case Flashcards
Marginal Ridge Discrepancies
a. Kepic/O’Leary – no correlation between marginal ridges and poorer perio parameters b. Pihlstrom - (looked at Mx first molars and found that un-even marginal ridges had more CAL (~0.5mm) and deeper PD than teeth w/ even marginal ridges
Male gender
Shiau 2010, systematic review and MA. Males have higher prevalence of periodontitis compared to females but not necessarily at greater risk for more rapid periodontal destruction. Sexual dimorphisms exist in immune function, involving both innate and acquired immunity. Men have higher levels of inflammatory cytokines, including interleukin‐1β and tumor necrosis factor‐α, than women, paralleling observed sex‐specific differences in periodontitis. Conclusion: Differential gene regulation, particularly in sex steroid–responsive genes, may contribute to a sexual dimorphism in susceptibility to destructive periodontal disease.
Interproximal plaque removal
KEIGER: RCT. proxabrush is more effective at removing interproximal plaque than floss in open interproximal spaces Kotsakis: Interdental brushes & waterjets are the best interproximal OH aid to decrease BOP. Flossing does not substantially decrease inflammation. However, no control over periodontal status (healthy vs reduced perio vs gingivitis)
How do you know that NST decreases inflammation?•
Caton: lack of sulcular epithelium ulceration, Less inflammatory infiltrate, More dense CT, Less perivascular edema at 4 weeks Caton developed interdental bleeding index - insert wooden pick interdentally, depressing papilla 1 -2 mm, repeated 4x, presence or absence of bleeding within 15 seconds Good index of epidemiological studies as it has high inter-examiner reliability
give evidence that it’s okay to retain hopeless teeth
Machtei - With (OFD), minimal detrimental effects; MT is key Wojcik – Treated and retained hopeless teeth can have no detrimental effect on alveolar bone levels on adjacent teeth at 8 years; MT is key
give evidence that you should EXT hopeless teeth
Machtei - Without perio tx, retained hopeless teeth caused 10x greater AL if you don’t treat them Grassi 1987 - Split mouth study involving SCRP and ext of hopeless tooth or retention og hopeless tooth. Found that Following extraction of hopeless teeth, the periodontal status of the adjacent teeth was more greatly improved that the contralateral side. In deep pockets (4-9mm), there was a 1.46mm PD decrease and 0.67mm CAL gain
what do you expect after SCRP
HUNG AND DOUGLASS META-ANAYLSIS: 4-6 mm =PD reduction of 1 mm, 0.5 mm CAL gain. 7+ mm = PD reduction of 2 mm, 1 mm CAL gain for deep initial periodontal probing depths
give me evidence that is it worthwhile to do reinstrumentation
Magnusson: patients whose hygiene did not drastically improve after first round of SRP showed significant benefits from additional round of SRP 16 weeks after initial instrumentation -Torfason: patients who were re-instrumented 4 weeks after initial therapy showed improved clinical gains compared to control (only instrumented at one visit) Rationale: patients with poor OH that can’t support surgery, initial instrumentation performed below office standard, inadequate response at all sites
why should you not re-instrument?
-Anderson 1996: Single episode of SCRP versus 3 rounds of SCRP. Second and third rounds of scaling were 24 hrs later. Residual calculus not removed after one episode of SCRP is not likely to be removed by repeated instrumentations. HOWEVER - THEY DID NOT ALLOW FOR SOFT TISSUE HEALING/SHRINKAGE WHICH MAY IMPROVE. Repeated episodes of SCRP does not eliminate the need for more invasive procedures (surgery). Badersten 1981: In single rooted teeth, a single initial episode of ultrasonic scaling is as effective as three episodes accomplished three months apart in the treatment.
How do you know that you are going to be better at local factor removal with surgery?
