Classification and Etiology of Perio Diseases Flashcards
What is gingivitis?
Inflammation of the Gingiva
Define Periodontitis…
Inflammation of the supporting tissues of the teeth. Usually a progressively destructive change leading to loss of bone and periodontal ligament. An extension of inflammation from gingiva into the adjacent bone and ligament.
What are the 8 Classifications of periodontal disease?
- Gingival diseases
- Chronic periodontitis
- Aggressive periodontitis
- Periodontitis as a manifestation of systemic diseases
- Necrotizing periodontal diseases
- Abscesses of the periodontium
- Periodontitis associated with endodontic lesions
- Developmental or acquired deformities and conditions
Describe dental plaque-induced gingival diseases…
Gingivitis associated with dental plaque only
Most common form of gingival diseases
Reversible once treated
Prevalence >90%
Characterized by the presence of clinical signs of inflammation confined to the gingiva
What are gingival diseases modified by medications?
Dental plaque-induced gingival diseases
Increasing in prevalence due to the increasing use of: Anti-convulsant drug (50% of pts)s: Phenytoin Calcium channel blocker (25% of its)s: Nifedipine, verapamil, diltiazem Immunosuppressive drug (33% of its)s: Cyclosporin A
What 3 origins contribute to nonplaque-induced gingival lesions?
Gingival diseases of: Bacterial origin Neisseria gonorrhea, Treponema pallidum Viral origin Herpes simplex viruses 1 & 2, Varicella zoster virus Fungal origin Candidasis, histoplasmosis
What are traumatic lesions of the gingiva?
Nonplaque-induced gingival lesions Traumatic lesions Factitial Toothbrush trauma Accidental Damage through minor burns from hot food or drinks
What are 3 classifications of periodontitis?
Chronic periodontitis
Aggressive periodontitis
Periodontitis as a manifestation of systemic diseases
Describe Chronic Periodontitis…
Associated with plaque and calculus
irreversible
Generally slow to moderate rate of progression
Extent and severity may be increase with host-modifying factors
Diabetes, smoking, and stress
Chronic periodontitis descriptors according tot he AAP update in 2015…
Localized < 30% of sites Generalized > 30% of sites Severity Slight, moderate, severe
2015 update
Generalized chronic periodontitis may be classified as periodontitis without a clear pattern of disease distribution of the affected teeth or >30% of teeth affected
age at detection be considered as a guideline in diagnosing aggressive periodontal diseases. The recommended age of younger than 25 years at the time of detection can be used, along with other diagnostic criteria.
Describe what slight periodontitis is according to the update in 2015?
Probing depths...>3 & <5 mm BOP...Y Rad bone loss...Up to 15% of root length or ≥ 2mm & ≤3 mm CAL...1-2mm
Describe what moderate periodontitis is according to the update in 2015?
PD…≥5 & <7 mm
BOP…Y
Rad Bone Loss…16-30% or > 3mm & ≤5 mm
CAL…3-4mm
Describe what severe periodontitis is according to the update in 2015?
PD…≥7 mm
BOP…Y
Rad Bone Loss…>30% or > 5mm
CAL 5+mm
What is aggressive periodontitis?
Rapid attachment loss and bone destruction
Amount of microbial deposits inconsistent with disease severity
Familial aggregation of diseased individuals
Describe Localized Aggressive Periodontitis…
Circumpubertal onset
Specific, robust serum antibody response
Localized to first molar or incisor
Describe Generalized Aggressive Periodontitis…
Poor serum antibody response
Generalized proximal attachment loss affecting at least 3 permanent teeth other than first molars and incisors
What 2 disease categories make up periodontitis as a manifestation of systemic diseases?
Hematologic disorders
Genetic Disease
What are some examples of Perio Hematologic Disorders?
Leukemia & Acquired Neutropenia
What are some examples of Perio Genetic Diseases?
Cyclic neutropenia, Down syndrome, Leukocyte adhesion deficiency
What are the 2 categories of necrotizing periodontal diseases?
Necrotizing ulcerative gingivitis (NUG)
Necrotizing ulcerative periodontitis (NUP)
Describe NUG, what 3 elements constitute a diagnosis?
