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Perio tutorials extra info Flashcards

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1
Q

What shows smoking summary?

A

Pack years - summary of tobacco exposure in life
Eg 1 pack a day for 5 yrs = 5pack years

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2
Q

What are we trying to achieve by diagnosing and managing perio?

A

o Tooth retention – prolong the lifespan of teeth
o Pocket reduction (and reducing inflammation)
o Healthy periodontium
o Improved function (of teeth, eg mastication)
o Reduced pain (not typical symptom of perio but can occur at very late stages when teeth have high mobilities, or have periodontal abcesses etc)
o Occlusal stability

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3
Q

What tx must occur before RSD tx?

A

 Extraction of hopeless teeth
* Eg those with high mobilities (grade 3)
* Periapical involvement that cannot be treated endodontically
* Can be offered IRDs (need to be designed hygeinically)
 Occlusal assessment
* Adjustments in a minimally invasive way to reduce interferences
* Hard occlusal guard
 Remove local risk factors
* Eg poorly contoured restorations, calculus, root grooves, furcations etc
 Perio-endo lesions
* Endo-treatment first

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4
Q

Why is it best not to leave a week between RSD tx sessions?

A

Ideally in practice, do not leave a week between treatment sessions, and have as few sessions as possible. If we leave too much time between sessions, already RSDed pockets can get reinfected from pockets that have not been treated yet. So makes more efficient by delivering in a short span of time.

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5
Q

What are the aims of RSD?

A

o Smooth biocompatible root surface
 Biocompatible = we want the soft tissues to be able to attach again to the smooth surface wherever possible
o Allow for healing
 I.e. removal of calculus
 Decontaminate root surface re:LPS (infected cementum)
 No plaque deposites
o To allow healing and pocket reduction

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6
Q

How does healing take place?

A

o Healing takes place via formation of a long junctional epithelium
 LJE is part of the gingival non-keratinised epithelium in the pocket area
 Can reattach to the root surface if it is smooth clean and decontaminated
o Resolution of gingival inflammation = shrinkage of tissues and reorganisation of collagen ‘tightening’ the epithelial cuff

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7
Q

What is prognosis vs risk?

A

o Prognosis = prediction of duration, course and disease outcome.
o Risk = deals with the likelihood that an individual will get disease, risk factors increase the chance of an individual getting disease

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8
Q

What are some general prognostic factors for periodontal tx?

A
  • Systemic health - Eg diabetes, will influence course of disease, treatment outcome and so on.
  • Hereditary – genetic factors – disease susceptibility - Might affect immune responses leading to more tissue destruction or poorer tissue healing, or impaired immune response to the bacteria
  • Stress/diet
  • Aetiology/diagnosis - Type of perio
  • Age
  • Smoking
  • Patient motivation
  • Correct disease management
  • Maintenance following treatment
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9
Q

What are some local prognostic factors for perio tx?

A
  • Plaque levels
  • Bacterial flora (virulence eg A.a., often found in pt with molar-incisor pattern and rapidly progressing attachment loss)
  • Pocket depth and location (deep pockets difficult to treat, back of mouth more difficult also)
  • Amount of attachment loss
  • Furcation involvement (reservoir for bacteria)
  • Quality of restorative work (overhangs etc)
  • Perio-endo lesions
  • Active perio disease, more active sites = poorer prognosis
  • Root length - Short roots = poor prognosis
  • Root shape - Eg root groovers – anatomical variations that can increase plaque retention
  • Crowding
  • Presence of calculus
  • Mobility - Grade 3 very poor prognosis, suggests apical involvement – but care re: occlusal trauma)
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10
Q

What are some individual tooth prognostic factors?