Caffese SCRP in molars- Brayer looked at single rooted teeth and found similar result) how many surfaces were calculus free? • 1-3mm: 86% open vs. 86% closed • 4-6mm: 76% open vs. 43% closed • 7+mm: 50% open vs 32% closed
how do you know that an open contact is a local factor
Hancock – young male Naval recruits (17-19 yo) without much disease. Significant relationship between open contact and food impaction and food impaction causes increased PD, attachment loss, and BOP Assessed open contact with double strand of unwaxed floss Jernberg – older patient population (mean 43 yo) a) Open contacts/food impaction associated with increased PD (0.27 mm) and AL (0.48 mm) 1. Open contact = floss slipping through during mastication 2. Looked at open contact with contralateral closed contact 3. Food impactions associated with occlusal interferences
tell me about bone sounding
a. Ursell: bone sounding vs surgical measurements correlation coefficient 97% with mean 0.29 mm difference b. Mealey: Bone sounding in furcations is accurate within 1 mm 85% of the time. Average difference between bone sounding and surgical measurements was 0.5mm. Bone sounding increase diagnostic accuracy 10% clinical detection of furcation invasion.
buchanan
d. Buchanan: Radiographic Calculus – Sens 43%; Spec 92% a) PPV 92%; NPV 46% Reported in text, Page 3 1. Sensitivity: w disease, how often test confirm presence 2. Specificity: w/o disease, how often test deny presence 3. PPV: test +, how often dx present 4. NPV: test -, how often dx non-present Hyer - a step of calculus greater than 0.5 mm more likely to be seen on radiograph. Greater than 30% of the root surface covered in calculus - more likely to be seen on radiograph. Altering the radiographs did not aid in its detection
calculus types
a) Four major crystalline forms 1. Hydroxyapatite (~ 58%) – major crystalline form in mature calculus 2. Magnesium whitlockite (~ 21%) 3. Octacalcium phosphate (~12%) 4. Brushite (~ 9%) – first crystalline form immature calculus
tooth proximity
Heins and Weider: Distance between roots and histology of bone a) 0-0.3 mm = no bone, direct PDL attachment between teeth b) 0.3-0.5 mm = Cortical bone only, no cancellous c) >0.5 mm = cortical and cancellous bone Hain Tal: distance between roots & defect type. *Correlates well w/ Sphere of Influence a) <2.5 mm = mostly horizontal bone loss b) 2.5 – 3.1 mm = possible to have single intra-bony defect c) > 3.1 mm = possible to have 2 intra-bony defects Waerhaug sphere of influence ranges from 0.5-2.7. mean 1.63mm Kim: Mand anterior teeth with <0.8mm inter-root distance 56% (RR = 1.56) more likely to lose ≥1mm bone over 10 years; evaluated on PAs and adjusted for confounders, like age and smoking
furcation classifications
i. Grade I incipient; pocket formation into flute; bone intact ii. Grade II moderate; pocket formation with loss of bone of varying depths; but not completely through iii. Grade III through and through; probable to opposite side with pocket formation iv. Grade IV exposed; furca is clearly visible due to loss of attachment and gingival recession • Hamp i. Degree I horizontal loss < 3mm ii. Degree II horizontal loss > 3mm but not all the way through iii. Degree III horizontal loss through and through • Tarnow and Fletcher (vertical component measured from ROOF of furca) i. Subclass A vertical loss 1-3mm ii. Subclass B vertical loss 4-6mm iii. Subclass C vertical loss > 7mm
maxillary 1st PM info why are furcations on this tooth significant?
Gher & Verino: 78% of maxillary first premolars have a concavity on the palatal (furcal) surface of the buccal root Mesial deVELOPMENTAL GROOVE exjsts on single rooted max 1st PM - worsening prognosis Joseph - study done on 100 extracted maxillary 1st PMs: 37% of maxillary first premolars are bifurcated. 1/3 in cervical, 1/3 in middle, 1/3 in apical Mean root trunk length (CEJ to furcation) = 7.9mm 100% prevalence of mesial and distal root concavities, mesial is deeper -Root concavities retain plaque, complicate patient home care and worsen tooth prognosis if exposed; professional maintenance of these areas is crucial.
What evidence exist that lack of dental care can contribute to periodontal disease?
a. Loe and Anerud – Norwegians and Sri Lankans a) SL had 3x rate of interproximal LOA/yr b. Becker – patients who were not treated and not maintained had more tooth loss compared to patients who were treated and maintained and even patients who were treated (but not maintained) – treatment was ScRP and osseous surgery Treated and maintained – lost 0.11 teeth/yr Treated but not maintained – lost 0.22 teeth/yr Not treated and not maintained – lost 0.36 teeth/yr Axelsson and Lindhe –study where 180 patients received only symptomatic treatment and 375 received regular maintenance care – showed that preventative programs could resolve gingivitis and prevent periodontitis and tooth loss whereas patients without care deteriorated.
