2. The Diseased Periodontium Flashcards
Classification of Periodontal Diseases and Conditions*
▪ Gingival Diseases
• Plaque-Induced Gingival Diseases
• Non-Plaque-Induced Gingival Lesions
▪ Chronic Periodontitis
▪ Aggressive Periodontitis
▪ Periodontitis as a Manifestation of Systemic Disease
▪ Necrotizing Periodontal Diseases
▪ Abscesses of the Periodontium
▪ Periodontitis Associated with Endodontic Lesions
▪ Developmental/Acquired Deformities and Conditions
*____ for the Classification of Periodontal Diseases
1999 International World Workshop
Classification of Periodontal Diseases and Conditions
▪ Gingival Diseases
• ____-Induced Gingival Diseases
▪ ____ Periodontitis
▪ ____ Periodontitis
plaque
chronic
aggressive
Plaque-Induced Periodontal Diseases
Gingivitis - ____ of the gingiva
Periodontitis - inflammation and destruction of the ____
Attachment apparatus: ____ & ____ and ____
inflammation
attachment apparatus
cementum
alveolar bone
PDL
Structure of the Periodontium
Can only see ____ histologically
PDL
Plaque-Induced Gingivitis
Mild > Moderate > Severe
Moderate > fair amount of ____
Severe > ____, ____ bleeding
____ classification
edema
edematous
spontaneous
subjective
Plaque-Induced Periodontitis
Severity can be based on: ____ levels (measurement you make with periodontal probe), look at extent of ____ relative to length of root (<25% is mild, 25-50% is moderate, >50% is advanced)
Need ____ in order to make classification
____ vary from individual to individual, and from anterior to posterior teeth
attachment
bone loss
PA radiographs
roots
Page and Schroeder Lesions
Defined four phases of disease: ____, ____ and ____; and then an ____ lesion: periodontitis
initial
early
established
advanced
Page and Schroeder Histologic Stages of Gingivitis and Periodontitis
Initial Lesion (Clinical Health)
- Slightly ____ vascular permeability and vasodilation.
- ____ flows out of the sulcus.
- Migration of leukocytes, primarily PMNs, in relatively ____ numbers through the gingival connective tissue, across the junctional epithelium and into the sulcus.
Early Lesion (Early Gingivitis)
- Increased vascular permeability, vasodilation and ____ flow.
- ____ numbers of infiltrating leukocytes (mainly PMNs and lymphocytes.
- Degeneration of ____.
- Collagen ____, resulting in collagen depleted areas of the connective tissue.
- Proliferation of the ____ and ____ epithelium into collagen-depleted areas.
No one has inflammation-____ periodontium > neutrophils migrate into JE into the gingival sulcus > low-level inflammatory reaction that cannot be seen clinically, but can be seen histologically
elevated
GCF
small
GCG large fibroblasts degradation junctional sulcular
free
Page and Schroeder Histologic Stages of Gingivitis and Periodontitis
Established Lesion (Established Gingivitis)
- ____ inflammatory cell infiltrate (PMNs, plasma cells, lymphocytes).
- Accumulation of inflammatory cells in ____ tissue.
- Elevated release of ____ and the ____ contents from PMNs.
- Significant collagen 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.
- Apical migration of the ____ epithelium to preserve an intact epithelial barrier.
- Continued collagen breakdown resulting in large areas of collagen depleted connective tissue.
- ____ resorption of bone.
Established = ____ from of periodontitis
dense connective matrix metalloproteinases (MMPs) lysosomal contents pocket
pocket plasma junctional osteoclastic severe
Page and Schroeder Lesions
Initial lesion > Early lesion > Established Lesion > Advanced Lesion
No radiographic evidence of ____!
alveolar bone loss
Healthy Periodontium
Lines represent the ____ bundles of the gingival CT
principal fiber
Healthy Periodontium
The measurement from the gingival margin to the most coronal aspect of the ____ is equal to the ____ depth.
- Histologically, the mean gingival sulcus depth is ____ mm.
- Clinically, the gingival sulcus depth ranges from ____ to ____ mm in health.
____ > presence of pathology; gingival sulcus is normal
JE gingival sulcus 0.6 1 3
Healthy Periodontium
Epithelial Attachment of Gingiva (mean of ____ mm)
Connective Tissue Attachment of Gingiva (mean of ____ mm)
Biologic Width = Epithelial Attachment + Connective Tissue Attachment = mean of ____ mm
CT only serve purpose of attaching ____ to the teeth
JE ends at the ____
1.0
1.0
2.0
soft tissues
CEJ
Health Periodontium
Histology:
- Intact junctional epithelium without ____.
- Intact connective tissue attachment of the gingiva to cementum via ____.
- Alveolar bone crest positioned approximately ____ mm apical to the
cementoenamel junction.
