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ICP - 4th year > Periodontics > Flashcards

Periodontics Flashcards

1
Q

What are the categories in the new classification of periodontal and peri-implant diseases and conditions 2017?

A

Periodontal diseases and conditions:
- Periodontal health, gingival diseases and conditions
- Periodontitis
- Other conditions affecting the periodontium
Peri-implant diseases and conditions.

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2
Q

What are the conditions within periodontal health, gingival diseases and conditions?

A
  • Periodontal health and gingival health
  • Gingivitis: dental biofilm-induced
  • Gingival diseases: non dental biofilm induced
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3
Q

What is periodontal health and gingival health?

A
  • Clinical gingival health on an intact periodontium
  • Clinical gingival health on a reduced periodontium
    • Stable periodontitis patient
    • Non-periodontitis patient
      Periodontal and gingival health is defined as absence of clinically detectable inflammation. There is a biological level of immune surveillance consistent with clinical gingival health and homeostasis. Clinical gingival health can occur on an intact periodontium or on a reduced periodontium. Physiological bone levels range from 1-3mm apical to CEJ. Clinical health can be restored following treatment of gingivitis and periodontitis.
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4
Q

What is gingivitis - dental biofilm induced?

A
  • Associated with dental biofilm alone
  • Mediated by systemic or local risk factors
  • Drug-influenced gingival enlargement
    Gingivitis dental biofilm induced is an inflammatory lesion resulting from interactions between plaque and the host’s immune inflammatory response. There will be local predisposing factors e.g. retentive factor and systemic modifying factors e.g. smoking can affect extent, severity and progression. It is confined to the gingiva and does not extend beyond the mucogingival junction. It is reversible by reducing levels of plaque. If there are 10% or more bleeding sites this is gingivitis.
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5
Q

What are gingival diseases - non-dental biofilm induced?

A
  • Genetic/developmental disorders
  • Specific infections
  • Inflammatory and immune conditions
  • Reactive processes
  • Neoplasms
  • Endocrine, nutritional and metabolic diseases
  • Traumatic lesions
  • Gingival pigmentation
    Gingival diseases non-biofilm induced is a variety of conditions not caused by plaque and usually do not resolve following plaque removal. If inflammation extends beyond the mucogingival junction it is unlikely to be plaque induced. It may be a manifestation of a systemic condition or may be localised to the oral cavity. It may be genetic/developmental, specific infections, inflammatory and immune conditions, reactive processes, neoplasms, endocrine, nutritional and metabolic disorders, traumatic lesions or gingival pigmentation. Examples are thermal trauma and herpes simplex.
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6
Q

What are the conditions within periodontitis?

A
  • Necrotising periodontal diseases
  • Periodontitis as manifestation of systemic diseases
  • Periodontitis
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7
Q

What are the necrotising periodontal diseases?

A
  • Necrotising gingivitis
  • Necrotising periodontitis
  • Necrotising stomatitis
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8
Q

What is periodontitis as manifestation of systemic diseases?

A

Classification of these conditions should be based on the primary systemic disease according to the International Statistical Classification of Diseases and Related Health Problems (ICD) CODES.

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9
Q

How is periodontitis classified?

A

It is staged based on severity and complexity of management. It is the percentage of interproximal bone loss in relation to root length.
- Stage I is initial/mild periodontitis
- Stage 2 is moderate periodontitis
- Stage III is severe periodontitis with potential for additional tooth loss
- Stage IV is very severe periodontitis with potential for loss of the dentition
It is also graded using evidence or risk of rapid progression, anticipated treatment response.
- Grade A - slow rate of progression
- Grade B - moderate rate of progression
- Grade C - rapid rate of progression
The extent and distribution also needs to be commented on - generalised/localised, molar/incisor distribution. Localised is less than 30% of the teeth and generalised is more than 30% of the teeth.

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10
Q

What are the other conditions affecting the periodontium?

A
  • Systemic diseases or conditions affecting the periodontal supporting tissues
  • Other periodontal conditions
  • Mucogingival deformities and conditions around teeth
  • Traumatic occlusal forces
  • Prostheses and tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis
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11
Q

What are systemic diseases or conditions affecting the periodontal supporting tissues?

A

These are systemic disorders that have a major impact on the loss of periodontal tissues by influencing periodontal inflammation:
- Genetic disorders
- Acquired immunodeficiency diseases
- Inflammatory diseases
Or they may be systemic diseases that influence the pathogenesis of periodontal diseases. Systemic disorders that can result in loss of periodontal tissues independent of periodontitis – neoplasms, other disorders that may affect the periodontal tissues.

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12
Q

Give two examples of genetic disorders which have an impact on loss of periodontal tissues?

A

Ehlers danlos syndrome:
- Hyperflexibility of joints
- Increased bleeding and bruising
- Hyperextensible skin
- Underlying molecular abnormality of collagen
Papillon-Lefevre:
- Palmoplantar hyperkeratosis
- Affects primary and secondary dentition
- Normal dental development until hyperkeratosis of palms and soles appears
- Mechanism poorly understood

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13
Q

What are the other periodontal conditions?

