Treatment and Management Flashcards
Define PSR 0
No bleeding, no calculus, and you are not yet into the black area
Define PSR 1
There is bleeding, but not calculus and you are not yet into the black area
Define PSR 2
There is bleeding and calculus, but you are not yet into the black area
Define PSR 3
You are into, but not completely covering the black area
Define PSR 4
You are completely covering the black area
Define the asterisk in PSR
Indicates the presence of:
- Recessions > 3.5 mm
- Inadequate attached gingiva
- Mobility
- Furcation involvements
Found during PSR.
When MUST complete periodontal charting be performed based on PSR findings?
- 2 or more scores of 3
- 1 or more scores of 4
What to do if PSR shows one score of 3 only?
Must do full periodontal charting in that sextant alone
What to do if PSR shows highest scores of 2?
Periodontal charting is not required
Who can check and sign off the work to be done based on this PSR?
323/32*3
Needs complete periodontal charting, checked by a hygienist, signed off by a periodontist
Who can check and sign off the work to be done based on this PSR?
4*12/212
Needs complete periodontal charting, checked by a hygienist, signed off by a periodontist
Who can check and sign off the work to be done based on this PSR?
222/223*
Needs periodontal charting in the 4th sextant, checked by a hygienist, signed off by a periodontist
Who can check and sign off the work to be done based on this PSR?
222/223
Needs periodontal charting in the 4th sextant, can be dealt with by a GP, unless GP requests consultation with a periodontist
Who can check and sign off the work to be done based on this PSR?
102/201
Does not need periodontal charting, can be dealt with by a GP
3 occasions when patients who need all measures recorded MUST have them recorded
- At initial perio exam
- At re-eval (after intial therapy has been completed)
- At every recall appointment
Define bleeding index
Divide number of sites which bleed by the total number of sites present in the mouth, then multiply by 100
Define the modified O’Leary plaque index
Divide the number of plaque sites by the total number of sites in the mouth, multiply by 100 and subtract this number from 100
Define class 0 mobility
No mobility to normal physiological mobility
Define class 1 mobility
Mobility greater than normal physiological mobility but ≤ 1mm in a BL direction
Define class 2 mobility
Mobility of 1 mm in a BL direction
Define class 3 mobility
Mobility of ≥ 1mm in a BL direction, or mobility in an apical direction (tooth is depressible in its socket)
Define class 1 furcation
Vertical but not horizontal exposure of furcation
Define class 2 furcation
Vertical and horizontal exposure of furcation
Define class 3 furcation
Complete exposure of both sides of furcation
Define class 4 furcation
A class 3 that is visible (can see to the other side of the furcation)
When should additional radiographs be taken?
AFTER the clinical exam has been performed
8 perio indications for radiographs
- Probing depth ≥ 4mm
- Any + recession
- Mobility
- Furcation involvement
- Inflammation around a tooth suspected to an invasion of biologic width
- Gingival pain/discomfort
- Presence of a lesion on the gingiva
- Sinus tract exiting on the gingiva (with a trace)
7 criteria of assessment for radiographs
- Presence/amount of horizontal bone loss
- Presence of vertical bone loss
- Crown:root ratio
- Suggestion of furcation involvement/arrows
- Widening of periodontal ligament space
- Presence of calculus
- Suggestion of invasion of biologic width
Normal apical distance of crestal bone from CEJ of teeth it’s supporting
0.4 - 1.9 mm
Define the extent of horizontal bone loss
- Mild <30% of root length
- Moderate 30 - 50% of root length
- Severe >50% of root length
Define crown:root ratio
Proportion of the tooth that is coronal to the bone : proportion of tooth that is apical to the bone
3 reasons why pockets of ≥ 4mm are considered pathological
- More difficult to instrument and have less calculus removed from them
- Gain clinical attachment following therapy, reducing pocket depth
- More likely to experience disease recurrence/periodontal breakdown following therapy
2 clinical signs to identify inflammation in perio chart
- Probing depth ≥4mm
- Bleeding on probing
Progression of attachment loss
- The inflammatory infiltrate unzippers the junctional epithelium (2 - 4 days)
- The collagen of the connective tissue is lysed and lost (4 - 10 days)
- Bone is resorbed (years)
Primary feature of aggressive periodontitis
Attachment loss which affects first molars and incisors
5 secondary features of aggressive periodontitis
- Familial history of disease
- Amounts of microbial deposits may be inconsistent with amount of destruction
- Progression may be self-limiting (burn-out)
- May be associated with a.a. and p. gingivalis
- May be associated with neutrophil defects
Define severity of attachment loss
- Mild = 1 - 2 mm
- Moderate = 3 - 4 mm
- Severe = ≥5mm
Define extent of chronic periodontitis
- Localized = <30% of sites affected
- Generalized = ≥30% of sites affected
Define extent of aggressive periodontitis
- Localized = incisors and first molars only with UP TO 2 other teeth
- Generalized = incisors and first molars PLUS at least 3 other teeth
2 reasons why radiographs are not sufficient to diagnose periodontitis
- Radiographs do not tell you anything about whether or not the patient has an inflammatory lesion
- Radiographs severely underestimate the presence of the most common interproximal osseous defect, CRATERS
When is there considered to be minimally attached gingiva?
