9. Diagnosis and Classification of Periodontal Disease Flashcards
Prevalence of Periodontitis
• NHANES 1988 - 1994: ____ periodontitis in US adults age 30 and older
• NHANES 2009 - 2010: ____ periodontitis in US adults age 30 and older
• NHANES 2009 - 2010: ____ moderate or severe periodontitis in US adults
age 65 and older
• How was perio disease defined? Classification is also important; in order to interpret the research data that we get
35
47
65%
• ____ Classification (Armitage) - outcome out international workshop
1999
What is Necessary for a Periodontal Diagnosis?
____
Systemic Diseases Medication Allergies
Smoking
____
Probing Depth (PD)
Recession (REC)
Clinical Attachment Level (CAL) Bleeding On Probing (BOP) Mobility
Furcation Involvement Plaque Index Bleeding Index
____Panoramic
Full Mouth Radiographs
medical history
clinical examination
radiographic examination
Probing Depth
• Sulcus 1-3mm; >\_\_\_\_mm is a pocket • Happens as a result of inflammation > coronal migration of gingival margin; also an apical migration of attachment apparatus > true periodontitis ○ True pocket (different from a \_\_\_\_)
3
pseudopocket
Probing Depth vs Clinical Attachment Level
• True pocket, by \_\_\_\_ migration and \_\_\_\_ migration (causing \_\_\_\_)
coronal
apical
CAL
Pocket vs Pseudopocket
• No attachment loss, but presence of a pocket - \_\_\_\_ (bc of lack of attachment loss)
pseudopocket
“Basic” Periodontal Disease Diagnosis
Health I. Gingivitis Periodontitis II. Chronic III. Aggressive IV. Periodontitis as a Manifestation of Systemic Diseases
* Superficial inflammation > \_\_\_\_ * Inflammation and attachment loss > \_\_\_\_ * Every patient should be in one of these three \_\_\_\_ * This is her classification
gingivitis
periodontitis
categories
“Special” Periodontal Disease Diagnosis
V. Necrotizing Periodontal Diseases
A. ____
B. ____
VI. Abscesses of the Periodontium
A. ____
B. Periodontal
C. ____
VII. Periodontitis Associated with Endodontic Lesions
A. Combined endodontic – periodontic lesions
necrotizing ulcerative gingivitis (NUG)
necrotizing ulcerative periodontitis (NUP)
gingival
pericoronal
Gingivitis
- ____
- ____ Index
- ____ Index
- Clinical attachment level (CAL)
- CAL = ____; CAL > ____, with no evidence of ____ attachment loss
BOP Plaque Bleeding 0 0 progressive
o VIII. A. Localized tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis
• 1. Tooth ____ factors
• 2. Dental ____
• 3. Root ____
• 4. ____ root resorption and ____ tears
anatomic restorations/appliances fractures cervical cemental
• 2. Gingival diseases modified by systemic factors
a. associated with the endocrine system
1) puberty-associated gingivitis
- • Inflammation, swelling, that doesn’t directly correlate to amount of ____ present - when a systemic factor is affecting it
2) ____ cycle-associated gingivitis
3) pregnancy-associated
a) gingivitis
b) pyogenic granuloma
- • Associated with ____
• ____ lesion
4) ____ mellitus-associated gingivitis
b. associated with blood dyscrasias (_____)
plaque
menstrual
pregnancy
localized
leukemia
Dental Plaque Induced Gingival Diseases
• 3. Gingival diseases modified by medications
a. drug-influenced gingival enlargements
(____, ____, ____ blockers)
- • Doesn’t correlate to amounts of ____
• Used for h____ patients (nifedipine/Ca channel blockers)
b. drug-influenced gingivitis
1) oral ____-associated gingivitis
2) other
anticonvulsants
immunosuppressive
Ca-channel
plaque
hypetensives
contraceptives
Dental Plaque Induced Gingival Diseases
• 4. Gingival diseases modified by malnutrition
a. ascorbic acid-deficiency gingivitis
b. other
• Ascorbic acid - \_\_\_\_ deficiency
vitamin C
o I. B. Non-Plaque-Induced Gingival Lesions
• 1. Gingival diseases of specific bacterial origin
a. Neisseria ____-associated lesions
b. Treponema ____-associated lesions
