1A. Periodontal Pathology I Flashcards
• Typically, what’s the measurement from the CEJ to the alveolar crest in health? Answer: somewhere b/w ____. Sometimes, it’s a little controversial as to if it’s closer to 2mm, bc I’m gonna give you a number in a minute that would argue that it’s closer to 1mm, but in radiology, they’ve probably said 2mm.
1 and 2mm
Structures of the Periodontium in Health
The measurement from the ____ to the most ____ is equivalent to the depth of the gingival sulcus.
This typically ranges between ____mm.
gingival margin
coronal aspect of JE
1 to 3
Structures of the Periodontium in Health
The measurement between the most coronal aspect of the JE and it’s most apical extent represents the length of the ____ of gingiva to the tooth surface (~1mm).
The measurement between the most apical aspect of the JE and the bone crest is equivalent to the length of the ____ attachment of the gingiva to the tooth surface (~1 mm).
epithelial attachment
connective tissue
Biologic width = ____
____ attachment (1mm) + ____ attachment (1mm) = biologic width
2mm
epithelial
connective
Experimental Gingivitis Model
Initial study conducted by Harold Löe and his colleagues in Aarhus, Denmark.
Purposes:
- To attempt to produce ____ in patients with healthy gingiva by withdrawing all active efforts directed towards oral cleanliness, and
- to study the sequence of changes in the ____ and in the gingivae thus produced.
gingivitis
microbial flora
Experimental Gingivitis Model
Conclusions:
• ____ is essential for the development of gingivitis.
• The presence of certain bacteria at the onset of gingival inflammation suggests that there may be ____ organisms acting as periodontal pathogens.
• Individuals are differentially ____ to developing gingivitis; some develop the disease more quickly than others.
• Removal of ____ leads to resolution of gingivitis.
bacterial plaque
specific
susceptible
plaque
The Natural Progression of Periodontal Disease in Humans
- 480 male laborers at two tea plantations in Sri Lanka.
- No conventional oral ____ measures or dentistry; all subjects displayed uniformly large aggregates of ____, calculus and stain.
- Virtually all sites exhibited ____.
hygiene
plaque
gingival inflammation
The Natural Progression of Periodontal Disease in Humans
Three subpopulations were identified based on the rate of progression of disease (determined by CAL and tooth loss.
• ____ Progression (8%)
• ____ Progression (81%)
• ____ Progression (11%)
rapid
moderate
no
The Natural Progression of Periodontal Disease in Humans
“ Perhaps the finding of a small group (10%) of Sri Lankan tea laborers, participating in these studies who showed no progress of periodontal disease beyond the ____, was the most significant result.
The mere presence of such a group among a population who generally exhibits various degrees of rampant periodontal disease, is surprising and intriguing, and will be subject to future study.”
gingival lesion
◦ First of all: the 17yo pt was not free of dental plaque. She just didn’t have lot of calculus on her teeth, but there was a lot of plaque. In my mind, I would say that keeping teeth free of plaque is probably not the ____ (see the x) for why different people have different presentations bc obviously if it were just a matter of keeping plaque off, then you would expect that the patient in the top left pic would have teeth that looked like what’s seen in the lower right radiograph, and that just isn’t the case.
explanation
Page and Schroeder Histologic Stages of Gingivitis and Periodontitis
Initial Lesion (Clinical Health)
- Slightly elevated vascular ____ and vasodilation.
- ____ flows out of the sulcus.
- Migration of ____, primarily PMNs, in relatively small numbers through the gingival connective tissue, across the junctional epithelium and into the sulcus.
Early Lesion (Early Gingivitis)
- Increased vascular ____, vasodilation and GCG flow.
- Large numbers of infiltrating ____ (mainly PMNs and lymphocytes.
- Degeneration of ____.
- ____ degradation, resulting in collagen depleted
of the connective tissue.
