W6 Flashcards
What is the examination sequence?
1 - Patient History
2 - Extra oral examination
3 - Intraoral examination
4 - Perio Chart
5 - Radiographic Examination
6 - Special tests
What are the 8 aims of perio assessment?
1 - Identify pathology
2 - Identofy risk factors
3 - Collect relevant data to establish a diagnosis
4 - develop short medium and long term prognosis
5- Formulate treatment plan
6 - establish baseline data for follow up assessment
7 - Communicate with patient
8 - Satisfy professional dentolegal requirements
What are the aspects of Patient History?
1 - Presenting complaint
2 - Dental History
3 - Medical History
4 - social history
5 - diet
6 - Oral Hygeine
What does SOCRATES stand for in determining the characteristics of a patients presenting complaint?
Site
Onset
Character (what does it feel like)
Radiation
Associated factors
Timing
Exacerbations (what makes it worse)
Severity
What do we gather during dental history
Oral hygeine habits
Dental Visits
Previous conditions
current concerns
History of dental attendance
3 reasons for taking medical history
1 - To identify medications and conditions (may affect treatment and presentation of periodontitis)
2 - To identify systemic conditions (require special precautions)
3 - To identify transmissible diseases (present hazard to clinician)
What are examples of allergies?
Penicillin
sulphar containing antibiotics
Certain spices eg mint (irritating for some mucousal diseases - oral lichen planus)
Management of Allergies
double check with patient even if its ticked no
Examples of anticoagulants and bleeding dyscrasias
Apixaban
Warfarin
Haemophillia A
Management of risk of prolonged bleeding
Consult with patients medical practitioner - temporarily taken off anticoagulant - consider referal
Antibiotic propylaxis/ cover
- Antibiotics taken 1 hour before invasive dental procedure for patients at risk of infective endocarditis
- Optimise patients oral hygiene to reduce risk of bacteraemia (bacteria in blood) from daily oral hygiene and mastication
Procedures with high risk of bacteraemia
Sub gingival root debridement
Dental Extractions
Periodontal Surgery
Examples of steroid cover
Long term Prednisolone
Management of steroid cover
- Consider amount of stress induced by dental procedures and need for increase dose of corticosteroid
- Consider steroid dose and duration
Risk of medication - related osteonecrosis of the jaw (MRONJ) examples
Prolia (denosumnab)
Bisphosphonates
Management of MRONJ
- Increased risk for MRONJ if patient on medications for more than 3 years
- Refer to OMFS for extractions and surgery
Examples of Immunosuppression
Chemotherapy
Methotrexate
Management of Immunosuppression
Consider antibiotic cover or delaying treatment
Examples and comments for Osteoradionecrosis
- Head and neck therapy
- History pf radiotherapy to the head and neck
- Non healing extraction sockets
Management of Osteoradionecrosis
Dental Fitness prior to radiotherapy
Referral to OMFS/dental unit
Management of Coronary ischaemic syndrome
Defer elective dental procedures for 6 months following myocardial infarction, stent placement, coronary artery bypass
Examples of cardiac pacemakers
pacemakers/defibrillators
New units shielded from EMFs generated by ultrasonics
Management of Cardiac Pacemakers
Old units may not be shielded - avoid ultrasonic scalers
Uncontrolled diabetes involvement in wound healing
Poor wound healing and resistance to bacteria
Uncontrolled diabetes management
Consider antibiotic cover or delaying treatment
Examples of Systemic conditions (8)
- smoking
- diabetes
- Cardiovascular disease
- pregnancy/hormonal fluctuations
- Immunosuppressed states
- drug induced gingival overgrowth
- Stress
- Genetics
What is in Social History
- Family responsibilities
- Language Barriers
- Sources of stress
- Ethnicity
- Occupation
- Socioeconomic status and education levels
- Family History of periodontitis and hereditable diseases
relevant information when investigating oral hygiene habits
Erosive and cariogenic elements in patients diet
Alcohol consumption
Frequency
Parent/carer education levels
Supervised brushing for children
What factors can you visually assess involving periodontal tissue
- Changes in size (recession vs gingival hyplasia)
- Colour (pink, red, cyanotic (purple))
- Contour (Pointed = healthy, blunted papilla and bulbous = inflammed)
Tone (firm = healthy, spongey and retractable = loss of tissue tone) - Thickness
- Consistency
- Texture
- Position
- Location of inflammation
How much attached gingiva is required for health?
2mm
Amount of keratinised gingiva on thick (flat) phenotype?
Broad Zone
Amount of keratinised gingiva on thin (scalloped) phenotype?
Narrow zone
Tooth shape of thick phenotype
Square with large contact area and short papilla
Tooth shape of thin phenotype
elongated and triangular
Does thin phenotype have recession after treatment?
yes - needs to be maintained
Does thick phenotype have recession after treatment?
no - resists recession
How do we assess plaque and calculus deposits?
