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IODC > Periodontology > Flashcards

Periodontology Flashcards

1
Q

Antimicrobials: What are the principles of treatment of periodontal therapy? (3 types of mechanical plaque control)

A 
 Patient performed
 Non-surgical root surface
cleaning
 Surgical root surface cleaning (flap)
The role of other factors – Smoking / stress / systemic medication and disease
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2
Q

Antimicrobials: What is the role of systemic antimicrobials in periodontal treatment?

A

Acts as an adjunct to mechanical treatment in:
 Aggressive forms of periodontitis
 Necrotising forms of periodontal diseases (NUG, NUP)
 Periodontal abscess ?
 Deep periodontal pockets not responding to
RSD
 Progressive or active disease  Guided tissue regeneration

(not usually chronic adult periodontitis)

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3
Q

Antimicrobials: What are the choices of antimicrobials for systemic use?

A

 Tetracyclines (historical)
 Metronidazole
 Combinations of metronidazole and amoxicillin
 Azithromycin

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4
Q

Antimicrobials: What antimicrobial would you use for aggressive periodontitis? (details)

A

 Metronidazole (400mg) and amoxicillin (500mg) both TDS, 7 days
 Azithromycin 500mg daily for 3 days

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5
Q

Antimicrobials: What antimicrobial would you use for deep periodontal pockets not responding to RSD or progressive/active disease?

A

 Amoxicillin / metronidazole combination
 Azithromycin
Antibiotic sensitivity testing

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6
Q

Antimicrobials: What antimicrobial would you use for periodontal abscesses?

A 
As an adjunct to mechanical treatment (in some circumstances): 
 Metronidazole
 Amoxicillin/Clavulanic acid
 Azithromycin
 Tetracycline
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7
Q

Antimicrobials: What are some of the problems with Azithromycin?

A
  • Can prolong QTc interval -also an effect of some other drugs – increased risk of abnormal heart rhythm
  • Interaction with statins
  • Other interactions
  • Must check BNF / check with pharmacist or GP if in doubt
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8
Q

Antimicrobials: What are the problems with evaluating systemic antibiotics?

A

 Prospective, randomized placebo-controlled, double blind trial ideal
 Majority of older studies fall short
 Evidence base emerging following more recent studies

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9
Q

Antimicrobials: What is the evidence base for systemic antimicrobials?

A

Systematic review (Herrera et al. 2002):
• Additional benefit (CAL/PPD) - deep pockets
• Reduced risk of further CAL loss - progressive or
“active” disease
• Aggressive disease - might have adjunctive benefit
• Amoxicillin and metronidazole combination - improves clinical outcomes in aggressive periodontitis
If systemic antibiotics are to be used, they should commence at the completion of RSD, which should be completed within one week (Herrera et al. 2008)
Azithromycin - improved outcomes in chronic periodontitis in deep pockets

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10
Q

Antimicrobials: What are the advantages of systemic antimicrobials?

A

 Useful for aggressive / active / progressing sites (pus formation - refractory)
Multiple sites
Low cost
Less clinical time

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11
Q

Antimicrobials: What are the disadvantages of systemic antimicrobials?

A

Dependent on patient compliance
Unwanted side effects
Can produce microbial resistance to antimicrobials
Can lead to sensitivities and allergies

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12
Q

Antimicrobials: What locally applied antimicrobials exist for use?

A 
 Metronidazole (Elyzol)
 Chlorhexidine (PerioChip) (Chlosite
gel)
 Minocycline (Dentomycin)*
  Doxycycline (Atridox)*
* no longer available in the UK
  • used to be more popular 10-20 years ago
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13
Q

Antimicrobials: What are the indications for locally applied antimicrobials?

A
  • FEW SITES
  • POOR RESPONSE TO DEBRIDEMENT
  • DEEP SITES IN MAINTENANCE PATIENTS
  • REPEAT APPLICATIONS ?
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14
Q

Antimicrobials: What is metronidazole 25% Elyzol?

A

• Semi-solid suspension gel (25% metronidazole)
• Forms “liquid crystals” on contact with water
• Water in matrix dissolves metronidazole –
diffuses into surroundings
• Stable for 3 years less than or equal to 25 degrees

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15
Q

Antimicrobials: How do you use metronidazole (Elyzol)?

