Periodontal Treatment 2 Flashcards
What are the 2 types of periodontal diseases?
Plaque induced gingivitis and periodontitis
What do both plaque induced gingivitis and periodontitis have in common?
They are periodontal diseases, are inflammatory conditions, caused by the formation and persistence of biofilm
What is plaque?
Niofilm with a sticky colourless deposit
What does plaque attach to?
Tooth surfaces, periodontal tissues, connective tissues
What is calculus?
Calcified deposits found attached to the surfaces of tooth and other solid structures - often brown or pale yellow
What covers calculus?
Plaque
Where can calculus be present?
Supra or subgingival
What is calculus detected by?
Direct vision, probing or on radiographs
Name a plaque retentive factor.
Calculus
What are the resistance factors for microbial dysbiosis?
Innate immune response, adaptive immune response, inflammation, other structural components
What are the risk factors for microbial dysbiosis?
Smoking, dental plaque accumulation, socioeconomic status, genetic factors, overall inflammatory burden
What are the clinical manifestations of plaque induced gingivitis?
Change in colour of the gingivae
Marginal gingival swelling
Loss of contour of interdental papilla
Bleeding from the gingival margin on probing/brushing
Plaque is presentation gingival margin
No clinical attachment loss or alveolar bone loss
Gingival sulcus measures 3mm or less from gingival margin to the base of the junctional epithelium
Reversible
What are the clinical manifestations of periodontitis?
Loss of periodontal connective tissue attachment
Gingival sulcus >3mm from the gingival margin to the base of the junctional epithelium which has migrated apically with the formation of a true periodontal pocket.
Alveolar bone loss
Irreversible
What are the stages of periodontal management?
Screening, assessment, treatment, monitoring
What are treatment outcomes affected by?
Early diagnosis, prevention and prompt intervention, screening using BPE
How do you perform a BPE?
Walking the probe around each tooth and recording only the worst score
Describe the WHO probe
Ball ended 0.5mm in diameter, black band from 3.5-5.5mm, second black band 8.5-11.5mm
Describe the UNC probe
15mm long, markings at each mm and colour coding at the 5th, 10th and 15th mm
What sort of probing forces is used for BPE?
20-25grams
Which probes are used for BPE?
WHO and UNC
What teeth are used for the BPE?
All teeth in each sextant with the exception of 3rd molars unless 1st and 2nd molars are missing, each sextant must have at least 2 teeth for recording
What score is the recorded for each sextant in BPE?
The highest score
What is a code 0 BPE?
Probing depth <3.5mm, first black band visible, pocket depth <3mm, no BOP, no calculus
What is a code 1 BPE?
Probing depth <3.5mm, first black band visible, <3mm pocket depth, BOP, no calculus
What is a code 2 BPE?
Probing depth <3.5mm, first black band visible, pocket depth <3mm, possible BOP, calculus present
What is a code 3 BPE?
Probing depth 3.5-5.5mm, partially visible first black band, pocket depth 4-5mm, possible BOP, calculus BOP
What is a code 4 BPE?
Probing depth >5.5mm, first black band completely disappeared, pocket depth >6mm, possible BOP, possible calculus
How do you mark furcation involvement on BPE?
use of a *
What is the treatment for BPE 0?
No need for treatment
What is the treatment for BPE 1?
OHI
What is the treatment for BPE 2?
OHI, removal of plaque retentive factors including all supra and sub gingival calculus
What is the treatment for BPE 3?
OHI
6PPC
Risk factor assessment
Radiographs
PMPR
What is the treatment for BPE 4?
OHI
6PPC
Risk factor assessment
Radiographs
PMPR
Asses need for specialist referral
what is the treatment for BPE *
OHI
6PPC
Risk factor assessment
Radiographs
PMPR
Asses need for specialist referral
What is generalized gingivitis classified by?
> 30% BOP
What is localised gingivitis classified by?
10-30% BOP
When should a code 3 BPE continue with treatment in line with code 4?
With pockets >4mm and/or radiographic evidence of bone loss due to periodontitis
What is generalized periodontitis classified by?
> 30% of teeth
What is localized periodontitis classified by?
<30% of teeth
What are the 3 different types of periodontitis?
Molar-incisor, localized, generalized
What is interproximal recession a sign of?
Bone loss and periodontitis
What is screening information useful for?
Reaching a diagnosis of gingivitis/periodontitis
Assist in formulation of treatment plan or specialist referral
Determine whether detailed charting or special tests needed
What is the BSP guidelines for BPE code 3
If there is a code 3 then this sextant should be reviewed AFTER treatment and a 6 point pocket chart completed for that sextant only
What is the SDCEP guidelines for code 3
6 point pocket chart should be completed for that sextant BEFORE and AFTER treatment
Why do we take radiographs to investigate periodontal disease?
