Periodontology tutorials Flashcards by Ziyad Zakariya

What are the signs of periodontal stability?

BoP < 10%
PPD < 4mm
No bleeding on probing @ 4mm sites

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What are the signs of patient engagement in perio treatment?

BoP < 30%
Plaque < 20%
or > 50% improvement in both

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What are 3 ideal outcomes of periodontal treatment?

Reduce inflammation and pocket depths
Regain attachment of long junctional epithelium
Reducing rate of progression of alveolar bone loss

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Based on SDCEP criteria, What proportion of >5mm pocket depths would a patient have following successful periodontal treatment?

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What is the difference in quality of debridement and efficacy between ultrasonic scalers and hand scalers?

If done with correct technique, there is no difference

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What is the definition of a non responding site?

Pocketing that remains the same depth following non-surgical instrumentation

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Give 4 treatment options for non responding sites

Continued non surgical instrumentation - re-attempt step 2
Surgical debridement through surgical access to pocket
Resective surgery
Regenerative surgery

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What is periodontal access surgery ?

Surgical debridement of full depth of pocket which cannot be accessed with non-surgical instrumentation

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What is resective surgery?

Removal of pocketing by changing archtecture of hard and soft tissues to achieve shallow probing depths

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What is regenerative surgery?

Adding material into infrabony or furcation defects to regenerate attachment

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What is the rationale behind step 3?

To treat non-responsive sites to step 2 with
* targeted repeated non surgical instrumentation
* To consider the use of invasive surgical techniques to gain access for subgingival PMPR in deep pockets
* Regenerate or resect areas

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What is a residual pocket?

A deep pocket that persists after carrying out initial periodontal therapy ( step 1 and step 2)

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What PPD is a deep residual pocket?

> 6mm

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What PPD is moderately deep residual pocket?

4-5mm

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In a stage III periodontitis patient with residual pockets after the first and second step of periodontal therapy, when is it recommended to take access flap surgery instead of repeated subgingival PMPR?

> 6mm

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If referral/expertise is not an option, what is the minimum level of primary care required for management of residual pockets associated with/without infrabony defects or furcation involvement after completion of step 1 and step 2 of periodontal therapy? (2)

Repeated subgingival instrumentation ( with or without access flaps)
Regular supportive periodontal care than includes subgingival instrumentation

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A patient with poor engagement with OHI wishes to undertake periodontal surgery. What is the recommendation for this?

This is a contraindication as surgical interventions need excellent OH compliance

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What is the adequate management of residual deep pockets in Stage III after step 1 and step 2

Resective surgery

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What is the adequate management for residual deep pockets associated with infrabony defects (>3mm) after step 1 and step 2 ?

Step 3 - targeted non surgical sub-gingival instrumentation / Refer to secondary care

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Management of molars with Class 2 or 3 furcation involvement and residual pockets after step 1 and step 2 ?

Step 3 - targeted non surgical subgingival instrumentation / Refer to secondary care
Furcation involvement alone is not an indication for XLA

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Management options for maxillary interdental class II furcation involvement after step 1 and step 2 ?

Step 3 involving non surgical instrumentation
Refer for
regenerative surgery
root resection
access surgery

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Management options for class III furcation involvement after step 1 and step 2?

Step 3
* non surgical instrumentation
* access surgery
* tunneling
* root resection

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What is the choice of regenerative biomaterials for promoting healing of residual deep pockets associated with a deep infrabony defect? or class II molar buccal furcation involvement?

Regenerative surgery with
* barrier membranes (deprotinised bovine bone mineral or collagen)
* enamel matrix derivative

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What is gingivitis?

Presence of bleeding on probing, erythema and oedema, with no loss of attachment or bone loss

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What is chronic periodontitis?

Loss of gingival and periodontal tissues from current or historic chronic inflammation of the periodontium

What is necrotising ulcerative gingivitis?

Immunosuppression resulting in oral commensal bacteria causing necrosis and ulceration of the gingival tissues with no bone loss

What is necrotising ulcerative periodontitis?

Immunosuppression resulting in oral commensal bacteria causing necrosis and ulceration of the gingival tissues with bone loss

What is a periapical abscess?

