Step 2 Flashcards
Why do we re-evaluate after step 1
Re-evaluating after step 1 is an opportunity to identify successes and failures in step 1 treatment and to encourage further positive changes, seek reasons for failures, and possibilities to modify any suboptimal outcomes from step 1.
Success of periodontal treatment is dependent patients engaging with
Carrying out good oral hygiene
Modifying risk factors (if possible)
What is an engaging patient
Favourable improvement in OH indicated by >= 50% improvement in plaque and marginal bleeding scores
OR
Plaque levels less than 20% and bleeding levels less than 30%
OR
Patient has met targets outlined in their personal self-care plan as determined by their healthcare practitioner
What results would a non-engaging patient have
Insufficient improvement in OH indicated by less than 50% improvement in plaque and marginal bleeding scores
OR
Plaque levels greater than 20% and bleeding greater than 30%
OR
Patient states preference to a pallative approach to periodontal care
What palliative periodontal care can be given to non-engaging patients
If the patient remains non-engaging, they may enter a cycle of palliative periodontal care (PCP), which involves regular removal of calculus and re-motivation. Although less effective than full treatment, PCP could prolong tooth retention in non-engaging patients
When repeating step 1 what should be done
- find out WHY!
- remotivate and reinforce preventive advice
- Advise subgingival instrumentation will not give optimal results if plaque control is suboptimal
- Supra and subgingival PMPR of clinical crown to facilitate good oral hygiene
What does step 2 involve
Subgingival instrumentation (root surface debridement/PMPR on root)
1. Reinforce OH, risk factor control, behaviour change
2. Subgingival instrumentation, hand or powered (sonic/ultrasonic)
3. Use of adjunctive systemic antimicrobials determined by practitioner accredited for level 2 and 3 care
What isthe terminology to replace scaling
Subgingival PMPR
What does subgingival PMPR refer to
the removal of contaminated material, leaving the root surface smooth
How do you prepare for subgingival instrumentation
If BPE4 – you will have a 6PPC – this will guide where you need to carry out the subgingival instrumentation
If BPE3 – you may NOT have a pocket chart so you should look for the sextants that score 3 and identify which surfaces of which teeth have the 5-5mm pockets.
Check if the patient has radiographs - you should have these visible as this helps visualize the tooth/root anatomy, and can help visualize the shape of the pocket.
Decide which sites you plan to complete at this visit.
Inform the patient what you plan to do.
What is full mouth debridement
All the sites with pockets >3mm are instrumented - either at one visit or two visits within 24 hours
What is full mouth disinfection
All the sites with pockets >3mm are instrumented - either at one visit or two visits within 24 hours. The pockets are irrigated with 0.2% Chlorhexidine (CHX) and the patient uses CHX spray and mouthwash for 1-2 weeks
What is the pros and cons for either full mouth or quadrant approach
Both methods are equally effective
Limited additional benefit of a single visit or within 24 hours
The original full mouth protocol is intense and may not be realistic in practice
S3 guidelines suggest that subgingival periodontal instrumentation can be performed with either quadrant-wise or full mouth delivery within 24 hr.
The full mouth approach causes an acute systemic inflammatory response – The S3 guidelines advise that clinicians should consider the general health of their patients when planning full mouth treatment
When is perio treatment with antibiotics carried out
Usually only in specialist care and is not recommended
What effects does supragingival and subgingival PMPR have on the microflora in the mouth
Significantly reduces the levels and prevalence of pathogenic species –
e.g P. gingivalis, T. denticola – can reverse dysbiosis
Complete elimination of these species is unrealistic
How does supra and sub PMPR affect hard and soft tissues
Decrease in gingival inflammation
Shrinkage of the gingival tissues leads to recession
Increase in collagen fibers in the connective tissue beneath the pocket and formation of long junctional epithelial attachment
This results in decrease in pocket depth and increase in attachment level
Very little change in bone height at sites with horizontal bone loss
Vertical defects display some infill and gain in bone height
What are the main effects of supra and subgingival PMPR
Decrease in gingival inflammation
Shrinkage of the gingival tissues leads to recession
What is involved in the healing process following PMPR
Gain in attachment is due to long junctional epithelium formation and improved tissue tone (inflammatory infiltrate is replaced by collagen)
Greatest changes observed 4-6 weeks after therapy
Gradual repair and maturation of tissues over 9-12 months
What causes the regain in attachment of gingiva to tooth
Gain in attachment is due to long junctional epithelium formation and improved tissue tone (inflammatory infiltrate is replaced by collagen)
Why is subgingival plaque control required for successful treatment
Without subgingival control there is
-Decreased gingival inflammation
-Limited effect on probing depth
-No change in attachment levels
-No alteration in subgingival microflora in deep pockets (>6mm)
What are the results with BOTH supra and subgingival plaque control
Decreased gingival inflammation
Reduction in probing depth
Gain in probing attachment level
Marked changes in the subgingival microbial flora
How would the exclusion of supragingival plaque control affect results
Initial reduction in inflammation and pocket depth
Pockets are re-colonised by bacteria from supragingival plaque
Disease recurs
What results indicate successful treatment
Inflammation (Bleeding on Probing) <10%
Plaque scores <15%
Reduction in Probing Depth <4mm
Gain in Probing Attachment Level
How is a patient re-evaluated
ASK
-Changes in symptoms (eg bleeding on brushing, sensitivity)
-Experience of using recommended OH aids/regimen
-Changes in MH
Look
-MPBS
-6PPC – often the ‘review chart’ - can use the ‘full chart’
-Compare the review chart with the initial chart – look at sites that have improved, and sites that have not.
-Try to work out why and what you can do next
After step 2 what happens
Re-evaluate after 3 months and then progress to step 3 or step 4 if stable
What is re-evaluation
Repetition of indices taken at baseline such as:
Probing depths
Bleeding scores
Plaque score
Tooth mobility
Furcation
Attachment levels
AND COMPARE
Why does treatment fail
Inadequate patient plaque control
-Lack of compliance
-Inadequate explanation from clinician
-Lack of dexterity
Residual subgingival deposits
-Deep pockets
-Furcation lesions, concavities and root grooves
-Inexperienced operator or not enough time spent performing instrumentation
Systemic risk factors
-Smoking
-Uncontrolled diabeties
What is supportive periodontal therapy
Plaque control must be reinforced – remotivate /re-educate patient
Examine for signs of recurrent disease
Retreat any recurrence or new disease – repeat subgingival PMPR, polishing and other treatment as necessary
Arrange recall to review the patient and monitor periodontal status
