Step 3

Question 1

Advantages of local anti microbials in periodontal tx?

Answer 1

Reduced / no systemic dose

High local conc

Less likely for drug interactions

Site specific

No issue with pt compliance

Question 2

What may be included in step 3?

Answer 2

Repeated subgingival pmpr with or without adjunctive therapies

Access flap surgery - for debridement

Respective flap surgery - removal of inflamed gingival tissue

Regenerative flap surgery

Question 3

What treatment adjuncts are there in step 3?

Answer 3

Disinfectants - chlorhexadine, periochip

Locally delivered antibiotics

These are adjuncts to pmpr as they do not mechanically remove biofilm / calculus

Question 4

What is periochip?

Answer 4

Biodegradable gelatin matrix - 2.5mg chlorhexadine digluconate

• insert to pocket following pmpr
• released slowly over 7 days
• good for single spot deep pocketing / furcation

Question 5

Give another locally delivered antibiotic for periodontal tx

Answer 5

Dentomycin periodontal gel

• delivered into pocket after pmpr
• 3-4 applications required every 14 days @ 0,2,4,6 weeks
• not repeated within 6 months

Question 6

What is the SDCEP guidance on local antimicrobials in perio

Answer 6

Can be used as adjunct to non responding sites, not routinely used for patients with periodontal disease though

Question 7

How can systemic anti microbials be used for perio tx?

When used?

Answer 7

Proposed to act by suppressing bacterial species responsible for biofilm growth

• not used routinely due to risk vs benefit of antibiotic stewardship and resistance

Question 8

What pts would be considered for systemic antimicrobials?

Answer 8

Grade C perio in young individuals - high rate of progression

Question 9

What systemic tx is used in GDH for perio?

Answer 9

Full mouth instrumentation followed by 400mg metronidazole, TTD for 3 days

Question 10

What is periostat?

Answer 10

Low dose, sub-anti microbial dose of doxycycline along with PMPR

• currently no evidence contributes to resistance
• does require long term medication though, so issue with compliance

Not recommended by SDCEP! - unclear benefit

Question 11

If expert referral not available, what tx?

Answer 11

Repeated root surface PMPR and subgingival PMPR, with consider open flap debridement

Question 12

When access flap surgery recommended?

Answer 12

Residual pockets >=6mm in pts with stage III periodontitis

• no medical contra-indications
• teeth of reasonable prognosis
• furcation disease
• compliance
• <20% plaque and <10% marginal bleeding
• pt tolerate procedure under LA
• cost
• post op aesthetics

Question 13

What tooth may contraindicate gingival surgery?

Answer 13

Difficult Access to the non-responding site

Shape of defect

Pros / endo considerations

Tooth position / anatomy
- overeruption
- proximity to adjacent roots
- tilting

Question 14

What systemic issues may contraindicate periodontal surgery?

Answer 14

Smoking - impaired wound healing

Unstable angina, uncontrolled hypertension,, MI/Stroke within 6 months

Uncontrolled diabetes

Immune suppressed pts

Anticoagulant pts

Question 15

Aims for access surgery in perio?

Answer 15

Access areas of continued inflammation

Pockets >6mm

Question 16

Re-evaluation of gingival surgery?

Answer 16

Review in 3 months

PMPR form hygienist at 6 weeks

Question 17

What defects are high risk of relapse after perio surgery?

Answer 17

Angular bone defects

Question 18

Indications for regenerative periodontal surgery?

Answer 18

• intrabony defects 3mm or deeper
• class 2 or 3 furcation defects

Question 19

How can intrabony defects be treated?

Answer 19

Guided tissue regeneration

Enamel matrix derivative
- tissue healing agent derived from porcine tooth germ
- induce re attachment in periodontal procedures

Question 20

Why treat furcation lesions?

Answer 20

Reasonable survival rates observed over 4-30 years
- class II better prognosis than cIII

Economic
- tooth retention after perio more cost effective than extraction and prosthetic replacement

Patient preference
- strong pt preference for keeping sound tooth

Question 21

What is tunnelling?

Answer 21

For mandibular class 3 furcations (through and through)

• bone and soft tissue recontoured to allow insertion of interdental brush