Perio Flashcards
(117 cards)
1
Q
Give examples of non-plaque induced gingival diseases
A
- herpetic gingival stomatitis
- genetic
- immune conditions e.g. lichen planus
- vitamin c deficiency
2
Q
Periodontal health definitions
A
- patients with an intact peridontium
- patients with a reduced periodontium due to causes other than periodontitis and
- patients with a reduced periodontium due to periodontitis
3
Q
gingival health definition for an intact periodontium
A
absence of:
- bleeding on probing
- erythema and edema
- patient symptoms
- attachment and bone loss
physiological bone levels range from 1 to 3mm apical to ACJ
4
Q
plaque induced gingivitis features
A
- associated with dental biofilm alone
- mediated by systemic or local risk factors
- drug influenced gingival enlargement
- no radiological bone loss
- no interdental recession
5
Q
Localised vs generalised gingivitis
A
localised
<30% BOP
generalised
>30% bleeding on probing
6
Q
potential modifying factors of plaque induced gingivitis
A
systemic conditions
- sex steroid hormones e.g. menstrual cycle, puberty, pregnancy, oral contraceptives
- hyperglycaemia
- leukaemia
- smoking
- malnutrition
oral factors enhancing plaque accumulation
- prominent sub gingival restoration margins
- hyposalivation
7
Q
what bpe code indicates the need for a radiographic assessment
A
3 or 4
8
Q
what defines successful periodontal treatment?
A
good oral hygiene
gingival health definition achieved
- < 10% BOP
- </= 3mm pocket depth
no increasing tooth mobility
a functional and comfortable dentition
9
Q
reason for trying to eliminate pockets
A
teeth with pockets greater than 4mm are more likely to be lost in the future
- deeper the pocket, increased likelihood of tooth loss
10
Q
necrotising gingivitis clinical features
A
ulcerated and necrotic papillae and gingival margin resulting in a characteristic punched-out appearance
ulcers are covered by a yellowish, white or greyish slaim
- when removed, underlying connective tissue becomes exposed and bleeds
lesions develop quickly
severe pain
bleeding readily provoked
first lesions are most often seen interproximally in the mandibular anterior region
11
Q
necrotising stomatitis signs
A
- bone destruction extended through alveolar mucosa
- larger areas of osteitis and bone sequestrum
12
Q
Periodontits - how to describe the distribution/extent of disease
A
localised
< 30% of teeth
generalised
> 30% of teeth
molar incisal pattern
13
Q
step 2 - how to determine whether patient is engaging
A
plaque levels <20% and bleeding levels <30%
OR
>50% improvement in plaque and bleeding scores
as well as no obvious risk factors to control
14
Q
factors influencing decision for periodontal surgery
A
smoking
compliance
oral hygiene
systemic disease
suitability of site
prognosis of tooth
availability of specialist treatment
patient preference
15
Q
step 4 treatment consists of…
A
supportive periodontal care
reinforce OH, risk factor control and behaviour change
regular targeted PMPR as required to limit tooth loss
consider evidence based adjunctive to control gingival inflammation
- toothpaste
- mouthwash
16
Q
What is a gingival abscess?
A
an abscess localised to the gingival margin
17
Q
define ‘periodontal abscess’
A
Infection within a periodontal pocket which can be acute or chronic and asymptomatic if freely draining
18
Q
what is a pericoronal abscess associated with?
A
partially erupted tooth
- most commonly 8s
19
Q
Why do teeth with a periodontal abscess tend to have a poor prognosis?
A
as a result of rapid destruction of periodontal tissues
20
Q
What are the signs and symptoms of a periodontal abscess?
