Periodontics Flashcards
give a definition of gingival health (3 points)
knife edges scalloped gingival margin
pink
absence of BOP
give four examples of local plaque retentive factors
calculus
restorative margin
crowding
mouth breathing
give two examples of systemic modifying factors that increases plaque retention
sex hormones
medication
what is a false pocket
proliferation of sulcular epithelium and enlargement of gingivae with no clinical LOA
what is a true pocket
apical migration of sulcular epithelium and plaque accumulation on root surface which perpetuates inflammation and continued apical migration of epithelium
how far away from the ACJ does alveolar bone usually sit
1-2 mm
what is the keystone pathogen of periodontal disease
P. gingivalis
what aspects of immune response protects against plaque
saliva
epithelium (physical)
GCF which has antimicrobial properties and antibiotics
what are MMPs
matrix metalloproteinases which are degradative enzymes secreted by inflammatory cells causing tissue destruction
in periodontitis what cells secrete MMPs
host cells
name three effects smoking has on the gingiva
increased gingival keratinisation
vasoconstriction of gingival tissues
impaired antibody function
name the two types of BPE probes
WHO probe
UNC 15 probe
what is the WHO probe
0.5mm ball
black band at 3.5mm-5.5mm
black band 8.5mm-11.5mm
what is a requirement for BPE
must be at least 2 teeth in the sextant
what is the treatment if the highest BPE score is a 1
OHI
what is the treatment if the highest BPE score is a 2
PMPR and OHI
what is the treatment if the highest BPE score is a 3
OHI and RSD
what is the treatment if the highest BPE score is a 4
OHI RSD and assess for more complex
what is the treatment plan for a BPE of 3
radiographs
initiate periodontal therapy (PMPR) and 6PPC after 3 months
what is the treatment plan for BPE of 4
radiographs and full perio assessment (6PPC)
what are the six Ramfjord’s teeth
16, 21, 24, 36, 41, 44
what modified plaque and bleeding scores would you find in an engaged patient
less than 35% bleeding
less than 30% plaque
more than 50% reduction in BOTH
what is a grade 0 tooth mobility score
tooth moves around 0.1-0.2mm in horizontal direction
what is grade 1 tooth mobility score
tooth moves 1mm in horizontal direction
what is grade 2 tooth mobility
tooth moves more than 1mm in horizontal direction
what is grade 3 tooth mobility
tooth moves in horizontal and vertical direction
when might single tufted brushes be used
clean malaligned teeth
clean distal surfaces of last molar teeth
clean teeth affected by localised gingival recession
give three advantageous properties of chlorhexidine mouthwash
long substantivity
broad antimicrobial spectrum
adsorption to oral surfaces - including enamel
give two disadvantages of chlorhexidine mouthwash
interferes with taste
stains teeth
according to SDCEP guidelines when is the only time anti-plaque mouthwash should be prescribed
when pain limits patient’s ability to perform mechanical plaque removal
what is the TIPPS acronym
talk
instruct
practice
plan
support
what three things should be on the patient agreement form
diagnosis
self care plan
agreement statement
name the desired outcome of scaling and RSD
create a root surface compatible with biological reattachment
what effect does PMPR have on the microflora
significantly reduces levels of pathogenic species - p.gingivalis and t.denticola
what 3 effects does PMPR have on the soft tissues
decrease in gingival inflammation
recession of gingival tissues due to shrinkage
increase in collagen fibres in connective tissue
what is gain in attachment following RSD attributed to
long junctional epithelium formation and replacement of inflammatory infiltrate by collagen
when is greatest change seen in tissues after RSD
4-6 weeks after therapy
give three reasons why periodontal treatment may fail
inadequate patient plaque control
residual subgingival deposits
systemic risk factors
what is marginal bleeding
bleeding from gingival margin when gingivae have been gently touched - indicator of self-performed plaque control
what is bleeding on probing
bleeding from base of the pocket which indicates presence of inflammation - does not mean there is active disease
what is the name of the probe used for furcation assessment
Naber’s probe
give three components of gingival crevicular fluid
AMPs
cytokines
IgG
give four virulence factors of P.gingivalis
asaccharolytic
gingipains
atypical LPS
inflammophilic
what does asaccharolytic mean
