Transcript for:
Understanding Periodontium and Its Diseases

Title: URL Source: blob://pdf/43eaefb4-c689-4a3d-8d07-b3fe5cb0b527 Markdown Content: Perio - FINAL Chapter 1 1. Tissues of the periodontium & main function Structure Main Function Gingiva - Provides tissue seal around the cervical portion of teeth - Protects the underlying tooth -supporting structures Periodontal Ligament (PDL) - Suspends and maintains the tooth in its socket - Refer to Functions @ end of document * Cementum - Anchors the ends of PDL fibers to teeth so the tooth stays in its socket - Protects the dentin / blocks dentinal tubules Alveolar Bone - Surrounds and supports the roots of the tooth 2. Different characteristics associated with diseased and healthy tissues State JE Connective Tissue Attachment Periodontal Ligament Fibers Alveolar Bone Health JE Coronal to CEJ Tight Intercellular junctions Intact; supragingival fiber bundles provide support to gingiva and JE Intact; attach root to the bone of the tooth socket Intact; supports and protects root of tooth Gingivitis JE at CEJ Widened intercellular junctions Epithelial extensions into connective tissue CT damage Intact Intact Periodontitis JE apical to CEJ Widened intercellular junctions Epithelial extensions into CT Destruction of supragingival fiber bundles Destruction of periodontal ligament fibers Exposure of cementum to pocket environment Destruction of bone Eventual tooth loss 3. Difference in desmosome and hemidesmosome a. Desmosome: connects epithelial cells to other epithelial cells i. (cell -to -cell junction) b. Hemidesmosome: connects epithelial cells to another basement membrane i. Cell -to -basal Lamina 4. JE and its functions a. Specialized epithelium forms base of sulcus & joins gingiva to tooth; base of sulcus made of coronal -most cells of JE; thin/nonkeratinized = easy point of entry for bacteria to invade connective tissue 5. Functions and types of the different gingival fibers a. Supra gingival fiber bundles (gingival fibers) - network of rope -like collagen fiber bundles in gingival connective tissue; located coronal to crest of alveolar bone; Sub gingival fiber bundles strengthen attachment of JE to tooth i. Together the JE & fibers are referred to as = Dentogingival unit b. Supra gingival fibers classified based on orientation, insertion site, & connected structures. i. (AG) Alveologingival fibers from periosteum of alv. bone crest into ging. connective tissue; attach ging. to bone ii. ( C ) Circular fibers encircle tooth in ring -like manner coronal to alv. crest & not attached to cementum of tooth iii. (DG) Dentogingival fibers embedded in cementum near CEJ & fan out into ging connective tissue; attach ging to teeth iv. (PG) Periosteogingival fibers extend laterally from periosteum of alv bone; attach ging to bone v. (IG) Intergingival fibers extend in mesiodistal direction along entire dental arch and around last molars in the arch; link adjacent teeth in the dental arch unit vi. (IC) Intercircular fibers encircle several teeth; link adjacent teeth in dental arch vii. (IP) Interpapillary fibers located in the papilla coronal to the transseptal fibers; connect oral and vestibular interdental papillae of posterior teeth viii. (TG) Transgingival fibers extend from cementum near CEJ and run horizontally b/w adjacent teeth, link adjacent teeth in dental arch ix. (TS) Transseptal fibers pass from cementum of one tooth, over crest of alv bone, to cementum of adjacent tooth; connect adjacent teeth & secure alignment in arch 6. Pathogenesis a. The sequence of events that occur during the development of a disease of abnormal condition 7. Characteristics and risk factors of gingivitis vs periodontitis also know the expected progression of both Gingivitis Periodontitis ** Most common form of Periodontal Disease** - May persists for years without progressing to periodontitis - Infection is confined to gingiva; no attachment loss; is REVERSIBLE - Presents within 4 -14 days after no flossing or brushing, depending on host Apical migration of JE; painless Disease is intermittent, inactive, and episodic *** Most common form of periodontitis, is Chronic Periodontitis *** 8. Active disease state vs stable a. Active continued apical migration of JE over time b. Inactive Stable; JE no longer migrating i. The majority of pockets in most adults are inactive 9. Chronic disease vs acute a. Acute gingivitis sudden onset & short duration; professional and self -care return gingiva to healthy state b. Chronic gingivitis long -lasting; may exist for years w/o progressing to periodontitis i. typically, painless and more commonly encountered than acute gingivitis 10. Position of the alveolar crest and gingival margin to the CEJ a. Free ging/ging margin coronal to CEJ b. Alv . crest 1-2mm apical CEJ c. What does the different positions of these mean? 11. Kinds of bone loss and their characteristics a. Patterns i. Horizontal More common 1. Gingival Connective Tissue > Alveolar bone > PDL Space ii. Vertical rapid progression, harder to treat, leaves trench -like area of missing bone along the root b. Infrabony Pockets ***** i. Base of the pocket/Je Apical to the crest of the bone 1. This type of pocket is seen on periodontitis 2. Vertical or angular bone loss pattern 3. Classified on the basis of the # of osseous (bony) walls remaining. c. Suprabony i. Base of the pocket/JE is coronal to the crest of the alveolar bone 1. This type is a result of tissue destruction that occurs in periodontitis 2. Horizontal bone loss pattern d. Interproximal i. Most common place for bone loss and periodontitis e. Furcation Involvement i. Only multirooted teeth; progresses rapidly 12. Characteristics of the different stages and grades of periodontitis Stages Interdental CAL Radiographic bone loss Tooth Loss Probing depth Bone Loss OTHER Stage I 1-2 mm Coronal 1/3 (>15% loss) NONE 4 mm or less Horizontal Stage II 3-4 mm Coronal 1/3 (15 -33% loss) NONE 5 mm or less Horizontal Stage III 5 mm or more Extending to the mid -1/3 of root or beyond 4 or less 6 mm or more Vertical (3 mm or greater) Stage IV 5 mm or more Extending to mid -third of root AND beyond 5 or more 6 mm or more Vertical (3 mm or greater) Need for complex rehabilitation > Grades Description > AStable; Low rate of disease over a 5 -years > -No evidence of CAL or radiographic bone loss > -Heavy biofilm deposits with low level of tissue destruction > -Modified by nonsmokers and normoglycemic patient > BModerate rate, less than 2 mm increase of CAL over 5 years > -Tissue destruction in line with expectations given amount of biofilm deposits > -Modified by smoking less than 10 cigarettes a day > -hbA1c of less than 7% in pt.s w/ diabetes > CRapid Rate, greater than 2 mm increase of CAL over 5 years > -tissue destruction EXCEEDS expectations given then amount of biofilm deposits > -Modified by smoking 10 or MORE cigarettes a day > -HbA1c of 7% or greater in pts with diabetes 13. Refractory VS. Recurrent periodontitis Refractory Recurrent -Unknown Etiology - Pt. being monitored & exhibits continued attachment loss despite - Receiving continuous professional therapy - Practicing effective self -care - Following recommended schedule for maintenance visits Treatment of the Refractory - Reviewing self -care - Scaling and root planning - Use of systemic and local antibiotics - Removal of hopeless teeth - Correcting restoration overhangs - Surgery - Frequent maintenance visits New signs of destructive perio that reappear after therapy, -because the disease was NOT adequately treated, -and/or the pt. did NOT practice adequate self -care > Return of destructive periodontitis that had been > previously arrested > > Anyone with a prior history of disease is at risk for > recurrence > > Happens especially with non -compliance and professional care 14. Most common form of periodontal disease a. Gingivitis this is REVERSIBLE 15. Know the characteristics of a pregnancy tumor b. Aka, Pregnancy Granuloma/ Pyogenic Granuloma c. Painless, non -cancerous tissue enlargement d. commonly found maxillary anterior papillary and gingival region. e. Bleeds easily if disturbed, regresses after giving birth. 16. Know the drugs that may cause gingival enlargement and the characteristics of this condition f. Anticonvulsants i. Phenytoin (Dilantin) Control seizures (50% cases) ii. Celontin g. Calcium Channel Blockers (nifedipine) (15% cases) i. Hypertension ii. Angina iii. Arrhythmias h. Immunosuppressants // antirejection therapy (30% cases) i. Cyclo sp orine Given to tran sp lant patients i. Sodium Valproate i. Depakene antidepressant/ anticonvulsant (RARE) 17. Know the following diseases. j. Primary herpetic gingivostomatitis i. Very Painful k. Erythema multiforme i. Disorder of skin and mucous membranes due to an allergic reaction or infection ii. Large symmetrical red blotches resembling a target all over the skin iii. Cause unknown, may involve hypersensitive reaction iv. Swollen lips often with crust formation v. Lesions on gingiva involve bullae that rupture leaving ulcers l. Lichen planus i. Common inflammatory condition that can affect the skin, hair, nails, and mucous membranes 1. Forms white lacy white patches, sometimes with painful sores 2. Is chronic and may last for several years 3. Six different types of Lichen Planus m. Gingival disease of specific bacterial origin i. Necrotizing Periodontal Diseases 1. (Treponema spp., Selenomonas spp., Fusobacterium spp., Prevotella intermedia, and others) ii. Gonorrhea (Neisseria gonorrhoeae) iii. Syphilis (treponema pallidum) iv. Tuberculosis (Mycobacterium tuberculosis) v. Streptococcal gingivitis (strains of streptococcus) 18. Modifying factors of dental plaque induced gingival disease a. Systemic -- Plaque initiates the disease and then specific systemic factors found in the host, modify the disease process 1. Puberty associated gingivitis elevation of Progesterone & Estrogen a. Plaque at gingival margins, no bone loss, intense inflammatory response 2. Menstrual Cycle Gingivitis a. Increased in Progesterone and estrogen i. Intense inflammatory response at interdental papilla, enlarged red papilla, Reversible after ovulation 3. Pregnancy - Associated Gingivitis // Pregnancy Granuloma a. Elevated Estrogen & Progesterone b. Plaque increased response c. Regresses after postpartum d. Increased tooth mobility / widened PDL e. Elevated Levels of Prevotella Intermedia (as seen in all hormonal associated gingivitis) 4. Diabetes Mellitus a. Due to changes in elevation of blood glucose levels (hyperglycemia) b. Common in children with uncontrolled type 1 diabetes 5. Leukemia -Associated Gingivitis (Associated with blood dyscrasia) a. Abnormal proliferation of white blood cells in blood and bone marrow b. Inflammation starts at papilla and spreads to attached gingiva c. An exaggerated response to plaque resulting in increased bleeding and tissue enlargement b. Medication i. Drug influenced gingivitis an exaggerated inflammatory response to dental plaque and a systemic medication 1. Oral Contraceptive Gingivitis a. Used to have high levels of estrogen and progesterone ii. Drug Influenced Gingival Enlargement An increase in size of gingiva resulting from systemic medications 1. Etiology Unclear // Excessive production of collagen by gingival Fibroblasts 2. Onset within 3 months // Exaggerated response of plaque // high occurrence in children Gingiva on anterior sextants most affected / First observed at interdental papilla 3. ***** KNOW MEDICATIONS PREVIOUSLY STATED*** a. Cyclosporine // Dilantin // Sodium Valproate // Calcium Channel Blockers c. Malnutrition i. Affects infants , Institutionalized elderly, Alcoholics 1. Ascorbic Acid Deficiency (Vitamin C) a. An inflammatory response to dental plaque aggravated by chronically low vitamin C levels i. Bright red, swollen, Ulcerated, bleeds easily 19. Gingival Pocket VS. Periodontal Pocket a. Gingival Pocket vi. A deepening of the gingival sulcus as result of swelling or enlargement of the gingival tissue 1. pseudo -pockets are when there is no apical migration of the JE 2. In gingivitis, however, the coronal portion of the JE detaches from the tooth resulting in slight increase of probing depth 3. Causes (1) detachment of the coronal portion of JE (2) increased tissue size from swelling of tissue b. Periodontal Pocket a. A pathologic deepening of the gingival sulcus i. Occurs as result of the (1) apical migration of JE (2) Destruction of PDL Fibers (3) Destruction of Alveolar Bone ii. Apical migration movement of cells to JE from their normal position (coronal to CEJ) to a position Apical of CEJ. b. TWO TYPES i. Suprabony pocket (supra=above) 1. Horizontal Bone loss a. The JE, forming the base of pocket, is located coronal to the crest of alveolar bone ii. Infrabony pocket (infra=below) 1. Vertical Bone loss a. JE, is located APICAL to the crest of alveolar bone. The base of pocket is located within the cratered area of the bone alongside of the root surface. 20. Need to refer to the old 1999 classification system? a. The AAP Classification (American Academy of Periodontology) a system for periodontal diseases and conditions b. You may need to refer to this older classification in order to determine the current terminology for the disease. > c. Early onset periodontitis (1989) is now called aggressive periodontitis (1999) 21. Descriptors for gingival tissues a. Color (pink, fiery red, purplish, pigmentation) b. Consistency (firm, resilient under compression/ spongy flaccid) c. Texture (stippling, shiny) d. Contour (cratered, blunted, pointed) e. Margin (slightly coronal, or coronal to CEJ due to swelling) f. Bleeding (present or not present/ suppuration) Infra VS. Supra 22. Localized vs Generalized disease a. Localized 30% teeth or less a. Inflammation conf ined to the tissue of a single tooth or a group of teeth b. Generalized 30% or MORE a. Inflammation of the gingival tissue of ALL or most of the mouth c. Can also be portions of the gingival tissue (Papillary, Marginal, Diffuse) 23. Necrotizing Periodontal Diseases a. Necrosis is Cell Death a. Necrotizing gingivitis (NG) vii. Limited to gingival tissues b. Necrotizing Periodontitis viii. Necrosis of gingival tissues, PDL & alveolar bone c. Necrotizing Stomatitis ix. Severe necrosis extends beyond gingiva to other parts of the oral cavity; Tongue, cheeks, palate x. Bone denudation occurs through alveolar mucosa tissue xi. Most severe, rarest form of NPD ** Plaque induced gingival disease is the most common gingival disease, as well as, the most common form of periodontal disease *** 24. Common types of mucogingival deformities a. Gingival Recession a. MOST COMMON i. apical displacement of the gingival margin with respect to the CEJ ii. Associated with attachment loss and with exposure of root surface to the oral environment 25. Parts of the implant a. Dental Implant - a nonbiologic device surgically inserted into the jawbone to (1) replace a missing tooth (2) Provide support for a prosthetic denture b. Implant Body the root of the implant that is surgically placed into the living alveolar bone c. Abutment titanium post that attaches to the implant body xii. Protrudes partially or fully through the gingival tissue xiii. Supports the crown or denture xiv. Biocompatible (not rejected) with the body 26. Difference in peri -implant diseases and their characteristics a. Peri -implantitis a. Periodontitis in tissues surrounding an Osseointegrated implants, result in bone loss i. Affects soft and hard tissues, plaque induced inflammation, progressive loss of alveolar bone ii. May progress in nonlinear and accelerating pattern 1. Signs of Inflammation 2. Presence of bleeding and suppuration upon probing 3. Increased probing depth 4. Progressive bone loss as seen on Radiographs b. Peri Implant Mucositis a. Plaque induced gingivitis in tissues surrounding an implant b. Reversible if plaque is effectively removed, otherwise, it may progress to Peri -implantitis i. Red Tissues ii. Swelling iii. Bleeding iv. Increased Probing Depths 27. Periodontium surrounding an implant vs a natural tooth a. Tissues Surrounding A Dental Implant BW = JE an d CT fibers pg.22 28. Osseointegration means a. The direct contact of the living bone with the surface of the implant body with no intervening PDL; b. an Osseointegrated implant is functionally ankylosed to surrounding bone without the PDL; c. osseointegration is the major determinant for implant success. 29. Best maintenance cycle for implants and how the patient and clinician can clean them a. Implant bone restorations (fixed or removable) should obtain professional dental exam at least every 6 months as a lifelong regimen b. 3-month intervals usually appropriate for the 1 st year c. After initial 12 -months, a 3 - to 6 -month interval may be used 30. Role of each team member plays in the dental office when it comes to diagnosing and treating patients d. Disclose periodontal condition share information e. Disclose info about potential outcomes (risks) a. Discuss evidence -based research to determine goals and treatment appropriate for the patients diagnosis and alternative options b. Consider patients preferences and circumstances - jointly review plan, record and share plan, agree on follow -up/ schedule c. Documentation - implementation and evaluation JE Attaches to the implant surface (biologic Seal) Connective Tissue Run parallel To or encircle the implant PDL NONE Cementum NONE Alveolar bone Makes direct contact with the implant surface (osseointegration) CAIRO CLASSIFICATION 31. Phases of periodontal therapy and what is involved in each phase Phase Measures and Procedures Phase 0 Assessment phase and preliminary therapy Health History Comprehensive Oral Examination Assessment data collection Radiographs as indicated Diagnosis of oral conditions Tx of urgent conditions Planning of non -surgical therapy Referral for care of medical conditions Extraction of hopeless teeth Phase 1 Non -surgical Periodontal Therapy Self -Care education Nutritional counseling Nicotine Cessation counseling Periodontal Instrumentation Antimicrobial Therapy Correction of local Risk Factors Fluoride Therapy Caries Control and Temporary Restorations Occlusal Therapy Minor Orthodontic Treatment Reevaluation of Phase I Therapy Phase 2 Surgical Therapy Periodontal Surgery Endodontic Surgery Dental Implant Placement Phase 3 Restorative Therapy Dental Restorations, Fixed and removable prosthesis Reevaluation of overall response to TX Phase 4 Periodontal Maintenance Ongoing care at specified intervals RT1 - Level of Cal = 3 mm - NO detectable loss of interproximal attachment RT2 - Level of CAL = 4 mm - Interproximal attachment loss 3 mm RT3 - Level of CAL = 6 mm - Interproximal attachment loss 8 mm 32. Know what the SHARE decision making process is and what the characteristics are for shared decision making with the patient a. Agency for Healthcare Research and Quality (AHRQ) b. crux of patient -centered care c. Shared Decision -Making = collaborative process that recognizes the patients right to make decisions about their care after being fully informed about options d. SHARE approach: i. S Seek pt. participation 1. Summarize perio condition, include them + caregivers in discussion ii. H Help pt. explore/compare tx options 2. Avoid technical jargon, provide evidence -based tools iii. A Assess pt. values/preferences 3. Encourage dialogue, listen, show empathy iv. R Reach decision w/ pt. 4. Ask/confirm their decision, assist follow -through & removing tx barriers v. E Evaluate pt.s decision 5. Revisit plan for any changes Textbook Questions Chapter 1 1. What is not one of the tissues of the periodontium? a. Body of the mandible 2. Cementum is NOT necessary to the health of the periodontium because the underlying dentin will protect the root if the cementum is removed by toothbrush abrasion or from dental procedures a. FALSE 3. Which tissue of the periodontium may be pigmented in dark -skinned individuals? a. Attached Gingiva 4. Healthy gingival tissue ALWAYS has a dimpled appearance known as stippling a. FALSE 5. One function of the attached gingiva is to prevent the free gingiva from being pulled away from the tooth when tension is applied to the alveolar mucosa a. TRUE 6. Which of the following forms the base of gingival sulcus? a. Junctional Epithelium 7. On the tooth side, the PDL fibers are embedded in which of the following structures? a. Cementum 8. Cementum does NOT have its own blood supply; it receives it nutrients from the PDL a. TRUE 9. Which of the following is the thin layer of bone that lines the tooth socket? a. Alveolar Bone Proper Chapter 2 1. Which of the following tissues serves as a covering tissue for the outer surfaces of the body and a lining tissue for body cavities such as the mouth, stomach, and intestines? a. Epithelial Tissue 2. What tissue fills the spaces between the tissues and organs of the body? a. Connective Tissue 3. What epithelial layer is comprised of cells with nuclei that act as a cushion against mechanical stress and