1. The Normal Periodontium Flashcards
Clinical periodontal exam:
• Insert measuring instrument between the gum and tooth
◦ Instrument stops where you have the ____ (where the most coronal aspect begins)
connective tissue attachment
Gingival epithelium
____ epithelium
____ epithelium
____ epithelium
oral
sulcular
junctional
Epithelium-function
- ____
- Dependence on the ____ tissues
- Clinical implications
The epithelium has a dependence on the connective tissues, which has clinical implications:
i.e. ____ - trying to put epithelialized tissue when it’s lacking
Epithelium takes its characteristics from the underlying ____ tissue - AKA, the ____ of the tissue is from the connective tissue
protective connective free gingiva graft connective phenotype
Connective tissues
\_\_\_\_ components Fibers \_\_\_\_ substance Blood vessels \_\_\_\_
cellular
ground
nerves
Connective tissues - function
- ____
- Resorptive - means that it ____ over
- ____ - gives some bulk and ____
- Nutritive - nutrition for cells and ____
- ____ - awareness of ____
Formative turns supportive structure vessels sensory sensation
RETE PEGS
Rete pegs:
Projections from ____ into the ____ tissue
epithelium
connective
Epithelial-connective tissue interface
- Rete pegs
- Straight
Rete pegs - usually at the epithelial-connective tissue interface
• Tend to be ____
• Quite distinct in terms of their ____
straight
shape
Periodontium
- ____
- ____
- ____
- ____
The orientated cell and fiber attachment system is the structure and the form of the periodontium.
gingiva
PDL
cementum
alveolar bone
The tissues are described in terms of
____ - redness
Contour
Texture - various ____
____ - underlying structure of the tissues
color
indentations
consistency
Connective tissues-fiber
- ____
- Elastic
- ____
- Reticular
These are all within the connective tissue fiber matrix
collagen
oxytalan
Gingiva
\_\_\_\_ margin Marginal gingiva \_\_\_\_ gingiva? Attached gingiva \_\_\_\_ junction Gingival groove
Free gingiva contains a question mark because: historically this existed, but more recently, it has been ____ as to whether there really is a free gingiva.
gingival
free
mucogingival
questioned
Thickness of ____ gingiva varies considerably between individuals
If have very small amount of attached gingiva, may be more susceptible to ____ (only 1 or 2 mm here)
If have large amount gingiva (5-7mm), resistant to ____
attached
recession
recession
GINGIVA
____ gingiva has varying thickness in different areas on same person - due to normal ____ variation.
attached
anatomic
MGJ
Mucogingival junction = Junction between ____ and ____
gingiva
mucosa
MELANIN- COLOR INFLUENCE
Images depict the influence of ____ in color of gingiva
There are normal variations in melanin concentration in different areas
• These variations are ____
gingiva
normal
INTERDENTAL PAPILLAE
Interdental papillae here is more blunted and flattened
Again, gingiva takes the form of the ____ area.
interdental
Interdental Papilla
Interdental papilla here is less of a ‘col’ and more of a ____
peak
In the middle area (col), it is ____
◦ Buccal and lingual aspects are ____
but on the middle it is non-keratinized
In this slide, can see variations in the width of the col in different areas
• Has some significance clinically:
◦ As look from buccal to the lingual in the incisor, get an idea of the relationship between the buccal and the lingual –> as get to the interdental area, it is a ____ area.
◦ As look from buccal to the lingual in the molar, there is a wider area that is inaccessible to viewing
‣ The interdental area is more distant and more interproximal
‣ This larger surface area can contribute to ____ because:
• These areas are more inaccessible and at greater distance from buccal and lingual papilla and thus plaque can accumulate here
◦ Contributes to more disease - could be gingivitis initially, and more periodontitis more long term
• Patients can get more plaque stuck between larger ____ than thinner anterior teeth
non-keratinized keratinized wider plaque molars
Gingival sulcus
- Borders
- ____
depth
SULCI-TISSUE TYPES
In relation to the variations in gingival sulcus, there are tissue types.
