Treatment Adjuncts and Perio Surgery

Question 1

What are the aims of step 3?

Answer 1

Treat those areas of the dentition not responding adequately to step 2 with the purpose of gaining further access to subgingival instrumentation, or aiming at regenerating or resecting this lesions that add complexity in the management of periodontitis.

Question 2

What are the options for step 3?

Answer 2

Treatment adjuncts- local, systemic (in combination with subgingival PMPR).

Access surgery

Regenerative surgery

Furcation treatment options

Question 3

What treatment adjuncts might be used locally?

Answer 3

Disinfectants- chlorhexidine (periochip)

Locally delivered antibiotics- dentomycin

May be indicated in unresponsive sites where surgery is contra-indicated or not desired
- adjuncts to PMPR.

Question 4

What is Periochip?

Answer 4

Biodegradable gelatin matrix
2.5mg chlorhexidine gluconate
Insert into the pocket following PMPR- chlorhexidine is slowly released over 7 day period.

Question 5

How effective is periochip?

Answer 5

Short improvements in PPD compared to subgingival PMPR alone

No significant differences in CAL
Insufficient data on bleeding and pocket closure.

Question 6

What is Dentomycin periodontal gel?

Answer 6

2% minocycline gel
- acts to reduce the bacterial load of the pocket.
- Delivered via a syringe following subgingival PMPR, into the pocket.

requires 3-4 applications every 14 days.

Treatment should not usually be repeated within 6 months.

Question 7

Is Dentomycin effective?

Answer 7

Can lead to short term improvement in PD and CAL compared to subgingival PMPR alone.

Question 8

With regards to local antimicrobials, what does SDCEP recommend?

Answer 8

Not recommended for routine care and management of patients with a diagnosis of periodontitis.

Question 9

With regards to systemic antimicrobials, what does SDCEP recommend?

Answer 9

Do not use adjunctive systemic antibiotic therapy for the routine care and management of patients with a diagnosis of periodontitis.

Consider referral to a specialist for those patients who would benefit from adjunctive systemic antibiotic therapy- those patients whose level of disease suggests a high susceptibility.

Question 10

What is the mechanism of action of systemic antimicrobials?

Answer 10

Proposed to act by suppress the bacterial species responsible for biofilm growth, leading to a less pathogenic oral environment.

Question 11

Why aren’t systemic antimicrobials recommended in all perio patients?

Answer 11

Antibiotic resistance
GI disturbance
Changes to the gut microbiome

Question 12

Under what circumstances would systemic antimicrobials be considered?

Answer 12

Periodontitis grade C in younger adults where high rate of progression is documented.

Young patients with systemic risk factors that is causing a high rate of progression.

Question 13

What systemic antimicrobials would be used?

Answer 13

400mg metronidazole TDS 7 days

Question 14

What is host modulation therapy?

Answer 14

Uses local or systemic drugs as adjuncts to conventional periodontal treatment, with the aim of modifying the destructive aspects of the host inflammatory response to the microbial biofilm.

Question 15

What drugs are used for host modulation therapy?

Answer 15

Periostat- sub antimicrobial dose doxycycline

Requires systemic medication over long period of time, which may impact on compliance.

Question 16

With regards to host modulation, what is the SDCEP recommendation?

Answer 16

Not recommended for the routine care and management of patients with a diagnosis of periodontitis.

Question 17

What is the general recommendations for periodontal surgery?

Answer 17

If deep residual pockets remain after step 1 and step 2- surgical treatment is effective but complex and should be carried out by dentist with additional specific training or by specialists in referral centres.

If secondary care no available in your area, we recommend repeated supra and sub-gingival PMPR with frequent supportive care.

Question 18

Based on SDCEP guidelines, when might periodontal surgery be indicated?

Answer 18

In sites where good quality non-surgical perio treatment has not resolved periodontal pocketing and there is ongoing inflammation/infection.

Perio pocketing greater than or equal to 6mm.

In cases with suitable patient, tooth and defect factors
- No medical contra-indications
- Teeth of reasonable prognosis
- Infra-bony defects, furcation disease

Question 19

What patient factors need to be taken into consideration for perio surgery?

