tutorials

Question 1

ideal outcomes for periodontal tx

according to SDCEP

Answer 1

Plaque scores below 15%
Bleeding scores below 10%
Probing depths less than 4mm

Or significant improvement in all 3 aspects from pts baseline

Then progress to supportive periodontal care

Question 2

pt with pockets 5mm+
should you try non-surgical perio tx or refer to specialist

Answer 2

try - likely some improvement

Deep pocket is less likely to respond because it is hard to clean down the pocket depth – reason there: anatomical, thin buccal plate etc. Pocket more than 5mm highly likely deposits left on root surface after specialist instrumentation, still capable to heal if you do enough
* Initial improvement after instrumentation seen at 9m

Specialist tx often what you to try it first
* NHS need to have done step 1 and 2 of tx in primary care and pt engagement

Question 3

options for perio referral

Answer 3

NHS dental hospital (crieteria needs)
hygienist (more time and more frequent visits)
private specialist options

give options to pt - they may have preference

Question 4

questions to ask pt at review

Answer 4

• How are they getting on with their oral hygiene and interdental cleaning, bleeding
• If they smoked – have they tried to quit? Success?
• Noticing any sensitivity
• Mobility
• Any changes to medical history (diabetes)
• Alcohol
• Stress levels
• any Dental tx placed – plaque traps

Review pt initial presenting complaint – has it been addressed

Question 5

modified bleeding score is from

Answer 5

gingival margin

Question 6

BOP is from

Answer 6

base of pocket

Question 7

‘non responding’ site after tx is

Answer 7

Plaque scores above 15%
Bleeding scores above 10%
Probing depths more than 4mm

Or no significant change in plaque, BOP or probing depth from the pt’s baseline

4mm pocket and no BOP =stable
4mm and BOP = not stable
4mm+ = not stable

Question 8

‘non responding’ site after tx is

Answer 8

Plaque scores above 15%
Bleeding scores above 10%
Probing depths more than 4mm

Or no significant change in plaque, BOP or probing depth from the pt’s baseline

4mm pocket and no BOP =stable
4mm and BOP = not stable
4mm+ = not stable

Question 9

options for tx of ‘non responding sites’

Answer 9

Targeted PMPR on those sites

Surgical periodontal therapy

Question 10

surgical periodontal therapy options

4

Answer 10

• **open flap debridement **
• gingivectomy
• guided tissue regeneration
• local antimicrobials into deep pockets

Av difference between surgical and non is less than 1mm

Need right site and right pt
* Narrow down to right criteria – surigical and non surgical can have big impact, but not wide picture

Question 11

adv and risk of surgical perio therapy

Answer 11

adv - pocket depth reduction

risks -
* bleeding, bruising, swelling, infection, nerve damage, pain,
* Specific to perio – can’t guarantee results, gingival recession, sensitivity

Question 12

periodontal emergency

what is it

Answer 12

acute condition involving the periodontium causes pain resulting in pt seeking urgent tx

Tx and management is needed to prevent further damage to periodontium and to improve pts physical and psychological wellbeing.

Question 13

periodonta emergencies
examples

7

Answer 13

• Gingival abscess
• Periodontal abscess
• Perio-endo abscess
• Peri-corinitis abscess
• Necrotising gingivitis
• Necrotising periodontitis
• Subgingival root fracture

Question 14

periodontal abscess

what is it

Answer 14

localised accumulation of pus within gingival wall of perio pocket that destroys collagen fibre attachment and the loss of alveolar bone

active period of perio breakdown which occurs whist there is marginal closure of deep pocket that blocks drainage
* often seen in pts who have untreated perio or recurrent infection during active tx

Question 15

periodontal abscess

presentation

Answer 15

Presents as oval elevation on gingivae near lateral aspect of root
* Deep abscesses may be more difficult to see and appear as diffuse swelling or red area

Swelling on gingiva and pus
* Usually associated with deep perio pocket with BOP and tenderness
* Suppuration can occur through fistula or through pocket
Pain
Fever and swollen or enlarged LN
Inc tooth mobility
Bone loss likely

Question 16

periodontal abscess

management

Answer 16

Carry out careful sub-gingival instrumentation short of the base of the periodontal pocket to avoid iatrogenic damage; local anaesthesia may be required.

If pus is present in a periodontal abscess, drain by incision or through the periodontal pocket.

Recommend optimal analgesia.

Do not prescribe antibiotics unless there are signs of spreading infection or systemic involvement.

Recommend the use of 0.2% chlorhexidine mouthwash until the acute symptoms subside.

