tutorials Flashcards
ideal outcomes for periodontal tx
according to SDCEP
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
pt with pockets 5mm+
should you try non-surgical perio tx or refer to specialist
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
options for perio referral
NHS dental hospital (crieteria needs)
hygienist (more time and more frequent visits)
private specialist options
give options to pt - they may have preference
questions to ask pt at review
- 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
modified bleeding score is from
gingival margin
BOP is from
base of pocket
‘non responding’ site after tx is
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
‘non responding’ site after tx is
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
options for tx of ‘non responding sites’
Targeted PMPR on those sites
Surgical periodontal therapy
surgical periodontal therapy options
4
- **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
adv and risk of surgical perio therapy
adv - pocket depth reduction
risks -
* bleeding, bruising, swelling, infection, nerve damage, pain,
* Specific to perio – can’t guarantee results, gingival recession, sensitivity
periodontal emergency
what is it
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.
periodonta emergencies
examples
7
- Gingival abscess
- Periodontal abscess
- Perio-endo abscess
- Peri-corinitis abscess
- Necrotising gingivitis
- Necrotising periodontitis
- Subgingival root fracture
periodontal abscess
what is it
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
periodontal abscess
presentation
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
periodontal abscess
management
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.
necrotising gingivitis
what is it
Severe inflammatory condition of gingiva caused by pathogenic bacteria
Limited to gingival tissue
ANAEROBIC BACTERIA
COMMON IN SMOKERS, IMMUNOSUPPRESED AND POOR OH
necrotising gingivitis
presentation
MARGINAL GINGIVAL ULCERATION,
LOSS OF ID PAPULLAE,
GREY SLOUGH ON SURFACE OF ULCERS,
PAUNFUL
Pain, swelling, bleeding, halitosis
necrotising periodontitis
what is it
Severe inflammatory condition of gingiva caused by pathogenic bacteria
Involves loss of attachment of periodontium
CLINICAL ATTACHMENT LOSS, BONE DESTRUCTION
necrotising periodontitis
presentation
Pain, swelling, bleeding, halitosis, LOA, malaise, fever, ulcerated gingivae
CLINICAL ATTACHMENT LOSS, BONE DESTRUCTION
necrotising gingivitis/periodontitis
management
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.
perio endo abscess
what is it
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
perio endo abscess
presentation
Swelling with or without pus
Deep pocketing to root apex
CLINICAL ATTACHMENT LOSS AND TOOTH WITH NECROTIC OR PARTIALLY NECROTIC PULP
perio endo abscess
management
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.
cause of this
chemical trauma - phosphoric acid burn
descirbe this lesion
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
pt symptoms assocaited with this lesion
pain
hallitosis
bleeding
possible causes of this chemical burn
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
how to manage chemical ginigival trauma
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 *
what caused this
PRIMARY HERPETIC GINGIVOSTOMATITIS (this disease normally shows vesicles)
warning to pt with this
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
signs of herpetic gingivostomatitis
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
symptoms of herpetic gingivostomatitis
Fever
Pain
Halitosis
Lymphadenoptathy
Bad odour
Sores
what is this
RECURRENT HERPES SIMPLEX:
Reactivate is in neural ganglions
Decreased immune system = local reactivation
describe lesion
Lesions (vesicles) affecting the hard palate
Localised around 12 13 14
Multiple small vesicles
Erythematous appearance
Shiny
describe this presentation
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