A

• Subgingival debridement first • Syringe into pocket until over
flowing – wipe off excess
• Reapply one week later

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16
Q

Antimicrobials: How effective is metronidazole gel? (Elyzol)

A
  • Effective antimicrobial conc. < 1 day
  • Substantial amount swallowed
    May enhance effects of SRP

Preferred use as an adjunct: slowly progressing periodontitis, grade II furcations, angular bony defect

Not for treatment of refractory or aggressive periodontitis, periodontitis in patients with predisposing illness or those under medical treatment, grade III furcations

Contra-indicated in patients allergic to sesame seeds and other precautions

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17
Q

Antimicrobials: What is periochip, what are the depth requirements for use and how does it work?

A

• Chlorhexidine digluconate 2.5 mg in gelatine
• Minimum depth > 5mm
• Biodegrades releasing
chlorhexidine over 7–10 days

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18
Q

Antimicrobials: How effective is periodontal chip?

A

PerioChip replaced at 3m & 6m, seeing if PD > 4mm remained

results - At 9m: Significant decrease in PD & increase in AL in PerioChip group

Enhanced effects of surface root planing (SRP) especially deep sites

• Gain in bone noted and/or no loss, whereas 25% showed bone loss with SRP alone

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19
Q

Antimicrobials: When is minocycline 2% used? (dentomycin) does it work? —

A

• Moderate to severe chronic periodontiitis
• Adjunct to root surface debridement of
sites greater or equal to 5mm in depth
• Not to be repeated within 6 months

  • conflicting results, various application recommendations
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20
Q

Antimicrobials: what is doxycycline 8.5% (atridox) and how is it used? —

A 
 Gel that solidifies in minutes
 Does not flush out
 Sustained release 7-10 days
 Absorbed and does not require removal 
 Effective against periodontal pathogens
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21
Q

Antimicrobials: Does Atridox work? —-

A
  • Enhanced effects of root surface debridement
  • Works in smokers
  • Suggested use for non-responding sites
  • No longer available in UK
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22
Q

Antimicrobials: What are the advantages and disadvantages of locally applied antimicrobials?

A

High local concentration of antimicrobial with minimum unwanted side effects
Less reliance on patient compliance
Useful for isolated sites
But:
More expensive
 Effective?
- doesn’t stay in pocket for very long, can be washed away when patient rinses or difficult to place in pocket can pop out

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23
Q

Antimicrobials: Do Antimicrobials work?

A
  • Huge variation in studies
  • Additional improvement in probing and clinical
    attachment (mean < 1mm) v RSD alone
  • Increased number of sites with PPD reductions ≥ 2mm

but Predictability? is it worth it for a change in only 1mm in PPD?

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24
Q

Antimicrobials: What outcome measures are used to evaluate the effectiveness of antimicrobials and RSD?

A

PPD reduction
CAL gain

Overall – scientific evidence supports use of adjunctive local antimicrobials in deep or recurrent sites, but no definitive practical advice given due to risk of bias in evidence published.
Not for the management of local aggressive periodontitis

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25
Q

Antimicrobials: What are the BSP guidelines for antimicrobials?

A
  • They have little place in routine periodontal therapy
  • antibiotic resistance increasing
  • limit use of antibiotics to specific situations
  • drainage of infection and removal of cause still pertinent so can avoid using antimicrobials in a patient that is systemically well
  • relatively few circumstances in peril where systemic or locales applied agents appropriate
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26
Q

New classification: What three forms of periodontitis have been identified?

A

necrotising, periodontal as a manifestation of systemic disease and periodontitis (previously chronic or aggressive)

27
Q

Management of Periodontitis in the maintenance phase: What is the treatment strategy for periodontitis?

A 
Initial treatment
 Cause-related therapy
 Non-surgical treatment
 Surgical treatment
 Maintenance/Supportive therapy
28
Q

Management of Periodontitis in the maintenance phase: What is initial management based on?

A

 Emergency treatment (where necessary)
 Extraction of teeth which are irrational to treat
 Patient information
 Plaque control including correction of plaque
retention factors
 Root surface debridement
 Initial occlusal adjustment (where necessary)
 Reassessment and monitoring

29
Q

Management of Periodontitis in the maintenance phase: What is the treatment aim of periodontal treatment?

A

Shallow pockets with no bleeding 4mm or less

30
Q

Management of Periodontitis in the maintenance phase: What do you review in a periodontal review at 3 months?

