Periodontology Flashcards
1
Q
In regards to perio, what is the criteria for an “engaging patient”?
A
- improvement in OH >50%
- plaque levels <20%
- bleeding <30%
- meeting targets in self-care plan
2
Q
In regards to perio, what is the criteria for a “non-engaging patient”?
A
- insufficient improvement in OH <50%
- plaque levels >20%
- bleeding >30%
- states preference to palliative approach
3
Q
After sub-gingival debridement, what is the criteria in order for a patient to be considered “stable”?
A
- no periodontal pockets >4mm with BOP
- no remaining deep sites >6mm
4
Q
After sub-gingival debridement, what is the criteria in order for a patient to be considered “unstable”?
A
- deep sites remain >6mm
- BOP in pockets >3mm
5
Q
What does NSPT stand for?
A
Non-surgical periodontal therapy
6
Q
What is the aim of NSPT?
A
To control dysbiosis, by controlling microbial load and reducing inflammatory cell infiltrate.
7
Q
What advantage does NSPT have for periodontal surgery?
A
Improves tissue quality which helps handling during surgery
8
Q
When is periodontal surgery indicated (give 3 scenarios)?
A
- Persistent deep pocketing >6mm in isolated sites after REPEATED phases of NSPT
- Infra-bony defects >3mm
- Furcation involvement (Class II)
9
Q
What are the three types of periodontal surgery?
A
- Resective
- Reparative
- Regenerative
10
Q
what does Resective periodontal surgery involve?
A
The removal of damaged gum tissue
11
Q
What does regenerative periodontal surgery involve?
A
Use of tissue-stimulating proteins to encourage body’s natural ability to regenerate bone and tissue
12
Q
What does reparative periodontal surgery involve?
A
Removal of tissue from one part of the body (often roof of mouth) and re-attachment of it to the area where the gum has receded.
13
Q
What 5 advantages can periodontal surgery offer?
A
- Pocket reduction
- Improvement of gingival contour
- Improvement of access for oral hygiene measures
- Access to inaccessible, non-responding sites for diagnosis and management
- Regain lost clinical attachment
14
Q
What are 9 direct contraindications to periodontal surgery?
A
- Insufficient self-performed OH
- Gross mobility of tooth
- Acute infection
- Irregular attender/unmotivated patient
- MH unfavourable
- Heavy smoker
- Tooth of limited prognosis
- Little benefit to be gained from surgery
- Gingival contour post surgery likely to be unacceptable
15
Q
What are systemic absolute contraindications for periodontal surgery?
A
- bleeding conditions (INR3-3.5, low platelets)
- recent MI or stroke (<6 months)
- recent vascular prosthesis placement or transplant (<6-12 months)
- significant immunosuppression
- active cancer therapy
- IV bisphosphonate treatment
16
Q
What are two relative systemic contraindications for periodontal surgery?
A
- Poor wound healing
- Social history of smoking
17
Q
What effect can smoking having on periodontal surgery outcome?
A
Impairs wound healing, can lead to less attachment gain and pocket depth reduction after surgery.
18
Q
What are the main principles of flap design for periodntal surgery?
A
- Keep flap as minimal as possible
- Every design is unique to clincial situation
- Careful handling of tissues at all times
- Measure interdental papilla to determine handling
19
Q
What are the 5 post-op instructions after periodontal surgery to be given to patients?
A
- Take regular analgesia
- Use of ice packs for first 12 hours to reduce swelling
- Avoid surgical site when brushing until sutures removed, use Chlorohexidine mouthwash during this time.
- Suture removal at 5-7 days
- No probing or instrumentation of site for 3 months MINIMUM (9-12 months if biomaterials used)
20
Q
Give two examples of Resective periodontal surgery.
A
- Gingivectomy
- Root Resection
21
Q
Give two examples of repair/re-attachment periodontal surgery.
A
- Open flap debridement (OFD)
- Modified widman flap (MWF)
22
Q
Give three examples of regenerative periodontal surgery.
A
- Guided tissue regeneration (GTR)
- Bone Grafts
- Enamel matrix protein (Emdogain-EMD)
23
Q
Define, pocket elimination procedures which establish a morphologically normal attachment but with apical displacement of the dental-gingival complex.
A
Resective periodontal surgery
24
Q
What surgical procedure is most appropriate for management of abnormal overgrowth of gingival tissues by resection/re-contouring the gingivae.
A
Gingivectomy
25
What are the three causes of gingival overgrowth?
1. Inflammatory (due to plaque)
2. Drug-induced
3. Related to systemic conditions
26
What are the 4 contraindications for Gingivectomy?
