supportive periodontal care Flashcards
who needs supportive periodontal care
patients who have had periodontal treatment
always a perio pt - need to be treated differently to non perio
often referred back to GDP
where is supportive perio care carried out
pt referred back to GDP
- “The patient would benefit from regular supportive periodontal care ideally at three month intervals. The three monthly supportive visits should include removal of supra and any sub-gingival plaque and calculus using local anaesthetic if necessary. Oral hygiene instruction should be provided as required. The periodontal pocket probing depths should be reviewed at 12 month intervals to allow early detection and treatment of any disease recurrence or progression.”
why bother with supportive periodontal care
Patients who are not maintained in a supervised recall program subsequent to active treatment show obvious signs of recurrent periodontitis (e.g., increased pocket depth, bone loss, or tooth loss).
The more often patients present for recommended supportive periodontal treatment (SPT), the less likely they are to lose teeth.
- Treated patients who do not return for regular recall are at 5.6 times greater risk for tooth loss than compliant patients – need to engage the pt
- Patients with inadequate SPT after successful regenerative therapy have a fiftyfold increase in risk of probing attachment loss compared with those who have regular recall visits.
- successful supportive= les likely to be lost*
- more complex tx more important it is to maintain it
when is supportive periodontal care
determined by risk assessment for each individual pt
risk of disease progression in pt influenced by (6)
- BOP
- PD
- Tooth loss
- Systemic conditions - diabetes
- Bone loss/age - ABC grading
- Environment - smoking
How many tick and to what extent
generally supportive care intervals for mod-adv perio pt
every 3 months
maybe more or less frequent depending on stability
3 parts to suppportive periodontal care
Part I - examination
Part II - treatment
Part III - report, cleanup and scheduling
Part I supportive perio care
examination
- Medical history changes
- Oral pathologic examination
- Oral hygiene status (plaque chart)
- Gingival changes e.g. inflammation, recession, BOP
- Pocket depth changes - periodontal and peri-implant
- Mobility changes
- Occlusal changes e.g. drifting
- Dental caries
- Restorative, prosthetic, and implant status
part II supprotive perio care
treatment
- Oral hygiene reinforcement
- Supra gingival scaling
- Root surface debridement
- Polishing - easier to keep clean
part III supportive perio care
report, cleanup and scheduling
- Write report in chart.
-
Comment what you found at that app so can look at sequential and compare
- May need X-rays of sites
-
Comment what you found at that app so can look at sequential and compare
- Discuss report with patient.
- Schedule next recall visit.
- Schedule further periodontal treatment.
- Schedule or refer for restorative or prosthetic treatment.
primary aim of SPD examination
primarily looks for changes that have occurred since the last evaluation
- Has plaque score changed? Worse – why?
- Not in isolation – reflect on what they have been like
part II treatment
care
Required scaling and root surface debridement are performed, (based on pocket chart/plaque chart - 4mm/BOP).
- Care must be taken not to instrument normal sites with shallow sulci (1 to 3 mm deep – that do NOT have any calculus)
- repeated subgingival scaling and root planing in initially normal periodontal sites result in significant loss of attachment - LEAVE ALONE
remove plaque and calculus is greater than 4
- will get worse if leave
- Need to remove plaque at regular basis to help imp
.
what to do if recurrence of periodontal disease occurs
reasons for recurrence established
causes for recurrence of periodontal disease (6)
- inadequate plaque control - pt
- failure to comply with SPT schedules - pt
- Inadequate/ insufficient tx - failed to remove all the potential factors favouring plaque accumulation.
- Incomplete calculus removal in areas of difficult access.
- Inadequate restorations placed after the periodontal treatment was completed.
- Presence of some systemic diseases that may affect host resistance to previously acceptable levels of plaque ask
dentist role in
- inadequate plaque control - pt
- failure to comply with SPT schedules - pt
causing recurrence of perio
compliance issue
dentist’s responsibility to teach, motivate, and control the patient’s oral hygiene technique, and the patient’s failure is the dentist’s failure.
SPD challenges
Less than 1/5 complete comply with their schedule for 8 years
Down to dental team to persuade pt
importance of getting pt compliance in SCD
perio pts at risk of perio disease for whole life
- Pockets in furcation areas may not have been eliminated by initial treatment or surgery.