Following acute management, review within 10 days and carry out definitive periodontal instrumentation and arrange an appropriate recall interval.

Question 17

necrotising gingivitis

what is it

Answer 17

Severe inflammatory condition of gingiva caused by pathogenic bacteria
Limited to gingival tissue

ANAEROBIC BACTERIA

COMMON IN SMOKERS, IMMUNOSUPPRESED AND POOR OH

Question 18

necrotising gingivitis

presentation

Answer 18

MARGINAL GINGIVAL ULCERATION,
LOSS OF ID PAPULLAE,
GREY SLOUGH ON SURFACE OF ULCERS,
PAUNFUL

Pain, swelling, bleeding, halitosis

Question 19

necrotising periodontitis

what is it

Answer 19

Severe inflammatory condition of gingiva caused by pathogenic bacteria
Involves loss of attachment of periodontium

CLINICAL ATTACHMENT LOSS, BONE DESTRUCTION

Question 20

necrotising periodontitis

presentation

Answer 20

Pain, swelling, bleeding, halitosis, LOA, malaise, fever, ulcerated gingivae
CLINICAL ATTACHMENT LOSS, BONE DESTRUCTION

Question 21

necrotising gingivitis/periodontitis
management

Answer 21

use the Oral Hygiene TIPPS behaviour change strategy to highlight the importance of effective plaque removal and to show the patient how he/she can achieve this
Where applicable, give smoking cessation advice

Remove supra-gingival plaque, calculus and stain and sub-gingival deposits using an appropriate method - LA may be required.

Due to the pain associated with the condition, the patient he patient may only be able to tolerate limited supra- and sub-gingival debridement in the acute phase

Recommend the use of either 6% hydrogen peroxide or 0.2% chlorhexidine mouthwash until the acute symptoms subside.

If there is evidence of spreading infection or systemic involvement, consider prescribing metronidazole

Following acute management, review within 10 days and carry out further supra- and sub- gingival instrumentation as required and arrange an appropriate recall interval.
* if no resolution of signs and symptoms occurs, review the patient’s general health and consider referral to a specialist in primary or secondary care.

Question 22

perio endo abscess

what is it

Answer 22

Combination of perio and endo lesions in endo and or pulpal tissues – result of communication between perio pocket and pulp

CLINICAL ATTACHMENT LOSS AND TOOTH WITH NECROTIC OR PARTIALLY NECROTIC PULP
Deep pocket surrounding non vital tooth
Generalised perio disease may be present with localised pain

Question 23

perio endo abscess

presentation

Answer 23

Swelling with or without pus
Deep pocketing to root apex

CLINICAL ATTACHMENT LOSS AND TOOTH WITH NECROTIC OR PARTIALLY NECROTIC PULP

Question 24

perio endo abscess
management

Answer 24

Carry out endodontic treatment of the affected tooth.

Recommend optimal analgesia.

Do not prescribe antibiotics unless there are signs of spreading infection or systemic involvement.

Recommend the use of 0.2% chlorhexidine mouthwash until the acute symptoms subside.

Following acute management of the lesion, review within 10 days and carry out supra- and sub-gingival instrumentation if necessary and arrange an appropriate recall interval.

Question 25

general presentation for perio emergency

Answer 25

* Pain – most common reason * Discomfort * Infection * Halitosis * Fever * Swollen/enlarged lymph nodes * Malaise * Bleeding * Abscess can give increased mobility * Ulcerations

Question 26

possible special tests for suspected perio emergency

Answer 26

Radiographs – PA * BONE LOSS – MAYBE MORE PERIO PT * CARIES OR HEAVILY FILLED TOOTH – ENDO LESION * APICAL LESION Sensibility testing * EPT * Ethyl chloride

Question 27

periodontal abscess characteristics

Answer 27

caused by impacted of foreign body in the gums which leads to an abscess non draining infection of a periodontal pocket * Bacteria enters the soft tissues surrounding the periodontal pocket – causes inflammatory process leading to destructive of connective tissue Dull constant pain can be in: * Perio pt who has active tx * pt who has untreated perio disease

Question 28

periapical abscess characteristics

Answer 28

This is a localised collection of pus in the alveolar bone at tooth root apex Caused when infection extends through dental pulp through apical foramen into the peri-radicular tissue * Inflammatory reactions to infection in the pulp * Most commonly caused by necrotic pulp tissue Radiolucency in PA area, deep caries, failed restoration Clinically swelling close to root apex – periapical

Question 29

pain to hot and throbing pain likely abscess type

Answer 29

periapical abscess (endo)

