Unit 3 Flashcards
What are the goals of periodontal treatment?
- Eliminate gingival inflammation
- Reduce periodontal pockets and infection
- Arrest destruction of soft tissue and bone
- Reduce abnormal mobility
- Establish optimal occlusal function
- Restore tissue destroyed by disease
- Reestablish gingival contour
- Prevent recurrence of disease
What is the tissue response to local and systemic treatment?
- epithelium: restore surface continuity (decrease ulcerations)
- CT: attach bone to cementum and establish bone height
- Bone: restore balance between formation and resorption
- Cementum: attach periodontal fibers
What is the primary goal of local therapy?
-removal of plaque and all factors that favor its accumulation to resolve inflammation
- debridement: scaling, root planing, ultrasonics
- margination-smooth overhangs
- chemotherapeutics-mouth rinses, essential oils
What are the clinical results we are looking for from perio treatment?
- elimination of gingival inflammation
- cessation of gingival bleeding
- elimination of perio pockets and infection
- cessation of pus formation
- cessation of bone loss
- reduction in abnormal tooth mobility
- establishment of optimal occlusal relationships
- restoration (not replace) of destroyed periodontal tissues
- restoration of physiologic gingival contour
- prevention of recurrence
What are possible plaque retentive factors?
- calculus
- OH’s
- food impaction
- malpositioned teeth
- recession
- gingival enlargement
- pockets
- furcations
- rough restorations
What is systemic therapy and what purposes does it have in the dental hygiene environment?
-plays less of a role in perio therapy and tends to be used as an adjunct to local or surgical therapy
- control of systemic complications of acute infections
- to control post treatment bacteremia
- supportive nutrition therapy
- control of systemic diseases that aggravate a perio condition (diabetes)
- special precautions associated with surgical tx (control pre and post surgical infection)
- host modulation
What are some local factors that promote healing?
- Removal of plaque & plaque retentive factors
- Removal of degenerated tissue debris
- Immobilizing the healing area (e.g. perio dressing, splint)
What are some local factors that delay healing?
- plaque biofilm
- tissue trauma and excessive tissue manipulation during treatment
- the presence of foreign bodies (calculus left in pocket, necrotic tissue, tissue tags, toxins remaining on the root surface)
- repetitive treatment procedures that disrupt the orderly cellular activity in healing (reprobing and rescaling before healing is complete)
What are some systemic factors that delay healing
- impaired or insufficient blood supply needed to heal
- hormones - glucocorticoids hinder repair by depressing inflammatory reaction, suppressing fibroblast growth and collagen production
- systemic stress, thyroidectomy, testosterone, ACTH and large doses of estrogen suppress formation of granulation tissue and retard healing
- generalized infections (body has a lot more to fight off than just plaque in the pocket)
- diabetes and debiliting diseases that affect resistance and repair
- smoking
- poor nutrition (esp VitC & protein)
- aging can diminish capacity though is not absolute
What are some systemic factors that promote healing
- a good blood supply that brings oxygen and nutrients to the area promotes healing
- optimal nutrition
- overall good systemic health
What are the different healing processes after perio therapy?
- regeneration
- repair
- new attachment
- reattachment
These forms of healing have significance in the clinical and histological results obtainable by treatment
What are the cellular healing processes following perio tx?
- removal of degenerated tissue debris
- replacement of tissue destroyed by diseases
Define regeneration
natural renewal of tissues produced by growth and differentiation of new cells & intercellular substances to form new tissues
- normal, continuous physiolical process replace tissues/cells that mature and die
- normal healing process after any type of injury
- impeded by bacteria and their products
- perio therapy enables tissues to properly carry out their inherent regeneration capacity
Define repair
restores continuity of the diseased gingival margin and reestablishes a normal sulcus at the base of the pocket
- replaced tissue is functional but not precisely the same in appearance and function as the original
- process is sometimes called healing by scar
- arrests bone destruction without necessarily increasing bone height
- is the main healing pattern after periodontal therapy unless special procedures are used to reconstruct the periodontium and fully restore the tissues and attachment apparatus to its original state
Define new attachment
new PDL fibers embedded in new cementum and the attachment of gingival epithelium to the tooth surface previously denuded by disease
- regeneration of the perio ligament is a key factor in new attachment because it provides continuity between bone and cementum
- the perio ligament also contains cells that produce and remodel cementum and bone
- new attachment occurs minimally in phase 1 therapy (non-surgical therapy)
- refers to the new junctional epithelium & attached connective tissue fibers formed on ZoneB - periodontium restored on the root surface previously denuded by disease
Define reattachment
- the ideal
- repair in areas of the root not previously exposed to a pocket (e.g., surgical detachment, trauma, tx of periapical lesions, etc.)