displays nutrients from breakdown of proteins and peptides
how does the host detect bacteria on gingival epithelial cells
via TLRs
what does TLR activation lead to
production of pro-inflammatory mediators which trigger the acute inflammatory response
what does the TLR activation of the chemokine/ cytokine gradient lead to
monocytes and lymphocytes follow the gradient into the gingival tissue
what are the purpose of the monocytes and lymphocytes in gingivitis
they phagocytose invading bacteria
release degradative enzymes into GCF
what is the role of neutrophils in the periodontal tissues
to ensure health
they release their contents in GCF
what is the result of excessive neutrophils in a dysbiotic environment
leads to chronic inflammation and contributes to periodontal destruction
what is the role of MMPs in periodontitis
remove damaged tissue, degrade it and allow for regeneration of tissue
however chronic recruitment leads to bone destruction
what are osteoclasts derived from
immune cell - monocytes
How are osteoclasts made
activated T/B cells release RANKL into the perio lesion
RANKL binds to RANK receptor on pre-osteoclast
when it binds - causes differentiation into osteoclast
what is the role of OPG
to inhibit RANKL binding to RANK and inhibiting bone resorption
how does OPG work
binds to RANK receptor on pre-osteoclast
RANKL cannot bind
results in less bone resorption
what is inflammation in relation to OPG and RANKL
high RANKL and low OPG levels
what is the function of a mini sickle
removes supragingival calculus from buccal and lingual
triangular in cross section
sharp pointed - not to be used below gingival margin
what is the function of a columbia curette
semi circular cross section
used for supra and subgingival scaling throughout the whole mouth
what is the function of the yellow hoe scaler
buccal and lingual sub-gingival scaling
what is the function of the red hoe scaler
mesial and distal surface sub-gingival scaling
what is the function of the grey gracey curette
subgingival scaling of upper and lower anterior teeth
what is the function of the orange gracey curette
mesial scaling of posterior teeth
what is the function of the green gracey curette
buccal and lingual scaling of posterior teeth
what is the function of the blue gracey curette
distal surfaces of posterior teeth
what is the first step in the bsp periodontal treatment
building foundations for optimal treatment outcomes - eg explaining risk factors, control plaque and bleeding through OHI
removing plaque retentive factors
when should you reevaluate a patient after BSP step 1 periodontal treatment
after 6-8 weeks
if 6 weeks after step 1 the patient is seen to be non-engaging, what would be the next step
repeat step 1
if 6 weeks after step 1 the patient is seen to be engaging, what is the next step
step 2 - subgingival instrumentation
what is involved in S3 step 2 periodontitis treatment
reinforce OHI
subgingival instrumentation
use systemic antimicrobials if required
name the structures blanked out by the navy squares
name the five cardinal signs of inflammation
pain
heat
redness
swelling
loss of function
what is biofilm
aggregate of microorganisms that adhere to each other on a surface - these cells are embedded within a self produced matrix
what is the keystone pathogen in periodontal disease
porphyromonas gingivalis
name four ways that P gingivalis can evade the host immune system
gingipains
adhesions
fimbriae
capsular polysaccharide
what is a periodontal emergency
gum swelling, mouth pain, difficulty brushing/ eating due to pain, unexplained bleeding and loose teeth
how should acute periodontal emergencies be managed in the first instance
with local measures - do not prescribe abx unless systemically unwell or signs of spreading infection
what is a perio-endo lesion
a pathological communication between endodontic and periodontal tissues of a given tooth
how is a periodontal abscess differentiated from a periapical abscess
if the tooth is non-vital or not
if non-vital = periapical
name the four components of the periodontium
gingiva, periodontal ligament, cementum, alveolar bone
how do endo-perio lesions present on radiographs
as a J-shaped lesion - with radiolucencies around the roots of the teeth only
what are treatment options for a tooth with an endo-perio lesion
XLA
pulp extirpation
abx if systemic involvement
subgingival instrumentation after endo treatment or XLA
what are the two forms of internal root resorption
inflammatory
