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1
Q

what is periodontal disease

A

comprises a group of related conditions, both acute and chronic characterized by inflammation of the periodontal tissues in response to the presence of dental plaque.

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2
Q

what is gingivitis

A

Plaque-induced inflammation of the gingivae characterised by red, swollen tissues which bleed on brushing or probing

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3
Q

what is chronic periodontitis

A

Characterised by the destruction of the junctional epithelium and connective tissue attachment of the tooth, together with bone destruction and formation of periodontal pockets.

The disease progresses slowly and the amount of bone loss tends to reflect the age of the patient over time

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4
Q

What is aggressive periodontitis

A

A severe condition usually found in a younger cohort of patients, which may be associated with a familial history of aggressive periodontitis.

Disease progression is rapid and the degree of destruction of the connective tissue attachment and bone is severe, considering the age of the patient.

Plaque levels may be inconsistent with the level of disease seen

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5
Q

What is necrotising ulcerative gingivitis

A

Painful ulceration of the tips of the interdental papillae. Grey necrotic tissue is visible and there is an associated halitosis (see figure 5.8). The condition is termed necrotising ulcerative periodontitis (NUP) in the presence of connective tissue attachment loss and bone destruction.

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6
Q

What is periodontal abscess

A

Infection in a periodontal pocket which can be acute or chronic and asymptomatic if freely draining

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7
Q

What is perio-endo lesions

A

Lesions may be independent or coalescing and the bacterial source originates either in the periodontium or the root canal system

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8
Q

what is gingival enlargement

A

Thickening of the gingivae which can occur as a response to irritation caused by plaque or calculus, repeated friction or trauma, fluctuations in hormone levels or the use of some medications

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9
Q

What are the significant risk factors for periodontitis

A

smoking and diabetes

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10
Q

what is smoking thought to do

A

reduce gingival blood flow therefore suppressing the signs and symptoms of gingivitis, impair wound healing and increase production of inflammation mediating cytokines

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11
Q

how does diabetes effect periodontitis

A

Poorly controlled diabetes enhances the signs and symptoms of gingivitis and periodontitis and has an adverse effect on wound healing, making treatment more difficult.

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12
Q

what are other factors that increase severity of periodontitis

A 
Family history 
Stress 
Diet
Obesity
Osteoporosis
Rheumatoid arthritis
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13
Q

What medications result in a risk of gingival enlargement

A

calcium channel blockers (hypertension)
phenytoin (epilepsy)
ciclosporin (antirejection)

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14
Q

What are local risk factors that increase the risk of periodontal disease

A

calculus, mispositioned teeth, overhanging restorations and partial dentures

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15
Q

What should you do regarding risk factors

A

Ensure you have an up to date medical history for all patients.
Explain to patients who smoke the effect smoking can have on their oral health and general health. Direct patients to smoking cessation services
Explain to patients who have diabetes that poorly controlled blood sugar levels increase the risk of developing periodontal disease or worsening existing periodontal disease. Consider communicating with their GMP if necessary
Explain to all patients the benefits of a healthy, balanced diet to their overall health and oral health in particular
Ensure that patients who are pregnant are aware of their increased risk of developing pregnancy gingivitis. Highlight the need for more frequent visits for dental prophylaxis or, if required, supportive periodontal therapy during pregnancy.

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16
Q

when should dentate patients be screened for periodontal disease

A

at every routine examination

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17
Q

what does screening involve

A

probing of the periodontal tissues to assess the presence of bleeding on probing, plaque and calculus deposits and the depth of any gingival or periodontal pockets which may be present.

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18
Q

what is the probing force

A

25g which is equivalent to the force required to blanch a fingernail

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19
Q

why does bleeding on probing occur

A

inflammation of the periodontal tissues occurs in response to the presence of dental plaque microorganisms and results in bleeding on probing except in smokers where the inflammatory response is suppressed

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20
Q

what does the absence of bleeding in patients with a history of periodontitis suggest

A

an absence of bleeding on probing suggests that the tissues are now stable.

