DX Flashcards
Gingivitis vs Periodontiti
● Periodontal Health: absence of clinically detectable inflammation
o Absence of BOP is a strong indicator of good periodontal health
o BOP < 10% indicates periodontal health
o
● Gingivitis – reversible Early signs
▪ Under microscope
● Dilation and engorgement of the capillaries and thinning or micro-ulceration of the sulcular epithelium
● Vasculitis of blood vessels adjacent to the junctional epithelium
● Progressive destruction of the collagen fiber network (collagen-poor)
● Cytopathologic alterations of resident fibroblasts (cell-rich)
● Progressive inflammatory immune cellular infiltrate (predominantly lymphocytic
Gingivitis: Characteristics
▪ Plaque to initiate the inflammation
● Clinical signs and symptoms are confined in the gingival unit (not to bone yet)
▪ Systemic modifying factors
● Stable attachment may or may not experience further attachment loss
▪ Reversibility
o Criteria
▪ The clinical signs of inflammation are erythema, edema, pain (soreness), heat, and loss of function
▪ These may manifest clinically in gingivitis as:
● Swelling, seen as loss of knife-edged gingival margin, and blunting of papillae
● Bleeding on gentle probing
● Redness
● Discomfort on gentle probing
o Radiographs CAN’T be used to diagnose gingivitis
Gingivitis: tools
o Tools
▪ Gingivitis can be simply, objectively, and accurately identified and graded using Bleeding on Probing Score (BOP%)
▪ A case of dental plaque-induced gingivitis is defined as ≥ 10% bleeding sites with probing depths ≤ 3mm
● Localized gingivitis: 10-30% bleeding sites
● Generalized gingivitis: >30% bleeding sites
▪ (Boles said to not really focus on the 30% part for bleeding sites, just know that if they come in with a low plaque score, but bleeding is still high, there is still something going on there).
Periodontitis: Irreversible
– irreversible, no cure for periodontitis only control
Staging and Grading
● PD is no longer considered diagnostic
o Inflammation has effect on penetration of probe, may also move gingival margin coronally
o Use interproximal attachment loss (2 or more non-adjacent teeth)
▪ CAL – using worst site interproximally
o Use probing depth as a ‘complexity’ factor (difficulty of tx)
● Step 1: Initial Case Overview to Assess Disease
o Screen:
▪ Full mouth probing depths
▪ Full mouth radiographs
▪ Missing teeth
o Mild to moderate periodontitis will typically be either Stage I or II
o Severe to very severe periodontitis will typically be either Stage III or IV
● Step 2: Establish Stage
o For mild to moderate periodontitis:
▪ Confirm CAL
▪ Rule out non-periodontitis causes of CAL (cervical restorations or caries, root fractures, trauma, etc.)
▪ Determine max CAL or RBL
▪ Confirm RBL patterns
o For moderate to severe periodontitis:
▪ Determine max CAL or RBL
▪ Confirm RBL patterns
▪ Assess tooth loss due to periodontitis
▪ Evaluate case complexity factors (severe CAL frequency, surgical challenges)
● Step 3: Establish Grade
o Calculate RBL (% of root length x 100) divided by age
o Assess risk factors (smoking, diabetes…)
o Measure response to scaling and root planing and plaque control
o Assess expected rate of bone loss
o Conduct detailed risk assessment
o Account for medical and systemic inflammatory considerations
● Staging: 1-4 based upon severity of disease and complexity of case management
o Considers
▪ CAL – using worst site interproximally
▪ Amount and % of BL
▪ Probing depth
▪ Presence/extent of ridge defects and furcation involvement
▪ Tooth mobility
▪ Tooth loss (due to periodontitis if known)
o Ensure the problem cannot be attributed to non-periodontal causes such as:
▪ Gingival recession due to trauma (toothbrush/toothpaste)
▪ Dental caries extending to or below the gingival margin
▪ Defect on distal of 2nd molars caused by malposition or extraction of a 3rd molar
▪ Endodontic lesion draining through marginal periodontium (deep probing depth)
▪ VRF (usually isolated deep probing depth)
o Complexity:
▪ Takes into account overall probing depths’
