13. Final Case Review

Question 1

Normal Periodontium

First of all: normal periodontium has been taught so many times. You should print this image into your mind:
• Where is your CT and JE and PDL and alveolar bone and gingiva? (points to all of them on the diagram)
• Where is your keratinized tissue and your attachment gingiva? You need to really remember all of this.
• Where are you going to probe?
◦ The ____, the pocket.

Answer 1

sulcus

Question 2

When you look at a periodontitis patient, you need to see the reasoning behind the disease. How does it happen?
◦ At the beginning, you need to have ____ to initiate the disease - plaque. Also, your ____ - your body is helping you to defend against the bacteria, but it might also cause some breakdown of the connective tissue and bone.
◦ In the first year, I talked about some perio-systemic relationships. You also need to consider that ____
and diabetes will influence the disease.
◦ Also remember the clinical signs of all of the diseases of initiation.

Answer 2

bacteria
host response
smoking

Question 3

• Erosion (sometimes called corrosion): usually in the ____ area of facial surface of tooth. May be caused by ____ or citrus fruits.
• Abrasion: loss of tooth substance by ____ wear. Horizontal ____ (scrubbing) with an abrasive dentifrice is the most common cause.
• Attrition: occlusal wear due to ____ contacts with opposing teeth. Results in ____ on the occlusal surfaces of teeth. May be due to functional or ____ habits.
• Abfraction: ____ loading resulting in tooth flexure, mechanical microfractures, and tooth substance loss in the cervical area. May appear similar to ____.

For the periodontal examination, periodontists will always focus on the gum, but it’s not only the gum that is important. You need to analyze the tooth as well. There are some signs (erosion, abrasion, attrition, and abfraction) that are closely related to occlusion. As a periodontist, I think that it’s important to think about occlusion; it could be part of your treatment plan.

Answer 3

cervical
acid beverages
mechanical
toothbrushing
functional
wear facets
parafunctional
occlusal
erosion

Question 4

Facial & Lingual Probing

✓ ____ the probe
✓ Parallel to ____

When you probe, you are recording 6 points in Axium, but you’re not probing only 6 points. You should WALK the probe around to every single point. Write down the deepest parts of each section as your number for that section/one of the six points.

When you are probing, do you need to remove the probe after every single point? ____. You stay in the sulcus for the entire time. You’re just walking the probe around. This also makes patients feel more comfortable. So, put your probe in the pocket and very quickly walk through and find the deepest part to mark.

**Repeats again: walking the probe is the key point!

Answer 4

walking
vertical axis
no

Question 5

Forget about everything I’ve talked about so far (perfect) and let’s talk about what’s really important, the ____ (points to osseous crater cartoon):
• Pretend that the left pic is your bone and the right pic is your grandma’s bone. Lots of periodontal disease
patients lose bone in the interproximal area. “A lot of patients have this.” - says this 390 times.

• Probing:
◦ Healthy patient: most likely will have similar readings between probing at the line angle interproximally and at the full interproximal area/closer to the contact point
◦ Periodontal disease patient: much ____ probing in the crater area (full interproximal area/closer to the contact point) than in the line angle area

Answer 5

crater defect

deeper

Question 6

Interproximal Probing

• to detect ____ point of interdental crater
• probe should be placed ____

We need to have a little bit of angulation of the probe tip to the middle part of the interproximal surface bc a LOT of patients have the crater defect.
• If you see a 20yo patient, do you still need to do this? Yes, but you won’t feel the drop that you would if probing
a crater defect.
• If you probe the interproximal area in a healthy patient, you’ll have similar probing at line angle or full inteproximal
area. Actually, a lot of young patients may have a little bone loss in that crater area and it’s your job to catch it.

When you are probing, esp in posterior area, the ____ part of probe should be as close to contact point as possible. Don’t have very exaggerated angles of probing either, because that will cause inaccuracies too. If you probe like this (middle pic), you won’t miss interproximal crater defect.

Answer 6

deepest
obliquely
coronal

Question 7

What Is Clinical Attachment Level (CAL)?
• CAL: distance between the ____ and the tip of the ____ (base of the sulcus/ pocket)

What is CAL?
◦ ____ - I’ve said this 1000x, but make sure you remember it. This measurement is the base of ALL of perio diagnosis, so don’t forget this definition.

Answer 7

CEJ
periodontal probe

CEJ to base of pocket

Question 8

Miller’s Classification of Mobility (1938)

Class 1
The first distinguishable sign of ____ greater than normal

Class 2
Movement of the crown as much as ____mm from normal position in any direction

Class 3
Movement of crown > ____mm in any direction and /or ____ depression / rotation of the tooth

Answer 8

movement
1
1
vertical

Question 9

Miller’s Classification of Mobility (1938)

There are some classifications we need to know. Mobility class 1-3 uses Miller Classification. Remember this classification!!
• For class 3 it’s the easiest bc you may have \_\_\_\_ depression, but horizontal movement is also very big here. This wording is from the original paper (reads the slide) — this means that from normal position to buccal, there’s more than 1mm (for class 3). If you combine buccal and lingual (aka if you look at movement from buccal to lingual and not just from normal to buccal or normal to lingual), you need to have more than \_\_\_\_mm to be class 3. Don’t be confused bc the paper used 1mm, but that was only bc it was from NORMAL position to B or to L, but if you combine B and L, it should be more than 2mm to become class 3.