Answer 19

Oral hygiene- less than 20% plaque and less than 10% margin bleeding.

Quality of maintenance available and patient access to it

Ability of patient to tolerate procedure

Likely patient compliance in terms of maintenance after surgery

Cost and patient acceptance

Aesthetic of the site and the potential for post-op recession

Question 20

What tooth factors need to be taken into consideration for perio surgery?

Answer 20

Access to non-responding sites

Shape of defect

Prosthodontics/endodontic consideration

Tooth position/anatomy
- tilting
- over-eruption
- proximity of adjacent roots
- enamel pearls
- ridges/root grooves

Question 21

What systemic/medical factors need to be taken into consideration for perio surgery?

Answer 21

Smoking- impairs wound healing, significantly reduces the chance of improvement from surgical intervention

Unstable angina, uncontrolled hypertension, MI/stroke within 6 months.

Poorly controlled diabetes

Immunosuppressed patients

Anticoagulants and antiplatelets

Question 22

What operator factors must you consider for perio surgery?

Answer 22

Skill and experience- should be provided by dentists with additional specific training or by specialists in referral centres.

Access to tier 2 or tier 3 care

Question 23

What must you make the patient aware of during the consent process for perio surgery?

Answer 23

Reason for providing surgical treatment
Other treatment options available
Consequences of not providing surgery
Mature of the surgical procedure
Post-op consequences- pain, swelling, bruising, potential time off work, tooth sensitivity, failure to resolve the pockets, tooth mobility, non vitality, recession.
Requirement for ongoing post-op maintenance
Cost

Question 24

What steps are involved in access surgery/open flap debridement?

Answer 24

Assess site- good OH, still residual pocketing despite step 1 and step 2.

Full thickness flap raised to expose the root surface, periodontal bone and associated defect.

Defect granulation tissue remove and root surface curettage.

Suture and aim for primary closure- use monofilament suture to decrease plaque accumulation on the sutures.

Review patient one week alter to remove sutures
- hygienist appointment 6 weeks after surgery.

Then step 4 maintenance.

Question 25

When would you expect long-epithelial reattachment to the root surface to occur?

Answer 25

6-8 weeks post-surgery.

Question 26

What is regenerative periodontal surgery?

Answer 26

Tissue regeneration including bone and functional PDL formation, which could include the use of membranes and grafts, and the application of biologic agents.

Question 27

What are the indications for regenerative surgery?

Answer 27

Intrabony defects 3mm or deeper as assessed radiographically.

Class 2 or class 3 furcation defect

Question 28

What is guided tissue regeneration?

Answer 28

Place a barrier membrane +/- addition of bone-derived grafts into the bony defect.
- this acts as an osteo-inductive scaffold for the vascularisation and cell ingrowth from base of the defect.
- Need a membrane on top to prevent gingival epithelium or connective tissue from entering the bone defect.

Question 29

What is enamel matrix derivative?

Answer 29

Emdogain- tissue healing agent derived from porcine tooth germ.

Forms a matrix on the root surface that mediates production of cementum by modulation the wound healing process.

It can induce the regeneration of a functional attachment in periodontal procedures.

Question 30

Why treat furcation lesions?

Answer 30

Reasonable survival rates observed over 4-30 years.

Tooth retention after perio surgery more cost-effective than extractions and replacement with implant-supported prosthesis.

Question 31

What are the options for furcation surgery?

Answer 31

Regenerative surgery- class II furcations in upper and lower.

Root resection/root separation- usually for class III lesions or multiple class II lesions.

Tunnelling- class III lesions.

Question 32

What is required for root resection/root separation?

Answer 32

Good quality endodontic treatment

Good root separation as assessed radiographically- not possible with fused roots.

Remaining roots should not be hyper mobile

Remaining tooth structure should be restorable

Motivated patient, excellent OH, low caries rate

Question 33

What is tunnelling?

Answer 33

Bone and soft tissue recontoured to allow insertion of interdental brush.

Question 34

What are the risks associated with tunnelling?

Answer 34

Root hypersensitivity
Root caries

Question 35

What is access surgery also commonly referred to as?

