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.