A
  • Periodontal abscesses

- Endodontic-periodontal lesions

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14
Q

What are the mucogingival deformities and conditions around teeth?

A
  • Gingival phenotype
  • Gingival/soft tissue recession
  • Lack of gingiva
  • Decreased vestibular depth
  • Aberrant frenum/muscle position
  • Gingival excess
  • Abnormal colour
  • Condition of the exposed root surface
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15
Q

What are traumatic occlusal forces?

A
  • Primary occlusal trauma
  • Secondary occlusal trauma
  • Orthodontic forces
    It is any occlusal force that results in injury to teeth e.g. excessive wear or fracture. There is no evidence from human studies that traumatic occlusal forces lead to periodontal attachment loss, NCCL or gingival recession. They lead to adaptive mobility in teeth with normal support and to progressive mobility in teeth with reduced support.
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16
Q

What are prosthesis and tooth related factors?

A
  • Localised tooth-related factors
  • Localised dental prostheses-related factors
    Infringement of restorative margins within the supracrestal connective tissue attachment is associated with inflammation and/or loss of periodontal tissue. It is not clear if it is due to plaque, trauma, toxicity of dental materials or a combination. There are tooth related anatomical factors e.g. enamel pearls are related to plaque induced gingival inflammation and loss of periodontal tissues.
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17
Q

What are the peri-implant diseases and conditions?

A
  • Peri-implant health
  • Peri-implant mucositis
  • Peri-implantitis
  • Peri-implant soft and hard tissue deficiencies
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18
Q

What is peri-implant health?

A

Clinically peri-implant health is characterised by an absence of erythema, bleeding on probing, swelling and suppuration. There is no increase in probing depth compared to previous examinations. There is absence of bone loss beyond crestal bone level changes resulting from initial bone remodelling. Peri-implant health can exist around implants with normal or reduced bone support. Baseline radiographic measurements following completion of implant support prostheses recommended.

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19
Q

What is peri-implant mucositis?

A

It is characterised by bleeding on gentle probing, erythema, swelling and/or suppuration may be present. Increased pocket depth is often seen due to swelling or decrease in probing resistance. There is an absence of bone loss beyond crestal bone level changes resulting from initial bone remodelling. There is strong evidence that peri-implant mucositis is caused by plaque biofilm. There is very limited evidence for non-plaque induced peri-implant mucositis. Peri-implant mucositis can be reversed with measures aimed at plaque biofilm elimination.

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20
Q

What is peri-implantitis?

A

It is a plaque associated pathological condition occurring in tissues around dental implants, characterised by inflammation in the peri-implant mucosa and subsequent progressive loss of supporting bone. Sites show clinical signs of inflammation, bleeding on probing and/or suppuration, increased pocket depths and/or recession of the mucosal margin in addition to radiographic bone loss. Peri-implant mucositis is assumed to precede peri-implantitis. It is associated with poor plaque control and with patients with a history of severe periodontitis. The onset may occur early following implant placement. In the absence of treatment, it progresses in a non-linear and accelerating pattern. Keratinised mucosa may have advantages regarding patient comfort and ease of plaque removal.

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21
Q

In the absence of previous data what is the diagnosis of peri-implantitis based on?

A
  • Presence of bleeding and or suppuration on gentle probing
  • Probing depths of 6mm and above
  • Bone levels greater than or equal to 3mm apical of the most coronal portion of the intraosseous part of the implant
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22
Q

What are peri-implant soft and hard tissue deficiencies?

A

Following tooth loss healing leads to diminshed dimensions of the alveolar process/ridge that result in bone hard and soft tissue deficiencies. There are large ridge deficiencies where there is severe loss of periodontal support, extraction trauma, poor tooth position, endodontic infections, root fractures, thin buccal bone plates. Other factors affecting the ridge include medication, systemic diseases reducing the amount of naturally formed bone, tooth agenesis, pressure from prostheses.

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23
Q

What causes peri-implant soft tissue deficiencies?

A

Risk factors associated with recession of the peri-implant mucosa:
- Malpositioning of implants
- Lack of buccal bone
- Thin soft tissue
- Lack of keratinised tissue
- Surgical trauma
Papilla height between implants and teeth is affected by the level of the periodontal tissues on the teeth adjacent to the implants. The height of the papilla between implants is determined by the bone crest between the implants. Results are equivocal whether the buccal bone plate is necessary for supporting the buccal soft tissue of the implant in the long term.

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24
Q

What is included in the diagnosis statement of periodontal disease?

A
  • Disease extent - localised/generalised/molar-incisor
  • Periodontitis
  • Stage - I/II/III/IV
  • Grade - A/B/C
  • Stability - currently stable/in remission/unstable
  • Risk factors - smoking/diabetes
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25
Q

Clinically how do you stage periodontitis?

