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Perio Flashcards

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1
Q

Reasons for NSPT failure

A

Inc. PPD
Inc. width tooth surface
Poor access: unable to angle/adapt curette
Tenacious calculus
Root fissures/concavities/furcation
Defective restoration margins subgingival

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2
Q

Relationship between chance of calculus removal and PPD

A

Inverse
<3mm = 83%
3-5mm = 39%
>5mm = 11%

Av. depth plaque-free surface established = 3.73mm
Instrument can reach 5.52mm

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3
Q

Objectives of PD surgery

A 
Eliminate local factors 
Eliminate/red. PPD
Restore alveolar bone architecture 
Regenerate functional attachment apparatus 
Crown lengthening 
Correct mucogingival defects
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4
Q

Surgical PD therapy techniques

A 
Gingivectomy 
Flap surgery
Osteoplasty
Tunnelling
Root resection
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5
Q

Gingivectomy vs flap surgery

A

Gingivectomy

  • excision of gingiva
  • root SP then packed + PD membrane placed
  • 2ry healing
  • can’t Tx bony defect

Flap surgery

  • raise flap to level of mucogingival margin
  • allow visualisation of root for SP
  • can use to Tx bony defect
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6
Q

Discuss tunnelling and root amputation

A

Tunnelling

  • furcation 3
  • osteotomy + gingivoplasty to expose furcation
  • allows proper cleaning of furcation
  • adv: long roots, short trunk, adequate separation
  • disadv: root caries, sensitivity

Root amputation

  • furcation 2/3
  • remove 1 periodontally involved root cf whole tooth
  • req. endo
  • risk #
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7
Q

What is an infra-bony defect?

A

Occurs when base of PPD is apical to crest of alveolar bone

1 wall: only 1 wall remaining; i.e. M remaining, B+L lost
2 wall: 2 walls remaining; M+B remaining, L lost
3 wall: 3 walls remaining; defect not broken through B/L plate
Interproximal crater: bone b/w 2 teeth lost, B/L plates intact

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8
Q

Goals of periodontal therapy

A 
Infection control
PPD red./eliminated
Regeneration 
Long term success/results
Aesthetic improvement
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9
Q

Why can wound healing in OC be challenging?

A

Open system: exposed to OC via sulcus lots of bacteria -> infection
Surface healing w/ poor blood supply
- only supply through surrounding tissues + remaining PDL

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10
Q

Properties of ideal regenerative perio material

A

Promote proliferation + migration of cells from PDL
Inhibit proliferation of epithelial + gingival connective tissue into wound
Enhance space provision + wound stability

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11
Q

Examples of regenerative perio materials

A

Grafting
Enamel Matrix Protein/Derivative
Growth + Differentiation factors
Platelet rich plasma

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12
Q

Principles that success of perio regeneration is dependent on

A

PASS

1ry closure + site protection allowing for undisturbed healing
Angiogenesis: blood + undifferentiated mesenchymal cells
Space creation + maintenance for bony ingrowth
- if collapses will heal by long junctional epithelium
Stability: blood clot formation + uneventful healing

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13
Q

Requirements of regenerative perio membrane material

A

Biocompatible
Not elicit inflammatory response
Maintain barrier function
Noncollapsible; maintain space

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14
Q

Importance of enamel matrix proteins

A

EMP deposition on developing tooth root req. for cementum formation
PDL + alveolar bone formation dependent on cementum

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15
Q

Biological effects of EMD

A

Inc. attachment rate + migration of PDL cells
Inhibit epithelial down growth
Antibacterial effect on plaque
Stim. proliferation + differentiation of pre-osteoblasts
Osteopromotive w/ decalcified freeze dried bone allograft
Inc. osteogenic activity bone marrow
Inc. no gingival fibroblasts

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16
Q

Rationale for combination perio regenerative therapy

A

Enhance periodontal regeneration by GTR/GF/EMD

Provide space + enhance wound stability by means of grafting materials into defects w/ complex anatomy

