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Periodontology > Treatment Adjuncts and Perio Surgery > Flashcards

Treatment Adjuncts and Perio Surgery Flashcards

1
Q

What are the aims of step 3?

A

Treat those areas of the dentition not responding adequately to step 2 with the purpose of gaining further access to subgingival instrumentation, or aiming at regenerating or resecting this lesions that add complexity in the management of periodontitis.

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2
Q

What are the options for step 3?

A

Treatment adjuncts- local, systemic (in combination with subgingival PMPR).

Access surgery

Regenerative surgery

Furcation treatment options

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3
Q

What treatment adjuncts might be used locally?

A

Disinfectants- chlorhexidine (periochip)

Locally delivered antibiotics- dentomycin

May be indicated in unresponsive sites where surgery is contra-indicated or not desired
- adjuncts to PMPR.

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4
Q

What is Periochip?

A

Biodegradable gelatin matrix
2.5mg chlorhexidine gluconate
Insert into the pocket following PMPR- chlorhexidine is slowly released over 7 day period.

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5
Q

How effective is periochip?

A

Short improvements in PPD compared to subgingival PMPR alone

No significant differences in CAL
Insufficient data on bleeding and pocket closure.

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6
Q

What is Dentomycin periodontal gel?

A

2% minocycline gel
- acts to reduce the bacterial load of the pocket.
- Delivered via a syringe following subgingival PMPR, into the pocket.

requires 3-4 applications every 14 days.

Treatment should not usually be repeated within 6 months.

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7
Q

Is Dentomycin effective?

A

Can lead to short term improvement in PD and CAL compared to subgingival PMPR alone.

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8
Q

With regards to local antimicrobials, what does SDCEP recommend?

A

Not recommended for routine care and management of patients with a diagnosis of periodontitis.

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9
Q

With regards to systemic antimicrobials, what does SDCEP recommend?

A

Do not use adjunctive systemic antibiotic therapy for the routine care and management of patients with a diagnosis of periodontitis.

Consider referral to a specialist for those patients who would benefit from adjunctive systemic antibiotic therapy- those patients whose level of disease suggests a high susceptibility.

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10
Q

What is the mechanism of action of systemic antimicrobials?

A

Proposed to act by suppress the bacterial species responsible for biofilm growth, leading to a less pathogenic oral environment.

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11
Q

Why aren’t systemic antimicrobials recommended in all perio patients?

A

Antibiotic resistance
GI disturbance
Changes to the gut microbiome

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12
Q

Under what circumstances would systemic antimicrobials be considered?

A

Periodontitis grade C in younger adults where high rate of progression is documented.

Young patients with systemic risk factors that is causing a high rate of progression.

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13
Q

What systemic antimicrobials would be used?

A

400mg metronidazole TDS 7 days

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14
Q

What is host modulation therapy?

A

Uses local or systemic drugs as adjuncts to conventional periodontal treatment, with the aim of modifying the destructive aspects of the host inflammatory response to the microbial biofilm.

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15
Q

What drugs are used for host modulation therapy?

A

Periostat- sub antimicrobial dose doxycycline

Requires systemic medication over long period of time, which may impact on compliance.

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16
Q

With regards to host modulation, what is the SDCEP recommendation?

A

Not recommended for the routine care and management of patients with a diagnosis of periodontitis.

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17
Q

What is the general recommendations for periodontal surgery?

A

If deep residual pockets remain after step 1 and step 2- surgical treatment is effective but complex and should be carried out by dentist with additional specific training or by specialists in referral centres.

If secondary care no available in your area, we recommend repeated supra and sub-gingival PMPR with frequent supportive care.

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18
Q

Based on SDCEP guidelines, when might periodontal surgery be indicated?

A

In sites where good quality non-surgical perio treatment has not resolved periodontal pocketing and there is ongoing inflammation/infection.

Perio pocketing greater than or equal to 6mm.