A
- swelling
- pain
- tooth may be TTP in lateral direction
- deep periodontal pocket
- bleeding
- enlarged regional lymph nodes
- fever
- tooth usually vital
- commonly pre-existing periodontal disease
- suppuration (discharge of pus)
21
Q
Outline how you would treat an emergency patient presenting with a periodontal abscess
A
- Carry out careful sub-gingival instrumentation short of the base of the periodontal pocket to avoid iatrogenic damage (LA may be required)
- if pus present - drain by incision or through periodontal pocket
- recommend optimal analgesia
- do not prescribe antibiotics unless signs of spreading infection or systemic involvement
- recommend use of 0.2% chlorohexidine mouthwash until acute symptoms subside
- following acute management, review and carry out definitive periodontal instrumentation and arrange an appropriate recall interval
22
Q
What antibiotics can you prescribe to a patient with a periodontal abscess if there are signs of a systemic infection?
A
- Phenoxymethylpenicillin 250mgx2, 4x a day for 5 days
- Amoxycillin 500mg, 3 times daily for 5 days
- Metronidazole 400mg, 3 times daily for 5 days
23
Q
If you were to prescribe a patient presenting with a periodontal abscess antibiotics, what must you also do?
A
mechanical therapy should also be used
- to disrupt biofilm
- and reduce bacterial load
24
Q
What is an Endo-periodontal lesion?
A
a pathological communication between the Endodontic and periodontal tissues of a given tooth
tooth is suffering from varying degrees of endodontic and periodontal disease
25
What are the acute causes of an Endo-periodontal lesion?
- trauma
- perforation
26
Outline the signs and symptoms of an Endo-periodontal lesion
- deep periodontal pockets reaching or close to the apex
- negative or altered response to pulp vitality tests
- bone resorption in the apical or furcation region
- spontaneous pain
- pain on palpation or percussion
- tooth mobility
- crown and gingival colour alterations
-sinus tract
- purulent exudate
27
Outline the possible routes of communication between the pulp and periodontium
- exposed dentinal tubules
- lateral and accessory canals
- furcal canals
- apical foramen
28
What is the main route of communication between the pulp and periodontium?
- the apical foramen
29
perforation - potential causes
extensive dental caries
resorption
operator error
- e.g. root canal instrumentation or post preparation
30
What does perforation lead to?
communication between the root canal system and either peri-radicular tissues, periodontal ligament or the oral cavity
31
Why can infection arise from the apical foramen?
- microbial and inflammatory by-products may exit the apical foramen causing peri-radicular infection
- apex is a portal of entry for inflammatory by-products from deep periodontal tissues to affect the pulp
32
outline how you would treat a patient presenting with a Perio-endo lesion
- carry out Endodontic treatment on affected tooth
- recommend optimal analgesia
- do not prescribe antibiotics unless signs of spreading infection or systemic involvement
- recommend 0.2% chlorohexididne mouthwash until symptoms subside
- review within 10 days and carry out supra and sub gingival instrumentation if necessary
- arrange appropriate recall interval
33
Endo-perio lesions are classified by...
Endo-perio lesions with root damage
- root fracture or cracking
- root canal or pulp chamber perforation
Endo-Perio lesions without root damage
- endo-periodontal lesion in peridodontitis patients
- endo-periordontal lesion in non-periodonitis patients
34
endo-periodntal lesions without root damage: give the classifications/grades
grade 1
- narrow deep periodontal pocket in 1 tooth surface
grade 2
- wide deep periodontal pocket in 1 tooth surface
grade 3
- deep periodontal pockets in more than 1 tooth surface
35
Necrotising periodontal disease risk factors
stress
sleep deprivation
poor oral hygiene
smoking
immunosuppression
malnourishment (developing countries)
36
Necrotising periodontal disease - acute phase treatment
superficial debridement to remove soft and mineralised deposits
- ultrasonic devices recommended = minimal pressure
- perform daily for 2-4 days
advise use of 0.12% chlorhexidine mouthwash twice daily
37
necrotising periodontal disease - aims of acute phase treatment
- arrest the disease progress and tissue destruction
- control patients feeling of discomfort and pain that is interfering with nutrition and oral hygiene practices
38
necrotising periodontal disease - treatment following acute phase
treat pre-existing condition
- normally occurs over a pre-existing chronic gingivitis or periodontitis infection
control predisposing factors
- sleep
- smoking
- stress
- vitamin supplements
39
why might gingival surgery be indicated for a patient following resolution of necorotising periodontal disease?
gingival craters way be present
- favours plaque accumulation and disease recurrence
40
Define 'excessive occlusal force'
occlusal force which exceeds the reparative capacity apparatus, resulting in occlusal trauma and/or excessive tooth wear
41
define the term occlusal trauma
injury resulting in tissue changes within the attachment apparatus, including the periodontal ligament, as a result of occlusal force
42
Tooth mobility can be accepted, unless...