Define epithelial adaptation and describe how it differs from new attachment
- the pocket epithelium is closely adapted to but not attached to the root
- is called healing via a long junctional epithelium and represents a type of repair
- is the primary healing pattern after most perio therapy
What is the clinical and histological result of epithelial adaptation?
- histologically the attachment is not real attachment but healing via a long JE
- depends on this process where cells generate first and are able to establish themselves on the healing area
- is now accepted as a good clincial result of perio therapy because it seems to be as resistant as true attachment
Define the term periodontal reconstruction
Process of regeneration of cells and fibers and remodeling of the lost periodontal structures resulting in:
- Gain in the attachment level
- Formation of new PDL fibers
- A level of bone significantly coronal to that present before treatment
Regeneration of the PDL is the key to reconstruction because it provides continuity between the alveolar bone and cementum and also because it contains cells that can synthesize and remodel the 3 CT cells of the alveolar part of the periodontium.
What are the possible results or healing process of tissue reconstruction?
if epithelial cells (A) proliferate along the root first you get a long junctional epithelium
if cells of gingival CT (B)– populate first you get fibres parallel to the tooth surface with no attachment to cementum
if bone cells (C) arrive first, root resorption and ankylosis may occur
when only PDL fiber cells (D) proliferate coronally you get new formation of cementum & PDL
Outcome depends on which cells generate first and are able to establish themselves in the healing are
What does the final outcome of perio treatment depend on?
- whcih cells generate first and are able to establish themselves in the healing area
- a prediction of the course, duration and outcome of disease based on knowledge of it’s pathogenesis and risk factors
What is an unwanted outcome of perio therapy?
No repair
- insufficient control of infection (plaque removal)
- inadequate debridement of site/lesion (plaque removal)
- absence of long-term maintenance program
- insufficient control of systemic diseases
Define prognosis
-a prediction of the course, duration and outcome of disease based on knowledge of its pathogenesis and risk factors
When in the course of client care is prognosis determined?
-can only make a provisional prognisis befroe
When in the course of client care is prognosis determined?
- can only make a provisional prognosis before tx
- can’t be done until you see how tissue responds to tx
based on level of disease and home care control
How do prognostic factor sdiffere from risk factors?
- Risk is likelihood that an indiv. will develop a disease in a specific period; are characteristics that put a person at risk for dev. disease
- Prognostic factors predict the outcome of disease
- Can be the same factor, e.g. diabetes
- Prognosis can change following treatment and re-evaluation of the perio status
- based upon the various factors, and can be different for the whole dentition versus a single tooth
- the prognosis can change following treatment and re-evaluation of the perio status
How is prognosis classified?
- provisional prognosis - a tentative prognosis pending evaluation results of phase 1 therapy
- individual prognosis - evaluates probable outcome for individual teeth
- overall prognosis - evaluates probable outcome for the dentition as a whole
What are the other types of prognosis?
- good
- fair
- poor
- questionable or guarded
- hopeless
Which prognosis are based on ‘the probability of obtaining stability of the periodontal supporting apparatus”?
- favourable
- questionable
- unfavourable
- hopeful
What are some clinical factors to consider when determining prognosis?
- age
- pocket depth
- CAL
- height of remaining bone
- presence and type of bony defects
- plaque control
- client compliance
What are systemic & environmental factors to consider when determining prognosis
- smoking
- systemic disease or condition
- genetic factors
- stress
What are local factors to consider when determining prognosis?
- plaque and calculus
- subgingival restorations
- anatomic factors
- mobility
What are some prosthetic and restorative factors that can determine prognosis?
- caries
- nonvital teeth
- root resorption
What are some prosthetic and restorative factors that can determine prognosis?
- caries
- nonvital teeth
- root resorption
What is the relationship between diagnosis and prognosis?
