4. Comprehensive Periodontal Disease Flashcards
Goals
Collect as much ____ as possible
• Clinical signs & symptoms
Risk factors: systemic, local Dental history
Clinical examination
Establish a ____
Disease classification
Etiology
Give a ____ to the patient
Tooth by tooth
Will vary with patient acceptance of treatment and type of treatment
information
diagnosis
prognosis
Patient Information Collection
____, ____ model, and an ____ picture
x-ray
study
intraoral
Basic Evaluation of a Dental Patient ✦ \_\_\_\_ history ✦ \_\_\_\_ history ✦ \_\_\_\_ examination ✦ \_\_\_\_ examination
medical
dental
radiographic
clinical
Basic Evaluation of a Dental Patient
- Medical History • \_\_\_\_ Classification • Systemic diseases • \_\_\_\_ • Allergies • \_\_\_\_ • Family history
Last week, we talked about ASA Classification. This is the ____ evaluation you should make of the patient.
You have to ask the patient of their systemic disease. For example, diabetes, smoking, and high blood
pressure are all things you need to be aware of before you begin examining the patient.
For medication, if a patient has high blood pressure, maybe they are taking a ____ blocker that can cause gingiva hyperplasia. Gingiva hyperplasia can also result from a patient taking ____ for seizures.
Organ transplant patients take ____ . These 3 kinds of drugs are closely related to perio, so it is
important to understand the patient’s medication.
Also, it is important to check a patient’s allergies, particularly antibiotics, in case you need to pre-medicate with antibiotics.
Smoking is very related to perio, it has been shown in many studies.
Family history is also very important. Some cases of high ____ or diabetes are related to family history; it is important to ask them if there is any history of gum disease in their family. For example, ____ is very related to family history.
ASA
medication
smoking
first
calcium channel
dilantin
cyclosporin
blood pressure
aggressive periodontitis
ASA Classification
1 A normal healthy patient
2 A patient with ____ systemic disease
3 A patient with ____ systemic disease
4 A patient with severe systemic disease that is constant threat to ____
5 A moribund patient who is not expected to survive without the ____
6 A declared ____ patient whose organs are being removed for donor purposes
• Treating only ASA \_\_\_\_
mild systemic life operation brain-dead
I-III
Basic Evaluation of a Dental Patient
Dental history
- ____
- Dental restoration
- ____ treatment
- Dental visit habit
- ____ habits
trauma
orthodontics
oral hygiene
Basic Evaluation of a Dental Patient
• Panoramic ○ Not clear, but provides an overall view ○ Can visualize the whole jaw and \_\_\_\_ ○ \_\_\_\_ extracted - it's better to have a pan • Full mouth x-ray ○ PA and bite-wings ○ \_\_\_\_ PA and \_\_\_\_ posterior bite-wing § BW: better angulation, better \_\_\_\_ level, and easier to assess \_\_\_\_ caries ○ If bone levels are low: \_\_\_\_ bite-wing
TMJ
impaction
14 4 bone IP vertical
Basic Evaluation of a Dental Patient
Clinical examination
- ____ examination
- ____ examination
- Examination of the ____
- Examination of the ____
extraoral
intraoral
teeth
periodontium
Examination of the Teeth
Wasting Disease of the Teeth
any gradual loss of tooth substance
Formation of Smooth, Polished Surfaces without Regard to the Possible Mechanism of this Loss
____
____
____
____
erosion
abrasion
attrition
abfraction
Erosion (Corrosion)
Sharply Defined Wedge-shaped depression in the ____ area of the ____ tooth
Generally affects a ____ of teeth
Enamel > Dentin, Cementum
Etiology
Decalcification by ____ (1949, McCay CM, Wills L) or ____ in combination with the effect of acid salivary secretion are suggested causes
* Adjacent teeth end up having similar lesions * Begins at \_\_\_\_ and extends into \_\_\_\_
cervical facial group acidic beverages citrus fruits
enamel
dentin/cementum
Abrasion
Loss of tooth substance that is induced
by ____ wear other than that of ____
____-shaped or ____-shaped indentations with a ____, shiny surface
____ > dentin of root
Etiology
____ with an abrasive dentifrice and the action of ____ are frequently mentioned, but aggressive tooth-brushing is the most common cause
Horizontal brushing at ____ angles to the vertical axis of the teeth
* Abrasion is observed more often than \_\_\_\_ * Usually combined with gingival \_\_\_\_
mechanical mastication saucer wedge smooth
cementum
toothbrushing clasps right erosion recession
Attrition
Occlusal wear that results from functional contacts with ____ teeth
Occlusal or incisal surfaces worn by attrition are called ____
Etiology
A certain amount of tooth wear is ____, but accelerated wear may occur when abnormal ____ or unusual functional factors are present
opposing
facets
physiologic
anatomic
Attrition
The ____ of the facet on the tooth surface is potentially significant to the periodontium
____ forces on the vertical axis of the tooth to which the periodontium can adapt most effectively
____ facets direct occlusal forces laterally and increase the risk of periodontal damage
angle
direct
angular
Abfraction
Etiology
Result from ____ loading surfaces causing tooth flexure and mechanical ____ and tooth substance loss in the ____ area
• Presence of microfractures • Lesions are \_\_\_\_ and \_\_\_\_ than abrasion ○ More \_\_\_\_ (rather than U-shaped)
occlusal
microfractures
cervical
deeper
sharper
V-shaped
Dental Stains
____ deposits
- Origin
Hypersensitivity - ____ exposed by gingival recession
• Root surfaces exposed by gingival recession may be hypersensitive to ____ changes or ____ stimulation. Patients often direct the clinician to the sensitive areas. These may be located by ____ exploration with a probe or cold air.
