clinical management of perio disease

Question 1

What are the goals?

Answer 1

Restore health
Eliminate disease
Improve quality of life
Clinical goals

Question 2

What is oral health?

Answer 2

A state of health of the teeth and supporting tissues and of efficiency, as is reasonable to safeguard general health
GENERAL DENTAL SERVICES REGUALTIONS

Question 3

What is disease?

Answer 3

Medically defined abnormalities in anatomical structures +/ physiological/biochemical processes

Question 4

What are the clinical goals?

Answer 4

No progression
Reduction in probing depth
No probing depth >5mm
No BOP
No smoking
Plaque score <20% surfaces

Question 5

What might affect the treatment?

Answer 5

Susceptibility to genetic factors
Plaque control
Previous perio disease
Smoking
Stress
Some systemic diseases
Diet

Question 6

What is our treatment strategy?

Answer 6

Initial treatment
Cause-related therapy
Non-surgical treatment
Surgical treatment

Question 7

What is initial management?

Answer 7

Emergency treatment 
Extraction of hopeless teeth
OHE
Plaque control
Correction of plaque retentive factors
PMPR
Initial occlusal adjustment
Reassessment and monitoring

Question 8

What does the oral hygiene in the prevention of perio diseases study show?

Answer 8

Single OHE instruction + toothbrush demo + PMPR = +ve effect on reduction of gingival inflammation in adults w gingivitis

Lack of evidence that toothbrush designs differ

Brushing 2x daily probably optimal

Most people aren’t effective brushers

Rotation/oscillation powered- reduce plaque and gingivitis more than manual (which reduces 1/2)

Tepes quicker and more effective than floss

Special tailored advice and monitoring

Question 9

Cochrane reviews in 2019 studies showed?

Answer 9

Floss/Tepes + tooth brushing may reduce plaque/gingivitis more than tooth brushing alone

Tepes more effective than floss?

Evidence for tooth cleaning sticks and oral irrigators- limited and inconsistent

Question 10

What does other recent evidence show?

Answer 10

Tepes are most effective interdentally

Flossing isn’t effective

Question 11

What does non-surgical treatment involve?

Answer 11

Remove plaque retentive factors
PMPR
PMPR of perio pockets 4+mm under LA
1 month oral health check
Review 3 months following complete treatment
Further treat of non-responding sites
Methods of delivery (quadrant v full mouth)

Question 12

What is subgingival PMPR?

Answer 12

Pockets 4+mm
Remove sub gingival plaque/calculus
Removal of surface toxins
Under LA
Predominantly ultrasonic
Periodontal hoes (files of needed)

Question 13

Quadrant or full mouth approach?

Answer 13

Systemic review 2008- no difference

2005- single visit full mouth debridement may have limited additional benefit and quicker

2006 w 1 year follow up- no difference of reoccurrence of pockets

Question 14

What are we looking for during review at 1 month?

Answer 14

Symptoms
Risk factors
Plaque score

Question 15

What are we looking for during review at 3 months?

Answer 15

Plaque scores
Probing depths
Bleeding indices
Mobility scores
Recession 
Furcation

Question 16

What outcomes are we aiming for with subgingival PMPR?

Answer 16

Reduced probing depth
Less bleeding
No suppurations
Improved tissue contour

However, might have
Recession
Increased sensitivity
Other complications

Question 17

Is perio treatment effective?

Answer 17

Cobb 2002

Greatest changes in probing depths and attachment levels occur within 1-3 months post treatment

Question 18

When is perio treatment complete?

Answer 18

Residual pocket depths 6+mm represent incomplete

Residual pocket depth 6+mm and BOP 30+% represent tooth loss risk

11 years maintenance care- 2008 study

Question 19

Is perio treatment effective?

Answer 19

Published work- tooth loss during (2.4%, 5.5%, 2.2-13.2%) overall (2.3%, 16.6%, 8.4%)

Patient reported outcome measures- PROMS, questionnaires against other surgery’s eg. Hip replacement

Question 20

How is perio monitored?

Answer 20

Probing depths
Recession 
Inflammation (bleeding)
Plaque control
Mobility
Drifting/immigration
Dentine sensitivity 

Remotivate
Patients need to be able to clean sub gingivally
Think about reinfection tissues and episodic nature of disease
Risk profiles can change during

Question 21

What did Mombelli 2019 think about maintenance?

