Periodontics Finals Revision PDF

**[Periodontics Finals Revision]** Signs of ginigival health: - Gingiva is pink and firm - Interdental papillae are pyramidal - Gingiva is keratinised and stippling present - Gingival crevice depths are 3mm or less Histology - Non-keratinised junctional epithelium cells are attached...

**[Periodontics Finals Revision]** Signs of ginigival health: - Gingiva is pink and firm - Interdental papillae are pyramidal - Gingiva is keratinised and stippling present - Gingival crevice depths are 3mm or less Histology - Non-keratinised junctional epithelium cells are attached to the tooth surface by basal lamina and hemidesmosomes - Non-keratinised squamous cell epithelia line the gingival crevice - Keratinised oral epithelium extending from the free gingival margin to the mucogingival line Risk Factors of Perio - Local - Calculus - Enamel pearls - Crowding - Overhanging restorations - Removable partial dentures - Furcation involvement - Traumatic occlusions - Akerly classification: System used to describe enamel projections or extensions that can contribute to furcation involvement or perio - Type I: a small enamel projection that doesn't reach the function - Type II: an enamel projection that extends close to furcation but doesn't enter it - Type III: extends into the furcation, potentially contributing to periodontal breakdown - Systemic - Smoking - Impairs WBC function - Reduces gingival blood flow - Impacts wound healing - Diabetes - Adversely affects wounds healing and increased susceptibility to infection - Genetics - Hypo and hyper responsive host responses to presence of subgingival plaque - Hormonal change - Pregnancy - Puberty - Drugs - Phenytoin - Cyclosporin - CCBs - Can all cause gingival hyperplasia - Age - Stress - Predisposes to necrotising - Systemic diseases manifesting periodontal disease - Papillon-Lefevre syndrome - Ehlers-Danlos syndrome - Chediak-Higashi syndrome - Neutropenias - Langerhans cell histiocytosis - Down's syndrome Basic Periodontal Exam - Assesses a patient's periodontal status - Uses a WHO periodontal probe of: - 0.5mm diameter ball end - Coloured band extending 3.5-5.5mm from the tip - Second band is 8.5-11.5mm - Score of 3 requires PPDs in that sextant - Score of 4 requires full mouth PPDs - Take radiographs if code 3, 4 or \* - Exceptions: - 8s not included unless 6s/7s missing - Not suitable for implants - Instead to a 6-point pocket chart - If sextant has one tooth, include in adjacent sextant - Force of 20-25g applied - BPE code: - 0 - No pockets \>3.5mm, no calculus, no BOP - No treatment required - 1 - No pockets \>3.5mm, no calculus but BOP - Treatment= OHI - 2 - No pockets over 3.5mm, but either calculus (supra or sub) or a plaque-retentive factor is present - Treatment= OHI +/- calculus removal or correction of plaque retentive restoration - 3 - Pockets 3.5-5.5mm deep - Treatment= initial therapy (OHI, risk factor control smoking cessation advice, scale, correction of plaque-retentive factor) and then 6 point pocket chart in that sextant alone - 4 - Pockets \>5.5mm - Treatment= initial therapy as for 3, then full mouth PPDs, subgingival PMPR +/- referral to a periodontal specialist - \* - Loss of attachment \>7.5mm or a furcation involvement Simplified BPE in CDH - Simplified BPE for 7-11 year olds - Codes 0-2 - Full range of codes for 12-17 year-olds - Only include: - All 6s - UR1 - LL1 - To avoid problem of false pocketing, gingival stability not usually achieved until 16yo - Refer to specialise if: - Signs of aggressive perio - Pt not responding to treatment for chronic perio - Child has systemic diseases associated with perio - MH significantly affects periodontal treatment - Cases requiring evaluation - Periodontal surgery - DIGO - Drug-induced gingival overgrowth Furcation Involvement - Management - None - OHI, PMPR, monitor - Tunnel preparation - Furcationplasty - Hemisection - Root resection - XTN - Bone graft - Classification of furcation involvement - I - Horizontal attachment loss \3mm deep but not through and through - III - Complete horizontal attachment loss "through and through" destruction BSP Flowchart - Stable - BoP\4mm with BoP New Grading - Course of action in a patient with code 3: - Radiographs - Initial perio therapy - Review in 3months and PPDs in involved sextants - If pockets \4mm, treat as code 4 - Pt has 29 teeth and \>4mm in 65% PPDs - Diagnosis - Generalised periodontitis - 113/174 points affected with \>4mm pockets - \>30% teeth affected - If just molars and incisors were affected, dx would be molar-incisor periodontitis - How to grade - rate of progression of disease - \% bone loss (at greatest point due to perio- not post XTN sites) divided by age Gingival Crevicular Fluid - Serum exudate derived from ginigva and periodontal ligament - Mediated by bacterial products from subgingival plaque - Diffuse intercellularly and accumulate adjacent to buccal mucosa of junctional epithelium - Creates an osmotic agent - During inflammation, gingival crevicular fluid becomes more like an inflammatory exudate, delivering local components of the inflammatory process into the pockets - This helps flush bacteria and debris from the sulcus, containing immune components that help in host defence - Proportions depend on: - Presence and composition of plaque - Rate of turnover of gingival connective tissue - Permeability of epithelia - Degree of inflammation Aetiology of Periodontitis - PLAQUE - Disease is initiated and maintained by substances produced by microorganisms within the plaque biofilm - Inflammatory response creates a pocket; ideal environment for microbial colonisation - Provides nutrients, low O2 levels and high CO2 levels - Established periodontitis is associated with anaerobic gram -ve rods - To colonise on smooth tooth surfaces, microorganisms require an acquired pellicle - Think layer of salivary glycoproteins - Biofilm: - A collection of organisms; held together with a matrix structure, on a surface interface - Microorganisms are more resistant to attack - Strength is greater in numbers - Phenotype can change in biofilms - Slow growth (due to lack of nutrients) means antimicrobials targeting growth are ineffective - Re-dox potential of biofilm deactivates antimicrobials - Anaerobic bacteria predominate in the deeper layers (as O2 used by superficial bacteria) - Bacteria in biofilm formation can be up to 1000x more resistant to antimicrobials than planktonic bacteria Pathogenesis of Periodontitis - Initial lesion - 24 hrs: vasodilation and increased vascular permeability of adjacent tissues - 24 days: increased GCF flow releases antibodies and protease inhibitors - Early lesion - After 1 week: erythema due to increased vasculature, lymphocytes and neutrophils are predominant - Collagen fibres break down to create space for more neutrophils and lymphocytes - Established lesion - Junctional epithelium begins to lose contact with enamel - After 21 days, junctional epithelium converts to pocket epithelium Toxins - Polymorphonuclear leukocytes (PMNs) are the predominant defence cells against plaque bacteria - If they contain the infection, periodontal destruction is less likely - They produce collagenases (MMP which breaks down the protein collagen in the tissues), enzymes and inflammatory mediators - Harmful toxic substances released by bacteria: - Leukotoxin - Ammonia - Sulfuric acid - Butyric acid - LPS endotoxin - Bacteriocins Clinical Attachment Loss (CAL) - Measurement of the apical cell of the junctional epithelium in relation to the cemento-enamel junction - CAL= probing depth+ recession - Mild - 1-2mm - Moderate - 3-4mm - Severe - \>5mm - False pocketing can rise when gingival margin expands coronally - E.g. drug-induced inflammation - Despite crevice deepening beyond 3mm, apical cell of junctional epithelium remains at the CEJ and there is no CAL Radiographs - PAs are gold standard - Obtain a 2D pic of bone level in relation to CEJ and tooth root length - DPTs are indicated in complex cases where there are a variety of dental concerns - Can supplement DPT with PAs in anterior sextants as these areas often distorted - Horizontal BWs show early bone loss - To reduce dosage of radiation: - Collimation (esp to parotid glands and orbit) Root Surface Instrumentation - Non-surgical management of periodontal disease - Supplemented with smoking cessation (*ask, advise, assess, assist, arrange)*, OHI and initial gross scale - Aims: - Eliminates endotoxins - Disrupts biofilm - Removes subgingival calculus - Healing post-op: - 1-8 hours - Acute inflammatory reaction - 1-2 days - Epithelial reattachment at base of pocket - Adheres to root surfaces via hemidesmosomes and cementum - 3-6 weeks - Formation of collagen replacing granulation tissue - Reduced probing depths - Several months - Continued maturation of connective tissue and possible bony infil Local Adjuncts - CHX 0.2% - Check for allergy! - Bacteriostatic at low concs - Bactericidal at high concs - Disrupts negatively charged cell walls - Reduces bacterial counts within saliva by 50-90% - Can cause staining and taste disturbace - PerioChips - 5mm long- can't be placed in pockets \