In cases with suitable patient, tooth and defect factors
- No medical contra-indications
- Teeth of reasonable prognosis
- Infra-bony defects, furcation disease

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19
Q

What patient factors need to be taken into consideration for perio surgery?

A

Oral hygiene- less than 20% plaque and less than 10% margin bleeding.

Quality of maintenance available and patient access to it

Ability of patient to tolerate procedure

Likely patient compliance in terms of maintenance after surgery

Cost and patient acceptance

Aesthetic of the site and the potential for post-op recession

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20
Q

What tooth factors need to be taken into consideration for perio surgery?

A

Access to non-responding sites

Shape of defect

Prosthodontics/endodontic consideration

Tooth position/anatomy
- tilting
- over-eruption
- proximity of adjacent roots
- enamel pearls
- ridges/root grooves

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21
Q

What systemic/medical factors need to be taken into consideration for perio surgery?

A

Smoking- impairs wound healing, significantly reduces the chance of improvement from surgical intervention

Unstable angina, uncontrolled hypertension, MI/stroke within 6 months.

Poorly controlled diabetes

Immunosuppressed patients

Anticoagulants and antiplatelets

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22
Q

What operator factors must you consider for perio surgery?

A

Skill and experience- should be provided by dentists with additional specific training or by specialists in referral centres.

Access to tier 2 or tier 3 care

23
Q

What must you make the patient aware of during the consent process for perio surgery?

A

Reason for providing surgical treatment
Other treatment options available
Consequences of not providing surgery
Mature of the surgical procedure
Post-op consequences- pain, swelling, bruising, potential time off work, tooth sensitivity, failure to resolve the pockets, tooth mobility, non vitality, recession.
Requirement for ongoing post-op maintenance
Cost

24
Q

What steps are involved in access surgery/open flap debridement?

A

Assess site- good OH, still residual pocketing despite step 1 and step 2.

Full thickness flap raised to expose the root surface, periodontal bone and associated defect.

Defect granulation tissue remove and root surface curettage.

Suture and aim for primary closure- use monofilament suture to decrease plaque accumulation on the sutures.

Review patient one week alter to remove sutures
- hygienist appointment 6 weeks after surgery.

Then step 4 maintenance.

25
Q

When would you expect long-epithelial reattachment to the root surface to occur?

A

6-8 weeks post-surgery.

26
Q

What is regenerative periodontal surgery?

A

Tissue regeneration including bone and functional PDL formation, which could include the use of membranes and grafts, and the application of biologic agents.

27
Q

What are the indications for regenerative surgery?

A

Intrabony defects 3mm or deeper as assessed radiographically.

Class 2 or class 3 furcation defect

28
Q

What is guided tissue regeneration?

A

Place a barrier membrane +/- addition of bone-derived grafts into the bony defect.
- this acts as an osteo-inductive scaffold for the vascularisation and cell ingrowth from base of the defect.
- Need a membrane on top to prevent gingival epithelium or connective tissue from entering the bone defect.

29
Q

What is enamel matrix derivative?

A

Emdogain- tissue healing agent derived from porcine tooth germ.

Forms a matrix on the root surface that mediates production of cementum by modulation the wound healing process.

It can induce the regeneration of a functional attachment in periodontal procedures.

30
Q

Why treat furcation lesions?

A

Reasonable survival rates observed over 4-30 years.

Tooth retention after perio surgery more cost-effective than extractions and replacement with implant-supported prosthesis.

31
Q

What are the options for furcation surgery?

A

Regenerative surgery- class II furcations in upper and lower.

Root resection/root separation- usually for class III lesions or multiple class II lesions.

Tunnelling- class III lesions.

32
Q

What is required for root resection/root separation?

A

Good quality endodontic treatment

Good root separation as assessed radiographically- not possible with fused roots.

Remaining roots should not be hyper mobile

Remaining tooth structure should be restorable

Motivated patient, excellent OH, low caries rate

33
Q

What is tunnelling?

A

Bone and soft tissue recontoured to allow insertion of interdental brush.

34
Q

What are the risks associated with tunnelling?

