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BDS5 Periodontology OSCE > Periodontology > Flashcards

Periodontology Flashcards

1
Q

What figures does healthy gums do matter define good oral hygiene/engaging patient by

A
  • plaque scores <30% and bleeding scores <35%
    OR
  • 50% improvement (marginal BOP and plaque scores)
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2
Q

What figures define an engaging patient defined by according to BSP guidelines

A
  • favourable imrpovements in oral hygiene (50% improvement)
    OR
  • plaque levels <=20% and bleeding scores <= 30%
    OR
  • px has met the targets outlined for them in their personal self care plan determined by their HCP
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3
Q

What figures define optimal post-tx outcomes according to SDCEP guidelines

A
  • plaque scores <15%
  • bleeding scores <10%
  • probing depths <4mm
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4
Q

What figures define periodontal stability post-tx according to BSP 2017 guidelines

A
  • BOP <10%
  • PPD <=4mm
  • no BOP at 4mm sites
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5
Q

What figures define periodontal remission post tx according to BSP 2017 guidelines

A
  • BOP => 10%
  • PPD <= 4mm
  • No BoP at 4mm sites
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6
Q

What figures define periodontal instability post tx according to BSP guidelines

A
  • PPD => 5mm
    OR
    PPD =>4mm + BOP at 4mm sites
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7
Q

What should be done before step 1 of periodontal tx as per S3 guidelines

A
  • extract any teeth with hopeless prognosis or unsavable teeth e.g grade 3 mobility
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8
Q

What is step 1 defined as

A
  • building foundations for optimal treatment outcomes
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9
Q

What occurs in step 1 of the S3 guidelines

A
  • explain disease, risk factors, tx alternatives, risks and benefits of tx
  • explain importance of OH, encourage behaviour change to improve OH
  • reduce risk factors
  • provide individually tailored OHI
  • supra/subgingival scaling of the clinical crown
  • select recall period
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10
Q

When can a patient be moved onto step 2

A
  • if they are considered engaging
  • refer to BSP/HGDM guidelines to define an engaging px
  • if non-engaging, repeat step 1 at every visit (palliative care)
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11
Q

What does step 2 consist of (S3 guidelines)

A
  • subgingival PMPR
  • reinforce OH, risk factor control, behaviour change
  • adjunctive microbials may be used
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12
Q

When should we re-evaluate a patient after step 2

A
  • 3 months
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13
Q

When should a patient be moved onto step 3

A

if they are considered ‘unstable’ as per BSP guidelines

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14
Q

What does step 3 consist of

A
  • reinforce OH, risk factor control, behaviour change
  • moderate 4-5mm residual pockets undergo re-PMPR
  • deep residual pocketing –> consider alternative causes/referral
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15
Q

If a patient is stable, and they move onto step 4, what will they recieve

A
  • maintenance
  • supportive periodontal care
  • reinforce OH, risk factor control, behaviour change
  • regular targeted PMPR to limit tooth loss
  • consider evidenced based adjunctive efficaious toothpastes and/or mouthwash to control gingival inflammation
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16
Q

What is the maintenance recall for step 4

A

3-12 months
individually tailored

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17
Q

What are reasons for deep pockets not resolving

A

Skills of operator
* plaque removal technique
* ability to motivate the px
Local factors
* root morphology
* overcrowding
* overeruption
* poor restoration margins
Systemic factors
* smoking
* poorly controlled diabetes
* immunosuppressive drugs

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18
Q

When is referral acceptable to secondary care

A
  • generally depends on the healthboard
  • one of the criteria may be thta step 1/2 have been attempted in primary care, and re-evaluated prior to referral
  • there is also the option of private referral, px should always be given this option
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19
Q

What are common initial complaints periodontal patients may inform you of at their maintenance reviews

A
  • bleeding on brushing
  • sensitivity
  • black triangles
  • problems with OH routine
  • mobility
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20
Q

A patient may ask you of the tx options for non-responding sites. What are these

A
  • Nothing
  • Repeated subgingival instrumentation with/without adjunctive therapy
  • access flap (periodontal surgery)
  • resective periodontal surgery
  • regenerative periodontal surgery
  • XLA
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21
Q

What are the stages of periodontal treatment (not S3 guidelines, but came up in BDS4 tutorials so best to know I guess)

A
  1. disease control phase (PMPR)
  2. re-evaluation
  3. reconstructive
  4. mainteance
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22
Q

What are sites that are most likely to require surgical tx (access flap)

A
  • deep residual pocketing
  • angular bone loss
  • furcation disease
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23
Q