A
  • % bone loss - Horizontal or vertical?
  • CAL/pocket depth
  • Distribution and type of bone loss
  • Furcation (presence and severity)
  • Mobility
  • Apical involvement
  • Perio-endo lesions
  • Crown to root ratio (affects mobility)
  • Bleeding on probing (current inflammation)
  • Root morphology
  • Pulpal involvement/caries
  • Occlusion
  • Local plaque retentive factors (anatomy, iatrogenic)
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11
Q

What are some operator-related prognostic factors?

A
  • Early diagnosis
  • Ability to treat disease
  • When to refer
  • Maintenance
  • Interaction with patient – explanation of patients role in disease management
  • Ability to deliver OH message
  • Smoking cessation management
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12
Q

Radiation regulations

A

o Use only when necessary and aim to minimise dose to patient
o International commission on radiological protection:
 Justification
 Optimisation
 Limitation
o Ionising radiotion regulations 1999
 Safety of workers and public
 Maintenance of equipment
 As low as reasonably practiceable (ALARP)
o Ionising radiation (medical exposure) regulation 2000 (IR(ME)R)
 Concerned with patient safety
 Responsibilities of staff (employer, referrer, practitioner, operator)

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13
Q

What types of bone loss are these?

A

 A = health. In health bone levels are around 1mm below the CEJ. But we use the CEJ on radiographs.
 B = horizontal bone loss
 C = vertical bone defect

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14
Q

What types of bone loss are these?

A

 D = crescentic
* Characteristic, associated with occlusal trauma (with periodontal disease = secondary occlusal trauma)
 E = widening of the PDL (funneling like defect). Primary occlusal trauma, no periodontal bone loss. Removing the occlusal trauma here will allow bone to remodel (which wont happen in D due to underlying perio bone loss)
 F = horizontal bone loss with furcation involvement
* Confers a poorer prognosis to the tooth. Difficult area to clean for patient and operator. More risk of apical infection.
* Exposure of furcal canals running from furcation to pulp tissues, which can cause loss of vitality in that area.

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15
Q

What types of bone loss are these?

A

 G = J-shaped lesion, associated with a perio-endo lesion. Bone loss to the apex of the tooth.
* Diagnosed by radiographic appearance.
* Also classically will be non-vital since pulp tissues are involved
* Deep pocket associated with this defect.
* Treatment involves endo first, then perio treatment. Looking for bony infil into this defect. Then XLA eg if lots of mobility and bone loss or pt doesn’t want treatments.
* Guarded prognosis for these teeth.
* Remember the possibility of perio-endo lesions when a pt has residual deep pocketing!
 H = J-shaped lesion, perio-endo lesion involving only 1 root of a molar tooth.
* In multi-rooted teeth you may get some residual vitality of the tissue due to involvement of only one root

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16
Q

What types of bone loss are these?

A

 I = normal
 J = crescentic pattern of bone loss
* In case of implants, it is just circumferential bone loss around implants
* Bone loss around implant (not necessarily associated with occlusal trauma as in natural dentition)
 K = bone loss all around the implant
* Could be immediate non-integration
* Subsequent placement and loss of integration at a later date
* Would have to extract this implant
* Mobile implants might be due to the crown (superstructure might be lose) but if due to implant then must extract

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17
Q

What is the normal bone anatomy with implants?

A

There is no typical anatomy in terms of bone levels associated with implants. It depends on the type of implant, how it was placed, what level it was placed etc. No definitive landmark. Use postoperative radiographs to assess the extent of the bone loss in comparison to the start.
Exposed threads is a concern.

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18
Q

What is a good indicator/finding around implants?

A

Suppuration is an important finding around implants. BOP isnt a great indicator.

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19
Q

How do biofilms and the distance between teeth affect the bone loss?

A

In terms of the biofilm, it is said to have an effect of bone loss around 1.5mm from that biofilm.

If roots are close together and both teeth have biofilm then it gives a horizontal patern. If further apart, will give a vertical like defect.

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20
Q

How does an isolated biofilm on a tooth appear as bone loss?

A

More vertical

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21
Q

Pros and cons of LCPAs - why are they the long cone periapical radiographs?

