1
Q
what is supra and sub pmpr?
A
- Professional mechanical plaque removal (PMPR) is a term that describes the control of dental plaque biofilm and calculus and the management of the crown and root surface during periodontal care
- Supragingival pmpr
o targeted intervention aims to remove accessible plaque biofilm and calculus deposits from the crown of the tooth. This is carried out in Step 1 of treatment. - Subgingival pmpr
o This targeted intervention aims to remove plaque biofilm, endotoxin and calculus from the root surface of the tooth.
o Step 2 of treatment. However, where subgingival calculus is readily accessible and removable, it can be removed during Step 1 of treatment
2
Q
explain systemic antibiotics for perio?
A
- suppressing the bacterial species responsible for biofilm growth, leading to a less pathogenic oral environment
- systemic antibiotics may be considered for specific patient categories (e.g. periodontitis Grade C in younger adults where a high rate of progression is documented) but suggests that adoption of this management option should be determined by a specialist
3
Q
assessing the response to perio treatment
A
- Patients are typically reviewed at 6-12 weeks post-treatment.
- Reassessing symptom control
o Following successful competition of Step 1 of therapy, the patient can expect that gingival inflammation will reduce and the symptom of bleeding on brushing (i.e. marginal bleeding) will diminish along with pain (e.g. from exposed root surfaces, periodontal infections) and halitosis. However some symptoms (e.g. drifted teeth, poor aesthetics) may only be addressed once Steps 1-3 have been completed. - Monitoring plaque control
o Engaged step 1 therapy
plaque levels of ≤20%, or
≥50% reduction in plaque from baseline measurements, or
targets for improvements in plaque levels can be agreed by the patient and clinician. - Monitoring bleeding control
o Engaged step 1
marginal bleeding levels of ≤30%, or
≥50% reduction in marginal bleeding from baseline measurements, or
targets for improvements in marginal bleeding levels can be agreed by the patient and clinician. - Monitoring periodontal probing pocket depth
o The BSP-S3 guideline suggests that a goal of treatment is shallow probing pocket depths of ≤4 mm with no bleeding at 4 mm sites
4
Q
what is com-b model
A
- Capability, Opportunity and Motivation to perform the Behaviour
- used model to understand the factors influencing an individual’s behaviour
5
Q
what is management of diagnosis of perio health?
A
6
Q
management of diagnosis of gingivitis
A
7
Q
how to manage teeth with furcation involvement?
A
- For teeth with Grade I furcation involvement, provide non-surgical treatment with the aim of achieving medium/long term retention of the tooth.
- For teeth with Grade II or III furcation involvement, especially those that are holistically assessed as being of ongoing value to the patient and their dentition, provide nonsurgical treatment with the aim of achieving medium/long term retention of the tooth.
- The guideline includes a specific statement that furcation involvement is not an indication for extraction.
-Manage teeth with Grade I furcation involvement non-surgically and provide advice regarding home care and maintenance.
-For teeth with Grade II or III furcation involvement, provide non-surgical treatment and advice regarding home care and maintenance.
8
Q
what is management of other perio conditions?
A
- necrotising periodontal disease, drug-induced gingival enlargement, puberty gingivitis, leukaemia
- brief summary examples
o Genetic/developmental disorders (e.g. hereditary gingival fibromatosis);
o Specific infections (bacterial origin [e.g. necrotising periodontal diseases], viral origin [e.g. Coxsackie virus, Herpes simplex virus], fungal origin [e.g. candidosis]);
o Inflammatory and immune conditions and lesions (hypersensitivity reactions, autoimmune diseases of skin and mucous membranes [e.g. lichen planus], granulomatous inflammatory conditions [e.g. orofacial granulomatosis]);
o Reactive processes (epulides [e.g. fibrous epulis]);
o Neoplasms (premalignant leukoplakia/erythroplakia, malignant squamous cell carcinoma, leukaemia, lymphoma);
o Endocrine, nutritional, and metabolic diseases (e.g. vitamin C deficiency);
o Traumatic lesions (physical/mechanical insults [e.g. toothbrushing trauma; lip or tongue piercing], chemical injury [e.g. etching], thermal injury [e.g. burns of mucosa]);
o Gingival pigmentation (e.g. amalgam tattoo).
9
Q
what to do for gingival recession?
A
10
Q
what is drug induced gingival enlargement?
A
Calcium channel blockers for hypertension
o Amlodipine
o Nifedipine
- phenytoin for epilepsy
- ciclosporin, an anti-rejection drug which can also be prescribed for some autoimmune disorders
11
Q
what is puberty associated gingivitis?