A

You use the worst value at any site in the mouth where it is due to periodontitis. If the patient has lost teeth due to bone loss this is apical third and severe IV. Stage I is <15% or <2mm. Stage II is coronal third of root. Stage III is mid third of root. Stage IV is apical third of root.

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26
Q

Clinically how do you grade periodontitis?

A

Grading is the percentage bone loss in relation to the patients age so the speed of progression. It can be slow A, moderate B or severe C. The percentage bone loss/age. Grade A is <0.5, B is 0.5-1 and grade C is >1.

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27
Q

How do you assign a current disease status to periodontitis?

A
  • Currently stable - BOP less than 10%, PPD less than or equal to 4mm, no BOP at 4mm sites
  • Currently in remission - BOP greater than or equal to 10%, PPD less than or equal to 4mm, no BOP at 4mm sites
  • Currently unstable - PPD greater than or equal to 5mm or
  • PPD less than or equal to 4mm and BOP
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28
Q

What is root surface debridement?

A

Root surface debridement is the removal of deposits (plaque, calculus) and a thin layer of cementum bound endotoxin from the root surface. It can use ultrasonic instrumentation, hand instruments and irrigation with saline.

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29
Q

What are the limitations of closed RSD? (what does RSD help with)

A
  • Progressive and aggressive breakdown
  • Persistent acute episodes e.g. periodontal abscess
  • Deep complex bone defects – difficulties with adequate debridement
  • Severe hyperplasia or tissue deformity
  • Pathology e.g. epulides
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30
Q

What are the aims of periodontal surgery?

A
  • Gain access to root surface for effective debridement
  • Visualisation of bone defects
  • Improvement in tissue contour
  • Reduction in pocketing (probeable pocket depth)
  • Removal of chronically inflamed tissue
  • Encourage regeneration of lost periodontal support
  • Removal of hyperplastic gingival tissue
  • Crown lengthening
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31
Q

What are the indications for each type of periodontal surgery?

A

Gingivectomy:
- Hyperplasia
- False pockets (not due to loss of attachment, due to soft tissue growth coronally)
- Adequate attached gingiva
Replaced flap (raise flap, clean and replace where it was originally):
- Deep persistent bleeding (suppurating) pockets
Apically repositioned flap (raise flap, clean and suture flap more apically)
- Pocket elimination
- Crown lengthening
- Unsuccessful gingivally encroaching restorations
If you have adequate keratinised tissue you can cut off the excess at the CEJ. If not you can reposition apically.

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32
Q

What are the considerations before periodontal surgery?

A
  • Has non-surgical therapy been undertaken and reviewed at an appropriate interval?
  • Is patient suitable – medically, emotionally. (same complications as with oral surgery e.g. excessive bleeding, bisphosphonates)
  • Do they understand procedure (consent, limitations, complications, aesthetic effect) risks: recession, post-operative pain, bleeding, sensitivity
  • Does pathology warrant surgery
  • Is oral hygiene adequate? – if not surgery can do more damage
  • Has restorative strategy been considered?
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33
Q

What are the surgical techniques for periodontal surgery?

A
  • Excisional e.g. gingivectomy (cut tissue and remove it)
  • Flap - replacement (reattachment) e.g. replacement flap, original and modified Widman flap, replace in same position
  • Flap - repositional e.g. lateral, apical, coronal (suture flap in different position)
  • Mucogingival procedures e.g. grafts (recession, lost interdental papilla)
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34
Q

What are the stages of gingivectomy?

A
  • Local anaesthetic
  • Pocket depth markings – probe into sulcus and measure depth of pocket, pierce from outside the depth of pocket to create bleeding point
  • Incisions – cut tissue above where markings are to give pockets 1-2mm, do a bevel (going upwards) so as not to leave thick tissue (external incision bevel)
  • Removal of excised tissue
  • Scaling – may see calculus that was hidden under tissue
  • haemostasis
  • Dressing
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35
Q

What are the stages of flap procedures?

A
  • Local anaesthetic
  • Incisions (use of relieving incisions) incision is internal bevel or sulcular. bevel the other way around as we want to preserve tissue in this case but just remove pockets OR we can go sulcular with a crevicular incision, this is when we want to preserve as much tissue as possible. With resective surgery expect some recession (bevel method)
  • Raise flap
  • Curettage
  • RSD
  • Irrigation
  • Sutures (pack for ARF)
    If aesthetics are important then do crevicular but if not do internal bevel incision to completely remove pocket epithelium.
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36
Q

What are the two types of surgery?

A

Resective and regenerative.

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37
Q

Once the roots have been accessed with surgery what can be done?

A
  • Root surface debridement and granulation tissue removal
  • Root surface treatment and application of therapeutic agents if appropriate e.g. bone morphogenic proteins - emdogain
  • Odontoplasty – removal of enamel to improve access for plaque control for furcations
  • Root division/amputation – if only one root removed and crown remains this is root amputation, if you section the crown and roots into two this is root separation, if one half is removed this is hemisection
  • Osteoplasty – if you thin the bone that is covering the root (bone is causing prominent gingival appearance)
  • Ostectomy – removing bone
  • Placement of GTR (place membrane so soft tissue grows where it is meant to and not into bone defect where bone has been removed)/graft materials
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38
Q

What are the options for regenerative surgery?

