step 3

Question 1

What are the aims of step 3 treatment?

Answer 1

To treat areas not responding to step 2 with the purpose of gaining further access to subgingival instrumentation or aiming at regenerating or resecting the lesions that add complexity in periodontitis management (infrabony defects and furcation lesions)

Question 2

Give 2 examples of local microbials

Answer 2

Disinfectants - chlorhexidine
Locally delivered antibiotics

Question 3

What is a periochip?

Answer 3

A 2.5mg chlorhexidine digluconate biodegradable gelation matrix inserted into a pocket following PMPR
No significant differences in CAL

Question 4

What is dentomycin periodontal gel?

Answer 4

2% minocycline gel
Syringe delivered into pocket following subgingival PMPR
3-4 applications every 14 days
Can lead to short term improvements in PPD and CAL

Question 5

What is the BSP and SDCEP guidance on local antimicrobials?

Answer 5

May be considered as an adjunct to subgingival instrumentation
Not recommended for routine care and management for periodontitis patients

Question 6

How do systemic antimicrobials work?

Answer 6

By suppressing the bacterial species responsible for biofilm growth, leading to a less pathogenic oral environment

Question 7

What is the BSP and SDCEP guidance for using systemic antimicrobials?

Answer 7

Not recommended - don’t want antibiotic resistance

Question 8

When should antibiotics be considered and how should they be given?

Answer 8

Periodontitis grade C in younger adults where a high rate of progression is documented
Full mouth instrumentation in a 24 hour period followed by 400mg metronidazole three times daily for 7 days

Question 9

What is host modulation therapy?

Answer 9

Uses local or systemic drugs as adjuncts to conventional periodontal tx aiming to modify the destructive aspects of the host inflammatory response to the microbial biofilm
Uses a sub-antimicrobial dose of doxycycline

Question 10

Name 4 other drugs used in host modulation therapy

Answer 10

Any from:
- statins
- bisphosphonates
- probiotics
- NSAIDs
- Omega-3 fatty acids
- metformin

Question 11

When is periodontal surgery indicated?

Answer 11

In sites where good quality non-surgical periodontal tx has not resolved periodontal pocketing and there is ongoing inflammation/infection
In periodontal pocketing ≥6mm
In cases with suitable pt, tooth and defect factors:
- no medical contra-indications
- teeth of reasonable prognosis
- infrabony defects, furcation involvement

Question 12

What pt factors should be considered in step 3?

Answer 12

OH - <20% plaque, <10% marginal bleeding
Quality of maintenance care available and pt access to it
Ability of pt to tolerate procedure
Likely pt compliance post surgery
Cost and pt acceptance
Aesthetics of the site and potential for post-op recession

Question 13

What tooth factors should be considered in step 3?

Answer 13

Access to non-responding sites
Shape of defect
Prosthodontics/endodontic considerations
Tooth positioning/anatomy:
- tilting
- overeruption
- proximity to adjacent roots
- enamel pearls
- ridges/root grooves

Question 14

What systemic/medical factors should be considered in step 3?

Answer 14

Smoking
Unstable angina, uncontrolled hypertension, MI/strokes within 6 months
Poorly controlled diabetes
Immunosuppressed pt
Anticoagulants - DOACs, warfarin, antiplatelets

Question 15

What is included in the consent process in step 3?

Answer 15

Reason for providing tx
Other options for management, including no tx
Consequences of not providing surgery
Nature of surgical procedure
Post-op consequences - positive and negative
Requirement for ongoing post-op maintenance
Costs

Question 16

What are the aims of access surgery/open flap debridement?

Answer 16

Access to areas of continued inflammation or infection
Usually for areas PPD≥6mm
To allow access for surgical debridement

Question 17

What are the steps of access surgery

Answer 17

Tooth with deep pocket, god superficial gingival health and good OH
Full thickness flap raised
Defect granulation tissue removed and root surface curettage to leave clean root surface and bone
Suture and aim for primary closure
Healing at 3 months should show resolution of periodontal pocketing, may see recession due to previous horizontal bone loss
Healing by repair and long-epithelial re-attachment to the root surface

Question 18

What is particularly at risk of relapse after periodontal surgery?

Answer 18

Angular bone defects

Question 19

What are the indications of regenerative periodontal surgery?

Answer 19

Infrabony defects 3mm or deeper as assessed radiographically (this is not the proving depth
Class 2 or 3 furcation defect

Question 20

What is guided tissue regeneration (GTR)?

Answer 20

Uses barrier membranes and bone-derived grafts
Membrane prevents gingival epithelium or connective tissue from entering the bone defect and to induce osteogenesis and PDL regeneration
Creates a space to act as a scaffold for vascularisation and cell ingrowth from base of defect

Question 21

What is enamel matrix derivative (EMD)?

Answer 21

Called Emdogain
Tissue healing agent derived from porcine tooth germ
Forms a matrix on the root surface that mediates the production of cementum by modulating the wound healing process
This can induce the regeneration of a functional attachment in periodontal procedures

Question 22

Why are furcation lesions treated?

Answer 22

Clinically - good survival rates over 4-30 years - class 2 better than 3
Economic - tooth retention after perio surgery is more cost effective than extraction and replacement with implant supported prosthesis
Pt preference - strong preference for tooth retention

Question 23

What are the 4 options for furcation surgery?

Answer 23

Regenerative surgery
Root resection
Root separation
Tunnelling

Question 24

What are the 3 types of regenerative surgery?

Answer 24

Mandibular class II
Maxillary class II (buccal)
Maxillary class II (interdental) can also consider root separation or root resection in these cases

Question 25

What is required for root resection/root separation?

Answer 25

Good endo tx
Good root separation radiographically - not fused
Roots should not be hypermobile
Remaining tooth structure should be restorable
Must have motivated pt, excellent OH and low caries rate

Question 26

What is tunnelling, when is it carried out and what are the risks?

Answer 26

Bone and soft tissue re-contoured to allow insertion of interdental brush
Carried out in mandibular class 3 lesions
Risks - root hypersensitivity and root caries