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Periodontics Flashcards

1
Q

How does periodontal abscess form?

A

1.As an acute exacerbation of untreated perio

2.During periodontal therapy or immediately after scaling

3.In refractory periodontitis (low response to treatment)

4.Due to dislodgement of calculus

5.Treatment with antibiotics but without debridement – change in subgignival microbiota leading to superinfection

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2
Q

What are the most common causes of acute conditions of the mouth?

A

76% tooth related

18% periodontal related

6% other

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3
Q

What is the standard steps to diagnose dental pain?

A
  1. History taking
  2. Visual examination
  3. Pulp sensibility testing in form of electrical pulp testing and other teeth
  4. Percussion testing
  5. Periodontal probing
  6. Palpation
  7. Crack detection
  8. Radiograph
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4
Q

What are common acute periodontal conditions?

A
  1. Periodontal abscess
  2. Necrotising periodontal disease like NG and NP
  3. Endo-perio lesions
  4. Pericoronitis
  5. Ulcerations/oral pathology which presents on gingiva
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5
Q

Why do we do the 6 step motion for periodontal pockets?

A

To define any fine points of bone loss around the tooth through systematic approach to probing.

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6
Q

What are the two types of abscesses around the tooth?

A

Periapical abcess (at the apicies of the tooth) or periodontal abscess (lateral to the root of the tooth)

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7
Q

What are the causes of acute tooth pain?

A
  1. Reversible pulpitis
  2. Irreversible pulpitis
  3. Endodontic abscess
  4. Cracked tooth
  5. Root fracture
  6. Occlusal related pain
  7. Dentinal hypersensativity
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8
Q

What happens in periodontal abscess?

A

Existing turtous pockets becomes isolated and favour formation of abscesses due to changes in composition of microflora and anaerobic bacteria virulence.

Host defences could make pocket lumen inefficient to drain increased suppuration (common in immunocomprimised).

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9
Q

What is the treatment for necrotising gingivitis?

A

1.Debridement under LA

2.Irrigate area with Betadine (povidone-iodine antiseptic)

3.Chlorhexidine mouth rinse twice daily for a week

4.Investigation of causative factors

  1. If systemic symptoms exist – amoxicillin 500mgs tds+ metronidozole (very important for your anaerobic bacteria) 400 mgs bs x 5-days. You need to debride prior to this as the antibiotic will not be able to penetrate the biofilm througb the crevicular fluid!
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10
Q

What is the treatment for periodontitis?

A

1.Debridement under LA and draining of the pus if patient can tolerate. If they can not tolerate, give LA, drain the pus and give antibiotics and recall in 3 days.

2.Irrigate area with Betadine (povidone-iodine antiseptic)

3.Chlorhexidine mouth rinse twice daily for a week

4.Investigation of causative factors

  1. If systemic symptoms exist – amoxicillin 500mgs tds+ metronidozole (very important for your anaerobic bacteria) 400 mgs bs x 5-days. You need to debride prior to this as the antibiotic will not be able to penetrate the biofilm througb the crevicular fluid!
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11
Q

When can periodontal abscesses occur?

A
  1. As acute exacerbation of an untreated periodontitis
  2. During periodontal therapy or immediately after scaling due to calculus being lodges in the pocket
  3. In refractory periodontitis (treatment resistant periodontitis)
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12
Q

What are predisposing factor to periodontal abscess?

A

1.Furcation areas because they are hard to clean.

2.Patients with diabetes – impaired cellular immunity, decreased leukocyte chemotaxis and bactericidal activity.

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13
Q

How come periodontal abscess occur in patient without periodontitis?

A

1.Impaction of foreign bodies like orthodontic elastics or popcorn

2.Local factors affecting tooth morphology

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14
Q

What is the presentation of periodontal abcess?

A

1.Ovoid elevation of the gingival along lateral aspect of the root

2.Oedematous, red gingiva with calculus usually present

3.Pus coming out of the gingival margin

4.Increased tooth mobility

5.Pain on plapation

6.Some systemic symptoms may be observed

  1. Pulp sensibility testing
  2. Radiographic analysis using a gutta percha
  3. Absence of caries
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15
Q

What is the most common bacteria in in gingivitis and periodontitis? What is type of bacteria are they?