A

Regeneration will not occur with poor OH or smoking. After raising a flap you can either allow blood clot to form and true bone to form or pack bone graft in. With blood clot you need optimum conditions for true bone to form.

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39
Q

What are the stages of flaps?

A
  • Raising flaps
  • Relieving incision
  • Replacement of flap
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40
Q

What are the different suture techniques?

A
  • Interrupted
  • Vertical mattress (external or internal) external will press tissue down and internal raises it up
  • Horizontal mattress - good for extraction sockets
  • Sling - used if palatal tissue is fixed and you want to raise buccal tissue coronally
  • Continuous - good for multiple sites, danger is if one end is cut the whole thing will come up as it is all connected
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41
Q

What is a modified Widman flap?

A

(Ramfjord and Nissle 1974):
- Incision 1mm buccally from gingival margin with angle almost parallel to tooth long axis
- This preserves tissue and eliminates pocket epithelium and you get better healing -
preserving interdental papillae - minimal recession
- Flap raised exposing only a few mm of bone
- Intracrevicular/horizontal incisions to release pocket lining
- Careful curettage of bone
- Debridement of root surfaces
- Replace flaps to cover interdental bone and suture

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42
Q

What is the post-operative care for periodontal surgery?

A
  • Appropriate analgesia – paracetamol/ibuprofen at beginning
  • Suture removal 7-10 days
  • CHX 0.2% mouthrinse twice a day for the first 2-3 weeks. Patient not to perform mechanical cleaning and not to chew in the treated area during this period
  • Use soft toothbrush and toothpicks for interdental areas after the above period
  • 2 weekly dental visits to monitor plaque control
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43
Q

What are the signs of success for flap surgery?

A
  • Decrease in inflammation
  • Less bleeding on probing
  • Decrease in pocket depth
  • Increase in attachment
  • Eliminate pus
  • No increase in mobility
  • Improvement of tissue contour
  • Stabilisation of bone levels
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44
Q

What is the evidence for periodontal surgery?

A
  • Michigan group (Ramfjord et al 1987) and Gothenburg group (Lindhe et al 1984) looked at outcome of surgical and non-surgical perio treatment
  • All surgical procedures resulted in a decrease in PD with a greater reduction at initially deeper sites
  • Surgical therapy created greater short term reduction of PD than non-surgically performed RSD but long term (5-8 years) results showed variability in outcomes
  • In sites with shallow initial probing depth both short and long term data shows that surgery creates a greater loss of clinical attachment than non-surgical treatment whereas in sites with initially deep >7mm pockets a greater gain of clinical attachment is generally obtained with surgery
  • In molar sites the outcome of surgical approach was better than non-surgical treatment
  • Surgery without osseous recontouring results in equal or greater clinical attachment gain than surgery with osseous recontouring
  • Deliberate excision of the pocket epithelium and soft tissue lesion by curettage did not improve the healing result
  • Patients with good post op plaque control maintained clinical attachment levels and PD reductions after surgery more consistently than patients with poor OH
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45
Q

What are the indications for an apically positioned flap?

A
  • Pocket elimination

- Crown lengthening

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46
Q

What are the disadvantages of apically positioned flaps?

A
  • Roots exposed - sensitivity and increased risk of caries

- Poor aesthetics - recession

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47
Q

What are the stages of apically repositioned flaps?

A
  • Incisions
  • Raising flap, curettage and RSD
  • Suturing and securing the flap apically
48
Q

In an apically repositioned flap what incisions are made?

A
  • Labially: inverse bevel incisions 1 or 2mm depending on amount of keratinised tissue, the more you have the more you can remove
  • Palatally: gingivectomy
  • Relieving incisions may be necessary so you can slide the flap down
49
Q

In an apically repositioned flap what is done after incisions?

A
  • Raise a flap labially beyond the mucogingival junction
  • Curettage of pocket lining
  • Root surface cleaning
  • Reposition apically – raise flap beyond MGJ and move flap in apical direction
50
Q

In an apically repositioned flap what sutures are done?

A
  • Sling sutures tied labially
  • Pack to cover the palatal gingivectomy and secure the flap apically
  • Post operative care and healing: pack and sutures for 1 week, healing with pocket elimination, root surface exposed
51
Q

In crown lengthening is bone removed?

A

In crown lengthening you will need to remove some bone, however in periodontal disease bone will already be done so this doesn’t need to happen.

52
Q

What is frenectomy?

A

This is occasionally indicated in patients with a prominent labial frenum attached to interdental papilla – non-surgical vs surgical management. Outline of procedure:

  • Incision around frenum
  • Lip incision and undermining of edges to facilitate suturing
  • Lip wound sutured
  • Coe-pack dressing over gingival wound
53
Q

What groups are periodontal plastic procedures divided into?

