Word Document Flashcards
A patient attends with a space between 13 and 14
- What investigations should you do and why?
o BPE – screening tool for periodontal health status
o PGI – to assess plaque and bleeding levels with BPE >1
o 6 point pocket chart – to assess periodontal disease, true pocketing, gingival recession and mobility when BPE scores >3
o Periapical radiographs to assess bone levels, prognosis of the teeth, any radiolucencies
o Study models to monitor change over time
A patient attends with a space between 13 and 14 - Other than aesthetics, why would restoring this space be challenging?
o The space is relatively small and if the teeth are of good prognosis you would be reluctant to remove healthy tooth tissue and place veneers or crowns.
o Composite could be used to make either the 13 or 14 bigger to help close the gap but this may be more noticeable to a patient and others.
A patient attends with a space between 13 and 14 - What problems are associated with implant placement in this case?
o Inadequate space available – requires 7mm
o Inadequate bone levels due to periodontal disease
o Current uncontrolled periodontal disease
- How would you identify vertical bony defects?
- PA radiographs
- 6 point pocket chart
Explain how vertical bony defects occur
- The radius of destruction of plaque determines this pattern. It is approximately 1.5-2mm and if the interproximal bone is greater than this then the pattern is vertical/angular in nature.
ie it depends on how thick the bone was initially. * Depends on the shape of the bone to begin with.- Narrow - horizontal bone loss.
- Wider bone - angular bone loss.
- How is vertical bone defects classified?
Goldman HM and Cohen
- 1 wall defect
- 2 wall defect – heal better
- 3 wall defect – heal better
- What are the treatment options for vertical bone defects?
- Closed/open RSD to allow healing by repair
- Pocket elimination with osseous resection where the flap is repositioned apically
- Regenerative techniques for new bone, periodontal ligament and cementum.
- How do you determine success of HPT?
- SDCEP = Pocket depths <4mm; Plaque scores <15%; Bleeding scores <10%
- However, this may not be achievable for all patients, so patients with significantly improved oral hygiene, reduced bleeding on probing and considerable reduction in probing depths from baseline can be considered to have responded successfully to treatment.
- The patient is deemed to be suitable for regenerative periodontal surgery. What is the indications for this?
o 2 and 3 wall defects
o Grade 2 furcation in mandibular teeth
o Grade 2 buccal furcation in maxillary molars
if regenerative periodontal surgery fails, what are teh 2 alternative treatment options for the management of the quadrant affected?
o Root resection
o Tunnel preparation
o Hemisection
o XLA
o Palliative care
How does perio bone loss occur?
The factors involved in bone destruction in periodontal disease are bacterial and host mediated. Bacterial plaque products induce the differentiation of bone progenitor cells into osteoclasts and stimulate gingival cells to release mediators that have the same effect.21,57 Plaque products and inflammatory mediators can also act directly on osteoblasts or their progenitors, thereby inhibiting their action and reducing their numbers.
Bacteria responsible for perio disease
P. gingivalis, B. forsythus, T. denticola.
In a perio chart, what results would show the teeth with worst prognosis?
o Loss of attachment – less supporting structures for the tooth; increased risk of tooth loss
o Mobility – reduced bone support; increased risk of tooth loss
o Furcation involvement – more difficult to keep clean, increasing risk of caries etc.
- What patient factors affect prognosis of teeth?
o Smoking
o Systemic disease – diabetes, immunosuppression, pregnancy
o Drug history
Elderly patient presets with anteriors drifting and increase in over jet
- What could be causing this movement?
- Active and uncontrolled periodontal disease
- What are the causes of periodontal disease?
Local cause:
- Calculus build up
- Malpositioned teeth
- Overhanging restorations
- Partial dentures
Systemic cause:
- Smoking
- Medical conditions – diabetes, CVD, RA, osteoporosis
- Family history – genetics
- Patient factors – stress, diet, obesity, pregnancy
- Medications – Ca Channel blockers (amlodipine); anti-epileptic (phenytoin) and immunosuppressive (cyclosporine)
What are the treatment options for periodontal disease?