wear? a. Nonkeratinized Layer 4. Epithelial cell junctions are cellular structures that can attach a. Both i. An epithelial cell to a neighboring epithelial cell ii. An epithelial cell to basal lamina 5. The function of cell junctions is to a. Allow cells to bind together to function as a STRONG structural unit 6. A cell junction that connects an epithelial basal cell to the basal Lamina is termed a. Hemidesmosomes 7. In MOST places in the body, the epithelium meets the CT in a wavy, uneven junction. a. TRUE 8. The deep extensions of epithelium that reach down into the CT are termed a. Epithelial ridges 9. CT is comprised of a gel -like substance, fibers, and few cells. a. TRUE 10. The sulcular and junctional epithelia are keratinized epithelial tissues a. False 11. The epithelium that forms the base of the sulcus and joins the gingiva to the tooth is called a. Junctional Epithelium 12. In the JE, epithelial cell attaches to the neighboring epithelial cells via a. Desmosomes 13. The JE attaches to the tooth surface via the a. Hemidesmosomes and the internal basal lamina 14. The JE attaches to CT via the a. Hemidesmosomes and external basal lamina 15. What is NOT a function of the supragingival fiber bundles a. Suspend the tooth in its bony socket 16. An important function of the cementum of the tooth is to attach the PDL fibers to the tooth a. TRUE 17. Alveolar bone is mineralized CT a. TRUE Chapter 3 1. The sequence of events that occur during the development of a disease is termed a. Pathogenesis 2. Which of the following are types of periodontal disease? a. Gingivitis & Periodontitis 3. In gingivitis, the position of the junctional epithelium is CORONAL to the cementoenamel junction. 4. Which of the following structures is intact in gingivitis? a. Periodontal ligament fibers & alveolar bone 5. In gingivitis, increased probing depth of a gingival pocket is the result of which of the following? a. Enlarged Tissue 6. Permanent destruction of the tissues of the periodontium occurs in which state? a. Periodontitis 7. Which pattern of bone loss results in a fairly even, overall reduction in the height of the alveolar bone? a. Horizontal Bone loss 8. What type of bone resorption occurs in an uneven oblique direction affecting only one tooth? a. Infrabony defect 9. Continued apical migration of the junctional epithelium is a. Site of active disease 10. The pathologic deepening of the gingival sulcus is a. Apical Migration Chapter 4 1. What is considered periodontal disease a. Gingivitis & Periodontitis 2. All of the following are categories of periodontitis EXCEPT a. Gingivitis 3. What is following fall s in the category of the other conditions affecting periodontitis? a. Traumatic occlusal forces 4. What is a classification of periodontal disease that is described as a group of periodontal diseases that could be associated with an ascorbic acid deficiency? a. Endocrine, nutritional, and metabolic diseases 5. All of the following are gingival diseases except a. Necrotizing stomatitis 6. Which of the following describes Stage III Periodontitis? a. Severe periodontitis with potential for additional tooth loss 7. Which of the following are the 3 major forms of periodontitis? a. Necrotizing periodontitis, periodontitis, periodontitis as a manifestation of systemic disease 8. Peri -implant disease includes all of the following EXCEPT a. Peri -implant health Chapter 5 1. A papilla that is enlarged and appears to bulge out of the interproximal space is called a. Bulbous 2. Papilla that appears is to have been scooped out leaving a concave depression in the mid -proximal area is called a. Cratered 3. In gingivitis, the position of the gingival margin is a. Coronal to the CEJ 4. A persons complexion can determine the shade of pink in healthy tissues a. True 5. If gingival tissues are healthy, they will ALWAYS have a stippled appearance a. False 6. Gingivitis in which the inflammation affects only one group of teeth is termed: a. Localized gingivitis 7. Inflammation of the gingival margin, papilla, and attached gingiva may be classified as a. Diffuse Chapter 6 1. Periodontal diseases involving the inflammation limited to the gingiva in response to dental plaque are termed a. Plaque -induced gingival diseases 2. Which of the following is the most common type of periodontal disease? a. Plaque -induced gingival diseases 3. Gingivitis from poor self -care that has existed for years without progressing to periodontitis is termed a. Plaque -induced gingivitis 4. Redness, swelling, bleeding, and tenderness of the gingiva in response to dental plaque only are clinical signs of the which of the following? a. Plaque -induced gingival diseases 5. Gingivitis i s an adolescent as a result of an exaggerated inflammatory response to a relatively small amount of plaque and increased levels of sex hormones a. Puberty - associated gingivitis 6. Gingivitis as a result of an exaggerated inflammatory response to plaque and hormone changes in a pregnant woman that includes a localized mushroom -shaped mass projecting from a gingival papilla is termed a. Pregnancy -associated pyogenic granuloma 7. Gingivitis as the result of a severe reaction to the initial infection with the herpes simplex type -1 is termed a. Primary herpetic gingivostomatitis 8. Gingivitis as the result of an allergic reaction to an ingredient in toothpaste is termed a. Intraoral allergic reaction 9. Examples of medications that cause gingival enlargement include all EXCEPT a. Nonsteroidal anti -inflammation 10. Ascorbic acid -deficiency gingivitis is a severely low level of a. Vitamin C 11. Non - plaque -induced gingival lesions a. May have various causes Chapter 7 1. A bacterial infection of the periodontium characterized by a slow destruction of the periodontal ligament, slow loss of supporting bone, and a good response to periodontal therapy is termed a. Periodontitis 2. New signs and symptoms of destructive periodontitis that reappear after periodontal therapy because the disease was not adequately treated and/or the patient did not maintain adequate self -care is termed a. Recurrent form of disease 3. Periodontitis in which 30% or LESS of the sites in the mouth have experienced attachment loss and bone loss is termed a. Localized periodontitis 4. Periodontists in which MORE than 30% of the sites in the mouth have experienced attachment loss and bone loss is termed a. Generalized Periodontitis 5. Probing Depth of 5 mm or less that shows as even horizontal bone loss on radiographs occurs in which of the following stages of periodontitis a. Stage II 6. Tissue destruction that is characterized by increased CAL of 2mm or more over a 5 -year period has a grade of a. Grade C Chapter 8 1. A pseudo membrane is evidence of necrotizing periodontal disease. Necrotizing periodontitis has associated CAL and bone loss a. TRUE 2. All of the following are predisposing factors for necrotizing periodontal disease EXCEPT a. Chewing gum 3. Gingival recession is considered a mucogingival deformity. Gingival recession can be a result of tooth mispositioning in the arch a. TRUE 4. Class II Miller Classification for Gingival Recession Indicates a. Recession does not extend into MGJ 5. With the Cairo classification system, which type is associated with recession from traumatic toothbrushing? a. RT1 Chapter 9 1. In a dental implant patient, the titanium post that protrudes through the tissue into the mouth is termed the a. Abutment 2. The tissues that surround a dental implant are the a. Peri -implant tissues 3. The implant -to -connective - tissue interface for a dental implant is the same as the CT interface with a natural tooth a. FALSE 4. Periodontal Pathogens can destroy bone much more rapidly along a dental implant than along a natural tooth a. TRUE 5. Periodontitis in the tissues surrounding a dental implant is termed a. Peri -implantitis 6. Standard Gracey metal periodontal instruments are safe for use on dental implants a. FALSE Chapter 10 1. The key to answering the second basic diagnostic question is a. Attachment loss 2. Migration of the junctional epithelium to a position apical to the level of the CEJ is termed a. Attachment Loss 3. Signs of periodontal disease are features of the disease that are observed by a. The clinician 4. The natural level of the junctional epithelium is located a. At the same level as the CEJ 5. Staging of periodontitis defines a. Severity of disease 6. ADA Case Type II patients are defined as patients having a. Slight (mild) periodontitis 7. Self -care education for a patient is normally provided during which phase of treatment a. Nonsurgical periodontal therapy phase 8. Disease grading indicates a. Rate of progression of disease Chapter 11 1. A systemic approach to clinical problem solving which allows the integration of best available research evidence with clinical expertise and patient values is called a. Evidence -based healthcare 2. Examples of shared decision -making characteristics include all of the following EXCEPT a. Develop a tx plan for what you think is best for the patient 3. Sharing expertise includes a. Clinician and Patient Collaboration ** Important Points in Lectures ** - The sulcular epithelium has very thin, little keratinization Functions of PDL Sun -Shine Never Falls Rain - Sensory Transmits tactile pressure and pain sensations - Supportive attaches the tooth to the bony socket and suspends the tooth so it does not grind on the bone during chewing - Nutritive Function Has blood vessels that provide nutrients to cementum and bone - Formative Contains Cementoblasts that produce the cementum throughout the life of the tooth - Resorptive contains osteoclasts that can resorb the bone and the cementum 5 PDL fibers AIOHA Fibers - Alveolar Crest Group Extend downward from cementum to alveolar crest; Resists HORIZONTAL movement - Horizontal Group run in a horizontal direction from cementum to bone; Resists HORIZONTAL pressure against the crown when chewing - Interradicular Group Occur only in Multi -rooted teeth in the furcation area; Stabilize the tooth in its socket - Oblique Fiber Group run in diagonal direction; Resist VERTICAL pressure that threatens to drive the root into the socket - Apical Group Extend from tooth apex to bone; Resists forced that might lift the tooth out of socket Sharpey Fibers Ends of PDL fibers that are embedded in the cementum and the alveolar bone Types of Cementum -Acellular -No Living Cells -First to Form (Coronal 3 rd ) -Mostly Sharpey fibers -Cellular -Cementoblasts