A
  • Gingival augmentation
  • Root coverage procedure
  • Dental papilla reconstruction
54
Q

What is gingival augmentation with free gingival graft?

A

Gingival augmentation with free gingival graft is for when you have inadequate band of keratinised tissue around teeth so you want to increase width of keratinised tissue. You lower the band of loose tissues and suture them at the level of the sulcus. Keratinised tissue is taken from the palate. The palatal wound is covered by coe pack and acrylic palate (donor site). The recipient site has the free gingival graft sutured in place. Therefore after healing you will have a thicker band of keratinised tissue. This will not manage the recession, this is done in root coverage procedure.

55
Q

What is a root coverage procedure?

A

Root coverage procedure is when you raise a flap and reposition to cover the root surface to treat recession.

56
Q

What are the indications for surgical treatment of localised gingival recession?

A
  • Continued inflammation
  • Progressive breakdown
  • Aesthetics
  • Frenal pull
  • Pocketing beyond MGJ
  • Some situations when advanced restorative procedures are planned
57
Q

What techniques can be used for localised gingival recession?

A
  • Laterally repositioned flap – if adjacent tooth has lots of keratinised tissue
  • Coronally repositioned flap – adequate band of keratinised tissue below recession
  • Free gingival graft followed by coronally repositioned flap
  • Guided tissue regeneration
  • Connective tissue graft
58
Q

What is guided tissue regeneration?

A

Placing membranes under the flap to encourage soft tissue healing. If using titanium membranes and others you will need another surgery to remove the membranes. There are resorbable membranes so you don’t need another surgery.

59
Q

What is a connective tissue graft?

A

Placing connective tissue under flap (take from palate) to make it a bit thicker and it will gain more keratinised tissue so less likely to relapse. This is used if there is little keratinised tissue. If this was coronally advanced without connective tissue it would be prone to recession again. A flap is raised in the palate and connective tissue with an epithelial border is dissected out. The wound is closed using sutures and the graft transferred to the recipient site. An envelope technique can be used which doesn’t need relieving incisions.

60
Q

What is involved in a pre-operative assessment prior to surgical treatment for recession?

A
  • Is surgical treatment warranted?
  • Is recession stable following monitoring?
  • Medical and social assessment
  • Tooth vitality
  • Radiographic examination
  • Informed consent and clinical records, chance of success is 80-85%, if taking tissue from palate warn patient about wound in palate
61
Q

What is Miller’s classification of recession defects?

A
  • Class I is recession that doesn’t pass the mucogingival junction and there is no loss of interdental tissue/bone - the papilla are intact
  • Class II is a defect/recession where you still have interdental tissue intact but recession reaches MGJ, responds to root coverage procedures like class I
  • Class III is recession and loss of interdental papilla/bone above the MGJ
  • Class IV is recession and loss of papilla at or below MGJ
    Look at pic in notes.
62
Q

What is the evidence for surgery for recession?

A
  • All root coverage procedures can provide significant reduction in recession depth and clinical attachment level gain for Miller class I and II recession type defects (Chambrone and Tatakis 2015)
  • There is a large body of evidence to support the use of CAF procedures alone or with CT grafts or EMD for periodontal plastic surgery (Cairo et al 2014)
  • Subepithelial CT graft based procedures provide the best outcomes as they result in superior percentages of mean and complete root coverage and significant increase of the width of keratinised tissue (Chambrone and Tatakis 2015)
  • Clinical guidelines suggest the best way to surgically treat Miller class I and II single gingival recession defects is using the CAF procedure in combination with CT grafts (Pini-prato et al 2014)
63
Q

What is the junctional epithelium?

A

It is attached directly to the tooth and is below the sulcular epithelium. It has a protective role against periodontal disease.

64
Q

What is regeneration?

A

The goal of periodontal therapy is to stop the progression of disease, involves formation of a long junctional epithelium. Regeneration is a more idealistic goal to restore the structure and function of lost periodontal tissues (root cementum, PDL, alveolar bone, connective tissue attachment). Regeneration is used only in vertical defects. It is used for intrabony defects.

65
Q

What are the regenerative techniques?

A
  • Bone substitutes
  • Guided tissue regeneration
  • Growth factors and biologicals
  • Grafting and combined therapies
66
Q

What are the uses of bone substitutes?

A
  • Bone forming cells – osteogenesis
  • Serve as scaffold – osteoconduction
  • Contains bone inducing substances – osteoinduction
67
Q

What are the bone substitute types?

A
  • Bone autogenous (own bone)
  • Bone allografts (donor, human bone)
  • Bone xenograft (bio-oss) (animal bone)
  • Bone alloplastic materials – hydroxyapatite bioactive glasses (synthetic)
68
Q

What is bio-oss?

A
  • Clot stabilisation is facilitated by Bio-oss interconnecting macro and micropores
  • There is revascularisation, migration of osteoblasts and in-growth of woven bone which is enhanced by bio-oss scaffolding
  • Lamellar bone and bio-oss are successfully integrated after approximately six months. Bio-oss is included in the natural physiologic remodelling process
69
Q

What is bio-glass technology?