When the measure of attached gingiva (amount of gingiva to mucogingival junction minus mid-buccal/mid-lingual probing depth) is 1 mm or less. 1 mm may be clinically acceptable in the absence of other clinical signs (i.e. bleeding on probing)
What is the protocol for radiographs regarding implants
All implants MUST have a radiograph taken once a year for follow-up
Also, radiographs must be taken if an implant exhibits any clinical signs or symptoms
Define initial therapy (also known as phase I therapy or non-surgical therapy)
The first in the chronologic sequence of procedures that contitute periodontal treatment. Objective is to alter or eliminate the microbial etiology and factors that contribute to gingival and periodontal diseases to the greatest extent possible, therefore halting the progression of disease and returning the dentition to a state of health and comfort.
4 constituents of initial therapy
- Initiation of a comprehensive daily plaque control regimen
- Thorough removal of calculus and microbial plaque
- Correction of defective restorations
- Treatment of carious lesions
7 therapies to manage contributing local factors to periodontitis
- Complete removal of calculus
- Correction of replacement of restorations and prosthetic devices with unfavorable contours
- Restoration or temporization of carious lesions
- Treatment of food impaction areas
- Treatment of occlusal trauma
- Extraction of hopeless teeth
- Possible use of antimicrobial agents including necessary plaque sampling and sensitivity testing
10 parameters of data collection to properly formulate a comprehensive treatment plan
- General health and tolerance of treatment
- Number of teeth present
- Amount of subgingival calculus
- Probing pocket depths and attachment loss
- Furcation involvements
- Alignment of teeth
- Margins of restorations
- Developmental anomalies
- Physical barriers to access (i.e. limited opening or tendency to gag)
- Patient cooperation and sensivity (i.e. requiring use of anesthesia or analgesia)
5 steps in the sequence of procedures in initial therapy
- Plaque control instructions
- Removal of supragingival and subgingival plaque and calculus
- Recontouring defective restorations and protheses and performing necessary occlusal adjustments
- Caries control
- Tissue re-evaluation
Time between re-evaluation and initial therapy
4 - 6 weeks
5 expected improvements in clinical parameters after initial therapy
- Reduction of probing depth
- Reduction in percentage of sites with bleeding on probing
- Improvement in gingival tissue contours (rolled margins with edema and erythema –> sharper margins, pink color, absence of edema)
- Improvement in mobility scores in certain teeth
- Improvement in patient’s oral hygiene
Why is there 1 to 2 mm of recession following initial therapy?
Tissue shrinkage due to reduction in inflammation
13 possible secondary etiologies for periodontitis (as per Dr. Malkinson)
- Calculus
- Hopeless teeth
- Malposed teeth
- Impacted teeth
- Caries
- Overcontoured restorations
- Open margins
- Overhangs
- Occlusal trauma
- Ill-fitting prostheses
- Narrow embrasures
- Open contacts
- Tissue-invasive bacteria
5 parameters of the “Evaluation Criteria Staircase” by level
- Probing pocket depth _<_4mm
- No clinical signs of gingival inflammation
- No bleeding on pocket probing
- No further loss of clinical attachment
- No further loss of alveolar bone
When does the formation of a long junctional epithelium occur?
As early as 2 weeks after Sc/RP
Average PD reductions following Sc/RP
- 1.29 mm in pockets that were 4-6mm deep
- 2.16 mm in pockets that were ≥7mm deep
3 mechanisms of probing depth reduction following Sc/RP
- RECESSION
- Gain in clinical attachment via formation of long junctional epithelium
- Reconstitution of the integrity of the junctional epithelium
4 consequences of performing evaluation of initial therapy too early
- Subgingival microbial shift back to health has yet to occur
- Inflammation has yet to resolve
- Tissue shrinkage has yet to occur
- Repair via long junctional epithelium has yet to occur
4 consequences of performing evaluation of initial therapy too late
- Subgingival microbiota has shifted from disease to health and back to disease
- Inflammation has returned
- Tissue has rebounded
- Long junctional epithelium has broken down
What is considered too early and too late for evaluation of initial therapy?
