etiologies of periodontal diseaes Flashcards
periodontitis
____, ______ inflammatory disease
____ damage
Types/categories
- ______ PD
- Periodontitis as a ______ of ______ diseases
- Periodontitis Stage ___, Grade ___
what 4 things affect it
Chronic, multifactorial inflammatory disease
Irreversible damage
Types/categories
Necrotizing PD
Periodontitis as a manifestation of systemic diseases
Periodontitis Stage I-IV, Grade A-C
host inflammatory response, microbial shift, environmental factors, genetics
health microbiological determinants:
host determinants:
environmental determinants:
(biofilm composition)
(tooth anatomic factors and host status)
(smoking/stress)
what are the 3 steps to properly diagnosing periodontitis
- Identify attachment loss in more than TWO NONADJACENT TEETH
- attachment loss must be related to periodontitis
- Other potential etiologies (such as F/L recession, root fracture, impacted wisdom teeth, migrating teeth, and defective restorations) should be excluded - Identification of the form of periodontitis (e.g., necrotizing, manifestation of systemic conditions, or periodontitis)
- Description of the presentation, based on the staging and grading system
Pocket formation/gingival recession __________
Bacterial infection with ____ to ____ destruction
- __ to __% of population severe destruction; ____pts slight to moderate
- when Host response in severely ______ > severe breakdown is more commonly observed
Prevalence increases with ____; remember:
- ___ percent, or ___ million American adults, have mild, moderate or severe periodontitis
- Adults __ and older, prevalence rates increase to ____ percent
Clinical Signs?
Pocket formation/gingival recession interproximally
Bacterial infection with slow to moderate destruction
- 10 to 20% of population severe destruction; most pts slight to moderate
- Host response in severely compromised severe breakdown more commonly observed
Prevalence increases with age; remember:
- 47.2 percent, or 64.7 million American adults, have mild, moderate or severe periodontitis
- Adults 65 and older, prevalence rates increase to 70.1 percent
inflammation, infection, furcations, mobility, IAG, open embrasure spaces for food impaction, drifting teeth due to attachment loss
what is necrotizing perio*
three typical clinical features: necrosis of the papilla, bleeding; and pain.
This condition is associated with an impairment of the host immune response
*necrotizing forms are considered periodontal emergencies that need immediate attention. Rare to see.
what is manifestation of systemic disease perio
many diseases and conditions can affect the periodontal tissues by
1) influencing the course of periodontitis
2) affecting the periodontal supporting tissues independently of dental plaque biofilm-induced inflammation.
what is chronic periodontitis
common, chronic inflammation of the periodontal tissues which is caused by the accumulation of large amounts of dental plaque
what is aggressive periodontitis
rapid progression and patients often display a different pattern of bone loss compared to those suffering from chronic periodontitis.
Typically affects younger people.
NECROTIZING PERIODONTAL DISEASE (severely and chronically compromised)
adult predisposing conditions
child predisposing conditions
clinical conditions for adults and children
adult predisposing conditions:
- HIV/AIDS with CD4 counts less than 200 and detectable viral load
- other severe systemic conditions that cause immunosuppresion
child predisposing conditions
- severe malnouishments
- extreme living conditons
- severe viral infections
clinical conditions for adults and children:
- necrotizing gingivitis
- necrotizing periodontitis
- necrotizing stomatitis
- noma
- possible progression
NECROTIZING PERIODONTAL DISEASE (temporarily or moderately compromised)
gingivitis pt predisposing conditions
gingivitis clinical conditions
periodontitis pt predisposing conditions
periodontitis clinical conditions
local factors predisposing
local factors clinical conditions
gingivitis pt predisposing conditions:
- uncontrolled factors like stress, nutrition, smoking
- previous NPD (residual craters)
gingivitis clinical conditions
- generalized NG
- possible progression to NP
periodontitis pt predisposing conditions
- common predisposing factors
periodontitis clinical conditions
- NG infrequent
- progression
- NP infrequent profession
local factors predisposing
local factors clinical conditions
NUP > HIV assoc. Necrosis of gingival tissues combined with loss of attachment and bone
___, _____ onset
Spontaneous ____
______, _____ odor, fever, lymphadenopathy
Rapid, ______ bone loss
Painful _______
Extremely rapid ________
Can produce loss of _____ within ___
Characterized by _____of gingival tissues, ___, and _____ bone loss
Associated with severe ______
PAIN, SUDDEN onset
Spontaneous BLEEDING
PSEUDOMEMBRANE, FETID odor, fever, lymphadenopathy
Rapid, IRREGULAR bone loss
Painful INFECTION
