Periodontology Flashcards
define resorption
loss of dental hard tissues due to clastic activities
classification of resorption
internal (inflammatory/replacement)
external (surface, inflammatory, replacement, cervical)
what stimulates or inhibits osteoclasts?
parathyroid hormone,
osteoprotegrin (stops osteoclast activity)
RANKL - stimulated blastic activty
Internal resorption classification
originates and affects root canal wall
inflammatory or replacement
What is root resorption
alteration or damage to protective layer of precementum or predentine
inflammation must occur to the unprotective root surface
directly - trauma
indirectly - inflammatory response after injury
What is the destructive phase of RR?
short lived destruction - continues if stimulus is present
if long lived destruction - continues until enough root is resorbed or is resorbed completely
what is the inflammatory response of RR?
the healing phase, cementoblasts causing cemental healing if small lesions
least favourable is bone cells - get ankylosis (replacement resorption)
occurs if diffuse injury (>20%)
aetiology of IIRR
outer odontoblast and predentine layer damaged - underlying mineralised dentine exposed to odontoclasts
trauma, caries, perio infections, heat, pulpotomy, ortho etc
need blood supply
clinical presentation of IIRR
+ve vitality test, asymptomatic, might have active pulpitis, sinus tract in late stage, pink spot possible
radiographic presentation of IIRR
might be chance finding.
uniform radiolucent enlargement of pulp canal, outline of canal is distorted, no adjacent bony defect, continuous periphery of lesions with canal
IIRR treatment
if salvageable - RCT
need ultrasonic irrigation with NaOCl to get into shape
cant mechanically debride
CaOH intracanal medicament
obturate with thermoplastic GP (can use master apical point for apex)
if perforated - XLA
What is external inflammatory RR
precementum layer gets thinner as you go apically
shallow resorption of cementum often with involvement of small amount of underlying dentine
aetiology of EIRR
prolonged stimuli to area (infection), trauma, pressure, endodontic stimulus
How to diagnose EIRR
Sub clinical issue, might cause mobility,
pressure = radiographic shortening and blunting of root apices. tooth still vital.
trauma causes more extensive loss, might lose vitality
if infection then might have lateral canal
Treatment of EIRR
orthograde RVCT, reduce ortho pressure, remove impacted tooth, halt infective stimulus
What is external replacement resorption (ankylosis)
bony trabecluae develop in PDL space and fuse to root surface
replacement of root surface with bone, AKA ankylosis
may be transient or self limiting
How to diagnose ankylosis?
often sub clinical, only when 10-20% surface affected, might get infra occlusion, lack of mobility, change in percussive sound
radiogrpahically - moth eaten look, loss of PDL space
CBCT, PA, upper standard occlusal
Management of ankylosis
once established - no effective Tx. camouflage
monitor - may infraocclude.
XLA and implants
What is external cervical resorption and what are predisposing factors?
localised resorptive lesion of the cervical area of the root below epithelial attachment. usually on traumatised tooth, internal/external bleaching, ortho, oral surgery
classified by heithersays classification (1-4, least to most severe)
what are the clinical signs of ECR?
often asymptomatic, might have pink spot lesion, BOP, loss of PDL support and attachment, granulation tissue perforate at gingival margin (looks like gingivitis)
eventually causes pulp necrosis
radiographically
asymmetric radiolucency, still have tramlines of canal, corresponding loss of alveolar bone, multilocular and superimposed on pulp
need parallax
What are the management options of ECR?
Refer
raise flap, curette granulation tissue, treat with TCA (tricholoroacetic acid) to cause coagultion necrosis of resorptive tissues without PDL damage
remove undermined enamel and dentine
restore with GI or comp
How to aid diagnosis of resorption?
Good Hx ( trauma, ortho, crowns, pulpotomy, internal bleaching, impacted teeth, perio disease and Tx, contact with cats, pagets disease, papillo le fevre)
Exam (tooth colour, restoration, percussion, mobility, LOA, EPT/ethylCl)
Imaging (multiple PAs, CBCT)
What are the classifications of periodontal disease?
- Gingival diseases
- chronic periodontitis
localised or generalised - aggressive periodontitis
localised or generalised - periodontitis as a manafestation of systemic disease
- necrotising periodontal disease
(ANUG/ANUP) - abscesses of the periodontium
- periodontitis associated with endodontic lesions
- developmental or acquired deformities and conditions
What are the BPE scores?