- Proliferation of the ____ and sulcular epithelium
collagen-depleted areas.
permeability
GCF
leukocytes
permeability leukocytes fibroblasts collagen junctional
Page and Schroeder Histologic Stages of Gingivitis and Periodontitis
Established Lesion (Established Gingivitis)
- Dense ____ cell infiltrate (PMNs, plasma cells, lymphocytes).
- Accumulation of inflammatory cells in ____ tissue.
- Elevated release of ____ and the lysosomal contents from PMNs.
- Significant ____ depletion and epithelial proliferation.
- Formation of ____ epithelium containing large numbers of PMNs.
Advanced Lesion (Periodontitis)
- Predominance of PMNs in the ____ epithelium and pocket.
- Dense inflammatory infiltrate in connective tissues that is made of predominantly ____ cells.
- ____ migration of the junctional epithelium to preserve an intact epithelial barrier.
- Continued collagen breakdown resulting in large areas of collagen depleted connective tissue.
- ____ resorption of bone.
inflammatory connective MMPs collagen pocket
pocket
plasma
apical
osteoclastic
Bacterial Biofilms
Matrix that are adherent
to each other and/or to surfaces or substrates.
- May contain a single or multiple ____ species.
- Composed of multiple ecological “____” communities
- Numerous distinct ____ exist within a biofilm each with radically different pHs, [oxygen], temperatures and electrical potentials.
- Biofilms exhibit ____ circulatory systems
- Biofilm bacteria exhibit metabolic ____.
- Bacteria living within a biofilm are relatively ____ to host defense mechanisms.
- Bacteria living within a biofilm are relatively resistant to systemically and locally
delivered ____.
bacterial micro microenvironments primitive cooperativity resistant antimicrobials
• Now we look at someone who has gingivitis and look at their histologic situation - we can see that the junctional epi (the coronal aspect of it) has moved slightly ____, the apical aspect of JE has NOT ____ and is still at the CEJ, and the bone crest has not ____ either. So, e.g. of how someone could get this situation - they start off in perio health and then do the experimental gingivitis model for enough time to collect some plaque on their teeth and then they have this histo situation.
◦ Does anyone remember what else happens here that I didn’t put into the picture? (answer: ____)
‣ Edema where? Why does edema happen? He heard like 5 answers and didn’t understand any of them
(I can relate to this on a spiritual level, since this sentence is me throughout all of dental school, tbh). (see below)
changed
changed
changed
edema
Determinants of the microbial
• Where are the fluids in edema coming from?
◦ If we’re talking about edema, we’re not going to say the fluids come from the gingival sulcus. The fluid might
contribute to what’s in the gingival sulcus, aka GCF, but in order to get edema, there are certain structures that you have to have present. Think about Dr. Ali’s lectures when he talked about inflammation. (tbt to one hell of an exam @FS2) There’s increased vascular permeability and vasodilation, so we’re talking about blood vessels. Where are the blood vessels? They’re in the gingival connective tissue. There are no blood vessels in the epi itself. So, there’s a collection of edematous fluid in the gingival connective tissue, and there was an anatomic change that I told you about that occurs as a result of edema in the underlying connective tissue: the gingival margin can migrate in an incisal or ____ direction.
‣ Why is this important?
• As a result of incisal/coronal movement of the gingival margin, some of the plaque that’s
accumulated supra-gingivally is now gonna be positioned ____. That matters because it’s going to develop into a different ____ than the plaque that existed supra-
gingivally. Now we have to think of sub-G conditions and how that impacts the composition of the plaque matrix. Change in the position of the JE = pretty minor; just about a fraction of a millimeter.
coronal
sub-G
microenvironment
• Now looking at periodontitis picture.
◦ Number of significant changes:
‣ The apical extent of JE is NO LONGER AT THE ____. The remnants of the epi attachment have moved ____, and that’s indicated by this yellow arrow. This is a very significant change.
‣ In periodontitis, there is overt resorption of ____ bone. We can measure the amount of bone loss based on comparing where the crestal bone is to where it was in health - can range from 1-15mm depending on how long the root of the tooth is.
