Chicken Pasta Flashcards

Question

Discuss evidence that local anesthetics reduce vasculature to periodontium?

Answer 1

22.8 Retzepi: Injection of local anesthetic with vasoconstrictor reduced microvascular blood flow of 66-75%, which was similar in buccal and palatal papilla.

Answer 2

22.9 Baab: 30 pts underwent flap surgery. 134mL of blood lost on average but the range is large. Suggests limit of 2 hours per surgical area since no patients lost more than 125mL in this amount of time. Always recommend hydration post surgically. Be prepared for fluid replacement if >500mL blood is lost.

Answer 3

22.14 Takei: Describes this technique to use in anterior of mouth with wide interdental spaces to help preserve normal papilla, obtain better esthetic result, prevent exposure of graft material and get primary closure, and prevent having an interdental crater. Did all suturing with cross external horizontal mattress.

Answer 4

22.17 Hiatt: 16 dogs. Did flap surgery. Tested strength of flap adhesion. By 2 weeks, the flap couldn't be completely separated from the tooth. Flap is secure at 2 weeks.

Answer 5

Marx, 2003: | 3 Years

Answer 6

Ramanauskaite 2019: - Mandibular nerve average size: 2.1-5 mm - Average distance of mandibular nerve to alveolar crest: 16.0 mm - 70% of the time, the mandibular nerve follows the lingual plate - A bifid mandibular canal prevalence is 0.35% via PANO and 65% of patients using CBCT - Kim: Three-dimensional histologic reconstructions revealed that the inferior alveolar artery and the inferior alveolar vein traveled above the inferior alveolar nerve in 8 (80%) of 10 patients, with the artery being lingual to the vein. - Anterior loop has been identified in 61.5% of patients. - Anterior loop on average ranges from 0.4-6.0 mm (longer in males) - therefore a safety distance of 3-6 mm is recommended anterior to mental foramen. - Mental foramen 3.47 mm tall and 3.59 mm wide. 46-62% of time located apical to apex of premolars, and 25-38% of time located coronal to apex. Accessory mental foramen are noted between 7-15% in CBCT scans. - Lingual foramen: occur almost 100% of the time and are located about 14mm apical to alveolar crest. They are entrances of canals that lead from the cortical bone surface to itnraoessous region. These are branches from either the submental (facial artery branch) or sublingual (lingual artery branch) vessels. Perforation of the lingual cortical plate during implant preparation may result in injury either to the lingual nerve (if above mylohyoid muscle) or to the adjacent sublingual and/or submental arteries.(if below mylohyoid muscle). - Incisive canal: Contains the nasopalatine nerve, terminal branch of nasopalatine artery, connective tissue, fat, veins, and salivary glands. Average length is 8.1-9.9 mm and terminates into the nasal cavity, usually two branches and mean diameter is 3.49 mm. After tooth loss, the incisive foramen may emerge from alveolar crest and can enlarge by about 32%. - Maxillary Sinus: Lined by militated respiratory epithelium and exhibits a radiographic thickness of 0.8 - 1.99 mm. Average volume of sinus is 31cm^3. Tips of implants penetrating to depths of up to 2mm in experimental canine studies were found to be either fully or partially covered with newly formed bone and separated by intact membrane. When greater than 2mm, implants communicated with sinus but failed to induce any pathologic reactions. However, there are reports of chronic sinusitis when implants were penetrating into nasal cavity. - Most common complication during sinus floor elevation is perforation of membrane, which occurs from 9-60% of time. Risk of perforation increases with septae. Which are cortical bone and oriented in both horizontal and vertical planes. Classified as primary (evolve during growth of face), or secondary (result from tooth loss and bone resorption). The posterior superior alveolar artery and inferior orbital artery: major branches of the maxillary artery that provide blood supply to the bony walls and membrane of the sinus - Ventialtion of the maxillary sinus is ensured via the osmium natural. The osmium is located in the upper apsect of the medial sinus well and has an oval or slit-shape.

Answer 7

19. 17 Huynh-Ba, 2010: | - 87.2% of time, average buccal plate thickness is <1mm with average of 0.8mm.

Answer 8

- Upregulates complement and Fc receptors on neutrophils and monocytes - Upregulates adhesion molecules on fibroblasts and leukocytes and endothelial cells - Induces osteoclast formation and bone resorption (RANKL) - Stimulates MMP and PG production by macrophages, PMNs, and fibroblasts - Induces other interleukins and TNF-alpha - Causes release of IL-8, which attracts PMNs. PMNs release enzymes that are capable of destroy pathogens - Causes release of histamine and kinins which promote vasodilation, which enhance antibodies and complement

Answer 9

- Dysbiosis is a microbial shift, referring to the concept that some diseases are due to a decrease in the number of beneficial symbionts and an increase in the number of pathogens. The long standing paradigm is that, as periodontitis develops, the oral microbiota shifts from one consisting primarily of gram + aerobes, to one consisting of gram - anaerobes. - Not everyone knows why this imbalance is created, a lot of people think this has to deal with the immune system and certain organisms that colonize. - Another definition: In the structure of the dental plaque biofilm, there is a succession in microbial colonization with a dramatic shift in flora from health to disease and establishment of a gram- negative anaerobic flora in sites with periodontal pocketing.

Answer 10

- Trap nutrients - Engage in the primary production of their own nutrients - Form a digestive consortium (By-products of one organism serve as nutrients for another) - Protect other bacteria from antibacterial agents and phagocytes

Answer 11

- 6 K antigen serotypes - Induces proinflammatory cytokine production - LPS induces IL-1, IL-6, IL-8 and activates osteoclasts - Leukotoxin - pore forming protein leading to apoptosis and necrosis - Proteolytic enzymes (gingipains) - Degrades antibodies and complement - Groel heat shock protein - Fimbriae - Promotes adhesion and epithelial invasion

Answer 12

- Cigarettes contain 2,550 known toxins including benzene, pesticides, tar, and carbon monoxide - Smoking affects innate and specific immunities - Innate - Neutrophil motility, chemotaxis, and phagoctyosis are reduced - Specific - antibody production, especially IgG, and immune regulatory t-cells are reduced - Smoking increases bacteria adhesion and is selective for more gram - bacteria - Increased production of cytokines from neutrophils and macrophages in smokers (such as PGE-2, TNF-a, IL-1) - Decreases oxygen tension in the sulcus which favors more gram- bacteria - Nicotine has been shown to reduce fibroblast activity - Suppression of OPG (which is protective) - Decrease perfusion through blood vessels (but increased vessels) - Direct cellular cytotoxicity of smoking Literature: - Periodontitis-free subjects who had smoked 5+ pack years were 18 times more likely to be infected by pathogenic bacteria than non smokers. - Tomar & Asma (2000): Know that current smokers are 4x more likely to have periodontal disease and there is dose response relationship with periodontal disease. Use this paper of "how long should a patient quit smoking before they are considered a non-smoker?" - 11 years. Tomar (2000) performed a study utilizing the NHANES data set - showed that current smokers were 4x more likely to have periodontitis than never smokers. Also, at ≥11 years, there were no differences noted in prevalence of periodontal disease for former smokers and never smokers. Alharthi (2019) JPerio Paper: found with NHANES data set found that for each year of smoking cessation, patients have a reduction in odds of having periodontitis as 2.5-5.2% per year and smoking cessation is consistently associated with a reduction in tooth loss risk, with the risk of tooth loss approaching that of never smokers after 10-20 years of cessation. Ravida, HL Wang (Michigan) (2020) J Clin Perio: A total of 258 patients were included in the review with at least one annual PMT visit followed for a mean duration of 290.7 months (24.2 years). 91.9% of the patients were well maintained, 7.4% were downhill, and 0.8% were in the extreme downhill group. A statistically significant association was found between increasing smoking intensity and tooth loss due to periodontitis (TLP). Former smokers (OR 2.56) and current smokers (OR 4.38) were statistically more likely to have any TLP compared to never smokers. A dose-response pattern was observed for TLP as never smokers through former and current light to current heavy smokers lost 2.5%, 4.1%, 5.6%, and 10.3% of their teeth respectively. The longer the duration since smoking cessation, the lower the probability of TLP for teeth for both former light and heavy smokers. Each additional year since quitting smoking reduced the risk of TLP by 6%. There was a washout period of 15 years for the risk of TLP for a former smoker to approximate the baseline risk of a never smoker. BL: Current and former smokers lost significantly more teeth due to periodontitis and exhibited a dose-response pattern compared to never smokers. It took 15 years of smoking cessation for the risk of tooth loss due to periodontitis for former smokers to reach that of never smokers. Naji (2020): stated that the OR of being a poor responder was 2.4 compared to a non-smoker. Significantly more non-smokers are good responders compared to smokers.

Answer 13

Zander (1953) performed a study to evaluate this and found 4 mechanisms of which calculus attaches to the tooth: - To the secondary cuticle (thought to derive from epithelial attachment as it contacts cementum) - To microscopic irregularities in cementum where Sharpeys fibers attach - By penetration of bacterial matrix in cementum - Into mechanical undercuts of cemental resorption areas - Then, Canis (1979) performed the same study and confirmed ¾ of Zanders findings, but did not find evidence through SEM of direct bacterial penetration as mode of calculus attachment.

Answer 14

- Osteoimmunology refers to the study of regulation of osteoclastogenesis through the Receptor Activator of Nuclear Factor kB Ligand. RANKL has been described as the "master switch regulator" for osteoclastogenesis. - Osteoblasts express RANKL on their cell membrane. When this ligand binds to the RANK receptor on a pre-osteoclast, it signals the cell to differentiate into an active osteoclast. The decoy receptor for RANKL, called osteoprotegerin, blocks this activation mechanism, thus helping to maintain bone homeostasis. In periodontal disease, the ratio of RANKL to osteoprotegerin increases, whereas in health, the ratio is decreased. - Osteoblasts and periodontal ligament fibroblasts express RANKL on their cell membrane. T cells not only express membrane bound RANKL, but also secrete it in soluble form. The pro-inflammatory cytokines interleukin-1 and interleukin-6, TNF-a, and PGE2 signal these cells to express membrane bound RANKL, and the T cell to secrete RANKl. These cells are already increased in the periodontal lesion and are indirectly involved in periodontal bone loss. Thus, when the lesion has advanced toward the periodontal ligament and alveolar bone, the up-regulation of RANKL may lead to bone loss and subsequent deepening of the periodontal pocket. - Gingival fibroblasts produce osteoprotegerin, which may help prevent bone resorption in the earlier stages of periodontal disease where the lesion is primarily confined to an area beneath the epithelium.

Answer 15

- Bone loss - Kribbs (1983) showed that decreased bone mineral density in systemic skeleton leads to reduction in oral bone density (maxilla and mandible) - J Prosth (1992) published article that osteoporosis increases resorption of residual ridge after tooth extraction in maxilla and mandible. - Tooth loss - Daniell and Krall (1983,1994) showed risk of tooth loss increases with OP and there is greater prevalence of edentulism in osteoporosis. - Periodontitis - Epidemiologic - Penoni (2017) - there is a significant relationship between osteoporosis and clinical attachment loss (0.32mm) but the magnitude of the effect is not impressive. - Longitudinal (Cross-sectional) - Yoshihara (2004) examined the relationship between BMD and clinical attachment level changes over 3 years (progressive sites defines as CAL with change >3mm). The number of progressive sites was about double in men that had osteoporosis than those without. - Haas (2009) showed that a group fo Brazilian women who were taking HRT had similar prevalence of periodontitis with women who were premenopausal, than those women who were not taking HRT which had significantly higher prevalence of periodontitis and greater % of teeth with CAL >5mm. (Not strong level of evidence). - Interventional trial evaluating HRT vs Calcium/Vitamin D supplement - Civitelli (2002) evaluated tens of thousands of women comparing those on HRT and those just on supplements. Found that those taking only vitamin D/Ca, it was the same or better than those taking HRT.

Answer 16

20.3 Varthis - Retrospective cross sectional study. Overall prevalence of ICL was 52.8% (92/174 implants): 78.2% was on the mesial surface and 21.8% on the distal surface

Answer 17

- 20.9 Van Assche: Retrospective. Early CS exposures averaged 1.96mm of marginal bone loss (range: 0.2-3.2 mm) , 2 stage submerged averaged .01mm, and 1 stage averaged .14mm of bone loss. Stage 1 and 2 implants were not significantly different but early exposures had significantly more bone loss.

Answer 18

- 20.11 Staubli - Korsch et al. (2014, 2015): reported differences in the prevalence of BOP depending on the cements applied. Less BOP was found with temporary zinc oxide-eugenol cement (46%) than methacrylate cement (96%). BL: Excess cement could serve as a risk indicator for peri-implant disease, especially for restorations with submucosal crown margins and short soft tissue healing time. The type of cement and frequency of maintenance may also play a role in this process. - Excess cement was not observed when restorations were cemented with zinc oxide-eugenol based cements. Methacrylate-based cements are associated with presence of excess cement, an alteration of the peri-implant microbiome favoring the colonization of periodontal pathogens and the development of suppuration. Zinc oxide-eugenol based cements may be a good alternative.

Answer 19

- 20.28 Saurez-Lopez and Wang HL: Systematic Review. BL: Soft tissue thickness of more than 2mm is required for the establishment of biologic width to minimize early MBL and Platform Switching is only effective with adequate mucosal thickness. Therefore, evaluation of soft tissue thickness at time of implant placement and the use of soft tissue graft with presence of thin tissue are strongly recommended.

Answer 20

- Non-working contacts - Youdelis and Mann, 1965 - Retrospective study of 54 patients looking at RECORDS, not patients - 53% of patients had non working contacts and those teeth had significantly greater mobility, bone loss, PD in teeth with nonworking contacts - These patients had significant disease though - Shefter and McFall, 1984 - Periodontal exams on 66 patients - 56% of patients had nonworking contacts (Most common was 2nd molar) - No relationship between nonworking contacts and periodontal disease but these were young patients with minimal disease - Jin and Cao, 1992 - 32 Chinese patients - No relationship between nonworking contacts and PD, AL, bone height - Teeth with mobility/fremitus had greater PD, AL, bone loss - Occlusal discrepancies - Nunn & Harrel, 2001 - Retrospective review of 89 patients in private practice - Teeth with occlusal discrepancies had significantly deeper mean PDs (5.8mm) compared to teeth without discrepancies (4.8mm). - Nunn & Harrel, 2009 (CROSS-SECTIONAL VERSION) - Following situations had significantly deeper PD than those without occlusal discrepancies - Centric prematurity (0.9mm deeper) - Slide in centric (0.8-1.2mm deeper) - Balancing contact only (1.0mm deeper) - Balancing and working contact (1.0mm deeper) - Protrusive contact on posterior tooth (0.5mm deeper) - Protrusive contact on anterior tooth (0.2mm shallower) - Bernhardt, 2006 (SHIP STUDY) - Largest cross sectional study to date with excellent occlusal exams (n=2980) - Non-working contacts increased PD by 0.13mm and CAL by 0.14mm - CONCLUSION: presence of non-working contact on a tooth is associated with increased PD and CAL, but magnitude of effect is fairly small

Answer 21

- Increased mobility, fremitus, wear facets, tooth migration, tooth fracture, pulpal symptoms

Answer 22

- Cortellini, 2001 - 55 pts had GTR with membrane, 54 pts had GTR without membrane. Mobility negatively affected CAL gain. - The greater the mobility at baseline, the smaller the CAL gain at 1 year - Trejo & Weltman, 2004 - Retrospective study. 36 teeth with Miller 0, 13 teeth with miller 1, 15 teeth with miller 2. - No significant difference in PD reduction or CAL gain in different mobility categories. - Teeth with mobility up to and including Miller class 2 respond similar to nonmobile teeth one year following regeneration surgery - NOTE: teeth that clinicians felt needed splinting were excluded from this study - Schulz, 2000 - Prospective trial (Germany) to evaluate effect of splinting on bone replacement grafts - 33 subjects had bony defects treated with Biocoral (natural coralline calcium carbonate) - 11 subjects had 18 test teeth splinted before surgery 11 subjects had 16 test teeth splinted at suture removal (1 week POT) 11 subjects had 17 teeth not splinted at all - Splints were FPDs, temporary crowns, light cured resin - Splints removed 8-11 months after surgery - PD reduction and CAL gain significantly better in both splinted groups compared to non-splinted group - Better PD reduction/CAL gain in teeth splinted before surgery than 1 week after surgery, but not significantly so - Schulz et al. Clin Oral Invest 2000 - Occlusal Adjustment/Mobility and Periodontal Therapy PD Reduction (mm) CAL Gain (mm) Splinted before surgery 5.4* 5.1† Splinted 1 week after surgery 4.3* 3.5 † Not splinted 2.2 1.7

Answer 23

- 21.2. Emler: Repetition and reinforcement were of significant value in improving the oral hygiene performance of the school children over a period of one year. - 21.4 Glavind: Regardless of the method of instruction, improvements in home care occur with instruction.