0 - healthy ginigval tissues. no BOP
1 - BOP, pockets <3mm, no plaque retention factors
2 - pockets <3mm, plaque retention factors
3 - pockets 3.5-5.5mm in deepest area
4 - pockets >5.5mm
* - furcation involvement
What are the treatment options for the BPE scores?
0 - OHI 1 - OHI 2 - OHI and removal of PRF 3 - OHI, scaling and root planing 4 - OHI, scaling, root planing (surgical or non surgical)
what are risk factors for periodontal disease?
smoking, poorly controlled diabetes
What are features of a periodontal abscess?
tooth is usually vital
pain on lateral movements
tooth usually mobile
loss of alveolar crest on x-ray
What are features of a periapical abscess?
tooth is usually non-vital
TTP vertically
tooth may be mobile
loss of lamina dura on x-ray
What comes under the banner non-surgical treatment planning?
Oral hygiene instruction, mechanical plaque control (tooth brushing and interdental cleaning), chemical plaque control
scaling and root surface debridement
What are contraindications to periodontal surgery?
poor plaque control
systemic diseases
smoking
teeth with poor long term prognosis
Types of surgical periodontal intervention?
apically repositioned flap, osseous surgery (osteoplasty, ostectomy), furcationplasty, tunnel preparations, root resection, hemisection, extraction, gingivectomy guided tissue regeneration (bone grafts, enamel matrix derivatives), mucogingival surgery (free grafts or pedicle grafts)
What is supportive periodontal therapy?
success of treatment is characterised by reduction in BOP, reduction in pocket depth and change of gingival contour.
need constant monitoring of BOP and pocket depths and plaque levels and radiographs
6ppc 8-12 weeks after treatment
What is Millers classification of ginigval recession?
Class I - recession does not extend past MGJ, no interdental bone loss
Class II - recession just beyond MGJ, no bone loss
Class III - recession to or beyond MGJ, some interdental bone loss, no movement of teeth
Class IV - recession to or beyong MGJ, interdental bone loss, malpositioned teeth
Who gets periodontal support care and what is included
anyone who has had perio treatment. if pts arent given supportive therapy they are 6x more likely to lose teeth
3month intervals for sub and supragingival plaque removal. OHI. 6PPC every 12 months (SDCEP guidelines)
What is included in supportive periodontal care?
- examination - looking for anything that can affect their plaque retention factors and what factors have changed since last evaluation
- treatment options - scaling and RSD - but not <3mm sulci
- reporting, cleaning, scheduling for further treatment - motivation, check reason for recurrence
What are reasons for perio disease recurrence after successful treatment?
- Inadequate or insufficient treatment that has failed to remove all the potential factors favoring plaque accumulation.
- Incomplete calculus removal in areas of difficult access. • Inadequate restorations placed after the periodontal treatment was completed.
- Failure of the patient to return for periodic checkups. This may be a result of the patient’s conscious or unconscious decision not to continue treatment or the failure of the dentist and staff to emphasize the need for periodic examinations.
- Presence of some systemic diseases that may affect host resistance to previously acceptable levels of plaque.
What are treatment options for pockets of 6mm?
- root surface debridement
- cause related therapy
- nothing
- open flap curattage
How would you consent a patient for treatment?
explain risks explain benefits explain what happens if no treatment likely chance of success other possible treatment options explains the cost
When you are treating a paitent, they complain of central crushing pain in their chest. what is the most likely diagnosis and what is your management?
- MI or angina
- ask pt if they have had this before
- ABCDE
- give O2 - 15L/min with non rebreather mask
- sublingual GTN 2x400ug actuations (repeat after 3 mins)
- call ambulance
- give 300mg crushed asprin
When do you review treatment in a perio patient and why?
need to wait at least 6 weeks, best 8 to assess whether junctional epithelium has reattached, but not too long as can get re-colinisation and calculus preventing healing and need to re-treat
What findings would suggest that perio treatment has been successful?
no BOP reduction in pocket depts to <4mm increased tone of ep reduction in gingivitis and inflammation reduction in plaque and calculus levels
If a perio patient has a traumatic occlusion, how would you proceed?