replacement
what is internal inflammatory resorption
caused by trauma or damage to predentine
root canal coronal to lesion is necrotic but apically is vital
appears as round radiolucency of root canal
what is treatment for internal inflammatory resorption
orthograde endodontics, intervisit medicament and thermal GP obturation
what is internal replacement resorption
uncommon, associated with previous trauma, caries or periodontal infection affecting pulp
tooth root as cloudy appearance and outline of canal appears wider
what is the treatment for internal replacement resorption
orthograde endodontics and obturation with thermoplastic GP
what are the four types of external root resorption
cervical
inflammatory
replacement
surface
what is external surface root resorption
pressure induced resorption which stops progressing once pressure removed
root apices appear blunt or shorter than unaffected teeth - PDL intact
what is the treatment for external surface resorption
remove source of pressure
what is external inflammatory resorption
pulp is necrotic - triggered by damage to root surface and periodontium
roots appear short and ragged root ends with a periapical radiolucency
what is the treatment for external inflammatory resorption
endodontic treatment
what is external cervical resorption
tooth has pink spot at cervical aspect
causes - damage to subepithelial cementum, infection, orthodontics, non-vital tooth whitening
what is the treatment for external cervical resorption
monitor
XLA and prosthetic replacement
surgical repair and endodontics
how is external cervical root resorption classified
1 - affects crestal area
2 - affects coronal 1/3
3 - affects mid 1/3
4 - affects apical 1/3
what is external replacement resorption
caused by severe luxation or avulsion injury
the PDL is crushed and degenerates - osteoclasts come and remove degenerated PDL but also some cementum
osteoblasts lay down alveolar bone - tooth becomes ankylosed and infra-occluded
clinically has high pitched percussion note
what is the treatment for external replacement resorption
monitor (if non-growing patient)
decoronate
allow for healing (rare)
what are the aims of step 3 periodontal treatment
treat non-responding sites
consider referral for non-responding pockets more than 6mm
adjunct options
name examples of treatment adjuncts for step 3 periodontal treatment
local antimicrobials (chlorhexidine or tetracyclines)
periochip
dentomycin periodontal gel
what is periochip
biodegradeable gelatin matrix
2.5mg chlorhexidine digluconate
inserted into pocket following PMPR
releases slowly over 7 days
what is dentomycsin periodontal gel
2% mincocycline gel
syringed into pocket after PMPR
3-4 applications every 2 weeks
reduces pathogenic load in pocket
when are systemic antimicrobials considered for perio patients
in young patients with rapidly progressing disease (C)
only delivered by specialists
full mouth PMPR in 24 hour period with 400mg metronidazole TID for 7 days
what is periostat
use of drugs to modify host inflammatory system
sub antimicrobial dose doxycycline
when is periodontal surgery considered
stage III
residual pockets of 6mm or more
quality non-surgical periodontal treatment has not resolved pocketing
what patient factors must be considered for periodontal surgery
compliance
good plaque control and little bleeding
cost and patient acceptance
what tooth factors must be considered for periodontal surgery
tooth position
anatomy of tooth
shape of defect
access to non-responding sites
what systemic factors must be considered before periodontal surgery
smoking
poorly controlled diabetes
unstable angina or stroke or MI within 6 months
immunosuppression
anticoagulants
why are monofilament sutures used after periodontal surgery
to prevent plaque adhering to it
what are the three most common mucogingival surgeries
free gingival graft
pedicle graft
connective tissue graft
what are three aetiological aspects of gingival recession
local - excessive toothbrushing, traumatic incisor relationship, chewing habits
generalised - periodontal disease
local or generalised - complication of ortho treatment
what is the classification for gingival recession
1 - no interproximal tissue loss
2 - interproximal tissue loss not as significant as mid-buccal
3 - interproximal tissue loss worse than buccal loss
name three treatment options for gingival recession
eliminate habits and remove piercings
oral hygiene instruction
topical desensitising agents
gingival veneer
mucogingival surgery
