Periodontology Flashcards
What is the diagnosis for patient who has generalised bone loss on full mouth periapicals?
Generalised Periodontitis (include stage and grade)
What clinical and lab investigations can be done for Periodontal disease?
Thorough History (SH/FH)
6PPC
Mobility
Furcation involvement
BPE
MPBS
Microbiological analysis of crevicular fluid swab
What are the factors to consider when deciding on prognosis of individual teeth in periodontal disease?
Loss of attachment
Mobility
Furcation involvement
What are the reasons for PMPR being unsuccessful?
Patient does not comply with OH regime
Inadequate PMPR by dentist
Difficulty in accessing deep pockets and furcations
Patient is immunocompromised/has systemic disease
Poor restoration causing plaque trap
Dentist fails to motivate patient
Patient continues smoking
What are the reasons for antibiotics not being effective in treating perio?
Biofilm must be disrupted to allow for efficacy
How would you manage a periodontal abscess with systemic involvement?
Subgingival PMPR- short of base of pocket
If pus- incision and dilation of pocket
Recommend analgesia
0.2% CHX until symptoms subside
Prescribe Pen V 250mg for 5 days
When free of pain- recall for PMPR
What would be the signs of improved health following a periodontal treatment? (engaging patient)
Probing depths- <4mm
BOP- less than or equal to 30% (aiming for <10%)
Plaque scores- less than equal to 20% (aiming for 15% overall)
** or 50% reduction
What investigations would you do for patient with space between 13 and 14?
BPE- screening tool for periodontal health
MBPS- assess OH
6PPC- to assess periodontal disease
PA radiogaphs- to assess bone levels, prognosis
What are the issues with placing implants in patients with periodontal disease?
Risk of future peri-implantitis
Inadequate space
Inadequate bone levels
Soft tissue defects
What bacteria are involved in ANUG?
P.Intermedia
Fusobacterium
Treponema
What are the signs and symptoms of ANUG?
Pain
Bad breath
Sloughthing of gingival tissue
Loss of papillae- punched out appearance
Bleeding
Lymphadenopathy
Pseudomembrane formation
What are the risk factors for ANUG?
Stress
HIV
Sleep deprivation
Young age
Poor OH
Smoking
Leukaemia
How do you manage ANUG?
Ultrasonic PMPR
CHX 0.2% x 2 daily
Ibruprofen if fever
Diet advice and supplements
AB- 400mg metronizadole TID for 3 days (no alcohol)
What information would you provide to a patient when consenting them for Periodontal surgery?
Risks:
Gingival recession
Infection
Surgical complications- pain, bleeding, bruising, swelling, need for suturing
Benefits:
More effective removal of calculus and biofilm as you have direct vision
Other options:
Repeat PMPR
RISKS OF NO TX:
Increased pocket depth, mobility, likelihood of tooth loss
After treatment, patient complains of central crushing pain across chest and down left arm. What is the likely diagnosis and immediate management? (pt is conscious)
MI
-> Give oxygen- 15L per min
-> Chew 1 aspirin tablet 300mg or crush and place under tongue in edentulous patients
-> Send to jubilee if STEMI/ Royal infirmary if NSTEMI
What information is given to patients after periodontal surgery?
How long after suture removal in perio surgery do you schedule a review?
What are the causes of AB not being effective for periodontal disease?
Lack of mechanical disruption of biofilm
What is a periodontal abscess?
Acute exacerbation of an existing periodontal pocket
-> associated with food packing and tightening post-HPT
What are the signs and symptoms of perio abscess?
Swelling
Pain
TTP in lateral direction
Bleeding
Suppuration
Lymphadenopathy
Fever
How can periodontal abscess be differentiated from Periapical?
Periodontal abscesses tend to be more acute
Lack of PA pathology radiographically
Tooth tends to be vital in Perio abscess
Perio tends to have narrow bone loss on one side
How do you manage occlusal trauma in a patient with periodontal disease?
