATES AEROSOL (INFECTION)
- CAN DE-CEMENT OR DE-BOND RESTORATIONS
- WITHOUT COOLANT CAN CAUSE THERMAL DAMAGE
- NURSE REQUIRED
where is calculus most common?
near salivary gland openings
- sublingual gland- lower anteriors lingual
- upper molars- parotid gland opening
what is the difference between supra and sub gingival calculus?
supra- hard but brittle, yellow/brown, detected by BPE probe and 3in 1- direct vision
sub- very hard- attached to root surface, hard to detect use bpe probe and 3 in 1 if loose pocket- green black colour- indirect vision
why is it necessary to remove calculus?
does not cause disease but is a risk factor for periodontal disease as it is:
- rough plaque retentive factor
- SURPRAGINGIVAL IMPEDES OH
- can absorb bacterial endotoxins as porous
- needed to render root surface biologically compatible with healing and allows new epithelial attachment to previously pathogenically altered root surface and formation of LJE.
- UNDERESTIMATED PPD’S- MASK DISEASE
- sub gingival calculus has layer of unmineralised plaque on surface
define a true pocket
- LOA- JE migrates apically
- ulceration at base of pocket
- DISEASED ROOT SURFACE- CALCULUS WITH LAYER OF SUB GINGIVAL PLAQUE
what is the aim of RSD?
render root surface biologically compatible with healing to allow new epithelial attachment and formation of LJE to previously pathologically altered root surface. By
- reduce overall no of microorganisms
- reducing proportion of GNAB
- leaving residual gram + aerobic bacteria
- remove subgingival calculus
- remove sub gingival plaque
- REMOVE BACTERIAL ENDOTOXINS
- remove necrotic surface cementum
- disrupt pathogenic bacteria in sub gingival biofilm
- reduction in plaque thickness- changes environment- more 02 available
why use LA for RSD?
soft tissues and root dentine is highly innervated- can cause pain
what must you warn patients of before beginning treatment?
- post op sensitivity
- gingival shrinkage - periodontal tissues rarely regenerate and if they do it is minor
what is full mouth disinfection? and why is it carried out
to remove as much bacteria as possible within 24-48hrs to minimise risk of re-infection by adjacent teeth
- f/m RSD
- OHI
- chemical adjunct- chlorahmexidine or antibiotic though little evidence of effectiveness
- only done on small number of those who have not responded to initial treatment.
what evidence is there for RSD on shallow pockets?
- little improvement
- may lose further attachment due to trauma
what evidence is there for pockets 4-6mm and >6mm?
4-6mm
- proven effective with average ppd decreasing by 1mm
- gain attachment of 0.5mm
> 6mm
- proven effective with average ppd decreasing by 2mm
- gain attachment of 1mm
how do you carry out RSD?
- reassess pockets for ppd and bop
- administer LA
- explore root surface with probe
- carry out pre USS to remove bulk of sub gingival calculus
- re-explore RS with probe
- use hand instruments to remove residual calculus (small deposits remaining will still Redner RS biologically compatible with healing)
- re-check with probe and repeat if necessary
- flush debris and bacteria from pocket with post USS
- POI
- leave for 10-12 weeks
what are the 5 phases of treatment planning?
- initial clinical examination and pain relief
- cause related non-surgical therapy
- reassessment
- definitive treatment
- maintenance or supportive therapy
explain phase 1 of treatment planning
- relief of pain= priority
- full initial exam including radiographs to form diagnosis and treatment plan.
- includes P+B charts, 6ppcs, radiographs
explain phase 2 of treatment planning
based on initial exam and radiographic evidence: do
- clinical checks - this can include checking caries, overhangs, deficiencies, sensitivity testing ( if furcation involvement as accessory canals, PA pathology or extensive bone loss- hopeless prognosis)
- discussion- discuss findings, diagnosis, tx options, risk factors with patient- gain consent
- advice- give tailored OHI (TIPPS), diet advice, risk factors advice e.g smoking cessation, advice on modifiable risk factors.
- begin treatment- this can include extractions of teeth with hopeless prognosis, PMPR supra, PMPR sub gingival and RSD to remove calculus , remove overhangs, poorly fitted dentures, restore carious teeth.
what is phase 3 of treatment planning?
reassessment
- P+B charts
- 6ppcs
- assess OH and pt cooperation
- update diagnosis (periodontal stability)
- assess whether patient is engaging or non-engaging
what is an engaging pt?
- > 50% improvement in plaque and bleeding scores
- plaque levels <20% and bleeding levels <30%
what is a non-engaging patient?
- <50% improvement in plaque and bleeding scores
- > 20% plaque levels and >30% bleeding levels
- expresses that they would prefer palliative approach
what is phase 5?
- when patient is stable after treatment- successful tx
- supportive therapy
- tailored OHI and simple PMPR at stable sites if necessary
- reinforce RF modification
when should maintenance patient be recalled?
initially- more frequent to ensure stability is demonstrated over period of time and OH is very good
- IS INDIVIDUALISED
Low susceptibility and low RF- 6m-1yr
high susceptibility and high RF- 3 months
-when not stable- active tx
what are the signs of treatment failure?
- pockets >5mm
- pockets >4mm with BOP
- discomfort
- inflammation
- further LOA
- poor OH
why may an individual not respond to treatment?
most common=poor OH
- poor communication- improper technique advised, tepes not resized
- misunderstanding- not practicing in chair as part of TIPPS
- underlying systemic disease- uncontrolled or undiagnosed type 1 diabetes, CVD
- immunocompromised
- high susceptibility to periodontal disease i.e genetics
inadequate debridement due to: - tenacious calculus
- furcation involvement
- instruments not sharpened
- poor operator skills
- deep, torturous pockets
- incorrect diagnosis- may be endodontic problem
- complex root morphology
- smoker
- taking medications that interfere with good OH due to gingival overgrowth- cyclosporine, amlodipine, phenytoin, amitriptyline
- poor manual dexterity (palliative??)
- teeth had poor prognosis (severe bone loss)
what should be done if non responding initially?
- address cause and pt cooperation
- repeat tx
what should be done if non responding and non engaging?
- if RF not modified (can’t/won’t) and unable to achieve stability
- palliative care
what is palliative care?
- must discuss with patient
- simple PMPR every 3 months
- if teeth become excessively mobile or abscessed most likely XLA- must be discussed prior to palliative care
- slow disease and keep patient comfortable and maintaining function
- can be moved to active treatment again if OH/RF good
if patient has good OH, tx has been repeated and still poor response, what should be done?
phase 4- definitive tx
- referral to consultant
- chemical adjunct
- periodontal surgeries
- endodontic tx
when should you refer?
- complex root morphology
- BOP and SUP despite good OH
- complex med hx- bleeding disorders
- high susceptibility
must have good OH and modified RF and have had at least 1 course of tx
name the types pf periodontal surgery that may be carried out?
- flap surgery- open flap of gingivae for thorough clean or if furcation involvement
- gingival graft
- bone graft
- guided tissue regeneration
what is guided tissue regeneration?
most effective formation of new attachment as epithelial cells regenerate faster than bone/pdl cells- guided tissue regeneration gives bone/pdl cells time to regenerate
- surgically open flap of gingivae
- thoroughly clean root surface RSD
- place nonstick membrane to hold epithelium and CT back (gortex or teflon) to allow pdl/bone cells to regenerate
- suture tissue
- leave for 3-6 months
- forms stable new attachment
chemical adjuncts