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21
Q

what is the BPE

A

simple and rapid screening tool

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22
Q

what does the BPE not provide

A

a diagnosis

does not tell you extent of the problem

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23
Q

what does BPE allow

A

it does indicate what further assessment and periodontal treatment is required

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24
Q

what probe is used for BPE

A

WHO CPITN

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25
why is the BPE not suitable for reassessment following treatment
it does not provide information about how the individual sites respond to treatment
26
what should patients be asked when doing BPe
ask if they are aware of any symptoms which may indicate the presence of periodontal diseases.
27
what is done in a full periodontal examination
involves the charting of recession, probing depths, bleeding on probing and mobility of every tooth. It is carried out using a calibrated periodontal probe such as the 15mm or PCP 12mm probe or the Williams 10 mm probe
28
what is the normal position of the GM
at the CEJ
29
where may the Gm be in healthy young patients or in cases where the GM is swollen
coronal
30
what are the main drivers for patients to seek treatment
. Patients may be concerned by the aesthetic implications of receding gums, also root surfaces may be sensitive, and these can be main drivers for them to seek treatment.
31
what is probing depth
probing depth is the distance from the gingival margin to the base of the pocket
32
Why can the position of the gingival margin change
The position of the gingival margin can change due to swelling or recession
33
what does the prevention of periodontal diseases and maintenance of the PD tissues rely on
on the ability and willingness of the patient to perform and maintain effective plaque removal
34
what is TIPPS
- Talk with the patient about the causes of periodontal disease and discuss any barriers to effective plaque removal - Instruct the patient on the best ways to perform effective plaque removal - Ask the patient to practice cleaning his/her teeth and to use interdental cleaning aids whilst in the dental surgery - Put in place a plan which specifies how the patient will incorporate oral hygiene into daily life - Provide support to the patient by following up at subsequent visits
35
What is the best way on delivering advise
through hands on demonstrations. Remember consent is required
36
What should you talk about with the patient
Talk with the patient about the causes of periodontal disease and why good oral hygiene is important. Talk with the patient about what he/she has to do to achieve good plaque removal.
37
What can be used when describing the causes of periodontal disease
Use of a visual aid may help patients understand the disease process and the effects of plaque on the periodontal tissues.
38
What do you say to patients when talking about what they have to do to achieve good plaque removal
Brush regularly using an effective technique. Use a fluoride-containing toothpaste and ‘spit don’t rinse’ during tooth cleaning. Clean interdentally once a day.
39
What should the manual and toothbrush heads be like
should be small and of a medium texture and should be changed when obvious signs of wear appear.
40
What toothpastes are more effective at reducing plaque
triclosan and a co- polymer
41
How should the interdental brush fit
snugly into the interdental space without the wire rubbing against the tooth.
42
How should you instruct
Instruct the patient in the use of the oral hygiene tools. Demonstrate, in the patient’s mouth while he/she holds a mirror, how to systematically clean each tooth using a toothbrush (manual or rechargeable powered) as well as how to use floss and/or interdental brushes. Confirm that the patient knows what to do. If he/she does not, show the patient again.
43
What should you do in practice
Ask the patient to practise i.e. to clean his/her teeth in front of you Ask the patient for some feedback.
44
why should you ask the patient to practice infront of you
* This provides an opportunity to correct the patient’s technique if required and ensures that the patient has really understood what he/she needs to do. * Confirming that the patient is doing the task well will boost confidence and also help him/ her to remember when at home.
45
why should you ask the patient for some feedback
Ask how his/her teeth feel, as clean teeth should feel smooth to the tongue. • Address any concerns the patient has if there is bleeding after brushing or interdental cleaning.
46
what should you do in the plan
Help the patient plan how to make effective plaque removal a habit. To act as an incentive for the patient, tell him/her that you will ask at the next visit
47
how can you help the patient make effective plaque removal a habit
Ask the patient when would be the best time for him/her to brush and clean interdentally. Suggest using another regular activity as a reminder – such as immediately before going to bed and after getting up.
48
what should you ask the patient at the enter visit
• “Have you tried using interdental cleaning aids?” • “How did your action plan work?”
49
How should you support the patient
Ensure you support the patient to achieve effective plaque removal by following-up on the advice at subsequent appointments.
50
How should you go about helping a patient to quit smoking
