Periodontology

Notes

Risk Factors

Tobacco and Periodontal Health

6 times more likely to show periodontal destruction

Poorer response to treatment

Increased risk of recurrence

• reduction in gingival flow
• impaired white cell function
• impaired would healing
• increased production of inflammatory cytokines enhancing tissue breakdown

Smokers often display :

• Greater calculus formation
• Higher mean probing pocket depth, moth sites with deep pockets
• Greater gingival recession
• Greater alveolar bone loss, furcation involvement
• Less bleeding on probing

Immunology of Periodontitis

• Sulcular and junctional epithelial cells
• Neutrophils / PMNs
• Complement system
• Cellular and humoral immune responses
• Chemical mediators of inflammation

IL-8 → chemoattractant, guide neutrophils into tissues via chemotaxis

C3a and C5a → blood vessels dilate, leaky, allow blood serum to enter tissues, carry innate defence proteins and cells

In periodontitis, defects in neutrophil function :

• Hyper-reactivity - excessive release of oxygen radicals and elastase
• Excess release of cytokines and chemokines e.g. IL-8, IL-1β, TNF⍺
• Defective chemotaxis

Re-chargeable power toothbrushes provide significant benefits over manual brushes in plaque removal

Ultrasonic instruments (> 25KHz) superior to sonic (< 25KHz) scalers

Hand instruments of choice for sub-gingival instrumentations : area-specific Gracey curettes - only one cutting edge, do not traumatize soft tissue wall of pocket

Desquamative Gingivitis

• Lichen planus
• Pemphigus
• Mucous membrane pemphigoid
• SLE

Gingival Overgrowth

• Irritation, plaque, calculus, repeated friction or trauma
• Medications e.g. CCB (amlodipine, nifedipine), immunosuppressant (ciclosporin) and anticonvulsant (phenytoin)
• Mouth breathing

Syndromic Periodontitis

• Papillon-Lefèvre syndrome
• Ehlers-Danlos syndrome
• Chédiak-Higashi syndrome

Aggressive Periodontitis

• Non-surgical debridement 1 week - max 2 weeks
•  Aggregatibacter Actinomycetemcomitans

(Churchill)

• Amoxicillin 500 mg TDS 7 days
• Metronidazole 400 mg TDS 7 days
• Periodontal surgery - to access the root surface (occasionally)

(BSP)

• Amoxicillin 250 mg TDS 7 days
• Metronidazole 200 mg TDS 7 days
• Doxycycline 100 mg OD 21 days (allergic to penicillin)

Necrotizing Periodontal Diseases

• Fuso-spirochaetal anaerobes
• Metronidazole 200 mg TDS 3 days

Periodontal Screening (BPE)

Dentition divided into 6 sextants

At least 2 teeth for a sextant to qualify for recording

Light probing force : 20 - 25 g

BPE for children : 6 index teeth

7 - 11 y/o : code 0 - 2 only

12 - 17 y/o : code 0 - 4*

Radiographic Periodontal Assessment

• Horizontal bitewings
• Vertical bitewings
• Periapicals
• Dental panoramic tomographs (DPT)

Bleeding on Probing (BOP)

• reflective of response to periodontal treatment
• useful indicator at reassessment stage

Classification of Probes

❶ First generation - conventional and hand held probes

❷ Second generation - pressure-sensitive probes, lack tactile sensitivity
❸ Third generation - computerized probes e.g. Florida probe, Foster-Miller probe, Toronto Automated probe
❹ Fourth generation - 3-dimensional probe
❺ Fifth generation - ultrasonographic probe

Silness & Loe Plaque Index

0 - no plaque
1 - thin film ✖ visible by naked eye, disclosing agent ✔
2 - moderate accumulation
3 - heavy

Diagnosis

Non-surgical Therapy

Side effects :

• ↑ gingival recession
• longer looking teeth (anterior)
• ↑ gaps between teeth (black triangles)
• ↑ sensitivity - toothpastes containing potassium salt, oxalates, arginine can reduce  dentine sensitivity
• soreness
• food packing

Periodontal Surgery

• Access for debridement
• Regenerative surgery
• Crown lengthening - scalpel / electrosurgery / soft tissue lasers
• Management of recession (mucogingival surgery)