Control periodontal disease
- Carry out a BPE and then PGI and 6 point pocket chart if there are BPE scores of 3 or 4
- OHI – toothbrushing, inter dental cleaning, single tufted brush use, plaque disclosing tablets, mouthwash use and denture hygiene
- Review restoration margins
- Removal of supra-gingival plaque, calculus and staining
- RSD where necessary In pockets >4mm
- Review in 3 months
Mobility control
- Splint the teeth if they are mobile and causing issues when eating/brushing
Susan is a 29 year old patient who is a regular attendee at your practice, she has previously undergone periodontal treatment, she attends as an emergency complaining of pain in her upper front tooth. On examination you notice a swelling pertaining to the 11, TTP and there is associated lymphadenopathy.
- Give 2 differential diagnoses for what this condition could be
- Periodontal abscess
- Periapical abscess
Susan is a 29 year old patient who is a regular attendee at your practice, she has previously undergone periodontal treatment, she attends as an emergency complaining of pain in her upper front tooth. On examination you notice a swelling pertaining to the 11, TTP and there is associated lymphadenopathy. Give 2 special investigations you would undertake to confirm your diagnosis
o Sensibility testing EPT and EC - non vital in periapical abscess and vital in periodontal abscess cases
o Periodontal charting – check the condition of the rest of the mouth for any other periodontal problems
o PA radiographs to show if there is a periapical radiolucency present
Susan is a 29 year old patient who is a regular attendee at your practice, she has previously undergone periodontal treatment, she attends as an emergency complaining of pain in her upper front tooth. On examination you notice a swelling pertaining to the 11, TTP and there is associated lymphadenopathy. - State 2 ways that you could drain the swelling
- drainage through pocket retraction or incision – irrigate with CHX/saline
Susan is a 29 year old patient who is a regular attendee at your practice, she has previously undergone periodontal treatment, she attends as an emergency complaining of pain in her upper front tooth. On examination you notice a swelling pertaining to the 11, TTP and there is associated lymphadenopathy. - Give your initial management of this patient’s swelling if not endodontically involved
o Incision and drainage of the abscess
o Gentle sub gingival debridement (RSD)short of the base of the pocket to avoid trauma and spreading infection
o Hot saline mouthwash
o OHI
o Pain relief
o Antibiotics – amoxicillin 500mg 3x for 5 days if the patient is systemically unwell or immunocompromised
o Review within 10 days and Follow up HPT
A 22 year old presents at your surgery complaining of pain. You can smell his halitosis from the waiting room,
- On examination it is clear that he has ANUG. Describe 4 intra oral signs of ANUG
o Halitosis
o Grey necrotic tissue slough that wipes off to reveal marginal ulcerative tissue
o Crater like ulcers
o Painful ulceration of the tips of the interdental papilla
o Reverse gingival architecture
- What 4 risks factors pre-dispose someone to ANUG
o Smoking
o Stress
o Poor oral hygiene
o Immunosuppression e.g. HIV
Outline treatment for a patient suffering with an acute episode of ANUG
Local measures
Remove supra gingival and sub gingival deposits
provide oral hygiene advice using TIPPS
Smoking cessation
Use of 6% hydrogen peroxide or 0.2% CHX mouthwash until scute symptoms subside
Systemic measures
Metronidazole tablets 200mg for 3 days when there is systemic involvement or persistent swelling despite local measures
* Send: 9 tablets
* Label: 1 tablet three times daily
Review within 10 days:
Carry out further supra and sub gingival scaling
If no resolution, review patients general health and consider referral to specialist dare
What is TIPPS
- Talk – about causes of periodontal disease and any barriers to plaque removal
- Instruct – best ways to perform effective plaque removal
- Practice – practice cleaning teeth and using interdental aids in surgery
- Plan – put into place a plan of how the patient OH fits in with daily life
- Supports – follow up with patient
Q29 - refer to PA radiographs. - What is your diagnosis? What lead you to this diagnosis. What is your treatment plan.
