Perio Flashcards
(9 cards)
Periodontal abscess / 6mins
A 50 year old male patient attended for HPT with hygienist 3 months ago , their 35 is tender and has a swelling around the tooth and has an 8mm pocket distally as well as suppuration
The patient is systematically well and has a normal body temperature
Provide your diagnosis to the patient and discuss how would you like to investigate the matter further?
- Start by saying what u
“ I can see an abscess but we have two types of abscess so we need to take further tests to confirm the correct diagnosis and then treat it the right way “ - Ask examiner for sensibility testing and a PA radiograph
EPT 35 and 36 are positive and PA shows periodontal/periapical pathology
” due to the swelling + the presence of a pocket with pus + bone loss from radiograph I can confirm that the diagnosis is a periodontal abscess”
” This can be associated with food packing and tightening of the gum following periodontal therapy , also it is TTP in a lateral direction, deep pockets are present with bleeding and pus formation , usually the tooth is vital (alive) and is commonly associated with a pre-existing periodontal disease “
- Treatment
1. Irrigate through pocket
2. debridement
3. hot salty mouthwash and analgesia
In detail :
Subgingival instrumentation short of the base of the pocket , drain pus by incision or through the pocket , CHX mouth was and analgesia
XLA tooth if hopeless prognosis
Arrange recall to see patient again to start periodontal therapy and review abscess
” you will not need any antibiotics since it is a localised infection
Localised aggressive periodontitis (6 mins)
Diagnose from OPT and explain diagnosis and management
- start by telling the patient the radiographic and clinical findings, explain diagnosis and stage/grade of periodontitis (Periodontitis Molar-incisor pattern Stage IV
Grade C, Currently unstable risk factors - family history - Features
~ patient generally fit and well / young
~ associated with a family history of aggressive periodontitis
~ rapid loss of attachment which is not proportional to the level of plaque present
~ Localised if only 6s and incisors affected with less than 2 other teeth , can start in puberty, robust antibody response
~ Generalised if 3 teeth involved other than 6s and incisors , pt under the age of 30 , episodic nature of destruction with poor antibody response
~ associated with Papillon-Lefèvre syndrome (PLS) (inherited disease)
- Tell patient about the disease
~ evidence that it is more common in people with a genetic predisposition to periodontal disease
~ other factors such as smoking and poor OH have an impact
~ it is important to screen and monitor close relatives with a patient with severe periodontitis
~ Discuss prognosis of teeth with regard to loss of attachement , mobility and furcation involvement
~ emphasise to pt that it is still treatable as they may lose hope - Treatment
1. Baseline records ( 6ppc)
2. OHI
3. PMPR ( supra and sub)
4. XLA and replacement of hopeless teeth
5. Refer to periodontal therapy and specialist for non responding sites
ABs side effects include vomitting / abs resistance / nausea
ANUG / 6 mins
30-year old patient (not registered with GDP)
C/O signs of ANUG
Smokes 20 cigs a day
Otherwise fit and well
Has cervical lymphadenopathy
Discuss diagnosis with patient and proposed treatment plan
( no need to obtain more information from the patient )
- Introduce yourself and designation
- Take a brief history
“ can you tell me what is going on? , are in pain? any bleeding? “
ask about systemic symptoms , stress , OH and smoking - Explain diagnosis
“ Mr X i am afraid you are suffering from a condition called acute necrotising ulcerative gingivitis or ANUG which is a rare condition presenting as an acute form of gum disease, which means that the gum disease progress and develop much faster than normal gum disease, the ulcers are due to bacteria breaking down gum tissue “ - Explain aetiology
“ it can be caused by a variety of reason but it tends to cluster in people who are stressed , smokers or poorly nourished “
” Poor OH and immunocompromised (HIV) pts have a higher risk of developing it “
- Explain symptoms
“ Common symptoms include
1. bleeding
2. painful gums
3. painful ulcers at the tip of the papillae
4. receding gums between teeth
5. bad breath
6. metallic taste in mouth
7. excess saliva
8. difficulty speaking or swallowing “
9. punch out appearance with gre pseudomembrane
” The disease can also extend beyond the mouth and cause systemic symptoms like swollen lymph nodes or a high temperature”
- Discuss management
1. reassure it can be managed with local measures
2. good OHI
3. NSPT under LA
4. MW such hydrogen peroxide 6% or CHX 0.2%
5. smoking cessation
6. stress reduction
7. due to systemic involvement ; 3 day regimen of metro
8. analgesia
9. advise to register with GDP
~ review pt within 10 days
~ it can recurr so it is important to manage risk factors
ANUG is a Fusospirocheteal infection
Comparing pre and post treatment pocket charts ( 12 mins)
Indicate where healing has occurred , where it hasn’t and reasons for failure
- Missing teeth - identify causes
- Gingival margin - from ACJ , to incdicate recession
- Probing depths - indicates treatment difficulty
- LOA - indicated deverity of disease
- Bleeding on probing - indicates disease activity
- Mobility - poor prognosis and may give rise to symptoms
- Furcation - treatment difficulty
- Reasons for failure?