- progressively increasing
- gives rise to symptoms
- creates difficulty with restorative treatment
43
treatment options to reduce tooth mobility
control of plaque induced inflammation
correction of occlusal relations
splinting
44
How does a healthy periodontium respond to occlusal trauma?
PDL increases in width until forces can be adequately dissipated
tooth mobility increased as a result
PDL width returns to normal if demand subsequently reduced
45
If the demand of occlusal forces is too great or adaptive capacity of the PDL is reduced, what are the possible consequences?
PDL width continues to increase
PDL width and tooth mobility fail to reach a stable phase
46
secondary occlusal trauma - define
injury resulting in tissue changes from normal of excessive occlusal forces applied to a tooth with reduced periodontal support
- occurs in the presence. of attachment loss, bone loss and normal/excessive occlusal force
47
occlusal trauma - signs
tooth mobility which is progressively increasing
and/or
tooth mobility associated with symptoms
with
radiographic evidence of increased PDL width
48
What is fremitus?
palpable or visible movement of a tooth when subjected to occlusal forces
49
diagnosing occlusal trauma - clinical signs
- progressive tooth mobility
- wear facets
- tooth migration
- tooth fracture
- thermal sensitivity
- root resorption
- radiographic widening of PDL space
- fremitus
50
why may tooth migration occur in occlusal trauma cases?
- loss of periodontal attachment
- unfavourable occlusal forces
- unfavourable soft tissue profile
51
tooth migration - management
- treat the periodontitis
- correct occlusal relations
either
- accept tooth position and stabilise
or move teeth orthodontically and stabilise
52
when may splinting be appropriate?
mobility is due to advanced attachment loss
mobility causing discomfort or difficulty when chewing
teeth need to be stabilised for debridement
53
splinting - downsides
- does not influence rate of periodontal destruction
- may create hygiene difficulties
54
describe why patients with periodontitis are more likely to develop diabetes
periodontitis is associated with higher Hba1c and fasting blood glucose levels
severe periodontitis associated with increased risk of developing diabetes
55
compared to individuals without diabetes, how much more likely is a patient with diabetes more likely to develop periodontitis?
2-3 times
56
Periodontitis management - pt with diabetes
Ask patient if type 2 diabetes is well controlled
explain patients with diabetes that sub-optimally controlled blood sugar levels increase risk of developing periodontal disease or worsening of existing Periodontology
ensure patients understand the need for effective oral hygiene
57
Aims of step 3
to treat areas of the dentition not responding adequately to step 2
58
step 3 periodontal therapy may include
repeated sub gingival instrumentation with or adjunctive therapies
access flap surgery
respective flap surgery
regenerative flap surgery
59
periodontal surgery indications
sites where good quality non surgical treatment has not resolved periodontal pocketing and there is ongoing inflammation or infection
pocketing >/= 6mm
teeth of reasonable prognosis
60
patient factors required to be suitable for surgery
oral hygiene
<20% plaque. <10% marginal bleeding
ability of patient to tolerate procedure
likelihood of compliance post surgery
cost and patient acceptance
aesthetics of site and potential for post-op recession
61
systemic/medical contraindications for periodontal surgery
smoking
unstable angina , uncontrolled hypertension, MI/stroke within 6 months
poorly controlled diabetes
immunocompromised patients
anticoagulants
62
what cases may systemic antimicrobials be considered in periodontitis?