Generalised periodontitis - stage 4, grade C.
Bone loss affects more than 30% of teeth.
Bone loss extends tot he apical third of tooth 36 distal root (worst site of bone loss) - ~75% loss => stage 4.
Worst bone loss (75%)/patients age 28 = >1 => grade C.
Treatment plan according to BSP S3 perio guidelines - refer to diagram and memorise.
How would you decide the prognosis of individual teeth.
o Loss of attachment
o Mobility
o Furcation involvement.
- Why would mechanical root surface debridement not be successful in eliminating pocket bacteria?
o Inadequate RSD due to poor technique or lack of operator experience
o Specific pocket sites may be inaccessible to instrumentation meaning bacteria can invade dentinal tubules
o Failure to disrupt the biofilm
o Patient not adhering to OHI
When should antibiotics be utilised for perio
o Antibiotics should only be used if there is systemic involvement or if the patient is immunocompromised. Antibiotics should not be given to all patients as it increases risk of antimicrobial resistance meaning the biofilm will be able to resist the antibiotics.
o Systemic antibiotics may also not deal with or reach pocket bacteria alone
Antibiotics can be given to patients with ANUG or ANUP for a short period or they can be given to patients who still have perio progressing despite excellent oral hygiene and sufficient treatment.
How would you manage a periodontal abscess that has systemic involvement?
o Carry our careful sub gingival scaling short of the base of the periodontal pocket to avoid iatrogenic damage
o If pus is present, drain by incision or through the periodontal pocket
o Give patient advice on taking analgesics for pain relief
o Use of 0.2% CHX mouthwash until acute symptoms subside
o Prescribe antibiotics due to systemic involvement
Amoxicillin capsules, 500mg for 5 days
* Send: 15 capsules
* Label: 1 capsule three times daily
Or metronidazole tablets, 200mg for 5 days
* Send: 15 tablets
* Label: 1 tablet three times daily
Refer to ANUG and ANUP lecture for treatments.
In the case of necrotising ulcerative gingivitis, remove supra-gingival and sub-gingival
deposits and provide oral hygiene advice.
* Due to the pain associated with NUG, the patient may only be able to tolerate
limited debridement in the acute phase.
In the case of pericoronitis, carry out irrigation and debridement.
If drug treatment is required, an appropriate 3-day regimen is:
Metronidazole Tablets, 200 mg
Send: 9 tablets
Label: 1 tablet three times daily
:Advise patient to avoid alcohol (metronidazole has a disulfiram-like reaction with alcohol).
Do not prescribe metronidazole for patients taking warfarin.
Or
Amoxicillin Capsules, 500 mg
Send: 9 capsules
Label: 1 capsule three times daily
Amoxicillin, like other penicillins, can result in hypersensitivity reactions, including rashes and anaphylaxis,
and can cause diarrhoea. Do not prescribe amoxicillin to patients with a history of anaphylaxis, urticaria or
rash immediately after penicillin administration as these individuals are at risk of immediate hypersensitivity
Patient arrives with swelling above tooth 11 with no systemic symptoms
- Give a differential diagnosis
- Periapical abscess
- Periodontal abscess
- Endo periodontal lesion.
Patient arrives with swelling above tooth 11 with no systemic symptoms. - Further tests to confirm diagnosis
- Sensibility testing – non vital tooth related to periapical abscess
- Periapical radiographs to look for radiolucency at apical region
- Periodontal charting to check for active periodontal disease
Patient arrives with swelling above tooth 11 with no systemic symptoms. - There is a 10mm probing depth on palatal side of tooth. What may have caused the swelling?
- A periodontal abscess which is an acute exacerbation of an existing periodontal pocket caused by trauma to the pocket epithelium or obstruction of the pocket entrance. Bacteria and food can colonise inside the pocket and without adequate cleaning and RSD this pocket becomes further infected causing an abscess to form.