1. Patient factors
~ not compliant with OH
~ MH - diabetes, immunocompromised , pregnant, poor diet
~ SH - smoking and stress
~ Pt unable to carry out OH effectively due to dexterity issues ( PArkinsons or dementia pts) or hard to reach areas such as wisdom tooth or furcation area
- Clinician factors
~ inadequate debridement
~ low experience
~ inability to disrupt biofilm - Tooth related factors
~ Overhangs and poor margins
~ Root morphology , furcation, vertical bony defect making it hard to access for debridement
~ very deep pockets
Healing = no BOP , 4mm or less probing depths
Comparing pre-post perio charts ( another answer)
- Jim is one of your periodontitis patients who is attending your clinic for a review of their periodontal treatment. The patient is being re-evaluated 3 months after Step 2 with no adjuncts. [12]
The patient, who is 45 years old, works as a solicitor for a large firm. They were a smoker, and records say the patient mentioned they will quit smoking from the initial exam appointment onwards. Jim’s medical history was checked today, which reveals he is now currently being investigated for diabetes.
The initial exam diagnosed him as Generalised Periodontitis Stage IV grade C – currently unstable, risk factors: smoker.
You record the plaque, bleeding and pocket depths at re-evaluation. Provided below are both pocket charts from the initial exam and re-evaluation.
Discuss with the patient the results of their new pocket chart, comparing this one with the one taken at initial exam. You should include the following information:
a) any changes in plaque or bleeding,
b) where healing has occurred,
c) where healing has not happened,
d) any reasons for failure of healing,
e) management options for residual pockets
~ introduce yourself
~ Explain purpuse of appt is to re-evaluate perio status after therapy
~ Changes in plaque and bleeding
* More than 50% reduction from 66% to 30%
* Show areas where plaque has reduced (anterior teeth and upper palatal surfaces)
* Show that some areas need more work ( lower right lingual, buccal , lower left lingual)
* Some reduction in bleeding but not significant ( target is less than 30% )
* Bleeding reduction occured in maxillary teeth and lower posteriors need further work
~ Changes in probing depths
* Overall reduction in probing depths but insignificant in most deeper pockets , 3.9% to 3.6%
* Upper and lower anteriors have some reduction in pocket depths
* Still need work as we still have residual pockets in lower right and left lingual surfaces
~ Reasoning for no changes
* Ask about OH
* Ask about smoking
* Discuss how diabetes might affect periodontal tissues
* Discuss effectiveness of non surgical instrumentation on hard to reach sites
~ Management for residual pockets
- OHI
- Repeat subgingival instrumentation
- Refer to secondary care for surgical instrumentation
Why is smoking a risk factor for periodontal disease?
- Reduced gingival blood flow
- impaired wound healing
- Impaired white cell function
- Increased production of inflammatory cytokines which increase tissue destruction
Why is diabetes a risk factor for periodontal disease?
- Poor wound healing
- Immunosupressed - poor inflammatory response
- AGE products increase inflammation
- Neutrophils defects
- A regular chronic periodontitis patient of yours presents to their scheduled appointment complaining of severe pain to the lower left corner of their lower jaw. [EQ]
The patient reports to be unable to brush their teeth in the area due to the severe pain and was worried about causing more bleeding in the area. History taking reveals type 1 diabetes which is diet controlled.
On examination, there is asymmetry with severe tenderness over the left body of mandible with no lymphadenopathy and no fever. Intra-oral examination shows heavy accumulation of dental plaque with swelling of the buccal gingivae around the lower left molars.
Deepest pocketing was 9mm at the distal-buccal of unrestored sound tooth 36. Ethyl chloride and electric pulp testing reveals a vital pulp. On probing this pocket, significant bleeding and pus discharge occurred.
a. What is the diagnosis? What specific features of this presentation brings you to this conclusion?
b. If a radiograph was to be taken for this patient, which one would you go for and what radiographic signs would you expect?
c. What is the treatment for this condition?
d. How would you explain to a patient the effect of diabetes on periodontal conditions?
Diagnosis
* Periodontal abscess
* Chronic periodontitis
* Vital tooth
Radiograph
* Periapical of 36
* Localised alveolar bone resorption
* Localised angular bone defects
Treatment
* LA
* Subgingival PMPR short of base of pocket 9
* PMPR to clear residual plaque
* PMPR to drain pus
Post op
* Analgesia / CHX MW
Review and continue PMPR / OHI
Diabetes advice
* Diabetes and periodontal disease affect each other
* Uncontrolled blood sugar level is known risk factor for periodontal disease
* Recurrent periodontal abscess mat indicate poorly controlled diabetes
* Treating gum disease will likely improve the control of diabetes
* Regular attendance and compliance with treatment is important