A

Porphyromonas Gingivalis and Treponema denticola.

P. Gingivalis - gram-negaitve, anaerobic, rod shaped bacteria

T. Denticola - gram negative, obligate anaerobe (killed by oxygen), spirochaete bacteria.

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16
Q

What is the most common bacteria in acute periodontal conditions?

A

Aggregatibacter Actinomycetemcomitans.

AA is a gram negative, facultative anaerobe (can switch to oxygen thus can occur in none deep pockets)

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17
Q

What is the common bacteria associated with being a bridge between commensal (green) and pathogenic (red) bacteria? aka orange bacteria?

A

Fusobacterium Nucleatum.

F. Nucleatum is a Gram-negative, anaerobic bacterium.

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18
Q

What are some of the predisposing factor for necrotising gingivitis?

A
  1. Local factors – poor oral hygiene, plaque retentive factors (overhangs, crowded teeth and calculus), cigarette smoking
  2. Systemic factors – stress, poor nutrition (vitamin C deficiency), hormonal imbalance, systemic disease affecting immune response
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19
Q

What are the features of necrotising gingivtis?

A

1.Necrosis of interdental papillae and loss of gingival margin contour

2.Bleeding, halitosis and pain in the site

3.Punched-out and cratered depression/lesions in interdental sites covered with greay or grey-yellowish pseoudomembrane

4.Patient complains of metallic taste

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20
Q

What are the features of necrotising periodontitis?

A
  1. Sever pain
  2. Necrosis of gingival tissues, PDL and alveolar bone
  3. Create rlike defects
  4. Squestration of pieces of bone may emerge
  5. Buccal and alvrolar bone involvement
  6. Most common in patient with systemic immunocomprimising conditions such as HIV, sever malnutritiona and other.
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21
Q

What is the treatment of necrotising periodontitis?

A

Referral to specialist – IMMEDIATE. They will perfomr debridement and curettage of the area in association with high dose antibiotics.

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22
Q

What are the different types of boney defects? How do you determien them? Which one have the best treatment?

A

Types of boney defects

3 wall defect - bone only missing in specific site and surround on 3 different sides. This defect can be considered intrabony - best treated with regeneration.

2 wall defect - bone missing on multiple sites with only 2 sites surrounding the defect. This defect can be considered infrabony - can be treated with regeneration but not as successful

1 wall defect - bone missing on 3 different sites of the tooth and is only supported by 1 wall. This defect can be considered infrabony - regeneration is mostly unsuccessful.

Can be determined with step motion perio probing and radiographs.

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23
Q

What is pericoronitis?

A

It is a localised infection in gingival tissue and mucosa surrounding a partially erupted tooth. Patient complain of a sore tooth. Explain to patient that pain actually arises from infection and inflammation in the soft tissues surrounding the tooth and not the tooth itself.

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24
Q

What are the the symptoms of pericoronitis?