Patient arrives with swelling above tooth 11 with no systemic symptoms . This was a perio abscess. - How will 11 be treated?
o Drainage via incision or via pocket with instrumentation to dilate
o Genital sub gingival debridement
o Hot saline mouthwash use or 0.2% CHS mouthwash
o Antibiotic use if there is systemic involvement
o Follow up with HPT
Tooth 15 is root treated with a 9mm pocket and vertical bony defect radiographically
- Give 3 differential diagnoses
perio abscess
Endo perio lesion
Peripical abscess
Perio abscess classification
Refer to Herrera et al 2018 table 2.
Endo perio lesion
Refer to Herrera et al 2018 Table 6.
Tooth 15 is root treated with a 9mm pocket and vertical bony defect radiographically - What is in the initial treatment of the tooth
- Re root treatment of the tooth
Tooth 15 is root treated with a 9mm pocket and vertical bony defect radiographically - Treatment fails and the tooth is extracted: give 2 options for replacement of the tooth
o RPD
o Bridge
o Implant
- Patient would like an implant but what would you look for first?
o General – smoking status; medical history – bisphosphonate use
o Local – alveolar bone quantity, quality and levels; suitable space to place the Implant 7mm between crowns
- Give 2 types of intervention for inadequate bone levels for implants
o Guided tissue regeneration
o Bone grafting
o Biological mediators – Emdogain (enamel matrix derivative)
o Sinus lift
Tooth 46 shows generalised HBL, vertical defect and furcation involvement
- Describe the pattern of bone loss that will be seen on radiograph
- Vertical bone defects are generally V-shaped and are sharply outlined
- What is the mechanism of vertical bone defect
o The radium if destruction of plaque determines the bone defect
o It is approximately 1.5-2mm and if the interproximal bone is greater than this then the pattern is vertical/angular.
- How do we classify vertical bone defects
Goldman HM and Cohen
1 wall defect
2 wall defect – heal better
3 wall defect – heal better
- We proceed with HPT and re evaluation then surgery – how would you determine success clinically (3 points)
- SDCEP = Pocket depths <4mm; Plaque scores <15%; Bleeding scores <10%
- However, this may not be achievable for all patients, so patients with significantly improved oral hygiene, reduced bleeding on probing and considerable reduction in probing depths from baseline can be considered to have responded successfully to treatment.
- Surgery failed – give 2 alternative options for the management of the quadrant
o Root resection
o Tunnel preparation
o Hemisection
o XLA
o Palliative care
Metronidazole targets what type of bacteria? What about amoxicillin?
Metronidazole is for anaerobic bacteria - p. gingivalis is anaerobic.
Amoxicillin is a more wide spread and less specific antibiotic than metronidazole so they can be sued in combination.
Contraindication of amoxicillin
Penicillin allergy.
Metronidazole contraindications
Alcohol intake, increases anticoagulant effect of warfarin, pregnancy.
What happens when patients consume alcohol on metronidazole?
Inhibits breakdown in the liver of acetaldehyde in patients who are drinking alcohol. The acetaldehyde will then accumulate and casue widespread vasodilation, sweating, nausea and headaches.
4 types of periodontal surgery
Access therapy - gain more access to the root surface in peristing pockets.
Resective therapy - to remove infected soft tissue of the gingivae and infected bone. Now only used in the case of furcation resective treatment ie tunnel preparation, root resection/hemisection, gingivectomy (hyperplasia), crown lengthening before prosthetic tx.
Regenerative therapy for infrabony defects or augmentation of the edentulous ridge.
Mucogingival therapy - perio plastic surgery - gingival augmentation, root coverage, gingival preservation at ectopic tooth eruption, preservation of ridge collapse associated with tooth extraction.
Access therapy aka
Open flap debridement.
Types of pockets
Refer to slide in Step 3 lecture.
Carter.
Intrabony defect
Vertical bone loss
Horizontal bone loss.
Tunnel procedure
Bone and tooth are recontoured to allow insertion of an ID brush.
Root resection
Root is removed completely to get rid of the furcation completely - RCT of the tooth should be done prior.