Answer 24

- 21.12 Dorfer, 2016 - Brushing twice/day over 36 months with a powered or manual tooth brush showed no significant differences in gingival recession progression. - 21.13 Tritten, 1996 - Both a standard manual toothbrush and a sonic toothbrush (Sonicare) are capable of removing supragingival plaque and reducing signs of gingival inflammation. However, the sonic toothbrush was statistically superior in removal of plaque from hard to reach areas such as interproximal regions.

Answer 25

- 21.15 Fairbrother, 2000. - Pyrophosphates - Inhibits conversion of calcium phosphate to hydroxyapatite thereby decreasing crystallization and crystal growth - Lower amounts of pyrophosphates are found in heavy calculus formers

Answer 26

- 21.17 Valkenburg, 2016. - Systematic review. Tooth brushing with a dentifrice does not provide an added effect for the mechanical removal of dental plaque.

Answer 27

- 18.9 Temmerman: 5 yr prospective study. 48 postmenopausal women. Implants have similar survival rates in osteoporotic patients as healthy pts.

Answer 28

- 18.12. Colella: Systematic Review. Implant failure in irradiated patients is significantly greater in the maxilla than mandible. Most implant failures occurred within 36 months of surgery, and failure was rare when the radiation dose was <45Gy. The timing of implant placement and radiation therapy was not found to significantly influence implant failure.

Answer 29

- 18.13. Machtei: Implants placed after removal of a failed implant have a lower survival rate than the first implant placed. Failure was not associated with any particular implant or patient related factors. The authors hypothesize that failure may be associated with a possible negative effect of the particular implant site or "site specific etiological background" in which previous failure had occurred. - 18.14 Chrcanovic: Retrospective study. 11,000 implants. Survival 1st attempt = 93.6%, 2nd attempt = 73.6%, 3rd attempt = 64.3%. Failure rates are higher for implants placed at previously failed sites, this study did not show a difference in failure rates between a 2nd and a 3rd implant. Poor bone quality was associated with increased failure rates. Use of SSRI's and antithrombotic agents increased failure rates.

Answer 30

- Oral epithelium and CT (500um a day) - Woven bone (30-50um a day) - Lamellar bone (0.9-1.0um a day) PDL (50-60um a day) Lamellar bone and PDL are hard to get.

Answer 31

- Regeneration of lost periodontal structures through differential tissue responses - Prevention of epithelial migration - Barrier membranes used to cover bone and periodontal ligament - Only the PDL cells have the potential for regeneration of the attachment apparatus - PDL cells have ability to differentiate to become cementoblasts, osteoblasts, and fibroblasts. PDL cells carry this potential. - Most regeneration occurs within 1 month (4-6 weeks) allowing the PDL cells to beat the epithelial cells - Barrier membrane techniques: epithelium exclusion from the root or existing bone surface - Principles of GTR: - Clot stabilization - Wound protection - Space creation

Answer 32

- CollaPlug - type 1 bovine collagen - 0.5 months - Ossix Plus - type 1 porcine collagen - 4-6 months - Bio-Gide - type 1, 3 porcine collagen - 6 months - Cytoplast (RTM Collagen) - 6-10 months - BioXclude (Amnion chorion tissue) - Unsure

Answer 33

Different ways you can cross link collagen (main way is through chemical modification) which allows for low solubility, increased stability - which can help for membranes to last long.

Answer 34

- Defect morphology - # of walls remaining: Cortellini, 1993 - Depth of defect: Cortellini, 2017 - Width of defect: Stavropoulos, 2017 - Angle of defect: Steffensen, 1989, Cortellini, Tonetti, 1999 - Oral hygiene/compliance with maintenance: Cortellini, 1996 - Systemic health status: Reynolds, 2015 - Smoking: Reynolds, 2015 - Cortellini, 2004 - Surgical factors - flap design, defect and root morphology, material employed, flap position, membrane exposure

Answer 35

- Stavropoulos, 2010: Wide/deep and narrow/shallow defects healed similar in dog study and did not make difference between the two. They used bio-oss and biogide.

Answer 36

Defect angle: - Bjorn Steffensen - <45 degs = bone gain - >45 degs = bone loss - Cotellini and Tonetti, 1999 - Angle ≤25 degs vs angle ≥37 degs - More favorable with ≤25 degs

Answer 37

- Papilla preservation flap - Takei, 1985 - Modified papilla preservation - Cortellini, 1995 - Simplified papilla preservation - Cortellini, 1999 - Minimally invasive surgical technique - Cortellini, Tonetti, 2007 - Single flap approach - Tromebelli, Rassperini, 2013 - Modified MIST (minimal flap with single flap approach)zx- Corellini, Tonetti, 2009 - Soft tissue wall technique - Rasperini, 2013 - Connective tissue wall technique - Zucchelli, 2014 - Entire papilla preservation, Aslan, 2015

Answer 38

- Lindhe, Nyman 1984 - 14 year follow up in osseous patients - 61 patients - Extracted hopeless teeth prior to therapy - Strict maintenance every 3-6 months - 93% of sites had PD <4 mm, <1% developed >6 mm - 1.2% of teeth lost due to periodontitis - Washington (Ammons and Olsen), 1980, 1985 - Split mouth study design with APF with/without osseous - 5 year follow up - 8 patients - More breakdown seen in sites without osseous, especially deeper sites - you were more likely to have PD reduction at sites >5mm and less likely to have 4+mm pockets with BOP after 5 years (18% vs 42%). - Nebraska (Kaldahl, 1988, 1996) - 51 patients in split mouth study design followed up at 7 years - Flap osseous had significantly greater probing depth reduction in sites ≥5mm - Flap osseous had less breakdown in sites with initial PD ≥7mm versus root planing and MWF - Hopeless teeth extracted to obtain physiologic architecture Contrast this evidence with Becker (Arizona) and Ramfjord (Michigan) studies

Answer 39

- Mobelli, 1995 - 4 patients, 52 teeth - Evaluated micro differences between osseous resection surgery with/without root planing and did plaque sampling - Decreased pathogens in both groups - Alteration in ecological environment affected microbiological composition

Answer 40

- CEPs - Root flutings - Palato-radicular grooves - Tooth position - Trauma - Other entities (plaque/calculus) - Colonization of pathogenic microorganisms (sphere of influence - Waerhaug) - Tooth/tooth - root/root relationship (Tal)

Answer 41

- Horning, 2000 - live studies - Buccal exostoses/lipping - 76.9% at patient level - 7% of all teeth - Mandibular tori - Dry Skull - 27% overall, 25% in caucasian, 34% in African-American

Answer 42

- Wilderman, 1970 | - Following osseous surgery, you will get 1.2mm of resorption and 0.4mm of repair, leaving a net loss of 0.8mm.

Answer 43

- PALATAL APPROACH (Ochsenbein, Bohannan) 1963 - Avoids buccal furcation exposure - Avoids a shallow buccal vestibule - More cancellous bone on palate - All keratinized tissue - Wider interdental space - Greater access - Natural cleansing action of tongue - LINGUAL APPROACH - (Tibbetts, Ochenbein) 1976 - Avoids buccal furcation exposure - Avoids dealing with shallow vestibule - Base of defects are usually lingual - Thicker bone - Slightly wider embrasures - Natural cleansing action of tongue

Answer 44

- Genetic factors (not modifiable) - Racial/ethnic group (not modifiable) - Smoking (#1 environmental factor) - Poor oral hygiene (infrequent dental care) - Systemic disease - Compromised host immuno-inflammatory defense - Obesity

Answer 45

- Ervasti, 1985: - When you look at patients with just diabetes compared to non-diabetic group, there is no difference in gingival bleeding between the two groups. But poorly controlled diabetic patients have markedly increase in bleeding. - "In diabetic patients where their blood sugar control is good, they kind of look like people without diabetes on average. In diabetic patients where their blood sugar control is not as good, they then will have more bleeding."

Answer 46

INTERVENTIONAL DATA - Sgolastra, 2013 - SR/MA - 315 patients - 5 studies - compared SRP alone (no systemic antibiotics) to no treatment or coronal scaling - SRP was associated with a significantly greater reduction in HbA1c of 0.65% compared to controls - Engebretson, 2013, Periodontal Medicine Workshop - MA of 9 studies, 719 patients - Any type of periodontal therapy with/without antibiotics - SRP was associated with a significantly greater reduction in HbA1c of 0.36% compared to controls - Chapple, Genco, 2013 Periodontal Medicine Workshop - SUMMARY: Randomized control trials consistently demonstrate that mechanical periodontal therapy associates with approximately 0.4% reduction in HbA1c at 3 months, a clinical impact equivalent to adding a second drug to a pharmacological regime for diabetes. - Engebretson, 2013, JAMA, RCT - Largest RCT we have - 240 subjects that only had SRP with no antibiotics, 235 patients with only oral hygiene instruction - No significant change in HbA1c in either group from baseline to 3-6 months. No significant change in HOMA (insulin sensitivity). - KEY NOTES: only minor/average periodontal response to treatment (SRP alone not enough treatment to associated with HbA1c change) and MOST subjects had well to moderately well controlled DM (7-9%). - D'Aiuto, Lancelet, 2018 - 244 patients RCT - Evaluated effect of "intensive periodontal therapy" - At 12 months, HbA1c in intensive periodontal therapy group had mean 0.6% lower HbA1c than control group. - So if you want to see dramatic increase in A1c, this will happen more frequently with intensive periodontal treatment. - Quintero, 2018 - 93 Type 2 DM patients - SRP more likely to have impact on glycemic control when baseline HbA1c control is poor (>9%)

Answer 47

- Soehren and Van Swol, 1979 - Limited bone quantity - Based on clinical experience, recommended cancellous bone harvest at 8 weeks in maxilla and 12 weeks in mandible. - 8-12 weeks optimal time Perio to capture osteoblastic phase and mature tabeculae

Answer 48

- Calculus alone is not a primary etiologic factor for periodontitis (Allen & Kerr) and long junctional epithelium can attach to calculus (Listgarten & Ellegaard) - Sites with calculus tend to have more attachment loss due to plaque (Cercek) - Residual calculus delays healing (Fujikawa)

Answer 49

- Ciprofloxin - Metronidazole - Rifampin

Answer 50

a. Cairo et al i. Recession type 1 (RT1): Gingival recession with no loss of interproximal attachment. Interproximal CEJ is clinically not detectable at both mesial and distal aspects of the tooth. ii. Recession type 2 (RT2): Gingival recession associated with loss of interproximal attachment. The amount of interproximal attachment loss (measured from the interproximal CEJ to the depth of the interproximal sulcus/pocket) is less than or equal to the buccal attachment loss (measured from the buccal CEJ to the apical end of the buccal sulcus/pocket). iii. Recession type 3 (RT3): Gingival recession associated with loss of interproximal attachment. The amount of interproximal attachment loss (measured from the interproximal CEK to the apical end of the sulcus/pocket) is greater than the buccal attachment loss (measured from the buccal CEJ to the apical end of the buccal sulcus/pocket). b. Pini-Prato et al: Subclassification of recession i. Classified the presence/absence of CEJ as: 1. Class A (detectable CEJ) 2. Class B (undetectable CEJ) ii. And the presence/absence of cervical concavities or "step" on rot surface as: 1. Class + (presence of cervical step >0.5mm) 2. Class - (absence of cervical step) iii. Class (A-): CEJ detectable without step iv. Class (A+): CEJ detectable with step v. Class (B-): CEJ undetectable without step vi. Class (B+): CEJ undetectable with step

Answer 51

a. Hamp Index (measured from furcation entrance to furthest extent into furcation) i. Degree 1: Horizontal bone loss that does not exceed 1/3rd of the tooth width. Probe penetration up to 3mm into the furcation. This means from the furcation entrance, NOT the soft tissue. ii. Degree 2: Horizontal loss that exceeds 1/3rd of the tooth width but is not through and through. Probe penetration greater than 3mm but not communication with opposite side. iii. Degree 3: Horizontal loss that is through and through b. Tarnow and Fletcher (Subclassification of vertical bone loss) i. Subclass A - 0-3mm ii. Subclass B - 4-6mm iii. Subclass C - >7mm

Answer 52

a. Hancock: young population i. Open contacts leads to food impaction which can lead to increased probing depths. No direct correlation between open contacts and pocket depths though in this population b. Jernberg: Adult patients - open contact meant floss slipping through during mastication i. Open contacts had increased probing depths and attachment loss

Answer 53

i. Buchanan 1. Sensitivity - 43%, Specificity - 92%, PPV - 92%, NPV - 46% ii. Hyer, Deas 1. Low sensitivity, high specificity, high PPV 2. If calculus is present on >30% of root surface area, then sensitivity will increase. Also if diameter of calculus was >0.5mm 3. Changes in digital images did not increase sensitivity

Answer 54

Sharan i. Superior curvature of sinus floor, and extraction of maxillary molars can lead to sinus pneumatization ii. Also need to be careful when doing osseous is close presence to sinus floor

Answer 55

a. Sonnier and Horning - skulls from museum i. Palatal tubercles - 56% ii. Mandibular tori - 27% (increased prevalence in males) iii. Palatal tori - 20% (increased prevalence in females) b. Holtzclaw i. 78% prevalence in live patients

Answer 56

a. Sphere of influence i. Waerhaug - average of 1.63mm, range of 0.5-2.7mm b. Heins and Weider i. Distance between roots and histology of bone ii. 0-0.3mm - no bone, direct PDL attachment between teeth iii. 0.3-0.5mm - cortical bone only, no cancellous iv. >0.5mm - cortical and cancellous bone c. Haim Tal i. Distance between roots and type of bone loss - correlates well with sphere of influence ii. <2.5mm - mostly horizontal bone loss iii. 2.5-3.1mm - possibility to have single intra-bony defect iv. >3.1mm possibly to have 2 intra-bony defects d. Kim i. Mandibular anterior teeth with <0.8mm inter-root distance will have 56% more likely to lose >1mm bone over 10 years

Answer 57

a. Silness | i. Increased plaque and inflammation due to inability to clean the teeth properly

Answer 58

a. Matheny i. Inflammation causes increase in number of blood vessels, but decreased perfusion of blood vessels, which leads to stagnant O2 poor blood (cyanosis).

Answer 59

a. Ursell i. Bone sounding vs surgical measurements correlation coefficient 97% with mean 0.29mm difference. b. Mealey i. Bone sounding in furcation is accurate within 1mm 85% of time. Average distance between bone sounding and surgical measurements was 0.5mm. Bone sounding increases diagnostic accuracy 10% of clinical detection of furcation invasion.