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17
Q

Define furcation

A

Pathologic resorption of bone in the anatomic area of multi-rooted teeth where roots diverge

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17
Q

Horizontal and vertical classification of furcation defect

A

Horizontal: Hemp

  • 1: loss of PD support <3mm
  • 2: >3mm but not through-and-through
  • 3: through and through

Vertical: Tarnow + Fletcher

  • A: bone loss <3mm
  • B: 4-6mm
  • C: >7mm
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18
Q

Dx of furcation defect

A

X-ray

  • indicate existing furcation involvement
  • can’t provide Dx of classification

Clinical: Naber’s probe

  • B+L: good reproducibility + validity
  • MP: less reliable
  • DP: most difficult, poor reproducibility
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19
Q

Tx of F1

A

OH
NSPT: consider odontoplasty
PD supportive therapy

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20
Q

Management of single mandibular F2

A

Regeneration
NSPT + odontoplasty
Surgical: OFD, apically positioned flap, osteoplasty

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21
Q

Tx of combined mandibular F2 defect

A

2 + 1

  • regeneration
  • NSPT + odontoplasty
  • surgical

2 + 2

  • tunnelling
  • NSPT + odontoplasty
  • resection/hemisection
  • surgical
  • regeneration
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22
Q

What does successful perio regeneration req.?