Predisposing factors: Stress, smoking, poor oral hygiene, & immunosupression Diagnosis based on three criteria: 1. Interproximal necrosis 2. Pain 3. Bleeding
Describe NUP…
Loss of attachment and bone
Ulceration and necrosis of gingival
Rapid destruction and exposure of underlying bone
Spontaneous bleeding and severe pain
What 4 clinical manifestations may come with an abscess?
Localized purulent infection May exhibit one or more of the following: Gingival swelling Draining fistula Pain on percussion Increased mobility
Common situations that predispose to abscess formation - can you think of 4?
Deep periodontal pockets
Incomplete calculus removal
Foreign body impaction
Repeat antibiotic use
What are the 3 Abscesses of the Peridontium?
Gingival
Periodontal
Pericoronal
Describe what a Gingival Abscess is…
Involves interdental or marginal gingival
Not associated with a periodontal pocket
Typically does not involve the PDL
Describe what a Periodontal Abscess is…
Most frequently encountered of the 3
Arises from a preexisting pocket
Bacterial etiology
Describe what a Pericoronal Abscess is…
Same as periodontal, though around a partially erupted tooth
Describe Periodontitis associated with endodontic lesions…
Combined lesions
Infections of periapical tissues caused by pulpal death can locally join with separate infections from periodontal pockets
Order of TX for combined endo/perio lesions?
The endodontic infection should be controlled before beginning definitive periodontal therapy
When regenerative or bone grafting techniques are planned
What are 4 categories of Developmental or acquired deformities and conditions?
- Tooth anatomical factors
- Mucogingival deformities around teeth
- Mucogingival Deformaties on edentulous ridges
- Occlusal Trauma
What are some examples of tooth anatomical factors that can affect Perio?
cervical enamel projections, enamel pearls, furcation anatomy, tooth positions and proximity
What are some characteristics of mucogingival Deformaties around teeth?
Soft tissue recession, lack of keratinized tissue, gingival excess
What are some examples of Mucogingival Deformaties on edentulous ridges?
Ridge deficiencies, lack of keratinized tissue, aberrant frenum, muscle position
What are the 2 sub groups of occlusal trauma?
Primary
Secondary
Primary Etiology?
Microbiological
Host
What is secondary etiology
Environmental
Local Factors
What is dental plaque?
Primary Factor
Organized mass adhering to teeth, prosthesis, and oral surfaces
Classified as supragingival and subgingival
What is the composition of plaque?
80% water
20% solid
Salivary glycoproteins, extracellular polysaccharides, proteins, lipids
Describe Supragingival Plaque…
Coronal to gingival margin
Forms rapidly
Aerobic > anaerobic
Describe Subgingival Plaque…
Apical to gingival margin
Growth may be influenced by supragingival plaque
Anaerobic > aerobic
Where does early plaque formation occur faster
In the mandibular arch
Molar areas
Buccal surfaces of the maxillary teeth
Interdental regions compared to strict buccal or oral surfaces
Tooth surfaces facing inflamed gingival margins
What is a Biofilm?
Organized Structure
Microcolonies of bacterial cells distributed in a shaped matrix or glycocalyx
What are the Organic Constituents of a Biofilm?
Polysaccharides, proteins, glycoproteins and lipid material
What are the Inorganic Constituents of a Biofilm?
Calcium, phosphorus, and trace minerals
As mineral content increases the plaque mass becomes calcified forming calculus
What are some unique features of Biofilm?
Protection-glycocalyx that encloses microbial community
Nutrition-matrix is capable of trapping nutrients
Quorum sensing-communication between bacteria
What are the 4 plaque development phases?
Adherence
Lag Phase
Rapid Growth Phase
Steady State
What happens during the adherence phase?
Pellicle formation
Glycoprotein
Cell surface proteins
Initial colonization gram + facultative bacteria
What happens during the lag phase?
Shift in genetic expression
What happens during the rapid growth phase?
Plaque maturation
Co-aggregation/co-adhesion
Quorum sensing
What happens during the steady state stage?
Internal transfer of nutrients
Growth slows
Tolerance
Resistance
What is the Non-specific plaque hypothesis?
Disease results from “elaboration of noxious products by the entire plaque flora”
It is not the specific bacterial but the entire microbial community
Control of disease depends upon amount of plaque accumulation
What is the Specific plaque hypothesis?