Extremely rapid DESTRUCTION
Can produce loss of ATTACHMENT within DAYS
Characterized by necrosis of gingival tissues, PDL, and alveolar bone loss
associated with severe IMMUNODEFICIENCY
objectives for Nonsurgical Therapy for Periodontitis
Non-surgical periodontal therapy (NSPT) is your ________
_____ periodontal pathogens
Remove ______ biofilm
Resolve _______
Eliminate ______ and other _____ risk factors
________ disease progression
Non-surgical periodontal therapy (NSPT) is your scaling and root debridement
Reduce periodontal pathogens
Remove subgingival biofilm
Resolve inflammation
Eliminate calculus and other local risk factors
Arrest disease progression
principles of NSPT
Assess ____ factors
Self-care pt ______
Create a ______ biologically acceptable ____ surface
Instrumentation
Appropriate ______
_______ at regular intervals
Eliminate/suppress infectious microorganisms
Eliminate or control the source of the infection to prevent ________
Establish an environment which promotes resolution of _______
Consideration of ___ factors
Reduce ____, reduce _____, stabilize ______ levels
Assess risk factors
Self care pt education
Create a smooth biologically acceptable root surface
Instrumentation
Appropriate referral
Re-evaluation at regular intervals
Eliminate/suppress infectious microorganisms
Eliminate or control the source of the infection to prevent re-infection
Establish an environment which promotes resolution of inflammation
Consideration of host factors
Reduce biofilm, reduce pockets, stabilize attachment levels
what can our outcomes be impacted by? (6)
Depth of pockets (we can only reach up to 7mm)
Accessibility/location
Furcation involvement
Sensitivity
Active infection
Patient motivation/understanding
ASSESSMENT PHASE
Have patient _______
They will not “buy in” without feeling ______ in the process
Have them identify ____ sites versus ____ sites: SHOW the _____ chart
Have them identify where ______ accumulates (with your two-tone, new versus old plaque too!)
Help patient acknowledge disease ______
Develop ______ and _____ plans with the patient
Designed to: (3)
Have patient participate
They will not “buy in” without feeling included in the process
Have them identify healthy sites versus disease sites-SHOW the perio chart
Have them identify where plaque accumulates (with your two tone, new versus old plaque too!)
Help patient acknowledge disease status
Develop goals and education plans with the patient
Designed to: Inform, Motivate, Elicit Cooperation
bleeding on probing
Check at ____ appt
Sign of ______/______ infection
Measure of _____ success
Check at every appt
Sign of re-infection/active site
Measure of long-term success
limitations of BOP
Medication impacts
- ______
- ______
- ______
Menstruation
Dietary supplements
- _______
- ______
_______ force
Local trauma
- _____ impacting
- _______ habits
Smoking
Medication impacts
- Aspirin
- Anti-coagulant therapy
- Hypertensive medications
Menstruation
Dietary supplements
- Ginkgo
- St. John’s Wart
Probing force
Local trauma
- Food impacting
- Flossing habits
Smoking
bleeding assessment - opportunity to design and evaluate effective _______ self-care therapies
- ______/______ options
- Irrigation
- _______ therapy
- _______ aids
bleeding assessment - opportunity to design and evaluate effective adjunctive self-care therapies
- Brushing options
- Flossing options
- Irrigation
- Antimicrobial therapy
- Adjunctive aids
the pt should be informed of (4)
Areas resistant to therapy
Changes in therapy outcomes
Need for re-treatment
Other health problems
severe cases
____% of the population with perio
_______ infection results in _____ within supporting structures of teeth
Characterized by _____ destruction of PDL, bone, high risk for ____ loss and ___ response to therapy
Disease severity inconsistent with ______ of plaque biofilm
Commonly ______ (___ marker test is for this gene specifically)
Elevated ___ and ___
PMN’s ________ defect
8-20% of the population with perio
Bacterial infection results in inflammation within supporting structures of teeth
Characterized by rapid destruction of PDL, bone, high risk for tooth loss and poor response to therapy
Disease severity inconsistent with amount of plaque biofilm
Commonly familial (PST marker test is for this gene specifically)
Elevated PGE and IL
PMN’s chemotaxis defect
molar/incisor distribution
*Specific _____ associated with _______ periodontitis forms
___ to ___ % familial, siblings
Onset: _____
Permanent ____ molars and ____ incisors = major rapid ___ loss
Rads = _______ bone loss, rapid
______, ____ and ______
__ x faster
__ to __ % in __ weeks in one study!
*Specific pattern associated with aggressive periodontitis forms
25 to 50 % familial, siblings
Onset: puberty (YOUNG) (chronic is associated with molars)
Permanent first molars and central incisors = major bone loss, and rapid
Rads = vertical bone loss, rapid
Diastema, Migration and Mobility
4 x faster
25 to 60 % in 9 weeks in one study!