Hemisection
The tooth is halved to elimate the furcation. For example, we cut a mandibular molar in half vertically. One half is extracted and the other half is restored as a premolar. The tooth is RCT’d first.
Keep one of the roots to maintain bone levels and prevent further resorption.
Exclusively performed in the mandible.
Successful resective procedures
Endo must be successful, root separation and removal must be feasible (this is why hemisection is only done in the mandible), the remaining roots should not be hypermobile. The remaining tooth structure must be restorable. The patient should be motivated to maintain plaque control. Additional caries prevention strategies may be required to prevent caries of the exposed root.
Factors for teeth with furcation extraction
Recurrent symptoms, little remining attachment, gross mobility, non-functional teeth.
However, best to maintain teeth for as long as possible, even if it is only for bone levels for possible implants later.
- What is a healthy periodontium response vs physiological vs pathological responses to traumatic occlusion?
o Healthy periodontium – widening of the PDL; no LOA or inflammation. Will resolve once occlusion is amended
o Healthy but reduced periodontium – same as above but due to reduced PDL there will be increased mobility
o Periodontitis – widening of PDL; LOA: May have some mobility increase; bleeding on probing and plaque present
- How do You manage traumatic occlusion in a patient with periodontal disease?
o Address the causative problem – high restorations, parafunction etc
o Use of a bite raising appliance
o HPT and OHI
Bite raising appliance
bite raising appliance (BRA) is a long-term treatment that can be used to protect your teeth if you grind/clench your teeth (which can cause damage), or to relieve pressure caused by tension in your jaw (temporomandibular joint or TMJ).
The appliance is made from soft acrylic and usually fits over your lower teeth. It is designed to
stop your upper and lower teeth from touching when you close your mouth.
What factors can influence local mobility
o Existing periodontal disease
o Occlusal trauma causing widening of the PDL
o Alveolar bone loss
o Resorption/trauma
o Smoking
When might splinting be advised?
o When there is increased mobility due to advanced loss of attachment making it difficult for the patient to eat or clean.
o Splinting can also facilitate HPT including RSD as the teeth will be stabilised.
- Why is there a decrease in mobility after treatment?
- Due to increased tissue tone and long junctional epithelium attachment with successful HPT
Junctional epithelium
The junctional epithelium (JE) is an epithelial component that is directly attached to the tooth surface and has a protective function against periodontal diseases.
- What can you do if the PDL is widened after successful treatment?
- Reduce contacts within the occlusion that is causing the traumatic occlusion or fremitus on that given tooth
. Mrs Patel is 45 and has soreness in her right cheek which is reddened on the buccal mucosa with a shorty Lacey edge immediately adjacent to tooth 47. This tooth is perfectly sound amalgam with abutments for rest seats and clasps on CoCr partial denture which has been worn for 5 years. Bleeding 6mm mesio-buccal pocket with associated grade 1 mobility. Periapical shows 47 has mesial bone loss but no periapical pathology.
- What are your provisional diagnosis?
o Traumatic lesions
o Lichenoid tissue reaction – amalgam
o Chronic periodontal disease
Mrs Patel is 45 and has soreness in her right cheek which is reddened on the buccal mucosa with a shorty Lacey edge immediately adjacent to tooth 47. This tooth is perfectly sound amalgam with abutments for rest seats and clasps on CoCr partial denture which has been worn for 5 years. Bleeding 6mm mesio-buccal pocket with associated grade 1 mobility. Periapical shows 47 has mesial bone loss but no periapical pathology. - What additional investigations could be undertaken and how would you arrange these?