and Fibroblasts -Forms after tooth eruption -Deposited throughout life -Fewer Sharpey Fibers Cementoenamel Junction - The Cementum may have 1 of 3 relationships with the enamel. - HINT OMG 1. Overlap 60% cementum overlaps the enamel 2. Meet 30% cementum meets enamel 3. Gap 10% small gap of cementum & enamel Perio Exam 2 Review 2021 50 multiple choice questions - 60 -minute time limit Know what the immune system protects the body against and what it reacts to: o Save the life of the host!!! NOT to save the hosts teeth/bone structure o Protects against infection/invasion. Microbes ; bacteria, fungi, protozoa, algae, viruses. Know the 5 cardinal signs and symptoms of acute vs chronic inflammation also know the differences Two stages of inflammation Acute Chronic A short -term , normal process that protects and heals the body. The acute inflammation process is achieved by the increased movement of plasma and leukocytes from the blood into the injured tissues. The bodys 1st line of defense to microbial challenge. A long -lived, out -of -control inflammatory response that continues for more than a few weeks. It is a pathologic condition that can destroy healthy tissue and cause more damage than the original problem. (invasion/ injury) Examples: Asthma, Diabetes, Rheumatoid Arthritis, Gingivitis, Periodontitis, Atherosclerosis Five Classic Signs of Acute Inflammation Heat rise in tem p; increased blood Redness increased blood Swelling accumulation of plasma and leukocytes at the site Pain excess fluid in the tissues puts pressure on sensitive nerve endings, causing pain Loss of function swelling and pain The classic warning signs seen in acute inflammation usually are absent in chronic inflammation. The problem may go unnoticed by the host (patient). Clinically, pain is absent. Why does chronic inflammation occur? Occurs because the body is unable to rid itself of invading organism. The invading microorganisms are persistent and stimulate an exaggerated immune response. Steps of acute inflammation Blood vessels near the infected site become more permeable. PMNs are the first cells to arrive at the site. PMNs release cytokines. The liver produces C -reactive protein (CRP). If the body succeeds in eliminating all the microorganisms, the tissue will heal, and inflammation will cease. The inflammatory response can become so intense that it does permanent damage to the body tissues. Chronic inflammation is characterized by an accumulation of macrophages. Macrophages engulf and digest microorganisms. Leukocytes release inflammatory mediators that perpetuate the inflammatory response. Homeostasis The goal at this stage of the inflammatory process is to establish homeostasis. Homeostasis is the process of the bodys tissue maintaining its optimal state of being. Return to homeostasis is catabasis. Immune cells leave the area, tissue structures return to normal and blood flow is reduced with no damage to tissues. Remission and Exacerbation Signs and symptoms of chronic inflammation may partially or completely disappear during a period of remission . The signs and symptoms may recur in all of their severity in an active period of disease known as exacerbation. Resolution Process The resolution process uses cells to provide stop signals that lead to shut down and clearance of immune cells. Once this is accomplished, the body actively shuts down the inflammatory response to limit damage to the host. The shut -down process prevents progression of inflammation from acute to chronic. Proinflammatory mediators, like PMNs, are recruited during the acute phase Overproduction of these mediators cause destruction of connective tissue matrix and resorption of bone Pro -resolving lipid mediators are produced to terminate PMN recruitment Chronic inflammation occurs if the host is unable to stop recruitment of PMNs, which has pathologic effects on the host Periodontal Disease Dysfunction of the resolution pathways that shut down the inflammatory process. The result is a failure of periodontal tissues to heal and a chronic, progressive, and destructive, non -resolving inflammation. Current theory of pathogenesis: Pathogenesis that leads from health to gingivitis to periodontitis is complex and multilayered. Microbial infection activates the host response Acute inflammation is the first line of defense against microbial invasion After microbial challenge has been eliminated, host must be able to shut down the response Resolution of acute inflammatory response must be effective. Periodontitis is associated with unresolved inflammation. Genetic and environmental factors modify the inflammatory response Mediators are produced by cells of the inflammatory response Innate immunity Adaptive immunity Present at birth Develops throughout life Not antigen specific ( no immunologic memory) Antigen -specific ( immunologic memory) Present always (immediate response to infection) Lag time between infection and response (develops in response to infection) Does not improve with repeated exposure to an infectious agent Memory develops which may provide lifelong immunity to reinfection to the same infection agent Know what specifically causes these signs and symptoms and what these do in the process of inflammation o Five Classic Signs of Acute Inflammation Heat increased quantity of blood Redness -- increased blood in the area Swelling the result of accumulation of plasma and leukocytes at the site Pain excess fluid in the tissues puts pressure on sensitive nerve endings, causing pain Loss of function the result of swelling and pain Know the cells that arrive first at the site of infection: PMNS! Aka. Neutrophils Complement system: Complement System: a complex series of proteins circulating in the blood that works to do 4 things Destruction of pathogens Opsonization of pathogens Recruitment of phagocytes Immune clearance Components of complement can destroy certain microorganisms directly by forming pores in their cell membranes. For this task, the complement system creates a protein called the membrane attack complex. This protein can puncture cell membranes of certain bacteria (lysis ). The complement system facilitates the capture and destruction of bacteria by phagocytes. Complement components coat the surface of bacteria, allowing the phagocytes to recognize, engulf, and destroy bacteria. Opsonization is the most important action of the complement system. The complement system can recruit additional phagocytic cells to the site of an infection. The complement system acts as a housekeeper for the body by removing immune complexes from circulation. Definitions: MMPS do to periodontal tissues: o MMPs are a family of 12 enzymes that act together to breakdown connective tissue matrix . o In health , MMPs facilitate normal turnover of the periodontal CT matrix. o High MMP levels result in extensive collagen destruction in the periodontal tissues. o Without collagen, the tissues of the gingiva, periodontal ligament, and supporting alveolar bone degrade. This results in gingival recession, pocket formation, and tooth mobility. o MMP are responsible for excessive loss of CT 60 -70% (early gingivitis stage) Prostaglandins o PGE most alveolar bone destruction in periodontitis o Trigger Osteoclasts to destroy alveolar bone What the host response is and how it affects the periodontium: o The way our body reacts to a microbial challenge. It is our host/inflammatory response and not the actual periodontal pathogens that damage the periodontium in periodontal disease. (review chronic inflammation) Chemotaxis leukocytes are attracted to an infection site in response to biochemical compounds released by invading microorganisms. Phagocytosis leukocytes engulf and digest microorganisms. Opsonization coating of the surface of a microorganism by complement components to facilitate the engulfment and destruction by phagocytes Functions of cytokines: o Recruit PMNs and macrophages to infection site. o (Signal to the immune system to send more phagocytes to site of infection.) o Increase vascular permeability that increases movement of immune cells into the tissues. o Can initiate tissue destruction and bone loss in chronic infections, such as periodontal disease. o Cytokines: produced by many different cells PMNs, macrophages, B -lymphocytes, epithelial cells, gingival fibroblasts, and osteoblasts. Produced in response to tissue injury. Cytokines important in periodontal disease include IL -1, IL -6, IL -8, and TNF - alpha. Cytokine general name for powerful regulatory proteins released my immune cells that influence the behavior of other nearby cells. Is the immune response the same for every person and every site in each individual's mouth? o The host/immune response is different for every individual and is based on a multitude of factors. Factors Influencing Hosts Failure to Control Bacterial Challenge: Abnormal PMN function Persistence and virulence of bacteria in the biofilm Acquired and environmental factors (ex. smoking/stress) Systemic factors (ex. uncontrolled diabetes/genetic factors) Osteoclasts VS. Osteoblasts: o Osteoclasts breakdown existing bone matrix o Osteoblasts synthesize collagen and other bone proteins. Effects of smoking on periodontal disease:( page 385 -387 in book) o Plaque is more likely to have periodontal pathogens such as P. Gingivalis in smokers. o Smoking depletes the commensal/beneficial bacteria. o Lower oxygen tension in the periodontal pocket, which provides a favorable environment for anaerobic bacteria. o Smoking favors early acquisition and colonization of periodontal pathogens in oral biofilms. o Greater alveolar bone destruction, 2.7X greater than in non -smokers. Bone mineral content may also be lower. o Nicotine suppresses osteoblasts, and increases the secretion of IL -6, TNF -alpha, and MMPS , which accelerates the damage to the periodontium by our inflammatory mediators. Impacts on the immune system, which affects periodontal disease: Decreased signs of inflammation, decreased gingival crevicular blood flow which causes impaired gingival blood flow due to vasoconstricting properties in nicotine. Neutrophil function in the peripheral circulation is impaired (remember PMNs are the 1 st responders and are neutrophils). Antibody production is impaired (immunoglobulins are produced by B - Cells) Effects of diabetes on periodontal disease o Diabetes is a chronic, lifelong metabolic disorder in which the body does not produce and/or properly use insulin. o Insulin is a hormone needed to convert sugar, starches, and other food into energy that the body uses to sustain life. Diabetes does not favor or influence growth of a specific periodontal pathogen. Individuals with diabetes can have an accelerated and exaggerated gingival inflammation compared with those without the disorder, despite a similar bacterial challenge. o Diabetes can create a defective neutrophilic function and hyperresponsiveness of monocytes/macrophages and increase of proinflammatory cytokines. 