1. Narrow attached gingiva
2. Planned osseous re-contouring
3. Infra-bony periodontal pockets
4. Medical contraindications- especially bleeding disorders
27
What are the 6 indications for Gingivectomy?
1. Gingival enlargement/overgrowth persists despite non-surgical care
2. Supra-bony periodontal pocketing
3. Trauma caused by gingival overgrowth
4. Interference with speech and aesthetics
5. Excellent home care
6. Wide zone of attached gingivae
28
What are the 5 disadvantages of Gingivectomy?
1. Limited indications
2. Heal by secondary intention (painful!)
3. Risk bone exposure
4. Wastes attached gingiva
5. Excessive recession in periodontal disease
29
What surgical procedure is most appropriate for smaller areas of gingival re-contouring?
Electrosurgery
30
Define a surgical procedure which apically repositions the soft tissue and alveolar bone to expose more tooth structure, and increase the length of the clinical crown.
Surgical crown lengthening (SCL)
31
What is the aim of surgical crown lengthening?
Surgically maintain biological width whilst apically repositioning the gingival level
32
What are the 7 indications for surgical crown lengthening?
1. Toothwear
2. Poor gingival aesthetics
3. Restoration of subgingival lesions
4. Replacement of crowns with deep margins
5. Management of coronal third fractures
6. Management of infringement of biologic width
7. Develop ferrule for pulp-less teeth restored with posts
33
What are the 6 contraindications for surgical crowns lengthening?
1. Poor plaque control
2. Poor compliance
3. Non-functional teeth or teeth of poor strategic value
4. Periodontal destruction
5. Endodontic compromise
6. Medical history considerations
34
What are 5 surgical crown lengthening complications?
1. Poor aesthetics due to black triangles
2. Transient mobility of the teeth
3. Root sensitivity
4. Rebound of marginal tissues
5. Root resorption
35
Define the the type of periodontal surgery which reduces pockets but without replication of the normal attachment, i.e. healing is by formation of long junctional epithelium.
Repair/re-attachment surgery
36
What are the two aims of open flap debridement surgery?
1. Access for root surface debridement under direct vision
2. Assessment of root surface
37
What are the 5 indications for open flap debridement?
1. Excellent maintenance
2. Site >6mm with BOP or suppuration
3. Horizontal bone loss pattern
4. Vertical defect <3mm
5. Isolated periodontal pockets remain
38
Name 3 contraindications for open flap debridement.
1. Aesthetic region
2. Need for bone graft/membrane
3. Complex function/bone defects
39
What are the 3 advantages of open flap debridement?
1. Healing by primary intention
2. Minimal crestal bone resorption
3. Effective in pockets 6-7mm
40
What are the 4 disadvantages to open flap debridement?
1. Can be unpredictable
2. No new true attachment
3. Risk of recession
4. Interdental craters
41
Define the type of periodontal surgery that recreates the complete attachment apparatus of bone/cementum/functionally orientated periodontal ligament against previously exposed root surface.
Regenerative surgery
42
What is the difference between reparative and regenerative periodontal surgery?
Reparative involves development of long junctional epithelium and crestal remodelling
Regenerative involves new cementum, PDL and alveolar bone being formed
43
What are the three main aims of regenerative periodontal surgery?
1. Regenerate defect
2. Remove factors associated with disease progression (residual deep sites, infrabony defects, * involvement, BOP)
3. Enhance access for plaque control and maintenance
44
What is the criteria for a “regenerated defect” after regenerative periodontal surgery?
- gain clinical attachment
- minimise soft tissue recession
- increase in bone volume
45
What is the outcome of epithelial cells repopulating tooth root after periodontal surgery?
Formation of long junctional epithelium
46
What is the outcome of gingival connective tissue cells repopulating tooth root after periodontal surgery?
CT attachment or root resorption
47
What is the outcome of bone cells repopulating tooth root after periodontal surgery?
Root resorption and ankylosis
48
What is the outcome of mesenchymal cells from PDL repopulating tooth root after periodontal surgery?
Regeneration
49
What is the criteria for case selection for regenerative periodontal ligament against surgery?
1. Infra-bony defect associated with periodontal pocket of >6mm (depth of vertical defect >3mm)
2. Class 2 furcation in mandibular molars
3. Single class 2 furcation in maxillary molars
50
What two factors improve the prognosis for good regeneration following regenerative periodontal surgery?
1. Narrow defect (<25 degrees) ideally
2. Higher number of bony walls
51
Define the regenerative surgical technique which uses a mechanical barrier (membrane) to selectively enhance the establishment of PDL and peri-vascular cells in osseous defects to initiate periodontal regeneration.
Guided tissue regeneration (GTR)
52
What are the three aims of guided tissue regeneration?
