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BDS4 Perio > Step 3 and Surgery > Flashcards

Step 3 and Surgery Flashcards

1
Q

What were the S3 guideline developed using?

A

Systematic review of evidence

Representative guideline group

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2
Q

What should we do before we start the steps for S3 guidelines pathway?

A

Extract hopeless teeth

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3
Q

What should we do at step 1 in periodontal treatment?

A

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

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4
Q

What is done following step 1?

A

Non-engaging patient- repeat

Engaging patient- step 2
-> consider referral

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5
Q

What are the signs of an engaging patient?

A

> 50% reduction in plaque and bleeding scores

Plaque levels- less than or equal to 20%

Bleeding levels- less than or equal to 30%

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6
Q

What is done in step 2 of the S3 guidelines?

A

Subgingival PMPR- hand and ultrasonic

Reinforce OHI, risk factor control, behaviour change

Adjunctive systemic antimicrobials

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7
Q

What is done following step 2?

A

Re-evaluate after 3 months

Stable- step 4

Unstable- step 3 (managing non-responding sites)

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8
Q

What is done in step 3 of the S3 guidelines?

A

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

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9
Q

What is done following step 3 is successful?

A

Maintenance recall (step 4)
-> intervals of 3-12months depending on patient

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10
Q

What is done in step 4?

A

Supportive care

Reinforce OH, RF control, behaviour change

Regular targeted PMPR

Adjunctive toothpaste and/or mouthwash to control inflammation

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11
Q

When are systemic antibiotics used in periodontal treatment?

A

Only in selected cases once combined with mechanical disruption of biofilm

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12
Q

What is a biofilm?

A

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

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13
Q

What is the treatment protocol for combining antimicrobials and PMPR?

A
  1. OH
  2. Supragingival/Subgingival PMPR of all indicated sites (ideally within 1 week)
  3. 400mg metronidazole TID for 7 days (+/- Amoxicillin 500mg TID 7 days)
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14
Q

What are the contraindications for metronidazole?

A

Alcohol intake

Warfarin- increases anticoagulant effect

Pregnancy

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15
Q

What are the ADV of local antimicrobials?

A
  • 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
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16
Q

What are the disadvantages of local antimicrobials?

A

Expensive

Still require RSD/biofilm disruption

Limited indications

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17
Q

When is periochip (local antimicoial containing CHX) used?

A

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

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18
Q

What are examples of antibiotic local antimicrobials for perio?

A

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)

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19
Q

What is an alternative therapy used as local antimicrobial for perio?

A

PerioWave- photo-disinfection
-> irrigate, illuminate

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20
Q

How is OFD carried out?

A

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

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21
Q

What POI are given following open flap debridement?

A

Reinforce mechanical plaque control

Soft tooth brush

CHX for 1-2 weeks

Analgesics- 2-3 days

Consider AB

Remove sutures after 1 week

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22
Q

What are the indications for a gingivectomy?

A

Gingival enlargement or overgrowth

Idiopathic gingival fibromatosis

False pocketing

Minor corrective procedure

CLS

To allow plaque control

To allow restorative dentistry

To improve aesthetics

23
Q

How is gingivectomy carried out?

A
  1. Identify bottom of pocket with probe
  2. Mark outer aspect to create bleeding point
  3. Make scalloped external bevel incision (45 to long axis) apical to bleeding point
  4. Remove detached gingicae
  5. Consider gingivoplasty to create aesthetic contour
  6. PMPR of root
  7. Periodontal dressing to reduce post-op discomfort and prevent plaque colonisation (7-days)
24
Q

How does exposed tissue heal following a gingivectomy?

A

Secondary intention

25
Q

What is regenerative therapy used for?

A

Infra-bony/Infra-radicular defects

26
Q

What are the objectives of regenerative therapy?

A

Obtain shallow, pockets by reconstruction of attachment apparatus

Limit recession of gingival margin

27
Q

What are the aims of RPT?

A

Increased periodontal attachment in severely compromised teeth

Decrease deep pockets to make them easier to maintain

Reduce vertical, horizontal and furcation defects

28
Q

What is the difference between horizontal bone loss and vertical?