- Sparse number of neutrophils transmigrating from the vascular plexus through the junctional epithelium into the sulcus.
Clinical Findings:
- Gingiva is ____ (can be ____).
- Clearly defined ____ junction.
- Gingiva is ____.
- ____ gingival margins.
- Gingiva is ____.
- Probing depths of ____ to ____ mm without bleeding on probing
Radiographic Findings:
- Clearly defined alveolar bone crests positioned approximately ____ mm apical to the cementoenamel junction.
- Clearly defined ____.
- Absence of ____ defects.
- Intact ____ bone.
____ = spaces bt multi-rooted teeth are filled with defined bone
rete ridges
gingival fiber bundles
2
coral pink pigmented mucogingival firm 1 3
2
lamina dura
infrabony
furcal
infurct
Periodontal Probing of the Healthy Periodontium
The histologic sulcus has a mean depth of ____ mm while clinically, probing depths range from ____ to ____ mm due to penetration of the junctional epithelium (up to ____ of its length).
We do not have sufficient ____ sensation to stop at the mean depth of gingival sulci; that’s why the depths are ____ than what they actually are
0.6
1
3
50%
tactile
deeper
The Early Lesion: Mild Gingivitis
Clinical Findings: - Marginal gingiva is slightly \_\_\_\_ and edematous. - Slightly \_\_\_\_ gingival margins. - Increase in probing depth (typically less than \_\_\_\_ mm) and minimal \_\_\_\_. - Clearly defined \_\_\_\_ junction. - Gingiva is \_\_\_\_. Radiographic Findings: - No \_\_\_\_ relative to health.
erythematous rounded 1 BOP mucogingival stippled changes
The Early Lesion: Moderate Gingivitis
Clinical Findings: - Overlaps with mild gingivitis; no \_\_\_\_ dividing line. - Increased \_\_\_\_ and edema. - \_\_\_\_ gingival margins. - Increase in probing depth (typically less than \_\_\_\_ mm) with \_\_\_\_. - Loss of \_\_\_\_. - Clearly defined \_\_\_\_ junction. Radiographic Findings: - No \_\_\_\_ relative to health.
clear cut erythema rounded 1 BOP stippling mucogingival changes
The Early Lesion: Mild to Moderate Gingivitis
Histology:
- Lateral proliferation of junctional epithelium yielding additional ____.
- ____ blood vessels.
- Increased numbers of transmigrating PMNs in the JE.
- Accumulation of inflammatory cells (PMNs and lymphocyte) cells immediately
subjacent to the ____ at the site of ???
- Cytopathic alterations of ____.
- Intact connective tissue attachment of the gingiva via ____.
- Alveolar bone crest positioned approximately ____ mm apical to the CEJ.
rete ridges dilated JE resident fibroblasts gingival fiber bundles 2
Gingival Pocket
Gingival Pocket – deepening of the ____ resulting primarily from an increase in the bulk of the ____ without ____ of the junctional epithelium or appreciable destruction of the underlying connective tissue.
Coronal aspect of JE ____ from surface of tooth, and ____ migration of gingival margin > change in ____ depth
gingival sulcus
gingiva
apical migration
detaches
apical
coronal
Periodontal Probing of Mild to Moderate Gingivitis
Relative to health, there may be an ____ in probing depth detected in patients with mild gingivitis due to penetration of the JE to within ____ mm of its apical aspect by the probe.
Inflamed CT lack ____ when compared to normal health
Compromised ____ > increase in probing depth
increase
0.1
strength
attachment
The Established Lesion: Severe Gingivitis
Clinical Findings:
- Tissue may have a ____ color.
- ____ bleeding.
- Increased erythema and edema.
- ____ of marginal and interproximal gingiva.
- Increase in depth of gingival ____ with bleeding on probing.
- Further loss of ____.
- Clearly defined ____ junction.
Radiographic Findings:
- No ____ relative to health.
cyanotic (bluish) spontaneous "overgrowth" pockets stippling mucogingival
changes
The Established Lesion: Severe Gingivitis
Histology:
- Further lateral proliferation of junctional epithelium yielding additional ____.
- Formation of ____ epithelium.
- Accumulation of ____ cells and ____ in the connective tissue.
- Leukocyte ____ at plaque front.
- Severe ____ damage and further collagen loss.
- Further loss of ____ supporting the marginal gingiva
- Intact connective tissue attachment of the gingiva via ____.
- Alveolar bone crest positioned approximately ____ mm apical to the CEJ.
Inferior aspect of JE doesn’t ____, still remains at the CEJ
During periodontitis, the ____ structure moves apically (including the inferior aspect of the JE)
rete ridges pocket plasma immunoglobulin "wall" fibroblast collagen gingival fiber bundles 2
move
whole
Gingival Pocket
Gingival Pocket – deepening of the gingival sulcus resulting primarily from an increase in the bulk of the ____ without apical migration of the junctional epithelium or appreciable destruction of the underlying connective tissue.