Splint teeth
Fix occlusal relation - remove high restorations
Control plaque induced inflammation with PMPR
What factors can influence mobility in teeth?
Short roots
Widened PDL
Shorter PDL
Inflamamtion
When is splinting advised for patients with occlusal trauma?
If mobility is advanced
If it is causing issues eating
If teeth need to be stabilised for PMPR
Why is there a decrease in mobility after periodontal treatment?
As treatment can facilitate gain in attachment
-> long junctional epithelium formation
-> Improved tissue tone- inflammatory infiltrate is replaced with collagen
What may you do if the PDL is still widened after successful treatment?
Look at the occlusion for any potentially traumatic areas and adjust
How is localised and generalised periodontitis differentiated?
Localised- <30% of teeth affected
Generalised- >30%
- Molar-incisor pattern also seen
What bacteria is implicated in Periodontitis?
A.a
P.gingivalis
T.Forsythia
T. Denticola
How is aggressive periodontitis managed?
What are the features of teeth with poor periodontal prognosis?
Mobility- loss of bone support
Furcation involvemet- difficult to clean
Lack of vitality
LOA- less soft tissue support
If only a pocket chart is given, what information would be required before determining final prognosis and diagnosis?
Smoking status
Drug history
Systemic disease
Radiographs
What are the causes of a patient discomfort in case of mobile 21 and severe recession?
Sensitivity due to exposed root dentine
Traumatic occlusion
What investigations can be done for patient who present with periodontal disease?
6PPC
MPBS
Periapical radiographs
Smoking status
What are the diseases in 2017 periodontal classification?
- Health- intact or reduced periodontium
- Plaque induced gingivitis
- Non-plaque induced gingival conditions- L/G
- Periodontitis- L/G/MI
- Necrotising Periodontal diseases
- Periodontitis as manifestation of systemic disease
- Systemic diseases affecting perio tissues
- Perio abscesses
- Perio-endo lesions
- Mucogingival deformities and abnormalities
What are clinical signs of healing in periodontal disease?
Gingival recession- presence of black triangles
Reduced BOP
Clinical attachment gain- reduced probing depth
What is the difference between vertical and horizontal bone loss?
Vertical (angular occurs in thicker parts of bone)- zones of destruction destroy some of the septum between teeth but part remains
Thinner areas of bone are subjected to horizontal where the septum is lost totally
How does a healthy peridontium react to traumatic occlusion?
PDL width increases until force from occlusion can be dissipated and then stabilises
-> Will return to normal after demand is reduced
No LOA or inflammation
**IF healthy but reduced- more mobility
IF perio- LOA may be faster
What is CHX?
Biguanide antiseptic
What is the mode of action of CHX?
Dicationic
-> 1 cation adheres to pellicle and 1 disrupts bacterial membrane
Effective against Gram+/- bacteria, fungi and viruses
What is the substantivity of CHX?
12 hours
What are the side effects of CHX?
Staining
Anaphylaxis
Taste disturbance
Salivary gland enlargement
What are the uses of CHX in dentistry?
ANUG/P
Denture stomatitis
OH in patients who are struggling to brush
To treat oral ulceration
Denture stomatitis
As Endodontics irrigant
To test dam in Endo
To irrigate under operculum in periocoronitis
If high caries risk
What does TIPPS stand for? (periodontal OHI)
Talk
Instruct
Practice
Plan
Support
What is recorded on periodontal pocket chart?
Gingival margin level
Pocket depth
LOA
Bleeding
Mobility
Furcation Involvement
Teeth missing
What are the disadvantages of pocket charts?
Probing depth may vary between operators (subjective?)
If done prematurely it can disrupt healing socket
Cannot be done in children- immature, false pocketing common
Asumes all patients have same root length
What are the causes of gingival recession?
Periodontal disese
PMPR
Traumatic toothbrushing
Traumatic OB
Ortho
Poor margins on indirect restorations
How can recession classified?