A

PDL cells

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23
Q

Factors affecting healing following PD surgery

A 
Pt: OH, smoking
Tooth
Gingiva: recession, biotype
Initial PPD
Membrane exposure/infection
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24
Factors affecting outcome of PD surgery
``` Defect - size — 2x2mm predictable; 5x4mm unpredictable - morphology - angle Soft tissue management/flap recession Space maintenance Tooth - endo condition - mobility ```
25
Tx of single maxillary F2 defect
Buccal - regeneration - NSPT + odontoplasty - SPT Interproximal - NSPT + odontoplasty - SPT - regeneration - resection
26
Tx of combined maxillary F2 defect
Interproximal - SPT - NSPT + odontoplasty - resection/root separation - tunnelling Buccal + Interproximal - SPT - resection/separation - tunnelling - NSPT + odontoplasty
27
Tx of F3 defects
L - tunnelling - root separation - NSPT - root resection - XLA U - root resection - NSPT - tunnelling - root separation - XLA
28
When should perio re-evaluation be carried out?
Following SRP - junctional epithelium reestablish: 1-2/52 - connective tissue repair: 4-8/52 8/52 too long Ideal: 4-8/52
29
What is supportive periodontal therapy?
Procedures performed at selected intervals to assist PD pt maintain OH
30
Objectives of SPT
Min. recurrence + progression of PD/implant disease Red. incidence tooth/implant loss Inc. probability of locating + Txing other oral disease/condition
31
Compare trial and compromised SPT
Trial: maintain borderline PD conditions over period to further assess need for corrective therapy while maintaining PD health on balance throughout mouth - inadequate gingiva - gingiva architectural defects - borderline pockets - furcation defects Compromised: slow progression of PD disease in pt corrective therapy indicated cannot be provided due to: - health - economics - poor OH - recalcitrant defects post-corrective therapy
32
Rationale for SPT
PD biofilm rebounds 2/52 following SRP (Wennstrom, 2011) Clinical success w/ regular maintenance (Becker, 2001) Residual bleeding PPD >4mm inc. risk progression + tooth loss Limit incidence + freq. tooth loss Limit CAL
33
When should alternatives to locally delivered antimicrobials be considered in perio?
Multiple PPD>4mm in 1 Q LDAs failed to control PD Anatomical defects; infrabony defect
34
Criteria for perio referral
Aggressive/severe PD - PPD >6mm - excellent plaque: <20% - failed respond RSD w/ LA Acute: desquamative gingivitis, necrotising PD Drug induced gingival conditions + localised gingival swelling Localised significant root exposure in otherwise stable pt
35
Rationale behind new perio classification
Pts exhibit different disease progression Little evidence aggressive + chronic perio different states and req. different Tx Evidence multiple factors influence outcome System based on severity fails to comprehend; complexity + risk factors
36
Why did BSP introduce modified WWP guidelines?
Simplify; aid implementation into general practice Speed up Dx Continue use of BPE; used universally
37
Discuss distribution of PD
Molar-incisor pattern Localised: <30% Generalised: >30%
38
Discuss staging of PD
Indication of disease severity + complexity of Tx Measurement: % radiographic bone loss - single worst site in mouth
39
PD stages
Root divided into 1/3 starting 2mm apical from CEJ 1: initial; <15%/>2mm 2: mod.; coronal 1/3 3: severe w/ potential for tooth loss; mid 1/3 4: severe w/ potential for loss of dentition; apical 1/3
40
Discuss PD grading
% bone loss/Age A: slow; <0.5 B: mod; 0.6-1.0 C: rapid; >1.0
41
Discuss current activity of PD
Stable - PPD <4mm - BOP <10% - no BOP in PPD=4mm Remission - PPD <4mm - BOP >10% - no BOP in PPD=4mm Unstable - PPD >4mm - BOP >10%
42
Discuss risk factor profile of PD
``` Smoking Uncontrolled DM Stress Immunosuppression Genetics ```
43
Dx summary for PD
``` Distribution PD Stage Grade Current activity Risk factors ``` Generalised Perio Stage 3 Grade B currently in Remission. Risk; smoking 15/d
44
Osteoplasty vs ostectomy
Osteoplasty - reshape bone to guide gingiva - don’t remove supporting bone - furcation 1 Ostectomy - removal of supporting bone to even out surface
45
Resection vs regeneration
Resection - removal of hard tissue - create flat osseous architecture to facilitate better adaptation of soft tissue - red. PPD, inc. recession Regeneration: addition of regenerative/grafting material to rebuild lost apparatus
46
General Tx for infrabony defects and favourability to regeneration/resection
Greater no. walls remaining, inc. favourability to regeneration - except 4 wall defect Less walls req. resection Deep defects - narrow: most favourable - wide: regeneration Shallow: req. resective Tx
47
List localised-tooth related factors that predispose to PD
``` Accumulations Morphology Enamel pearls Cervical enamel projections Bifurcation ridges Root #s Root proximity Accessory canals Cervical root resorption + Cemental tears Occlusion/Trauma Malocclusion Post-XLA defect Habits Altered passive eruption ```
48
Discuss development of calculus
Calcification of plaque starts within 4-8h | Mineralised: 50% 2d, 60-90% 12d
49
Significance of calculus accumulations