A 
 Check that all the necessary treatment has been carried out (incl replacement
restorations etc.)
 Check Oral Hygiene (plaque score)
 6-point charting
 Evaluation – is treatment aim
reached?
 Plan follow-up
31
Q

Management of Periodontitis in the maintenance phase: Why are maintained patients more likely to have successful outcomes?

A

Re-motivation.
 Patients cannot clean subgingivally
 Re-infection issues.
 Episodic nature of disease. - some evidence

32
Q

Management of Periodontitis in the maintenance phase: What does the SDCEP say about periodontal management of patient?

A

check slide

  • carry out oral examination and use oral hygiene TIPPS to address inadequate plaque control
  • dental prophalyxis to remove supra gingival plaque, calculus, and stain and sub gingival deposits if necessary
  • supportive periodontal therapy - carry out root surface instrumentation….
33
Q

Management of Periodontitis in the maintenance phase: What is the structure of an average maintenance appointment?

A

once all pockets are down to 4mm or less and very little bop

  • DIAGNOSIS/ PROGNOSIS
  • RISK LEVEL
  • INTERVAL
  • RSD
  • SP/OHI/CHLX/F-/POL
  • NOTES
34
Q

Management of Periodontitis in the maintenance phase: What is the clinical criteria for diagnosis and prognosis?

A
  • bop
  • pocket depth, CAL
  • furcation -analysis
  • occlusionandarticulation,mobility
  • evaluationrestorations/prosthese
  • examinationforcaries
35
Q

Management of Periodontitis in the maintenance phase: What is the radiological criteria for diagnosis and prognosis?

A
  • Bone levels in relation to CEJ
  • Type of bone defect
  • furcation-analysis
  • bredth of periodontal space - widened? or tilted teeth
  • impacted teeth
  • evaluation restorations/prosthese
  • examination for caries
36
Q

Management of Periodontitis in the maintenance phase: What are the causes of periodontitis?

A 
• bacterial flora Quality
 • compliance/concordance
• Oral hygiene (15% plaque =
acceptable)
• number &amp; depth of pockets 
• furcation involvement
• restorative retention factors - quality of restorations
37
Q

Management of Periodontitis in the maintenance phase: What factors lead to resistance of periodontitis?

A
  • systemic factors - diabetes, medication, pregnancy, HIV, Crohn’s disease, sjorgren’s syndrome, radiotherapy, menopause
  • genetic factors?
  • age
  • smoking - greater than 10 a day
  • stress
  • drinking
38
Q

Management of Periodontitis in the maintenance phase: How does bOP affect risk of periodontitis?

A

greater than 25% increased risk

lower than 10% reduced risk

39
Q

Management of Periodontitis in the maintenance phase: What is the recall for maintenance in the first year?

A

3 monthly for the first year

then risk assess to adjust recall rate

40
Q

Management of Periodontitis in the maintenance phase: How often should you recall low, medium and high risk patients?

A

Low risk - 6-12 months
medium - 4 months
High risk - 3 months

more than 4 items in the high risk - requires further investigation and diagnosis (check risk analysis table)

41
Q

Management of Periodontitis in the maintenance phase: How often should you do a full periodontal assessment and radiological assessment of bone levels in long term maintenance?

A
  • Full periodontal assessment every 2 years

* Radiological assessment every 5 years

42
Q

Management of Periodontitis in the maintenance phase: What is the aim of maintenance?

A

maintain infection control by helping the patient control plaque through a well structure maintenance programme

43
Q

Aggressive periodontitis: What is the new name for aggressive periodontitis?

A

Immune mediated periodontitis

44
Q

Aggressive periodontitis: What is periodontitis?

A
  • Inflammatory condition affecting the supporting structure of the teeth
  • Multifactorial aetiology
  • Variety of presentations
45
Q

Aggressive periodontitis: Who is the damage caused in periodontal disease done by?

A

host response

46
Q

Aggressive periodontitis: Which factor can the patient control?

A

Bacteria

47
Q

Aggressive periodontitis: What factors affect the host response?

A 
• Stress
– Short term
– Long term
– Poor coping strategy
• Diet
• Exercise 
• Illness
• Sleep
• Smoking
48
Q

Aggressive periodontitis: Common features of immune mediated perio?

A

• Patientsotherwise
clinically healthy
• Rapidattachmentloss and bone destruction
• Familial aggregation

49
Q

Aggressive periodontitis: secondary features of immune mediated perio?