What are the periodontal emergencies

A
  • gingivalmabscess
  • periodontal abscess
  • perio-endo abscess
  • acute herpetic gingivostomatitis
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24
Q

How should you tx a gingival abscess

A
  • drain, irrigate, 0.2% CHX mouthwash
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25
Q

What is the tx for a periodontal abscess

A
  1. subgingival PMPR short of the base of the pocket
  2. drain and incise abscess
  3. Recommend optimal analgesia
  4. AB for px with systemic symptoms
  5. CHX 0.2% twice daily until acute symptoms subside
  6. review for definitive periodontal tx
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26
Q

What are the symptoms of perio-endo lesions

A
  • deep periodontal pockets reaching close to apex
  • negative/altered response to pulp sensibility tests
  • bone resorption in apical/furcation area
  • spontaneous pain
  • pain on palpation/percussion
  • perulent exudate
  • tooth mobility
  • sinus tract
  • crown and gingival colour alterations
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27
Q

What is the tx for perio-endo lesions

A
  • carry out endo tx
  • use of 0.2% CHX mouthwash to manage acute symptoms
  • review within 10 days and carry out sub/supra PMPR as necessary
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28
Q

What is tx for NUG/NUP

A
  • ultrasonic debridement - helps remove necrotic tissue and disease causing bacteria to stimulate healing
  • 0.2% CHX or 6% hydrogen peroxide mouthwash and soft toothbrush. No smoking
  • Possible AB prescription
  • smoking cessation etc (risk factor control)
  • refer if no resolution/underlying health conditions
  • supra/sub gingival PMPR for those with NUP
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29
Q

Why is hydrogen peroxide mouthwash useful in px with NUP/NUG

A

it has a bubbling action that can help get rid of necrotic tissue

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30
Q

What AB for NUG/NUP

A

same as pericoronitis
metronidazole 400mg 9 tablets TID

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31
Q

Why is metronidazole the drug of choice for NUP/NUG

A
  • anaerobic bacteria
  • metronidazole targets these effectively
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32
Q

When should AB be prescribed for NUG/NUP

A

systemic symptoms only
otherwise self limiting

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33
Q

What are cautions with metronidazole

A
  • alcohol use - nausea, stomach pain, etc
  • breast feeding
  • warfarin - potentiates warfarin
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34
Q

1999 periodontal classification

A
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35
Q

2017 classification

A
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36
Q

What were the problems in the 1999 classification that lead to the 2017 one

A
  • difficult to identify aggressive periodontitis vs chronic - didn’t seem to relate age to it
  • no diagnosis for gingival health- one bleeding site meant gingivitis
  • didn’t leave room for diagnosis of previous periodontits
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37
Q

Limitations of BPE

A
  • screening tool only
  • limited value in patients who have already been diagnosed with periodontitis - importance of the interproximal attachment loss
  • cant be used on implant patients
38
Q

Although 4mm is the threshold for active disease, what else should we consider

A
  • deeper pockets of 5/6mm in the absence of bleeding do not always represent active disease, particularly soon after periodontal tx
  • excise clinical judgement
  • quite importance in the context of moving a patient to step 3/4
39
Q

Define gingival health

A
  • <10% BOP
  • physiological bone levels 1-3mm apical to CEJ
40
Q

What is plaque induced gingivitis defined as

A

can be on intact/reduced periodontium
no BL
no IP attachment loss

41
Q

What are examples of non-plaque induced gingival diseases

A
  • hereditary gingival fibromatosis
  • herpetic gingival stomaitits
  • candida albicans (immunosuppressed)
  • lichen planus
  • mucous membrane pemphigoid
  • vitamin C deficiency
42
Q

What are the symptoms of necrotising gingivitis

A
  • necrosis and ulcers on interdental papillae
  • gingival bleeding
  • pain
  • pseudomembrane formation
  • halitosis
  • extraoral/regional lymphadenopathy/fever
  • no bone loss
43
Q

What are the symptoms of necrotising periodontitis

A
  • in addition to the NG symptoms, bone loss, periodontal attachment loss, frequent extra oral signs
  • bone sequestra in IS
44
Q

Give examples of conditions that result in periodontitis as a manifestation of the systemic disease

A
  • hypophosphatasia
  • down’s syndrome
45
Q

What are exampels of systemic diseases that affect the periodontal tissues

A
  • squamous cell carcinoma
46
Q

What are causes of periodontal abscess in a pre-existing periodontal px

A
  • undiagnosed periodontits
  • non-responsive to tx
  • post-scaling
  • post-surgery
47
Q