Plaque Index - O’leary Index
What is Plaque Index - O’leary Index
- Records presence of plaque on individual tooth surfaces (4 per tooth)
- Expressed as a whole k=mouth percentage
- Can utilise plaque disclosing solution
- record presence of plaque at dentogingival level
- Can be used as motivating tool
What is a frenum
Thin fold of mucosa enclosing muscle fibres which attaches to the lip mucosa, underlying periosteum and bone
Where do u see frenae
Maxillary arch - Facial midline stablising lips
Mandibular arch - facial midline (stabilising lips), ligual frenum (stabilising tongue)
What dental factors are important to identify as they can impact on periodontal health and disease? (12)
Caries
fractures
Stains
Calculus
Hypersesitivity
Mobility
Missing teeth
Diastemas
Open contacts
Crowding/rotation
supraeruptions
Restorations
what are the 7 probe based tests?
Probing Depth
Recession
Pseudopockets
Clinical Attachment loss
Bleeding on probing Suppuration on probing
Furcation involvement
what is the healthy probing depth
1-3mm
how is cal calculated
adding recession to proving depth
what is suppuration
pus- neutrophil rich exudate
seen in poorly controlled diabetics
what is a grade 1 furcation
less than 1/3 of the root trunk
what is a grade 2 furcation
more than 1/3 of the root trunk but not all the way through
what is a grade 3 furcation
through and through
what are the 4 common probing errors
- Incorrect angualtion
- Probe stopped by restorations
- use of probe in different diameters and markings
- using high force greater than 25 Ncm
what is a furcation
exposed area of where the root divides
why does a site bleed on probing
presence of inflammation within a pocket
presence of bacteria
what does measuring the whole mouth percentage bop indicate?
how much is affected
severity
what is the main limitation of all periodontal tests including radiographs
only show bone loss that has occured within the buccal and lingual plate
what are the 6 advantages of using radiographs
- Relatively non invasive
- inexpensive
- Quick to produce
- provides significant diagnostic
-information in one image - can be stored and reassed at anytime
- Can estimate disease activity overtime by comparing radiographs
what are the 6 disadvantages of radiographs
- exposes patient to xray radiation
- insensitive to small changes
- retrospective - no current info on disease activity
- Cannot detect pocketing
- Anatomical structures may overlie lesions in trabecular bone
- To detect cancellous bone loss, the cortical bone must be involved
Are cone beam CT scans indicated for periodontal diagnosis
no - need a specific reason eg implants
horizontal bone loss
flat - easy to debride
vertical bone loss
difficult to debride
what are the two anatomical features of a tooth that are used for the calculation of radiographic bone loss
root apex
CEJ
what is the threshold for severe bone loss on an xray
more than 50%
what are the 4 special tests in periodontics
pulp testing
use a frac finder or tooth sleuth to find cracked cusps
Microbiological tests
Genetic tests
what is frequency of disease: prevelance
Number of disease cases at a given point in time
what is frequency of disease: incidence
number of cases appearing over a defined period of time
what is senstivity
number of diseased patients who are correctly identified as having disease - that is the diagnostic marker leads to a minimum number of false negative diagnosis
What is specificity
the number of healthy persons who are correctly determined to not have the disease - that is the diagnostic marker leads to a minimum number of false positive diagnosis
who does periodontitis risk increase in
Males
smokers
increases with age
how is plaque index measured
assesses the presence or absense of plaque deposits at gingival margin as y/n
how is gingival index measured
scores severity of gingival inflammation 1-4
average core/tooth = GI tooth
Average score/dentition = GI Dentition
how is BOP measured
assessed by absence or presence
y/n
expressed as a whole mouth percentage
what are indicies
numerical expressions representing a defined set of disease criterea - summarise and characterise the disease state of a patient
what are the four limitations of periodontal indicies
no assessment of past periodontal disease
no record of alveolar bone loss or recession
record of calculus assumes bop has occured even if it hasnt (overestimates bop)
presence of deeper pockets persisting after treatment assumes presence of calculus and bop as they are in the same code
what does BPE stand for
basic periodontal examination
what does PSR stand for
periodontal screening and recording
what does CPITN stand for
community index of periodontal treatment needs
what does code 0 indicate for periodontal indices
nothing - preventative care
what does code 1 indicate for periodontal indices
BOP for BPE, PSR and CPITN
what are the treatment recommendations for code 1
oral hygiene instructions and plaque and stain removal
what does code 2 indicate for periodontal indices
BOP, calculus, overhangs/defective resto margins for BPE, PSR and CPITN
what are the treatment recommendations for code 2
OHI
plaque and calculus and stain removal
remove overhangs
what does code 3 indicate for periodontal indices
3.5-5.5mm pockets for BPE, PSR and CPITN
what are the treatment recommendations for code 3
radiographs, subgingival debridement
OHI
possible referal
what does code 4 indicate for periodontal indices
greater than 5.5mm pockets for BPE, PSR and CPITN
what are the treatment recommendations for code 4
full perio chart
complex treatment including surgery
referal to specialist
what does code * indicate for periodontal indices in BPE
furcation involvement of CAL greater or equal to 7mm
what does code * indicate for periodontal indices in PSR
furcation involvement, abnormal tooth mobility, mucogingival problems or significant gingival recession
what does code * indicate for periodontal indices in CPITN
furcation involvement
what are the treatment recommendations for code *
full perio chart
what does code X indicate for periodontal indices
PSR - Sextant absent or fewer than 2 teeth in a sextant
what recordings are CPITN, BPE and PSR
sextant
what codes require perio charting
3 and 4