A
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22
Q

Describe OPG’s for perio assessment - pros and cons

A
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23
Q

Anatomy of OPG

A
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24
Q

Pros and cons of vertical bitewings

A
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25
What is the justification for PA's in perio?
Justification: PA’s will give the best diagnostic yield for the patient. If x-ray does not give the information you needed, then you need to repeat the radiograph. Must be a diagnostic x-ray (which is why grading is important too).
26
Why are shorter roots an issue?
Bone loss will equate to a higher percentage of bone loss
27
Clinical health vs gingivitis vs periodontitis
28
What is the difference between primary and secondary prevention?
o Primary prevention – preventing the inflammatory process from destroying the periodontal attachment i.e., treating gingivitis o Secondary prevention – (once disease is already developed) preventing the recurrence of gingival inflammation, which may lead to additional attachment loss in successfully treated periodontitis
29
What is the WHO definition of periodontal success?
Retaining 20 teeth by age 80
30
What are the key risk factors for perio (systemic)?
o Genetics o Age (immune system less effective, more destructive) o Nutrition o Smoking o Diabetes o Stress
31
What did the DEPPA (PreViser) study show?
 A simple behavioural intervention using individualised periodontal disease risk communication, with or without GPS, decreased plaque and bleeding and increased interdental cleaning over 12 weeks  This is the first study in the field to show that risk communication and behavioural techniques such as goal-setting, planning, and self-monitoring can improve periodontal outcomes (Risk factor assessment tool)
32
Why is risk-based prevention useful?
To tailor OHI and tx and advice to those who are at higher and lower risks accordingly
33
What cells are important in periodontitis pathogenesis?
o Neutrophils – first line defence cells o Bacteria cells o Epithelial cells – line periodontal pocket
34
How does time affect risk factors?
Over a longer period of time means there is an accumulation of risk over the years
35
What bacteria are involved in periodontitis (the complexes)?
36
How do bacteria cause perio disease?
Quantity - increased number of bacteria and increased plaque biofilm - gingivitis Quality - type, virulence factors (enzymes, toxins, metabolic products) can cause periodontal tissue damage
37
How do periodontal pathogens in the plaque biofilm cause recruitment of neutrophils?
37
Give a summary of the host response involved in the periodontitis disease process
38
Describe the neutrophils in patients with periodontitis
o Hyperactive and hyperreactive - Leads to excess production of reactive oxygen species/MMPs o Compromised chemotaxis - Perio patient neutrophils will take longer to reach the site of infection whilst also causing more damage along the way o Accumulation in periodontal tissues and not cleared - Non resolving chronic inflammation o Neutrophil killing - Phagocytosis – intracellular killing – controlled, no damage to periodontal tissues - Degranulation – where neutrophil is unable to engulf the bacteria, eg if there is a lot of bacteria present. Releases free radicals and enzymes outside of cell, extracellular killing, causing bacteria death as well as collateral tissue damage = periodontal tissue damage o Neutrophil extracellular traps - As neutrophil dies off, they release a DNA strand (net) which have antimicrobial molecules that trap bacteria - They activate the innate immune system, help in resolving infection
39
Summarise the aetiology of inflammatory periodontal disease
Host inflammatory response - hyperinflammatory response & reduced antioxidant defences Bacteria - composition move to pathogenic flora and increased bacterial load (80% immune response; 20% bacteria)
40
What are the challenges with antibiotics?
Getting antibiotic to site of infection Achieving a therapeutic dose Maintaining that dose for a sufficient time Choosing the correct antibiotic Avoiding resistance (Biofilm must be disrupted) Ensuring patient compliance Ensuring appropriate use
41
When is it acceptable to have a poorly designed denture?
If teeth have poor prognosis and it is being used as a transitional denture - to acclimatise the patient to this. NOT if a patient wants to retain their teeth.