Ask the patient if he/she (still) smokes (or uses smokeless tobacco) and record the response Ask if the patient has considered the effect smoking has on his/her oral health and general health and the benefits of stopping. Ask if the patient is interested in stopping smoking. Offer patients who are interested in stopping smoking information on local smoking cessation services as these increase their chances of a successful quit attempt.
51
what should you say if the patient states they have given up smoking
If the patient states that he/she has given up, congratulate this achievement. Remind the patient that stop smoking services are always available if he/she is finding it difficult to remain a non-smoker.
52
what should you do if patient does not wish to stop smoking
Some patients may not wish to stop smoking; accept this in a non-judgemental way, but leave the offer of future help open if the patient changes his/her mind.
53
what should you say regarding other lifestyle factors
Evidence that a high sugar diet is a risk factor for dental caries and that a high level of alcohol consumption is a risk factor for cancer of the mouth, larynx, pharynx and oesophagus as well as many other chronic diseases. Emerging evidence also suggests that diet, obesity and level of physical activity are associated with periodontitis and that diet may influence the outcome of periodontal therapy.
54
what are the key recommendations in regard to the treatment of gingival conditions
- Ensure the patient is able to perform optimal plaque removal - Remove supra gingival plaque, calculus and stain and sub-gingival deposits - Ensure that local plaque retentive factors are corrected
55
what is plaque induced gingivitis
Gingivitis is plaque induced inflammation of the gingivae characterized by red swollen tissues that bleed on brushing or probing.
56
what is gingivitis not associated with
with apical migration of the junctional epithelium or connective tissue attachment loss and alveolar bone destruction.
57
when re clinical signs visible
after around seven days of undisturbed plaque accumulation and the severity of the inflammatory response is greater in older people than in the young. The condition is reversible after the establishment of effective plaque removal.
58
What should you say to patients regarding gingivitis
Explain to the patient that untreated gingivitis is a risk factor for periodontitis, which can lead to tooth loss, but that he/she can reduce this risk with good oral hygiene. Remove supra-gingival plaque, calculus and stain and sub-gingival deposits using an appropriate method Ensure that local plaque retentive factors are corrected Re-assess at a future visit to determine whether the gingivitis has resolved.
59
what should you do for patients regarding drug induced enlargement
Where there is mild gingival enlargement, use the Oral Hygiene TIPPS Remove supra-gingival plaque, calculus and stain and sub-gingival deposits using an appropriate method. Highlight to the patient the areas where supra- gingival deposits are detected. Ensure that local plaque retentive factors are corrected Where the gingival enlargement hinders adequate plaque removal or interferes with the normal function of the oral cavity, consider consulting the patient’s physician or referring for specialist periodontal care.
60
What is pregnancy-associated ginvitis
The changes in hormone levels and to the immune response associated with pregnancy have been implicated in the development or worsening of gingivitis.
61
how should you deal with pregnancy associated gingivitis that is mild
Where the condition is mild, use the Oral Hygiene TIPPS behaviour change strategy to highlight the importance of effective plaque removal and to show the patient how she can achieve this Ensure that local plaque retentive factors are corrected - for example, remove overhanging restorations or alter denture design Explain to the patient that the condition is likely to resolve once her baby is born or following the cessation of breastfeeding, assuming her oral hygiene is adequate.
62
how should you deal with pregnancy associated gingivitis that is severe
Give oral hygiene and smoking cessation advice as detailed above. Remove supra-gingival plaque, calculus and stain and sub-gingival deposits using an appropriate method. Highlight to the patient areas where supra- gingival deposits are detected. These patients may require more frequent recall visits during pregnancy and additional care. Ensure that local plaque retentive factors are corrected - for example, remove overhanging restorations or alter denture design Explain to the patient that the condition is likely to resolve once her baby is born or following the cessation of breastfeeding, assuming her oral hygiene is adequate
63
What is puberty associated gingivitis
Gingivitis is commonly observed in pre-teens and young teenagers where the increased inflammatory response to plaque is thought to be aggravated by the hormonal changes associated with puberty
64
how should you deal with those that have puberty associated gingivitis
use the Oral Hygiene TIPPS behaviour change strategy to highlight the importance of effective plaque removal and to show the patient how he/she can achieve this Remove supra-gingival plaque, calculus and stain and sub-gingival deposits nsure that local plaque retentive factors which may hinder oral hygiene efforts, such as overhanging restorations, are corrected Where the gingival enlargement hinders adequate oral hygiene or interferes with the normal function of the oral cavity, consider referring to a consultant in paediatric dentistry, consultant in restorative dentistry or specialist periodontist.
65
what is unexplained gingival enlargement