o Incisional biopsy of the lesion on buccal mucosa for histological examination r.e LTR; SQCC; LP
o Clinical photographs
o Periodontal HPT – PGI; 6PPC
o Refer to GMP; Oral Med
o Refer to dermatology for patch testing for CoCr
Mrs Patel is 45 and has soreness in her right cheek which is reddened on the buccal mucosa with a shorty Lacey edge immediately adjacent to tooth 47. This tooth is perfectly sound amalgam with abutments for rest seats and clasps on CoCr partial denture which has been worn for 5 years. Bleeding 6mm mesio-buccal pocket with associated grade 1 mobility. Periapical shows 47 has mesial bone loss but no periapical pathology. - What are mrs Patel’s options for management of these problems
o Lichenoid reaction – replace amalgam with composite
o Chronic periodontal disease – HPT
o Lichen planus – correct deficiency, medication use; SlS free toothpaste
o Traumatic lesions – adjust CoCr clasps
o Oral cancer – referral to oral med given biopsy results if present for 3 weeks
- Give the average horizontal bone loss for: incisors, canines, premolars, molars
o Incisors – 6.3mm
o Canines – 8.5mm
o Premolars – 10mm
o Molars – 12.8mm
- What is the difference between horizontal and angular bone loss?
o Horizontal bone loss is found where plaque destroys bone completely between 2 roots with the radius of destruction of plaque approx 2mm. Horizontal bone loss refers to the loss in height of the crystal bone around the teeth,
o The radius of destruction of plaque determines this pattern. It is approximately 1.5-2mm and if the interproximal bone is greater than this then the pattern is vertical/angular in nature. Angular bone loss is generally V shaped with a sharp outline.
- How is angular periodontitis caused?
- When the pathway of inflammation travels directly into the PDL space following plaque pattern generally caused by localised plaque retention factors and poor OH and interdental cleaning.
- Define localised and generalised bone loss
- Localised Affects <30% of sites
- Generalised affects >30% of sites
- Define mild, moderate and severe bone loss
o Mild <30%
o Moderate 30-50%
o Severe >50%
- What are the new periodontal disease classifications?
- Health
a. Intact periodontium
b. Reduced periodontium due to causes other than periodontitis e.g. crown lengthening surgery - Plaque induced gingivitis (localised/generalised gingivitis)
a. Intact periodontium
b. Reduced periodontium due to causes other than periodontitis
c. Associated with dental biofilm alone
d. Mediated by systemic or local risk factors
e. Drug influenced gingival enlargement - Non plaque induced gingival disease and conditions
- Periodontitis
a. Localised <30% of sites affected
b. Generalised >30% of sites affected
c. Molar-incisor pattern - Necrotising periodontal disease
- Periodontitis as a manifestation of systemic disease
- Systemic disease or conditions affecting the periodontal tissues
- Periodontal abscesses
- Periodontal-endodontic lesions
- Mucogingival deformities and conditions
- What 7 things are recorded on a periodontal pocket chart?
o Loss of attachment
o Degree of recession
o Pocket depth
o Plaque index
o Bleeding on probing
o Mobility
o Furcation involvement
o Missing teeth
- How is mobility graded?
o 0 = physiological movement 0-0.2
o 1 = <1mm horizontal movement
o 2 = 1-2mm horizontal movement
o 3 = >2mm horizontal and vertical movement (rotation and depression)
- How is furcation graded?
o 1 = <3mm horizontal (<1/3)
o 2 = >3mm horizontal but not through and through (>1/3)
o 3 = through and through defect
- How is gingival recession graded?
- Millers classification
Millers classification of recession
Refer to diagrams.
- Give 2 disadvantages of a pocket chart
o Probing depths are subjective between operators so may have different readings
o True pocket depth may not be measured accurately if sub gingival calculus is blocking the probe from gaining full access to the periodontal pocket
o Assumes all patients have same root length so may appear worse than the actual disease
HPT
HPT – PGI, 6PPC, diet diary, OHI, supra gingival scaling, sub gingival scaling of true pockets >4mm at the start of treatment and then at 3 months regarding SDCEP guidelines for BPE scores 3 or 4
- What are the local factors for gingival recession?
o Periodontal disease
o Parafunctional habits
o Traumatic tooth brushing causing abrasion
o Abrasive toothpaste
o High frenal attachments
o Crowding
o Traumatic overbite
o Fixed orthodontic appliances
o Poor marginal fit restorations
o Smoking
- How can recession be measured?