Answer 60

i. Tan 1. Viable bacteria are found within calculus using SEM ii. Allen and Kerr 1. Sterile or non-sterile calculus implanted into guinea pigs a. Sterile calculus produced foreign body reaction b. Non-sterile calculus produced constant abscess with suppuration iii. Anerud 1. Sri-lankans develop subgingival calculus 6-8 years following eruption of tooth, calculus contributed to more rapid AL compared to Norwegians without calculus iv. Richardson and Bowers 1. Calculus is generally found about ½ depth into intrabony defects v. Fujukawa 1. Healing with calculus in place is delayed, but is possible with good oral hygiene

Answer 61

i. Hydroxyapatite (58%) - mature calculus ii. Magnesium whitlockite (21%) iii. Osteocalcium phosphate (12%) iv. Brushite (9%) - 1st crystalline to form in immature calculus v. Development order 1. Brushite - osteocaclium phosphate - magnesium whitlockite -hydroxyapatite

Answer 62

a. Shiau i. There are genetic risk factors that may explain males having higher prevalence. ii. Also, increase in estrogen for females are bone protective, while testosterone in men increases bone metabolism. iii. Males have increased innate immune response, and females have higher adaptive immune response.

Answer 63

i. Graetz 1. Maxillary molars with FI-3 and advanced bone loss have greatest risk of tooth loss. Increased mobility, furcation invasion, residual PD associated with higher risk of molar loss during SPT. ii. Nibali (2017) 1. Untreated site with irregular perio therapy (SHIP study) led to significantly higher risk for tooth loss with all three degrees of furcation invasion comparing to molar without furcation. iii. Nibali (2016) 1. Systematic review/meta analysis that were treated and in frequent maintenance, presence of furcation invasion approximately doubles the risk of tooth loss for up to 10-15 years. However, only 30% of FI 3 molars lost in between 5-15 years. iv. Salvi 1. Showed smokers, noncompliance with SPT and deep residual PDS = risk for tooth loss. Hamp 1 was not worse than no furcation but Hamp 2 and 3 are risk for tooth loss.

Answer 64

Removal of local factors PD Reduction and CAL Gain Reduce Inflammation Reduce Microbiological Parameters Get to know patient Bone Sounding

Answer 65

i. Caffesse 1. Performed SRP on teeth and then extracted the teeth and evaluated of % free calculus surfaces. Results showed we are good at closed SRP in shallow pockets, but not good in deeper pockets. Closed Open 1-3mm 86% 86% 4-6mm 43% 76% >6mm 32% 50% ii. Waerhaug 1. SRP in combination flap surgery in some cases a. <3 mm PD: 89% plaque free b. 3-5mm PD: 63% plaque free c. >5mm PD: 11% plaque free iii. Stambaugh & Dragoo: 1. You are not good at scaling beyond 4mm and cannon reach below 5.5mm a. Average curette efficiency was 3.73mm b. Average instrument limit is 5.52mm - how deep the curette tip can reach

Answer 66

Lindhe 1. 2.9mm for NST (Loss of AL below this number, and gain AL if PD above this) 2. 4.2mm for surgical therapy 3. 5.4mm where you will gain more attachment with surgical rather than NST

Answer 67

i. Caton - gingival biopsies before and after treatment showed less inflammatory infiltrate, less bleeding, less ulcerated CT, and less BOP ii. Davenport - Histology on hopeless teeth showed bleeding sites have more inflammatory infiltrate, widened intracellular spacing, more fluid flow, more leukocytes

Answer 68

i. Caton, Proye, Polson 1. After SRP, all parameters improved at 4 weeks and maintained to 16 weeks. 2. "The significant decreases in plaque, gingival and bleeding indices, and pocket depth as well as the significant gingival recession and gain of clinical attachment which were present at the 4 week point were maintained at 8-16 weeks after root planing. It was concluded that the favorable clinical changes which occur in periodontal pockets within 1 month after a single episode of subgingival root planing combined with improved oral hygiene can be maintained for an additional 3 month period."

Answer 69

i. Waerhaug | 1. Showed healing occurs with LJE

Answer 70

i. Cugini 1. SRP resulted in decrease in number of red complex microbes up to 12 months following SRP, however, all were not totally eliminated and some species increased ii. Jones, O'Leary 1. SRP was able to render root surfaces approximately as free of detectable endotoxins as were uninvolved healthy root surfaces.

Answer 71

Thymol, Eucalyptol, Menthol, Methylsalicylate

Answer 72

i. Essential oil that disrupts the cell wall and inhibits bacterial enzymes. Vehicle is alcohol, 22-27% content. ii. There is up to 34% reduction in gingival inflammation and plaque with Listerine use x2 daily iii. Gunsolley 1. 25% anti-plaque and 16-30% anti-gingivitis, 60% effectiveness of CHX

Answer 73

I want the patient to use whatever interproximal aid that is easiest for them, and that they will actually use. Use proxabrush as soon as patient loses papillary guidance. In a 3 way crossover design, Kiger showed that TB+proxabrush had lower plaque levels, especially interproximal compared to TB alone or TB+floss.

Answer 74

i. Fleischer 1. Multirooted teeth showed that an open approach allowed for significantly more calculus removal, especially for a periodontal resident - also showed that even when opened and experienced clinician, yielded calculus free furcation only 68% ii. Brayer 1. Single rooted teeth with 4+ mm PDs needed open approach for calculus removal iii. Caffesse 1. Probability of leaving residual calculus increases as pocket depth increases. Over 4mm it is 30-40% closed and 50-75% open. iv. Waerhaug 1. Sites >5mm 90% of surfaces have remaining plaque which gives rise to new plaque formation and prevention of junctional epithelium.

Answer 75

Ammons and Olsen i. Less recurrence of disease at 5 years compared with apically positioned flap. ii. Osseous has less residual pockets and less BOP compared to flap curettage 5 years out

Answer 76

Kaldahl and Kalkwarf I. Better PD reduction and fewer extractions over 7 years compared to MWF flap. II. Osseous had better PD reduction especially at deeper sites

Answer 77

a. Ross and Thompson i. 88% of maxillary molars with furcation invasions survived 5-24 years (degree 1 furcation mainly). NO surgery performed, only soft tissue therapy and coronal reshaping. b. Graetz - 18 year follow up molar prognosis i. Degree 0 or 1 furcation invasion is not a risk factor for molar loss. ii. Maxillary molars with FI-3 and advanced bone loss are at greatest risk of tooth loss iii. Increased mobility, furcation invasion and residual pocket depth are associated with a higher risk of molar loss during maintenance iv. 1.89x risk of molar loss for every 1mm of residual PD following active therapy

Answer 78

a. Why 3 months? i. Ramjford and Morrison showed that 3 months maintenance is adequate to maintain the periodontal condition even if patients hygiene is not perfect (however in this population, they had good OH - since they have low GI) ii. Mousques 1. Without proper OH, the proportions of microorganisms will return to baseline values at 3 months. b. Regular maintenance i. Axelsson and Nystrom 1. 30 year maintenance of patient with NST and MWF if necessary. Pt was recalled at 3,6,12 month intervals. Plaque scores at 30 years was less than baseline and incidence of tooth loss was low in all groups. ii. Lindhe and Nyman 1. Showed patient with advanced periodontitis could be maintenance with treatment and regular maintenance.

Answer 79

15.1. Gargiulo: 30 microscopic human specimens. Sulcus .69mm JE .97mm CT 1.07mm

Answer 80

``` 15.3. Tarnow - When the distance from the base of the contact to the crest of the bone increased, the percentage of sites with an intact papilla decreased. Distance % Times Papilla Present 3 - 5 mm 100% 6 mm 56% 7 mm 27% ``` BL: When the distance was ≤5 mm, the papilla was almost always present, whereas the papilla was usually missing when the distance was ≥7 mm.

Answer 81

15.7. Herrero: A biologic width of 3 mm is rarely obtained following crown lengthening procedures. Clinicians should be more aggressive in their surgical treatment and should take measurements during the procedure to prevent impingement of biological width following placement of a restoration. According to this article, you are more likely to remove more on the facial and less on the the distolingual.

Answer 82

15.12. Kepic and O'leary: 100 pts. (NO) There were low correlations found between pocket depth, attachment loss, plaque, calculus, or gingival inflammation with the status of the marginal ridge relationship. Uneven marginal ridges discrepancies are less important than plaque and calculus deposits in periodontal health. Philstrom: (YES) Max 1st molars with uneven marginal ridges means difference in CEJ level which means vertical defects. These sites show increased PDs, BL, and LOA.

Answer 83

15.13. Flores-de-Jacoby: Subgingival margins resulted in no improvement in clinical health 1 year after restoration placement, and a clear shift to more pathogenic composition of bacteria in the subgingival plaque (spirochetes, filaments, motile rods). 15.14. Schatzle: 26 year follow up from Loe studies and the norwegian cohort. Subgingival margins result in consistently and significantly higher levels of inflammation versus controls. Longitudinally, subgingival margins become closer to supragingival status via the persistent inflammation resulting in greater rates of attachment loss.

Answer 84

15.14. Lang: 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. 15.15 Jeffcoat: Bone loss was found to be greater around teeth with overhangs in all periodontal disease types. In that sense, the impact of the patient's periodontal status did not influence the prevalence of bone loss associated with overhanging amalgam restorations, but did have an impact on the magnitude of the effect - the more severe the periodontal disease, the greater the effect of the overhang. Also, the size of the overhang had a similar effect on magnitude. SIZE MATTERS.

Answer 85

15.18 and 15.19. Chandler and Bergman: Show that RPDs do not increase incidence of caries, tooth mobility or periodontal disease. No evidence to suggest RPDs contribute to periodontal breakdown. With regular recall, maintenance, and OHI to enhance motivation and prevention, pts can maintain high level of hygiene.

Answer 86

15.20. Stetler: Subgingival restorations with a narrow width of keratinized gingiva exhibited a greater degree of inflammation. If a subgingival restoration is to be placed in such an area with poor plaque control, increasing the width of keratinized gingiva should be considered.

Answer 87

Dragoo: This study provides histologic evidence that some epithelial and CT adherence may be obtained on resin-ionomer restorative materials.

Answer 88

8.11. Lindhe: 265 patients. Loser sites were defined as those with an increase in probing attachment of >2mm. 60% (161) of subjects showed no loss of attachment >2mm in the 2-year period. 40% (104) of subjects demonstrated ³1 loser site, which identified the patient has having active disease. Loser sites were most frequently detected in older subjects, interproximal areas, at molar sites, and at surfaces with initial advanced LOA.

Answer 89

Linear Progression 8.12. Jeffcoat: 76% of the active sites had a linear (continuous) disease progression. The prevalence of disease activity is dependent on the threshold for probing attachment loss used. This is an inverse relationship, i.e. as the threshold for disease activity increases, the prevalence of disease activity decreases. In this study the majority of active sites had linear disease progression. Random Burst Exacerbation and Intermission

Answer 90

8.14. Silva: Active sites demonstrated significantly greater numbers of P. gingivalis and total number of anaerobes compared to the inactive sites. Active sites also had significantly increased RANKL, IL-1b, and basal MMP-13 activity. Active sites demonstrated increased CD4+, CD8+, and CD19+ WBCs, but this difference was not significant. Actively progressive lesions of periodontitis showed higher levels of destructive cytokines, bacteria, and immune cells. No difference in the clinical parameters of active and inactive sites was observed.

Answer 91

8.16. Lang: Retrospective study of 55 pts on 4 yr mainenance program. if a site bleeds 4 out of 4 maintenance appointments you still have a 70% chance of no attachment loss. Attachment loss was defined as > 2mm over the last 2 years. 8.17. Lang: Absence of BOP - negative predictive value was 98%, positive predictive value was 6%. Continuous absence of BOP is a reliable indicator for the maintenance of periodontal health. The presence of BOP is not a good indicator of disease progression, in a perio maintenance population. 8.21. Claffey: SRP completed in 17 pts. Maintenance done for 3.5 years every 3 months. 87% of sites with BOTH BOP >75% AND 1mm or more INCREASE IN PD had LOA at 42 months. Persistent BOP combined with either a deep residual probing depth or increase in PD may be useful in identification of sites at risk for progression of periodontal disease. BOP alone is not as predictive of LOA.

Answer 92

8.20. Kaldahl and Kalkwarf: Gingival suppuration was a weak prognosticator in subjects treated with periodontal disease.

Answer 93

8.22. Davenport: Group A had greater infiltrated connective tissue (ICT), greater pocket fluid flow rates, higher presence of plasma cells (68% in ICT volume), greater proliferation/extent of rete pegs, pocket and junctional epithelium, and widened intercellular spaces compared to Group B, which had mainly mononuclear cells (22% in ICT volume). 8.23. Caton: Biopsies taken from bleeding sites revealed denser, highly extensive inflammatory CT infiltrate than stopped-bleeding biopsies, which had infiltrate into the dental aspect alone. Plasma cells, PMNs, lymphocytes, macrophages, monocytes, unidentified cells, and interstitial spaces increased, while fibroblasts, endothelial cells, and collagen decreased in bleeding sites. These changes were all statistically significant. Stopped-bleeding sites, however, were dominated by fibroblasts, collagen, and endothelial cells and showed improved clinical parameters. Significant CT repair occurred in the first 4 weeks post-op. Inflamed sites have decreased fibroblast and collagen content, elongated rete pegs, increased interstitial spaces, and an ulcerated, sulcular epithelium.

Answer 94

Rahim-Wostefeld: 198 out of 1,611 teeth were lost 20 years after APT. 84 were lost in the first 10 years, 114 in years 10-20. Tooth loss was found to be higher in maxillary (15%) than mandibular teeth (9.7%), higher in molars (21.1%) compared to anterior (6.1%) and premolars (13.9%), and higher in single rooted teeth (91% retained) vs multirooted teeth with furcation involvement (76.5% retained). The risk for tooth loss increased in abutment teeth (OR= 3.9 for fixed, OR= 2.9 for removable). Bone loss >60% (OR=11.5) and furcation involvement (OR=4.152) were significantly associated with tooth loss. 46.7% of teeth in the >80% bone loss category could be retained for 20 years. 35.5% of teeth deemed hopeless were lost at 20 years. Those patients considered non-adherent lost 154 teeth (17.6%), which was three times higher than those in the adherent category (6%). Adherence prevented tooth loss (OR=0.371). Teeth with bone loss >60% were able to be maintained in 84.2% of adherent patients and only 52.4% of non-adherent patients. Teeth with furcation involvement at baseline were able to be maintained for twenty years in 80% of adherent patients. Smoking led to an increase in tooth loss however it did not reach statistical significance compared to non-smokers. Bottom Line: There is a strong correlation between tooth loss and patient adherence to SPT. Teeth that have been assigned a hopeless prognosis may be able to be retained for 20 or more years in patients following recommended SPT. Teeth used as an abutment for fixed or removable have a higher risk for tooth loss.

Answer 95

Sanders GTR study: said that there worse outcomes in GTR in RCT teeth compared to vital teeth. But, it depends on the quality of RCT as well. In 1-2 cases they found continued pathology in the site even though it was already treated. So it just looked at RCT or NOT, it did not access the quality of the study. Cortellini: said that GTR was the same with RCT compared with vital teeth in their results. Defects were initially deeper but treatment effects were the same. This study had RCT fillings and GOOD RCT fillings in the study. Those with bad RCT had RCTs redone. So quality of treatment is different between the two.

Answer 96

16.RR1. Rotstein: 1. Dentinal Tubules Exposed dentinal tubules are direct pathways for bacterial entry and occur as a result of disease, anatomical variations, and/or therapeutic measures. In response to chronic inflammation and the normal aging process, dentinal tubule diameter decreases over time. Developmental defects result in dentin exposure where the cementum and enamel to not effectively meet - 18% prevalence overall and 25% in the anterior. These defects are also present in developmental grooves. 2. Accessory Ports Characterized as accessory and lateral canals, these ports of entry allow for direct bacterial penetration into the pulp. The majority are found in the apical 1/3 of the root with an incidence of 23-76% overall. 3. Apical Foramen The apical foramen is considered the primary mode of communication between pulpal and periodontal tissues. Chronic apical infections can elicit the progression of periodontal inflammation. Treatment consists of removing the primary etiology and infected pulpal tissues to assist in the healing of apical lesions and any associated periodontal pathology. Iatrogenic factors

Answer 97

``` 16.5. Gutmann: 29 teeth (28.4%) exhibited 43 patent canals in the "furcation region" (defined as the actual furcation and 4 mm apical of the internal root surface). ```

Answer 98

16.16. Cortellini and Tonetti: 1 year study on 208 intrabony defects. In this group of consecutively treated patients, RCT did NOT negatively affect the healing response of deep intrabony pockets treated with GTR or the stability of the regenerated defect.