Recession classification
Miller a) Class 1: recession does not extend to mucogingival junction (MGJ), no interdental bone loss b) Class 2: Recession extends to or beyond MGJ but no interproximal bone loss c) Class 3: Recession extends to or beyond MGJ and some interproximal attachment loss or teeth malpositioning d) Class 4: recession extends to or beyond MGJ and severe bone/soft tissue loss in interdental area and/or severe tooth malpositioning. Cairo RT1: no interproximal loss, interproximal CEJs not clinically detectable RT2: interproximal loss, buccal attachment is apical or EQUAL ro interproximal attachment RT3: interproximal loss, buccal attachment is coronal to interproximal
Furcation entrance size
BOWER: furcation width of 200 ext mandibular and maxillary molars. 81% were less than 1mm. More than half were less than 0.75. Most could not fit the blade of a curette.
how deep can you clean
Stambaugh (7 posterior teeth included with 30 minutes spent cleaning each tooth) a) Average curette efficiency depth = 3.73 mm for plaque free b) Average curette limit = 5.52 mm where scratches evident c) Mesial sites cleaned the worst, DL sites were best
waerhaug #s
PD Non-surgical (plaque free surfaces) 0-3 89% 3-5 63% >5mm 11%
critical PD
Lindhe 2.9mm for NST (lose AL below it and gain AL if PD above this) b. 4.2mm for Surgical therapy c. 5.4mm where you will gain more attachment with surgical rather than NST
Give evidence of alcohol as a risk factor for periodontitis
Moderate alcohol drinking: 1-2 drinks/day for men (1/day for women) Heavy alcohol drinking: men >4 drinks/day; women >3 drinks/day Tezal: Used NHANES data Association between alcohol abuse and & CAL 5 drinks/week = O.R =1.2 for CAL 10 drinks/week = O.R. = 1.4 for CAL Alcohol consumption may be associated with increased severity of CAL in a dose-dependent fashion. Wang SR, MA Risk of periodontitis increased by 0.4% for each 1 g/day increment in alcohol consumption.
Mechanisms for alcohol use causing periodontitis
1) decreased complement, PMN function, altered T cell function 2) cytotoxic effects to cells by alcohol 3) altered clotting cascade, damage to liver and clotting factor production 4) nutritional and vitamin deficiencies
Modified Aldrete score
Aldrete Score: Activity: 2 - Able to move 4 extremities spontaneously on command 1 - able to move 2 extremities 0 - unable to move any extremities Respiration: 2 - breathe deeply and cough 1 - shallow dyspnea 0 - apnea Consciousness: 2 - fully awake 1 - arousable on calling 0 - non responsive Circulation: 2 - BP within 20 mmHg of original BP 1 - BP 20-50 mmHg of original BP 0 - BP 50 or more mmHg of original BP Color: 2 -Normal 1 -Pale, jaundiced, blotchy 0 - Cyanotic
BMI categories
BMI categories (high muscle density tends to be higher in number) Underweight <18.5 Normal weight 18.5-24.9 Overweight 25-29.9 Obese 30-34.9 Units are kg/m2
Effects of smoking on periodontium
-increased collagenase production (MMP-8) -decreases neutrophil qualitative function (decreases enzyme production, decreased chemotaxis) - changes in cytokine profile (e.g. increased IL-8) -suppression of OPG (which is protective) - decreased oxygen tension leading to increased gram negative bacteria - change in fibroblast wound healing (altered migration, root surface attachment) - decrease perfusion through blood vessels (but increased vessels) - direct cellular cytotoxicity of smoking - changes in IgG levels
how does smoking cessation affect periodontal disease risk
Fiorini: SR. Smoking cessation associated with decreased AL, PD and bone loss Rosa 2014: Prospective study. Patients got SCRP and then smoking cessation therapy afterwards and were follow up to 2 years. After 2 years, the subjects that quit smoking had significantly higher clinical attachment gain, reduction in PD and in the proportion of sites with CAL >3mm. Better response to non-surgical periodontal therapy results in patients who quit smoking. Bergstrom 2014: Sweden. A decline in smoking is related to a decrease in periodontal disease prevalence. Al-Harthi 2018: Used NHANES data from NHANES 2009-2010 and 2011-2012. Cross-sectional study. Each additional year of smoking cessation was associated with an additional 2.5-5.2% (3.4%) reduction in the odds of having periodontitis.