A
- Gingivitis is commonly observed in pre-teens and young teenagers where the increased inflammatory response to plaque is thought to be aggravated by the hormonal changes associated with puberty. The presentation may vary between individuals and in some cases marked gingival enlargement can occur.
12
Q
what is leukaemia gingiva
A
- Gingival enlargement, inflammation and bleeding can be a sign of an underlying medical condition that requires investigation, such as undiagnosed leukaemia, in both children and adults
13
Q
what do for gingivits or gingival enlargment for medication or puberty?
A
14
Q
explained combined endo-perio lesions?
A
- Combined endodontic-periodontal lesions occur where a patient not only has clinical attachment loss but also a tooth with a necrotic, or partially necrotic, pulp
- Pulpal damage may occur as a result of exposure of accessory canals in patient with a diagnosis of periodontitis, or the lesion may be associated with damage to the root or root surface itself, independent of periodontal disease
- lesions can be difficult to diagnose, therefore a clinical examination and the use of special tests (radiographs and vitality tests) are required to assess both the periodontal (swelling, bleeding or suppuration, increased probing pocket depth) and endodontic (presence of root damage or perforation, pulpal status, presence of fistula, tenderness to percussion) signs
- Management will involve both endodontic and periodontal treatment, although the endodontic source of infection should be eliminated with root canal treatment in the first instance.
15
Q
explain periodontal abscess?
A
o Periodontal abscesses most frequently occur in pre-existing periodontal pockets and are characterised by localized accumulation of pus within the gingival wall of the periodontal pocket/sulcus
o They cause rapid tissue destruction, which may compromise tooth prognosis, and are associated with risk for systemic dissemination
16
Q
what to do for periodontal abscess?
A
17
Q
what to do for necrotising gingivitis and periodontiis?
A
- Necrotising gingivitis is characterised by marginal gingival ulceration with blunting/loss of the interdental papillae and a grey sloughing on the surface of the ulcers
- characteristic halitosis and is often painful.
- associated with anaerobic fusospirochaetal bacteria and is more common in patients who smoke, the immunosuppressed and those with inadequate oral hygiene
- Necrotising periodontitis is diagnosed in the presence of connective tissue attachment loss and bone destruction.
- metronidazole is the drug of first choice where there is systemic involvement or persistent swelling despite local measures.
18
Q
explain pregnancy associated gingivitis?
A
o changes in hormone levels and to the immune response associated with pregnancy have been implicated in the development or worsening of gingivitis.
o Most cases will resolve after delivery of the baby
o breastfeeding can extend the duration of the condition
o long periods lying flat in a dental chair should be avoided in the third trimester, where possible.
19
Q
explain periodontitis in pregnancy?
A
20
Q
what is ppint of long term perio care?
A
- prevent the development of primary disease in those with a diagnosis of periodontal health;
- prevent disease recurring in patients with a diagnosis of gingivitis or periodontitis;
- recognise new or recurrent disease at an early stage;
- support patients with a diagnosis of periodontitis sustain improvements gained during active treatment.
21
Q
long term perio care for perio pts?
A
- aims to maintain periodontal stability, prevent disease recurrence and, if disease does recur, recognise it early and intervene to limit tissue damage. It combines aspects of monitoring, prevention and treatment and is an active process of re-assessment and re-treatment, where required.
- Supportive perio care for pt diagnossi of perio (step 4)
22
Q
explain management of pts with dental implants?
A
- directly into bone either immediately after a tooth is extracted or after bone has healed
- bone grows directly onto the titanium surface and leads to osseointegration of the implant
- implant is loaded, by attaching a restoration to it
- principal difference between a tooth and an implant is that between tooth and bone there is a periodontal ligament whereas there is a direct connection between an implant and bone
- Like teeth, implants are susceptible to the effects of bacterial plaque and calculus formation, leading to an inflammatory response in the peri-implant tissues, either superficially in the mucosa or more deeply in the bone
- Peri-implant tissues can also become inflamed in response to the presence of a foreign body, such as excess residual cement which may be present if an implant restoration is cemented rather than screwed in place
- Peri-implant disease is known to be multi-factorial and both biological and non-biological factors increase the risk of the disease and implant loss
23
Q
Risk factors for peri-implant disease in patients with periodontitis
A
o Patients who have active periodontal disease or a history of periodontitis present specific challenges when implants are being considered
o The risk of development of peri-implant diseases, along with the prognosis of any remaining teeth and the dentition overall, should be considered for each individual patient during the planning phase
o In addition to periodontitis, patient-related risk factors to be considered during treatment planning include
smoking;
diabetes;
the likelihood of further tooth loss;
lack of adherence to maintenance care;
inadequate oral hygiene
24
Q
what to tell pts with perio considering implants?
