Periodontics Flashcards
How does periodontal abscess form?
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
What are the most common causes of acute conditions of the mouth?
76% tooth related
18% periodontal related
6% other
What is the standard steps to diagnose dental pain?
- History taking
- Visual examination
- Pulp sensibility testing in form of electrical pulp testing and other teeth
- Percussion testing
- Periodontal probing
- Palpation
- Crack detection
- Radiograph
What are common acute periodontal conditions?
- Periodontal abscess
- Necrotising periodontal disease like NG and NP
- Endo-perio lesions
- Pericoronitis
- Ulcerations/oral pathology which presents on gingiva
Why do we do the 6 step motion for periodontal pockets?
To define any fine points of bone loss around the tooth through systematic approach to probing.
What are the two types of abscesses around the tooth?
Periapical abcess (at the apicies of the tooth) or periodontal abscess (lateral to the root of the tooth)
What are the causes of acute tooth pain?
- Reversible pulpitis
- Irreversible pulpitis
- Endodontic abscess
- Cracked tooth
- Root fracture
- Occlusal related pain
- Dentinal hypersensativity
What happens in periodontal abscess?
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).
What is the treatment for necrotising gingivitis?
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
- 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!
What is the treatment for periodontitis?
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
- 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!
When can periodontal abscesses occur?
- As acute exacerbation of an untreated periodontitis
- During periodontal therapy or immediately after scaling due to calculus being lodges in the pocket
- In refractory periodontitis (treatment resistant periodontitis)
What are predisposing factor to periodontal abscess?
1.Furcation areas because they are hard to clean.
2.Patients with diabetes – impaired cellular immunity, decreased leukocyte chemotaxis and bactericidal activity.
How come periodontal abscess occur in patient without periodontitis?
1.Impaction of foreign bodies like orthodontic elastics or popcorn
2.Local factors affecting tooth morphology
What is the presentation of periodontal abcess?
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
- Pulp sensibility testing
- Radiographic analysis using a gutta percha
- Absence of caries
What is the most common bacteria in in gingivitis and periodontitis? What is type of bacteria are they?
Porphyromonas Gingivalis and Treponema denticola.
P. Gingivalis - gram-negaitve, anaerobic, rod shaped bacteria
T. Denticola - gram negative, obligate anaerobe (killed by oxygen), spirochaete bacteria.
What is the most common bacteria in acute periodontal conditions?
Aggregatibacter Actinomycetemcomitans.
AA is a gram negative, facultative anaerobe (can switch to oxygen thus can occur in none deep pockets)
What is the common bacteria associated with being a bridge between commensal (green) and pathogenic (red) bacteria? aka orange bacteria?
Fusobacterium Nucleatum.
F. Nucleatum is a Gram-negative, anaerobic bacterium.
What are some of the predisposing factor for necrotising gingivitis?
- Local factors – poor oral hygiene, plaque retentive factors (overhangs, crowded teeth and calculus), cigarette smoking
- Systemic factors – stress, poor nutrition (vitamin C deficiency), hormonal imbalance, systemic disease affecting immune response
What are the features of necrotising gingivtis?
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
What are the features of necrotising periodontitis?
- Sever pain
- Necrosis of gingival tissues, PDL and alveolar bone
- Create rlike defects
- Squestration of pieces of bone may emerge
- Buccal and alvrolar bone involvement
- Most common in patient with systemic immunocomprimising conditions such as HIV, sever malnutritiona and other.
What is the treatment of necrotising periodontitis?
Referral to specialist – IMMEDIATE. They will perfomr debridement and curettage of the area in association with high dose antibiotics.
What are the different types of boney defects? How do you determien them? Which one have the best treatment?
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.
What is pericoronitis?
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.
What are the the symptoms of pericoronitis?
1.Difficulty swallowing
2.Limited opening
3.Enlarged lymph nodes
4.Fever
5.Facial cellulitis
6.Pain
7.Localised swelling
8.Pus discharge
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
What are some other periodontal lesion that may occur?
1.Herpetic gingival lesions
2.Dermatoses
3.Lichen planus
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
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
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.
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.
What is considered to be Grade B periodontitis
- Less then 2mm bone loss over 5 years
- 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)
- Heavy biofilm deposit and periodontal destruction are roughly equal thus following a pattern of more biofilm=more destruction
- Smoking less then 10 cigarettes per day
- HBA1c level of less then 7.0 in diabetic patient
What is considered to be Grade C periodontitis?
- More than 2mm bone loss over 5 years
- 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)
- Low biofilm deposit and large amount of periodontal destruction. Unequal pattern, resulting in small amount of biofilm but large amount of destruction.
- Smoking more than 10 cigarettes per day
- HBA1c level of more than 7.0 in diabetic patient
What instrument can be used for a gingevectomy?
A kirkland knife
What are some of the options of regeneration that can occur during periodontal treatment?
- Gingival connective tissue growth resulting in root resoprtion. This is not ideal.
- Epithelium growth and formation of long junctional epithelium. This occurs in closed and open debridment
- Alveolar bone prolifiration resulting in ankylosis. This is not ideal.
- PDL and bone regeneration resulting in strong tisseu attachement - this is the goal of GBR
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.
