Periodontics Flashcards

Question

Clinically how do you stage periodontitis?

Answer 1

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.

Answer 2

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.

Answer 3

- 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

Answer 4

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.

Answer 5

- 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

Answer 6

- 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

Answer 7

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.

Answer 8

- 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?

Answer 9

- 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)

Answer 10

- 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

Answer 11

- 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.

Answer 12

Resective and regenerative.

Answer 13

- 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

Answer 14

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.

Answer 15

- Raising flaps - Relieving incision - Replacement of flap

Answer 16

- 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

Answer 17

(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

Answer 18

- 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

Answer 19

- 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

Answer 20

- 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

Answer 21

- Pocket elimination | - Crown lengthening

Answer 22

- Roots exposed - sensitivity and increased risk of caries | - Poor aesthetics - recession

Answer 23

- Incisions - Raising flap, curettage and RSD - Suturing and securing the flap apically

Answer 24

- 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

Answer 25

- 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

Answer 26

- 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

Answer 27

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.

Answer 28

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

Answer 29

- Gingival augmentation - Root coverage procedure - Dental papilla reconstruction

Answer 30

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.

Answer 31

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

Answer 32

- Continued inflammation - Progressive breakdown - Aesthetics - Frenal pull - Pocketing beyond MGJ - Some situations when advanced restorative procedures are planned

Answer 33

- 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

Answer 34

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.

Answer 35

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.

Answer 36

- 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

Answer 37

- 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.

Answer 38

- 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)

Answer 39

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

Answer 40

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.

Answer 41

- Bone substitutes - Guided tissue regeneration - Growth factors and biologicals - Grafting and combined therapies

Answer 42

- Bone forming cells – osteogenesis - Serve as scaffold – osteoconduction - Contains bone inducing substances – osteoinduction

Answer 43

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

Answer 44

- 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

Answer 45

- 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

Answer 46

- 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

Answer 47

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.

Answer 48

- Attraction - Attachment and proliferation - Differentiation - Alveolar bone

Answer 49

(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

Answer 50

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.

Answer 51

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.

Answer 52

- 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)

Answer 53

- 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

Answer 54

- After flap surgery - primary intention, long junctional epithelium - After gingivectomy - secondary intention

Answer 55

- 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

Answer 56

- 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

Answer 57

- 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

Answer 58

- 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.

Answer 59

- May not be able to get cavitron into pocket - May want to enlarge furcation to allow patient to clean - Pocket elimination

Answer 60

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

Answer 61

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

Answer 62

- 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

Answer 63

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.

Answer 64

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

Answer 65

- 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

Answer 66

- 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

Answer 67

- 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

Answer 68

- 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.

Answer 69

- Plaque control - Fluoride toothpastes - Desensitisers such as: - Supaseal, duraphat, seal and protect, cervitec - Desensitising toothpastes - Dentine bonding agents

Answer 70

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

Answer 71

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

Answer 72

- Laterally repositioned flap - Free gingival graft - Coronally repositioned flap - Guided tissue regeneration - Free connective tissue graft (raise flap, remove connective tissue)

Answer 73

``` 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 ```

Answer 74

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.

Answer 75

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

Answer 76

- 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

Answer 77

- 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

Answer 78

- 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

Answer 79

- Primary occlusal trauma - adequate bone support but PDL widening - Secondary occlusal trauma - bone loss and PDL widening

Answer 80

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)

Answer 81

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.

Answer 82

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.

Answer 83

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

Answer 84

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.

Answer 85

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

Answer 86

- Selective grinding in CO (ICP) and excursions - Restorations - Orthodontics

Answer 87

- 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

Answer 88

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

Answer 89

- Direct adhesive composite fibre splint - Wire splint - Indirect cast splints – metal backing good for grinding cases

Answer 90

- 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

Answer 91

- Shared load among teeth to prevent unwanted extraction of mobile teeth e.g. prior to periodontal therapy - Bring teeth into function

Answer 92

- Increases plaque retention factor | - May overload adjacent teeth