Answer 99

- Crestal alveolar bone height - Vertical: 1.0-3.0 mm (Cargiulo, 1961_ - 2.1-4.1 mm (Becker, 1997) - Horizontal: 3.0 mm (Tal) - Dimension of interproximal space (distance from contact point to the alveolar crest) - Natural tooth: <5 mm (Tarnow, 1992) - Single Implant: <5 mm (Choquet, Hermans) - Two Implants: <3.5mm (Tarnow, 2003) - Soft tissue appearance - Flat is better than pronounced and high scallop (salami, 1995) - Thick biotype is better than thin (Koi's) - Minimal buccal plate thickness - >1.8mm in anterior implants (Spray, 2000) - Contact areas (Triangular vs square) - Square is better than triangular (Kois, 2011)

Answer 100

17.1 RR1: Zetu and HomLay Wang: - Inter-dental papillae: <5mm (Tarnow, 1992) - Implant-tooth: papillae: <4.5mm (Salama, 1998) - Implant-implant: <3.5mm (Tarnow, 2003) - Implant-pontic <5.5mm (Salama, 2004) - Tooth-pontic: <6.5mm (Salama, 2004) - Pontic-pontic: <6mm (Salama, 2004)

Answer 101

Individual unattached implant is immobile. · no radiographic evidence of peri-implant radiolucency. · < 0.2 mm / year vertical bone loss after 1 year after loading. · No signs or symptoms such as pain, infections, neuropathies, paresthesia or violation of the mandibular canal. · At 5 years minimum 85% success and at 10 years minimum 80% success.

Answer 102

17.1 Albrektsson: The "Albrektsson criteria" are still valid today (pg 34): · Individual unattached implant is immobile. · no radiographic evidence of peri-implant radiolucency. · < 0.2 mm / year vertical bone loss after 1 year after loading. · No signs or symptoms such as pain, infections, neuropathies, paresthesia or violation of the mandibular canal. · At 5 years minimum 85% success and at 10 years minimum 80% success.

Answer 103

17.3 Torabinejad: systematic review. 6+ year survival rates are as follows: endo (97%), implant crown (97%), fixed dental prosthesis (82%) 6+ year success rates are as follows: endo (84%), implant crown (95%), fixed dental prosthesis (80%)

Answer 104

17.4 - Ritter: CBCT retrospective study of 1000 patients. Distance of alveolar crest to mental foramen ranged from 1.5mm to 12.5mm. Diameter was 3.4mm (males slightly greater). Anterior loops are found in 31% of patients. The mean size of the anterior loop in males was 1.6 ± 0.74 mm (maximum 4.6 mm) versus 1.4 ± 0.63 mm (maximum 4.4mm) for females.