A periapical pathology with pus accumulation associated with an infected tooth

What os a periodontal abscess

A pathology associated with localised accumulation of non draining pus within the gingival wall of periodontal pocket associated with rapid tissue destruction

What is an endo-perio lesion?

* Pathologic communication between pulpal and periodontal tissues

* Stage 4 grade C generalised periodontitis * complaining of pain in LLQ * History of deep pocketing in posterior quadrants * Multiple >6mm pockets in LLQ * You take clinical photographs and a PA of 36 Describe the clinical presentation?

Swelling of region associated with LL6, absence of erythema or bleeding on visual inspection

Deep pocketing associated distal root of 36, large >3mm infrabony defect distal of 36

* Mobility * Sensibility testing

Previous PMPR resulted in reattachment of junctional epithelium which trapped bacteria deep in the pocket, long term proliferation of non-draining pus associated with periodontal infection causing significant localised bony destruction

* Deep pocketing * Periodontitis patient * Poor access to site for cleaning * Impaction of food * Diabetes

Using the appropriate classification, what is the differential diagnosis?

Periodontal abscess

* Careful sub-gingival PMPR short of base of pocket * Drain abscess * Prescribe analgesia * AB if systemic involvement or spreading infection * CHX 0.2% rinse 2xD for 7 days for symptomatic relief

* Pt complaining of pain in URQ anteriorly * He had some dental work done on tooth in the quadrant a couple months ago, but since moving is unable to visit his dentist * You take clinical photographs and two radiographs of tooth 12 Describe the clinical presentation?

Sinus present at mid-apical level of tooth 12

* Post placement, radiopacity present on distal surface of the post , possibly perforation

Perforation during post placement

Endo-perio lesion

* Refer for re-rct

What is the diagnosis ? and describe 5 clinical presentations?

** Necrotising gingivitis/periodontitis ** * Severe gingival bleeding * necrosis of interdental papilla * Pseudomembrane formation * lymphandenopathy * possible associated bone loss

What symptoms may the patient have?

* Pain * Halitosis * foul taste

Give 5 risk factors for this condition?

* HIV/AIDS * immunosuppression * Stress * Fatigue * Malnourishment * alcohol/smoking

A different patient presents with same presentation but have significant bone loss away from the periodontium, what is the diagnosis?

Necrotising stomatitis

What initial treatment would you carry out?

* Supragingival PMPR * CHX MW twice a day for 7 days * AB if systemic symptoms (metronidazole) * OHI * Return in 3 days for subgingival PMPR * Treat predisposing systemic factors

At review visit the patient condition has stabilised, but there is evidence of gingival loss. Give a surgical option for the management of Superficial craters and Deep craters?

* Superficial - gingivectomy / gingivoplasty * Deep craters - Periodontal flap surgery

Describe the clinical presentation?

Erosion/atrophy of gingivae of tooth 22

What symptoms may the patient have?

* Pain / sensitivity to gums

The patient mentions he had a restoration placed on that tooth a few days ago, what may have caused this lesion?

Acid-etch leaking into gingivae

What initial treatment would you give this patient?

Desensitising agent , topical anaesthetic (lidocaine)

Describe the clinical presentation?

Full thickness erythema of the gingivae

What are your differential diagnosis? (4)

* Bullous condition * Oral lichen planus * Systemic lupus erythmatosus * Primary herpatic gingivostomatitis

after further investigations, the condition turns out to be Primary Herpatic gingivostomatitis Give 2 ways in which a sample may have been collected for lab testing?

* Oral swab * Oral rinse

What information is included on a virology request form? (6)

* Patient information * Clinician information * Date and time sample was taken * Sample type * Test required * Brief clinical details of the presentation/differential diagnosis

What treatment would you carry out?

* Reassure and Educate patient about the condition * Soft diet and hydration * Rest and analgesia * If the patient is immunosuppressed = prescribe acyclovir

Describe the clinical presentation?

Multiple unilaterally-resenting small ulcerations on left side of hard palate

What is the most likely condition associated with this?

Shingles

What 3 symptoms might the patient have?

* Severe pain * Eating difficulties * Parasthesia

What is the pathogenesis of this condition?

** Caused by Varicella-Zoster ** * Initially presents as chicken pox in childhood * Retrograde transport to the trigeminal ganglion * Triggers lead to anterograde transport leading to shingles

What four things that may trigger this condition?