Question 30

examination for suspected perio-endo lesion

Answer 30

Ask pt if they have perio disease muscosa * Gingival recession * pockets- in diff qudrants or just one tooth (don’t have perio if just one tooth – more of a perio endo lesion * press on pocket can we see suppuration INTERDENTAL RECESSION INDICATES BONE LOSS – PT IS A PERUO PT Sinus or tract – is it coming from an abscess or from perio pocket PALPATE – check tooth for mobility, TTP, vertical and horizontal

Question 31

periapical absess tx

Answer 31

Incise and drain abscess Carry out endo tx of affected tooth Recommend analgesia Recommend use of 0.2% CHX mouthwash

Question 32

antibiotic for abscess

Answer 32

Phenoxymethylpencillin 250MG TABLETS 2 4X A DAY FOR 5 DAYS ALLERGIC TO PENICILLIN – METRONIDAZOLE – 400MG 1 TABLET 3X DAY FOR 5 DAYS

Question 33

bacteria involved in periodontal disease | 4

Answer 33

P.gingivalis *Porphyromonas gingivalis* (black, gram neg) Prevotella intermedia (black, gram neg) T.forsythia *Tannerella forsythia* (gram neg) Treponema denticola (gram neg)

Question 34

necrotising ulcerative perio/gingivitis what type of infection

Answer 34

oppurtunistic

Question 35

pt symptoms for necrotising periodontal disease

Answer 35

Halitosis Pain Very characteristic for necrotising gingivitis/periodontitis Only type of gingival inflammation that is excruciatingly painful Ulceration of the gums pain Bleeding SYSTEMIC INVOLVEMENT Swollen lymph nodes - particularly submental, submandibular, to jugular digastric nodes Fever General malaise

Question 36

risk factors for necrotisng periodontal disease

Answer 36

* SMOKERS, * IMMUNOCOMPROMISED * POOR OH * Young adults with predisposing factors (in developed countries) - Stress, sleep deprivation, poor OH, smoking, immunosuppression (HIV, leukaemia) * MALNOURISHED

Question 37

special tests for necrotising gum disease

Answer 37

Radiographs – these can be taken to assess bone levels and help establish diagnosis between necrotising ulcerative gingivitis v periodontitis

Question 38

tx for necrotising periodontal diseases

Answer 38

OHI – highlight importance of effective plaque removal and show pt how to carry out proper oral hygiene * Smoking cessation advice if necessary Remove supra and sibgingival plaque deposits – PMPR * Due to pain pt may only be able to tolerat elimited debridement in acute phase * LA is important, divide tx into short visits for pt comfort but tx must be carried out quickly (debridement) in order to get rid of layers of dead tissues * US better than hand instruments – due to water washing away, better at cleaning and with managing pain If pt has systemic involvement or spreading infection considering antibiotics * Metronidazole – good for anaerobic bacteria -400mg – 9 tablets 1 tablet 3x day for 3 days * NO ALCOHOL - disulfiram reaction with alcohol If pain preventing brushing can use 0.2% CHX mouthwash 2x day no more than 10 days - as antiseptic to stop plaque forming. Cause staining and taste disturbance. CANT USE WITHIN 30MINS OF TOOTHBRUSHING AS THEY INACTIVATE EACH OTHER Review within 5-7 DAYS TO REVIEW * carry out further PMPR, ASSESS UNDERLYING CAUSE IF DIDNT BEFORE and then appropriate recall * If can’t find underlying cause - refer to GP

Question 39

CHX mouthwash prep and warninng

Answer 39

0.2% 2x daily no more than 10 days * Cause staining and taste disturbance. * CANT USE WITHIN 30MINS OF TOOTHBRUSHING AS THEY INACTIVATE EACH OTHER

Question 40

metronidazole prescription

Answer 40

for necrotising peridontal diseases with systemic symptoms 400mg – 9 tablets 1 tablet 3x day for 3 days NO ALCOHOL - disulfiram reaction with alcohol good for anaerobic bacteria

Question 41

cause of this

Answer 41

chemical trauma - phosphoric acid burn

Question 42

descirbe this lesion

Answer 42

Erosive lesion localised to specific area Can range from mucosal slough to complete mucosal detachment with extension into submucosa Ulcerative lesion around apex of 12, grey slough, oval shaped, erethryoluekoplacic appearance Erosions or ulcers and can be associated with gingival recession Can be asymptomatic or cause intense localised pain ina rea of lesion Thermal injury – painful for pt, appearance is erythmateous, desquamated and ulcerated whereas chemical lesions may appear from direct contact of agent over the mucosa leading to vesciles, erosions or ulcers