Answer 105

``` 17.15 - Mardinger: 12 cadavers dissected. - Most vessels found: - Above mylohyoid muscle—canine area - Beneath mylohyoid muscle—posterior ``` - Mean vertical distances (alveolar crest to vessels): - Canine—15.6 mm (range 6-26 mm) - Mental foramen—15.3 mm (range 2-26 mm) - Second molar—11.6 mm (range 2-22) - Mean horizontal distances (lingual plate to vessels): - Canine—2.8 mm (1-7.5 mm) - Mental foramen—3.95 mm (1-9 mm) - Second molar—2.8 mm (1-7 mm) - Vessels of concern—both run in antero-posterior direction: - Submental artery (branch of facial artery)—runs inferior to mylohyoid muscle - Sublingual artery—runs superior to mylohyoid muscle

Answer 106

22.2. Aljateeli (Michigan study): 12 pts got SRP before modified widman. Other 12 just had modified widman. Results - Performing nonsurgical periodontal treatment prior to periodontal surgery yields better results in terms of PD reduction than performing surgical treatment alone, though both modalities result in improvement in PD and CAL from baseline.

Answer 107

22.4. Mormann: 3 sources of blood supply pdl, alveolar bone, and periosteum. The following concepts should be employed in flap design: 1. The base should be broad enough to include major gingival vessels. 2. Length:width ratio should not exceed 2:1. 3. Minimal tension should be created in suturing and tissues should be managed gently. 4. Partial thickness flaps to cover avascular sites need to have enough blood vessels included in them (i.e. don't make them too thin). 5. Apical portion should be full thickness when possible. Blood supply of the facial gingiva runs in an apico-coronal direction. Releasing incisions should be limited and spared at mid-axial sites to preserve local vasculature.

Answer 108

22.12 Cattermole: 18 pts. Split mouth study. Half mouth had scalloped, other half got linear. There is initially greater gingival inflammation (higher GI scores) with the linear incision compared to the scalloped incision. By three weeks of healing, there was little difference in the degree of healing. No differences between the incisions could be noted at 12 weeks.

Answer 109

22.16 Pippin: 6 pts. Apically positioned flap. Some had sulcular incisions, some had inverse bevel incisions. Then did block sections and histo. The fate of pocket epithelium in an apically positioned flap placed upon alveolar bone appears to be a degeneration. Epithelial loss occurs relatively quickly and completely, and by day 7 epithelial elements were undetectable. The two types of surgical procedures paralleled each other, during healing and by day 21 were undistinguishable.

Answer 110

22.18. Staffileno: Contraindications for split thickness flap: Areas of thin tissue where likelihood of perforation or flap necrosis is possible such as the lingual aspect of the mandible from the second premolar posteriorly. Indications for split thickness flap: Apically positioned flaps, rotational or lateral positioning, suturing a flap to periosteum, gain dimension of the flap mesiodistally with vertical incisions. Contraindications for full thickness flap: Autogenous or contiguous soft tissue grafts (both in the donor and recipient sites) due to increased osseous resorption and decreased rate of repair. Where apical repositioning would lead to be direct bone exposure. BL: When choosing between a full or a partial thickness flap reflection, the clinician must consider the histological response and plan the mode of treatment properly so that flap preparation will enhance and make possible a satisfactory end result. The split thickness flap is less traumatic and provides better flexibility and protection of existing supporting structures than full thickness flap reflection but the full thickness flap maintains the integrity of the flap tissue.

Answer 111

22.21: Machtei: 2 year study. 12 pts had osseous. When the post-surgical bone sounding measurements were <3 mm, the two year mean PD was significantly less than when the post-surgical sounding measurements were >4 mm

Answer 112

22.26 Cortellini and Tonetti: Controlling periodontal disease is crucial in regenerative therapy, for high BOP and plaque have been related to poor clinical outcomes in a dose-dependent manner. Smoking also has a negative effect upon regenerative therapy (attachment gain in smokers was an average of 2.1mm compared to 5.2 in non-smokers), which has also been determined to work in a dose-dependent manner. The type of defect also plays a crucial role on clinical outcome expectations, where wider defects can expect less attachment gain. More acute bony defects (≤25 degrees) gain consistently more attachment (average 1.6mm) than do those ≥37 degrees (Cortellini & Tonetti). Although it has been found that deeper defects experience greater fill, for both shallow and deep defects, complete resolution of the intrabony component should be expected. The number of bony walls also affects regeneration outcomes, with greater expectations for 3-wall than 1-wall defects, especially with resorbable membranes and the use of amelogenins. However, with the use of titanium-reinforced membranes or combination therapy, the number of walls did not influence clinical outcomes significantly. This questions the use of amelogenins in one- and two-wall defects. Root canal treatment has not been shown to negatively affect healing response in adequately endodontically treated teeth. Tooth mobility above 1mm horizontally has been shown to negatively impact periodontal regeneration. The most significant and predictable scenarios for periodontal regeneration are deep and narrow defects.

Answer 113

17.11. Rios: Angular deviation for free-hand implant placement found to be 7.6 degree compared to 2.2 degrees for guided implant placement Bone supported guide varies from 4-5%. This study was extra-oral (in vitro) on models.

Answer 114

Lazzara: DEAS FAVORITE - Mean BIC for Osseotite (72.96% ± 25.13%) was statistically higher than mean BIC for the machined surface (33.98% + 31.04%). - When bone quality was good, not much difference. when bone quality was poor, is when there is big difference. - this article was nail in coffin for machined surface implants and HA implants which shows improved success of HA implants in poor quality bone. - In poorer quality bone, a higher % of bone contacts Osseotite surface when compared to opposing machined surfaces on the same implant.

Answer 115

19. 11 Kan, 2003: - Interproximal of implant surfaces were around 6mm, mid facial was 3.63mm and surfaces of adjacent teeth were 4.2mm. Bone sounding in thick phenotypes were greater than thin phenotypes. - In comparison in Gargiulo, the average facial of dentogingival complex was 2.73mm, and here on facial was 3.63mm. - Also, the level of interproximal papilla of the implant is independent of proximal bone level next to implant but related to interproximal bone level next to adjacent teeth. - Evidently for anterior single implants with adjacent natural teeth, the implant papilla is independent of the bone levels at the interproximal surfaces of the implant and dependent on bone of adjacent tooth.

Answer 116

19. 14 Kan, 2011: b. The authors developed the following 4 classifications to describe the SRP: c. Class I: The root is positioned against the labial cortical plate (Fig 1) = 81.1% d. Class II: The root is centered in the middle of the alveolar housing without engaging either the labial or the palatal cortical plates at the apical third of the root (Fig 2) = 6.5% e. Class III: The root is positioned against the palatal cortical plate (Fig 3) = 0.7% f. Class IV: At least two thirds of the root is engaging both the labial and palatal cortical plates (Fig 4) = 11.7% The authors suggest that a Class I SRP is the most favorable position for immediate implant placement and provisionalization (IIPP) because the clinician are able to engage the palatal cortical plate and graft the facial implant socket gap. In a Class II SRP, clinicians need to assess the amount of bone apical to the root to determine if primary stability is possible since neither of the plates will be engaged during IPP. Class III SRPs are susceptible to fenestration/perforation of the labial plate during implant placement due to the presence of facial concavities. A Class IV SRP is a contraindication for IPP due to a lack of alveolar bone.

Answer 117

19. 22 Huynh-Ba, 2019: - At 12 months following implant crown delivery, no significant differences in outcomes were observed between immediate and early implant placement, and both protocols resulted in about 1mm of mid-facial mucosal recession.

Answer 118

19. 26 - Lops, 2008: - Inter-proximal papilla fill in immediately placed implants is more likely if the distance from the contact point to crest of bone is 3-5 mm and distance between the implant and adjacent tooth is 3-4 mm.

Answer 119

19. 6 Annibali, 2012: - a. Data indicated that there are no differences in terms of implant survival between PS and PM implant. Implants restored with platform switched restorations showed a lower amount of marginal bone loss over time when implants were restored with a larger mis-match, suggesting that 0.45mm is the cutoff needed for platform switching.

Answer 120

No, it does not. Loe's epidemiologic study evaluating the Sri Lankan individuals who did not perform any oral hygiene, and all patients had calculus and gingivitis, there were 11% that did not progress to periodontitis showing that some patients are able to eliminate the noxious stimuli, via a coordinated response of the innate and adaptive immune response. Side comment - lesions that do progress are the result of a heightened immune response in a susceptible host. The response may be due to: type and virulence of the bacterial plaque, host immune defects that are genetically determined or acquired, such as AIDS, decrease immune function resulting from medically related conditions (diabetes, leukemia, autoimmune diseases, social habits such as drug and alcohol abuse and smoking, and environmental factors such as stress and exposure to toxins.

Answer 121

BOP is GOOD INDICATOR OF NO DISEASE PRESENT. Lang performed a study in which he showed that the absence of BOP is a good indicator of health, however, BOP is not a good indicator of future progress of disease. He found that in patients with 4 consecutive maintenance appts, sites that bled all 4 times, only had a 30% chance of continued attachment loss.

Answer 122

Quirks: - Vagolytic drug (Tachycardia) - Increased HR, BP, and patient could become abruptly tachycardic - Avoid drug in tachycardic patient - Histamine release - Non-allergic histamine release - As long as redness stays on limb, consider non-allergenic response - Active metabolite - Called normeperidine that causes CNX excitatory - Do not give Meperidine in patients with seizure history - Renal toxic - Not huge deal in small doses - Dose - 25-100mg

Answer 123

- Inflammatory phase: - Vascular injury - Vasoconstriction - Platelet aggregation - Coagulation Cascade - Proliferative Phase (Cytokines continue to be a part of the process as its release leads to Fibroplasia, Granulation, and Epithelialization.) - Fibroplasia - Granulation - Epithelialization - Remodeling Phase

Answer 124

- Gingival recession is a common feature in populations with good oral hygiene as well as in populations with poor oral hygiene. Occurs either associated with gingivitis, or periodontal disease, through an extension of periodontal inflammation, tissue trauma, toothbrush abrasion, and iatrogenic procedures. Development of gingival recession may be related to a number of etiologic factors, and in general context, inflammation is constant. - Novaes: Inflammation occurs in an apically directed spreading through the connective tissues, with concurrent epithelial resorptive and proliferative reactions. Inflammation also spreads laterally towards the outer aspect of the gingiva and alveolar mucosa. As the inflammatory process caused by the biofilm destroys the CT, these tissues become partly covered by proliferating and migratory pocket pocket epithelium. Eventually anastomosis occurs between the pocket and the gingiva-mucosa epithelium as the intervening CT is progressively lost. This process seems to be slowly progressive and rarely associated with acute destructive gingival changes. - Patients with thin periodontium are more susceptible to recession due to inferior amounts of collagen, and also differently located and arranged fiber orientation, which favors the spread of the inflammatory process. - As far as occlusion and gingival recession, trauma from occlusion may induce bone resorption with concomitant development of a replacement periosteal-cemental attachment. - Deas explanation - not only do we have an apical spread of inflammation along the tooth, we also have a lateral spread of inflammation. This lateral spread from the pocket epithelium eventually can reach the oral epithelium and "anastomose." This creates a joining of the pocket epithelium and oral epithelium and there is no more connective tissue supporting the unattached gingiva, which will cause it to collapse, leading to recession. The same thing occurs with toothbrushing. We always have some form of inflammation. Toothbrushing can exacerbate that, and also physically thin the gingiva.

Answer 125

- The answer is both. Gingivitis could be non non-specific hypothesis, but periodontitis is more specific. Also related to host response. - Nonspecific plaque hypothesis states that periodontal disease results from the "elaboration of noxious products by the entire plaque flora." Larger amounts of plaque would lead to a higher production of these noxious products. - Observations that contradict this - some individuals with considerable amounts of plaque and calculus as well as gingivitis never develop into periodontitis. - Also, some sites in individual people can have periodontitis in site specific areas, with other sites unaffected, with advanced disease in other sites. - These findings are inconsistent with the concept that all plaque is equally pathogenic. Recognition of the differences in plaque at sites of different clinical status (disease vs health) led to transition from the nonspecific theory to the specific plaque hypothesis. - Specific plaque hypothesis - This concept that certain organisms harbor specific bacterial pathogens may provoke periodontal disease because key organisms produce substances that mediate the destruction of host tissues. - Generally, there are about 20 pathogens that are routinely found in increased proportions at periodontally diseased sites. - However, studies have shown that periodontal disease can occur even in the absence of defined "pathogens."

Answer 126

- Increased prevalence of loser sites (decrease threshold for definition of "loser sites"). As you go from threshold from 1mm to 2mm to incidence? 1mm would have higher incidence. So if site has lost 2mm of attachment, this is true positive. But if you say just 1mm of attachment loss, then we will have a bunch of false positives. - Prevalence of disease is dependent on threshold for attachment loss.

Answer 127

- Increase probing depths over time - Residual probing depth of 7mm or greater, increasing probing depth, and increased probing depth combined with BOP - So BOP by itself is not great predictor, but when combined with increasing probing depth, the predictive value goes up - The above is an article from Claffey that showed after initial non surgical therapy, loss of attachment throughout a 42 month follow up was most commonly seen in patients with residual probing depths of 7mm or greater (50% of sites with residual probing depth had LOA at 42 months) - 87% of sites with both BOP >75%, and 1mm or more increase in PD has LOA at 42 months. - Conclusion of Claffeys article was that persistent BOP combined with either a deep residual probing depth or increase in PD may be useful in identification of sites at risk for progression of periodontal disease. BOP alone is not as predictive of LOA.

Answer 128

- Caton (1988) did study on this and showed that biopsies from bleeding sites after SRP revealed denser, highly extensive inflammatory CT infiltrate than non bleeding sites. - Bleeding sites: - Increased: - Plasma cells, PMNs, lymphocytes, macrophages, monocytes - Decreased - Fibroblasts, endothelial cells, collagen - Non-bleeding sites: - Dominated by fibroblasts, collagen, and endothelial cells

Answer 129

- OP is a systemic disease characterized by microarchitectural deterioration, low bone mass, increased bone fragility, and increased risk of fracture. - It is diagnosed by using a DEXA scan (Dual energy x-ray absorptiometry) to evaluate a patient's bone mineral density. If the bone mineral density (BMD) is between 1-2.5 standard deviations below the mean, then the patient has osteopenia. If the patient is greater than 2.5 SDs below the mean, then you have osteoporosis. - The "T Score" is a BMD score relative to S.D away from the average normal healthy patient. One standard deviation is equal to 10-12% difference in bone mass. So the WHO defines osteoporosis as a T-score that s 25% lower than the average 30 year old or 2.5 SDs below the mean. (T score lower than -2.5). - Note about estrogen: estrogen levels help promote the activity of osteoblasts. When estrogen levels drop during menopause, the formation of osteoclasts is not inhibited.

Answer 130

Zhou (2009): - It is defined as a clinically symptomatic peri- apical lesion (diagnosed as radiolucency) that develops shortly after implant insertion while the coronal portion of the implant achieves a normal osseointegration (Quirynen et al. 2003). Retrograde peri- implantitis is generally accompanied by symptoms of pain, tenderness, swelling and/or the presence of a fistulous tract (Quirynen et al. 2005). Retrograde peri-implantitis begins at the apical portion of the implant, while the coronal portion of the implant maintains an osseointegrated status. There is an obvious radiolucency at the apical area of the implant in the radiograph. This should be distinguished from clinically asymptomatic, peri-apical radiolucency, which is usually caused by placing implants that are shorter than the drilled cavity or by a heat- induced aseptic bone necrosis (McAllister et al. 1992: Reiser & Nevins 1995: Ayangco & Sheridan 2001) and generally also attains osseointegration after 1-3 months of an unloaded, stress-free healing period. - PROPOSED MECHANISMS: Sussman & Moss (1993) presented two basic pathways to a common lesion between teeth and implants. When implant insertion results in devitalization of the neighboring tooth (e.g., because of insufficient distance to adjacent tooth, bone overheating during drilling or cutting off the blood supply to the pulp), this will cause an endodontic pathology that consequently may influence the osseointegrated implant (pathway 1). A peri-apical lesion from a neighboring devitalized tooth, on the other hand (pathway 2), can encroach upon the implant and contaminate it (e.g., reactivation of a dormant peri-apical lesion or removal of the peri-apical endodontic seal). - Histological evaluation of peri-apical tissues after endodontic therapy in cadavers, animals or humans clearly highlights that the apex of the endodontically treated tooth often exhibits histological signs of inflammation or existing microorganisms even when radiographs show optimal healing (Rowe & Binnie 1974; Green et al. 1997; Seltzer 1999). Green et al. (1997) reported that 26% of endodontically treated teeth with a normal radiographic appearance still had histologi- cal signs of inflammation - However, retrograde peri-implantitis, if not treated immediately, usually results in implant loss when the bone loss progresses to the complete implant surface. Histological evaluation of peri-apical tissues after endodontic therapy in cadavers, animals or humans clearly highlights that the apex of the endodontically treated tooth often exhibits histological signs of inflammation or exist- ing microorganisms even when radiographs show optimal healing (Rowe & Binnie 1974: Green et al. 1997: Seltzer 1999). Green et al. (1997) reported that 26% of endodontically treated teeth with a normal radiographic appearance still had histologi- cal signs of inflammation. - Treatment of retrograde peri-implantitis included re-treatment of adjacent RCT until symptoms resided or surgical treatment aimed at debridement of implant surface. Neither treatment was successful if ISQs <60. And some people believe they should remove as soon as possible.

Answer 131