Aid diagnosis and helps with staging and grading of the disease
Helps determine prognosis of teeth
Assessment of the morphology of affected teeth
Pattern and degree of alveolar bone loss
Monitoring of the long-term stability of periodontal health
Which radiographs can be used to assess periodontal disease?
horizontal and vertical bitewings, periapicals, OPTs
What do horizontal bitewings show?
Early localised bone loss, presence of poorly contoured restorations, subgingival calculus
What do vertical bitewings show?
Non-distorted views of bone levels in relation to CEJ
What is the gold standard radiograph for periodontal assessment?
Periapicals
What is the structure of the periodontal treatment plan?
Immediate/emergency care, initial disease control, re-evaluation, reconstructive, maintenance/supportive care
What types of disease control is there?
Extraction of hopeless teeth, hygiene phase therapy, caries management, endodontic therapy, provisional prostheses
What are the components of hygiene phase therapy?
Dental health education, OHI, scaling and RSD, removal of other plaque-retention factors, re-evaluation
What is the aim of disease control through hygiene phase therapy?
Arrest to disease process, regenerate los tissue, maintain periodontal health long term - keep teeth
What do you educate patients on with dental health education?
Modifiable risk factors
Plaque control
Behavioral change (risk factor management, effective plaque removal)
Gingivitis and periodontitis
What can you use to help explain disease and patient’s role in management?
Pictures and diagrams
Radiographs
Plaque disclosing tablets
Sites of gingivitis compared to health in mouth
Toothbrushing technique
Check patient understands
Which medical issues may be risk factors for periodontitis and should be looked out for in medical history taking?
Diabetes, medications (Ca channel blockers cause hyperplasia), dental attendance, smoking, holistic approach (diet, stress etc,)
What are modified plaque and bleeding scores?
Partial mouth recording systems rather than full mouth plaque and bleeding scores
What teeth are used to assess modified plaque and bleeding scores?
Ramfjords teeth
How many surfaces of teeth are used for plaque and bleeding scores?
3
What is a code 0 for modified plaque?
No plaque visible even when probe used
What is code 1 for modified plaque?
Some plaque visible only when probe was used to skim the tooth surface
What is code 2 for modified plaque?
Visible amount of plaque which can be seen without use of probe
Which surfaces are used for modified plaque?
Interproximal, buccal, palatal/lingual
Which teeth are used as Ramfjord’s teeth
16, 21 and 24, 36, 41 and 44
How do you calculate the modified plaque/bleeding score?
Scores for each surface are added to get a total, these are then divided by total number - 36 for plaque, 24 for bleeding.
What does modified bleeding measure?
Marginal bleeding
What does marginal bleeding reflect?
How well the patient can carry out effective plaque control daily
How do you measure marginal bleeding?
Probe run gently at 45 degrees around the gingival sulcus in a continuous sweep and then check for bleeding for up to 30s after
How many and which surfaces are used for modified bleeding?
4 - mesial, distal, buccal, palatal/lingual
What is code 0 modified bleeding?
No bleeding
What is code 1 modified bleeding?
Bleeding present
How do you calculate modified bleeding?
Scores for each surface should be added to get a total score, divide by the maximum bleeding score (24)
What do you do if there is one of Ramfjords teeth missing?
If there is an appropriate alternative tooth use that tooth and if not then use code N, deduct the number of surfaces form the total maximum score
How do you know if a patient is engaged or not after taking modified plaque and bleeding scores?
Less than 35% bleeding score and less than 30% plaque score OR greater than 50% improvement in both
What do you do with a non-engaging patient?
RSD should be delayed, patient should be informed, identify any barriers, continue with OHI, motivation and behaviour change
What does periodontal charting measure?
Probing depth, recession, bleeding on probing, mobility, furcation
What is grade 1 furcation involvement?
Furcation opening can be felt on probing but involvement is less than one third of the tooth width
What is grade 2 furcation involvement?
Loss of support exceeds one third of the tooth width but does not include whole furcation
What is grade 3 furcation involvement?
Through and through involvement
what is grade 0 mobility?
Physiological mobility of 0.1-0.2mm
What is grade 1 mobility?
Increased mobility of the crown of the tooth - 1mm
What is grade 2 mobility?
Visually increased mobility of the crown of tooth exceeding 1mm in horizontal direction
What is grade 3 mobility?
Severe mobility of crown of tooth in both horizontal and vertical directions
What can manual probing measurements be influenced by in full periodontal charting?
The resistance of the tissues, size, shape and tip diameter, site and angle of probe insertion, pressure applied, presence of obstructions such as calculus, patient discomfort
What sort of things are discussed in OHI?
Ask patient to bring current oral hygiene aids
Ask how often they are being used and replaced in a non-judgmental way
Discuss toothbrushes
Dental floss and tape
Interdental sticks and brushes
Ask patient to demonstrate and then modify technique
Use disclosing tablets
Carry out modified plaque and bleeding scores
What advice is given for manual toothbrushing?
The Bass technique
Bristles directed into gingival sulcus at 45 degrees, warn against vigorous brushing, medium soft filament brush, wait 30mins to an hour after eating prior to brushing
What toothbrushing advice should be given in general?