How do you know that smoking is risk factor for periodontal disease?
Tomar and Asma (NHANES III data) – OR of 4.0 for perio disease in smokers; cross-sectional data i. Dose dependent effect noted (OR 2.8 for <9 cig/day, OR 5.9 for >31 cig/day) ii. OLD THOUGHT: After 11 years of non-smoking, OR of perio prevalence returns to non-smoker levels Bergstrom: 3x more bone loss in smokers vs non smokers (10 year cohort)
types of maintenance
- Types of maintenance and indications a. Schallhorn/Snider, 1981 – Discuss different types of MT and breakdown of MT apt a) Preventative Periodontal MT – prevent occurrence of perio in periodontally healthy pt b) Trial MT – to maintain borderline cases and assess over time, the need for corrective therapy c) Compromised MT – to slow the progression of dz when surgical therapy not indicated due to Finances, Poor Hygiene, Lack of Restorative Plan, Medically Compromised d) Post- Treatment MT – prevent recurrence of active disease e) 52min average which included 28 minutes of polishing/flossing/ultrasonic/hand instrumentation
tell me about listerine
a. Listerine = essential oil a) Thymol, eucalyptol, methol, methysalicylate b) When used 2x daily, 34% reduction in gingival inflammation and plaque if used 2x daily c) Used as a preprocedureal rinse can reduce bacterial load by 94% d) MOA = cell wall disruption and inhibition of bacterial enzymes e) Negative = contains 21-27% alcohol which can cause patients irritation
Wilderman timeline
a. Immediate – clot formation and inflammatory response with PMN migration and polyband formation under the clot b. 1-2 days – epithelial migration begins at a rate roughly 0.5 mm per day beneath the polyband; mØ clean debris c. 3-4 days – a) fibroblastic activity increases and a disorganized CT matrix is forming b) Angiogenesis and vascular budding begins (requires 2 weeks for completion) c) Osteoclastic activity begins and peaks within first week d. 1-2 weeks – increasing collagen production and content, with osteoblastic activities beginning and osteoclastic activities decreasing e. 1 month – peak osteoblastic activity and completion of majority of collagen synthesis; collagen in parallel to root f. 6 months – maturation of CT and PDL insertion into the bone and root. New cementum formation. Periosteum formation. osseous surgery - average loss of crestal bone =0.8 mm (on buccal) - less bone is lost interproximally g. **** complete healing following osseous surgery required at least 6 months. Bone remodeling was seen out to 18 months. Collagen fibers were parallel to the long axis of the root until 5-6 months post-op, then they angled from an apical direction into and were attached to the root. increase in mobility immediately after and might take 6 months to see improvement.
Suture design and flap adaptation
a. Nelson: no difference between interrupted sutures vs. continuous sling suture in perio parameters; all pts got coe pak b. Machtei – 12 subjects. Flap placed <3mm from the bone results in avg PD of 2.5 mm where sites with flap placed 4 mm or greater had average PD of 3.5 at 2 years PENNER: Bone sound and it is less than 3 there is a 94% chance that the probing depth will be less than 3 Bone sound >3 there is a 50% chance the probing depth will be less than 3 at the 6 month follow up Penner vs. Machtei R=.56; R=.43 Osseous; MWF Stent Used; No Stent 3-6 month follow up; 2 year follow up
would you use abx for chronic p?