A
25
- Managing increased risks of peri-implant disease in patients with periodontitis
o Prior to placing implants in patients with a diagnosis of periodontitis, stabilise any periodontal disease around teeth which are to be retained, address modifiable risk factors (e.g. inadequate oral hygiene, smoking, systemic disease) and explain the need for ongoing periodontal and implant maintenance care after placement to reduce the risk of peri-implant disease.
o For all patients considering dental implant therapy, a periodontal examination is essential during the treatment planning phase to determine the periodontal status of the patient
o patients with a history of periodontitis should have the disease treated and stabilised for at least six months prior to the start of the implant treatment.
o Treatment and control of periodontal disease prior to implant planning, placement and restoration:
reduces the risk of peri-implant disease in those at higher risk;
helps the clinician to more predictably assess patient response and likely prognosis of remaining teeth;
gives the patient time to acquire skills in oral hygiene;
supports the clinician in providing a restoration with a good long-term prognosis.
26
General care of dental implants?
o Bone remodelling around the head of the implant occurs following placement and restoration. After the adaptive phase, bone levels in stable patients enter a steady state where crestal bone loss of no more than 0.2 mm annually should be expected. If osseointegration is successful, implant loss is rare
o Regular review and maintenance of implants enables the clinician to:
prevent inflammation developing around an implant;
identify any problems at an early stage, when treatment is more straightforward;
provide support for the restorative aspects of the prosthesis;
enhance the overall longevity of the implant and prosthesis.
o implants should be monitored regularly, with soft tissue health checked both visually and by probing
o monitoring of plaque, inflammation, probing depths (compared to baseline measurements), checking for bleeding and the presence of pus, and removal of supra- and submucosal plaque and calculus from the implant surfaces and restoration.
o ongoing care of implants, radiographs are used to monior bone stability over time
o periapical radiograph aligned using the long cone paralleling technique should be taken at the time of superstructure connection
o Further periapical radiograph, aligned using the long cone paralleling technique, should be taken at one year following this as a baseline for monitoring future changes in the bone level
27
how to examine peri-implant tissues
- oral hygiene
Inadequate oral hygiene around an implant and its restoration can contribute to inflammation and periimplant problems
Reduced manual dexterity in older patients may also contribute to increased plaque retention around a restoration
increased frequency of maintenance support to counter the increased risk should be considered.
28
how to examine peri-implant tissues
- probing
probing depth around healthy implants can be variable.
gentle probing pressure is advised and probing depth
marked increase in probing depth from baseline fixed points, together with suppuration and bleeding, suggests the presence of peri-implant inflammation and infection
absence of progressive bone loss, these signs indicate peri-implant mucositis. If progressive bone loss is present, then a diagnosis of peri-implantitis can be made
not appropriate to apply the Basic Periodontal Examination (BPE) for the assessment of implants
29
how to examine peri-implant tissues
- radiographs
clinical team placing the implant should provide a radiograph which shows bone levels around the implant at the time the superstructure is connected.
clinical team responsible for maintenance should take a new periapical radiograph using the long cone paralleling technique, showing the bone crest around the implant one year later.
show the degree of adaptive remodelling
30
how to examine peri-implant tissues
- calculus
Supramucosal calculus is more common around implants than submucosal calculus and this is generally easier to remove than the calculus attached to teeth.
implant threads are exposed, plaque biofilm and calculus removal from them can be difficult.
Soft supramucosal deposits can be removed using a rubber cup and an implant-specific prophylactic paste or an air polisher and glycine powder.
31
- Examining a patient for the first time after implant placement and restoration
o primary care team will often be responsible for implant monitoring and maintenance
o recommends baseline probing within 3 months of prosthesis delivery and advises that a baseline intra-oral radiograph be obtained at the completion of physiological remodelling to document marginal bone levels
32
what to do when a patient is seen for first time after implant placement and restoration?