1. Stop rapid down growth of epithelial cells
2. Create space for pluripotent cells from PDL to access root surface
3. Improve local anatomy, function and prognosis of teeth
53
What membrane is most often used for GTR?
Collagen membrane
54
What is the purpose of a membrane in GTR?
Act as a barrier to prevent cells apart from PDL cells migrating into site
55
What are the 4 types of bone grafts based on their sources?
1. Autograft
2. Allograft
3. Xenograft
4. Alloplast
56
Define an autograft.
From a donor site of the SAME person
57
Define an allograft.
From a different person, but human bone
58
Define a xenograft.
From an animal source (most often a cow- bovine deproteinised bone)
59
Define alloplast.
Bone graft using synthetic material
60
What is the purpose of bone grafts in periodontal surgery?
They support the flap, providing “space” and “stability” for regeneration
61
What is the purpose of emdogain?
Mimics the development of tooth supporting apparatus during tooth formation, and accelerates early wound healing.
62
What two cell types does EMD/EMP have direct effects on to increase cell proliferation and migration?
Bone and PDL fibroblasts
63
What are the 4 main advantages of regenerative periodontal surgery?
1. Successful in treatmnet of deep sites of 6mm or greater
2. Healing by primary intention
3. Improvement in volume of supporting tissues of tooth
4. Less recession for patient
64
What are the 3 main disadvantages of regenerative periodontal surgery?
1. Technically challenging to get a good outcome
2. Can be unacceptable for some patients depending on materials used (e.g. religious or ethical reasons)
3. Expensive materials
65
What is the most suitable management option available for grade 1 furcation-involved teeth?
Non-surgical periodontal therapy
66
What are the 3 most suitable management options available for grade 2 furcation-involved teeth with interproximal bone level below the furcation entrance?
1. Apically repositioned flap
2. Tunnel preparation
3. Root resection/separation
67
What are the 4 most suitable management options available for grade 3 furcation-involved teeth?
1. Apically repositioned flap
2. Tunnelling procedure
3. Root resection or separation
4. Extraction
68
What is the purpose of Odontoplasty in management of furcation lesion?
Reduces plaque accumulation by reshaping tooth surface with a bur
69
What is the disadvantage of Odontoplasty in the management of furcation lesions?
Can result in hypersensitivity and caries
70
In what circumstances is regeneration for furcation lesions not effective?
1. If entrance of furcation is below height of mesial/distal bone
2. Multiple class 2 defects in maxilla
3. Class 3 lesions
71
What is the most suitable management option available for grade 2 furcation-involved teeth with interproximal bone level coronal to the furcation entrance?
Graft + GTR
72
Define, location of the marginal tissue apical to the cemento-enamel junction with exposure of the root surface.
Gingival recession
73
What are the 4 possible etiological factors for recession?
1. Traumatic (e.g. toothbrushing, partial dentures)
2. Traumatic overbite
3. Periodontal disease
4. Poor restorative margins (plaque retention, encroach of biological width)
74
What are the three non-surgical interventions for management of recession?
1. Monitoring and prevention
2. Composite restorations
3. Gingival prosthesis
75
What are the two surgical interventions for management of recession?
1. Frenectomy
2. Grafting surgery
76
What 5 factors are related to increased risk of recession?
1. High muscle attachment/ frenal pull
2. Thin tissue phenotype
3. Alveolar dehiscence
4. Teeth outside alveolar bone after orthodontic treatment
5. Lack of keratinised tissue
77
What is a frenectomy and what is the aim of surgery?
Removal of local muscle insertion
Aim is to stabilise tissue and improve access for oral hygiene measures
78
What are the three indications for Frenectomy?
1. Unstable local tissue (movement, blanching on retraction)
2. Blocking access for OH measures
3. Non-recession indications (midline diastema in ortho, shallow vestibule for prosthesis)
79
What is a pedicle flap?
Where adjacent attached gingiva is moved to cover a region of recession using a split thickness flap
80
What is a free gingival graft?
Graft from palate formed of epithelium and small amount of underlying connective tissue is placed into a region with localised recession.
81
What are the aims of free gingival graft?
1. To create a band of keratinised mucosa
2. Remove frenal attachments
3. Prepare site for second procedure to increase root coverage
82
What is connective tissue grafting?
A surgical procedure where a split thickness flap is raised, released and then replaced in a more coronal position.
83
What is the more appropriate term used to describe palliative care?
Supportive periodontal care (SPC)
84
What % of individuals will get peri-implantitis?
20%
85
When should patient with Grade C periodontitis be referred to specialist care?
After initial preventative advice on risk factor management & OHI
86
What perio guidance provides high level summary guidance on the principles of periodontal & implant care provision?
BSP guidance on the parameters of Care (2020)
