Step 3 and Surgery Flashcards
What were the S3 guideline developed using?
Systematic review of evidence
Representative guideline group
What should we do before we start the steps for S3 guidelines pathway?
Extract hopeless teeth
What should we do at step 1 in periodontal treatment?
Explain disease- RF/treatment options
OHI- support behaviour change
-> provide tailored advice- ID cleaning, adjunctive toothpaste and mouthwash
Reduce risk factors- remove PRF, smoking cessation, diabetic control
PMPR- supra and sub gingival
Select recall period in line with RF
What is done following step 1?
Non-engaging patient- repeat
Engaging patient- step 2
-> consider referral
What are the signs of an engaging patient?
> 50% reduction in plaque and bleeding scores
Plaque levels- less than or equal to 20%
Bleeding levels- less than or equal to 30%
What is done in step 2 of the S3 guidelines?
Subgingival PMPR- hand and ultrasonic
Reinforce OHI, risk factor control, behaviour change
Adjunctive systemic antimicrobials
What is done following step 2?
Re-evaluate after 3 months
Stable- step 4
Unstable- step 3 (managing non-responding sites)
What is done in step 3 of the S3 guidelines?
Reinforce OH, RF control, behaviour change
4-5 mm pockets- re-perform Subgingival PMPR
> 6mm pockets- consider alternative causes
-> consider referral for surgery
If referral not possible - re-perform sub gingival PMPR
What is done following step 3 is successful?
Maintenance recall (step 4)
-> intervals of 3-12months depending on patient
What is done in step 4?
Supportive care
Reinforce OH, RF control, behaviour change
Regular targeted PMPR
Adjunctive toothpaste and/or mouthwash to control inflammation
When are systemic antibiotics used in periodontal treatment?
Only in selected cases once combined with mechanical disruption of biofilm
What is a biofilm?
Aggregate of microorganisms embedded within a self-produced matrix of extracellular polymeric substance (EPS) – DNA, proteins, polysaccharide
-> resistance to antibiotics, antibacterial agents and immune system of host
What is the treatment protocol for combining antimicrobials and PMPR?
- OH
- Supragingival/Subgingival PMPR of all indicated sites (ideally within 1 week)
- 400mg metronidazole TID for 7 days (+/- Amoxicillin 500mg TID 7 days)
What are the contraindications for metronidazole?
Alcohol intake
Warfarin- increases anticoagulant effect
Pregnancy
What are the ADV of local antimicrobials?
- Reduced systemic dose
- High local conc
- Superinfections unlikely
- Drug interaction unlikely
- Site specific
- Patient compliance not an issue- applied in appt
- Can use non-systemic agents
What are the disadvantages of local antimicrobials?
Expensive
Still require RSD/biofilm disruption
Limited indications
When is periochip (local antimicoial containing CHX) used?
If persisting pockets >5mm
Always with PMPR
Only in isolated pockets- if many in one area do OFD or systemic antibiotics and PMPR
If perio abscess- after evacuation of pus and PMPR
What are examples of antibiotic local antimicrobials for perio?
1 Arestin – 1 mg minocycline HCL microspheres
2. Atridox – doxycycline hyclate 10 %
3. Elyzol - 25 % metronidazole
4. Perio stat- 20mg doxycycline 2x daily for 3 months (sub therapeutic but inhibits collagenases)
What is an alternative therapy used as local antimicrobial for perio?
PerioWave- photo-disinfection
-> irrigate, illuminate
How is OFD carried out?
Provides improved visibility and access:
1. Intracrevicular incision is made through base of pocket and entire gingivae
2. Full thickness muco-periosteal flap is raised
3. Removal of granulose tissue and PMPR of root surfaces
4. Replace flap and suture
What POI are given following open flap debridement?
Reinforce mechanical plaque control
Soft tooth brush
CHX for 1-2 weeks
Analgesics- 2-3 days
Consider AB
Remove sutures after 1 week
What are the indications for a gingivectomy?
Gingival enlargement or overgrowth
Idiopathic gingival fibromatosis
False pocketing
Minor corrective procedure
CLS
To allow plaque control
To allow restorative dentistry
To improve aesthetics
How is gingivectomy carried out?
- Identify bottom of pocket with probe
- Mark outer aspect to create bleeding point
- Make scalloped external bevel incision (45 to long axis) apical to bleeding point
- Remove detached gingicae
- Consider gingivoplasty to create aesthetic contour
- PMPR of root
- Periodontal dressing to reduce post-op discomfort and prevent plaque colonisation (7-days)
How does exposed tissue heal following a gingivectomy?