Proximal Contact Relations
- Open contacts allow for ____ impaction
- Checked by means of clinical observation and with dental floss
- Abnormal contact relationships may also initiate occlusal changes. Ex: Shift in ____, Teeth opposite an edentulous site may ____. thereby opening the proximal contacts.
pigmented root thermal tactile gentle
food
midline
supererupt
Basic Periodontal Evaluation
- Evaluation of ____
- Evaluation of ____
- ____ charting
- Evaluation of ____ and interdental ____
- Evaluation of ____
oral hygiene soft tissues periodontal occlusion relationships radiographs
Evaluation of Oral Hygiene
- Presence or absence of ____, plaque, and/or calculus
- ____ index
- Evidence of ____ brushing and/or flossing• Posterior teeth (upper right)
○ Opening of ____ gland
food debris
plaque
traumatic
parotid
Silness & Loe’s Plaque Index (PI)
Score 0: No ____ in gingival area
Score 1: No plaque visible by the unaided ____, but plaque is made visible on the point of the ____ after it has been moved across surface at entrance of gingival crevice
Score 2: Gingival area is covered with a ____ to ____ thick layer of plaque; deposit is visible to the naked ____
Score 3: Heavy accumulation of soft matter, the thickness of which fills out niche produced by ____ and ____; ____ area is stuffed with soft debris
plaque eye probe thin moderately eye
gingival margin
tooth surface
interdental
Evaluation of Soft Tissue
____
Contour
____
Texture
color
consistency
Evaluation of Soft Tissue
• Color
In health ____
In acute inflammation ____
In chronic inflammation deep ____ to ____ or ____
coral pink red deep pink blue bluish-red
Evaluation of Soft Tissue
•Contour
In health gingival margins are ____ edged, papillae are ____, triangular and completely fill the ____
In disease the margins become thickened or ____, papillae may become ____ and bulbous, tips may be ____
knife
flat
embrasure
“rolled”
swollen
blunted
Evaluation of Soft Tissue
- Consistency
In health the gingiva is ____ and ____
In disease might become ____ or ____ and ____
firm
resilient
spongy
firm
fibrotic
Evaluation of Soft Tissue
- Texture
In health ____ may be present
In disease ____ may disappear and gingiva appears “____ and ____”
stippling
stiplling
smooth
shiny
Silness & Loe’s Gingival Index (GI)
Score 0: Normal ____
Score 1: ____ inflammation. Slight change in ____, slight edema, no ____
Score 2: ____ inflammation. Redness, edema and glazing, ____
Score 3: ____ inflammation. Marked redness and edema, ____, tendency toward ____
gingiva mild color BOP moderate BOP severe ulcerations spontaneous bleeding
Periodontal Charting
\_\_\_\_ Recession (REC) \_\_\_\_ Keratinized gingiva (KG) \_\_\_\_ Mobility \_\_\_\_
probing depth (PD)
clinical attachment level (CAL)
bleeding on probing (BOP)
furcation involvement
What Dose a Complete Perio Exam Kit Contains?