c. ____l species-associated lesions
d. other
Primary syphilitic chancre
• On the ____
Secondary oral syphilis
• Can have secondary presentations in the ____
gonorrhea
pallidrum
streptococcal
tongue
mucosa
Non-Plaque Induced gingival
• 2. Gingival diseases of viral origin a. herpesvirus infections
1) primary ____
• Mainly seen in ____, but seen in adults also
• Presents when exposed to HSV1
• Generalized in both the ____ and ____
• And very ____
2) recurrent oral herpes
• Common, >90% have recurrent oral herpes - inducer is ____
• Can happen also on ____ (keratinized tissue), not mucosa
• Happens as a response to localized stress - can occur as a response to ____ surgery
• Typical lesions - connective tissue graft for pontic development - recurrent oral herpes and a nathos lesion on the mucosa
3) ____ zoster infections
b. other
herpetic gingivastomatitis
children
gingiva mucosa
painful
stress
gingiva
periodontal
varicella
Non-plaque induced gingiva
- Gingival diseases of fungal origin
a. Candida-species infections
1) generalized gingival candidosis
• ____ patches on gingiva or mucosa
• Acute pseudomembranous candidio
• No white patches > ____
• Mainly seen in ____ patients, who may have been missing ____ > reduced vertical dimension of ____
white erythematous elderly teeth occlusion
Non-plaque induced gingiva
- Gingival diseases of fungal origin a. Candida-species infections
1) generalized gingival candidosis
b. linear gingival erythema• Line along ____ that is red, due to fungal
gingival margin
Non-plaque induced gingival lesions
• 3. Gingival diseases of fungal origin a. Candida-species infections
1) generalized gingival candidosis
b. linear gingival erythema
c. ____
d. other
histoplasmosis
Non plaque induced gingiva
• 4. Gingival lesions of \_\_\_\_ origin a. hereditary gingival fibromatosis • Was in the patient's family - \_\_\_\_ • 4 y/o > \_\_\_\_ lesions (reminds similar to \_\_\_\_-induced) • \_\_\_\_ to manage in young patients
b. other
genetic hereditary generalized drug difficult
Non-plaque induced gingival lesions
• 5. Gingival manifestations of systemic conditions a. mucocutaneous disorders
1) ____
2) ____
3) pemphigus vulgaris
4) erythema multiforme
5) lupus erythematosus
6) drug-induced
7) other
lichen planus
pemphigoid
Characteristics of Pemphigoid
• Approximately ____ of desquamative gingivitis cases
• ____l and ____ lesions, conjunctiva lesions, genital lesions
• Subepithelial ____
• ____ deposits of ____ and ____
50% gingival mucosal bullae basement membrane IgG C3
Characteristics of Lichen Planus
• Approximately ____ of desquamative gingivitis cases
• Reticular: striae of ____, sawtooth ____ [most ____]
• ____: bullous plaques with erythematous halo and striae
• ____: erosions with striae
• Different clinical manifestation - more ____ of a lesion
• Both mucosa and gingiva
• ____: tongue loses papillae, gingiva is thinned
25% wickham rete pegs common bullous erosive red atrophic
Non-plaque induced gingival lesions
• 5. Gingival manifestations of systemic conditions
a. mucocutaneous disorders
b. allergic reactions
1) ____ materials
2) reactions attributable to
a) toothpastes/dentifrices
b) mouthrinses/mouthwashes c) ____ additives
d) food additives
3) other
dental restorative
chewing gum
Allergic reaction to ____
* PFM crown that include \_\_\_\_ * \_\_\_\_ gingiva
nickel
nickel
erythematous
Allergic reaction to chewing gum additives
* \_\_\_\_ in chewing gum is a common allergen * \_\_\_\_ - difficult diagnosis - generalized reaction
cinnamon
uncommon
Non-plaque induced gingival lesions
- Traumatic lesions (factitious, iatrogenic, accidental)
a. ____ injury
b. ____ injury
c. ____ injury
chemical
physical
thermal
Self-inflicted chemical injury (aspirin)
• Must take an adequate ____ in order to determine whether it was mechanical, chemical, thermal, etc.