3 most common medications that cause gingival overgrowth: o Phenytoin/Dilantin (Anticonvulsants) o Nifedipine (Calcium channel blockers=beta -blockers) o Cyclosporine (Immunosuppressants) Know the signs and symptoms of leukemia associated gingivitis: o Inflammation of the gingiva Swollen, glazed, and spongy tissues that are red -deep purple in appearance and bleed with the slightest provocation or even spontaneously. Leukemic patients exhibit profuse gingival bleeding because of a reduction in the number of normal functioning platelets. o Gingival enlargement interdental papilla followed by marginal and attached gingiva. Enlargement due to increased filtration of immature leukemic cells in the gingiva. As gingiva enlarges, a periodontal pocket is created which will harbor more pathogenic microorganisms and worsen the inflammation. o Oral infection Leukemic patients are more susceptible to oral infection due to a reduction in the number of normal functioning white blood cells. Why local contributing factors cause issues with perio diseasemargins of restorations, calculus, partial dentures, root concavities, decay, food impaction, etc. o They do NOT initiate periodontal disease but are contributing factors. o Local factor can increase plaque biofilm retention. Things like a rough edge can make it difficult to remove plaque biofilm. o Local factor can increase plaque biofilm pathogenicity (disease causing potential). Calculus can harbor plaque biofilm and allow it to grow uninhibited for an extended period of time and perpetuate the gingival inflammation. o Local factor can cause direct damage to the periodontium. Ill -fitting dental appliance can put excessive pressure on gingiva. Traumatic toothbrushing can damage periodontium. Trauma from occlusion. Know the effect of stress on periodontal disease: o Acute stress Immunoenhancing o Chronic stress Increase of cortisol, which is anti -inflammatory and immunosuppressive. o Positive relationship between stress and periodontal disease. o Stress -induced behavioral changes may include reduced self -care, changed dietary habits, increased smoking, increased alcohol consumption, and nonadherence to periodontal maintenance regimens. Biological width and structures involved: o Biological width is the space on the tooth surface occupied by the junctional epithelium and the connective tissue fibers. Also called supra -crestal tissue attachment o Biological width violation can occur if the margin of a restoration encroaches upon zone of soft tissue occupied by the JE and connective tissue attachment fibers. If the margin is closer than 2 mm to the crest of the alveolar bone, it can result in resorption of the alveolar bone. The body will attempt to re -establish biologic width by re -creating room between the alveolar crest and the restoration margin to allow space for the JE and the connective tissue to reform. Local contributing factor and systemic contributing factor: o Local Intraoral conditions or habits that increase an individual's susceptibility to periodontal infection or than can damage the periodontium in specific sites within the dentition. Do not actually initiate either gingivitis or periodontitis, but these factors can contribute to the progression of an already established disease that is previously initiated by bacterial plaque biofilm. o Systemic conditions or diseases that increase an individuals susceptibility to periodontal infection by modifying or amplifying the host response to microbial infection. Can be modifiable (smoking) Can be nonmodifiable (genetic factors, age, gender) Primary and Secondary Occlusal Trauma: (pages 358 -59 in book) o Primary Excessive occlusal forces on a sound periodontium with no previous history of periodontal breakdown. High restorations/Excessive force on abutment teeth from partials/ Changes seen Wider PDL/Tooth Mobility / Pain Is Reversible o Secondary Occurs when normal or excessive occlusal forces are placed on teeth with an unhealthy periodontium previously weakened by periodontitis, thus contributing harm to an already damaged periodontium. May result in rapid bone loss and pocket formation Functional and parafunctional occlusal forces: o Functional occlusal forces are normal forces produced during the act of chewing food. PDL helps to provide a little bit of give to protect the tooth while chewing. o Parafunctional occlusal forces result from tooth -to -tooth contact when not in the act of eating. Clenching or bruxism. Can exert excessive force on the teeth and to the periodontium. Therapy may include occlusal adjustment or night guards. Know the difference in: o Dehiscence: loss of alveolar bone on one aspect of the tooth, typically the facial aspect, that leaves the areas of the root covered by soft tissue only. Dip in the bone. o Fenestration: a window of bone loss bordered by alveolar bone on its coronal aspect. (page 357 in book). Not commonly associated with Gingival Recession. Funny little window. Common adverse effects of oral piercings: o Oral piercings, such as a tongue piercing or lip piercing, can cause direct damage by mechanically traumatizing the periodontal tissues. Common adverse events associated with oral piercing include gingival recession, infection, swelling, bleeding, tooth fractures, and allergic reactions. o Oral jewelry needs to be removed prior to taking radiographs. Members of the dental team should be at the forefront of informing patients of the possible deleterious effects of oral jewelry. Vitamin deficiency may cause thinning of the alveolar process bone : o Vitamin D Possible link of obesity to periodontal disease: o Obesity appears to play a role of periodontitis through increased production of ROS (reactive oxygen species) inflammatory cytokines. oo Positive relationship between obesity and periodontal disease. o Elevated levels of TNF -a and IL -6 o Release of pro -inflammatory cytokines from adipose tissue in obese individuals provides a systemic inflammatory overload Intensifies infections, including periodontal disease. Overall risk factors associated with smokers and periodontal disease: o Smokers are 2 -3x more at risk for periodontal disease. o More than 4,000 chemicals are present o Impact on oral microbial biofilms Plaque biofilm may be colonized with more potential periodontal pathogens ## porphyromonas Gingivalis Favorable environment for growth of anaerobic bacteria in pockets. Depletes beneficial bacteria like treponema o Impact on the immune system Affects immune and inflammation Decreased signs of inflammation and impaired gingival blood flow. (gingiva is fibrotic/boggy and not much bleeding) Neutrophil function impaired. May decrease antibody production. o Impact on bone metabolism Associated with greater amount of alveolar bone destruction than nonsmokers. Nicotine may suppress osteoblasts and increases secretion of IL -6. May alter normal bone remodeling. # 5 stages of Polymicrobial Biofilm Function > Stage 1 > *Initial attachment > of microbes to the > pellicle > Stage 2 > *Permanent > Attachment > Stage 3 > *Maturation Phase I: > Self -Protective Matrix > Formation > Stage 4 > Maturation Phase II: > Mushroom -Shaped Microcolonies > Stage 5 > Dispersion: > Escape from > Matrix Within minutes after cleaning, a film forms over the tooth surface, called acquired pellicle Composed of salivary glycoproteins and antibodies Acquired pellicle protects enamel from acidic activity Within hours, free - floating microbes begin to attach to the pellicle Microbes able to withstand hydrodynamic forces attain permanent attachment Attached microbes produce substances to attract other microbes Coaggregation= genetically distinct bacteria become attached to one another Firmly attached bacteria secrete surrounding protective substance called extracellular protective matrix Consists of proteins, glycolipids, and bacterial DNA Microbes become cocooned in the protective matrix, protects against host - generated immune defenses Chronic disease is established Microbes cluster together and form mushroom -shaped microcolonies that attach to the tooth by a narrow base Microbial blooms develop when specific species grow at an accelerated rate Biofilm becomes thicker by stacking one microbial species on top of another forming polymicrobial colonies Fluid channels penetrate the protective matrix Fluid channels bring nutrients and oxygen to microbes and carry waste away Fluids saliva//beverages Direct cell -to -cell communication occurs via chemical signals resulting in transfer of genes among microbes Quorum sensing (QS) is when microbes in the biofilm release and sense small proteins to communicate with each other QS is used to trigger events like adhesion of additional microbes and formation of protective matrix QS allow bacteria to communicate and coordinate their behavior for growth and survival QS -- occurs inter species which allows for polymicrobial communities to thrive in oral biofilm Microbes disperse from the colony to spread and colonize other tooth surfaces 1. Leukocytes WBCs that capture microorganisms on their own a. PMNS (aka neutrophils) = first line of defense a. Capture and destroy invaders, die when engorged (short lived) b. Attractive by chemotaxis c. Contain strong bacterial digestive enzymes called Lysosomes d. Periodontal pathogens are mainly destroyed by PMNs b. Monocytes // Macrophages a. Called monocytes in blood stream b. Called Macrophages in tissue c. Slower to arrive than PMN d. Surround and destroy bacteria e. Long -Lived cells seen in chronic inflammation 1. Lymphocytes Small WBCs that reorganize and control invaders// help defend body a. B-Lymphocytes i. Activated and make millions of antibodies and pour into bloodstream ii. Types Plasma B -Cells & Memory B -Cells iii. Immunoglobulins Classes 1. IgM 2. IgD 3. IgA 4. IgG 5. IgE b. T-Lymphocytes i. Intensify response of other immune cells (macrophages/B -cells) to bacterial invasion ii. T-cells produce substances called Cytokines that further stimulate the immune response iii. Cytokine: General name