A

1.Difficulty swallowing

2.Limited opening

3.Enlarged lymph nodes

4.Fever

5.Facial cellulitis

6.Pain

7.Localised swelling

8.Pus discharge

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25
What is treatment for pericoronitis?
1.Debride area under operculum using monoject 2.Place patient on chlorexidine for a week 3.If major or systemic symptoms give amoxicillin in combination with metronidazole for one week 4.If it is recurring and tooth has a terrible position – extraction or operculectomy
26
What are some other periodontal lesion that may occur?
1.Herpetic gingival lesions 2.Dermatoses 3.Lichen planus
27
What to do if a patient has acute symptoms and you want to do debridement?
Give them anti-biotics and give them a few days and make them come back
28
When can periodontal disease cause endodontic problems?
If the periodontal pocket reaches the apex OR If there is a large laterla canal in the tooth OR When it reaches the furcation canal
29
When do you consider periodontal sugery?
After the initial phase of sub- and supra debridement for after about 8-10 weeks (to no breakdown the long junctional epithelium) if the pocket is above 6 mm with bleeding on probing. If it does not have BOP or is only 5mm, simple deplaque and debridement is sufficient.
30
When should you consider antibiotic for periodotal treatment in non-acute patient?
A young patient in stage 3 or 4 Grade B or C in adjunct to periodontal treatment.
31
What is considered to be Grade B periodontitis
1. Less then 2mm bone loss over 5 years 2. Bone loss to age ratio between 0.25 to 1.0 non inclusive radiographically (ie for a 50 year old patient the range is around 12.5-49.9 percent) 3. Heavy biofilm deposit and periodontal destruction are roughly equal thus following a pattern of more biofilm=more destruction 4. Smoking less then 10 cigarettes per day 5. HBA1c level of less then 7.0 in diabetic patient
32
What is considered to be Grade C periodontitis?
1. More than 2mm bone loss over 5 years 2. Bone loss to age ratio between 1.0 inclusive radiographically (ie for a 50 year old patient the range is around 50.0 percent and above) 3. Low biofilm deposit and large amount of periodontal destruction. Unequal pattern, resulting in small amount of biofilm but large amount of destruction. 4. Smoking more than 10 cigarettes per day 5. HBA1c level of more than 7.0 in diabetic patient
33
What is the purpose of periodontal surgical therapy?
The goal and purpose can only be considered in conjuction with complete periodontal treatment. SO first initial closed surgical root debridement and then open surgical root debridement. In Stage 1 and 2 perio, initial closed surgical root debridement is sufficient. In Stage 3 and 4, open surgical root debridement may be required.
34
How do you measure a pseudopocket?
1. Estimate the position of the CEJ 2. IDentify the gingival margin 3. Measure the sulcular depth 4. It is exceeds the distance between GM and CEJ than it can be considered a ture pocket 5. If it does not than it is a pseudopocket and the CEJ is covered by gingival
35
What is the reasons for carrying out periodontal surgery?
1.Improve access to root surfaces. 2.Removal of diseased tissues (periodontal pockets or granulation tissue). 3.Elimination of inflammation and pocket activity under LA. Halting the progression of the disease process. This may cause tissue shrinkage. 4. Enhancing of regeneration of periodontal tissue. 5.Removal of severely hyperplastic gingival tissues. This can be done with gingivectomy/gingivoplasty, flap surgery and minor osteoplasty. 6.Exploration of defects and removal of plaque retentive areas. 7.Restorative-crown lengthening. 8.Remove excess tissues after orthodontic extrusion.
36
What is important to understand about periodontal surgery?
Only small amount of attachment gain (through pocket healing) occurs after any form of conventional periodontal surgery at the base of the defect. Goal of treatment: a non bleeding pocket of 5 mm or less. This is a healthy pocket depth. Remember that presence of a pocket does not equate to active periodontitis but BOP and bone loss does.
37
What are some of the types of periodontal surgery?
1.Resective surgery – pocket depth reduction and removal of hyperplastic tissues 2.Access Flap Surgery 3.Periodontal regeneration 4.Mucogingival surgery 5.Implant surgery
38
What are the 4 different types of cementum?
1. Acellular Afibrillar Cementum (AAC): Protection of enamel surface (function not well understood). 2.Acellular Extrinsic Fiber Cementum (AEFC): Primary attachment for periodontal ligament fibers, crucial for tooth stability. 3.Cellular Mixed Stratified Cementum (CMSC): Adaptive and reparative functions, contributing to the periodontium's response to occlusal forces. Most important cementum in regeneration of the periodontal pocket. 4.Cellular Intrinsic Fiber Cementum (CIFC): Repair and regeneration of damaged cementum and periodontal ligament, maintaining root integrity.