Grade C in younger adults
- where a high rate of progression is documented
63
defects which usually respond well to periodontal surgery
infra-bony defects
furcation defects
64
aims of open flap debridement
access to areas of continued inflammation or infection
usually for areas PPD >6mm
allow access for surgical debridement
65
open flap debridement technique
full thickness flap raised to exposure affected root surface, periodontal bone and associated defect
granulation tissue removed from defect
root surface instrumented
suture and aim for primary closure
66
regenerative periodontal surgery indications
intrabony defects 3mm or deeper
class 2 or class 3 furcation defect
67
types of periodontal surgery
conservative approach
- preserving tissue
- access surgery
resective approach
- removing tissue
- resective surgery
reconstructive approach
- regenerative surgery
68
regenerative surgery - aims
aims to promote the regeneration of the periodontal tissues that have been lost
69
surgical techniques in regenerative surgery
regeneration of the PDL using membranes and grafts and the application of biologic agents
70
give examples of common mucogingival surgery procedures
free gingival graft
pedicle graft
connective tissue graft
71
localised gingival recession aetiology
excessive toothbrushing or incorrect technique
traumatic incisor relationship
habits
anatomical
complication of orthodontic treatment
72
What classification is used to describe types of gingival recession?
Cairo et al. (2011) classification
73
infra bony defects - classification
1 walled
2 walled
3 walled
(requires CBCT or flap raising to view)
74
recession type 1
no inter proximal tissue loss
- full root coverage may be achievable
75
recession type 2
interproximal tissue loss (from ACJ to base of pocket) not as significant as mid-buccal
- partial root coverage may be expected
76
recession type 3
gingival recession associated with loss of interprocimal attachment
interproximal tissue loss worse than mid-buccal
- no root coverage expected
77
gingival recession - treatment
record magnitude of recession
eliminate etiological factors
- remove piercings
- habits
ohi
topical desensitising agents
fluoride varnish
gingival veneer to cover exposed roots
crowns
- with great caee and appropriate diagnostic wax uo
mucogingival surgery
78
give examples of cases where crown lengthening surgery may be appropriate
to expose enough clinical crown to allow a restorative ferrule to be achieved
expose sub gingival restoration margins/secondary caries/fractures
correction of uneven gingival colour compromised aesthetics
- increasing excessive gingival display
79
peri-implant health; definition
absence of clinical signs of inflammation
absence of bleeding or suppuration on gentle probing
no increase in pocket depth compared to previous examinations
absence of bone loss beyond crestal bone level changes resulting from initial bone remodelling
allows for the presence of a single bleeding spot around the implant
80
peri-implant mucositis: definition
an inflammatory lesion of the peri-implant mucosa, in the absence of continuing marginal bone loss
- reversible
81
peri-implant mucositis signs and symptoms
erythema
bleeding on probing
swelling/suppuration
increase in pocket depth (due to oedema)
82
peri-implantitis: definition
peri-implant biolfim-associated pathological condition, occurring in tissues around dental implants, and characterised by inflammation in the peri-implant mucosa and subsequent progressive loss of supporting bone
83
peri-implantitis signs and symptoms
inflmmation
bleeding on probing and/or suppuration
increased probing depth and/or recession of the mucosal margins
radiographic bone loss compared to previous examinations
84
aetiology of peri implant mucositis
plaque, smoking, radiation therapy
85
aetiology of peri-implantitis
plaque, lack of regular supportive peri-implant care
86
implants - hidden costs
costs of maintaining implants estimated to be approx 5 times the cost of maintaining teeth
cost to treat peri-implantitis - £1500
87
what is primordial prevention?