* Immunosuppression * Ultraviolet light * Fever * Diabetes

How can this be transmitted?

* Direct contact * Air borne * Droplet

What 4 complications associated with this condition?

* Post herpetic neuralgia * Secondary bacterial infections * Ophthalmic zoster * Ramsay-hunt syndrome

What treatment would you carry out ?

* Prescribe aciclovir 800mg 5xD for 7 days * Preventative treatment

What 3 preventative treatment would you carry out for this condition?

* Early detection for prophylaxis 5% aciclovir topical cream * Manage triggers * HZV screening

Describe the clinical presentation?

Gingival hyperplasia

Give 3 drug types and conditions that may cause this?

* Immunosuppressants - cyclosporine * Calcium channel blockers - amlodipine * Anticonvulsant - phenytoin

What is the pathogenesis of this condition if induced by drugs?

* Drug interacts with fibroblasts * Overstimulation leads to gingival overgrowth and false pocketing

What are 4 risks associated with this condition?

* Plaque accumulation * Difficulty fulfilling oral hygiene * Caries * Periodontal disease

What is the rationale behind step 4?

* Maintain stability of periodontal disease * Preventing relapse of periodontal disease based on risk-based recall a combination of step 1 and 2

Following completion of active periodontal therapy, what are two diagnostic categories for step 4 patients?

* Periodontitis patients with a healthy reduced periodontium * Periodontitis patients with gingival inflammation

Give 5 preventative or therapeutic interventions used on step 4?

* OHI Reinforcement TIPPS at recall appointments * Repeated targeted PMPR * Risk factor control and behavioral change * Use of adjuncts such as toothpastes and mouthwashed * Records keeping

At what intervals should supportive periodontal care appointments be? and based on what?

3-12 months , based on risk and status of periodontal disease

What is the recommended interdental cleaning method for SPC patients?

Interdental brushes

What is the recommended adjunct that can be considered in specific SPC patients? and why?

* Antiseptics = CHX * To control gingival inflammation

What are the recommended 2 risk factors which should be controlled in SPC?

* Smoking * Diabetes

* Mr floss is a new patient * C/O - bleeding on brushing , loose 22 getting worse * SH - 50 yrs old , non-smoker * O/E - 12,21,22 - Grade III mobile 25,37,45 - Grade II mobile 11,24,36,46 ,47 - Grade I mobile BPE 4/4/4 4/3/4 * Describe the patient oral hygiene?

** Poor oral hygiene ** * interdental and posterior plaque * heavy calculus in lower anterior * Caries posteriorly on radiograph

* Mild oedema and erythema especially on 12,22 * Loss of interdental papillae * Recession on lower anteriors 41/31/32

* Heavily restored posterior dentition * Mild staining in palatal pits upper 2s

* Diet diary * Modifies plaque and bleeding scores * Full mouth six point pocket chart * Sensibility testing of 12

* Horizontal bone loss relative to clinical gingival presentation

* Generalised periodontitis, Stage 4 Grade ,C Risk factors non , currently unstable

* Angular bony defect

Give the 4 classes of angular bony defects types

* Class I = one walled * Class II = two walled * Class III = three walled * Class VI = combined osseous defects

How do angular bony defects form?

They for due to plaque accumulation in a specific region causing scalloping , may be due to * Endo-perio lesion * Occlusal trauma * Periodontal abscess

How may angular bony defects affect the treatment of a periodontal patient? (3)

* May respond poorly to non surgical instrumentation * May require treatment adjuncts such as CHX * May require surgical instrumentation or regenerative surgery

Give 4 members of the team that take care of a periodontal patient?

* General dental practitioner * Dental hygienist * Dental nurse * Oral health educator * Periodontal specialist

When prescribing LA, What 4 details should be included in Patient specific directions?

* Type of anaesthetic * Maximum does of anaesthetic * Frequency * Route of adminstration

When should periodontitis patients be referred ?

* Step 2 patients who have not responded to initial non-surgical therapy * Who show engagement with OHI and improvement in life style in risk factor management * Grade C patients after initial therapy

What information should be included in a referral letter?

* Referrer details * Patient details * Medical history * Social history * Clinical information

When should a dentist prescribe LA to hygienist ?

As required