What are causes of periodontal abscess in non-periodontitis px

A
  • impaction - e.g toothpick or rubber dam stuck
  • harmful habits e.g nail biting
  • orthodontic forces
  • gingival overgrowth
  • alteration of root surface e.g root fracture
48
Q

What is the classification of periodontal endo lesions

A
49
Q

What are examples of mucogingival deformities

A
  • gingival recession
50
Q

What is the classification of gingival recession

A

type 1 - buccal recession only
type 2 - buccal recession > IP recession
type 3 - IP recession > buccal recession

type 1 best prognosis for tx

51
Q

What is the impact of the inflamed GM

A
  • bleeds during operative procedures
  • unstable apicocoronal location
  • makes effective restorative dentistry impossible
52
Q

What is supracrestal attached tissues

A
  • composed of junctional epithelium and supracrestal connective tissue attachment
  • 2mm
  • placing a restoration more than 0.5mm into the sulcus will infringe on the supracrestal attachment
53
Q

What are the outcomes of encroaching on the supracrestal attachment

A
  • persistant inflammation
  • loss of attachment
  • pocketing
  • recession
54
Q

Describe how poorly controlled diabetes increases PD risk

A
  • hyperglycemia may increase activation of RANKL contributing to alveolar bone reduction
  • hyperglycaemia increases inflammation, activating the immune system further
55
Q

What test is best done to check for diabetic control

A
  • HbA1c
56
Q

What is the ranges for HbA1c for normal vs for diabetic

A

normal <6% (42mmol/mol)
diabetic >6.5% (48mmol/mol)

57
Q

What are tests that can be done for diabetes

A
  • random plasma glucose test - >11.1mmol/L on 2 occasions = diabetic
  • glucose tolerance test - fixed amount of glucose taken and response monitored (11.1mmol/L after 2hr diagnostic)
  • fasting glucose test = blood sugar from fasting px. 7mmol diagnostic
58
Q

What value of Hba1c indicates poor control

A

> 58mmol/mol

59
Q

What is HbA1c testing

A

glycated haemoglobin
measures the amount of blood sugar (glucose) attached to your hemoglobin

60
Q

What is the effect of smoking on periodontal health

A
  • vasoconstriction of gingival vessels
  • increased gingival keratinisation
  • impaired antibody production
  • impaired PMN function
  • increased production of proinflammatory cytokines
61
Q

What may probing depths be influenced by

A
  • resistance of tissues
  • size/shape of probe
  • site/angle of probe insertion
  • pressure applied
  • presence of obstructions
  • px discomfort
62
Q

What is an increase in attachment post subgingival PMPR due to

A
  • long junctional epithelium formation and improved tissue tone (inflammatory infiltrate replaced by collagen)
  • greatest change observed 4-6 wks
  • gradual repair 9-12 months
63
Q

Why is it important that AB are only used with mechanical therapy

A

biofilm disease - AB won’t penetrate biofilm to reach bacteria
mechanical therapy will reduce bacterial load and disrupt biofilm making them more available for the AB

64
Q

What bacteria are involved with NUG/NUP

A
  • provetalla intermedia
  • fusobacterium
  • treponema
  • selenomonas
65
Q

What are risk factors for NUG/NUP

A
  • stress
  • immunosuppression e.g HIV
  • malnutrition
  • sleep deprivation
  • poor OH
  • smoking
66
Q

Risk factors for perio-endo lesions

A
  • exposed dentinal tubules at ACJ - can be due to trauma or could be natural anatomy. Allows bacterial infiltration to the pulp
  • lateral/accessory canals - some patients have these canals in the coronal third, more at risk of bacteirla infiltration here in periodontitis
  • furcal canals - direct communication between pulp and periodontium. not all extend full length to PDL.
  • apical foramen - main communication. portal of entry (periodontal pathogens –> RC system) and portal of exit (periradicular infection)
  • perforation
  • developmental groove (upper incisors most common) - covered by epithelial atachment but if breached, can become contaminated
67
Q

What is the 1972 classification for perioendo lesions

A
68
Q

How to grade furcation?