42
What is the consensus statement on the use of antibiotics?
 Systemic antbiotics should not be used in most patients with periodontitis. But should be considered in specific patient groups eg young patients with grade C disease  If used should be in conjunction with mechanical debridement of subgingival biofilm  Evidence suggests that optimal outcomes are achieved when drug therapeutic levels are achieved at the time of debridement completion, which should be completed preferably within 7 days  Not enough evidence to support the use of antibiotics with periodontal surgery  Due to public health implications, use of systemic antimicrobials should be restricted, and if used ensure optimal conditions
43
When are systemic antibiotics indicated for use in perio?
* Grade C periodontitis. Amount of bone loss inconsistent with age risk factor profile. * Necrotising periodontal diseases (ANUG/ANUP) * Multiple lateral periodontal abscess (often indicated systemic involvement or underlying immune disease, eg undiagnosed diabetes) * Spreading infection/systemic involvement
44
Summarise the antibiotics used in perio
45
What are the outcomes we want to achieve following periodontal treatment?
o Want to achieve a reduction in:  Probing depth  Plaque level  Clinical signs of inflammation  Mobility and suppuration  Radiographic osseous lesion (Reduction more likely to happen in a narrow vertical defect than a shallow horizontal defect) o Want to achieve stability in:  CAL  Occlusal (no increase in occlusal overload)
46
What is the key part in maintenance of periodontal care?
Reinforcing OH
47
What is a suitable maintenance regime?
Regular recalls = 3/12 initially Careful monitoring (DPC, PS, BS) Encourage - Reinforce TAILORED OH Early remedial treatment (if indicated)
48
What are the challenges with maintenance of periodontal disease?
o Cost/convenience of appointments o Drop in patient motivation
49
What should you always put in your treatment plan in an exam scenario to do with perio?
Remotivate the patient - include at end in maintenance phase
50
What is palliative care?
Patient's we cannot help the prevention/cure of their disease (leading to death- in this case teeth are likely to be lost)
51
Why might patients not respond to tx or lose teeth prematurely?
Poor compliance with OH Not addressing other risk factors (Eg continued smoking, either pt choice or operator misinformation) Sleeping with dentures in (bad habit)
52
What should you document if you choose to commence palliative care with a patient?
 Plaque and bleeding scores  OHI given, risk factor control advice etc etc.  Discussions with patient * Risk factor control and consequences of continued behaviour (pain, mobility, aesthetic issues and toothloss)  Detailed recording – medicolegal POV
53
When might we go down the palliative care route?
 Might give pt benefit of doubt after 1 or 2 courses of RSD  If no benefit, not improving at all, might go down this route - Demotivated patients who are not willing to change!!
54
When do you refer according to the GDC?
55
What/who/where/when/how should we refer?
56
What other conditions might require an MDT approach that you would refer?
57
Where can we find the referral guidelines and what should we know at every practice about referring?
Guidelines/criteria: BSP. Hospitals have their own criteria eg e-referral process. Should know: - Named consultant to refer to a dental hospital - Local private specialists (including costs) - What are the referral criteria locally
58
What factors influence referral decisions?
59
What periodontal assessments should be well documented in particular?
Probing depths Attachment levels Bleeding sites Plaque scores Mobility
60
What should you include in your referral letter for perio?
Your address & telephone number Date Referring place consultant name, department and address Full patient details: full name, DOB, address, telephone number Reason for referral Urgent or routine referral Full details of condition, including history of complaint BPE Provisional diagnosis Tx provided already Do you wish tx or advice Patient attendance pattern Specific information - eg special tests/rads Signature and designation
61
What are the phases of treatment for periodontitis?
62
What is usually included in phase 0 of the tx plan?
63
What happens if the supracrestal tissue attachment encroached upon?