A
  • Under a microscope a bioglass particle would look very much like a piece of smooth sand. The size of these particles is about that of a grain of ordinary table salt
  • Upon introduction of bioglass into a defect site, an immediate chemical reaction starts with the body fluids which modifies the surface of the bioglass making it more attractive to organic molecules
  • The modified surface of the bioglass particles immediately begins to attract the body’s own building blocks for tissue regeneration – proteins which are already present in body fluids
  • In a continuing chemical reaction occurring over the next few days a framework of hydroxyl-carbonate apatite crystals forms on the surface of the bioglass particles which traps and bonds these building blocks to create a virtual nursery for new tissue growth
70
Q

What is guided tissue regeneration?

A
  • It is used for the prevention of epithelial migration along the cemental wall of the pocket and maintaining space for clot stabilisation
  • It involves placing a membrane barrier to cover the bone and PDL thus temporarily separating them from the gingival epithelium and CT
  • This prevents epithelial migration and favours repopulation of area by cells from PL and bone
  • Epithelial tissues develop faster than connective tissues
  • Membrane forms a barrier which prevents the down growth of the epithelium
  • Connective tissue then has a chance to develop further into the defect
  • Most biodegradable membranes e.g. bioguide
71
Q

What is enamel matrix derivative?

A

It is in the category growth factors and biologicals.

  • Amelogenin production and biological action
  • In tooth development the root sheath cells secrete enamel matrix proteins. Following formation of the protein matrix on the surface of the mineralising dentine, cementoblasts start producing cementum which anchors collagen fibres.
  • Enamel matrix derived proteins are used to make amelogenin (Emdogain) which is used for tissue engineering.
72
Q

What is the sequence of biological action after application of Emdogain during surgery?

A
  • Attraction
  • Attachment and proliferation
  • Differentiation
  • Alveolar bone
73
Q

What is the predictability of Emdogain gel treatment?

A

(Heden et al 1999)

  • 87% of sites > 2mm attachment gain
  • Majority of sites >4mm attachment gain
  • Average bone fill 69%
  • Emdogain technique is predictable way to enhance periodontal regeneration outcome
74
Q

How can peri-implantitis be treated with regeneration?

A

Peri-implant mucositis affects the soft tissues and can be treated with OH methods, reshape crown, antibiotics or surgical approach. There will be a little bit of bone loss after placement of implant and this will be a few mm due to the remodelling process. Once it gets further and the threads of the implant are exposed it needs to be treated. There is a higher risk of this in patients with a history of periodontitis. Place bio-oss around implant and membrane.

75
Q

Is emdogain useful for gingival recession?

A

Read notes.
Coronally repositioned flap in combination with the application of emdogaingel is a predictable treatment procedure for the achievement of a soft tissue root coverage and gain of clinical attachment while maintaining shallow pockets.

76
Q

What is the general post-operative care after surgery?

A
  • Give general advice, preferably written on what to expect such as pain, swelling etc
  • Oral hygiene advice (clean adjacent teeth gently, avoid surgery area, no interdental cleaning, chlorhexidine mouthwash 0.2% (flap), clean rest of mouth as usual, return in one week)
77
Q

What is done in the review appt one week after surgery?

A
  • Removal of pack or sutures
  • Rubber cup polish
  • Cleaning advice (gentle brushing, soft brush, gums with bleed, interdental cleaning gently, continue mouthwash for another week but beware staining, mucosal irritation, parotid problems, altered taste), treat any sensitivity with toothpaste or varnish
  • See patient again at 1 month and 3 months
78
Q

What type of healing occurs after periodontal surgery?

A
  • After flap surgery - primary intention, long junctional epithelium
  • After gingivectomy - secondary intention
79
Q

What is primary intention after a flap is replaced?

A
  • Fibrin and clot between tooth and flap
  • Organisation and replacement of granulation tissue
  • Epithelium grows down from gingival margin
  • Long junctional forms. This takes about 6 weeks
  • The deep of any vertical bone defect fills in. the alveolar crest resorbs
  • Over time the healed tissue shrinks and more crown is exposed
  • These changes are maximal at 3 months but occur up to about 6 months
80
Q

What occurs in secondary intention after gingivectomy?

A
  • Initial fibrin cover over wound under pack
  • Growth of epithelium from retained islets in wound and margins of area
  • Initial epithelialisation takes up to 2 weeks it may be necessary to repack after 1 week
  • Following healing the gingiva regrows to a certain extent and the gingival level moves coronally
  • These changes occur up to about 6 months
81
Q

What are the signs of success after flap surgery?

A
  • Decrease in inflammation
  • Less bleeding on probing
  • Decrease in pocket depth
  • Increase in attachment
  • Eliminate pus
  • No increase in mobility
  • Improvement of tissue contour
  • Stabilisation of bone levels
82
Q

What are the timings of the review appointments after surgery?