- Transmucosal attachment - Dennis Tarnow - as soon as you connect abutment to implant you will see marginal bone loss in all directions (vertical and lateral). - Weigl - micromovement of abutment with connection of implant ubiquitous present of environment causes some bone loss - Micro-gap - once you make abutment transmucosal then you will get biofilm accumulation present and establish "biological width" and end up with marginal bone loss - 20.2 Koutouzis: The Final Abutment Placement group exhibited a marginal bone level change ranging from 0.08 to 0.34 mm, whereas the Multiple Abutment Placements group exhibited a marginal bone level change ranging from 0.09 to 0.55 mm. Meta-analysis of the seven studies reporting on 396 implants showed significantly greater bone loss in cases of multiple abutment disconnections/reconnections.

Answer 132

- 20.5 Chrcanovic: Retrospective study. At the patient level, smoking (OR 3.065, 1.965 to 4.779) and antidepressants (2.477, 1.385 to 4.429) had a significant increase in early implant failure. At the implant level, smoking (OR 2.709, 1.737 to 4.226) and antidepressants (OR 1.735, 1.010 to 2.980) had a significant increase in early implant failure. - Peripheral serotonin levels can inhibit bone formation via osteoblastic serotonin receptors. Additionally, SSRIs may affect osteoclast differentiation. Studies have shown decreased bone quality in individuals with histories including mood disorders. These processes may impact the implant osseointegration. Smoking results in a 2.23 times higher likelihood of implant failure. Nicotine is anti-inflammatory and therefore may prevent osteoprogenitor and mesenchymal cell recruitment following implant insertion required for osseointegration to occur.

Answer 133

- 20.8 Kumar - Site level predictors of peri-implantitis were: PI ³ 1.5, offset placement of restoration on fixture, vertical depth of implant platform ³6mm from adjacent tooth, tooth loss due to periodontitis, and signs of periodontitis on adjacent teeth.

Answer 134

- 20.23 Dabdoub: The periodontal microbiome was distinct and more diverse than the peri-implant microbiome. Staph and Treponeme species were significantly associated with peri-implant tissues but not teeth. 85% of patients shared less than 8% of species between implant and tooth. - Kotsakis: - There is different substrate. The source bacteria are the same, they come from the teeth, and extra crevicular measures, tonsils, mouth, palate, but although you have the same source bacteria, the substrate is so different from a chemical, physical properties, that supports a different biofilm. There are many commonalities, but there are many differences as well. P. gingivalis, AA, they are not big players likely because they can not interact in a metal environment as well. There are other bacteria like Neisseria, Veilonella that are very resistant to metals, like iron. Iron has big side effects from bacterial cells. So there are different bacteria that end up prevailing, so if you look at key players, they may be the same, but at different levels. And P.G, you have low abundance keystone pathogen. So there is biofilm with a lot of commonalities, but many differences. Also, red complex is not a player at all. - Kumar did a lot of research on this and her findings were that "The peri-implant microbiome differs significantly from the periodontal community in both health and disease. Peri-implantitis is a microbially heterogeneous infection with predominantly gram-negative species, and is less complex than periodontitis."

Answer 135

- 20.26 Gobbato: Systematic Review. Although certain implant clinical parameters (GI, PI, mPI, and mBI) are increased in implants with < 2 mm of KMW, there seems to no relation to increasing PD. This may indicate that < 2mm of KMW is correlated with difficulty to perform adequate oral hygiene around implants. - 20.27 Perussolo - 4 yr prospective study. Implants with <2mm of KM displayed more MBL, plaque accumulation, tissue inflammation and brushing discomfort compared to sites with >2mm of KM.

Answer 136

- Occlusal Trauma: A histological term describing the injury resulting in tissue changes within the attachment apparatus as a result of occlusal forces. - Primary Occlusal Trauma: Injury resulting from traumatic occlusal forces applied to a tooth or teeth with normal support (normal bone and attachment levels: traumatic occlusal force). - Secondary Trauma: Injury resulting from normal or traumatic occlusal forces applied to a tooth or teeth with reduced support (bone/attachment loss present: occlusal force can be normal or traumatic).

Answer 137

Direction, Degree and Duration of Forces.

Answer 138

- Compression zone you will have compression of the PDL, Hemmorrhage, rupture of vessels, and bone/root resorption - Tension Zone you will get tension of the PDL: tearing of fibers, bone apposition (lighter forces), hemorrhage, rupture of vessels, and cemental tears

Answer 139

- Weinmann (1941): Looked at inflammatory cells: Inflammation follows the course of blood vessels into alveolar bone marrow spaces (Blood vessels are where inflammation cells come from) ○ Spread of inflammation into PDL is secondary ○ Defect morphology depends on location of blood vessels and thickness of bone - Macapanpan: Created trauma in PDL in rats. Found pressure zone at crest of bone and tension zone and found out that when rubber dam and occlusal truma are present, inflammation went straight down the PDL. So they found that occlusal trauma alters the pathway of inflammation (this led to Glickmans theory) - Glickman (1963): Theory of co-destruction (alteration of normal pathway of infection - development of angular bony defects with intrabony pockets) - Zone of irritation (marginal gingiva, interdental gingiva) - Transeptal fibers (in the middle) - Zone of co-destruction (PDL, Cementum, bone) ○ Zone of irritation is local destruction caused by plaque and INFLAMMATION ○ Zone of co-destruction (marked by bone, PDL, cementum) - In this zone, other factors such as trauma can alter the pathway of inflammation in this zone and result in increased destruction. ○ SO TRAUMA DOES NOT CAUSE INFLAMMATION - but when you have inflammation, combined with trauma, they are co-destructive that increases destruction of PDL and bone. - Waerhaug (1979): (dry skull study) - Angular bony defects are result of apical plaque progression in areas of sufficient bony thickness. - Angular defects occur in both presence and absence of occlusal trauma ○ Found same prevalence in vertical bone defects with teeth with occlusal trauma as compared to teeth without opposing tooth. So bacteria are problem, not occlusion. - Sphere of influence of plaque: 0.5-2.7mm range (average 1.6mm).

Answer 140

- Animal Studies - Limitations: different masticatory dynamics than humans (mainly mesial distal), occlusal trauma is acute, occlusal forces may be excessive compared to humans. - Lindhe, Ericsson, and the Scandinavians - Beagle dogs with splint bar device and jiggling forces. - Periodontally healthy dogs had increased mobility and vascular permeability to day 60 then physiologic adaptation (increased PDL width, mobility but with NO further loss of CT attachment). - Diseased dogs had progressive increase in mobility and vascular permeability with no adaptation at day 60. - Part 2: TOF in healthy but reduced periodontium results in physiologic adaptation - Part 3: Teeth with TOF + periodontitis had wider PDL, Greater mobility, more bone loss, 3 fold greater CT attachment loss. TOF in presence of inflammation increased progression of attachment loss! THIS SUPPORTS GLICKMAN! - Part 4: Inducing periodontitis in mobile teeth that have undergone physiologic adaptation. Periodontitis in mobile and non-mobile teeth lost similar amount of attachment meaning permanently increased mobility does NOT increase rate of attachment loss. - Part 5: They had both occlusal trauma and periodontitis and after removing the occlusal forces mobility decreased and PDL width but no improvement in attachment. Treating only the occlusal trauma has NO effect on CT attachment. - Polson and Zander - Squirrel monkeys with ortho elastics placed btwn the teeth - TOF in a healthy periodontium free of inflammation (1o O.T.) caused increased mobility and PDL width, some loss of bone height, but no loss of CT attachment - In a combined periodontitis-trauma lesion, removal of traumatic forces without resolving inflammation results in: - minimal change in mobility, bone height or volume, - no change in CT attachment level - In a combined periodontitis-trauma lesion, resolution of inflammation without removing traumatic forces results in: - some decrease in mobility and increase in bone volume - no gain in bone height or CT attachment level - In a combined periodontitis-trauma lesion, resolution of both inflammation and traumatic forces results in: - greatly decreased mobility - increase in bone volume - no gain in bone height or CT attachment level - Addition of trauma caused increased mobility, increased loss of bone height, but no increase in loss of CT attachment - traumatic occlusal forces do not alter progression of plaque-induced periodontitis - Conclusions from Animal Studies - In healthy periodontium, TOF will result in increased mobility, widened PDL, and loss of crestal bone height & volume (physiologic adaptation) - In absence of inflammation, TOF do not result in loss of CT attachment - Presence of tooth mobility per se does not increase rate of periodontitis - In presence of inflammation, occlusal trauma may increase loss of connective attachment and bone (did in dog model - did not in monkey model) - Removal of traumatic occlusal forces without resolving inflammation does not allow healing

Answer 141

- Harrel and Nunn, 2001 - No relationship between gingival recession and occlusal discrepancies - Gingival recession and tooth mobility: - Bernimoulin showed that there was no significant correlation found between gingival recession and tooth mobility and between tooth mobility and alveolar bone dehiscence. There was a positive significant correlation present between gingival recession and bone dehiscence.

Answer 142

- Ramfjord & Ash - "The need for occlusal adjustment should be based on a definite diagnosis of the presence of a traumatic lesion... rather than the location of an occlusal interference which may be of no significance." - Burgett, Ramfjord, 1992 - Greater A.L gain (0.4mm greater) in adjusted patients compared to non adjusted patients. Significant difference but not clinical difference - No difference in reduction of tooth mobility between groups - Nunn, Harrel, 2001 - Teeth with occlusal discrepancies had increase in probing depth over time. Teeth with no discrepancy or treated discrepancy did not. - Untreated occlusal discrepancies may result in less favorable responses to periodontal therapy or to greater increases in probing depth in untreated periodontitis

Answer 143

- Increasing mobility or fremitus - Discomfort during function - Parafunctional habits - Soft tissue injury - Food impaction - In conjunction with orthodontic therapy or orthognathic surgery - Traumatic injuries

Answer 144

- Widened PDL, Vertical bone loss, thickening of lamina dura, furcation bone loss, root resorption, alveolar radiolucency and/or condensation

Answer 145

- Kleinfelder & Ludwig, 2002 - Splinting periodontally involved teeth may increase maximal bite force - Unsplinted maximum bite force in reduced periodontium = 357N - Unsplinted maximum bite force in healthy periodontium = 378N - Splinting posterior teeth in reduced periodontium = 509N - Splinting posterior teeth in healthy periodontium = 534N - Mobility interferes with patient comfort - Mobility interferes with patient function - Prevent tipping of drifting of teeth - Prevent extrusion of unopposed teeth - Following orthodontic therapy - Following acute trauma to teeth - Esthetic and prosthetic demands

Answer 146

The model defines the key factors that influence health behaviors as an individual's perceived threat to sickness or disease (perceived susceptibility), belief of consequence (perceived severity), potential positive benefits of action (perceived benefits), perceived barriers to action, exposure to factors that prompt action (cues to action), and confidence in ability to succeed (self-efficacy).

Answer 147

- 21.6: Lang, 1973 - "Effective oral hygiene procedures at intervals of 48 hours are compatible with gingival health." However, if the interval between complete removal of bacterial plaque exceeded 48 hours, gingivitis developed. - This population were 32 DENTAL STUDENTS who knew how to effectively perform oral hygiene - 21.7: De Frietas, 2016 - Within 30 days, brushing and flossing q48h results in higher levels of gingival inflammation compared to q24h or q12h, which are both equivalent. - 39 subjects. Normal population (Not dental students). - Juliana Maier, 2020: self performed palque control in history of periodontitis. If you do at 12-24 hours, this appears to be sufficient to maintain gingival inflammation. If you wait until 48 hours, this is not sufficient. Which is OUR population as periodontists.

Answer 148

- 21.8 Waerhaug, 1981. - 4 monkeys - Tooth brush Bristles penetrate up to 1mm subgingivally. Toothbrushing alone is inadequate for total plaque control.

Answer 149

- 21.9 Dahlen, 1992 - 62 subjects. 2 yr study. - In a well maintained population (Scandanavians) Instruction and monitoring of self-performed plaque control, in addition to supragingival scaling may result in decreased quantity and composition of subgingival bacteria. - 21.10 Westfelt, 1998: (what is the importance of subgingival debridement in periodontitis patients? - 12 pts, split mouth study, pts had periodontitis unlike Dahlen study. - Combined supragingival and subgingival debridement is necessary to control periodontal disease progression in patients with advanced periodontal disease. Supragingival debridement alone does not suffice when treating advanced periodontal disease.

Answer 150

- 21.19 Kiger, 1991 - The interdental brush is more effective than floss at removing interproximal plaque in open interproximal areas. - 21.21 Kotsakis, 2018 - Interdental brushes and waterjets were found to be the best interproximal oral hygiene aids in reducing gingival bleeding. Flossing did not lead to substantial reductions in gingival inflammation. However, this study did not control for periodontal status (healthy periodontium, gingivitis, reduced periodontium) and it is well known that the gingival architecture, such as papilla height, alters the effectiveness of the interproximal oral hygiene aid.

Answer 151

- 18.1. Roccuzzo: 10 year prospective cohort study. 150 pts. Both Periodontally compromised groups had a significantly higher number of sites with PD>6mm compared to the PHP group. Additionally, radiographic bone loss >3mm was seen on 9.4% and 10.8% of implant surfaces for the moderate and severe groups, while none of the implants in the PHP group experienced radiographic bone loss >3mm. Patients who did not adhere to SPT showed worse results for plaque index, bleeding on probing, pocket depth, and number of teeth lost during SPT. - 18.3. Cho-Yan: Implant therapy can be successful in patients with a history of periodontitis, as long as the periodontitis is successfully treated. PCP with a recurrence of deep periodontal pockets of ≥6mm have a higher risk for peri-implantitis. Periodontally compromised patients who are treated with no recurrence of deep periodontal pockets can have similar long-term outcomes as PHP with appropriate implant and periodontal maintenance. - 18.4. Heitz-Mayfield, Huynh-Ba: Systematic Review: Odds ratios range 3.1-4.7 for a higher risk of peri-implantitis in previous periodontitis patients. Smokers have a greater risk of peri-implantitis than non-smokers, and if they have a history of treated periodontitis they also have an increased risk of implant failure and bone loss. - 18.5. Sousa: Systematic Review. Patients with more severe periodontal disease are at risk for higher incidence of implant failure, peri-implant bone loss, and peri-implantitis. It is also important to emphasize that the lack of SPT and the presence of smoking may negatively influence the implant outcomes.

Answer 152

- 18.6 Waasdorp: Systematic Review. Evidence from this systematic review suggests that immediate placement of immediate implants in infected sites is a predictable treatment. Studies revealed that complete debridement of the socket, guided bone regeneration, and the use of systemic antibiotics are critical components in the survival of implants placed immediately into infected sockets. - 18.7. Fugazzotto - Retrospective chart review of 64 pts. Implants placed immediately after extraction in sites with periapical pathology have similar survival to those placed in sites without periapical pathology in selected patients.

Answer 153

- Repair - Long junctional epithelium - Connective tissue adhesion and root resorption - Root resorption and ankylosis - Regeneration - New connective tissue attachment "New Attachment" is type of repair - get formation of CT fibers, JE, and sometimes cementum at a more coronal level on previously diseased root surface.

Answer 154

- Periodontitis causes root surfaces changes as a result of periodontal disease leading to degeneration of sharpeys fibers, accumulation of bacteria, and disintegration of cementum and dentin. The diseased root surface interferes with healing. - Root surfaces can be modified with thorough root planing and conditioning with chemical agents. - Root surface preparation allows for demineralization, removal of smear layer, eliminating endotoxins, delaying epithelium migration over treated roots, accelerates healing and new cementum formation and promotion of CT attachment. - Different types are Citric Acid, Tetracycline, Doxycyline, and EDTA. Most of evidence is beneficial in vitro and animal model, but no human clinical studies have determined a benefit of root conditioning for GTR with any agent investigated.

Answer 155

- Cortellini 3 wall: 95% of bone fill 2 wall: 82% of bone fill 1 wall: 39% Total clinical % fill: 73% Radiographic bone fill %: 59:

Answer 156

- Class 2 furcation: - More favorable results with BRG + GTR (Pontoriero, 1995) - Gem 21 (rhPDGF-BB) + DFDBA - favorable results (Nevins, 2003) - Class 3 furcation: No histological evidence of regeneration - rhPDGF-BB + B-TCP - class 3 furcation improvement (Mellonig, 2009)

Answer 157

- Compared root planing, Modified Widman, and osseous in split mouth design with 16 patients performed in experts of the field for each treatment modality. - Data showed similar results with each procedure - no benefit of any of the procedures.

Answer 158

- Removes attachment (Selipsky, 1976) - Exposes roots - Increases sensitivity - Compromised esthetics - Opens interdental spaces - Food retention - Requires additional hygiene time

Answer 159

- Elimination of shallow (1-2mm) 1-walled defects - Elimination of 1-2mm intrabony defects (craters) - Reduction of 3-4mm intrabony defects - Defects ≥5mm attempt regeneration or combined resection/regeneration - Corrective reverse architecture with minimal discrepancy between proximal and radicular crestal height - Improve access for existing class 1 or 2 furcation lesions not amenable to regeneration (barreling-in of furcations) - Reduction of thick ledges and exostoses - Avoid maxillary anterior teeth with exception of crown lengthening procedures - Mills Summary - Most predictable in thick phenotype with 5-6mm PDs - If PDs ≥7mm, osseous reduction will be compromised - Deep intrabony defects may require regeneration in combination with resection - Be judicious in amount of bone removal - Retain minimum of 1.0mm thickness at crest when possible - Over long-term, osseous resection offers better PD reduction & less potential for significant attachment loss - Compliance with periodontal maintenance is still a critical factor for success

Answer 160

- Proximity to maxillary sinus - Malar eminence of zygomatic process - Anterior ramps and external oblique ridge - Retromolar area (temporal crest)

Answer 161

- Lorato - Dry Skull - 30% - Nery - Dry Skull - 40% - Sonnier - Dry Skull - 56%

Answer 162

- Selipsky, 1976 - Bulk reduction of thick bone: osseous ledges and exostoses - Interdental fluting - Reduction of defect (crater) walls - Thinning radicular bone for ostectomy - Resection of radicular bone and widows peaks at the line angles - Final shaping and smoothing

Answer 163

- Metabolic dysregulation of glucose, protein, fat metabolism. - Long term complications: - Retinopathy - Neuropathy - Nephropathy - Macrovascular disease - Wound healing

Answer 164

1. Symptoms of diabetes plus a casual plasma glucose concentration ≥200 mg/dl 2. Fasting plasma glucose ≥126 mg/dl (8+ hour fast) 3. 2 hour post-prandial glucose ≥200 mg/dl during oral glucose tolerance test (MOST SENSITIVE TEST) 4. HbA1c ≥6.5% (Pre-diabetes is 5.7-6.4%)

Answer 165