Too early = <4 weeks
Too late = >8 weeks
What to do if patient came back for EIT late (i.e. 9 - 51 weeks after Sc/RP)
Perform regular maintenance scaling to remove plaque and calculus that has accumulated and bring patient back in 4 weeks for the EIT
What to do if patient came back for EIT more than a year after Sc/RP?
Must redo Sc/RP completely
4 things to do during an EIT appointment
- Perform a complete exam
- Make future treatment decisions with your patient
- Scale teeth as necessary
- Re-iterate oral hygiene instructions as necessary
2 decisions to be made at EIT
- Periodontal maintenance schedule
- Indicated future therapy
If the patient meets all 5 criteria of the Evaluation Critera Staircase, what do you do?
The patient needs no further therapy in that region (there is now a healthy reduced periodontium) and they MUST be put on a periodontal maintenance schedule
When do 4 mm pockets require surgery?
If there is a region of 4 mm pockets, all of which are BoP, inflamed, and associated with radiographic evidence of osseous defects
What do you do if the patient meets all criteria in the Evaluation Criteria Staircase EXCEPT they still have pockets of ≥5mm?
Surgical therapy is indicated and the patient must be put on a periodontal maintenance schedule
2 reasons why inflammation may resolve but probing depth did not
- Presence of osseous defects whether you can see them radiographically or not
- Tissue character (fibrotic gingiva will shrink less than edematous gingiva)
When does a pocket of ≥5mm NOT require surgery?
If there is an isolated pocket of 5 mm which is
- Not bleeding and not inflamed
- Not accumulating plaque or calculus
- Not associated with an osseous defect
- In a health, non-smoking patient with excellent oral hygiene and maintenance compliance
When can scaling and root planing be redone after initial therapy?
If you have an isolated pocket of 4 - 6 mm which:
- Has been Sc/RP
- Still has clinically detectable subgingival calculus
- Is not associated with an osseous defect
What to do if the patient only meets level 4 and 5 of the Evaluation Criteria Staircase?
Surgical therapy is indicated IF AND ONLY IF the cause of inflammation is NOT poor oral hygiene in the form of significant plaque and calculus accumulation. Patient MUST be put on a periodontal maintenance schedule
NOTE: OH must be improved PRIOR to surgery
Define periodontal maintenance
Procedures performed at selected intervals to assist the periodontal patient in maintaining oral health. These usually consist of examination, an evaluation of oral hygiene and nutrition, scaling, root planing, and polishing of teeth
10 parts of the periodontal maintenance
- Update of medical and dental history
- Extra-oral and intra-oral soft tissue exam
- Dental exam
- Periodontal exam and evaluation
- Implant evaluation
- Radiographic update and review
- Removal of bacterial plaque and calculus from supragingival and subgingival regions
- Selective root planing or implant debridement if needed
- Polishing of teeth
- Review of the patient’s plaque removal efficacy (OHI)
8 treatment considerations in periodontal maintenance
- Review and update medical and dental history
- Clniical examination (to be compared with previous measurements)
- Radiographic examination (update based on protocols and clinical judgment)
- Assessment of disease status or changes by reviewing the clinical and radiographic exams
- Assessment of OH, review OHI
- Treatment
- Communication
- Planning
5 parameters of the clinical examination for periodontal maintenance
- EOE
- IOE (oral soft tissue and oral cancer)
- Dental exam
- Periodontal exam
- Exam of implants and peri-implant soft tissue
8 parameters of treatment at periodontal maintenance
- Removal of supragingival and subgingival plaque
- Sc/RP
- OHI and emphasis on regular PM
- Counseling on control of risk factors such as smoking, stress, nutrition
- Occlusal adjustment if needed
- Use of systemic antibiotics, local antimicrobial agents or irrigation procedures if needed
- Root desensitization if indicated
- Surgical therapy if indicated
2 parameters of communication in periodontal maintenance
- Inform the patietn about their status and additional treatment if needed
- Consult with other health care providers involved in additional therapy
Usual frequency of periodontal maintenance
- For healthy patients or patients with gingivitis: 6 month recall
- For patients with a history of periodontal disease: 3 month recall
Define scaling
Instrumentation of the crown and root surfaces of the teeth to remove plaque, calculus and stains
Define root planing
Definitive treatment procedure to remove cementum and dentin that is rough, impregnated with calculus or contaminated with toxins or microorganisms
Gracey for anterior teeth
Gracey 1-2 and 3-4
Use of Gracey 5-6
Anteriors and premolars
Use of Hraceys 7-8 and 9-10