SCD requires
need well organised charting system to complare sequential probing depths - gives the most accurate indication of the rate of the loss of attachment
measurements for perio activity
no ‘test’ currently
clinicians rely on the information provided by combining probing, bleeding on probing, and sequential attachment measurements
- only way to measure stability is compare over time
perio sites that are not resolved
4mm+
- Need to keep close eye
- Need subgingival clean
- Otherwise guarantee to get worse
goal plaque score
below 20%
pt respond well to them
RSD and supra and sub gingival scaling in SPD
may need LA
consider it as ongoing treatment - active process
get plaque and calculus out of pockets
how many appointments should SPC take per go
try to get it down to 1 appointment
have a clear idea of what you are trying to and get across at start so can be efficient
full mouth periodontal charting
4 in one sextant
or 3 in more than one sextant
at baseline
(3 in only one sextant 6PPC for that sextant)
SCD subgingival and RSD where
sites >or= 4mm where there is subgingival deposits present or BOP
sires <4mm which have subgingival deposits
diagnosis for
Stage Periodontitis IV Grade C Generalised Periodontitis, unstable
what does the dot on the diagram mean
healthy
less than 4mm site - don’t need Tx
why is there still inflammation anteriorly
access issue - crowns
Tx for
Stage Periodontitis IV Grade C Generalised Periodontitis, unstable
HPT
Open Flap Curettage 14, 13, 12, 11, 21, 22, 23 and 24
Review
describe this photos post OFC
Persistent pockets round molars and premolars
X-ray
- Advanced bone loss
- Furcation bone loss
- Extensive restoration
Are we going to be able to resolve?
- Complete resoluation around molars - unrealistic
- Mobile - less suitable for surgery
- Poorer healing
what recession type is this
- Recession type 3
- Negative gingiva architecture
- No papilla - almost minus
- No bone
- Grafts don’t work
what is a consequence of successful perio
Gingival recession with successful perio
- Need to explain to pt before
- Some attachment junctional epith and connective tissue And gingival recession
how could this be aesthetically addressed
recession type 3
Options available for recession
- New crowns - issue long - need to prep root - narrow prep, long contact points already - cause perio likely as uncleanable
- Lead to more perio -> lose teeth
- Can tidy up crowns so margin less obvious but if make more apical not best as risky
- Gingival grafting - not for recession type 3
- Pink coloured restorative material
- Porcelain - same issues as crown lengthening (can lead to more perio)- can help not ideal aesthetics
- Composite
- Acrylic gingival veneer
- Flange of upper denture like, Retained by undercuts in upper teeth
- Pts quite like them
- Warn as they are at risk of root caries - need careful monitor and meticulous OH
how to make acrylic gingival veneer
Take upper impression
Make special tray
Horizotnal path of inseriotn
5-5 region
Block out - scult undercuts between teeth to point of max concavity
Dictate where acryclic go - red ribbon wax - need space for acrylic to go into
Liase with lab - tooth show, extension (larger more likely to break)
Check fit, check rub
Review and instruct on cleaning
Want them to take them out as much as possible - like shoes
what can be added to acrylic gingival veneer to boost aesthetics
stippling - can improve appearance but pt may not like texture
diagnosis
- Generalized gingival inflammation, brisk BOP
- Poor OH
- Moderately restored dentition
- Spacing upper and lower anterior
- Generalised tooth mobility
- Deep pockets 6-9
- Generalized moderate to advanced horizontal bone loss
- Advanced bone loss 14, 26, 31, 41
- recession
- Splaying and spacing of teeth
- Due to occlusal instability likely
- Stage IV, Grade C generalised periodontitis, unstable. Risk factors – variably controlled diabetes
Tx plan for
- Stage IV, Grade C generalised periodontitis, unstable. Risk factors – variably controlled diabetes
- HPT, review
- GDP re caries
complication of diabetic and SPC
compliance issue
Diabetics have many appointments – low compliance sometimes – manage life
what can be a good motivator for pt compliance for SPC
Can be good motivator if we have a solution for aesthetic
options for lower anterior prosthetic replacement
- PL co/cr
- Bridge
- Implants - not good for diabetics
- resin bonded bride
why would you build rest seats and guide planes into crowns
continguency
have option for CoCr in future
esp for perio pt as still potential for tooth loss
bonded wire retainer used in SPC
to prevent drifting of mobile teeth
esp if there has been poor prognosis teeth extracted in arch
what can be added to reduce spacing on upper anteriors
composite
how long will perio tx last
perio pt is pt for life
active perio tx can vary in length until get pt in a stable state (PPD under 4mm)
SPC after that - can be carried out by GDP