Do not encroach within 2mm of the alveolar crest. The periodontal tissues will adjust and retreat to recreate this and cause recession.
64
What aesthetic concerns might patients have?
Gingivae - texture/colour Periodontal biotype Contact points Fraenal attachment Tooth position Gingival recession Missing teeth
65
What is a periodontal biotype and how do we measure it?
o Important implications on how to manage aesthetics eg surgical implications o Thickness of the gingivae in the facio-palatal dimension  Place a probe in gingival sulcus and observe transparency
66
When do black triangles form?
o Black triangles if no infill of papilla o Paper demonstrated that when the measurement from the contact point to the crest of the bone was 5mm or less, the papilla was present in almost 100% of cases, but when distance was 6mm, papilla was only present in 56% of cases, and less for 7mm and more.
67
Describe fraenal attachments
o Eg causing a midline diastema o Often fraenal attachment can contribute to recession, often in lower anterior area, due to inhibiting cleaning in that area. In some cases fraenectomy or fraenoplasty may be required.
68
What are the causes of gingival recession?
Toothbrush trauma Chronic periodontal Periodontal therapy Dehiscence (defect of bone including socket margin) Direct trauma from teeth in opposing jaw Ill-fitting partial dentures (gum-stripper) Other trauma Gingivitis artefacta
69
How can we manage this recession?
 Consider prevention: detailed OH, Fl toothpaste and mouth rinse (to reduce risk of root caries), dietary counselling, stabilisation of active perio (with risk of further recession)  Further options: * Do nothing – if pt is able to keep clean, and is not worried about aesthetics * Gingival veneers * Root surgery (this pt not suitable for this)
70
What determines predictability of successful recession surgery?
It is the no loss of interproximal bone or soft tissue that allows us to determine the predictability of root coverage. To do with having a successful blood supply at the time of surgery. Need to know as a GDP because if they want surgery you cannot present them this option if they are a class 4 etc. Know when to write a referral.
71
Gingival anatomy
72
Millers classifications of recession
73
What considerations should you make for perio patients with missing teeth?
What aligns with the patient? Is it appropriate with the patients periodontal health? Status of adjacent teeth? Short term and long term replacement of those teeth?
74
What are the types of periodontal surgery?
o 1. Resective o 2. Regenerative o 3. Mucogingival = plastic o ALL REQUIRE EXCELLENT OH! And be periodontally and dentally stable.
75
What is resective surgery?
Resecting soft periodontal tissues (that are inhibiting cleaning)
76
What are the purposes of resective surgery?
 To facilitate patient’s oral hygiene  To reduce pocket depths  To remove localised or generalised gingival enlargement  To create more crown length
77
What are the indications for resective surgery?
 1. Non resolving pockets >5mm and 5mm with BOP  2. Grade 2 and 3 furcations  3. Non-resolving gingival enlargement  4. Requirement for crown lengthening (aesthetic or restorative reasons)  5. Root amputation, hemisection
78
What is a tunnelling surgery?
Increasing size of furcation to facilitate cleaning.
79
What are regenerative procedures?
Aimed at regenerating hardness of periodontal tissues
80
What is the purpose of regenerative procedures?
To re-gain attachment
81
What are indications for regenerative surgery?
82
What is mucogingival/plastic surgery?
Aimed at restoring/reshaping soft tissues
83
What is the purpose of mucogingival/plastic?
 To correct aesthetics  To address hypersensitivity  To stabilise tissues and prevent deterioration
84
What are the indications for mucogingival/plastic surgery?
Gingival recessions - usually Millers class 1-2
85
What are the contraindications for periodontal surgery?
o Current smoking o Poor OH/poor compliance o Overall unstable periodontal status o Caries and untreated oral disease o Medical conditions eg coagulation disorders, diabetes o Unrealistic patient expectations o Mucogingival in specific:  Inadequate tissue at donor or recipient site  Severe recession defect (Millers class 4)  Self-inflicted recession defects o Regenerative in specific:  Shallow and/or 1-walled defects
Perio
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