o Clinical photographs
o Study models
o 6 point pocket chart
- How is localised recession managed?
o Address the underlying cause e.g. atraumatic tooth brushing instructions; managing parafunctional habits
o Minimise other risk factors e.g. periodontal disease, smoking cessation
o Treat any areas of sensitivity with desensitising agents – fluoride varnish, sensodyne toothpaste; fluoride mouthwash, seal and bond
o Surgery – free soft tissue graft from palate or a coronal advancement flap in severe cases
- What are the modified systemic factors that can cause periodontitis?
o Smoking
o Stress
o Obesity – poor diet
o Diabetes
o Drugs – gingival hyperplasia with phenytoin; amlodipine and cyclosporine
o Hormone related – pregnancy, puberty
o Cardiovascular disease
- What are the defect systemic factors that can cause periodontitis?
- Monogenetic syndromes – Sickle cell; CF; PKD
- Down’s syndrome
- Why is diabetes a risk factor for periodontal disease?
o Diabetes causes delayed wound healing and links with periodontal disease due to the abnormal glucose regulation resulting in advanced glycerin end products being produced. These interact with cell surface receptors causing increased permeability and adhesion molecules of endothelial cells, increased chemotaxis and release of IL-6 and TNF-alpha by macrophages, increased MMPs and decreased collagen production by fibroblasts.
o Diabetes causes impaired neutrophil function, heightened inflammatory response, alteration of collagen metabolism, microangiopathy and impaired wound healing.
- What tests are carried out for diabetes and diabetes control?
o Fasting glucose test
o Glucose tolerance test
o HbA1c test every 3-6months
o Blood glucose home testing kits
- What is the normal value for HbA1c
- Ideal 48mmol/mol (6.5% or below)
- How does smoking affect the periodontal tissues?
o Pale fibrotic hyperkeratotic gingivae
o Reduced BOP from gingivae
o More advanced disease anteriorly
o More recession noted
o Prominent staining of hard and soft tissues
o Halitosis and xerostomia
- What is interleukin-1?
o It is a highly pro-inflammatory cytokines produced by epithelial cells, macrophages, dendritic cells, endothelial cells and B cells.
o It plays a central role in the regulation of immune responses.
- What are the aims of initial HPT?
- The reduction or elimination of gingival inflammation achieved through complete removal of all factors responsible for gingival inflammation e.g. calculus, defective restoration, plaque, carious lesions etc and achieving a clean and injection free condition.
- This initial stage aim is to motivate the patient to perform optimal OH.
- What is the overall aim of periodontal therapy?
- To preserve for a patient’s lifetime a dentition which, although affected by periodontitis, has levels of appearance and function that are acceptable to the patient.
How is periodontal therapy provided?
o TIPPS
o Regular re-enforcement of OHI
o Regular effective removal of plaque biofilm through scaling and RSD
o Regular removal of plaque retentive factors
o Smoking cessation advice
How is periodontal treatment deemed successful?
o Plaque scores <15%
o Bleeding scores <10%
o Probing depths <4mm
o However, it is recognised that this level of improvement may not be achievable for all patients; so patients with significantly improved oral hygiene, reduced bleeding on probing and a considerable reduction in probing depths from baseline can be considered to have responded successfully to treatment
What is TIPPS?
- Talk With patient about the causes of periodontal disease and discuss any barriers to effective plaque removal
- Instruct the patient on the best ways to perform effective plaque removal
- Ask the patient to practice cleansing their teeth and to use the interdental cleaning aids whilst in the surgery
- Put in place a plan which specifies how the patient will incorporate oral hygiene into daily life
- Provide support to the patient by following up at subsequent visits
Causes of gingival hyperplasia
Drug induced:
- Anti-epileptic = phenytoin
- Calcium channel blocker – amlodipine
- Immunosuppressant – cyclosporine
- What is the classic pattern of gingival hyperplasia?
- Starts at the interdental papillae and develops to include up to the entirety of the attached gingivae
- How does gingival overgrowth influence periodontal status?