Some people have a thinner periodontium while others have a thicker periodontium
• In different people, perhaps you have different thickness of ____
Phenotypically, people are different in terms of tissue type whether thick or thin
◦ Clinical significance:
‣ Thinner periodontium is perhaps more susceptible to ____ and ____ breakdown
sulcus
inflammation
periodontal
Thicker gingiva provides better conditions for ____ and ____ (blood flow; stable position of the gingival margin)
treatment
wound healing
HISTOLOGICAL SULCUS
Histological sulcus is present in microscope and in diagrams.
The attachment is an ____ - not an actual attachment with fibers.
adhesion
3 TYPES OF EPITHELIA
- ____ Epithelium
- ____ epithelium
- ____ epithelium
- Unique features of the gingival epithelium has clinical implications in relation to the ____ of periodontal disease, as well as ____ of the periodontium.
oral
oral sulcular
junctional
etiology
development
JUNCTIONAL EPITHELIUM
____ epithelium: the ____ cells are moving in ‘that’ direction - proceeded to move pointer upwards and to the right. Assuming he meant in the direction of the arrows.
dynamic
cuboidal
Sulcus-Junctional Epithelium
____ is associated with early changes of inflammation and gingivitis
Underlying connective tissue • Contains \_\_\_\_ • ICT = Infiltrated/ Inflammed connective tissue
ICT
collagen
Connective tissue
- ____ substance
- Water
- ____
- Proteoglycans
- ____
ground
glycoproteins
hyaluronic acid
GINGIVAL CUFF
Historically, thought that junctional epithelium ____ like a glue until get to free gingiva area then becomes almost ____ and a little bit loose - this is known as the ____
• Present in a ____ situation
adheres
detached
gingival cuff
healthy
Connective tissue
- Gingival fibers
Gingival fibers are ____ fibers which are extending from the tooth into the gingiva (indicated by red
Fibers between the adjacent teeth are called the ____ fibers
____ fibers are shown as dots as they are going around the tooth
Group of fibers going from the tooth into the ____.
collagen
trans-septal
sulcular
alveolar bone
Periodontal ligament
- Principal fibers - Principle fibers are going in a ____ and ____ direction
- Alveolar
- ____
- Oblique
- ____
- ____
^fiber structure of periodontal ligament •Periodontal ligament is one part of the ____
horizontal oblique horizontal apical interradicular
periodontium
PDL-INTERRADICULAR FIBERS
- Periodontal ligament has ____ fibers
- – All of these groups attach from the ____ through the ____
interadicular
cementum
alveolus
Periodontal ligament
- ____ fibers
Histological stain where can see fibers going into the bone
sharpey’s
PDL cells
\_\_\_\_ Cementoblasts \_\_\_\_ Cell rests of Malassez \_\_\_\_ Macrophages \_\_\_\_ Osteocytes \_\_\_\_
fibroblasts osteoblasts vascular and neural elements cementocytes undifferentiated cells
Fibroblasts: form ____
Cementoblasts: form ____
Osteoblasts: form ____
Epithelial cell rests of Mallasez: Groups of ____l cells that function for tooth formation
•After periodontium has developed, the epithelial cell rests of Mallasez are ____ groups of epithelial cells
Note: in regard to the cell rests of Mallasez, he said: “they travel from tooth formation in the dental papilla.” Was hard to understand and this sentence was unclear.
Vascular and neural elements: supply ____ and ____ aspects
Macrophages: did not say anything about these.
Cementocytes: precursors of the ____
Note: this was questioned by a student because we learned that the ‘blast’ precedes the ‘cyte,’ particularly in osteocytes and osteoblasts. Dr. Wang clarified the correct definition of osteocyte which is below. Still seems to be unclear whether the cementocyte precedes the cementoblast or vice versa.