A

Root hypersensitivity
Root caries

35
Q

What is access surgery also commonly referred to as?

A

Conservative approach

36
Q

What is resective surgery commonly referred to as?

A

Resective approach

37
Q

What is regenerative surgery also known as?

A

Reconstructive approach.

38
Q

What are the indications for mucogingival surgery?

A

Periodontitis lesions requiring reconstructive or regenerative treatment.

Mucogingival deformities that require periodontal plastic surgery- recession defects, reconstruction of papillae

Short clinical crowns where an increase in clinical crown height is required before restorations are constructed.

Removal of aberrant fern

Creation of a more favourable soft tissue bed pre-implant surgery

39
Q

What are the most common procedures for mucogingival surgery?

A

Free gingival graft- raise a split thickness flap to generate a connective tissue bed to graft on. Then harvest a graft from the palate and suture it in place.

Pedicle graft- expose the exposed root surface, then raise a split thickness flap from the tooth beside and rotate the flat laterally to cover the defect.

Connective tissue graft

40
Q

How can intra-bony defects be classified?

A

Classified by the number of walls that the defect encompasses.

1 wall
2 walls
3 walls

41
Q

What is the process of guided tissue regeneration?

A

Raise a full thickness flap
- observe the intrabony defect.

Bone graft and membrane placed in to defect
- bone graft can be from the same patient (autograft), from another person (allograft) or from an animal (xenograft).
- biomaterials- collagen, enamel matrix derivative (emdogain) or deproteinised bovine bon matrix.

Return flap and suture with black silk monofilament sutures to prevent plaque accumulation.

42
Q

What is a positive surgical healing outcome for access/resective surgery?

A

Long junctional epithelium formation.

43
Q

What is the surgical healing outcome for a grafting procedure?

A

New connective tissue attachments.

44
Q

What is gingival recession?

A

Apical migration of the gingival margin from the CEJ.

45
Q

What are the indications for treatment of gingival recession?

A

Poor aesthetics

Sensitivity

Difficult plaque control

46
Q

Describe the aetiology of localised recession?

A

Excessive toothbrushing

Traumatic incisor relationship

Habits- rubbing gingivae with fingernail/end of pencil/tongue, lip stud.

Anatomical- frenal pull, teeth out of alignment

47
Q

Describe the aetiology of generalised recession?

A

Ongoing periodontal disease or following resolution of inflammation after successful treatment

May also be because of ortho treatment

48
Q

What is the Cairo 2012 classification of gingival recession?

A

Recession type 1- no inter proximal tissue loss.

Recession type 2- inter proximal tissue loss not as significant as mid-buccal.

Recession type 3- Gingival recession associated with loss of inter proximal attachment.
- interpoximal tissue loss worse than mid-buccal.

49
Q

What are the treatment options for gingival recession?

A

Record magnitude of recession- clinically or study model and assess for progression on a regular basis.

Eliminate etiological factors- habits/remove piercings

OHI- single tufted brushes

Topical desensitising agents/fluoride varnish

Gingival veneer to cover exposed roots

Crowns (with crown lengthening surgery)

Mucogingival surgery- free gingival graft, pedicle graft, connective tissue graft.

50
Q

What would be considered a contraindication for mucogingival surgery?

A

If interproximal bone has been lost- full root coverage is not possible.

51
Q

What is crown lengthening?

A

Surgical crown lengthening aims to apically re-position the entire periodontal attachment including, usually, the alveolar bone.

52
Q

What are the indications for crown lengthening?

A

Increase the clinical crown height to give adequate retention for restorations

Expose enough clinical crown to allow a restorative ferrule to be achieved

Expose subgingical restoration margins/secondary caries/fractures

Correction of uneven gingival contour compromising aesthetics including excessive gingival display

53
Q

When should you refer?

A

Only after thorough non-surgical treatment

Highly motivated and engaged patients with good OHI and risk factor control

Non-smoker and no contraindicated medical history

Reasonable prognosis of tooth

Periodontology (7 decks)

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