• If it’s \_\_\_\_mm from the buccal to the lingual (which would correspond to 1mm from normal to buccal and 1mm from normal to lingual), then it’s class 2.
• If it's less than \_\_\_\_mm from normal to buccal or normal to lingual, then it's class 1.
• Wording on NBDE could confuse you and they could try to trick you, so memorize this wording. Know the difference in
measurements if it’s from normal to buccal or normal to lingual or if it's looking at buccal + lingual (essentially, just know if the question is using the normal position as a reference point for the measurement or if it's looking at total buccolingual mobility overall).

Answer 9

vertical
2
1-2
1

Question 10

Miller’s classification of recession

✤ Class I: Marginal soft tissue recession not extending to the ____ with no loss of ____ bone or soft tissue
✤ Class II: Marginal soft tissue recession extending to or beyond the ____ with no loss of ____ bone or soft tissue
✤ Class III: Marginal soft tissue recession extends to or beyond the ____ with interdental loss of ____ or soft tissue, apical to the CEJ but coronal to the level of ____ recession
✤ Class IV: Marginal soft tissue recession extends to or beyond the ____ with loss of interdental bone or soft tissue apical to the level of the ____ defect

Answer 10

MGJ
interdental
MGJ
interdental
MGJ
bone
soft tissue
MGJ
recession

Question 11

Miller’s Classification of Recession

Miller has another classification - recession. Remember that Dr. Perez talked about Cairo classification and I talked about Miller classification before - they are different things.
• Classes 1 and 2: no ____ tissue loss.
◦ The difference b/w class 1 and 2: if you reach the ____ or not.
• Classes 3 and 4: starting to have ____ tissue loss.
◦ Difference b/w 3 and 4:
‣ Class 3: ____ recession is more than interproximal tissue loss
‣ Class 4: ____ tissue loss is more apical than recession

Answer 11

interproximal
MGJ
interproximal
buccal
interproximal

Question 12

Furcation Involvement

Special Design Probe (____ Probe) for detect horizontal component of furcation lesions

If you see her using a straight probe to check the furcation, it’s because she has no time and is running between patients.

You should ALWAYS use ____ probe to check for furcation. Some studies show that it’s more accurate for checking the furcation. When you talk about furcation involvement, you’re talking about the ____ bone loss component. In our clinic, they don’t have marks, so we are kind of guessing (cheers to winging it). It’s always good to have a mark. This mark is usually is ____mm.

Answer 12

nabers
nabers
horizontal
3

Question 13

Hamp Classification of Furcation Involvement (1975)

Degree I. - horizontal loss of periodontal tissue support that is less than ____ mm

Degree II. - horizontal loss of periodontal tissue support that is greater than ____ mm but does not encompass the width of the ____ (Cul-de-sac)

Degree III. - horizontal destruction of periodontium that is ____

• If it's class 1, it's less than 3mm; that's why the marker is at 3mm.
• If it's class 2, it's greater than 3mm, but the defect is not "through and through."
• If it’s class 3, it’s a through and through defect.
◦ Aka you open the flap and then you see the through and through defect of the bone.
◦ **For reference: Another classification for furcation involvement (is similar to Hamp) is Glickman (sp?). For
that classification, they don't really talk about numbers, and there’s also class 4 furcation involvement.
‣ Glickman furcation involvement class 4 = you can directly see the \_\_\_\_ defect
(because of \_\_\_\_ loss) without opening the flap.

Answer 13

3
3
furcation
through and through

through and through
soft tissue

Question 14

1999 AAP International Workshop

• Chronic periodontitis can be further characterized by extent and severity

• ____: < 30% of sites involved
• ____: > 30% of sites involved

‣ Slight: ____ mm of clinical attachment loss
‣ Moderate: ____ mm of clinical attachment loss
‣ Severe: ≥ ____ mm of clinical attachment loss

Answer 14

localized
generalized
1-2
3-4
5

Question 15

I want to briefly talk about implants, because you haven’t learned about implants yet. Next year, we’ll have a lecture from her on basic implant surgery, but she wants us to see implants first.

What’s the difference b/w implant and tooth?
Implant does NOT have ____ around it. Implant directly contacts the bone. (quiz question)
There is no PDL around the implant, but the implant does have CT and JE.

Implant also has - above the crest - CT and long JE around the cervical part of the implant, but there are some differences b/w implant and tooth.
◦ Tooth: There’s some CT inserted into the cementum. It’s ____ to the root surface.
◦ Implants: no ____. Instead, it’s the material you use. The fibers are parallel to the implant surface.
‣ That’s also why ____ easily happens in implant-treated areas, aka one of the reasons is that the CT is parallel (and not perpendicular) to the implant surface.
‣ Sometimes, it’s also circular around the implant surface area, like a cuff sealing the area, but it’s NEVER ____ to the implant surface.
‣ Remember that the implant also has ____ epithelium.
‣ One more time: implant does NOT have ____ (she really stresses this).