Question 43

pt symptoms assocaited with this lesion

Answer 43

pain hallitosis bleeding

Question 44

possible causes of this chemical burn

Answer 44

Use of drugs as topical agents when not function (aspirin) Habits such as placing nicotine in buccal sulcus -SNUS Inappropriate oral hygiene habits = physical injuries (can be self induced such as finger nails or pencils or traumatic such as ortho forces, piercings Chemical causes can include use of bleaching agent due to inapporpiate use or poorly fitting trays Etching burn

Question 45

how to manage chemical ginigival trauma

Answer 45

Removal of cause via accurant pt history to identify source of trauma Heal on own but measure ulcer to see if grows or improves in size Symptomatic pain management * Analgesic advice *Apologise Cotton wool roll isolation or dam Change cotton wool after etch making sure damp when pulling one out Warn bout recession defect Heals within 10-14 days *

Question 46

how to prevent phosphoric etch burns

Answer 46

Cotton wool roll isolation or dam Change cotton wool after etch making sure damp when pulling one out Warn bout recession defect Heals within 10-14 days

Question 47

what caused this

Answer 47

PRIMARY HERPETIC GINGIVOSTOMATITIS (this disease normally shows vesicles)

Question 48

warning to pt with this

Answer 48

primary herpetic gingivostomatitis is VERY CONTAGIOUS PAY ADDITIONAL ATTENTION TO PROTECT YOURSELF AND ALSO WARN PT THEY ARE CONTAGIOUS * will be spread easily – use reserved cups, cutlery, plates etc to avoid spreading amongst family

Question 49

signs of herpetic gingivostomatitis

Answer 49

high grade fever all oral mucosa * painful ulcerative lesions of gingivae and mucsa * erythematous mucosa vesicles | SEE MAMMELONS SO NOT PEMPHIGOID AS THIS OCCURS IN OLDER PPL

Question 50

symptoms of herpetic gingivostomatitis

Answer 50

Fever Pain Halitosis Lymphadenoptathy Bad odour Sores

Question 51

cause of herpetic gingivostomatitis

Answer 51

herpes simplex virus type 1

Question 52

tx for herpetic gingivostomatitis

Answer 52

generally a mild and self-limited condition, and supportive care is generally adequate * nutritious diet, fluids, rest, analgesics * antimicrobial mouthwashes – 0.2% CHX 10ml rinse 1min 2xdaily– if toothrbushng is painful and this helps to control plaque accumulation and secondary infection (or hydrogen peroxide 6%) 2 week follow up to check resolution If pt is immunocompromised – systemic antiviral agent * ACICLOVIR tablets 200mg 1 5xdaily for 5days * Pt with primary herpetic gingivostomatitis will want this - Shortens duration of event and lessens chance of secondary infection

Question 53

what is this

Answer 53

RECURRENT HERPES SIMPLEX: Reactivate is in neural ganglions Decreased immune system = local reactivation

Question 54

describe lesion

Answer 54

Lesions (vesicles) affecting the hard palate Localised around 12 13 14 Multiple small vesicles Erythematous appearance Shiny

Question 55

triggers for recurrent herpetic gingivostomatitis

Answer 55

include UV light, physical/emotional stress, upper respiratory tract illness, cold weather, hormonal changes, and mouth/lip trauma.

Question 56

symptoms of recurrent herpetic gingivostomatitis

Answer 56

Pain Itching, tingling, burning feeling

Question 57

describe this presentation

Answer 57

Ulcers on lips – lymphocyte infiltration to gingiva and lips – red flag erythema and swollen gums acute untreated leukaemia * Swollen gums due to neutropenia changes * Unwell pt * Anaemia * Tiredness * Poor clotting * Bleed easily * Joint and bone pain

Question 58

drugs which can cause gingival hyperplasia

Answer 58

Anticonvulsant: Phenytoin Immunosuppressants: Cyclosporin (transplant patients) Calcium Channel Blockers: Nifedipine, Amlodipine | fibrous benign growth

Question 59

aciclovir cream prescription

Answer 59

5% apply to lesion every 4hrs (5xday) for 5 days 2g total

Question 60

aciclovir tablets prescription

Answer 60

200mg 1 tablet 5xday for 5 days 25 tablets total

Question 61

e.g. anticonvulsant

Answer 61

phenytoin

Question 62

e.g. immunosuppressant

Answer 62

cyclosporin (transplant pts)