EPIDEMIOLOGY DATA - Lalla, 2006 - Cross-sectional study of 182 (primarily type 1) diabetic children. Prevalence of diabetes increased risk of periodontitis with increasing age - 6-11 years: OR = 3.44 of having periodontitis - 12-18 years: OR = 20.3 of having periodontitis - Emrich, Shlossman 1991 - 20,000 pima indians. Attachment loss was much greater in diabetes patients than non-diabetes patients. Did not stratify glycemic control. - OR = 3.0. (Odds of having periodontitis was 300% greater compared to non-DM.) - Tsai, 2002 - 4,345 AMERICAN patients - NHANES III - Poorly controlled DM patients were 2.9 times more likely to have severe periodontitis than non-DM subject. Well-controlled diabetic patients had no increase of periodontitis. So level of glycemic control matters. - Taylor, 1998 - Poorly controlled diabetic patients have higher relative risk (11x) of progressive bone loss over 2 years compared to non-diabetic patients and well controlled diabetic patients.

Answer 166

- Altered microbial composition - Possible, has not been shown - Increased GF glucose concentration - Fibroblasts in periodontium do not like sugar - leading to altered wound healing - Vascular changes - Impaired host defenses - Monocyte/macrophage are HYPOfunctional but are upregulated in amount/response - Impaired collagen metabolism (AGE formation, altered collagenase) - Increased collagenase breaking down new collagen. AGE formation - glucose binds to amino terminal end of collagen becoming cross linked and can't be dissolved by collagenases.

Answer 167

Epidemiology and cross sectional studies - Borgnakke, 2013 - epidemiology SR - SR - some studies showed significant increase in incident diabetes in those patients with severe periodontal disease. - Teeuw, 2017 - cross-sectional - Patients with severe periodontitis had MEAN A1c significantly higher than people that were healthy. Conclusion: Patients with severe periodontitis have a greater risk for undiagnosed DM or prediabetes than periodontally healthy patients. Dental/periodontal office may be a good place for targeted HbA1c screening for undiagnosed dysglycemia. - Taylor, 1996 - Type 2 DM subjects with severe periodontitis have increased risk of worsening glycemic control (37% of patients) over 2 years compared to subjects without periodontitis (11% of patients). So presence of periodontitis has increased risk of worsening glycemic control.

Answer 168

- Changing the way the body uses insulin - Inflammation increases insulin resistance and makes blood sugar harder to control - Insulin resistance is the major cause of type 2 diabetes - the body cannot use the insulin that is being made in the pancreas; so blood sugar is not controlled

Answer 169

- Some of older literature (Morris 1957, Prichard, 1972) suggested endodontically treated teeth are poor candidates for regeneration. - Cortellini and Tonetti 2001 said there was no effect. - Conclusion: Regeneration may occur on endodontically treated teeth. No data for combined periodontic/endodontic lesions. Root fracture, incomplete root canal restoration or other endodontic pathosis may adversely affect the success of regeneration.

Answer 170

- Urist, 1965 - DFDBA was implanted in ectopic sites in rabbits, leading to bone formation. He proposed term "bone morphogenic protein"

Answer 171

- HENAA (Studies): Bowers, 1989 - Part 1: Submerged root vs non-submerged roots with flap curettage. Article was proof of new attachment apparatus on previously diseased root surfaces with more attachment in submerged roots - (no graft material used). - Part 2: DFDBA vs. non-grafted sites. Proof of enhanced periodontal regeneration in sites grafted with DFDBA including cementum, new bone, and greater chance for regeneration. Greater loss of alveolar crest height noted in non-grafted sites. Root resorption, ankylosis, and loss of pulp vitality were uncommon sequelae. - Part 3: INTRAbony defects with/without DFDBA covered with FGG. DFDBA enhanced formation of significantly more new attachment apparatus and greater chance for regeneration. More alveolar bone loss in non-grafted defects. FGG did not retard epithelial apical migration and did not enhance regeneration. No extensive root resorption, ankylosis, or pulp death as result of DFDBA in intrabony defects.

Answer 172

- Jones and O/Leary, 1978 - Residual calculus found after SRP most common on: - CEJ, root flutes, lines angles of roots - Anerud, 1991 - Common location of calculus formation is supra gingival on lingual mandibular incisors and buccal of maxillary molars, sub gingival at interproximal areas, and least common on buccal - Richardson, 1990 - 260 intrabony defects - Calculus found at midpoint of intrabony defect

Answer 173

- Masters and Hoskins, 1964 - 28.6% on mandibular molars - 17.0% on maxillary molars

Answer 174

- Moscow and Canut, 1990 | - 2.69%

Answer 175

- Withers, 1981 - 2.3% maxillary incisors - 4.4% maxillary lateral incisors - 0.28% maxillary central incisors - Kogon, 1986 - 4.6% maxillary incisors - 5.6% maxillary lateral incisors - 3.4% maxillary central incisors - about 54% extended onto the root

Answer 176

- Epidemiological Data - Sheiham, 1971 - English factory workers - Patients that smokers had significant greater plaque, calculus due to less than normal oral hygiene but there was no difference in disease severity - Bergstrom, Eliasson 1991 - Current smokers had more bone loss (1.71mm) on average compared to non-smokers (1.45mm). More bone loss was associated with higher cigarette consumption, longer duration, and higher lifetime exposure. - Martinez-Canut, 1995 - Direction correlation exists between increasing age and severity of attachment loss with tobacco use. - Tomar and Asma, 2001 - NHANES III Date - Current smokers have 4x more likely chance of having periodontitis than non-smokers - Dose dependent response - 11 years since quitting smoking had similar OR of periodontitis has never smokers - Alharthi, 2019, NHANES - Longer smoking cessation Perio was significantly associated with a lower likelihood of periodontitis. Smoking cessation is associated with decrease in risk of 2.5-5.2% reduction in odds of having periodontitis. - Ravida, HL Wang (Michigan) (2020) J Clin Perio: A total of 258 patients were included in the review with at least one annual PMT visit followed for a mean duration of 290.7 months (24.2 years). 91.9% of the patients were well maintained, 7.4% were downhill, and 0.8% were in the extreme downhill group. A statistically significant association was found between increasing smoking intensity and tooth loss due to periodontitis (TLP). Former smokers (OR 2.56) and current smokers (OR 4.38) were statistically more likely to have any TLP compared to never smokers. A dose-response pattern was observed for TLP as never smokers through former and current light to current heavy smokers lost 2.5%, 4.1%, 5.6%, and 10.3% of their teeth respectively. The longer the duration since smoking cessation, the lower the probability of TLP for teeth for both former light and heavy smokers. Each additional year since quitting smoking reduced the risk of TLP by 6%. There was a washout period of 15 years for the risk of TLP for a former smoker to approximate the baseline risk of a never smoker. BL: Current and former smokers lost significantly more teeth due to periodontitis and exhibited a dose-response pattern compared to never smokers. It took 15 years of smoking cessation for the risk of tooth loss due to periodontitis for former smokers to reach that of never smokers. - Naji (2020): stated that the OR of being a poor responder was 2.4 compared to a non-smoker. Significantly more non-smokers are good responders compared to smokers.

Answer 177

- Kotsakis, 2015, SR/MA - Effect of smoking on periodontal flap surgeries - All patients benefitted from flap surgeries but non-smokers demonstrated more reduction in PD and gain in CAL compared to smokers. 0.4mm less PD reduction in smokers may mean fewer pockets achieving adequate reduction and additional therapy may be required. - Grossi, 1997 - in SRP, Current smokers have less PD reduction, less CAL gain, less reduction in % of sites ≥5mm. Smoking cessation improves periodontal response and they respond like never smokers. - Ah, 1994 - Smokers have less PD reduction, less CAL gain regardless of type of periodontal treatment - Kaldahl, 1996 - Over 7 year period, current smokers have significantly less PD reduction and CAL gains compared to light smokers and never smokers.

Answer 178

- Tonetti, 1995 - 1 year follow up of smoking and GTR intrabony outcomes - Smokers had CAL gain of 2.1mm - Non-smokers had CAL gain of 5.2mm - Smokers were 4.3x likely to have a loser site compared to non-smokers.

Answer 179

Bollen, 1996: - Susceptible host (impaired immune response, diabetes, genetic predisposition, AIDS, etc) - Relative lack of beneficial bacteria (step, C ocharacea, V parvula) - Conducive environment (Perio pockets, smoking, inflammation, food impaction, etc) - Pathogenic Bacteria

Answer 180

Parvimonas micra, Filifactor alocis

Answer 181

- Amphotericin B - Nystatin - Polymixins

Answer 182

- Aminoglycosides (30s) - Clindamycin (50s) - Erythromycin (50s) - Tetracyclines (30s) - Azithromycin (50s)

Answer 183

- Bacitracin - Cephalosporins - Penicillins - Vancoymycin

Answer 184

- Van Winkelhoff, 1996 - Continued periodontal breakdown in spite of good mechanical therapy - Aggressive periodontal disease, whether early or late onset - Medical conditions predisposing to infection (HIV, DM) - Acute or recurrent severe periodontal infections (NUG, periodontal abscesses) - Peri-implantitis - GBR procedures, complex implant cases, sinus lifts, - Pre-op implant cases?? Regnerative therapy??

Answer 185

- Leukocyte-platelet-rich fibrin is considered a second generation platelet concentrate, characterized by a simplified preparation method without any biochemical manipulation or exogenous additives to the blood sample. - Venous blood is harvested and centrifuged in a tube without anticoagulants, resulting in three distinct layers: red blood corpuscles at the bottom, an intermediate layer that represents the L-PRF, and platelet-poor plasma (PPP) on top. - L-PRF is a dense fibrin scaffold that allows for enrichment of platelets and leukocytes, which release cytokines and growth factors, which aid in the healing process. - Neutrophils and macrophages eliminate bacteria and necrotic tissue via phagocytosis, which aid in debriding the wound preventing secondary infections. - Platelets and macrophages also secrete growth factors, including: - Transforming growth factor beta (TGF-B1) - Platelet-derived growth factor (PDGF) - Vascular endothelial growth factor (VEGF) - Insulin-like growth factor (IGF) - All these contribute to wound healing through stimulation of re-epithelialization, angiogenesis, and extracellular matrix formation. - L-PRF improves soft tissue wound healing by promoting angiogenesis and cell proliferation.

Answer 186

- 26.3. Becker (Arizona): 16 patients - 5 tear follow up. SRP, Osseous surgeyr, Modified Widman surgery all have similar effect PD reductions with slight changes in CAL after 5 years. Their bottom line was any periodontal therapy with proper OH and regular maintenance can maintain periodontal health.

Answer 187

- 26.8. Selipsky, 1976. Opinion paper. Interproximal bone provides more support than buccal and lingual surfaces due to surface area in contact with the tooth. Mobility decreases to pre-surgical levels within a year post-surgery (without splinting). Indications for splining teeth are: tooth replacement, patient comfort, orthodontic retention, preventing extrusion, and extreme parafunctional mobility.

Answer 188

- 26.13. Ochsenbein, 1995: - Generally 3 walled defects are good for regeneration, but believed that areas where 1-2 wall components exist, those heal with residual probing depth. - Residual bony defects: Strictly related to plaque control post operatively. Absence or presence of plaque is determining factor between regeneration or deterioration of bone. - Treatment of 1,2,3 walled approach: Manage the one and two-walled defects by osseous surgery and place a membrane in the 3-walled defect to allow for better adaptation and regeneration.

Answer 189

- 26. 14: Wilderman, 1964 - Permanently exposed bone: - Exposed cortical bone becomes necrotic. First phase of repair is osteoclastic phase (2-10 days). Osteoclasts resorb necrotic bone and a superficial fibrin clot develops at wound edges/severed PDL. Greatest bone formation occurs 21-28 days. - CT and Epithelium: By the 2nd day after surgery, granulation tissue profligates from exposed PDL, lateral wound edges, and papillae. 6 days post surgery tissue originates from marrow spaces and PDL. 14 days post surgery, there is union of these tissues. Epithelium completely covers CT at 21 days. CT and epithelium mature within 6 months. - Temporary bone exposure (flap surgery): - 2 days: Fibrin clot develops between flap and bone - 4 days: Granulation tissue replaces fibrin clot - 4-8 days: bone resorption occurs on periosteal surface of bone. - 10-21 days: new bone formation occurs Less net bone resorption occurs over the root if the flap is replaced. CT/epithelium heal in similar manner as above, but organization and maturation occur faster and complete maturation occurs within 3 months. - 26.15. Pfeifer, 1963. - Origin of new CT component of gingival tissue covering denuded bone is primarily the PDL. - 26. 17: Wilderman, 1970. - Average crystal bone loss after osseous surgery is 0.8mm. - 0-3 weeks: periosteal surface resorption occurs - 3-4 weeks: Bone repair by osteoblastic activity reaches peak with little apposition after 6 months - 2 months: Immature collagen fibrils are laid down parallel to root until 5-6 months which then angle apically to root surface.

Answer 190

- Loe, 1967: - 4 groups of 3 subjects each with healthy gingiva that had 5 day period of no oral hygiene. - Groups then rinsed with one of four solutions (tetracycline, vancomycin, Polymixin B, distilled water) - Results: Inflammation, gingival exudate reduced in antibiotic groups as well as alterations in bacterial flora. - BL: "Antibiotics may be valuable tools in further research on the correlation between bacterial colonization and initiation of gingival inflammation."

Answer 191

- Kuboniwa, 2010. - Ebersole, 2017 - Strep species (primarily S. gordonii, enables P. gingival to adhere to biofilm - P. gingival in biofilms decreases metabolic rate but increases in virulence - F. nucleate can create a reduced micro-environment optimal for P.g growth - T. denticola and P. gingival engage in "nutritional cross feeding" where metabolites of one serve as food sources for the other - Bacteria in biofilms are more resistant to phagocytosis

Answer 192

- Increases effectiveness of Amoxicillin by inactivation of B-lactamase. Most B-lactamse bacteria have greater affinity to calvulanic acid than penicillins which will allow penicillin to be effective

Answer 193

- TCNs inhibit collagenase, certain other MMPs: possible inhibition of cytokines (IL1B, TNF) and arachidonic acid metabolism - (Golub, 1998) - Low dose doxycycline therapy reduces mammalian collagenolysis (Golub, 1990) - May inhibit bone resorption induced by PTH, bacterial endotoxin, PGE2 by inhibiting phospholipase A2, and directly inhibit osteoclasts (Seymour & Heasman, 95)

Answer 194

- Sorsa, 92 - Primary collagenase from aggressive periodontitis patients is fibroblast derived (MMP-1) - Primary collagenase in Type 1 diabetes patients is derived from neutrophils (MMP-8) - MMP-8 is much more sensitive to TCNs than MMP-1

Answer 195

- Preshaw, 2004: - In 210 patients with RCT, Periostat reduced ≥7mm sites PD by 2.31mm vs 1.77mm for placebo - PD reduction ≥2mm in 43% OF Periostat sites vs 31% of Placebo sites - Greenstein, 2004 - Doxycycline has little effect on BOP - Significant reductions in PD and gains in CAL, but clinical significance is questionable <0.5mm - No guidelines on how long patients should take (results will only occur when patients are actively taking medication) - BL: Useful in certain patients, but reducing bacterial challenge often more important than modulating host response.

Answer 196

- Generally prescribed with Amoxicillin (synergistic effect) - Vanwinklehoff, 89) - Ineffective in vitro against A.a and Capnocytophaga but effective in vivo due to metabolic active metabolites through liver oxygenation and can then kill aerobic flora - Metronidazole/Amoxicillin has led to slight clinical + microbiological improvements over SRP alone (Berglundt, 98 - Rooney, 2002)

Answer 197

- Haffajee 2007, Lai 2011, Bartold 2013 - Macrolide antibiotic, binding to 50 s ribosome subunit - Effective against anaerobes and gram - bacilli - Concentrates in periodontal tissues 25x serum, penetrates fibroblasts and phagocytes 100-200x ECF - Anti-inflammatory and immunomodulatory properties - Greater improvement at PD >6mm than controls or DCN - Be careful administering to patients on Ca channel blockers

Answer 198

- Simmons, 2018 - Ampicillin, other penicillins, and tetracyclines have been suggested to cause a low incidence of oral contraceptive failure, although RIFAMPIN is the only one with a strong association - Several theories - not confirmed by literature but evidence does not support drug interaction between OC and non-rifampin antibiotics - Most women should expect no interaction but possible that obese women and possibly a small subset of others may be at risk

Answer 199

- Bollen, 96 - PD reduction from 0-8 weeks with decrease in pathogenic bacteria, however, PD and bacteria return and increase toward baseline values by 12 weeks

Answer 200

- Rationale - Impossible to eliminate all pathogens by mechanical therapy - Multiple bacterial reservoirs are present in oral cavity (tongue, tonsils, pockets, exposed roots), increase the likelihood of re-infection - Quadrant by quadrant therapy allows re-infection of treated sites by untreated sites - Evidence - Guerrero, 2005 - Amox/Met, 6 months, led to greater AL gain ≥2mm (25% test, 16% controls) - PD reduction ≥2mm (30% test, 21% controls) - Ramberg, 2001 - 115 patients, TXN for 3 weeks. 13 year follow up. - Test group at 1 year had gain of AL 3x that of controls (0.47mm vs 0.16mm). No difference at 3,5,13 years. - Rooney, 2002 - Met/Amox had greater PD reduction compared to SRP only - Borges, 2017 - 190 chronic Perio patients evaluating different Met/Amox regimens and primary outcome was presence of ≤4 sites with PD ≥5mm. - 14 days of Amox/Met had significant predictor of reaching clinical endpoint (OR: 5.26) - Rabelo, 2015 - SR of aggressive periodontitis - 14 studies showed greater PD reduction (1.05mm) and gain of CAL (1.08mm) with systemic ABs

Answer 201

- Matarazzo, 2008 - 43 smokers. Met/Amox had better clinical indices and microbiological parameters at 3 months compared to without - Chambrone, 2016 - SR of 7 trials. Smokers with CP: adjunctive use of local antimicrobials improved efficacy of SRP - Improvements in PD and CAL were not seen with use of systemic antibiotics combined with SRP - BL: Systemic antibiotics, if indicated, should be adjunctive to mechanical debridement. There is not enough evidence to support systemic AB use with conventional periodontal surgery. AB intake should start no later than the day of debridement completion. Debridement should be completed within a short time to optimize results.

Answer 202

- Mellado, 2001, Salkin 2003, - Study sent bacteria from same sites (collected with paper point) to 2 different labs. They found poor agreement on AB sensitivity of Metronidazole, Amoxicillin, and Tetracycline. May have found different results because culturing is difficult for gram - species and bacteria are not found uniformly in the pocket. - Empirical use of amoxicillin/metronidazole may be more clinically sound and cost effective than antibiotic selection based on culturing. - Cionca, 2010 - 51 patients evaluating benefit of Met/Amox. Results showed significantly better results for met/amox group regardless of pre-tx bacterial profile. Testing for bacteria showed no predictive value in identifying subjects who would benefit from antibacterial treatment. - BL: Microbiological testing does not alter treatment.

Answer 203

- Sanders: - With ABs, >50% fill in 85% of grafts. - Without ABs, >50% fill in 38% of grafts - Demolon: - No difference in results of GTR procedure with or without systemic Augmentin (very small n) - Loos, 2002: - No difference in GTR results with or without systemic ABs (very small n)

Answer 204