Answer 35

Conservative approach

Question 36

What is resective surgery commonly referred to as?

Answer 36

Resective approach

Question 37

What is regenerative surgery also known as?

Answer 37

Reconstructive approach.

Question 38

What are the indications for mucogingival surgery?

Answer 38

Periodontitis lesions requiring reconstructive or regenerative treatment.

Mucogingival deformities that require periodontal plastic surgery- recession defects, reconstruction of papillae

Short clinical crowns where an increase in clinical crown height is required before restorations are constructed.

Removal of aberrant fern

Creation of a more favourable soft tissue bed pre-implant surgery

Question 39

What are the most common procedures for mucogingival surgery?

Answer 39

Free gingival graft- raise a split thickness flap to generate a connective tissue bed to graft on. Then harvest a graft from the palate and suture it in place.

Pedicle graft- expose the exposed root surface, then raise a split thickness flap from the tooth beside and rotate the flat laterally to cover the defect.

Connective tissue graft

Question 40

How can intra-bony defects be classified?

Answer 40

Classified by the number of walls that the defect encompasses.

1 wall
2 walls
3 walls

Question 41

What is the process of guided tissue regeneration?

Answer 41

Raise a full thickness flap
- observe the intrabony defect.

Bone graft and membrane placed in to defect
- bone graft can be from the same patient (autograft), from another person (allograft) or from an animal (xenograft).
- biomaterials- collagen, enamel matrix derivative (emdogain) or deproteinised bovine bon matrix.

Return flap and suture with black silk monofilament sutures to prevent plaque accumulation.

Question 42

What is a positive surgical healing outcome for access/resective surgery?

Answer 42

Long junctional epithelium formation.

Question 43

What is the surgical healing outcome for a grafting procedure?

Answer 43

New connective tissue attachments.

Question 44

What is gingival recession?

Answer 44

Apical migration of the gingival margin from the CEJ.

Question 45

What are the indications for treatment of gingival recession?

Answer 45

Poor aesthetics

Sensitivity

Difficult plaque control

Question 46

Describe the aetiology of localised recession?

Answer 46

Excessive toothbrushing

Traumatic incisor relationship

Habits- rubbing gingivae with fingernail/end of pencil/tongue, lip stud.

Anatomical- frenal pull, teeth out of alignment

Question 47

Describe the aetiology of generalised recession?

Answer 47

Ongoing periodontal disease or following resolution of inflammation after successful treatment

May also be because of ortho treatment

Question 48

What is the Cairo 2012 classification of gingival recession?

Answer 48

Recession type 1- no inter proximal tissue loss.

Recession type 2- inter proximal tissue loss not as significant as mid-buccal.

Recession type 3- Gingival recession associated with loss of inter proximal attachment.
- interpoximal tissue loss worse than mid-buccal.

Question 49

What are the treatment options for gingival recession?

Answer 49

Record magnitude of recession- clinically or study model and assess for progression on a regular basis.

Eliminate etiological factors- habits/remove piercings

OHI- single tufted brushes

Topical desensitising agents/fluoride varnish

Gingival veneer to cover exposed roots

Crowns (with crown lengthening surgery)

Mucogingival surgery- free gingival graft, pedicle graft, connective tissue graft.

Question 50

What would be considered a contraindication for mucogingival surgery?

Answer 50

If interproximal bone has been lost- full root coverage is not possible.

Question 51

What is crown lengthening?

Answer 51

Surgical crown lengthening aims to apically re-position the entire periodontal attachment including, usually, the alveolar bone.

Question 52

What are the indications for crown lengthening?

Answer 52

Increase the clinical crown height to give adequate retention for restorations

Expose enough clinical crown to allow a restorative ferrule to be achieved

Expose subgingical restoration margins/secondary caries/fractures

Correction of uneven gingival contour compromising aesthetics including excessive gingival display

Question 53

When should you refer?

Answer 53

Only after thorough non-surgical treatment

Highly motivated and engaged patients with good OHI and risk factor control

Non-smoker and no contraindicated medical history

Reasonable prognosis of tooth