Incidence calculus, gingivitis + perio inc. w/ age Calculus doesn’t directly cause gingival inflammation Provides niche for plaque accumulation
50
Significance of dental staining re PD
Inc. surface roughness -> inc. plaque accumulation
51
Define: fornix, entrance, trunk, degree of separation, divergence of roots
Fornix: roof of furcation Entrance: area b/w non/separated parts of roots Trunk: body of root before roots diverge Degree of separation: angle b/w separating roots Divergence: distance b/w roots
52
Effect of root morphology on PD
Furcations, grooves, concavities make more difficult to clean thus allow for inc. plaque retention
53
Discuss enamel pearls + cervical enamel projections
Enamel pearls - developmental deviation; 1.1-9.7% - S: U7/8s - usually at furcation area - may contain dentine + pulp tissue - prevent connective tissue attachment Cervical enamel projection - developmental deviation - S: B LMs - apical projections of enamel - prevent connective tissue attachment
54
Effect of root #s + root proximity on PD
#s - significant inc. PPD - usually only 1 site Proximity - closer together = inc. risk - little interproximal space, less bone thickness
55
What is altered passive eruption?
Developmental condition w/ abnormal dento-alveolar relationships Gingival margin (sometimes bone) more coronal - > pseudopockets - > aesthetic concerns
56
Localised dental prosthesis-related factors predisposing to PD
``` Poor/invasive margins Overhangs Contours Decay Open/loose contacts DM + Procedures Removable prostheses Ortho appliances ```
57
Discuss effect of poor restorative margins on PD
Never good -> microleakage -> 2ry caries + PD breakdown Follow anatomy of tooth, not encroach further than req. Subgingival - deeper = higher chance inflammation - inc. PPD - inc. CAL - more bacteria - encroach on supracrestal tissue attachment -> pathological inflammation
58
Discuss contour of restorations effect on PD
Over-contoured - accumulate plaque - handicap OH - prevent self-cleaning mechanisms of cheek, lips, tongue Flat B/L contours - follow cervical contours - doesn’t accentuate cervical bulge
59
Discuss open contacts + overhangs effect on PD
Open contacts - forceful food wedging due to O forces - some move due to movement; can’t fix due to over-contouring - over T -> PD breakdown as difficult to clean Overhangs - inc. bone loss w/ med./L overhangs — small (<25%) less detrimental - removal improve status thus replace restorations
60
Side effects of dentures and ortho appliances (perio)
Dentures - plaque accumulation if poor OH - gingival inflammation/pressure - traumatic O forces Ortho - plaque accumulation - change plaque composition - gingival inflammation + enlargement - gingival recession - trauma: bands, elastics - bone loss - root resorption
61
Criteria for PD Dx
Interdental CAL >1mm at 2/+ nonadjacent sites OR Buccal CAL>3mm w/ PPD>4mm at 2/+ teeth
62
1ry features of aggressive PD
Familial tendency Otherwise healthy Rapid bone/attachment loss
63
2ry features of aggressive PD
Calculus deposits inconsistent w/ destruction Progression poss. self arresting Localised or generalised
64
Differentiate b/w localised + generalised aggressive PD
Localised - circumpubertal onset - 6s, Is - freq. A.a. - neutrophil function abnormalities - robust serum Ab response Generalised - <30y - at least 3 other teeth than 6s + Is - freq. A.a. + P.g. - neutrophil function abnormalities - poor serum Ab response
65
Evidence of aggressive vs chronic PD
No evidence of specific pathophysiology that enables differentiation Little consistent evidence different diseases
66
Goals of aggressive PD Tx
Arrest disease progression Regenerate tissues (if feasible) Achieve: comfort, aesthetics, function Prevent recurrence
67
Why is regenerative/reconstructive surgery usually favourable in aggressive PD pt?
Young Good OH 2/3 wall defects
68
Evidence for adjunct systemic antimicrobial therapy for Tx aggressive PD
Amoxicillin + metronidazole Significant benefit + attachment gain for PPD >6mm More beneficial @ initial phase cf reTx
69
Factors to consider re Tx furcations
``` Degree of involvement C:R + root length Root anatomy/morphology Root separation Strategic value Tooth mobility Req. RCT? Pros req.? PD condition adjacent teeth OH maintenance? Bone quality Cost Long term prognosis ```
70
Contra/indications for root resection
Indications - advanced caries - severe recession on 1 root - too close root proximity for prosthetic restorations - RCT failure - root resorption/#/perforation - severe vertical bone loss w/ 1 root Contra - poor C:R - red. supportive structure w/ RRs - unsuccessful RCT - long root trunk - fused roots - poor surgical access
71
What are the clinical endpoints for furcation Tx?
``` Complete closure (20%) Conversion to F1 (horizontal) Conversion to class A (vertical) ```
72
When should XLA be considered in furcation cases?
F3 + >75% bone loss Bone loss >50% + complete X-ray loss of bone in furcation Loss >70% bone height Bone loss to apex Terminal + unopposed tooth in arch Solitary D abutment w/ inc. mobility Affecting PD status adjacent teeth may serve as abutments Preservation may inc. complexity future implant procedures

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