• \_\_\_\_ probes to probe implants
Plastic
University of North Carolina UNC 15 probe
\_\_\_\_ with tapered end \_\_\_\_mm probe \_\_\_\_mm markings Color coded bands \_\_\_\_, 9-10,\_\_\_\_mm \_\_\_\_ to read
• Bottom of color band is \_\_\_\_, top of color band is \_\_\_\_
round 15 1 4-5 14-15 easy
4
5
Nabers 2N probe
\_\_\_\_ with tapered end Curved to access \_\_\_\_ 3-6-9-12 mm markings Color coded bands \_\_\_\_, 9-12 mm Used for the clinical diagnosis of \_\_\_\_ involvement
round
furcations
3-6
furcation
Normal Periodontium
• \_\_\_\_mm below the CEJ - this is considered as normal ○ CEJ to alveolar bone
2
Four Stage of Passive Eruption
• Active eruption - tooth erupts from alveolar floor to occlusal plane • Tooth approached occlusal plane - passive eruption • Young ○ JE is at \_\_\_\_ • As time goes on, it moves down but still remains at \_\_\_\_ • Argument that this is a \_\_\_\_ process • However, stage IV: \_\_\_\_ - pathologic
enamel
enamel
pathologic
recession
What are we probing for?
- Healthy: ____mm• Pocket is the pathologic deepening of the ____
0-3
sulcus
Pocket Depth
• ____ term
• Distance between the ____ and the
base of the ____ (most coronal cells of the junctional epithelium)
* Base of pocket = top of \_\_\_\_ * Probe accurately - probe should be at top of JE
histologic
gingival margin
base of the pocket
JE
Probing Depth • \_\_\_\_ term • Distance to which a probe penetrates into the pocket • Within the \_\_\_\_ in the absence of inflammation
* Probing depth is usually a little bit \_\_\_\_ * Can potentially drop into the \_\_\_\_
clinical
junctional epithelium
deeper
CT
What Is Important When Probing?
Probing ____
Probing ____
Probing ____
• Record the deepest pocket in each area
position
angulation
force
Facial & Lingual Probing
✓ ____ to Vertical Axis
✓ ____ the probe
parallel
walking
Interproximal Probing
✓ To detect deepest point of interdental crater
✓ Probe should be placed ____
* Most important picture in this lecture * Craters are normally present in \_\_\_\_ teeth * Coronal part of probe should be as close to \_\_\_\_ as possible, and the tip should be \_\_\_\_
obliquely
posterior
contact
angulated
Probing Force
- 25gm (____N)
- Depress ____ pad ____mm = 0.75N
0.75
thumb
1-2
Gingival Recession
• Location of the ____ apical to the ____
gingival margin
cementoenamel junction
Miller’s Classification of Recession
Class I: Marginal soft tissue recession not extending to the ____ with no loss of ____ or soft tissue
Class II: Marginal soft tissue recession extending ____ or ____ the MGJ with no ____ of interdental bone or soft tissue
Class III: Marginal soft tissue recession extends ____ or ____ the MGJ with ____ loss of bone or soft tissue, apical to the ____ but ____ to the level of soft tissue recession
Class IV: Marginal soft tissue recession extends ____ or ____ the MGJ with ____ of interdental bone or soft tissue ____ to the level of the recession defect
MGJ
interdental bone
to
beyond
loss
to beyond interdental CEJ coronal
to
beyond
loss
apical
What Is Clinical Attachment Level (CAL)?