Answer 15

PDL
perpendicular
cementum
periodontitis
perpendicular
PDL

Question 16

Microbiology of Specific Periodontal Diseases

• Periodontal health: Gram (____) facultative cocci and rods (Streptococcus & Actinomyces)
• Chronic periodontitis: Gram (____) anaerobic species ( P. gingivalis, T. forsythia, P. intermedia, F.
nucleatum, T. denticola )
• Localized aggressive periodontitis: ____
• Necrotizing diseases: ____, spirochetes, and Fusobacterium species
• Pregnancy-associated gingivitis: ____
• Periodontal abscesses : Gram (____) anaerobic species, F. nucleatum, P. intermedia, P. gingivalis, P. micros, and T. forsythia
• Peri-implant disease: Gram (____) anaerobic species

NBDE part 2 really loves asking which bacteria are associated with which diseases. You can have other bacteria than the ones listed, but the ones here are the ones that are most closely related to the conditions listed.
• Perio health: (reads slide) You may still have Gram (-) bacteria, but the amount is ____.
• Chronic periodontitis:
◦ What color complexes do you have here? ____. (reads slide)
• Localized aggressive periodontitis: very strongly correlated to Aa, but you don’t always need to have it. Most
of the cases have it.
• (Reads necrotizing diseases and pregnancy-associated gingivitis)
• Periodontal abscesses and peri-implant disease: very similar to chronic periodontitis. Just know that they are
similar. Gram (____) orange and red complexes.

Answer 16

-
-
Aa
p. intermedia
p. intermedia
-
-

lower
red and orange
negative

Question 17

Local factors

• ____ projections
• enamel pearls
• ____ ridge
• palatogingival groove
• ____ length
• root proximity
• ____ contact
• overhanging restorations

Answer 17

cervical enamel
intermediate bifurcation
root trunk
open

Question 18

Local factors

• Intermediate bifurcation ridge (C): I think I told you last year that this is the lower molar (left side of pic is distal root; right side of pic is mesial root). You have an intermediate bifurcation ridge (she says bridge, but I think she’s referring to the intermediate bifurcation ridge) here; if you have furcation involvement, it’s easy to have ____ accumulation here at the IR. It’s really hard to clean. If you don’t open up the tissue flap, you can’t really clean it well. That’s why intermediate bifurcation ridge is part of the local contributing factors.
• Some upper anterior teeth will have a palatogingival groove (D). This will make an isolated ____ depth and it might not be only an endo problem. Might also be a perio problem if this type of anatomy is there.
• Root trunk length (E): If you have ____ root trunks, it’s easier to get furcation involvement.
• Root proximity: this is very important because it makes the area hard to ____, either through non-surgical or surgical therapy

Answer 18

plaque
pocket
shorter
clean

Question 19

Local factors

• Open contact: Important because it’s easy for food to get trapped there. If you have an open contact, it’s better
to control this before you get to the ____ phase of your treatment.

• Overhanging restorations (F): When you are treating a phase 1 perio treatment, you need to work with restorative faculty to correct some of the local contributing factors. They might not be able to do definitive treatment at that time because we need to clear the periodontal condition in order to do ____ restorative, but you can either change to a temp crown or change the restoration.

Answer 19

phase 2

phase 2

Question 20

McGuire & Nunn

Good
Control of the etiologic factors and adequate periodontal support as measured clinically and radiographically to ensure the tooth would be relatively easy to ____ by the patient and clinician assuming proper maintenance.

Fair
Approximately ____%
attachment loss as measured clinically and radiographically and/or ____ furcation involvement. The location and depth of the furcation would allow proper ____ with good patient compliance

Answer 20

maintain
25
class I
maintenance

Question 21

McGuire & Nunn

Poor
____% attachment
loss and ____ furcations. The location and depth of the furcations would allow proper ____, but with difficulty.

Questionable
>____% attachment
loss resulting in a poor ____ ratio. Poor root form. ____ furcations not easily accessible
to maintenance care, or ____ furcations. ≥____+ mobility. Significant root proximity.

Hopeless
Inadequate attachment to maintain the tooth in health, comfort, and function. ____ was performed or suggested.

Answer 21

50
class II
maintenance

50
crown/root
class II
class III
2
extraction

Question 22

McGuire & Nunn

Dr. Perez talked about this before. This (McGuire and Nunn) is the classification she suggests we should know because NBDE really likes to test this. Five levels: good, fair, poor, questionable, and hopeless (which parallel responses to how dental school’s going as time goes on😅 ). The good thing about this classification is that there are some guidelines. I will show you another set of prognosis guidelines but you DON’T need to know those.
McGuire is easier for us to follow because you don’t know how predictable your perio treatment will be. While other prognosis guidelines are based on experience to make judgments about the teeth, this one (McGuire) is based on numbers, so we should use those. When she asks us in clinic about ____, she wants us to answer based on the McGuire classification.

Answer 22

prognosis