A
  • One week
  • 4-6 weeks OH support
  • 3 months (DO NOT PROBE BEFORE THIS)
  • 6 months (may need to wait before probing with some regenerative techniques)
    Expected results are shallow non-bleeding pockets with clinical attachment and bone gain.
83
Q

What are the advantages of flap surgery?

A
  • May not be able to get cavitron into pocket
  • May want to enlarge furcation to allow patient to clean
  • Pocket elimination
84
Q

What are the disadvantages of flap surgery?

A
  • Recession
  • More plaque accumulation on dentine surfaces…recurrence of disease
  • Resection can give rise to tissue damage on neighbouring teeth
85
Q

What are the complications of flap surgery?

A
  • During - pain, excessive bleeding, apex exposed, damage to flap
  • After - pain, secondary haemorrhage, sensitivity, infection, swelling
  • Long term - recession, dentine sensitivity, poor aesthetics
86
Q

What affects the variability in treatment outcome of periodontal surgery?

A
  • Surgical procedure: technique, operator skills
  • Patient factors: oral hygiene, smoking and infection control, general condition
  • Defect-characteristics: defect angle and width amount of loss of attachment and bone
87
Q

What is recession?

A

Recession is the apical shrinkage of the gingivae beyond the amelo-cemental junction (measured from the ACJ to gingival margin). It may be localised or generalised. It is an indicator of past disease but does not mean that active disease is present. Note: recession also occurs following the healing from effective periodontal treatment.

88
Q

What is the aetiology of gingival recession?

A

It is predisposing factors acting with precipitating factors. You need a combination of both.

89
Q

What are the predisposing factors of recession (what is there to start with)?

A
  • Lack of bone (developmental/acquired):
    • Thin cortical plates/prominent roots
    • Dehiscences/fenestrations
    • Long standing periodontitis
    • Occlusal trauma or excessive ortho. Force may cause dehiscences
  • Thin gingival tissue
  • Role of fraenum
  • Deep overbite
  • Rotation around retainers not passive
90
Q

What are the precipitating factors if recession (things that make you get recession)?

A
  • NB – all causes of gingival inflammation – provoke recession if predisposing factors present
  • Plaque induced gingival inflammation i.e. gingivitis and/or periodontitis
  • Traumatic toothbrushing
  • Direct repeated trauma e.g. complete overbite impinging on lower gingivae
  • Parafunctional habits
  • Iatrogenic cause e.g. ortho, bands, prostheses
  • Food trauma
91
Q

What problems does recession cause?

A
  • Patient anxiety about appearance as crown margins visible
  • Patient may be worried about tooth loss
  • Provides stagnation area for plaque/calculus, dentine holds plaque better so recession makes this worse
  • Sensitivity due to exposed dentine
  • Root caries which may lead to possible pulp death, continued breakdown and subgingival restorations
92
Q

How is recession managed?

A
  • Explain and reassure
  • Correct precipitating factors where possible e.g. ensure atraumatic plaque control
  • Thorough scale and polish
  • Restore carious root surfaces with respect for periodontium
  • Control any sensitivity
  • Fluoride application
  • Monitor
  • Where indicated:
    • Aesthetics e.g. gingival veneer
    • Surgical options e.g. laterally repositioned flap, grafts, apically repositioned flaps with/without regenerative techniques
      The outcome aimed for would be stabilisation/control of breakdown. Important to manage problems long term and review to maintain good standard of home care.
93
Q

How is sensitivity managed?

A
  • Plaque control
  • Fluoride toothpastes
  • Desensitisers such as:
    • Supaseal, duraphat, seal and protect, cervitec
    • Desensitising toothpastes
    • Dentine bonding agents
94
Q

How are patients with recession monitored?

A
  • Measure in mm and record from CEJ to top of gingival margin however this is subject to error
  • Clinical photographs
  • Study models
95
Q

What is looked at in a pre-operative assessment for recession?

A
  • Is surgical treatment warranted?
  • Is recession stable following monitoring?
  • Medical and social assessment
  • Tooth vitality
  • Radiographic examination
  • Informed consent and clinical records
96
Q

What are the surgical options for treating recession?

A
  • Laterally repositioned flap
  • Free gingival graft
  • Coronally repositioned flap
  • Guided tissue regeneration
  • Free connective tissue graft (raise flap, remove connective tissue)
97
Q

What were the results from 12 months evaluation of treatment of gingival recession with Emdogain?

A 
Abbas et al:
- Average root coverage 73% (60-70)
- Clinical attachment gain 58% (50-71)
- Patient satisfaction 8.5 (7-10)
- Maintaining shallow pockets and amount of keratinised gingiva
The method:
- Coronally advanced flaps
- Root surface conditioning with PrefGel
- Application Emdogain 
- Barricaid periodontal dressing
- Maintenance care
98
Q

What do systematic reviews show on the surgical management of recession?

A

Of the available SRs on root coverage procedures there is clear evidence that mainly coronally advanced flap alone or associated with subepithelial connective tissue grafts led to statistically significant improvement in gingival recession and attachment level gain, with or without improvements in the width of keratinised tissue.