for any protein that is secreted by cells and affects the behavior of nearby cells *** Phagocytosis The process by which leukocytes engulf and digest microorganism Major Events in the Inflammatory Response GRAM+ GRAM - Bacteria attached to tooth; Cocci / Rods > Streptococcus mitis > S. sanguis > Actinomyces viscosus Bacteria attached to epithelial lining; Spirochetes / Flagellated bacteria / Gram - Cocci and rods > Streptococcus oralis > S. intermedius > Porphyromonas gingivalis > Prevotella intermedia > Tannerella forsythia > Fusobacterium nucleatum Some Say Periodontal Probing Takes Forever Research Non -specific Plaque Hypothesis The amount of bacteria in a biofilm adjacent to the gingival margin leads to gingival inflammation and subsequent periodontal destruction. Specific plaque /Microbial Shift As periodontitis develops, the oral microbiota shifts from one consisting primarily of beneficial microbes to one consisting of pathogens. Microbial composition of the oral biofilm (rather than the amount) is the deciding factor in the development of peri odontal disease. An increase in the number of specific pathogens is associated with periodontitis. Bacteria in the biofilm change from predominantly gram -positive aerobic community to one consisting mainly of groups of gram -negative anaerobes. LAB REVIEW Furcation Involvement Class I Curvature of concavity can be felt with the probe tip; the probe penetrates no more than 1 mm. Class II The probe tip penetrates into the furcation greater than 1 mm but does not pass through. Class III The probe passes completely through the furcation. Class IV Same as class III with recession of the gingival margin. PSR Mobility Class I up to 1 mm horizontal displacement in a facial --lingual direction Class II greater than 1 mm but less than 2 mm of horizontal displacement in a facial --lingual direction Class III greater than 2 mm displacement in a facial --lingual direction or bouncing in the socket Perio Exam #3 REVIEW 40 multiple choice Best practice for dental hygienists is Best practice = practices/tx/therapies that are available based on best available evidence; important tool helping hygienists provide high quality care; derived from evidence -based care o Goal: use concepts, interventions, and tx known to promote higher quality care o Outcomes should be measurable and reproducible. Association = relationship between exposure and a disease that implies an exposure might cause disease Causal factor = (causality) an event or condition that plays a role producing an occurrence of a disease o ex. bacterium Mycobacterium tuberculosis develops to infectious disease TB. o Finding association b/w an event and a disease does not make it causal. New Research does NOT always mean better results. / Must be able to evaluate the literature and provide accurate information to each patient. Evidence Based Care o The conscientious, explicit, and judicious use of current evidence in care of pts o Goal -- assists healthcare professionals in applying most current and best scientific evidence to patient care 3 fundamental elements of Evidence based Care Incorporation of the best scientific evidence The healthcare providers clinical expertise The patients preferences and values (Cost, Pain, Impact on Family, Insurance) There is a GAP between What is known to be best practice & The care pts actually receive Levels of evidence - ranking system used in evidence -based care to describe the strength of the results in a clinical trial or research study - The higher the level of evidence, the better the quality - The lower the level of evidence, the greater the bias Systemic Reviews attempts to identify, appraise, and synthesize all the empirical evidence that meets pre -specified eligibility criteria to answer a given research question (Highest) PubMed / Cochrane Collaboration PICO process The structure for asking a clear focused question. P Patient / Problem > oPeriodontal pt. with bleeding and gingivitis I Intervention o A specific diagnostic test, tx, adjunctive therapy, medication, product, or clinical procedure (brushing & daily home irrigation) C Comparison o Identifies the specific alternative therapy or device that you wish to compare to the main intervention. (compared to brushing/flossing) O Outcome o Identifies the measurable outcome you plan to accomplish, improve, or influence . > (reduce gingivitis/bleeding within 4 weeks). Steps and process for NSPT -- Why we do it, who needs it, healing process, side effects, re -evaluation, maintenance, risk etc. - ch.24 NSPT Non -Surgical Periodontal Therapy ; term used to describe many nonsurgical steps used to eliminate inflammation in the periodontium of pt w/ periodontal disease, restore periodontium back to health; the gold standard - o the cornerstone of periodontal therapy & 1 st recommended approach to control perio infection ; return periodontium to healthy states that can be maintained by combination of professional & pt self -care Re -evaluation formal step after completion of NSPT; includes another perio assessment to determine how well periodontium responded to therapy Other Names Initial Periodontal Therapy / Phase I Tx / Soft tissue management, etc. Procedures needed o Self -Care Pt. Education / Periodontal Instrumentation / Use of Chemical Agents Broad Objectives o Eliminate living bacteria in the microbial biofilm o Eliminate Calcified Biofilm (calculus) o Return Periodontium to healthy states for continued maintenance by pt. and professionals Factors that influence Outcomes o Patient Compliance o Lifestyle / Systemic Factors o Disease Factors 4 goals of NSPT o To minimize the bacterial challenge to the patient o To eliminate or control local contributing factors for periodontal disease o To minimize the impact of systemic factors for periodontal disease o To stabilize the attachment level Treatment Plans Dental Biofilm Induced Gingivitis Stage I or II - Grade A Stage III or IV - Grade B or C Periodontitis Customized self -care instructions Periodontal instrumentation (prophylaxis) Eliminate local factors -overhanging restorations -caries -ill -fitting prostheses Re -evaluating periodontal response Customized self -care instructions Periodontal instrumentation (SRP) Eliminate local factors like -overhanging restorations - caries -excessive occlusal forces Correction of systemic risk factors smoking cessation and control of diabetes Re -evaluating periodontal response Customized self -care instructions Periodontal instrumentation (SRP) Eliminate local factors like -overhanging restorations -caries -excessive occlusal forces Correction of systemic risk factors smoking cessation and control of diabetes Re -evaluating periodontal response is surgery needed? > Chemical Agents for Dentinal Tubule Sensitivity > 1. In -office application of Potassium Oxalate, Ferric Oxalate > 2. Fluoride / fluoride varnish > 3. Potassium nitrate, strontium chloride, and sodium citrate found in toothpaste for sensitive teeth > Expectations of Healing > A. Shrinkage of the soft tissue and a shallow pocket depth > B. Readaptation of the tissues to the root forming a long junctional epithelium > C. Little change in the level of soft tissues resulting in a residual periodontal pocket > *NOTE -There is NO new formation of > -Bone > -Cementum > -Periodontal Ligament Fibers (PDL) Re -evaluation Appointment 1. Formal step following nonsurgical therapy 2. Reassess 3. Compare with initial assessment 4. Decide on a plan for periodontal maintenance Steps in Re -Evaluation 1. Medical status update 2. Thorough periodontal clinical assessment 3. Compare results with initial assessment 4. Decide on the next step in therapy 5. Perform or schedule additional nonsurgical therapy 6. Determine periodontal maintenance schedule 7. Refer for periodontal surgery if needed Different recommendations for OHI in interdental areas Aids for Interdental Plaque Biofilm Removal Interdental Aid Description / Example Indications for Use Dental Floss Unwaxed or Waxed thread Made of silk, nylon, or plastic Monofilament fibers Type I Excellent compliance to self -care regime Floss Holders Handheld device to hold the floss or single - use device containing a segment of dental floss (Reach -Access Flosser, Glide Floss Picks) Type I motivated but has dexterity issues Tufted Dental Floss Thickened yarn -like dental floss (J & J Super floss) Type II fixed bridges distal surfaces of last tooth -- Proximal surface of widely spaced teeth Interdental Brush Tiny nylon brushes on a handle (Butler Gum Proxabrush) Some Brands come in varying sizes (TePe interdental Brushes) Type II or Type III Distal surface of last tooth exposed furcation areas that permit easy insertion of the brush Embrasure spaces with exposed proximal root concavities End Tufted Brush Small Bristle tuft on a toothbrush - like handle (Butler End -Tuft Brush) Type III Distal surface of the last tooth in arch Lingual Surface of Mandibular Crowded or misaligned Exposed Furcation areas Pipe Cleaner Standard Pipe Cleaner Cut into 3 -inch lengths Type III Exposed furcation that permits insertion Tooth -Pick Holder A Round toothpick in a plastic handle (Marquis Perio -Aid) Type II or Type III Biofilm removal at Gingival Margin Furcation Areas / Root Concavities where teeth are widely spaced Triangular Wooden Wedge Triangular - Shaped toothpick generally made of basswood (J & J Stim -U-Den Type II or III Host modulation & what the different agents are Host Modulation Therapy o modifying a pt.s defense responses to help the bodys defenses limit damage causes by a disease. o In dentistry therapy focuses on how the body responds to the bacterial challenge rather than simply reducing that bacterial challenge posed by plaque biofilm Different Agents o Tetracycline Medications (ex. Doxycycline) o Chemically Modified Tetracyclines o Nonsteroidal Anti -Inflammatory Drugs (NSAIDS) o Bisphosphonates (ex. For osteoporosis) o Statin Medication o Dietary Supplements (omega -3 Fatty acids) o Other Types of Host Modulations Agents Enamel Matrix Proteins = Emdogain Bone Morphogenetic Proteins (BPM -2, BPM -7) Growth Factors Types of approaches to help with behavior change for patients Motivational Interviewing - Requires clinicians to adopt a particular philosophy or spirit of working with their patients . o The spirit = PACE Partnership Acceptance Compassion Evocation o Core Communication Skills OARS Open Ended questions Affirmation Reflections on Listening Summaries o Elicit Provide Elicit o Four Processes of