- Laskin - 4.6% failure rate with pre-op ABs - 10.0% failure rate without pre-op ABs - Orenstein, Lambert - Reduced failure rate in unstable implants and implants placed in smokers with peri-operative ABs - Esposito, 2013 - NNT is 25 to prevent one loss - Ahmad and Saad - 11,406 implant systematic review - >90% success for all treatment, no difference between Abx and control - Braun, 2019 - SR of 2,869 implants - Significantly greater # of implant failures present in placebo group vs. antibiotic group - Number needed to treat with ABs to prevent implant failure in one patient was 24. - But individual studies saw no differences so authors made no conclusion in favor of antibiotic usage

Answer 205

- Continued periodontal breakdown in spite of diligent mechanical therapy - Aggressive periodontal disease, whether early or late onset - Medical conditions predisposing to infection - Acute or recurrent severe periodontal infections (NUG, periodontal abscesses) - Peri-implantitis - GBR procedures, complex implant cases, sinus lifts - All implant cases, regenerative therapy?

Answer 206

i. Class 1: Recession that does not extend to MGJ ii. Class 2: Recession that extends to or past the MGJ with no interproximal bone loss iii. Class 3: Recession that extends to or past MGJ and loss of interproximal clinical attachment coronal to the margin of gingival recession iv. Class 4: Recession that extends to or past MGJ and loss of interproximal clinical attachment apical to the margin of gingival recession - Criticisms of Miller’s classification: Zuchelli, 2015 - Unclear distinctions between: (a) Class I or II for recessions beyond the MGJ with a small, probable keratinized tissue (KT) apical to the root exposure. (b) Class III and IV for the amount of interdental tissue loss.

Answer 207

- Zuchelli, 2015 - Aging: Buccal recession has 90% prevalence in >40 year olds (Serino, 94) - Oral hygiene: - Good: Recession due to toothbrush trauma, mostly buccal - Poor: Recession due to periodontal disease, including interproximal areas - Anatomical factors: - Dehiscences, Buccal placement of root, thin phenotype - Orthodontic therapy - Oral piercings - Malocclusion - Poorly designed partial denture and subgingival restorative margins

Answer 208

- Zuchelli, 2015 A. Esthetics B. Hypersensitivity 1. If no esthetic complaint  apply desensitizing agents  if ineffective, rstorative treatment 2. Esthetic complaint  surgical or combined restorative–surgical C. Keratinized tissue augmentation D. Root abrasion/caries—surgical or combined restorative–surgical E. Creates or augments keratinized tissue. F. Inconsistency/disharmony of gingival margin—surgery only

Answer 209

- Muller, 2000 - Mean thickness: 1.29-2.29mm - Thinnest in maxillary canines and mandibular centrals - Males > females - Smoking = non-smokers

Answer 210

- Bower, 1963 - Range 1-9mm - Narrowest mandibular canine and 1st premolar (2mm) - Widest is maxillary lateral (5.2mm)

Answer 211

- Lang, Loe 1972 - Sites < 2mm led to increased in inflammation and GCF in 32 dental students - Miyasato, 1977 - No difference in gingival inflammation with sites <2mm or >2mm. Gingival health is NOT associated with AT width - Wennstrom, 83, 87 - No attached tissue led to increase in inflammation clinically but not histologically (animal study) - 5 year patient study showed good oral hygiene does not lead to attached gingiva recession - Regeneration workshop: - If we have perfect hygiene, maybe you do not need AT

Answer 212

- Absence of KT: - Increased plaque accumulation, recession, need for surgical and non-surgical treatment, inflammation and attachment loss - Presence of KT: - Increase in soft tissue stability and decrease in plaque accumulation and indigence fo peri-implant mucositis, and peri-implantitis

Answer 213

- Shallow - Narrow - Shallow - Wide - Deep - Narrow - Deep - Wide Mills Response: - They categorized recession of narrow and shallow and narrow and deep - all based on root coverage. Reason is blood supply. - When you have recession, you have denuded roots which are avascular surfaces. They were looking for predictably of root coverage which all has to do with blood supply. Narrowly, you have BS laterally and apically. When wide, BS may not extend across avascular root surface to keep graft alive, but it may apically.

Answer 214

- Chambrone, Agudio 2016 - Long term results of treated vs untreated recession - 79.3% increase in recession over 9 years if left untreated

Answer 215

- Elliott & Bowers, 1963 - Skull study - Dehiscences: Maxillary (6%), Mandibular (14%) - Fenestrations: Maxillary (17%), Mandibular (6%) - Most likely to have dehiscence on mandibular canines and fenestrations on maxillary 1st molars

Answer 216

- Miller, 1982 1. Make a horizontal incision (butt joint) at the level of the CEJ. Outline of the flap is trapezoidal (broader at base). Extend one tooth bilaterally. 2. Prepare recipient site 3-5mm or more apical to the most apical part of exposed root 3. Place horizontal suture to stretch graft and secure in place 4. Place sling sutures and periosteal sutures to secure graft in place.

Answer 217

- James, 1978 - Dordick, Coslet, Seibert - FGG on bone leads to less swelling, better hemostasis, Healing lag for about 2 weeks. - Basically, healing of grafts on bone are delayed due to necessity for bone resorption to take place to expose vascular supply in marrow spaces. The delay is about one week. The less shrinkage of grafts on bone is associated with scarring due to exposed bone--thus MGJ does not migrate coronally as seen with grafts on periosteum.

Answer 218

- Indications - Increase zone of KT - Used in combo w/frenectomy to eliminate aberrant frenum or muscle attachment - Deepen the vestibule - Used for root coverage - Single or multiple teeth - Contraindications - Significant root coverage needed (greater than 2mm) - Systemic health issues - Size of grafted area to be addressed

Answer 219

1. Novaes - Gingival and Periodontal clefts have historically been given several etiologies to include: trauma from occlusion (Stillman, 1921), iatrogenic, facticial, or toothbrush trauma (Hirschfeld, 1934), and proliferation of pocket epithelium that anastomoses with oral epithelium in the presence of inflammation (Goldman, 1964). Inflammation is directional and multiphasic as it spreads not only apico-coronally through gingival connective tissues, but also progresses laterally towards the outer oral epithelium in a slowly progressive process with pocket epithelium migrating and eventually anastomosing with oral epithelium as hydrolytic enzymes degrade the connective tissue. Following hydrolytic enzyme degradation of CT, the epithelium from the pocket lining proliferates to cover the resorbed area. Ulceration will often be seen next to the accretion of plaque, calculus or debris. As the epithelium migrates, the oral epithelium wall eventually is degraded and merging of oral (gingival-mucosal epithelium) and pocket epithelium creates a soft tissue fenestration. If in a occlusal-apical direction, a dehiscence of soft tissue is created. Summary: Development of the periodontal cleft is due to constant inflammation. CT is destroyed, is covered by proliferating and migrating pocket-epithelium, and eventually anastomosis occurs b/w pocket and gingival epithelia. The thinner the tissues, the less CT present, and less time is needed for this to occur.

Answer 220

- Harrel and Nunn: Retrospective review. Looked at 91 patient records over 24 years. no apparent relationship between occlusal discrepancies and gingival recession.

Answer 221

- Gargiulo, Oliver, Sullivan % Atkins: - 0-2 days: Plasmatic circulation (diffusion of nutrients from host bed). Attachment by fibrin network - 2-4 days: Vascular invasion - 4-7 days: CT attachment - 10 days: Bridging of vascular channels - Epithelial sloughing occurs within the 1st week

Answer 222

- Donor Site - Acceptable donor tissue contains keratinized or parakeratinized epithelium and a dense lamina propria (i.e. edentulous ridge, palatal mucosa, or attached gingiva). - Grafts can be split or full thickness - The graft's thickness will determine its behavior: · A thicker graft will undergo greater immediate (primary) contraction upon detachment from the donor area due to its greater elastic fiber content. This same thick graft will undergo less secondary contraction during healing than a thinner graft. · A thinner graft can be easier to vascularize through diffusion · A thicker graft has greater resistance to functional stresses. · Minimizing trauma and dehydration to the donor tissue is essential for graft success. Immobilization of the Graft • Immobilization of the graft is extremely important in order for revascularization to occur. • Thicker grafts require greater immobilization. - Primary contraction: Immediate (due to elastic fibers) - Secondary contraction: During healing (due to cicatrization - contraction of fibroblasts)

Answer 223

- Matter, 1976 - Goldman, Cohen 1973 - Bridging: Graft over the denuded root survives by receiving circulation from capillaries in the vascular portion of the recipient site - Creeping attachment: Post-operative migration of the free gingival margin in a coronal direction (1mm between 1-12 months)

Answer 224

- Harris, 1997 | - Creeping attachment found with double pedicle flap with CT grafts of 0.8mm at 26-38 weeks

Answer 225

- Used as FGG primarily. - Porcine collagen 1,3 matrix, not cross linked, 3mm thickness - Apply dry and suture as needed with compact structure towards the flap and sponges structure towards the bone.

Answer 226

- Grupe, 1956 - Can be done with/without FGG - Primary indication—deep single type recession defect of mandibular incisor or mesial root of maxillary 1st molar where you have plenty of adjacent tissue - Low predictability and efficacy - Contraindication—high esthetic demands - Some clinical indications would be isolated defects. Want 1.5x width compared to recession area. Adequate bands of KT adjacent to the site would be tried to treat. - Histology healing would be long junctional epithelium. CT adhesion. Some articles would show 50% junctional epithelium and 50% CT attachment. For most part, it would be more LJE and some adhesion. In apical portion, a true attachment may take place.

Answer 227

- Bernimoulin , 1975 - Horizontal incisions made at CEJ and papillae coronal to that are de-epithelialized. Two vertical incisions bordering papillae adjacent to recession area are made.

Answer 228

- Zuchelli, 2000 - CAF + CTG 1. Coronally positioned flap 2. Split thickness envelope flap 3. Oblique incisions, papilla rotation 4. Flap midline determines rotation 5. Sling suture

Answer 229

- Raetzke's pouch (1985) - Use Blade to undermine and remove tissue underneath area of recession and tuck CT in pouch with no sutures. Palatal donor site incision completed by trap door approach.

Answer 230

- Hwang, Wang, 2006: Large SR. Average flap thickness was 0.7-1.46mm. A positive association exists between weighted flap thickness and mean and complete root coverage.

Answer 231

- Harris, 2003: 65% Lamina propria 35% submucosa (most adipose) Epithelium remains in 24/30 grafts

Answer 232

Miller classification was based on position of FGM in relationship to the MGJ. Cairo is based on FGM in relationship to CEJ.

Answer 233

- Yotnuengnit, 2004 Results: The percent of root coverage at 3 and 6 months postoperatively was statistically significantly associated with the GTA:VDA (Graft Tisse area: Visible denuded area) ratio. In patients who had 100% root coverage, the GTA:VDA ratio ranged between 10.92:1 and 21.95:1; in patients with <100% root coverage, the ratio was between 4.54:1 and 11.06:1. Conclusion: The GTA:VDA ratio should be at least 11:1, which is a significant factor for optimal root coverage result in the envelope procedure. Mills: Want CT graft to be 11x greater than the size of the visible denuded area. So the minimum is 11:1 where they saw you have 100% coverage. More important that you have LATERAL blood supply. Should extend at least 3mm beyond the dehiscence to take advantage of proximal tissue blood supply.

Answer 234

- Subepithelial CT graft where you get partial thickness dissection with outer flap covering graft. You wedge graft between two sources of blood supply. - Tunneling if you maintain periosteum. - Envelope pouch (Ratzkes technique) - Double pedicle - CAF

Answer 235

- Described by Tarnow: - Want a very small recession (1-2mm) like miller class 1, enough keratinized tissue with a low smile line. Technique no sutures. But fibrin attachment. Use some lateral blood supply so you want 2mm. Allowing blood supply interdental area to continue to be maintained. - Low smile line: Scarring post op. When you have a thinner perio phenotype, you could end up with a scar band. If you have a high smile line, this may be visible and not something you would want to do with your patients.

Answer 236

- Flap thickness - Mean thickness for success is around 0.8mm, but HomLay Wong did review and range was 0.8-1.2mm thickness for successful outcome. - Thick tissue has more layers of keratinized epithelium ECM, and collagen for protection and increased vascularity. - Position of gingival margin after you do CAF? - The more coronal advancement to the gingival margin to the CEJ (2-2.5mm) after suturing, the greater the probability of achieving complete root coverage. - How do you do this? - Not only would you do CAF, you would have to have vertical releasing incisions on both M/D. Deas believes the more coronal you can get above the CEJ, the better the outcome. He thinks that is the problem with tunneling, you can not advance it as far. - If you advance 2mm coronal CEJ, what happens to flaps when healing? (Flap will contract some) - Location in arch? - When dealing in posterior, you may have a root trunk that you are trying to advance a greater area due to the amount of root coverage needed. - Influence of inter-dental space - Loss of interdental tissues, and presence of NCCLs >1mm, decrease the ability to achieve CRC. - Greater distance, we have greater distance from contact point to bone, we may not expect as much root coverage. - Flap tension - Want it to be tension free, less than .4grams of force. If flap is too tense, more likely to contract. Not likely to get as much passivity or advancement as well. - What about the amount of KT? How does this affect predictability? - You want at least 2-3mm of KT. With CAF, 2mm of KT is a good indication for root coverage. - Smokers (Silva_ - Smokers exhibited poorer outcomes at 6 months, less root coverage on average, and frequency of complete root coverage was decreased. - Reasons for this are: - Smoking impacts gingival blood supply, nicotine inhibits production of collagen and non-collagen matrix proteins by fibroblasts, inhibits adhesion of fibroblasts to root surfaces.

Answer 237

- Freeze dried acellular dermal matrix of basement membrane and CT matrix. - Matrix: Has receptors sites for many growth factors and matrices for vascular support to aid in revascularization of graft itself. - Healing: Our tissue grows within it and it becomes incorporated into our tissue. Elastic fibers found that this is what remains following healing, which is an indirect indication that graft material is incorporated into native tissue. Alloderm has a lot of elastic fibers, elastin is one thing that pops out. Elastin is more prominent in alloderm compared to dermis. - Long term healing: Alloderm after 6 months has less root coverage compared to CTG. Not as stable as CTG. - Exposed: No, better not exposed. It is dead tissue, exposed and is acellular and avascular. - Width: 8-10mm. Whether CT being too thick or 10mm of ADM, the more crap you have jammed under the flap, the harder it is to coronally positioned flap. Deas believes the more coronal you can get magrin, the better outcome will be. Pat Allen says 7mm thickness is the mandible cause of a more shallow vestibule and harder to coronally advance. And he recommends 8mm in maxilla. Remember you have to wash and hydrate ADM. - Creeping: Yes, it can occur. There are case reports that it can occur. Possibility that it may occur with it.

Answer 238

- Thomas Van Dyke: Specialized pro-resolving mediators (SPMs) biosynthesized from 𝜔-3 PUFA (resolvins, protectins, and maresins) and upregulation of endogenous SPMs (lipoxins) help resolve inflammation. Also studies also showed that aspirin (ASA) triggers the synthesis of more potent SPMs, called ASA-triggered resolvins, ASA-triggered protectins, and ASA-triggered lipoxins that have a longer half-life in blood. SPMs promote the resolution of inflammation by reducing neutrophil infiltration, regulating cytokine/chemokine synthesis, attenuating systemic C-reactive protein and interleukin (IL)-1 production, decreasing the production of RANKL, and regulating macrophage-secreted pro-inflammatory cytokines.

Answer 239

AAOMS Paper, 2014: - MRONJ is the exposure of bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region that has persisted for more than 8 weeks and the patient is currently using or previously used anti-resorptive or angiogenic agents, and no history of radiation therapy to the jaws or obvious metastatic disease to the jaws. - Mechanisms: - Bisphosphonates and other antiresorptive medications such as denosumab, inhibit osteoclast differentiation and function, and increase apoptosis all leading to decreased bone resorption and remodeling. This occurs primarily in the alveolar bone due to the increased remodeling rate compared to other bones in the axial or appendicular skeleton. - Risk - MRONJ risk in cancer patients: Range of developing between 0.19% - 2%. Higher in patients on zolendronate and denosumab. The risk after tooth extraction among cancer patients with use of IV bisphosphonates ranges from 1.6-14.8% (retrospective study). A prospective study states prevalence was 2.8%. - MRONJ in osteoporotic patients (When compared to cancer patients receiving antiresorptive treatment, the risk of ONJ for patients with osteoporosis exposed to antiresorptive medications is about 100 times smaller. - 0.1% <4 years - 0.21% >4 years - The best current evidence/estimate for risk fo ONJ among patients exposed to oral bisphosphonates following tooth extraction is 0.5%. - Duration of BP use is risk factor for developing ONJ. - Management strategies - - Patients about to initiate IV antiresorptive or anti-angiogenic treatment for cancer: Non-restorable teeth and those with poor prognosis should be extracted and other elective dentoalveolar surgery. IV medication should be delayed until extraction site is mucosalized (14-21 days). - Patients about to initiate antiresorptive treatment for osteoporosis Educate patients about risks for MRONJ and 4 year time point. Importance of optimizing dental health throughout this treatment period and beyond should be stressed. - Treatment of patients receiving IV bisphosphonate use of antiangiogenic drugs: - Procedures that involve direct osseous injury should be avoided. - Non-restorable teeth may be treated by removal of crown and endo access. - No dental implants. - Treatment of patients receiving antiresorptive therapy for osteoporosis: - The risk of developing MRONJ associated with oral bisphosphonates increased when duration of therapy exceeded four years. - Patients should be informed of small risk of compromised bone healing (<1%). - If systemic conditions persist, the clinician may consider discontinuation of oral bisphosphonates for a period of two months prior to and three months following elective invasive dental surgery. - The efficacy of utilizing a systemic marker of bone turnover to assess the risk of developing jaw necrosis in patients at risk has not been validated. - For patients who have taken an oral bisphosphonate for less than 4 years and have no clinical risk factors, no alteration or delay in the planned surgery is necessary. Patients should sign consent understanding the risk with dental implants, as there is some evidence that demonstrated impaired long term implant healing. - For patients who have taken an oral bisphosphonate to less than 4 years and also taken corticosteroids or antiangiogenic medications, consider a drug holiday by contacting the physician. (corticosteroids and antiangiogenic agents may increase risk of developing MRONJ). - For patients taking oral bisphosphonates for more than 4 years with or without any concomitant medical therapy, perform drug holiday.

Answer 240

- High prevalence of disease or LOW threshold for disease

Answer 241

- Roos-Jansaker: - Implant survival lower and OR for peri-implantitis = 4.7 when subjects had more than 30% of teeth with bone loss ≥4mm. - Heitz-Mayfield, Huynh-Ba, 2009: - Survival rate lower but generally >90% with micro roughened surfaces. - Peri-implantitis more common in patients with past history of periodontitis (OR = 3.1-4.7) - Levin, 2011 - Overall survival rate is high but implant failure rate was markedly increased in severe periodontitis patients after 4 years. It takes a while to have enough bone loss to lose bone around implants. Hazard ratio for severe periodontitis was 8:1 for implant failure.