CAL: distance between the ____ and the tip of the ____ (base of the sulcus/ pocket)
cemento-enamel junction (CEJ)
periodontal probe
Clinical Attachment Level in Health
____ term
CEJ- base of the sulcus/ pocket
clinical
mild
moderate
severe
Clinical Attachment Level
Attachment loss measurements are the best assessment of how much damage has occurred to the ____
* Pocket depth represents your attachment loss * 1-2 = \_\_\_\_ perio * 3-4 = \_\_\_\_ perio * >=5 = \_\_\_\_ perio
periodontal apparatus
mild
moderate
severe
Masticatory Mucosa
Attached v.s. unattached gingiva
____ gingiva
MGJ (Muco-gingival junction): Demarcates ____ and ____
Another method that can be used to demarcate the mucogingival line is pushing the lip or cheek ____
• Marginal groove (free gingival groove) ○ Projection inside is the base of the \_\_\_\_ • Free gingival groove to sulcus = free gingiva ○ Not \_\_\_\_ • From groove to MGJ = \_\_\_\_ gingiva ○ Pink • Alveolar mucosa is not \_\_\_\_ ○ Red • Keratinized includes \_\_\_\_ and \_\_\_\_ gingiva
keratinized
keratinized gingiva
nonkeratinized mucosa
coronally
sulcus attached attached attached free attached
Lack of Keratinized Gingiva
- Lang & Loe, 1972 : minimum of ____ mm keratinized gingiva is necessary
- Kennedy, 1985 : No sig diff found in ability to control plaque & gingival inflammation irrespective of presence/ absence of ____
2
attached gingiva
Bleeding on Probing
- Gingiva is ____
- Pocket epithelium is ____ or ulcerated
- ____ after the removal of the probe or be ____ for a few seconds
-> recheck for bleeding ____ to ____ seconds after probing
inflamed atrophic immediately delayed 30 60
Mobility
All teeth have a slight degree of ____ mobility
physiologic
Miller’s Classification of Mobility (1938)
Class 1
The ____ distinguishable sign of movement 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 / ____ of the tooth
first 1 1 vertical rotation
Furcation Involvement
* Evaluating \_\_\_\_ bone loss * Using a \_\_\_\_ probe • Easier to catch furcation from \_\_\_\_ side
horizontal
naber’s
palatal
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 ____ of the furcation(Cul-de-sac)
Degree III. - horizontal destruction of periodontium that is ____
3
3
width
through and through
Line between adjacent at CEJ level Parallel Bone level
____ Represents the cortical bone lining the tooth socket
• Oblique ○ Interdental bone crest is \_\_\_\_ to CEJ ○ Normal bone level • Lamina dura
lamina dura
parallel
Radiographic Techniques
Long-cone paralleling technique - ____ beam
Bite-wing technique - ____ beam
- Taking a BW shows a more accurate ____ to CEJ level
- when you see a bone lesion it is better to assess from the BW
- If the pt has sever periodontitis (shown below) a ____ will be better
angled
perpindicular
bone
vertical
Radiographic Appearance of Periodontal Disease
Fuzziness & Disruption of ____
• \_\_\_\_ and \_\_\_\_ is key to periodontitis
Once the pt has attachment loss and bone loss it is no longer considered
gingivitis, it is now ____
If you see bone loss w/ a funnel shape and have disruption of lamina dura that is a sign of ____ periodontitis.
lamina dura
attachment loss
bone loss
periodontitis
chronic
Radiographic Appearance of Periodontal Disease
____ or ____ has been partially or completely destroyed
* Best way to assess bony structure is from \_\_\_\_ * Bone sampling
Usually these kind of teeth will have a little bit of ____.
You can see in this view where the oblique line here (circled in green) you may consider that bone loss but remember it is a 2D image you can’t know exactly how the bony structure is. The best way to asses the bony structure is a 3D image, CBCT.
labial
lingual bony plate
CBCT (3D)
mobility
Pattern of Bone Destruction
Horizontal bone loss
Vertical bone loss
This is horizontal and vertical bone loss. You can see the bone drops and follows the CEJ line. This isn’t the best picture b/c they have the restorations and you can’t see the
CEJ. But here you can roughly follow the CEJ line. In green circled area the CEJ line is totally different, so we know here we have vertical bone loss = ____.
angular defect
Radiographic Appearance of Periodontal Disease
Furcation involvement
Definitive diagnosis of furcation involvement is made by ____ examination, which includes careful probing with a specially designed probe (e.g., ____)
Same area, different angulation.
Radiographs should be taken at different ____ to reduce the risk of missing furcation involvement
clinical
nabers
Radiographic Appearance of Periodontal Disease
Furcation involvement
• Furcation arrow ○ \_\_\_\_ ○ \_\_\_\_, not very reliable
reference
subjective
Radiographic Appearance of Periodontal Disease
Calculus
This is seen a lot in clinical cases. When the plaque got calcified, it becomes \_\_\_\_, you can see tons of calculus in the X-rays for some pt. After the procedure you can use another X-ray to double check if you got all of the calculus out (this isn't done \_\_\_\_)
calculus
routinely
Advanced Imaging Modalities
CBCT
This is seen in a CBCT. It has been used more in ____ and ____ dentistry. The 3D image
will help you see exactly how ____ your bone is to determine if you need ____ procedure
before placing the an implant. But you can also use it to evaluate your ____. Not used
on every pt.
endo implant thick bone graft bony defect
Conclusion
Take Home Message
Periapical ____ examination should be part of each patient’s periodontal evaluation and should be coupled with other records
Radiographic evaluation should be updated every ____ years
Periapical radiographs often ____ the amount of periodontal bone loss, and ____ changes are usually not detected
radiographic
2
underestimate
early