39
What are the indication of resective gingival surgery?
1. Pocket depth reduction 2. Removal of hyperplastic tissue: idiopathic or induced by medication
40
What are the types of resective surgery?
1. Gingivectomy – removal of pocket epithelium, connective tissue and mucosal epithelium 2. Modified Widman flap – removal of pocket epithelium and connective tissue +/- osseous, leacing behind mucosal epithelium
41
What are indication and contraindication for gingivectomy?
Indications: Pocket depth reduction associated with horizontal bone loss and adequate width of keratinised mucosa and gingival hyperplasia Contraindications: Lack of keratinised mucosa and presence of vertical defects especially in aesthetic area
42
What instrument can be used for a gingevectomy?
A kirkland knife
43
What are the indications and contraindications for a modified widman flap surgery?
Indications: Pocket depth reduction associated with horizontal bone loss and adequate width of keratinised mucosa, gingival hyperplasia especially in aesthetic areas Contraindications: Lack of keratinised mucosa
44
What should you put on gigngiva after gignivectomy or modified Widman flap?
A periodontal dressing or COE pack for 24-48 hours
45
What is a gingivoplasty?
Reshaping of gingival tissues to improve gingival contours. Can be done with periodontal knife, scalpel, diamond stone or electrosurgery. Can be done after necrotising gingivitis.
46
What is the difference between post operative treament of gingivectomy and flap surgery?
1.Gingivectomy – sites can be probed 2-3 weeks after surgery 2.Flap surgery – need to wait 3-4 months
47
What can you do to improve bone levels after periodontal surgery?
You can add a boney material for regeneration. But remember, no probing for at least this much for each material: Perioglas – 6-12 months Bio-Oss – 12-18 months Emdogain – 2-3 years
48
What is the objective of periodontal regeneration?
To crease a physical barrier that permits the growth of bone and PDL cells rather than epithelial or gingival connective tissue into the periodontal defect. This process takes weeks to months thus probing in GBR should not be performed.
49
What are some of the options of regeneration that can occur during periodontal treatment?
1. Gingival connective tissue growth resulting in root resoprtion. This is not ideal. 2. Epithelium growth and formation of long junctional epithelium. This occurs in closed and open debridment 3. Alveolar bone prolifiration resulting in ankylosis. This is not ideal. 4. PDL and bone regeneration resulting in strong tisseu attachement - this is the goal of GBR
50
What is repair?
Healing mainly by resorption and ankylosis example of which is reimplantation of denuded root into bony socket
51
What is rettachment?
It is the reunion of existing collagen fibres after tooth avulsion
52
What is new attachment?
Formation of new collagen fibres which are embedded in newly formed cementum. This is the ideal process.
53
How does it take to regenerate periodontal tissues like alveolar bone, periodontal ligament and cementum?
3-6 months
54
What is the key of periodontal regeneration?
Formation of new cementum and bone
55
What are the consideration for regeneration?
1. Defect size and topography. 3 wall defects are the most stable for regeneration. 2. Defect cause 3. Technical difficulties. Access or patient factors. 4. Predictability. Always tell the patient the success rate. Grade 3 mobility, probably not the best idea.
56
What are are the indication for surgical corrections of gingival recession?
1.Increases in recession 2.Dentinal hypersensitivity 3.Aesthetic concerns of the patient
57
What are the most commonly used material in periodontal regenerations?
1.Bone grafts 2.Membranes 3.Growth factors
58
What does periodontal regeneration involve?
Regeneration involved the placmenet of a physical/biological barrier to ensure that the root surface becomes repopulated with cementum, PDL and bone. The placment of the physical/barrier permits the growth of bone and PDL cells rather than epithelial or gingival connective tissue into the periodontal defect.
59
What are the different types of bone grafts?
1.Autogenous – harvested from the patient 2.Autollogus – harvested from same species I.e. dead man bone 3.Alloplastic – bioactive glasses like Perioglass (don't really use anymore) 4.Xenografts – harvested from different species I.e. Bio-Oss which is bovine bone (need to inform the patient)