Osteocytes: Located next to the ____ - osteocytes are ____ that have been incorporated into the bone matrix
Undifferentiated cells: Cells which don’t have particular characteristics but have potential to form various things - thus they are ____
• Periodontal progenitor cells
• When stimulated in the appropriate environment - can form a ____ (periodontium = cementum, ligament, and bone - oriented in cell/fiber attachment way)
collagen
epithelial
residual
blood
sensory
cementoblasts
bone
osteoblasts
stem cells
periodontium
Osteoprogenitor cells are the stem cells of bone and form ____
Osteoprogenitor cells are derived from ____ cells. They form a population of stem cells that can differentiate into the more specialized bone-forming cells (i.e. osteoblasts and osteocytes).
Osteocytes are inactive ____ trapped in mineralized bone
When osteoblasts have completed a burst of ____ activity, most return to an inactive state, becoming ____ and ____-shaped and closely applied to the now-____ bone surface. Some osteoblasts, however, become surrounded by mineralizing bone matrix and lie within small cavities (____) in the bone. When this happens, the cell is called an ‘osteocyte’.
osteoblasts
primitive mesenchymal
osteoblasts osteoid-producing flattened spindle inactive lacunae
Periodontal ligament
clinical considerations
- ____
- Excessive forces
- ____
- Destruction
thickness
accidental exfoliation
Excessive forces can result in remodeling of periodontium
◦ Tooth can get more ____ as the ligament adapts
◦ The ligament adapts, remodels, and gets ____ with displacing forces
◦ Types of forces that are used professionally to do this = ____
‣ Orthodontists move the teeth with controlled forces:
• Use remodeling ability of periodontium and once it away from the displacing force, the ligament heals and goes back to a normal ligament width
Accidental exfoliation -
Example: If tooth is knocked out, then re-implanted into the socket and given a temporary stabilization - the ligament heals.
• It heals because the periodontal ligament is a ____ structure, thus if you can maintain the vitality of the cells - then stand a good chance of getting periodontal ligament reformation in situations of accidental exfoliation
◦ In endodontics, they are extracting and reimplanting teeth and trying to get the ligament to reform and trying to retain the cell vitality
◦ If stabilize teeth for longer period of time - do not get ligament reformed, but rather get bony union between the tooth and the root (=____)
Destruction of the ligament - determines how much repair one is able to get
◦ Ligament can get destroyed by periodontal disease = ____
◦ Look at root surface and consider in terms of managing it from a maintenance or reattachment point of view
◦ Destruction can also be ____ - using ____ for example, one can sometimes be removing
part of the periodontal fibers
loose
wider
orthodontic wires
cellular
ankylosis
periodontitis
mechanical
curettes
Cementum
- Location: ____, ____
- Cellularity: ____, ____
- Fiber presence, ____, ____
radicular
coronal
cellular
acellular
fibrillar
afibrillar
Apical Cementum
Histology image showing apical area of the tooth
Cementum is different in the different areas around the ____
-Dr. Max Listgarten did important work on cementum formation.
root
ALVEOLAR BONE
Crest of the bone follows the ____ and then rounds off ____
CEJ
interdentally
ALVEOLAR BONE
____ has been raised.
As part of procedure, flap was raised, and thus able to see normal bone anatomy and its three dimensional structure.