inflammation and bleeding can be a sign of undiagnosed leukemia in children and adults In cases where the gingivitis or gingival enlargement does not respond to treatment as expected or the extent of the condition is inconsistent with the level of oral hygiene observed, consider urgent referral to a physician
66
what are the key recommendations of treatment of periodontal conditions
• Ensure the patient is able to perform optimal plaque removal. • Remove supra-gingival plaque, calculus and stain and correct any local plaque retentive factors. Carry out root surface instrumentation at sites ≥4 mm probing depth where sub-gingival deposits are present or which bleed on probing. • Do not use antimicrobial medication to treat chronic periodontitis.
67
where does non-surgical periodontal therapy begin
it begins by motivating and instructing the patient in adequate self care, followed by re-evaluation of his/her level of oral hygiene.
68
what does non surgical instrumentation do
disrupt the plaque biofilm and remove calculus to give a clean, smooth tooth/root surface can then be completed both supra- and sub-gingivally
69
What is the key to success in the treatment of periodontal conditions
Key to the success of non-surgical periodontal therapy is regular re-enforcement of oral hygiene advice, regular, effective removal of the plaque biofilm38-41 and, where applicable, smoking cessation advice to bring about a life-long change in patient behaviour.
70
what is the goal of non surgical periodontal treatment
to achieve signs of periodontal stability which are easy to sustain
71
what are the optimal outcome of plaque scores
below 15%
72
what are the optimal outcome for bleeding
below 10%
73
what is the optimal outcome of probing depths
less than 4mm
74
What should the dentist do regarding treatment of periodontal conditions
explain to the patient the potential benefits of successful treatment explain to the patient their role in improving periodontal health use the TIPPS strategy remove supra gingival plaque, calculus and stain carry out RSI at sites of >4mm probing depth where sub gingival deposits are present or which bleeding on probing. local anaesthetsia may be required for this. only instrument sites of <4mm probing depths where sub-gingival deposits are detected advise the patient that they may experience some discomfort and sensitivity following treatment and to expect some gingival recession as a result of healing carry out a full PDE
75
what is the cleaning of subgignival root surface called
the cleaning of sub-gingival root surface is termed root surface instrumentation (RSI). It can equally be called root surface debridement (RSD)
76
what does the technique of RSI aim to do
This technique aims to mechanically remove microbial plaque and calculus without any intentional removal of the root surface. However, it is accepted that since root surface instrumentation is conducted blind, some removal of the root surface cementum may inadvertently occur.
77
how can RSI be done
using hand instruments or powered scalers (sonic or ultrasonic)
78
how is successful utilization of instruments done
Successful utilization of these instruments requires a thorough understanding of root anatomy and knowledge of which instrument works best in a particular area.
79
how should the tips of the sonic and ultra sonic be used
use only the sides of the working tip for debridement without applying lateral pressure use overlapping strokes to instrument all of the affected root surface.
80
how are instruments maintained
Overtime the cutting edge of the blade may dull. The hand instruments require meticulous maintenance to ensure that they remain fit for purpose.
81
how long should treatment be
The time taken to instrument each tooth will depend on the level of deposits, the tooth type, the depth of the pocket, whether there is furcation involvement, the presence of challenging anatomy and the location in the mouth. It can take several minutes of instrumentation to effectively debride the root surface adjacent to a deep pocket around a single tooth.
82
why may patients experience pain during RSI
due to root surface sensitivity and also because the base of pockets can be inflamed and painful
83
what is not advised regarding appointment planning
It is not advised to adopt a process of removing some deposits from all root surfaces at one appointment with the intention to revisit and remove remaining deposits at subsequent appointments.
84
why should you not remove some deposits in one appointment and leave some
This is because initial healing, after the gross deposits have been removed can make re-accessing the pocket more difficult and partial removal of deposits leaves behind rough areas which are ideal for bacterial proliferation. It is advised that the clinician concentrated on as many teeth, sextants or quadrants as can be thoroughly instrumented in the time available.
85
what are examples of local plaque retentive factors
mal positioned teeth, overhanging restorations, crown and bridgework, partial dentures and fixed and removable orthodontic appliances
86
what should you do regarding local plaque retentive factors
Explain to patients with local factors such as crowded teeth, partial dentures, bridgework and orthodontic appliances, the importance of plaque removal in these areas. Give instruction on how to clean adequately around fixed restorations and fixed appliances and how to clean removable prostheses. Ensure that fixed and removable appliances are well-designed and that they are a good fit. Modify overhanging or poorly contoured restorations or replace the restoration. Consider orthodontic treatment or extraction for mal-positioned teeth.

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