Direct bristles onto gumline and over whole tooth, brush twice a day for at least 2mins, be systematic, look in a mirror when brushing, use brush with a small head
What are single tufted brushes used for?
To clean maligned teeth, clean distal surfaces of last molar tooth, teeth affected by localised gingival recession
What is used for interdental cleaning?
Dental floss and interdental brushes
How do you use interdental brushes?
Should be a snug fit without the wire rubbing against tooth and patient should perform 8-10 back and forth strokes in each space
What is the most effective mouthwash?
Chlorhexidine
What are the advantages of chlorhexidine?
Possesses the property of adsorption to oral surfaces, long substantivity, broad antimicrobial spectrum
What is the disadvantage of chlorhexidine?
Interferes with taste and discolours teeth
When do you prescribe chlorhexidine?
When patients have pain which limits mechanical plaque removal (following sub-gingival instrumentation or patients with acute conditions)
When patients have behavioral changes to make what structure should you follow?
Explain - about the risk factors
Obtain - consent and demonstrate removal in patients mouth
Ask - patient to clean teeth and modify as necessary
Make - make a plan with patient (goal setting, planning, self monitoring)
What does TIPPS stand for?
Talk, instruct, practise, plan, support
What are the forms needed to sign by the patient for periodontal treatment?
Patient agreement form, consent form
What is the difference between the patient agreement form and the consent form?
Patient agreement form outlines the diagnosis, self care plan and agreement statement whereas the consent form has information about the clinical periodontal treatment and risks of said treatment
How are deeply located subgingival calculus found?
Probing fine pointed probe or ball-ended probe
When is subgingival root scaling done?
Once the patient has adequate plaque control
What is root surface debridement
The act of removing dead, contaminated adherent tissue, or foreign material
What is a mini-sickle used for and which tooth surfaces?
Supragingival - buccal and lingual
What are columbias used for and which tooth surfaces?
Sub-gingival, can be used anywhere but limited access to deep pockets
What are hoe scalers used for and which tooth surfaces?
Supra and sub gingival. The yellow is for buccal and lingual and the red is for mesial and distal
What are gracey curettes used for and for which surfaces?
Sub gingival PMPR
Grey = upper and lower
Anterior orange = mesial of posterior teeth
Green = buccal and lingual surfaces of posterior teeth
Blue = distal of posterior teeth
Where are universal scalers used and for which tooth surfaces?
Supra and especially sub-gingival. used anywhere throughout the mouth
What are the differences between powered and hand instruments?
Powered leaves a rougher surface
Powered produces aerosols
Water coolant causes cavitations in calculus
Ultrasonic may result in less unwanted tooth tissue removal
What is the objective of full mouth disinfection?
Prevent treated pockets being re-colonised by intra-oral translocation of bacteria
With full mouth disinfection what do you use for irrigation, tongue brushing and mouth rinsing?
Chlorhexidine
What are the effects of scaling and RSD on the microflora?
Significantly reduces the levels and prevalence of pathogenic species, complete elimination of these species is unrealistic
What is the effect of scaling and RSD on the hard and soft tissues?
Decrease in gingival inflammation
Shrinkage of the gingival tissues leads to recession
Increase in collagen fibers in the connective tissue beneath the pocket and formation of long junctional epithelial attachment, results in decrease in pocket depth and increase in attachment level,
Very little change in bone height at sites with horizontal bone loss
Vertical defects display some infill and gain in bone height
What is the gain in epithelial attachment due to?
Long junctional epithelium formation and improved tissue tone
How do you measure success after RSD?
Inflammation, reduction in probing depth, gain in probing attachment level
What does probing depth indicate?
The difficulty of treatment and the likelihood of recurrence
What does attachment levels measure?
Tissue destruction and the extent of repair
What is the effect of supragingival plaque control alone?
Decreased gingival inflammation, limited effect on probing depth, no change in attachment levels, no alteration in subgingival microflora in deep pockets
What is the effects of RSD without supragingival plaque control?
Initial reduction in inflammation and pocket depth, pockets are re-colonized by bacteria from supragingival plaque, disease recurs
What are the effects of RSD with supragingival plaque control?
Decreased gingival inflammation, reduction in probing depth, gain in probing attachment level, marked changes in the subgingival microbial flora
What do you do at re-evaluation?
Repeat the indices taken at baseline and the findings are then compared
How is success measured after re-evaluation?
Good oral hygiene, no bleeding on probing, no pockets >4mm, no increasing tooth mobility, functional and comfortable dentition
Why does treatment fail?
Inadequate patient plaque control, residual subgingival deposits, systemic risk factors
What are the advantages of supportive periodontal therapy?
Prevents recurrence of disease, stabilizes periodontal condition, maintains optimum periodontal health
What occurs during supportive periodontal therapy?
Plaque control must be reinforced, examine for signs of recurrent disease, retreat any recurrence or new disease, arrange recall to review the patient (every 3 months)