NO Haffajee and Socransky: when used in conjunction with SRP b) WMD 0.24 mm additional gain for chronic periodontitis not clinically significant Borges: Adjunctive use of metronidazole and amoxicillin with SRP may increase the proportion of patients reaching a clinical endpoint of having ≤ 4 sites with PD ≥ 5mm. 14 days antibiotic regimen appears to have a greater effect compared to a seven days regimen. Sgolastra: in generalized aggressive patients specifically, SR, MA, Significant CAL gain and PD reduction were shown with FMSRP +AMX/MET compared to FMSRP alone.
tell me about chlorohexidine
• Cationic bisbiguanide that binds to proteins within pellicle. Gold standard. Adheres to soft and hard tissues and is released slowly over time = substantivity. Ruptures cell membranes. Has 6-8 hour effectiveness • Negative side effects = tooth stain, increased calculus formation (cell membranes form a pellicle, irregular taste_(dysgusia) • SLS and fluoride in toothpaste inactives it • CHX decreases plaque by 50-55% Van Strydonck - SR: Dose dependent, but not concentration dependent. As an adjunct to normal OH, CHX can lower plaque by 33% and gingivitis by 26%.
Is periodontal maintenance effective long term?
Hirschfield and Wasserman: 600 patients, 15 years recall. Based on response to therapy, pts were divided into 3 groups—well maintained (WM – lost 0-3 teeth): 83%, downhill (D – lost 4-9 teeth): 13%, and extreme downhill (ED – lost 10-23 teeth): 4%. Initial tx approach had little effect on tooth retention at 15 yrs. . Most frequently lost tooth =Maxillary 2nd molar Least likely to be lost = Mandibular first premolars and canines, even with a poor prognosis. Residual mobility did not lead to tooth loss (even Class 3 mobility). Tooth loss of teeth in “well maintained” group was typically molars with FI How prognostic is BOP in predicting future CAL? Lang showed that sites that had BOP at 4/4 maintenance visits only broke down 30% of the time BOP is better at determining prognosis of whole mouth as opposed to a single site
tell me about accessory canals
Gutman said that up to 28% of multirooted teeth have lateral canal in the floor of the furcation
steps of osseous sx
STEPS OF OSSEOUS SURGERY: 1) Bulk reduction of thick bone 2) Interdental fluting 3) Reduction of crater walls 4) Removal of radicular bone and widow’s peaks 5) Final shaping and smoothing
fremitus classification
FREMITUS CLASSIFICATION: INGERVAL: mobility in function, MIP, excursives (Functional tooth mobility) Class I: mild vibration Class II: palpable vibration, no visible movement Class III: movement visible to the naked eye
Re-evaluation: Why at 4-6 weeks?
a. Mosques- 42 days for bacteria to repopulate the sulcus b. Caton- least inflamed microvascular density in coronal tissues after 4 weeks (signs of repair) c. Best time to intervene hygiene
Overhangs
Lang - Cross-over study in periodontally healthy patients. Overhanging restorative margins alter the subgingival microflora to a more periodontopathic composition, directly increasing inflammation; and, demonstrating a potential mechanism for increased bone loss associated with iatrogenic restorative factors. How common are overhangs? Brunsvold – found 33% of patients, 25% of restored surfaces Jeffcoat - Effect of overhanging amalgam restorations on the alveolar bone height in patients with various degrees of severity of periodontal disease. 100 pts -The larger the overhang, the more bone loss. Small overhangs (<20% IP space), unlike med and large, did not result in a significantly greater amount of bone loss. Severity of bone loss increased with age and the longer the overhang was present Authors suggest that bone loss from overhanging restorations may be due to increased plaque/calculus accumulation from difficulty of OH rather than mechanical irritation with a notion of time, i.e. state of continuous inflammation over a prolonged period. Bone loss was found to be greater around teeth with overhangs in all periodontal disease types. Rodriguez-Ferrer - Effective oral hygiene is impeded in areas with overhangs. Removal of overhangs should be addressed during initial periodontal therapy. Wang - Molars with crowns or proximal restorations had a significantly higher percentage of furcation involvement. Mean probing periodontal attachment loss was greater for restored than non-restored molars
Miller mobility classification
Class 0 - Normal (physiologic) movement when force is applied. Class I – Tooth can be moved less than 1 mm in a BL or MD direction. Class II - Tooth can be moved 1mm or more in a lateral direction (buccolingual or mesiodistal). Inability to depress the tooth in a vertical direction (apicocoronal). Class III - Tooth can be moved 1mm or more in a lateral direction (buccolingual or mesiodistal). Ability to depress the tooth in a vertical direction (apicocoronal).