Many of the criteria used in diagnosis and classification or periodontal diseases are also used in developing the prognosis
Factors that lead to disease will also affect the outcome of disease if it still persist after treatment
What is the prognosis for plaque induced gingivitis
good provided all local irritants are eliminated
What is the prognosis for plaque induced gingivitis modified by systemic factors?
prognosis depends on control of plaque and control or correction of systemic factor (when possible)
What is the prognosis of perio disease modified by medication?
surgical intervention usually necessary
continues use of drug usually results in recurrence of enlargement
What is the prognosis of chronic perio
good in slight to moderate provided inflammation can be controlled through good OH and removal of local factors
severe usually fair to poor
What is the prognosis of aggressive perio?
refer - prognosis determined by periodontist (fair, poor, questionable)
What are some guidelines to referring a client?
- Periodontal clients with probing depths deeper than 5mm and active disease after initial therapy
- Clients with any form of aggressive periodontitis
- Clients with recurring forms of periodontitis
- Clients with severe/advanced periodontitis
- Children or juveniles with periodontitis
- Furcations (at least Cl II)
- Frequent perio abscesses
- Isolated areas of bone loss
- Drug-induced gingival hyperplasia
- Advanced recession
- Peri-implantitis
What are some guidelines to referring a client?
- Periodontal clients with probing depths deeper than 5mm and active disease after initial therapy
- Clients with any form of aggressive periodontitis
- Clients with recurring forms of periodontitis
- Clients with severe/advanced periodontitis
- Children or juveniles with periodontitis
- Furcations (at least Cl II)
- Frequent perio abscesses
- Isolated areas of bone loss
- Drug-induced gingival hyperplasia
- Advanced recession
- Peri-implantitis
When should you refer to a dentist?
- cosmetic surgery
- implants
- crown lengthening
- edentulous ridge augmentation
When should you refer to a dentist?
- cosmetic surgery
- implants
- crown lengthening
- edentulous ridge augmentation
Which clients should be treated by a periodontist?
- Severe chronic periodontitis – furcations, angular defects
- Aggressive periodontitis
- Acute perio abscesses
- Significant recession
- Peri-implant disease
Which clients should be treated by a periodontist?
Level 3:
- Severe chronic periodontitis – furcations, angular defects
- Aggressive periodontitis
- Acute perio abscesses
- Significant recession
- Peri-implant disease
Which clients would benefit from co-management with a periodontist?
Level 2:
Those who at reevaluation present with:
-Early onset perio unresolved inflammation at any site
-Pockets ≥ 5mm; progressive attachment loss
-Vertical bone defects
-Radiographic evidence of progressive bone loss
-Progressive mobility
-Deteriorating risk profile
Level 1:
- Any patient with periodontal inflammation/infection and following conditions: diabetes, pregnancy, CVD, CRD
- Any candidate for the following treatments who might be at risk for perio infection: cancer therapy, cardiovascular surgery, joint replacement surgery, organ transplantation
Which clients would benefit from co-management with a periodontist?
Level 2:
Those who at reevaluation present with:
-Early onset perio unresolved inflammation at any site
-Pockets ≥ 5mm; progressive attachment loss
-Vertical bone defects
-Radiographic evidence of progressive bone loss
-Progressive mobility
-Deteriorating risk profile
Level 1:
- Any patient with periodontal inflammation/infection and following conditions: diabetes, pregnancy, CVD, CRD
- Any candidate for the following treatments who might be at risk for perio infection: cancer therapy, cardiovascular surgery, joint replacement surgery, organ transplantation
How does client age affect prognosis?
- dexterity
- ability to healsis?
- immune compromised?
- medications
- cognitive ability
- longevity of dentition
- age of development of perio - younger age decreased prognosis even though younger have greater repairative factor
How does pocket depth affect prognosis?
- ability to self cleanse
- ability to get into the pocekt with home care tools
- different bacteria is present in pocket
Less important than CAL and bone loss in prognosis
How does level of attachment affect prognosis?
- plaque retention
- surface texture
- sensitivity
How does height of remaining bone affect prognosis?
- mobility
- prognosis of dentition
- furcation exposures (ability to clean and need to change home care tools)
- horizontal bone loss is harder than vertical bone loss
How does presence and types of defects affect prognosis?
- ability to clean
- self cleansing ability
- plaque retention
How does self care/plaque control affect prognosis?
- compliance - good compliance = good prognosis
- cognitive ability
- dexterity
What sort of anatomic factors play a role in prognosis?
- crown to root ratio
- enamel pearl
- root concavity
- root proximity
- width of furcation
none of these are a problem until attachment changes