60
What are some of the membranes that can be used in regenerative surgery?
1.Xenografts – from different species like Bio-gide (porcine, little pig) 2.Synthetic – Polyglyclolic like Vicryl sutures
61
What are some of the growth factors that can be used for regenerative surgery?
1.Autogenous – platelet rich plasma 2.Xenograft – enamel matrix protein like Emdogain (very common) (requires prior etching) 3.Synthetic
62
What is the advantage of Bio-Oss and Emdogain comparing to Perioglas?
Both Bio-Oss and Emdogain results in formation of cementum
63
What is GTR?
Guided tissue regeneration refers to fixing the defects assosciated with loss of alveolar bone around teeth.
64
What is guided bone regeneration?
GBR involves the placement of a physical/biological barrier to ensure that the hard tissue deficiency becomes repopulated with bone. This exclusivley relates to the augmentation of resorped ridge.
65
What are the different types of alveolar bone defects?
Class 1 – Bucco-lingual deficiency Class 2 – vertical deficiency Class 3 – combination
66
What is the problem with black triangles?
1. Aesthetics 2. Food trapping 3. Trouble with pronouncing S sounds 4. Saliva extrusion
67
What is osteoinduction?
Recruitment of immature cells and stimulation of these cells to develop into pre-osteoblast e.g. bone healing situations
68
What is osteoconduction?
It permits bone growth on surface or pores. This occurs in bone implants.
69
What kind of membranes can you use in GBR?
Always use membrane in GBR. Non-resorbable reinforced or non-reinforced. Resorbable. Non-resorbable membrane require additional bone cover or extra material unlike reinforce
70
What is mucogingival surgery?
It is surgery usually performed to correct soft and hard tissue defects or deficiencies using soft tissue repositioning or grafting
71
What is crown lengthening?
Crown lengthening is a surgical procedure performed to expose a greater height of tooth structure in order to properly restore tooth proshtetically.
72
What are the indications of crown lengthening?
1. Excessive gingival display 2. Sever wear secondary to bruxism 3. Exposure of sound tooth structure for proper restorative therapy. This includes, rem pros, fix pros and endo.
73
What are the contraindications to crown lenghtening?
1.Teeth with extensive periodontal involvement 2.Risk of sever furcation exposure 3. Effect on aesthetics 4.Extensive caries in furcation areas or poor endodontic status of the tooth 5.Apical extent of fracture 6. Unfavorable furcation location
74
What are the steps for clinical examination for crown lengthening?
1.Check periodontal heatlh 2.Gingival width and thickness 3.Thickness of radicular bone 4.Probing sulcular depth 5.Aesthetic evaluation 6.Radiographic exam
75
What do we do for radiographic exam for crown lengthening?
1. Interdental crestal margin 2. Distance from contact point to interdental bone 3. Root length 4. Root morphology 5. Furcation location or root trunk length 6. Interdental width 7. Apical extend of caries, prior restorations, fractures or root perforations
76
What are the steps for crown lengthening?
1.Soft tissue resection if there is an overgrowth of tissues 2.Soft and hard tissue resection if bone level is incorrect height
77
What is the biological width?
From top of the junctional epithelium to the height of the bone which equal about 2mm which you need to maintain when doing crown lengthening planning to account.
78
What are the Miller Classification of gingival recession?
Class I – recession that does not extend to the mucogingival junction with no periodontal bone loss Class II – recession that extends to or beyond mucogingival junction with no bone loss Class III - recession that extend to or beyond mucogingival junction with loss of bone in the interdental area. Not good prognosis Class IV - recession that extend to or beyond mucogingival junction with loss of bone in the interdental area with exposure of interproximal root surface. Very unpredictable prognosis.
79
What kind of grafts can you do for recession?
Sub-epithelial connective tissue graft (very good results with this technique) Free gingival graft (unaesthetic as it creates white patches) taken from the palate Advanced flap: Coronally repositioned flap Rotational flap: Lateral sliding flap (creates recession in another tooth)
80
What are the indication for surgical correct of recession?
1. Increase in recession 2. Dentinal hypersensitivity 3. Aesthetic concerns of the patient 4. Persistent inflammation 5. Age
81
What are the two different types of gingival phenotype?
Type 1 - thick bone phenotype Type 2 - thin buccal bone phenotype

BDS 4 (21 decks)

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