Recession Index:
Type 1- no loss of interproximal attachment
-> CEJ is not visible medially and distally
Type 2- associated with loss of attachment
-> attachment loss inter proximally is less than buccal attachment loss
Type3- inter proximal attachment loss is greater than buccal attachment loss
How can recession be managed?
Treat sensitivity
Atraumatic brushing technique
Monitor
Grafting
Gingival veneer
How can recession be measure?
Photos
Studymodels
6PPC
What are the differential diagnoses for root treated tooth with 9mm pocket and vertical bony defect?
Perio-endo lesion
Endo-perio lesion
True combined lesion
What special investigations would you carry out for endo-perio/perio-end lesions?
PGI
6PPC
Sensibility testing
PA radiograph
What is the initial treatment for a previously treated tooth with perio-endo lesion?
ReRCT
If patient wants implants what factors are we looking to consider?
Bone quantity and quality
OH
Smoking
Patient motivation
Cost
MH- bisphosponates
What interventions can be carried out in patient who have inadequate bone levels?
Bone graft
Sinus lift
Guided tissue regeneration
Emdogain
How is vertical bone loss classified?
What are the indications for regenerative periodontal surgery?
What are the options if regenerative perio surgery fails?
What are the causes for lack of success in non-surgical perio therapy?
Lack of motivation on patient
Patient does not comply with dentist advice
Inadequate PMPR by dentist
Difficult access to certain pockets
Patient unable to stop smoking
Systemic disease
Inadequate restoration placed- plaque trap
What makes diabetes a risk factor for periodontal disease?
Hyperglycaemia can modulate RANKL (Over OPG
-> encouraging bone destruction
Production of Advanced Glycation End products in hyperglycaemia
-> increased production of pro-inflammatory cytokines and MMPS
Poorer wound healing
Impaired immune system
What tests are available for diabetes?
Fasting plasma glucose:
<6.1mmol/l- normal
6.1-7.0- impaired
>7.0- diabetes
Glucose tolerance Test:
<7.8- normal
7.8-11.1- impaired
>11.1- diabetes
What test is used to indicate diabetic control?
Glycated Haemoglobin- Hb1Ac
-> <6.5% is the aim (48mmol/mol)
What are the effects of smoking on periodontal tissues?
Reduced blood flow- impaired healing
Increased activation of immune system
Anaerobes favoured
What is the role of interleukin 1?
Pro-inflammatory cytokine- stimulates enzymes and osteoclasts to cause tissue destruction
What medications are associated with gingival hyperplasia?
Phenytoin
Ca channel blockers- nifidipine
Cyclosporin
How is drug induced gingival hyperplasia managed?
Control plaque- OHI, PMPR
If no improvement and good OH- liaise with GP to discuss changing medications
Consider gingival reduction surgery
What do the different values for BPE mean?
0- PPD <3.5mm, no BOP, no PRF
1- PPD <3.5mm, BOP, no PRF (plaque can be present)
2- PPD <3.5, BOP, plaque retentive factors (calculus and overhangs)
3- PPD between 3.5-5.5mm
4- >5.5mm
*- furcation involvement
What is the treatment for different BPE values?
0 = none
1 = OHI and plaque and gingivitis charts
2 = OHI, plaque and gingivitis charts and removal of PRF via PMPR or remove overhangs
3 = OHI, plaque and gingivitis charts, PMPR, 6ppc of the sextants with 3 either just after or before and after treatment and radiographs
4 = OHI, plaque and gingivitis charts, PMPR, 6PPC of whole mouth either just after or before and after treatment (B&A = SDCEP) , radiographs and possible referral
* = as for the score and possible specialist referral
How is mobility graded?
0 = physiological movement
1 = up to 1mm movement
2 = 1-2mm movement
3 = severe movement that impacts function, rotational and vertical (>2mm)
How are furcations graded?
1 = < 1/3rd (<3mm)
2 = > 1/3rd but not all the way through (>3mm)
3 = through and through