Posterior teeth buccal and lingual surfaces
Use of Graceys 11-12 and 15-16
Posterior teeth mesial surfaces
Use of Graceys 13-14 and 17-18
Posterior teeth distal surfaces
Differences between scaling and root planing strokes
- Root planing = long and lighter pressure, shaving in stroke
- Scaling = shorter stroke and more lateral pressure
Oral hygiene technique for children up to 9 years
Scrub technique (brush is moved back and forth)
Brushing technique advised for children 10 - 15 years
Bass technique (sulcular vibration brushing, directly pushing filaments toward roots of teeth at 45 deg angle lightly)
Brushing technique advised for adults
Modified bass (adding rolling motion to bass technique)
2 peri-implant pathologies
- Peri-implant mucositis (equivalent of gingivitis)
- Peri-implantitis (equivalent of periodontitis)
Define Power of ultrasonic scalers
Electrical energy in the handpiece used to generate insert movement
Define stroke of ultrasonic scalers
Distance the insert moves during one cycle
Define amplitude of ultrasonic scalers
One half the stroke
Define frequency of ultrasonic scalers
Number of times per second the insert tip moves back and forth during a cycle
Define cycle of ultrasonic scalers
One complete linear, circular or elliptical stroke path
Define lavage
Flushing of the sulcus; disruption of plaque biolfilm, and removal of necrotic tissue and blood
Define cavitation
Formation of bubbles in oral liquids/creation of shock waves in fluids
Define acoustic streaming
Fluid movement caused by ultrasonic waves
7 contraindications of ultrasonics
- Patients with pacemakers (esp. magnetostrictive)
- Significant respiratory problems
- Patients who are hypersensitive
- Demineralized areas on tooth
- Restorative materials (Porcelain)
- Dental implants
- Titanium implant abutments
Dental management in event of prehypertension
No changes in dental treatment. Monitor BP at each appointment
Dental managemetn of stage 1 hypertension
Inform pt of findings, routine medial consultation/referral, monitor BP at each appointment, no changes in dental treatment, minimize stress
Dental management of patient with systolic BP <180 and diastolic <110
Perform selective dental care (routine exam, prophylaxis, restorative nonsurgical endodontics and periodontics); minimize stress
Dental management of patient with systolic BP _>_180 or diastolic _>_110
Give immediate medical constultation/referral and perform emergency dental care only (to alleviate pain, bleeding, infection); minimize stress
2 antihypertensive meds that cause gingival overgrowth
Nifedipine
Amlodipine
2 drugs that may cause digoxin toxicity when concurrently administered with it
Macrolides
Tetracycline
Drug that may diminish antihypertensive efficacy of most drug classes
NSAIDs for more than 5 days
4 cases where antibiotics prior to dental procedures are recommended
- A prosthetic heart valve or who have has a heart valve repaired with prosthetic material
- History of endocarditis
- Heart transplant with abnormal heart valve function
- Certain congenital heart defects
- Cyanotic congenital heart disease
- Congenital heart defect that has been completely repaired with prosthetic material/devide for first 6 months after repair
- Repaired congenital heart disease with residual defects
Standard pre-treatment antibiotic
Amoxicillin 2.0 g 30 - 60 min before procedure
Alternate regimens for patients allergic to amoxicillin/penicillin
Clindamycin
Azithromycin
Clarithromycin
Cephalexin or cefadroxil
Pre-treatment antibiotic for patients unable to take oral meds
Ampicillin 2.0 g IM or IV within 30 min of procedure
2 options for patients unable to take oral meds and allergic to penicillin
Clindamycin or Cefazolin
Most common complication of diabetes
Hypoglycemia
Management of hypoglycemia
- Terminate dental therapy
- Provide approx 15 g oral carbs to patient
- If unable to take food or drink by mouth
- 25 - 30 mL 50% dextrose IV
- 1 mg glucagon IV
- 1 mg glucagon IM or subcutaneously
4 types of patients at risk who may be on anticoagulant or antiplatelet therapy
- Heart valve replacement
- Heart rhythm disorders
- Congenital heart defects
- Individuals with a history or risk of myocardial infarction, stroke or DVT
Recommended level of therapeutic anticoagulation
INR of 2 or 3
Appropriate procedures for INR less than 3.0
Infiltration anesthesia, scaling and root planing
Appropriate procedures for INR less than 2.0 - 2.5
Block anesthesia, minor perio surgery, simple extractions
Appropriate procedures for INR less than 1.5 - 2.0
Complex surgery or multiple extractions
6 risk factors for developing BRONJ
- Systemic corticosteroid therapy
- Smoking/alcohol
- Poor OH
- Chemotherapy/radiotherapy
- Diabetes
- Hematologic disease
5 reported conditions leading to BRONJ
- Extractoins
- RCT
- Periodontal infections
- Periodontal surgery
- Dental implant surgery