○ Ask specific ____
• Aspirin placed locally > self-inflicted chemical injury
• Cannot tell just by looking > need a good history
Self-inflicted chemical injury (H2O2)
• H2O2 > use as a mouthrise ____ > take good history
Facticious physical injury (floss)
Self-inflicted thermal injury
• ____ mucosa > hot food
Iatrogenic thermal injury (ultrasonic)
• Ultrasoinc without proper irrigation, or handpiece
• Can be both ____ and ____
history questions undiluted palatal extraoral intraoral
Non-plaque induced gingival lesions
• 7. Foreign body reactions
- Gingival enlargement, foreign body
- ____ treatment
orthodontic
Chronic Perio
____
____
clinical attachment loss (CAL)
bleeding on probing (BOP)
Chronic Periodontitis
1. Extent
• Generalized
CAL in > ____% of sites
Localized
CAL in ≤ ____% of sites
2. Severity Slight CAL = \_\_\_\_ mm Moderate CAL = \_\_\_\_ mm Severe CAL ≥ \_\_\_\_ mm
30 30 1-2 3-4 5
Characteristics of Chronic Periodontitis
- ____ progression rate with possible periods of ____ progression
- More prevalent in ____ but can occur in younger individuals
- Amount of destruction consistent with ____ factors
- Associated with a variable ____ pattern
- ____ calculus frequently present
- Not a ____ bacteria responsible > large numbers of bacterium involved
- Subging calculus - visual, tactile and radiograph (a lot if ____)
slow rapid adults local microbial subgingival
specific
radiograph
Generalized Slight Chronic Periodontitis
• Some local factors present - plaque, calculus
• May have some bone loss (or loss)
○ Attachemtn loss preceds bone loss by ____ months
Generalized Moderate Chronic Periodontitis
• A little bit older
• Generalized recession, and generalized bone loss
Generalized Severe Chronic Periodontitis
• Wouldn’t suspect ____ > not a lot of plaque, and no ____; would have to insert probe
• Not a lot of plaque > may have just had their prophy done
• FMX > a lot of bone loss, generalized and lcoalized bone loss
• Shouldn’t judge by age, or just by looking - have to do ____ measurements (probing) and ____
6 visually recession clinical FMX
Periodontitis Update
- Probing depth (PD)
- CAL
- BOP
- Full mouth radiographs• Safest bet to stick with clinical attachment loss
• Table summarizes update and the 1999 classification
• Update: three categories, slight (mild),moderate severe (advanced)
• Keep same guidelaines for CAL (1-2, mild, 3-4, mod >5 severe), keep BOP
• Include ____, and ____
○ More >3mm <5mm, that can be slight perio; 5-6 is mod; >7 severe; probing depth by itself doesn’t mean much, need radiograph
○ 15% silgt, 16-30 mod, >30 severe
○ Combine > use own ____ if not agreeing > then you look at ____
probing depth
radiographic bone loss
judgement
CAL
Inflammation on Reduced Periodontium Update
- Probing depth (PD) (=< ____mm)
- CAL (>____)
- BOP
- Full mouth radiographs
3
0
Healthy but Reduced Periodontium Update
- Probing depth (PD) (=< ____)
- CAL (>____)
- NO ____!!!!
- Full mouth radiographs
3
0
BOP
Aggressive Periodontitis
Systemic Diseases
Medication
CAL
BOP
Plaque Index
Radiographs
• For aggressive, you also need absence of \_\_\_\_, no \_\_\_\_ that affecting periodontium, and \_\_\_\_ index (very little relative to disease, opposite of chronic) ○ Little amounts, but a lot of disease • Radiograph - bone loss, but also typical characteristic patterns of bone loss
systemic diseases
medications
plaque
SAME EXTENT AND SEVERITE FOR AGGRESSIVE PERIO AS THERE IS FOR CHRONIC!!