▪ Evaluates RBL, both horizontal and vertical
▪ Evaluates furcation involvements, # of missing teeth, functionality
● Trump Cards
o Tooth Loss due to Periodontitis (if known)
▪ No tooth loss = Stage I or II
▪ ≤ 4 teeth = Stage III*
▪ ≥ 5 teeth = Stage IV*
▪ *Trump Card – if ANY teeth lost due to periodontitis, then automatically Stage III or IV
o Furcation involvement
▪ *Trump Card – furcation involvement of Grade 2 or 3 automatically puts patient into Stage III or IV
● Grading
o Considers biological features
▪ Rate of disease progression
▪ Risk for further advancement
▪ Potential threats to general health (including smoking, diabetes)
▪ Response to standard therapy
o Grading (A-C)
▪ o Primary Criteria
o Grading (A-C)
▪ A: Low risk of progression
▪ B: Moderate risk of progression
▪ C: High risk of progression
▪ *Initially assume Grade B, then seek specific evidence to shift to Grade A or C
o Primary Criteria Grading
o Primary Criteria
▪ Direct evidence (best)
● Historical RBL or CAL
▪ Indirect evidence (new pt’s)
● % BL/pt age
● Case phenotype
● Heavy plaque accumulation but minimal destruction vs. minimal plaque but major destruction
o Grade Modifiers (RISK Factors)
▪ Smoking and Diabetes
● Grade A: Slow rate = nonsmoker, non-diabetic
● Grade B: Moderate rate = ≤ 10 cigarettes/day; diabetic with HbA1c <7%
● Grade C: Rapid rate = ≥ 10 cigarettes/day; diabetic with HbA1c ≥7%
●
“If they are a well-controlled diabetic (non-glycemic) we don’t consider them to be at risk for periodontal disease…” (where grade A says “normoglycemic”)
“If they are a well-controlled diabetic (non-glycemic) we don’t consider them to be at risk for periodontal disease…” (where grade A says “normoglycemic”)
Trauma from Occlusion
● ***Trauma from occlusion in the absence of inflammation does not cause pocket formation or lead to loss of connective tissue (periodontitis or gingivitis)
● Non-Cervical Carious Lesions/Abfraction
o No evidence that traumatic occlusal force (TOF) causes non-carious cervical lesions
● Recession: Trauma from occlusion
o Evidence from observational studies that TOF does NOT cause gingival recession
o No credible clinical evidence to support existence of abfraction
▪ Abfraction will NOT cause recession!!!
● Problems Associated with Occlusal Trauma
o Lesion of occlusal trauma can only be confirmed histologically by block section biopsy 🡪 must use other surrogate indicators (Both clinical & radiographic indicators)
▪ 1. Fremitus: palpable or visible movement of tooth when subject to occlusal forces
● Shift of one tooth when in occlusion
▪ 2. Mobility
● Uses the mobility index to assess
▪ 3. Occlusal Discrepancies: working and/or balancing interferences
● Evidence of:
o Occlusal slide in CR or CO
o Occlusal interferences in protrusive mandibular movement
o Extremely steep cuspal inclines
▪ 4. Wear Facets
● May be a normal part of ageing
● Positive hx of clenching or bruxism
● Bruxism: grinding, clenching, or clamping of the teeth
o Increased mobility
o Pulpal sensitivity/bite tenderness
o Non-masticatory/excessive occlusal wear
o Muscle tenderness/spasm/hypertrophy/tiredness in the morning
o TMJ pain/jawlock
o Audible sounds
▪ 5. Tooth Migration
● Missing or tilted teeth
● Can have malocclusions as well
▪ 6. Fractured Tooth
▪ 7. Thermal Sensitivity
▪ 8. Discomfort/Pain on Chewing
o Radiographic Signs: Occlusal Trauma
. Widened PDL space
● Thickest at apices & alveolar crest = 0.2 mm
● Less at midroot = 0.15 mm
● Varies with functional/force status of tooth
● Also thickened lamina dura, vertical (angular) BL, furcal BL, alveolar RL and/or condensation
▪ 10. Root resorption
▪ 11. Cemental tear
Mucogingival Defects: Gingival recession
o Gingival recession - apical migration of the gingival margin with concomitant exposure of the root surface
o This condition affects a large population irrespective of Oral Hygiene
o Estimated prevalence:
▪ 54.5% of young adults
▪ 100% middle aged-elderly adults suffer from gingival recessions with an average prevalence of 78.6%
