Step Two of Treatment Flashcards
Why should you re-evaluate after step one?
Re-evaluating after step 1 is an opportunity to identify successes and failures in step 1 treatment and to encourage further positive changes
- Some sites will heal following effective step 1 treatment – so this reduces the amount of treatment the patient needs in step 2.
What is the critera for an engaging patient?
> 50% improvement in plaque and marginal bleeding scores
or
plaque levels <30%
bleeding level <35%
What should you do if patient is non-engaged?
- repeat Step1
- find out WHY!
- remotivate and reinforce
What are the 3 components of step 2?
reinforce OH, risk factor control, behavior change
subgingival instrumentation, hand or powered (sonic/ultrasonic), either alone or combination
use of adjunctive systemic antimicrobials determined by practitioner accredited for level 2/3 care
Powered vs Hand instruments for subgingival instrumentation?
Powered instrumentation may leave a rougher, grittier surface
Powered instrumentation produces aerosols
Water coolant – collapsing bubbles cause cavitation and coolant acts to flush the pocket
Ultrasonic/sonic tip designs may allow better access to furcations
Ultrasonic/sonic instrumentation may result in less unwanted tooth tissue removal
- No difference in terms of effectiveness of debridement
- Powered instruments are quicker, less fatiguing, easier
to use - Powered instruments have a poorer tactile sensation
What is sub-gingival instrumentation?
systematic removal of sub-gingival plaque, calculus and endotoxin from root surfaces
old term for sub gingival pmpr
How to prepare/set up for Subgingival instrumentation? (BPE scores, etc)
- 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 objective of a full mouth treatment?
prevent treated pockets being re- colonised by intra-oral translocation of bacteria
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
How is the aute inflammatory response possibly detected?
C-reactive protein levels may be elevated due to plaque invasion causing bacteremia.
What are the s3 guidelines concerning antibiotics?
systemic antibiotics as an adjunct to periodontal treatment would usually only be used in specialist care
What is the effects of supra/sub gingival PMPR?
On the 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
* Significantly reduces the levels and prevalence of pathogenic species – e.g P. gingivalis, T. denticola – can reverse dysbiosis
How is the healing process following subgingival PMPR?
What is the time scale?
- 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 does the repaired pocket differ compared to normal health?
The gain in attachment is the result of a long junctional epithelium + some connective tissue attachment. This long junctional epithelium is histologically distinct to the junctional epithelium found in health and attaches to the root surface.
What is the effect of supra gingival plaque control alone?
- Decreased gingival inflammation
- Limited effect on probing depth
- No change in attachment levels
- No alteration in subgingival microflora in deep pockets (>6mm)
What is the effect of Subgingival PMPR without Supragingival Plaque Control?
- Initial reduction in inflammation and pocket depth
- Pockets are re-colonised by bacteria from supragingival plaque
- Disease recurs
What is the effect of of Subgingival PMPR with Supragingival Plaque Control?
- Decreased gingival inflammation
- Reduction in probing depth
- Gain in probing attachment level
- Marked changes in the subgingival microbial flora
What are indicators of successful treatment?
- Plaque scores<15%
- Bleeding on probing<10%
- No Pockets > 4mm
- “Periodontal stability”
Does non surgical treatment work?
yes
* At 6-8 months:
* The weighted pocket depth (PD) reduction was 1.4 mm (95%CI: 1.0– 1.7)
* The proportion of pocket closure was estimated at 74%
What is the time scale for re-evaluation after step 2 and before step 3?
3 months to allow healing and remodelling
What are the components that need to be re-evaluated?
probing depths
bleeding score
plaque score
attachment levels
tooth mobility
furcation
If the patient is non-enagaging completely, what should the dentist do?
discharge to GDP for supportive care
What does step 4 (supportive PD therapy) acheive?
- Prevents recurrence of disease
- Stabilises periodontal condition
- Maintains optimum periodontal health
- Individually tailored Intervals of 3 -12months
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
Why does treatment fail?
inadequate patient plaque control
residual subgingival deposits
systemic risk factors (diabetes, smoking)