• **Why I say all of this is to get you to start thinking about the fact that the env in a periodontal pocket is different than the env in a gingival pocket, which is very different from the conditions that affect plaque that grows supra-gingivally. Supra-G plaque is exposed to saliva and a high O2 conc. of oral cavity.
◦ Middle pic (gingivitis):
‣ ____ from something where the plaque is bathed in saliva to a situation where some of it is bathed in gingival crevicular fluid
‣ O2 tension may be a little bit lower
◦ Right pic (periodontitis):
‣ All of the nutrients are derived from GCF
‣ O2 tension is very very very low, if theres even any O2 there at all
‣ Temp is different
◦ So, the types of bacteria found in each of these scenarios are dramatically different from one another - again, the composition of bacteria is driven largely by the characteristics of the local microenvironment that the bacteria are exposed to.
CEJ
crestal
transitiioning
• When we talked about this last year in the context of perio microbiology, we talked a lil bit about the ecologic plaque hypothesis said by Dr. Marsh. He already accepted that supra-G and sub-G plaque are different types of plaque, but he really appreciated that it was the ecology or the ____ of a given niche that dictated the types of organisms that were present.
• So, in a state of health:
◦ Minimal inflammation, low ____ flow, and a higher ____ conc
◦ Microflora = consistent with periodontal health
‣ Mainly ____, many of which are ____ anaerobic organisms
‣ His argument is that the reason for the presence of these organisms is the environment they were
exposed to - high O2 conc, carbs as nutrient source, and this whole idea that this was relatively consistent in the supra-G environment.
microenvironment GCF higher O2 gram-positive cocci and rods facultative
The ecologic plaque hypothesis
• Change in pt’s oral hygiene and plaque accumulates –> plaque induces an inflammatory reaction. The inflammatory reaction alters the flow of GCF, it alters the conc. of O2, and as a result, it drives the transition in the composition of the microflora from something that’s gram-positive and facultatively anaerobic to something that’s predominantly ____ composed of mainly ____ anaerobic organisms.
◦ If you remember, these were the types of organisms that are typically found in the pockets of patients who have periodontitis. His info was really trying to associate these changes in the composition of the microflora with the changes that occur from perio health to the environment that we find in the periodontal pocket.
gram negative
obligate
- Just reminding you - the organisms that are characteristic of early supra-gingival plaque, consistent with perio health, tend to be ____. (reads the names of the organisms associated with onset of gingival inflammation and also the names of the organisms that are associated with the induction of attachment loss)
- We will talk about individual organisms and the individual organisms are the ones he will ask us to remember.
- ***Bottom line: as we transition from health to periodontitis, there’s a transition from Gram-positive to ____ microflora and transition from something that’s predominantly ____ anaerobic to one that contains large numbers of strict ____ and ____ (organisms that prefers a little bit of CO2 in their environment).
gram-positive cocci and rods gram-negative facultatively anaerobes capnophiles
• NEED TO MEMORIZE THESE TWO LISTS
• This info is from work done by Forsythe research facility in Boston under direction of dr. Socransky
• Left box: consensus perio pathogens
◦ The ones that most people agree upon as being important.
◦ These first three (____, ____, ____) are the members of the red complex that was fined by Dr. S and his coworkers.
• Last year, I told you that these complexes (top pic with colored circles) are based upon the fact that you tend to find these organisms associated with each other. E.g. if you find Prevotella intermedia, there’s a high likelihood that you’ll find these other orange organisms with it, or organisms in the green circle with other organisms in the green circle.
• Similarly, for RED complex: if you find P. gingivalis, you’re also likely to find Tannerella forsythia and Treponema denticola. Some people think these three (red complex) are the really bad guys, but the American Academy of Periodontology argues that AA is also an important perio pathogen. Therefore, we NEED TO KNOW THESE FOUR ON THE LEFT (P. gingivalis, T. forsythia, T. denticola, ____).
p gingivalis
tannerella forsythia
treponema denticola
AA