Flap
ALVEOLAR BONE
Alveolar bone is sometimes a little more ____ - why it is called the ____ bone sometimes
•Some of the cells that are here may be the ____
spongey
cancellous
stem cells
The Periodontium
Anatomical structure together with gingival component
- This is normal ____ (we will discuss changes that occur with this with periodontal disease)
periodontium
You can see the bone crest being parallel to the CEJ. This is a normal situation. If you look at the bone morphology you can see lines. This represent formation of bone, layer of bone that are being deposited, bone formation (bone matrix). This ____, in small increment overtime is seen when grinding your teeth. The periodontium is a dynamic structure, the tooth ____ to compensate for the occlusion wear, you get this successive small and incremental bone deposition. As you wear teeth away teeth go back to occlusion by new bone being deposited on the crest. This is the normal situation. What is shown histologically is what one has stain with. There are fibers that dont show because this is a cell stain to show the cellular and alveolar component
linear deposition
erupt
Cellular stain (Left). Can see the orientation of the cell with fibroblast with the cementum. Can se the alignment of the cells in relation to the fibers (fiber stain on right) and the orientation and the attachment of the fibers to the CEJ area. Have Transseptal fibers in the fiber stain (right). Again You can see new bone formation due to ____. Can see junctional epithelium with some rete pegs as a result of inflammation in the tissue. This is the normal situation. You can see the marrow space as well
eruption
This is a periodontal bone. This is a ____ ended instrument to measure the space between the gum and the tooth. This is a particular marking system hear (3,5,7,8,9,10mm) This is a ____ marking system named after the head of perio in Toronto. The prob you will be using are calibrated in ____. Every 5mm you have a marking to make it more straight forward for reading
blunt
William’s
mm
The technique, the long axis of the probe ____ to the long axis of the tooth then into the sulcus until it stops
parallel
See different probing system but usually the prob finishes at the ____. The attachment is a ____ and not a ____ attachment. The probe stops at the end of the epithelium. This is the normal structure
CEJ
cellular
fiber
When having periodontitis you have pocket formation. And loss of alveolar bone. Probe goes ____ depth wise. The probe is the measuring device. See inflammation in the connective tissue
deeper
When one measure you go around various point around the tooth. These are the ____ area and these location points are next to the contact area on the mesial distal and middle area.
The contact area require specific identitifaction and location. why do you measure at several point around the tooth structure?
To see how the inflammation has spread around the circumference of the root called the ____ nature of periodontal diseases. It is not ____ around the tooth and varies in the different part around the tooth with different points where you measure difference and variability
contact
site specific
uniform
The pocket depth is the distance from the ____ to the position of the ____. You have loss of attachment from the CEJ to the en the probe
gingival margin
loss of attachment (LA)
It is important to account for the ____ in relation to the loss of attachment Here you see no loss of attachment
5mm pocket depth. The distance from CEJ to gingival margin is ____ and you have ____ of loss of attachment
Here 5mm pocket and you have ____ of gingiva and you have ____ of loss of attachment at that site. Attachment loss means periodontitis
5mm
1mm
4mm
recession
7mm
Histopathology of Periodontitis
Change in:
- ____
- ____
- ____
bone
cementum
PDL
Can see loss of attachment with ___. This is called ___ epithelium and with inflamed connective tissue (ICT).
The is the histopathology of periodontitis
rete pegs
Can see the probe and as a result there is bleeding on probing after pocket probing, not ___ type of probing
gingivitis
BOP
- ___
If you can quantitate the bleeding on probing on a quantitative basis you can be more accurate and sensitive on the presence of bleeding.
indices
Histopathologic progression of Periodontitis
- ___ and ___ classification
- Lesions: initial, early, established, advanced
This is classic method of ___. This is the one that will be emphasized the most in the histopathology that you learn
page
shcroeder
progression
Spread of Inflammation
- Stages of inflammation
- ___ pathways
- ___ through periodontium
- ___ versus ___ progression
- Altered pathway from ___ factor effect
- Accelerated progression after surgery in ___ dentitions
traditional pervasive acute chronic codestructive plaque-infected
Spread of Inflammation
In traditional pathways: inflammation go straight through the ___.
The spread of infection throughout the periodontium (he wrote a paper on this)
Acute ___ of disease activity (Socransky)
First person to be the author of your textbook was ___. At that time he said that if you have periodontitis and trauma from ___ you alter the spread of inflammation. Instead of going through the bone it spreads in the ___ and you have ___ pockets forming
Nyman (periodontist from Sweden) When he performed surgery, patient having plaque infection seem that there was greater ___ of disease compared to when the disease was only by itself. When doing surgery you should be carful that the infection and inflammation is well ___ or you will have accelerated progression of detachment loss
bone burst Glickman occlusion PDL infabony
spread
controlled
Osteoclastic bone resorption
The main ways that gingivitis cans spread to periodontitis. You have ___ bone ___
osteoclasts
resorption
Look through the pathway to periodontal disease!
YAY