33
what is recall and ongoing maintenance care?
o primary care team is responsible for ongoing maintenance care of the implant and its restoration,
o Recall appointments should be scheduled at least annually for all patients with implants
o However, those with specific risk factors, such as smoking, sub-optimally controlled diabetes, those with complex restorations which are hard to clean or those with additional needs may require to be seen more often. Patients with a history of periodontitis may be more susceptible to peri-implant disease and the recall interval for maintenance care should be scheduled to reflect this.
34
what is implant specific monitoring and maintenance should be carried out at each recal visit?
35
what is Implant-specific oral hygiene methods?
o patient should be encouraged to use an effective but atraumatic technique to avoid soft tissue injury
o stress that patients should use a gentle flossing technique and that the floss should not be forced below the peri-implant mucosal margin
o interdental brushes should fit snugly into the interdental space without the wire rubbing against the superstructure or adjacent tooth
o Rechargeable powered toothbrushes may be useful for any patient who cannot clean effectively with a manual brush.
o Patients with a single implant crown can be encouraged to treat the implant as they would their natural dentition and to clean it with a toothbrush, interdental brushes, dental floss and implant floss.
o Patients with an implant-supported bridge or denture will require personalised training in oral hygiene techniques, such as the use of interdental brushes, single tufted brushes, dental floss and implant floss, in addition to toothbrushing at the cervical/mucosal edge of the restoration, to clean these prostheses
o Remnants of these may act as a foreign body and have been implicated in an increased risk of peri-implant disease. Therefore, patients with exposed dental implant threads should be advised to use interdental brushes to clean around the affected implant.
36
what is tx of peri-implant mucositis?
o Peri-implant mucositis is mucosal inflammation in the absence of marginal peri-implant bone loss beyond crestal bone level changes resulting from initial bone remodelling.
o Clinical signs include redness, swelling, bleeding on gentle probing at more than one site around the implant, and suppuration
o goals of treatment are to achieve bleeding on probing at ≤1 site (bleeding should not be profuse) and absence of suppuration around the affected implant at 2-3 months after treatment.
o PMPR can be performed with ultrasonic or air polishing devices or with hand instruments. Short term use of patient-administered oral antiseptic rinses can be considered
37
what is tx of peri-implantitis
o Peri-implantitis is defined as a pathological condition occurring in tissues around dental implants, characterized by inflammation in the peri-implant mucosa and progressive loss of supporting bone.
o tissues will appear red and swollen, bleed on gentle palpation or probing and there may be suppuration
o Soft tissue inflammation is detected by probing (bleeding on probing indicates the presence of inflammation), while progressive bone loss is identified on radiographs. Recession of the surrounding mucosa can occur, exposing the implant threads
o Peri-implantitis can progress rapidly. The patient may also experience pain around the implant. However, this usually only occurs during episodes of acute infection.
o goals of treatment are residual peri-implant probing depths of ≤5 mm, BOP at ≤1 site (bleeding should not be profuse) and absence of suppuration around the affected implant
o Non-surgical interventions to manage peri-implantitis may be helpful in the initial stages of treatment to reduce inflammation and pathogenic microbiota.
o recommends initial non-surgical management. This includes oral hygiene instruction and motivation, risk factor control, prosthesis cleaning/removal/modification (including controlling biofilm retentive factors and evaluation of the components of the prosthesis where required and feasible), and supramucosal and submucosal PMPR around the implant
o PMPR around the implant can be performed with ultrasonic or sonic devices or hand instruments.
o surgical management is often required cases where there is progressive bone loss around the implant, implant removal may be a valid management option
o recognised that referral for management of peri-implantitis may either not be possible or may not be straightforward
o the primary care team is encouraged to provide treatment and support,
38
if soft tissue inflammation is present in implants?
39
what is bsp level referrals
- In general, patients with uncomplicated periodontal diseases (Level 1 Complexity) should be treated in general dental practice.
- Patients with stage II, III or IV periodontitis (>30% bone loss) and residual true pocketing of 6mm and above (Level 2 Complexity) should receive initial non-surgical treatment (Steps 1 and 2 of therapy) in general dental practice but may be accepted for referral in specific situations.
- Patients with Grade C or Stage IV periodontitis (bone loss >⅔ root length) and true pocketing of 6 mm or more (Level 3 Complexity) should be referred once lifestyle or behavioural risk factors have been addressed and appropriate non-surgical treatment (Steps 1 and 2 of therapy) undertaken in general practice.
40
what do you need for format referral?
41
how to do full mouth plaque and bleeding assessment?
42
what are modifying factors for perio?
43
what is tx prescritpion?
44
what is audit for alcohol intervention?
F- Perio sdcep
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