99
Q

What is the influence of occlusal trauma on the periodontium?

A

‘Trauma from occlusion is used to describe pathological alterations or adaptive changes which develop in the periodontium as a result of excessive occlusal stresses’.

100
Q

What is primary and secondary occlusal trauma?

A
  • Primary occlusal trauma is an injury to a periodontium of normal height as a result of excessive occlusal force
  • Secondary occlusal trauma is an injury to a periodontium of reduced height as a result of excessive occlusal trauma
101
Q

What is the aetiology of excessive occlusal load?

A
  • Premature contact: high restoration, tooth malposition, denture, orthodontics
  • Parafunctional habits such as bruxism and clenching
  • Tooth drifting following tooth loss or periodontal disease
  • Loss of posterior teeth
  • Occlusal discrepancy e.g. cross bite
102
Q

What are the clinical features of damage to the periodontium due to occlusal trauma?

A
  • Increased mobility
  • Fremitus – the movement of a tooth or teeth subjected to functional occlusal forces
  • Tooth migration
  • Pain and tenderness
  • Tooth surface loss
  • Temporomandibular signs
103
Q

What are the radiographic features of primary and secondary occlusal trauma?

A
  • Primary occlusal trauma - adequate bone support but PDL widening
  • Secondary occlusal trauma - bone loss and PDL widening
104
Q

Can occlusal forces cause angular bony defects?

A

There is controversy in the literature on whether:

  • Abnormal occlusal forces can change the course of plaque induced periodontal disease and cause angular bony defects in teeth with periodontitis Gilckman’s concept 1965
  • Or
  • Angular bony defects and pockets develop equally in teeth with or without occlusal trauma (Waehaug’s concept 1979)
105
Q

How can occlusal forces be classified?

A

Occlusal forces can be classified into two main categories including orthodontic type force and jiggling type trauma. Jiggling type trauma will be more destructive as the body cant decide what is going on so there is adaptation all round the tooth.

106
Q

Can jiggling forces cause pocket formation and affect connective tissue attachment?

A

Studies show in the absence of inflammatory disease, jiggling forces do not affect supracrestal connective tissue attachments and do not cause pocket formation in healthy periodontium. They may only cause PDL widening and increased mobility (physiological adaption) Green and Levine 1996. However, long term high intensity jiggling type trauma to teeth with active plaque associated inflammatory periodontal disease may act as a destructive co-factor and enhance the rate of disease progression Polson and Zander 1983.

107
Q

What are the types of tooth mobility?

A

Tooth mobility can be physiological or pathological. Physiological mobility is characterised by increased occlusal load and PDL widening in the absence of any active inflammatory disease. pathological/progressive mobility is often associated with actively progressing inflammatory periodontal disease and can be characterised by:

  • Increasing tooth mobility, tooth migration or drifting
  • Fremitus
  • Persistent discomfort on eating
108
Q

How are teeth with physiological mobility managed?

A

Teeth with physiological mobility and normal periodontal bone height as well as the mobile tooth with increased PDL width and reduced bone height after successful treatment of periodontal disease can be managed by occlusal adjustment if necessary Foz et al 2012.
Mobile teeth with normal PDL width but reduced height of bone in the absence of inflammatory periodontal disease can be managed without any treatment if they are asymptomatic or they can be splinted to the adjacent teeth if the mobility is causing discomfort for the patient Forabosco et al 2006.

109
Q

How are teeth with progressive pathological mobility managed?

A

Teeth with progressive pathological mobility, active bone loss and inflammatory disease have often poorer prognosis and the management options include:

  • Maintaining the tooth and treatment of the inflammatory periodontal disease and considering splinting the tooth to reduce the mobility
  • Extraction and replacement of the tooth
110
Q

What are the methods of occlusal adjustmen?

A
  • Selective grinding in CO (ICP) and excursions
  • Restorations
  • Orthodontics
111
Q

What are the types of splints?

A
  • Temporary – used for a few months during periodontal healing period
  • Semi-permanent – used longer before and after regenerative surgery
  • Permanent – used indefinitely
  • Fixed or removable
112
Q

Who are removable splints indicated for?

A

Removable splints are indicated for patients with TMD/parafunctional habits.

113
Q

What are the fixed splint types?

A
  • Direct adhesive composite fibre splint
  • Wire splint
  • Indirect cast splints – metal backing good for grinding cases
114
Q

What are the splint requirements?

A
  • Incorporate as many firm teeth around the arch
  • Hold teeth rigid
  • Not interfere with occlusion
  • Must not irritate surrounding soft tissues
  • Designed so it can be kept clean
115
Q

What are the splint advanatages?

A
  • Shared load among teeth to prevent unwanted extraction of mobile teeth e.g. prior to periodontal therapy
  • Bring teeth into function
116
Q

What are the splint disadvanatages?

A
  • Increases plaque retention factor

- May overload adjacent teeth

ICP - 4th year (9 decks)

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