YAY
Characteristics of Aggressive Periodontitis
Otherwise ____ healthy patient
Rapid attachment loss and bone destruction
Amount of microbial deposits ____ with disease severity
____ aggregation of diseased individuals
* No systemic disease or medication affecting CAL * Rapid attachment loss and bone destruction (v diff from chronic) * Need at least \_\_\_\_ examinations (in order to determine rate) * Small plaque, a lot of disease; cannot be explained by this only * Family lost teeth at very early age
systemically
inconsistent
familial
Characteristics of Aggressive Periodontitis
Localized Juvenille Periodontitis (LJP, 1989 Classification)
Age of onset in the ____ period
____ and ____, usually ____
Associated with ____ Abnormalities in neutrophil or monocyte function
* Not a current term - not used to diagnose - comes from \_\_\_\_ classification * Around puberty * AA > certain type of lozalized aggressive perio, this LJP
circumpubertal first molars incisors bilateral AA 89
Periodontitis as a Manifestation of Systemic Diseases
o IV. A. Associated with hematological disorders
• 1. Acquired ____
• 2. Leukemias
• 3. Other
o IV. B. Associated with genetic disorders • 1. Familial and cyclic neutropenia • 2. \_\_\_\_ syndrome • 3. Leukocyte adhesion deficiency syndromes • 4. \_\_\_\_ syndrome • 5. Chediak-Higashi syndrome • 6. \_\_\_\_ syndromes • 7. Glycogen storage disease • 8. Infantile genetic agranulocytosis • 9. \_\_\_\_ syndrome • 10. Ehlers-Danlos syndrome (Types IV and VIII) • 11. \_\_\_\_ • 12. Other
neutropenia down papillon hisocytosis cohen hypophosphatasia
Perio as a manifestation of systemic disease
____ disease
____
____
SAME EXTENT AND SEVERITY FOR PERIO!
systemic
CAL
BOP
“Special” Periodontal Disease Diagnosis
V. Necrotizing Periodontal Diseases
A. ____
B. ____
Necrotizing ulcerative gingivitis (NUG)
necrotizing ulcerative periodontitis (NUP)
Clinical Characteristics of NUG
• Interproximal necrosis and ulceration, ____ and ____ papillae
• ____ – spontaneous or on slight provocation
• ____ gingiva
- Gray ____
- Fetor oris (bad ____)
- Slight fever, ____ , lymphadenopathy
- First three must be present for NUG ***
- Periodontal disease - no pain
- The last three may be present, but not necessary
- Systemic ____ > slight fever, malaise, lymphadenopathy
punched-out
cratered
bleeding
painful
pseudomembrane
breath
malaise
manifestations
Pathogenesis of NUG
- Usually ____ individuals
- Associated with impaired ____
- Associated with ____ factors, such as stress, smoking, fatigue
- Associated with ____, spirochetes, ____ intermedia
- Typical in students around ____ period
- Specific bacteria
younger host response predisposing fusiform bacilli prevotella exam
Clinical Characteristics of NUP
• Interproximal necrosis and ulceration, punched-out and cratered papillae
• Bleeding – spontaneous or on slight provocation
• Painful gingiva
• Gray pseudomembrane
• Fetor oris (bad breath)
• Slight fever, malaise , lymphadenopathy
• In addition, ____ and ____
clinical attachment loss
alveolar bone loss
Abscesses of the Periodontium
A localized purulent infection
- ____: involves the marginal gingiva or interdental papilla
- ____: within the tissues adjacent to the periodontal pocket that may lead to the destruction of periodontal ligament and alveolar bone
- ____: within the tissue surrounding the crown of a partially erupted tooth
abscesses Usually seen with ____
gingival
periodontal
pericoronal
third molars
Characteristics of Periodontal Abscesses • \_\_\_\_ • Swelling • \_\_\_\_ • BOP • \_\_\_\_ • Tooth mobility
Pain
pocket
suppuration
Etiology of Periodontal Abscesses
Absence of periodontitis
____ impaction
Associated with ____ lesions
Presence of periodontitis
Untreated ____ after systemic antibiotic therapy
Residual apical calculus in deep pockets after non-surgical ____
* A lot of local factors > receive antibiotics > the marginal tissue is reduced, and the tissue can tighten > formation of an abscess when theres' subging calc in the pocket * IF some calculus is left, then the ifnlammation goes down but then it forms an abscess***
foreign object
endodontic
periodontitis
SRP
Periodontitis Associated with Endodontic Lesions
• Primary Endodontic Lesion
• Primary Endodontic Lesion with Secondary Periodontal Involvement
• Primary Periodontal Lesion
• Primary Periodontal Lesion with Secondary Endodontic Involvement
• “True” Combined Endodontic and Periodontal Involvement
* PPL > \_\_\_\_ pocket that can be an endodontic lesion, if it hits the pulp * True - bacteria from pulp and perio and \_\_\_\_ * \_\_\_\_ origin of lesion can tell you the course of treatment
deep
meet
primary
What is Gingival Recession?