Secondary intention
What is regenerative therapy used for?
Infra-bony/Infra-radicular defects
What are the objectives of regenerative therapy?
Obtain shallow, pockets by reconstruction of attachment apparatus
Limit recession of gingival margin
What are the aims of RPT?
Increased periodontal attachment in severely compromised teeth
Decrease deep pockets to make them easier to maintain
Reduce vertical, horizontal and furcation defects
What is the difference between horizontal bone loss and vertical?
Horizontal- supra-bony pocket
-> base of pocket is located coronally to alveolar crest
Vertical (angular)- infra bony pocket
-> subcrestal component involves root surface of one tooth
What is a crater?
Infrabony defect affecting 2 adjacent teeth
What are the classifications of infra-bony defects?
1 wall
2 wall
3 wall
What are the treatment options for Infra-body defects?
Closed/open root PMPR
-> healing by repair
Pocket elimination with osseous resection (historic)- remove infected soft and hard tissue
Regenerative techniques
What are the aspects of the triad of tissue engineering?
Scaffold
Cells
Signalling molecules
What are the strategies for Periodontal regeneration?
Space maintenance and clot protection
Selective cell repopulation
Provision of progenitor cells
Use of biological mediators – signaling molecules
-> combination
What are examples of biological mediators that may be used in PRT?
Platelet-derived growth factor
Insulin growth factor
Transforming growth factor
Bone morphogenetic proteins
Prostaglandin
Fibronectin
Enamel matrix proteins
What is Emdogain?
Enamel matrix protein derived from the porcine tooth germ
-> forms a matrix on the root surface that mediates the production of cementum
What is guided tissue regeneration?
Place barriers membranes of different types to cover bone and PDL temporarily separating them from gingival epithelium
-> prevents epithelial migration into wound
-> favours repopulation of area by cells from PDL and bone
What are the types of bioabsorbable membranes in guided tissue regeneration?
Natural- Collagen, connective tissue, oxidised cellulose
Synthetic- poly lactic acid, allloderm, polyurethanes, polyglycolic acid
What are the non-absorbable membranes used in guided tissue regeneration?
Millipore filter
GORE-TEX
Rubber dam
Ethyl cellulose
What are the objectives of bone grafts in guided bone regeneration?
Space maintenance and clot protection
Osteoconduction- scaffold
Osteoinduction- promoting osteoblast activity
Osteogenesis- osteoblast present in graft
What are the types of bone grafts?
Autografts
Isografts- genetically identical
Allograft- same species
Alloplasts- synthetic
Xenografts- different species
Ceramics/bioactive molecules- composite grafts
What are the steps in bone grafting in RPT?
- Identify vertical defect
- Use modified papilla ;preservation technique
- Root surface PMPR
- Apply graft
- Replace flap and suture
What is a furcation?
Anatomical area where roots divide
-> can only occur in multi-rooted teeth
What is a furcation defect?
Bone loss at the branching point of the roots
-> makes extraction in molars 8x more likely
How is diagnosis of furcation made?
Clinical exam
-> visual assessment
-> probing- nabers probes
Radiographic assessment
How are furcations graded?
1- horizontal attachment loss less than one-third (<3mm)
2- Horizontal attachment loss- more than one third (>3mm)
3- through and through (one furcation entrance to another)
What are the treatment options for furcation involvement?
Palliative-maintain plaque control (if non-symptomatic)
-> PMPR
Repair (small)
-> PMPR/OFD
Regeneration
-> GTR, GBR, emdogain
Eliminate
-> root resection
-> furcation plasty
-> tunnel procedure
-> extraction
What are the indications for periodontal regeneration?
2 or 3 walled proximal defects
Grade 2 furcation defects in mandible
Grade 2 buccal maxillary furcation defects
What are the issues with the regenerative approach for furcations?
Difficult to debride
Relatively avascular
Why is GTR preferred to OFD for furcations?
Greater vertical and horizontal bone fill
Better results in mandible
GTR and GBR in combination is better
What is the tunnel procedure?
Bone and tooth are recontoured to allow insertion of ID brush
What is a hemisection?
Half of the molar is extracted then other half is restored as premolar
What are the requirements for successful resective procedures?
Adequate endo
Remaining roots should not be hyperomobile
Root seperation and removal must be feasible
Remaining tooth structure must be restorable
Patient must be able to maintain plaque control
Additional caries prevention for exposed root
What would indicate extraction of tooth with furcation defect?
Recurrent symptoms
Little remaining attachment
Gross mobility
Non-functional tooth
What are the issues when treating vertical bone defects?
Difficult to instrument due to being very narrow, poor access, poor vision