____ pushes the gingival margin upwards
gingiva
edema
Periodontal Probing of Severe Gingivitis
Relative to health, mild and moderate gingivitis, there may be an additional ____ in probing depth detected in patients with severe gingivitis due to:
- ____ resulting in coronal migration of the gingival margin.
- probe penetration through the ____.
- The inferior aspect of the epithelial attachment does not move ____!
Severe gingivitis > penetrates the entire epithelium, and the intact ____ end up halting the probing depth
increased
edema
junctional epithelium
apically
principal fiber bundles
The Advanced Lesion: Periodontitis
Clinical Findings: Highly Variable - Presence of \_\_\_\_ and calculus. - Gingival \_\_\_\_ and edema. - Absence of \_\_\_\_. - \_\_\_\_ bleeding and/or \_\_\_\_. - Gingival \_\_\_\_. - Tooth \_\_\_\_ and/or fremitus. - Loss of \_\_\_\_. - The \_\_\_\_ junction may not be well defined. - Probing depths of \_\_\_\_ mm or greater with bleeding on probing. on probing. - Others
Smoking has a ____ factor
plaque erythema papillae spontaneous suppuration recession mobility stippling mucogingival 4
vasoconstrictive
The Advanced Lesion: Periodontitis
Radiographic Findings: Highly Variable
- ____ calculus.
- ____ bone loss.
- Bone loss in ____.
- Widening of ____.
- Others
subgingival
crestal
furcations
PDL
The Advanced Lesion: Periodontitis
Histology:
- ____ proliferation of the pocket (junctional) epithelium.
- ____ of the pocket (junctional) epithelium.
- Periodontal ____ formation.
- ____ blood vessels.
- Massive inflammatory infiltrate predominated by ____ cells.
- Further loss of collagen supporting the marginal gingiva including breakdown of the ____ making up the connective tissue attachment of the
the gingiva to the teeth.
- ____ resorption.
apical ulceration pocket dilated plasma gingival fiber bundles alveolar
Periodontal Pocket
Periodontal Pocket (True Pocket) – a pathologically deepened ____ resulting from ____ migration of the junctional epithelium along the root as the ____ is detached as a result of a disease process.
____ is degraded in periodontitis
Edema causing the ____ migration of the gingival margin
Most increase in probing depth is due to the ____ part of the JE and the movement of the entire ____…
gingival sulcus
apical
PDL
CT attachments
coronal
coronal
JE
Periodontal Pocket
____ of the junctional epithelium is likely to contribute to accumulation of bacteria and their products in the gingival connective tissue.
Presence of ____
Epithelium does not have vasculature; if you see bleeding coming from there, then the integrity of the ____ surface is comprised > an ulcerated epithelium
If this is in a periodontal pocket, referred to as a ____ epithelium (this is the explanation for BOP)
More common to have bleeding on periodontal pockets…
Disintegrating epithelial layer > ____ products can infiltrate the connective tissue > interact with innate and adaptive immune cells > ____ process > ____ > bone-resorption
JE acts as an important form of ____ immunity (as a physical barrier)
ulceration
RBC
epithelial
pocket
bacterial
inflammatory
osteoclastogenesis
innate
Pocket Epithelium
Cells are undergoing ____
apoptosis/necrosis
The Advanced Lesion: Periodontitis
The body appears to always protect the alveolar bone by covering it with healthy ____ (approximately ____ mm in thickness).
Perio probe sits above this ____
connective tissue
1
structure
Periodontal Probing of Periodontitis
The probe penetrates through the junctional epithelium and inflamed connective tissue until resistance occurs when it encounters healthy ____.
Can have measurements over ____mm and not have ____ loss
> 5mm: patient will have some ____ loss (with some exceptions, like ____)
connective tissue 4 attachment attachment drug-induced gingivitis
Suprabony versus Infrabony Periodontal Pockets
Suprabony Pocket:
The base of the pocket is ____ to the level of the underlying bone.
- Bone crest must absorb ____ and ____
Infrabony Pocket:
The base of the pocket is ____ to the level of the adjacent bone.
- Bone crest has ____ bone less
____ > gingival overgrowth
Position of base of pocket relative to bone crest…
coronal
apically
uniformly
apical
vertical
pseudopocket
Periodontal Pockets
Suprabony Pockets
The extent of bone loss is relatively ____. The pattern of bone loss is referred to as being ____.
Infrabony Pockets
The extent of bone loss is ____. The pattern of bone loss is referred to as being ____.
uniform
“horizontal”
variable
“vertical”