Gingival Recession: location of the gingival margin (GM)
____ to the cementoenamel junction (CEJ)
apical
What is Gingival Recession?
Gingival Recession: location of the gingival margin (GM)
apical to the cementoenamel junction (CEJ)
• due to periodontitis, that affects all ____ surfaces and is usually
____
• primarily related to ____ factors, that affects facial or lingual surfaces and is ____ or partially reversible with periodontal reconstructive surgery
• Or mechanical (facial or lignual) > \_\_\_\_ > can treat with grafting and can cover roots
tooth irreversible mechanical reversible reversible
MILLER CLASS FROM WANG!
Class I: ____ root coverage can be anticipated
Class II: ____ root coverage can be anticipated
Class III: ____ root coverage can be anticipated
Class IV: Root coverage ____ be anticipated
100%
100%
partial
cannot
VIII. B. Mucogingival deformities and conditions around teeth
2. Lack of keratinized gingiva
• Inability of patient to ____ effectively, and in placing a ____ - the soft tissue surrounding may not be able to withstand ____
brush
restoration
forces
VIII. B. Mucogingival deformities and conditions around teeth
4. Aberrant frenum/muscle position
• Bt max central incisors, or wherever ____ - ____ type defects
frenum
recession
o VIII. B. Mucogingival deformities and conditions around teeth
5. Gingival excess
a. pseudopocket
• Gingival ____
b. inconsistent gingival margin
• Gingival ____
• More aesthetic conditions
• Can be ____
c. excessive gingival display
• Gummy smile, showing a lot of ____
• Can be ____
d. gingival enlargement
• ____ patients - related to rotho appliances
excess excess treated soft tissue treated ortho
o VIII. B. Mucogingival deformities and conditions around teeth
6. Abnormal color
• ____ tattoo - used for apilocteomy
• Discoloration to ____ used
amalgam
restoration material
o VIII. C. Mucogingival deformities and conditions on edentulous ridges
• 1. Vertical and/or horizontal ridge deficiency
Class I: ____ (____)
Class II: ____ (____)
Class III: ____
* Cannot find II > when tooth extracted, horizontal doesn't always happen by itself, rare, \_\_\_\_ usually always happens * III> deficiency in both * In order to prepare for implant, need \_\_\_\_
bucco-lingual horizontal apico-coronal vertical combination
vertical
ridge dimensions
VIII. Developmental or Acquired Deformities and Conditions
D. Occlusal Trauma
Injury resulting in tissue changes within the
attachment apparatus as a result of ____
occlusal forces
VIII. D. Occlusal Trauma
• 1.Primary occlusal trauma: injury resulting in tissue changes from excessive ____ applied to a tooth or teeth with ____ support
• 2.Secondary occlusal trauma: injury resulting in tissue changes from ____ or ____ occlusal forces applied to a tooth or teeth with ____ support
* Primary - in the absence of \_\_\_\_ * Secondary - pt with \_\_\_\_, even normal forces, the perio cannot withstand bc its reduced
occlusal forces normal normal excessive reduced
periodontitis
perio
Clinical Signs of Occlusal Trauma • \_\_\_\_ • Fremitus • Occlusalprematurities • \_\_\_\_ (in presence of other clinical indicators) • Seen on \_\_\_\_/\_\_\_\_
- Tooth migration
- Fractured tooth(teeth)
- ____ sensitivity
- How do we diagnose? Not easy, no ____ measures
- Clinical or radiograph signs used to diagnose
- Fremitus - when you bite and your teeth move a lot; and ____ mobility
- Wear facets in presence of others, not by themselves
- Need to have some of these signs present
mobility (progressive) wear facets functional cusps incisal edges thermal objective functional
Radiographic Signs of Occlusal Trauma
• Widened ____ space
• Bone loss (____; vertical; ____)
• Root ____
• PDL is widened when compared to other teeth
PDL
furcation
circumferential
resorption
