Step 3 Treatment Flashcards
What defines a “non-responding site” in reference to perio?
What are the 4 sequential steps to periodontal therapy? (based on BSP guidelines)
- good OH & healthy lifestyle to reduce inflammation + supragingival PMPR
- Thorough subgingival PMPR
- More complex treatments e.g surgery & more subgingival PMPR
- Long-term supportive care to prevent relapse
What are the aims of Step 3?
- treat non-responding areas
- further access to subgingival instrumentation
- regenerating or resecting lesions that add complexity in periodontitis management
What may Step 3 include?
- repeated subgingival PMPR
- access flap surgery
- resective flap surgery
- regenerative flap surgery
What are local antimicrobials that can be used during step 3 perio treatment?
- disinfectants (e.g chlorhexidine)
- locally delivered antibiotics
- adjuncts to PMPR
- may be indicated in unresponsive sites where surgery is contraindicated or not desired
What is a periochip?
- biodegradable gelatin matrix
- 2.5mg chlorhexidine digluconate
- insert into pocket following PMPR
- released slowly over 7-day period
What is the effectiveness of periochip?
- short term improvements in PPD compared to subgingival PMPR alone
- improvements small, no significant difference in CAL
What is dentomycin periodontal gel?
- 2% minocycline gel
- syringe deliver, insert into pocket following subgingival PMPR
- 3-4 applications required every 14 days (0, 2, 4 and 6 weeks)
- reduces pathogenic load of periodontal bacteria in pocket
Give examples of local adjuncts that can be used in step 3 treatment?
- dentomycin periodontal gel
- periochip
What is the mechanism of systemic antimicrobials?
suppression of the bacyerial species responsive for biofilm growth, leading to a less pathogenic oral environment
Why are systemic antimicrobials not routinely prescribed for periodontitis treatment?
Antibiotic stewardship
- increasing incidence of bacterial resistance
Numerous side effects associated with systemic antibiotics
If you think that a periodontitis patient would benefit from systemic antimicrobials, what does the guidance suggest you do?
Refer to specialist
What patients may benefit from systemic antimicrobials as part of periodontal treatment?
- periodontitis grade C in younger adults with high rate of progression
- other systemic illness or predisposition to perio
What systemic antibiotic dose could be used as a part of periodontitis treatment?
- full mouth instrumentation in a 24hr period
- followed by 400mg TDS for 7 days
What is host modulation therapy?
Uses local or systemic drugs as adjuncts to conventional periodontal treatment
- aim to modify the destructive aspects of host inflammatory response to microbial biofilm
What is an example of host modulation therapy treatment used as perio treatment?
Periostat = sub-antimicrobial dose doxycycline
What are the downsides of host modulation therapy? [eg. periostat]
- requires pts to use long term systemic medication
- costly
- alterations to liver enzymes
When do we consider surgical perio treatment?
- deep residual pockets of > 6mm
- stage 3 and 4 may benefit
- no medical contraindications
- teeth of restorable prognosis
- infra-bont defects, furcation disease
What pathology tends to respond best to surgical periodontal treatment?
infra-bony defects
What does marginal bleeding show?
day-to-day ability to clean plaque from teeth at home
[different from bleeding at base of pocket]
What can occur post-periodontal surgery?
Recession
What tooth relating factors need to be considered when deciding if periodontal surgery is suitable?
- access to non responding sites
- shape of defect [pattern of bone loss]
- pros/endo considerations
- tooth position/anatomy = tilting, overeruption, proximity to adjacent roots, enamel pearls, ridges/root grooves
What systemic/medical relating factors need to be considered when deciding if periodontal surgery is suitable?
- smoking [impaired wound healing]
- unstable angina, uncontrolled hypertension, MI/stroke within 6 months
- poorly controlled diabetes
- immunosuppressed pts
- pt taking anticoags
What operator relating factors need to be considered when deciding if periodontal surgery is suitable?
- skill & experience of operator
What should be discussed with the patient to gain consent before periodontal surgery?
- reason for providing perio surgery
- other options for managing area
- consequences of not providing surgery
- nature of surgical procedures
- post-op complications
- requirement for ongoing post-op maintenance
- costs
What are the aims of access surgery/open flap debridment?
- access to reas of continues inflamation or infection
- for areas of PPD >6mm
What is stage 1 of periodontal access surgery?
- examination pre surgery shows deep periodontal pocket
- good superficial gingival health
- good OH
What is stage 1 of periodontal access surgery?
- full thickness flap raised to expose affected tooth surface, periodontal bone & associated defect
What is stage 3 of periodontal access surgery?
- defect granulation tissue removal and root surface curettage
- leave clean root surface and bone
What is stage 4 of periodontal access surgery?
suture and aim for primary closure [monofillament]
Why are monofilament sutures used in perio surgery as opposed to multifilament?
to prevent plaque adhering to it
What is stage 5 of periodontal access surgery?
- 3 months post surgical review
What defects are at high risk of relapse after periodontal surgery?
angular bone defects
What are indications for regerative periodontal surgery?
- intrabony defects 3mm or deeper as assessed radiographically
- class 2 or 3 furcation defects
What is guided tissue regeneration surgery?
- barrier membranes ± addition of bone-derived grafts
- membrane prevents gingival epithelium or connective tissue from entering 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
What is an example of a material used for regenerative periodontal surgery?
Enamel Matrix Derivative (EMD - emdogain)
How does enamel matrix derivative work?
- 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 perio procedure
Why should we treat furcation lesions?
- clinically relevant [reasonable tooth survival rates]
- tooth retention after perio surgery more cost-effective than XLA and replacement
- patient preference [pt wants to keep teeth]
What options are available to treat furcations surgically?
- regenerative surgery
- root resection
- root separation
- tunnelling
What furcation types respond well to regenerative surgery?
- mandibular class II furcations
- maxillary class II (buccal)
- maxillary class II (interdental)
When is root resection/root separation typically used?
class III furcation lesions or multiple class II furcation lesions in same tooth
When is root resection/root separation indicated?
- good quality endo treatment
- good root separation
- remaining roots should not be hypermobile
- enough remaining PDL support on remaining roots
- remaining tooth structure should be restorable
How does a hemi-section differ from a root resection?
remove part of crown as well as root
When is tunnelling furcation surgery used? What is involved?
Mandibular class III furcation lesion [through & through]
- bone and soft tissue recontoured to allow insertion of interdental brush
What risks are associated with tunnelling furcation procedures?
- root hypersensitivity
- root caries due to exposed dentine