preventing the development of risk factors
88
inpatients waiting implant placement, it is recommended that you:
carry out through assessment of patient's risk profile
manage modifiable risk factors/indicators for peri-implant disease
complete guideline conformed treatment of gingivitis and periodontitis to a stable endpoint and adherence to a supportive care program prior to implant placement
89
peri implantitis: how to diagnose in the absence of previous examination data
presence of bleeding and/or suppuration on gentle probing
PPD of greater than or equal to 6mm
bone levels greater than or equal to 3 mm apical of the most coronal portion of the intraosseous part of the implant
90
peri-implant disease predisposing factors
history of severe periodontitis
poor plaque control
no regular supportive peri-implant care
smoking
diabetes
91
local factors that may predispose to peri-implant disease
submucosal cement
positioning of implants limiting access to oral hygiene and maintenance
absence of peri-implant keratinised mucosa
occlusal overload
presence of titanium particles within peri-implant tissues
bone compression necrosis, overheating, micro motion or bio corrosion
92
role of the GDP in implant cases
regular routine holistic care of the patient before and after implants
patient prepration
- clinical
- emotional
information resource
- technical aspects - what pt should expect
- where to go and who to see
making the referral
after care and ongoing maintenance
93
how to assess a dental implant and its restoration
look for inflammation or infection
check OH
probe around implant
check restoration for signs of cracks, loosening and cleansability
radiograph
94
periodontitis - stable meaning
<10% BOP
95
periodontitis - currently in remission
BoP greater than or equal to 10% of sites
PPD less than or equal to 4mm
no BOP at 4mm sites
96
unstable periodontitis
PPD >/= 5mm
or
PPD >/= 4mm and BoP
97
classification of periodontal bone defects
angular/vertical bone loss
horizontal bone loss
furcation bone loss
98
local periodontitis risk factors
anatomical
- gingival recession
- furcations
- grooves
- enamel pearls
tooth position
- crowding
- tipping
- occlusal force s
- migration
- malignment
iatrogenic
- restoration overhangs
- defective crown margins
- poorly designed partial dentures
- orthodontic appliances
99
How does smoking increase the risk of periodontal disease?
vasoconstriction of gingival vessels
impaired antibody production
depressed numbers of T lymphocytes
increased production of pro-inflammatory cytokines
100
most ideal radiographs for assessing progression of periodontal disease and why?
periapicals
provides picture of bone levels in relation to both CEJ and total root length
can identify furcation involvement
can identify possible endodontic complications
101
Downsides of OPT radiographs in periodontal assessment
distortion in anterior sextants
102
grade 1 furcation involvement
initial furcation involvement
opening can be felt on probing but is less than 1 third of tooth width
103
Grade 2 furcation involvement
partial furcation involvement
loss of support exceeds one third of tooth width but does not include total width of furcation
104
grade 3 furcation involvement
through-and-through involvement
entire probe can pass through furcation
105
grade 1 tooth mobility
increased mobility of crown of tooth no more than 1mm in horizontal direction
106
grade 2 tooth mobility
visually increased mobility of crown exceeding 1mm in horizontal direction
107
grade 3 tooth mobility
severe mobility of crown in both horizontal and vertical directions impinging on function of the tooth
108
TIPPS stands for
talk
instruct
practise
plan
support
109
following root surface debridement, the greatest changes observed are seen how long after therapy?
4-6 weeks
110
Outline Periodontology treatment step 1
building foundations for optimal treatment outcomes
- explain disease, risk factors and treatment alternatives and risks and benefits including no treatment
- OHI and encourage behaviour change
- provide individually tailored advice
- select recall period
111
periodontitis step 2 treatment
reinforce OH and risk factor control
sub gingival instrumentation
112
periodontitis step 3
managing non responding sites
re-perform sub gingival instrumentation on moderate residual pockets - 4-5mm
consider alternative causes for deep residual pockets over 6mm
- consider referral
- if referral not possible - re-perform sub gingival instrumentation
If all sites stable after step 3 proceed to step 4
113
periodontitis step 4
maintenance
supportive periodontal care
reinforce OH
regular targeted PMPR to limit tooth loss
maintenance recall
- every 3-12 months
114
regenerative surgery indications
intrabony defects 3mm or deeper
class 2 or class 3 furcation defect
115
outline the surgical options for furcation defects
regenerative surgery
root resection
root separation
tunnelling
116
necrotising gingivitis - patient still has persistent swelling and/or systemic symptoms after scaling - what would you do?
prescribe antibiotics
Metronidazole 400mg 3x a day for 3 days
or
Amoxycillin 500mg 3x a day for 3 days
117
Why might antibiotics be ineffective in periodontal disease cases?
may be resisted by biofilms
may not reach site of disease activity
may have inadequate drug concentration and retention
may be inactivated