A 
• Microbial deposits not
consistent with
destruction.
• A.a nos and for some P.g
• Phagocyte abnormalities
• Hyper – responsive
inflam/immune response.
• Attachment and bone loss
may be self arresting
50
Q

Aggressive periodontitis: Genetic polymorphisms as risk factors for immune mediated perio?

A

• Polymorphonuclear (PMN) defects result in severe periodontal disease

  • LAgP is associated with a PMN defect
  • Chemotaxis
  • Phagocytosis
  • Bacterial Killing
  • AgP Patients have hyper-responsive PMN
51
Q

Aggressive periodontitis: What is clinical attachment loss?

A

recession + pocket depth?

52
Q

Aggressive periodontitis: What is the importance of diagnosis?

A
  • Medico legal
  • Early management priority
  • Treatment modality
  • Early referral
53
Q

Aggressive periodontitis: What is the antibiotic treatment?

A

• Regimen
- Amoxicillin 500mg plus metronidazole 400mg TDS 7 days
– Azithromycin 500mg once daily three days
• Counterproductive unless includes thorough debridement and homecare
• Ideally during first cycle of Non surgical
• MUST not be overprescribed - might give it for the type 2 diabetic who has improved OH but still around 40% plaque score

54
Q

Aggressive periodontitis: What is the treatment strategy?

A

Cause related therapy (Initial Therapy)

 Corrective therapy

55
Q

Aggressive periodontitis: What is the aim of periodontal tx?

A

less than 10% BOP

no pockets in the mouth over 4mm - toothbrush affects to 4mm under gum

56
Q

Aggressive periodontitis: What are the factors that influence complete calculus removal?

A

– Extent of the disease
– Anatomicfactors
– Skillsoftheoperator
– Instrumentsused

57
Q

Aggressive periodontitis: What are the 3 approaches to sub gingival infection control?

A

– Quadrant RSD (Gold standard)
– SinglestagefullmouthRSD
– SamedayfullmouthRSD - actual gold standard so bacteria at one side of the mouth doesn’t infect the other side

58
Q

Aggressive periodontitis: Why would non surgical treatment fail?

A

• Patient failure
Poormotivation/cooperation Patient circumstances
Patient medical history

  • Operator failure
  • Incorrectdiagnosis
  • Inadequatenonsurgical
  • Anatomical failure
  • Multiple intra-bony defects >3mm - thick resilient gums don’t heal as well
  • Furcationinvolvements
  • Very deep sites
  • Difficult anatomy of tooth bone or roots
  • Difficult access
  • Gingival Biotype
59
Q

Aggressive periodontitis: What are the aims of periodontal surgery?

A
  • Pocket reduction
  • Pocket elimination
  • Regeneration - Bio oss

when pockets require surgical correction

60
Q

Aggressive periodontitis: How do you maintain tx?

A
  • Key for all my patients initially 3 monthly hygienist visits
  • Supportive Periodontal therapy including OHI
  • Review annually including risk factors, hygiene methods and motivation
61
Q

Aggressive periodontitis: What do you include in a referral into secondary care?

A

All referrals will be expected to contain the following information:
• BPE scores;
• Summary of treatment already provided / the treatment
response;
• Details of known risk factors including smoking history (pack years) and quit attempts;
• Evidence of longitudinal monitoring of patients for whom there appears to be periodontal deterioration.

In normal circumstances referrals will only be accepted for treatment when the following treatment has been undertaken:
• Oral hygiene instruction with particular emphasis on the appropriate form of interdental cleaning;
• Supragingivalscalingandpolishing; • Subgingivalscaling.

62
Q

Aggressive periodontitis: Who gets considered for referrals to secondary care?

A

• BPEscoresof3or4
• Advanced chronic periodontitis (post initial
treatment)
• Aggressiveperiodontitis
•Medicalconditions,medicationhistoriesor syndromes that directly affect periodontal status
• Mucogingival problems, gingival recession or other periodontal defects for which surgery may be indicated, following initial therapy.
• Periodontal-endodontic lesions.

63
Q

Aggressive periodontitis: Who should not be referred to secondary care?

A

Patients who should not be referred for specialist
advice and treatment planning are those:
• With only gingivitis
• With poor oral hygiene or who are non responsive to, or non compliant with initial hygiene phase therapy provided in primary care
• With BPE scores of 2 or less.
• Economicreferrals

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