Answer 21

Mandatory for long term success
Patient and dental team need to work closely together
Combine efforts for plaque control and risk control

Question 22

What did Echeverría 2019 think about maintenance?

Answer 22

Perio can be treated but not eradicated
Personal maintenance- continuous removal of bacteria at gingiva level + professional assistance
Patient compliance, adherence and persistence for long term success

Question 23

What are some limitations of clinical measurements and radiographs?

Answer 23

Errors in probing depth measures
BOP (low sensitivity, smoking, medication, flow between sites)
Absence of bleeding (higher sensitivity)

Radiographs show hard calcified tissue only
Inter/intra operator variance and angulation
Patient factors and tolerance

Question 24

What are BSP guidelines on antimicrobials?

Answer 24

Little place in routine treatment
Antibiotic resistance increasing
Limit unless clear evidence base
Drainage of infection and removal of cause still pertinent
Few times where systemic/locally applied agents appropriate

Question 25

What is the role of systemic antibiotics?

Answer 25

Severe rapidly progressive forms of disease Refractory disease Necrotising forms of perio Abscesses

Question 26

What antibiotics can be prescribed for severe rapidly progressing perio?

Answer 26

``` Metronidazole 400mg (not to be had w alcohol or pregnant or warfarin) + amoxicillin 500mg- both TDS 7 days ``` Azithromycin 500mg daily 3 days ~increased risk abnormal heart rhythm Caution w statins and other drugs

Question 27

What is the role of locally applied antibiotics?

Answer 27

Metronidazole (Elyzol) Chlorhexidine (PerioChip) Minocycline (Dentomycin) Often in gel form Few sites? Poor response to debridement? Deep site? Repeat applications? Limited evidence, minimal benefit

Question 28

What is the role of perio surgery?

Answer 28

Non responsive sites Access for effective instrumentation Improve gingival/tooth morphology for cleaning Regenerate lost perio attachment Flap surgery- open flap debridement Gingivectomy- cut back tissues

Question 29

What guidelines do we follow?

Answer 29

EFP S3 lvl clinical practice 2020 | BSP implementation of European S3 lvl treatment 2021

Question 30

What are the steps of the BSP guidelines?

Answer 30

1. Building foundations for optimal treatment outcomes (behavioural change and risk factor control) 2. Subgingival instrumentation 3. Managing non-responding sites 4. Maintenance (supportive perio care)

Question 31

How can foundations be built for optimal treatment outcomes?

Answer 31

Explain disease, risk factors, alternatives, pros and cons and no treatment OHE importance Reduce risk factors (plaque retentive features, smoking cessation, diabetes control) Tailored OHE (interdental cleaning, PMPR etc) Select recall period based on guidance and risk factors

Question 32

How do we reevaluate the patient?

Answer 32

Non engaging patient= return to step 1 Engaging patient= plaque scores 20% or less, bleeding 30% or less (or 50% improvement) OR meet personal care plan

Question 33

How is subgingival instrumentation implemented?

Answer 33

Reinforce OHE, risk factor control, behaviour change Hand +/ powered PMPR Use of systemic antimicrobials if needed 1 month review after this to reinforce OHE plus plaque score, review Tepe sizes and any post-op complications Review after 3 months- full perio assessment If unstable= step 3 If stable= step 4

Question 34

How do we manage non-responding sites?

Answer 34

``` Reinforce OHE, risk factor control, behaviour change If moderate (4-5mm) pockets, reperform PMPR If deep (6+mm) pockets, consider alternative causes Consider referral or reperform sub PMPR ```

Question 35

How do we do maintenance?

Answer 35

Reinforce OHE, risk factor control, behaviour change Regular targeted PMPR to limit tooth loss Consider toothpaste/mouth wash to control inflammation Recall 3-12 months Need to maintain stability If recurrent disease- re assess

Question 36

What is the supportive care phase?

Answer 36

Aim to prevent reinfection/reoccurrence of disease Successfully treated patients remain at high risk for reoccurrence or progression

Question 37

What must recall visits include?

Answer 37

``` Med and smoking history update Oral hygiene assessment Full perio charting Sensibility testing of suspecting teeth OHE PMPR Fluoride on exposed roots Assess prostheses Radiographic evaluation 3-12 month recalls ```