waerhaug sphere of influence
0.5 - 2.7 mm. avg = 1.6 mm
root proximity to sinus
Sharan & Madjar: superior curvature of sinus floor, ext of 2nd molar or multiple molars and root proximity to sinus all lead to increased sinus pneumatization
Talk about suture material
chromic gut = multifilament absorbable suture made from collagen from intestine;. dissolved by enzymatic degradation, treatment with chromic acid salts to slow down degradation. maintains strength for 10-14 days. Moderate tissue reaction. Leknes - Placement of sutures in gingival tissues elicits an inflammatory reaction and that the magnitude of this reaction may vary with the suture material used. Braided silk sutures apparently cause a more extensive inflammatory tissue reaction in an environment characterized by moisture and infectious potential than ePTFE PTFE suture = monofilament polytetrafluoroethylene, chemical inertness. non-absorbable less risk of colonization by microorganisms of monofilament sutures vs braided. PGA - multifilament
CAMBRA
Caries Management by Risk Assessment why is this patient moderate? this patient is moderate because he only has conditions that out him in the moderate risk category high risk category examples: sugary foods or drinks for prolonged time period between meals, chemo/radiation, teeth missing due to caries in past 36 months, 3 or more carious lesions in past 36 months moderate risk category examples: 1 or 2 caries lesions/restorations in past 26 months, visible plaque, tooth morphology that compromises OH, exposred root surfaces, open contacts, medications that reduce salivary flow
When are you going to get the best oral hygiene in your patients?
At the re-eval. Edith Morrision showed that the very best oral hygiene you’re gonna get is at the re-eval
What factors contribute to clinical mobility?
o Attachment loss o Excessive occlusal forces
Tell me about furcation arrows
Deas/Mealey: Furcation Arrow – Sens 39%; Spec 92%; PPV 72%; NPV 75% An additional 120 uninvolved furcations were included as controls. The involved maxillary molars were radiographed with standard periapical radiographic techniques. Projected radiographs were evaluated independently by six dentists who determined whether there was a triangular radiographic shadow (“furcation arrow”) over the mesial and distal proximal areas. The association of the furcation arrow image with Degree 2 or 3 furcation involvement was significant when compared with uninvolved furcations. The image was equally apparent over mesial or distal furcations and was not affected by the existence of a buccal furcation involvement. The incidence of the image over both uninvolved proximal furcations and proximal furcations with Degree 1 involvement was low and did not differ significantly. Because the furcation arrow seldom appears over uninvolved furcations, the appearance of the image indicates that there is proximal bony furcation involvement. However, absence of the furcation arrow image does not necessarily mean absence of a bony furcation involvement because the arrow was not seen in a large number of furcations with Degree 2 or 3 involvement. Hardkopf: Dry skull study. Correlation between degree 2 or 3 furcation and furcation arrow.
tell me about maintenance after surgery
- Westfelt: Surgical tx patients with MT intervals of 2w, 4w, or 12w following therapy for first 6 months, then at 6 months all patient put on maintenance every 3 months a. Attachment loss was inversely proportional to maintenance interval i. Higher the interval; less the AL ii. Most critical within first year of tx
how do you get patients to increase compliance, what are traits that make a patient more/less compliant?
Wilson – compliance decreases with increase in number of years since active therapy and shorter intervals of maintenance; compliance increases if pt had surgery How to increase compliance when did below =patient compliance increase 16% to 32% 1) Accommodate patients schedules 2) Make appointments before pt leaves office 3) Appointment reminders via telephone 4) Allow pt to see general dentist hygienist if it is easier for them factors that have decreased compliance 1) Smokers (Ramseir) 2) Male (Novaes) 3) Younger (Novaes) 4) Increase years since surgery (Wilson) 5) Shorter intervals (Wilson) 6) Stressfull life events, neurotic (Umaki)
root caries
Reiker – 82% patients had at least one root surface with caries and/or a root filling; plaque scores = most important factor associated with root caries
blood pressure classification
Normal= <120/<80 Elevated: 120-129/<80 Stage 1: 130-139/80-89 Stage 2: 140+/90+ Hypertensive crisis is 180/120 Target for patients with diagnosed hypertension: <130/<80