Motivational Interviewing Engage Focus Evoking Planning Different types of abscesses of the periodontium An Abscess of the periodontium is an acute infection involving a circumscribed collection of pus localized within the gingival wall of the periodontal Pocket Suppuration is formation of pus; Gram - anaerobic bacteria Differentiation of the types of Abscesses; Table 30 -1 Characteristics Periodontal Abscess Pupal Abscess Definition acute infection of the periodontium infection of the tooth pulp that can sometimes extend into the periodontium Vitality Test Results Vital Pulp Nonvital Pulp Radiographic Appearance Bone loss present as an angular defect and/or furcation radiolucency Bone loss at tooth root apex Symptoms Localized, constant pain Bad taste in mouth Loss of alveolar bone Difficulty in Mastication Circumscribed local swelling Difficult to localize, intermittent pain Course Location Acute Rapid onset Pain and Discomfort Primarily Caused by an exacerbation of a chronic inflammatory periodontal Factors of Etiology= Lack of spontaneous drainage or inadequate host response Gingival Primarily limited to the gingival margin or the interdental papilla without involvement of the deeper structures of the periodontium Etiology can occur in a previously healthy mouth when some foreign object is forced into healthy sulcus Chronic Grows slowly No Pain * Forms after the spread of infection has been controlled by spontaneous Sinus Tract Periodontal Affects the deeper of the periodontium as well as the gingival tissues Usually occurs on site of w/ preexisting periodontal disease including preexisting periodontal pockets Pericoronal Pericoronitis Abscess of periodontium that involves soft tissues surrounding the crown of a partially erupted tooth. Covers the part of the occlusal surface of the teeth. Most frequent around Mandibular 3 rd molars The flap of tissue - Operculum When a patient should be referred when diagnosed with periodontal disease 1. Extent/complexity of periodontal disease 2. Desire to be treated by a specialist 3. General practitioner may not have the depth of experience to treat advanced cases 4. Presence of complicating medical factors Risk Factors Indicating Comanaging With a Periodontist 1. Unresolved inflammation and continued attachment loss despite nonsurgical periodontal therapy 2. Stage I II or Stage IV periodontitis with severe destruction 3. Intensive management of a Grade B or Grade C periodontitis 4. Gingival recession defects 5. Required surgical procedures for tissue augmentation or regeneration 6. Crown lengthening or Osseointegrated implants 7. Significant medical issues that affect management 8. General practice not comfortable treating *****Effects of periodontal disease on systemic diseases ??? Periodontitis is a chronic infection that may be a risk factor for a myriad of systemic diseases/disorders. Research shows an association between periodontitis and cardiovascular disease, pregnancy complications, diabetes mellitus, pneumonia, COPD, chronic kidney disease, rheumatoid arthritis, cognitive impairment, obesity, metabolic syndrome, and cancer. Chapter 34 Causes and treatment for viral oral conditions Necrotizing = PAIN 1. Acute infections of the periodontal tissues that involve tissue necrosis ---localized tissue death: 2. Necrotizing gingivitis 1. First appointment: 1. Gentle removal of pseudo membrane 2. Limited supragingival instrumentation 3. Self -care restricted to removal of debris with soft tooth brushing 4. Chlorhexidine rinses twice daily 5. Alternatively, equal parts hydrogen peroxide and warm water every 2 to 3 hours 6. Patient education ---avoid tobacco and alcohol 2. Second appointment: 1. Two days after initial appointment 2. Subgingival instrumentation 3. Further self -care instructions 4. Pay attention to systemic conditions 5. Discuss smoking cessation and limiting alcohol consumption 6. Suggest stress reduction and need for adequate sleep 3. Third appointment: 1. Five days after initial appointment 2. Complete subgingival instrumentation 3. Conduct further counseling for systemic and oral habits 4. Antibiotics may be necessary 5. Appoint for comprehensive clinical assessment to determine underlying chronic periodontal disease 4. Supportive maintenance therapy: 1. Following infection resolution 2. Assess periodontal status 3. Reinforce self -care 4. Control predisposing factors 5. Perform necessary periodontal instrumentation 6. Determine compliance with health habits, psychosocial factors 3. Necrotizing periodontitis 1. Immediate Referral to periodontist 4. Necrotizing stomatitis 1. Immediate consultation and referral to an oral pathologist, oral maxillofacial surgeon, and physician -Primary Herpetic Gingivostomatitis 1. HSV I oral herpes virus 2. HSV II genital herpes virus 3. Primary herpetic gingivostomatitis is usually caused by initial infection with HSV I 1. In rare cases it may be caused by HSV II 4. Keep in mind this disease is highly contagious . 5. PHG will regress on its own in about 2 weeks. 6. Control oral discomfort ---topical anesthetics can be used 7. Recommend frequent fluid intake to avoid dehydration 8. Refer to a physician if systemic symptoms are severe or the patent is unable to tolerate fluid intake Surgery Information 18 Different Types ?????????? 1. Flap for Access 2. Open Flap Debridement 3. Osseous Resective Surgery 4. Apically Positioned Flap 5. Bone Replacement Grafts 6. Guided Tissue Regeneration 7. Periodontal plastic surgery (#s 8 -15) 8. Free soft tissue autograft 9. Subepithelial connective tissue graft 10. Laterally positioned flap 11. Coronally positioned flap 12. Semilunar coronal repositioned flap 13. Frenectomy 14. Crown lengthening surgery 15. Gingivectomy 16. Dental implant placement 17. Periodontal microsurgery 18. Laser therapy Chapter Quizzes Chapter 22 1. Which of the following is a component of evidenced -based care? a. Scientific Evidence / Clinical Expertise / Patient Preference 2. Which type of evidence carries the highest rank? a. Systemic Review 3. The tendency to look for or interpret information that confirms our beliefs is called: a. Confirmation Bias 4. Factors that influence the type of care a patient selects include: a. Cost Of care / Pain Associated with Tx / Insurance Benefits 5. A well -rounded continuing education course will spur the need to a. Re -affirm some current ways of practicing / Re -energize the need to make change / Re - examine new ideas or concepts 6. New products and research are always superior to the traditional way of doing things. a. FALSE 7. Peer -reviewed journals use a panel of experts to review research articles for study design, statistics, and conclusions. a. TRUE 8. The goal of best practice is consistent, superior patient outcomes. a. TRUE Chapter 24 1. Which of the following is NOT a goal of nonsurgical periodontal therapy? a. Eliminate the need for daily self -care 2. successful periodontal debridement always results in the complete removal of all cementum from a root surface exposed due to clinical attachment loss. a. FALSE 3. The end point for periodontal debridement is which of the following? a. Return of soft tissue health 4. The type of healing that occurs following successful root instrumentation is a long junctional epithelium. a. True 5. Pain caused by dentinal hypersensitivity can result from mechanical, thermal, or chemical stimuli a. True 6. Management of mild dentinal hypersensitivity following nonsurgical periodontal therapy can include all of the following EXCEPT: a. Applying acidic solutions to the exposed tooth roots 7. When considering a decision for referral to a specialist in periodontics which of the following type of patients should normally be referred? a. Patients with Stage III periodontitis Chapter 25 1. Who should be involved in determining which devices and aids a patient uses for plaque control? a. The Dentist / Dental Hygienist / The Patient 2. Power toothbrushes should be recommended ONLY for individuals with a disability. a. FALSE 3. Patients with type II embrasure spaces need to use interdental brushes and wooden toothpicks to effectively control plaque biofilm. a. TRUE 4. A coated tongue is the primary oral malodor inducing factor. a. TRUE 5. Which of the following interdental aids would be recommended for a patient with type I embrasure spaces throughout the mouth? a. Standard Dental Floss 6. Which of the following might be recommended for plaque removal in an exposed furcation area on a tooth that has experienced gingival recession? a. An Interdental Brush 7. Which of the following is the most effective means for cleaning exposed root concavities ? a. An Interdental Brush 8. Dental floss has shown to provide superior biofilm and bleeding reductions when compared to alternative interdental aids. a. FALSE Chapter 28 1. Host modulation in dentistry commonly refers to which of the following? a. Using drugs to limit the damaging effects of the periodontal disease. 