Chapter 8 Flashcards
what is periodontitis
- alveolar and supporting bone destruction
- can affect children and adults
- not based on age, but on clinical and radiographic findings
what causes perio
- bacteria, causing:
- inflammatory/immune events
- microscopic changes in the connective tissue and epithelium
- development of perio
what are the 4 stages of of histopathogenesis
- initial
- early
- established
- advanced
what is the advanced lesion
- alveolar and supporting
- loss of connective tissue attachment
- the inflammatory infiltrate spreads in the connective tissue
- plasma cells (B cells) predominant
what is a pocket
- a pathologically deepened gingival sulcus
- in disease, the junctional epithelium becomes pocket epithelium
when is it a periodontal pocket
- when inflammation spreads into the body of the connective tissue – decreases collagen
- gingival fibers and connective tissue are destroyed, followed by apical and lateral migration of the junctional epithelium
- remember, a pocket refers only to soft tissue, not to bone. this is referred to as attachment loss
- as a consequence to destruction of the gingival fibres and apical migration of the JE there is bone destruction
what will occur when the pocket depth increases in a periodontal pocket
- ideal for bacterial growth
- difficult to maintain
what are the 2 types of periodontal pockets
- suprabony
- infra bony
what cemental changes are seen in the root surface with disease
- surface is rough
- easily absorbs endotoxins
- and bacteria and their by-products
- called necrotic cementum
how is bone destroyed with perio
- PMNs release prostaglandins. PGE2 destroys bone and PGs activate osteoclasts
- endotoxins destroy bone, which are released by gram negative bacteria
- B-cells
- release of IL-1, which stimulates PMN and collagenase
- cytokines from macrophages destroy bone, IL-1 also stimulates PGE2
is the degree of bone loss correlated with the depth of pockets
- no
- radiographically, extensive bone loss can also be associated with shallow pockets, due to surgery or recession
what does the pattern of bone loss depend on
- the route of the inflammatory infiltrate and route of tissue destruction
what are the 2 patterns of bone loss
- horizontal
- vertical
what is horizontal bone loss
- gingiva -> bone -> PD (principle fibers)
- bone is lost equally
- related to suprabony pocket
- bone resorption occurs from the outer aspect
what is vertical bone loss
- inflammation travels directly from the gingiva into the periodontal ligament
- bone loss is more rapid on one side of the tooth than the other
- gingiva to PDL to bone
- base of the deepest portion of the bony defect is apical to the alveolar bone crest creating an infra bony defect
what are the different types of infrabony defects
- vertical bone loss
- classified according to the number of osseous (bony) walls REMAINING around the defect
what is a 3 wall defect with an infrabony defect
- 3 bony walls remain and one is missing (easiest to repair in surgery bc 3 walls to connect to)
what is a 2 wall defect with an infrabony defect
- 2 bony walls remain and 2 are missing
- ‘crater’-M and D on adjacent teeth are missing, buccal and lingual walls remain (most common)
what is a 1 wall defect with an infrabony defect
- one bony wall remains and 3 are missing
- ‘hemiseptum’ defect – only the buccal or lingual wall remains
how far does the bone destruction process radiate
- 2 mm of the plaque mass
what are some factors impacting the pattern of bone loss
- thickness and width of the interdental septum
- wider interdental septum (>2 mm) (posterior teeth) versus septal bone (anterior teeth)
- thus mandibular incisors - mostly horizontal loss
- greater than 2 mm – probably vertical
how do we classify periodontitis
- extent
- severity
- grade
what is the extent of periodontitis
- localized: less than 30% of sites involved
- generalized: more than 30% sites involved
what is the severity of periodontitis
- stage I: CAL 1-2 mm
- stage II: CAL 3-4 mm
- stage III/IV: CAL greater than or equal to 5 mm
what are some other factors that can affect periodontitis
- smoking
- diabetes
- genetics
- HIV
- stress
- local factors (tooth related)
what types of bacteria are often found at periodontitis sites
- P. gingivalis
- T. forsythensis
- E. corrodens
when is periodontitis able to be diagnosed (what is present)
- apical migration of the JE
- alveolar and supporting bone loss seen on x ray
- soft tissue recession may be present
what is rapid progressing periodontitis
- less common (1% of population)
- replaces ‘early onset and aggressive periodontitis’ which included localized juvenile periodontitis, rapidly progressive periodontitis, and prepubertal periodontitis
- can occur at any age not limited to patients under 35
- divided into localized and generalized (localized replaces localized juvenile periodontitis)
what are common features of localized and generalized rapid progressing periodontitis
- patients are systemically healthy
- rapid attachment loss and bone
- familial predisposition
other features may include - elevated levels of AA
- abnormal functioning of phagocytes
- elevated levels of PGE2 and IL-1
(note: not all features here must be present for diagnosis) - often occurs at age of puberty
- min biofilm
- high levels of antibodies
- localized destructive sites
what is molar/incisor presentation for localized rapid progressing periodontitis
- first molar/incisors with interproximal attachment loss on at least 2 permanent teeth
- one of which is a first molar
- and with no more than 2 teeth other than first molars and incisors
- poor antibody response to the bacteria
- generalized interproximal loss on at least 3 permanent teeth other than first molars and incisors
what type of bacteria is often present with rapid progressive periodontitis
- AA
- PG
- P. intermedia
- C. rectus
- C. sp.
what are defects of the PMNs and macrophages
- malfunctions in phagocytosis and chemotaxis
- defect in either PMNs or macrophages but not both
- seen in 70-80% of patients with aggressive perio
- not seen in chronic periodontitis
what is refractory periodontitis (old term)
- do not respond favourably to conventions therapy and are considered resistant to treatment
30% are smokers (AAP)
what is peri-implantitis
- loss of bone that surrounds a functioning implant
- periodontitis on an implant
what is peri-implant mucositis
- gingivitis on an implant
- primary risk is bacteria
- treatment is similar
how can we treat periodontitis
- non-surgical start:
- re-evaluate 4-6/8 weeks
- determine surgery: pocket reduction or elimination. chronic – this is best treatment
- rapidly progressive perio: possible systemic antibiotics
what type of bone loss is infrabony
- vertical
what type of bone loss is suprabony
- horizontal
what does localized aggressive periodontitis include
- first molar or incisor with no more than 2 other teeth besides first molar/incisor
what does generalized periodontitis include
- generalized IP bone loss and destruction leaving at least 3 permanent teeth other than first molars/incisors