- Plaque control becomes increasingly difficult which results in an additional oedematous inflammatory component to the overgrowth but there is no evidence to suggest overgrowth predisposes periodontitis
How is gingival hyperplasia managed?
- HPT – OHI, supra and sub gingival scaling and plaque control
- Surgical removal of excess tissue – flap procedure
- Consult with GMP regarding change in medication
What does root surface debridement/instrumentation include and what does it not include?
It encompasses the processes of scaling (which is the removal of plaque and calculus from tooth surfaces), and removal of supragingival calculus. It is not root planing which is the removal of contaminated cementum, leaving the root surface smooth and hard - this will cause sensitivity and perhaps pain (the cementum should not be removed when removing the calculus and plaque).
Debridement definition
The act of removing dead, contaminated or adherent tissue or foreign material.
3 types of recession
Refer to lecture notes.
PMPR - What does it mean and what terminology does it replace?
PMPR stands for ‘Professional Mechanical Plaque Removal’ and it can be supragingival or subgingival. It replaces ALL previous terminology. Subgingival PMPR is an umbrella term and replaces root surface debridement or root planing.
Why are systemic antibiotics not often used for perio? Why are they sometimes used?
Because we are fighting against a biofilm which is an aggregate of microorganisms in which cells adhere to each other on a surface. These adherent cells are embedded within a self-produced matrix of extracellular polymeric substance - DNA, proteins, polysacharide.
Biofilms are resistant to antibiotics, antibacterial agents, hidden from immune system of host.
We only use systemic antibiotics in cases where OH is great and we are also mechanically disrupting the biofilm.
Advantages and disadvantages of local antimicrobials in perio ie periochip
Refer to step 3 slides.
Chlorhexidine local antimicrobial - periochip
refer to step 3 slides.
Local antimicrobial antibiotics
Arestin minocycline, elyzol metronidazole, atridox doxycycline.
Periostat doxycycline.
Host immune system modulation therapy
Not currently successful ie steroids makes perio worse as it weakens the immune system, NSAIDs cannot eb used long term due to stomach ulcer risk, anticytokine and biological therapies have too many side effects, bisphosponates etc.
4 forms of periodontal surgery
Refer to step 3 slides.
Open flap debridement
refer to step 3 slides.
Gingivectomy
Refer to step 3 slides.
Objective of regenerative periodontal therapy
We are aiming to improve long term clinical outcomes of teeth that are predominantyl compromised infrabony or intra-radicular defects.
The treatment objective is obtain shallow, maintainable pockets by reconstruction of the destroyed attachment apparatus and thereby also limit recession of the gingival margin.
Aims:
An increase in periodontal attachment of severe compromised teeth.
A decrease in deep pockets to a more maintainable range.
Reduction of the vertical and horizontal component of furcation defects.
Types of pockets
Refer to step 3 slides.
Suprabony and infrabony
suprabony defects as those where the base of the pocket is located coronal to the alveolar crest. On the other hand, infrabony defects are those with apical location of the base of the pocket relative to the bone crest.
Suprabony - horizontal.
Infrabony - vertical.
Crater
Osseous Craters: Craters are cup- or bowl-shaped alveolar. defects in inter-alveolar bone with bone loss approxi- mately equal on the contiguous roots or the concavities. present in the crest of inter-dental alveolar bone and are. confined within the facial and lingual bony walls.
Intrabony defect
periodontal defect within the bone sur- rounded by one, two or three bony walls or a combi- nation thereof’’.
This is classified based on walls present.
Infrabony defect management
refer to step 3 slides.
Strategies for periodontal regeneration
refer to step 3 slides.
Emdogain
Is an enamel matrix protein derived from the porcine tooth germ - it forms a matrix on the root surface that mediates the production of cementum.
Triad of tissue engineering
Cells, scaffold, signalling molecules.
Guided tissue regeneration
Refer to step 3 slides.
Bone grafts - objectives
Refer to step 3 slides.
Treatment strategies for furcation involvement
Refer to step 3 slides.