Only certain plaque is pathogenic
Pathogenicity depends on presence of or increase in specific microorganisms
What factors contribute to bacterial pathogenicity?
Virulence factors
Influence attachment
Provide protection
Provide mechanism for penetration of host tissue
Fimbria, capsule, glycocalyx, endotoxin, proteolytic enzymes
What type of bacteria are generally found in the Microbiota of periodontal health?
Gram-positive, Streptococcusand Actinomyces
What type of bacteria are generally found in Chronic Periodontal disease Microbiota?
Gram-negative, P. gingivalis and T. forsythia
What Microbiota are found in Localized Aggressive Periodontitis?
A. actinomycetemcomitans, Eubacterium, A. naeslundii, F. nucleatum, C. rectus
What Microbiota are found in Generalized Aggressive Periodontitis?
P. gingivalis, T. forsythia, A. actinomycetemcomitans, Campylobacter species
Periodontitist complexes
Blue, Purple, green, yellow, orange, red
Red Complex
Porphyromonas gingivalis
Tannerella forsythensis
Treponema denticola
Is there a Genetic Component to chronic periodontitis? If so, what percent?
Heritability for Chronic Perio=50%
IL-1β gene polymorphism
What are contributing factors for calculus?
Calculus Smoking Diabetes mellitus Age Anatomical factors Other
What is calculus?
Consists of mineralized bacterial plaque that forms on the surfaces of natural teeth and dental prostheses
Classified as supragingival and subgingival
Can form in as little as 48 hrs
What is Supragingival calculus?
Coronal to gingival margin and visible in the oral cavity
Hard with claylike consistency, easily detached from the tooth surface
Heterogeneous, filamentous microorganisms
Mineralized from Saliva
What is Subgingival calculus?
Located below the crest of the marginal gingiva
Typically hard and dense, may appear dark brown or greenish black
Homogenous, microorganisms are cocci, filaments and rods
Mineralied by GCF
How does calculus attach to a tooth?
Organic pellicle on enamel
Mechanical locking into surface irregularities or undercuts
Resorption bays, cemental tears, root gouging/caries
Intimate adaptation of calculus to cementum
How does one detect calculus clinically?
Probing
58% of surfaces thought to be clean had calculus (Sherman et al. 1991)
Calculus detection radiographically….
Radiographically
Sensitivity = 43.8%
Specificity = 92.5%
What are some stats regarding calculus removal efficacy based on PD?
1-3mm = 83% effective 3-5mm = 39% >5mm = 11%
How does calculus play a role in dental disease?
Promotes the retention of dental plaque and may increase the rate of plaque formation
Porosity can serve as a reservoir for pathogens and can retain noxious bacterial components
Delay healing up to 120 days if left on surgically treated teeth
Smoking effects on:
Local flora
No differences in bacterial counts between smokers and non-smokers(Preber and Bergstrom 1992)
Subjects positive for Aa, Tf, and Pgwas significantly higher in current smokers(Zambon et al. 1996)
How does smoking effect vasculature?
Peripheral vasoconstriction
Local ischemia
Smoking effects on surgical therapy? Non surgical therapy?
Non-surgical
Less favorable pocket depth reduction, less gain in CAL(Preber and Bergstrom 1985; Preber et al. 1995; Grossi et al. 1997)
Surgical
Less PD reduction and greater attachment loss(Ah et al. 1994)
How does smoking effect fibroblasts?
Fibroblast effects
Reduction in fibroblast secretion, with dose-dependent inhibition of proliferation(Tipton et al. 1995)
Altered attachment of fibroblasts to teeth(Raulin et al. 1988)
How does smoking affect PMN?
Decreased mobility and phagocytosis (Kenney et al. 1975)
How does smoking effect macrophages?
Decreased functional activity of macrophages
What are some general statistics in the US regarding Diabetes?
6-7% of the United States population has diabetes mellitus
40-50% of the people are unaware that they have the disease
Blacks and Hispanics have a higher prevalence
How does diabetes affect the periodontium?
Vascular changes Increased collagen breakdown Altered oral microbial flora Advanced glycogen endproducts (AGEs) Altered gingival crevicular fluid glucose Altered defense mechanisms
How does diabetes effect periodontal therapy?