A

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

29
Q

What is a crater?

A

Infrabony defect affecting 2 adjacent teeth

30
Q

What are the classifications of infra-bony defects?

A

1 wall

2 wall

3 wall

31
Q

What are the treatment options for Infra-body defects?

A

Closed/open root PMPR
-> healing by repair

Pocket elimination with osseous resection (historic)- remove infected soft and hard tissue

Regenerative techniques

32
Q

What are the aspects of the triad of tissue engineering?

A

Scaffold

Cells

Signalling molecules

33
Q

What are the strategies for Periodontal regeneration?

A

Space maintenance and clot protection

Selective cell repopulation

Provision of progenitor cells

Use of biological mediators – signaling molecules

-> combination

34
Q

What are examples of biological mediators that may be used in PRT?

A

Platelet-derived growth factor
Insulin growth factor
Transforming growth factor 
Bone morphogenetic proteins
Prostaglandin
Fibronectin
Enamel matrix proteins

35
Q

What is Emdogain?

A

Enamel matrix protein derived from the porcine tooth germ
-> forms a matrix on the root surface that mediates the production of cementum

36
Q

What is guided tissue regeneration?

A

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

37
Q

What are the types of bioabsorbable membranes in guided tissue regeneration?

A

Natural- Collagen, connective tissue, oxidised cellulose

Synthetic- poly lactic acid, allloderm, polyurethanes, polyglycolic acid

38
Q

What are the non-absorbable membranes used in guided tissue regeneration?

A

Millipore filter
GORE-TEX
Rubber dam
Ethyl cellulose

39
Q

What are the objectives of bone grafts in guided bone regeneration?

A

Space maintenance and clot protection

Osteoconduction- scaffold

Osteoinduction- promoting osteoblast activity

Osteogenesis- osteoblast present in graft

40
Q

What are the types of bone grafts?

A

Autografts

Isografts- genetically identical

Allograft- same species

Alloplasts- synthetic

Xenografts- different species

Ceramics/bioactive molecules- composite grafts

41
Q

What are the steps in bone grafting in RPT?

A
  1. Identify vertical defect
  2. Use modified papilla ;preservation technique
  3. Root surface PMPR
  4. Apply graft
  5. Replace flap and suture
42
Q

What is a furcation?

A

Anatomical area where roots divide
-> can only occur in multi-rooted teeth

43
Q

What is a furcation defect?

A

Bone loss at the branching point of the roots
-> makes extraction in molars 8x more likely

44
Q

How is diagnosis of furcation made?

A

Clinical exam
-> visual assessment
-> probing- nabers probes

Radiographic assessment

45
Q

How are furcations graded?

A

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)

46
Q

What are the treatment options for furcation involvement?

A

Palliative-maintain plaque control (if non-symptomatic)
-> PMPR

Repair (small)
-> PMPR/OFD

Regeneration
-> GTR, GBR, emdogain

Eliminate
-> root resection
-> furcation plasty
-> tunnel procedure
-> extraction

47
Q

What are the indications for periodontal regeneration?

A

2 or 3 walled proximal defects

Grade 2 furcation defects in mandible

Grade 2 buccal maxillary furcation defects

48
Q

What are the issues with the regenerative approach for furcations?

A

Difficult to debride

Relatively avascular

49
Q

Why is GTR preferred to OFD for furcations?

A

Greater vertical and horizontal bone fill

Better results in mandible

GTR and GBR in combination is better

50
Q

What is the tunnel procedure?

A

Bone and tooth are recontoured to allow insertion of ID brush

51
Q

What is a hemisection?

A

Half of the molar is extracted then other half is restored as premolar

52
Q

What are the requirements for successful resective procedures?

A

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

53
Q

What would indicate extraction of tooth with furcation defect?

A

Recurrent symptoms

Little remaining attachment

Gross mobility

Non-functional tooth

54
Q

What are the issues when treating vertical bone defects?

A

Difficult to instrument due to being very narrow, poor access, poor vision

BDS4 Perio (2 decks)

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