A
69
Q

How to grade mobility

A
70
Q

AB for periodontal abscess

A
  • phenoxymethylpenicillin (pen v) 250mg x 2 (500mg) dose 4xday for 5 days
71
Q

What is the antibiotic regimen for NUG/NUP

A
  • 400mg metronidazole TID 3 days
    or
  • 500mg amoxycillin TID 3 times daily
72
Q

What is the systemic AB prescription for young people with grade b/c periodontitis

A
  • 400mg metronidazole 3 times a day for 7 days
73
Q

What is a periodontal abscess

A
  • infection in periodontal pocket
  • can be acute/chronic
  • neutrophils increased, increased destruction, poor prognosis for tooth
74
Q

Effect of smoking on PD

A

o Has an effect on the oral microbiota, encourages the shift to anaerobic bacteria
o Increased activation of the immune system which encourages inflammation and tissue destruction
o Decreased healing capacity due to reduced blood flow

75
Q

Effect of diabetes on PD

A

o Hyperglycemia in diabetes may modulate RANKL:OPG ratio and contribute to alveolar bone destruction
o In hyperglycemia, production of AGE (advanced glycation end products) increase inflammation

76
Q

```

~~~

Diabetic factors that impact PD

A

o Degree of diabetic control
o Age of onset
o Duration of disease

77
Q

Analysing diabetic control

A

HbA1c give an indication of the average blood glucose level in the last 8-12 wks
48mmol/mol or >6.5% is diabetic, between 48-58 is considered good control
>58mmol/mol indicates poor control and at risk of diabetic complications

78
Q

Effect of obesity on PD

A

o Lack of nutrients can be a risk factor as can decrease function of the immune system
o Obesity can also have a proinflammatory effect which can encourage the periodontal disease

79
Q

What drugs cause gingival enlargement

A

o Anticonvulsant: phenytoin
o Immunosuppressant: cyclosporin
o Calcium channel blockers (nifedipine, amlodipine)

80
Q

How do drugs cause gingival enlargement

A

The interaction between the drug and host fibroblasts results in an increased deposition of connective tissue supporting a hyperproliferative epithelium
Good OH reduces the risk of this

81
Q

What systemic diseases are a risk factor for PD

A

o Papillon-Lefevre syndrome
o Down syndrome
o HIV infection
o Scurvy
o Pregnancy

82
Q

How is PD a risk factor for CV disease

A

o Bacteria from the diseased pockets under the gums can enter the blood stream and can trigger low levels of inflammation in the blood stream and body in general
o Across the lifetime this seems to increase the risk of developing heart disease
o It is unclear whether the increased risk is due to gum disease or shared risk factors including lifestyle factors such as smoking
o Thought that the endothelium is inflamed from activation of the immune system due to periodontal disease (indirect effect) resulting in the endothelium showing adhesions which can encourage circulating bacteria to adhere and initiate direct inflammation which can encourage processes such as atherosclerosis and hypertension

83
Q

How is PD a risk factor for pregnancy

A

Periodontitis may be a risk for preeclampsia in a similar mechanism to the one for CV disease

84
Q

How is PD a risk factor for RA

A

o Already activation of the immune system in rheumatoid arthritis
o The immune system is reacting to self tissue of the cartilage joints
o The theory is that if there is additional activation from the immune system due to the periodontal disease, then the response to the cartilage is stronger

85
Q

How is PD a risk factor for Alzheimers

A

o Activation of the immune system from periodontal disease can encourage production of plaques and tangles

86
Q

How is PD a risk factor for diabetes

A

o Studies have shown that periodontal infection may impair glycaemic control by increasing insulin tissue resistance

87
Q

What is a gingival abscess

A

o Localized to gingival margin
o Often caused by trauma, food impaction, recent surgery which can result in localized infection on the gingiva but is not associated with periodontal disease

88
Q

What is a periodontal abscess

A

o Usually related to pre-existing deep pocket also associated with food packing and tightening of gingival margin post HPT
o This is because after initial therapy, you can get tightening of the gingiva coronally resulting in less flow of plaque, toxins and neutrophils out of the gingival crevice resulting in acute infection

89
Q

What is a pericoronal abscess

A

o Associated with partially erupted teeth

90
Q

What is an endodontic-periodontal lesion

A

o Tooth is suffering from endo and perio disease

91
Q

Signs and symptoms of periodontal abscess

A

o Swelling of gingival margin
o Pain
o Tooth may be TTP in lateral direction
o Deep periodontal pocket
o Bleeding
o Suppuration
o Enlarged regional lymph nodes
o Tooth usually vital (except perio-endo lesion)
o Commonly pre-existing periodontal disease

92
Q

Treatment of periodontal abscess

A

o Carry out careful subgingival instrumentation short of the base of the periodontal pocket to avoid iatrogenic damage, LA may be required
o If pus is present in the periodontal abscess, drain by incision or through the periodontal pocket
o Recommend optimal analgesia
o Do not prescribe AB unless signs of spreading infection or systemic involvement
o Recommend use of CHX until acute symptoms subside
o Following acute management, carry out definitive periodontal tx and arrange appropriate recall interval

BDS5 Periodontology OSCE (15 decks)

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