Non-surgical
No difference in clinical, microbiological and immunological response after 4 months(Christgau et al. 1998)
Surgical and maintenance
Patients with diabetes respond well to treatment and remain successful with adequate
How does controlled vs. non controlled diabetes differ in periodontal treatment?
The level of control seems to play a role in the level of gingival inflammation and attachment loss (Cohen et al. 1970)
Poorly controlled diabetic patients had more gingival bleeding than well to moderately-controlled diabetic patients (Ervasti et al. 1985)
Age effects on:
Periodontium…
Decreased cellularity
Increased collagen fiber coarseness
Decreased collagen turnover
Gradual breakdown of the peridontium with age
Epithelium becomes thinner
Connective tissue becomes denser
PDL shows less fiber and cellular content and becomes irregular
Age effects on:
Treatment
No difference between healing responses of three age groups <40, 40-49, >49(Lindhe et al. 1985)
More frequent recall appointments due to recession and greater amounts of exposed cementum(Robinson 1979)
What are Cervical Enamel Projections? What are the 3 grades?
Prevalence
90% of isolated furcation involvements are associated with CEPs
Grade 1: Distinct change in the CEJ
Grade 2: Enamel projection approaching the furcation
Grade 3: Enamel projection extending into the furcation
Where are enamel pearls usually found?
Prevalence
Most common in the furcation region, particularly on third molars
They range in size from small to large with large pearls having underlying dentin and possibly pulp
What is an Intermediate bifurcation ridge?
Convex excrescence of cementum that runs longitudinally between the mesial and distal roots of mandibular molars
Prevalence
Found more frequently on first molars
Irregular contours make plaque and calculus removal difficult
What 2 teeth typically present with palatoradicular grooves?
Prevalence
8.5% of patients
4.6% (centrals 3.4%, laterals 5.6%)
47% terminated > 5 mm on the root surface
How can close root proximity effect periodontal treatment?
Areas of tight root proximity are difficult to treat and more vulnerable to breakdown
What age group typically presents with cementum tears?
Prevalence
More common in older patients
Accessory canals…
Prevalence
Occur in approximately 25-50% of molars
Tend to occur more frequently in first molars than second molars(Gutman 1978)
What restorative defects can greatly hinder periodontal treatment?
Overhangs
Act to extend the sphere of influence of plaque apically
Removal should be completed during initial therapy
Margin location
Biologic width invasion
What is Factitial injury?
Self-inflicted injuries can be difficult to diagnose
Injuries are produced in a variety of ways
Picking the gingiva with a fingernail
Improper use of toothpicks or other oral hygiene devices
Most often once identified pt can be instructed to avoid the injurious behavior
Why have a classification system?
Sets the stage for context for treatment planning
Helps in estimating outcomes
Communication with colleagues and patients
Allows researchers to study the same disease
Chronic Periodontal Prevalence
46% of adults over 30 years have chronic periodontitis
8.9% severe chronic periodontitis
37.1% non-severe chronic periodontitis
Likelihood of periodontitis increases with age
2 Forms of bacteria in Mouth
Planktonic/free flotation
Plaque/biofilm
Experimental Gingivitis in Man
Gingivitis in 10-21 days Increase quantity of plaque Increased quality of plaque Resolution within seven days of OH Bacterial plaque causes gingivitis Loe 1965
Natural History of Periodontitis in Man
480 male Sri Lankan tea laborers No conventional OH or dental care Three subpopulations Rapid progression –8% Moderate progression –81% No progression -11%
CEP’s
28.6% on buccal of mandibular molars
17% on buccal of maxillary molars
90% of isolated mandibular furcation involvements
What are the squealae of Marginal ridge discrepancies?
May lead to food impaction
Inflammation
Bone loss
Attachment loss
What are signs and symptoms of occlusal trauma?
Signs and symptoms of occlusal trauma Occlusal wear Fremitus Widened PDL Local angular defect Furcation bone loss Pain Fractured/chipped teeth
Define primary occlusal trauma…
Excessive occlusal forces to a tooth or teeth with normal support
Define secondary occlusal trauma
Normal or excessive occlusal forces applied to a tooth or teeth with a reduced periodontium
traumatogenicocclusion
Any occlusion that produces forces that cause an injury to the attachment apparatus
What are some long term complications of Diabetes?
Long-term complications Retinopathy Neuropathy Nephropathy Macrovascular disease Altered wound healing Periodontitis