2. Which of the following are considered to be pro -inflammatory biochemical mediators? a. IL -1 (interleukin -1) and IL -6 (interleukin -6) 3. When low -dose doxycycline is used in periodontitis patients, there is no known effect on the oral microflora. a. True 4. Which of the following is approved by the FDA for use in treating periodontitis patients? a. Low -dose doxycycline 5. The drug ibuprofen is an example of a medication that belongs in which of the following categories? a. NSAIDS Chapter 29 1. One of the indications for periodontal surgery is to provide access for improved periodontal instrumentation of the root surfaces. a. True 2. One relative contraindication for periodontal surgery can be a high risk for dental caries a. True 3. The term Healing by Repair means that the architecture and function of lost tissue is completely restored a. False 4. In bone replacement graft procedure, using an AUTOGRAFT means that the graft material is taken from the patient a. True 5. The term, Xenograft refers to a graft taken from a human other than the patient receiving the graft a. False 6. A subepithelial CT graft is a type of periodontal plastic surgery a. True 7. Esthetic crown lengthening surgery results in longer clinical crowns for the teeth a. True 8. The suture size 4.0 is SMALLER than the 3.0 suture a. True 9. When removing sutures following a periodontal surgery, the suture knot should always be pulled through the tissues a. False 10. When placing periodontal dressing, the primary guideline is to place as much bulk of dressing as possible over the wound surface a. False 11. Facial swelling following periodontal surgery is always a sign that healing will not occur properly a. False 12. During post surgical visits, it is important to remind patients to take all prescribed antibiotic medication. a. True Chapter 30 1. The three types of abscesses of the periodontium are: a. The Pericoronal abscess, the periodontal abscess, and the gingival abscess 2. One possible cause of the abscess of the periodontium is blockage of the orifice (or opening) of an existing periodontal pocket. a. True 3. The pulpal abscess originates in the periodontium, while the abscess of the periodontium originates from pulp of the tooth. a. False 4. Pericoronitis results from which of the following conditions? a. Tissue over crown 5. During treatment of a periodontal abscess, drainage of the pus is a critical step. a. True 6. Primary herpetic gingivostomatitis can occur with the initial infection with which of the following viruses? a. HSV1 Virus Chapter 32 1. When it comes to health behavior change it is important to recognize that patients are: a. Ambivalent about change 2. Which of the following is NOT an element of the philosophy of Motivational Interviewing? a. Persuasion 3. . When working with a patient on behavior change, Motivational Interviewing principles suggest it is preferable to: a. Use reflective listening 4. . Which of the following behaviors is NOT consistent with Motivational Interviewing principles: a. Ask yes/no questions to avoid getting off of the topic 5. When the clinician acknowledges the patients efforts and strengths toward change, this is: a. Affirmation 6. . One of the main goals of MI is to elicit internal motivation for change. When a patient engages in change talk, the MI practitioner should: a. Use reflective listening to elicit more change talk > Exam 3 perio -quizlets > 1. The furcation probe completely passes through the furcation between the mesial and distal roots; however, > the entrance to the furca is not visible clinically. > 1. The level of furcation involvement should be recorded as a class III > 2. If a pt. Presents with gingivitis, inflammation will always be clinically visible in these tissues. In > chronic periodontitis, inflammation can be present in the deeper structures of the periodontium without any > visible clinical signs of inflammation at the gingival margin > a. The first statement is false; the second is true > 3. Components of a comprehensive periodontal assessment > a. Level mucogingival junction > b. Level of free gingival margin > c. Fremitus > 4. Host modulation agents include: > a. Nonsteroidal anti -inflammatory drugs (NSAIDS) > b. Doxycycline > c. Bisphosphonates > 5. What is the primary pattern of healing after periodontal instrumentation? > a. Formation of a Long junctional epithelium > 6. When bone is grafted from one area of the patient's jaw to another, the graft is termed: > a. autograft 7. The hygienist applies pressure with a gloved finger against the facial gingival tissue and observes a pale -yellow material oozing from the orifice of the pocket. The hygienist assessed the tooth for: a. The presence of exudate 8. Tissue healing from flap surgery is healing by Repair , and results in formation of long junctional epithelium 9. Which of the following interdental cleaning devices would be the most effective in removing plaque biofilm from an interproximal root concavity? a. Interdental brush 10. The role of supragingival irrigation is to: a. Reduce the number of bacteria above the gingival margin 11. What type of surgery is performed to remove gingival overgrowth caused by taking a medication such as phenytoin? a. Gingivectomy 12. How long does the natural process of blocking open dentinal tubules on exposed (open) dentinal tubules usually take? a. A few weeks (2 -3) 13. The hydrodynamic theory for the origin of dentinal hypersensitivity proposes the following cause of sensitivity in open dentinal tubules: a. fluid movement within the tubules stimulates nerve endings associated with the odontoblastic processes 14. Best practice for dental hygiene involves: REP a. Research b. Expert opinion c. Personal experience 15. Indications for water flosser use are: a. Floss alternative for patients who have difficulty using dental floss b. Patients with orthodontic appliances c. Patients with implants 16. All exposed dentin is not always hypersensitive. Instrumentation of root surface can result in dentinal hypersensitivity 17. Professionally applied subgingival irrigation Has limited benefits 18. Which of the following is placed during guided tissue regeneration to control the rapid growth of epithelium into the wound? a. Barrier material 19. When a wound heals by forming tissue that does not restore the original architecture of the body part, it is referred to as: a. Healing by repair 20. Bleeding on gentle probing represents bleeding from the soft tissue wall of the periodontal pocket where the wall of the pocket is ulcerated due to disease. When assessing for bleeding, an alert hygienist will observe each site for a few seconds before moving on to the next site. 21. Dental hypersensitivity is associated with: a. Exposed dentin 22. Host modulation refers to a. Altering the pts immune defense responses b. Assisting the patient's ability to limit damage to the periodontium 23. Acceptable irrigating solutions include a. Essential oils b. Filtered water c. Chlorhexidine 24. Radiographs usually show more interradicular bone between roots of the teeth than what is actually present. Facial and lingual bones can be superimposed over a furcation. 25. Therapeutic mouth rinses are helpful in controlling: a. Gingivitis 26. measure the distance from the CEJ to the base of a pocket. a. Clinical attachment level 27. Know Which host modulation therapy agents has been approved for use by the FDA? 1. Doxycycline 28. What surgery is performed to give the general dentist access to restore a tooth with a crown? 1. Crown lengthening surgery 29. FALSE - After a dental implant heals, it is surrounded by cementum and periodontal ligament like a natural tooth. Implants are resistant to periodontal disease, so they will not lose supporting bone in the same manner as natural teeth. 30. What kind of periodontal surgery is performed to provide access to tooth surfaces for meticulous periodontal instrumentation? a. Periodontal flap for access 31. The flap tissue covering the occlusal surface of an unerupted crown is termed the; a. Operculum 32. Bone taken and harvested from a cadaver is termed: a. An allograft 33. Know what Formation of an abscess of the periodontium can occur by: 1. Suppuration / Blockage of periodontal pocket 34. How soon should a bone graft site be probed? a. When the periodontist determines it is safe 35. Which of the following interdental cleaning devices is effective in a type I embrasure space ? a. Dental floss 36. The hygienist is able to depress the tooth in its socket by applying downward pressure. This finding indicates that the tooth has ___ mobility. a. Class 3 37. New attachment Is union of a pathological exposed root with connective tissue or epithelium Chapters 3 3-36 Chapter 33 -Health Maintenance in Treated Periodontal Patients Online quiz 1. Periodontal maintenance goals include minimizing recurrence of periodontal disease and reducing the incidence of tooth loss a. True 2. Which of the following is NOT an objective of periodontal maintenance? a. Decrease attachment levels 3. Procedures performed during a periodontal maintenance appointment include patient interview, clinical assessment, and periodontal instrumentation. a. True 4. Which of the following has NOT been demonstrated to reduce root caries? a. Calcium Tablets 5. Research evidence suggests that a proper interval for periodontal maintenance is: 1. Every 3 months 6. Compliance is defined as the: 1. Extent to which a patients behavior coincides with medical or health advice 7. Giving the patient multiple self -care aids to use each day is a proven technique for improving patient compliance. 1. False Chapter 34 impact of Periodontitis on Systemic Health Online quiz 1. According to current research, the presence of systemic disease may increase the severity of periodontitis. The presence of periodontitis may have an adverse effect on an individuals systemic health. a. Both true 2. One hypothesis proposed to explain a possible link between periodontitis and cardiovascular disease is that periodontitis triggers the production of c -reactive proteins in the body a. True 3. The American Academy of Periodontology statement indicates that most pregnant woman do NOT require a periodontal examination. a. False 4. Pregnant women with severe periodontitis may develop bacteremia more frequently, exposing the fetus to aggressive periodontal pathogens a. True 5. Periodontal disease may exacerbate diabetes mellitus by worsening glycemic control over time a. True 6. Bacterial respiratory infections are thought to be acquired through aspiration of fine droplets from the oral cavity and throat into the lungs. a. True Chapter 35 Documentation and Insurance Reporting of Periodontal Care 1. Which of these terms is defined as the health care providers obligation to provide services to another person? a. Liability 2. Which term is defined as the failure to do something that a reasonable person would do under the same circumstances? a. Negligence 3. Yelling at a child in a loud voice is an example o f a. Intentional Tort 4. A dental chart or computerized record is considered a legal document. a. True 5. Patient comments should NOT be documented in a chart or computerized record. a. False 6. Three days after treating a patient, the hygienist realizes that she forgot to document a treatment procedure in a patients chart. Since hers was last entry in the chart, it is acceptable for her to just add the procedure to her previous entry. No one wil l ever know that she added this information 3 days later. a. False 7. If an error is made, the hygienist should erase the error or cover it with correction fluid. a. False 8. The hygienist just completed periodontal instrumentation on a new patient with Stage III periodontitis. Which of the ADA insurance codes should he or she enter on the insurance form? a. D4341 Periodontal Scaling and Root Plan ning 9. Which code would be entered on an insurance form for periodontal instrumentation completed during a 3 -month periodontal maintenance appointment? a. D4910 Periodontal Maintenance Procedures