HPT
correct any premature contact areas
dahl appliance if severe
BRA at night
what are local causes of tooth mobility?
attachment loss widening of PDL morphology roots length of roots inflammation PA lesions trauma
Patient attends your clinic with a periodontal abscess - outline your treatment
Hx of the infection Rx of infection administer LA establish drainage - through pocket or incise the heaviest part of abscess gentle sub gingival debridement HSMW if systemic - metronidazole 400mg TID 5 days HPT and maintenance
How would you treat a perio-endo lesion?
These need treatment of the perio condition - so sub gingival RSD and RCT to treat endo
When would you perform a 6PPC?
on any sextant scoring 3
whole mouth if any sextant scores 4
before and after treatment (SDCEP_)
after treatment only (BSP)
What information can you gain from a 6PPC?
mobility pocket depth LOA BOP teeth present furcal involvement sites with LOA
What are problems of the 6PPC
assumes average root lengths probing force/angulation calculus inflammation cooperation
What are treatment options for a tooth with furcation involvement (score 3)
furcationoplasty sectioning the tooth after RCT guided tissue regenetation expose more of the furcation to ease cleaning XLA
why is there a difference between vertical and horizontal bone loss?
occlusal trauma (glickmans theory) zone of destruction from plaque and thickness of cortical bone (waerhaugs theory) plaque traps
what different factors are considered when diagnosing aggressive or chronic periodontitis?
rate of destruction age of patient medical history family history sites affected degree of bone loss general OH
How do you treat ANUG?
ultrasonic debridement
hydrogen peroxide MW/CHX
OHI
metronidazole 400mg TID 3 days
What are indications for the use of CHX?
post oral surgery post periodontal surgery full mouth disinfection where OH is difficult root canal irrigant RAS chemotherapy pts to maintain OH ANUG candidal infection if at risk of secondary infection with PHG
how does biofilm develop?
adhesion colonisation accumulation develop complex community disperse
give virulence factors for p ging
biofilm formation LPS endotoxin production fimbrae for adhesion and invasion proteases complex plysaccharide production
What are some different constituents of saliva?
immunoglobulins lipase lysozyme mucins lactoperoxidase lactoferrin amylase
What are oral signs of anaemia?
beefy tongue RAS gingivitis burning mouth/dysasthetia glossitis angular cheilitis
What are oral signs of leukaemina?
gingival hyperplasia bleeding petechiae ulceration swellings predisposition to infections
List reasons a patient could be taking warfarin
heart valve replacement
atrial fibrillation
thrombophilia
ischaemic stroke
What can you do for a patient with haemophilia?
check with their consultant infiltrations, not blocks simple treatments not disrupting the gingivae supragingival scaling restorations
what are the types of vertical bony defects?
infrabony - one wall, two wall, three wall. interproximal crater
What is a periodontal abscess and how is it managed?
acute exacerbation of existing perio disease (from trauma or blockage)
LA, incise, drain, gentle pocket debridement short of base - stops spreading infection.
OHI, CHX, HSWM, XLA is possible. ABs if systemic/immunocompromised. HPT and review
what is the difference between generalised and localised aggressive perio?
generalised = 3 tteh other than 6s and 1s
localised - patient is generally healthy, rapid loss off bone, familial aggregation, low levels of plaque, around 30s onset
If there is a cause - then it is not aggressive perio - it is perio secondary to the cause
how do you treat aggressive perio?
daily removal of plaque and modify behaviours
What are the bactieral virulence factors causing perio?
leukotoxin, endotoxin, collagenases, fibroblast inhibitory factor, soluble heat labile factor
What are risk factors for causing Ag perio?
smoking
genetics
inherited diesases
papillon lefevre syndrome
how can you detect for the CAL to be below furcation?
probe - can use neighbour probe for finding furcation
radiographically
What are the grades of furcation involvement?
I - up to 3mm horiztontal attachment loss
II - >3mm horizontal attachment loss, not through and through
III - through and through
What are the different treatment options for furcation involvement?
repair - NST, ST
regenerate - GTR, graft
eliminate - tunnel, root resection, hemisection, XLA
palliate - supportive care
NST is best for grade I
What are aetiological factors for gingival recession?
iatrogenic toothbrushing traumatic occlusion trauma fraenal attachments - high or aberrant
What are some surgical procedures to treat gingival recession?
free soft tissue (free ginigval, connective tissue)
pedicle soft tissue (rotational, laterally positioned, transpositional)
advanced flap (coronally/semilunar coronally positioned)