molar/incisor: formerly known as __________
Onset of disease around ______; African American _____ most affected
Involving NO more than ____ teeth other than the ______ and ______
molar/incisor: formerly known as localized aggressive
Onset of disease around puberty; African American females most affected
Involving NO more than two teeth other than first molars and incisors
molar/incisor distribution
Lack of tissue _______ and minimal amounts of ______ that seem _______ with amount of periodontal destruction
Frequently associated with _________
_____ bone loss around _____ and _______: beginning around _____.
______ destruction despite ______ plaque and no _____ calculus deposits
Neutrophil ________ defect with this gene
_____ appearing gingiva – no clinical ________ ; Deep on ____ and in _____
Lack of tissue inflammation and minimal amounts of plaque that seem inconsistent with amount of periodontal destruction
Frequently associated with Aggregatibacter actinomycetemcomitans (Aa)
Vertical bone loss around first molars and incisors—beginning around puberty
Localized destruction despite sparse plaque and no supragingival calculus deposits
Neutrophil chemotaxis defect with this gene
Healthy appearing gingiva – no clinical inflammation; Deep on root and in epithelium
treatment
______ 1 gram _/day, __ to ___ days
_______, _______
___ after surgery
__-__ month recare
__ VBWX series each recare until resolved
____ Care
Microbiological monitoring
Perio surgery: may be indicated depending on amount of ______ and ________
tetracycline 1 gram 4/day, 7-21 days
amoxicillin, metronidazole
CHX after surgery
2-3 month recare
7 VBWX series each recare until resolved
self Care
Microbiological monitoring
Perio surgery: may be indicated depending on amount of attachment loss and dentition dysfunction
periodontitis associated with systemic conditions
Likely a condition associated with ________ issues (6)
immunological issues:
Down Syndrome
Leukocyte adhesion deficiency syndromes
Papillon‐Lefevre syndrome
Haim‐Munk syndrome
Chediak‐Higashi syndrome
Severe neutropenia
hematologic disorders: abnormalities in the structure or function of the _____ and blood forming tissues such as: (4)
acquired ________, _______, ____/____, other rare blood disorders
Hematologic Disorders
Abnormalities in the structure or function of the blood and blood-forming tissues such as:
Red blood cells
White blood cells
Platelets
Clotting factors
Acquired neutropenia, leukemia, AIDS/HIV, other rare blood disorders
CAN GENETIC DISORDERS CAUSE PD: yes! still being studied
Genetic disorder: disease caused by the _____ of a gene or by the products of a ______
Passed down in _______, but not always in each _______
(2)
Genetic disorder: disease caused by the absence of a gene or by the products of a defective gene
Passed down in families, but not always in each generation
Down syndrome, autoimmune disorders
mucogingival deformities and conditions
Mucogingival deformity: a significant alteration of the _____, size, and ______ between the gingiva and _______
most common example?
Mucogingival deformity—a significant alteration of the morphology, size, and interrelationships between the gingiva and alveolar mucosa
Recession of the gingival margin is the most common example
occlusal trauma with periodontal patients
what is secondary occlusal trauma
Rapid ____ and ______ may result
Widened ___, root ______, bone loss, ______, fremitus, _______, fracture, ______ sensitivity
Occlusal forces applied to a tooth or teeth that previously had attachment loss or bone loss, called secondary occlusal trauma.
Rapid bone loss and pocket formation may result
Widened PDL, root resorption, bone loss, mobility, fremitus, migration, fracture, thermal sensitivity
tooth abnormalities
Can be considered _____ contributing factors
______ enamel projections
Enamel ______
______ grooves
Malalignment
______-related issues
Can be considered local contributing factors
Cervical enamel projections
Enamel pearls
Palatolingual grooves
Malalignment
Prosthesis-related issues
Staging levels = _____ status
- Indicate the ______of the disease
- Complexity of disease _________
Grading = a ______ prediction
- Considers _______ biologic characteristics of the patient
- Estimating the ___ and likelihood of periodontitis _______
- _______
Staging levels = current status
- Indicate the severity of the disease
- Complexity of disease management
Grading = a future prediction
- Considers supplemental biologic characteristics of the patient
- Estimating the rate and likelihood of periodontitis progression
- Prognosis
step 1 staging/grading
Step 1: ____ Case Overview to Assess Disease
Mild to moderate periodontitis =
Severe to very severe periodontitis =
what do you use to determine
Step 1: Initial Case Overview to Assess Disease
Mild to moderate periodontitis
Typically, either Stage I or Stage II
Severe to very severe periodontitis
Typically, either Stage III or Stage IV
full mouth xrays, full mouth probing depths, missing teeth from perio
complexity score
Based on the __________ assuming the need to eliminate local factors
Considers the presence of: (7)
Besides the local complexity, individual case management may be complicated by ______ factors or _______.
Based on the local treatment complexity assuming the need to eliminate local factors
Considers presence of:
vertical defects, furcation involvement, tooth hypermobility, drifting and/or flaring of teeth, tooth loss, ridge deficiency and loss of masticatory function.
Besides the local complexity, individual case management may be complicated by medical factors or comorbidities.
what are the 3 options for extent and distribution
localized: under 30 percent
generalized: over 30 percent
molar/incisor pattern
stage 1 severity: 3
stage 1 complexity: 2
severity:
- 1-2mm CAL
- less than 15% RBL
- no perio tooth loss
complexity
- max probing depths 4mm or less
- mostly horizontal bone loss
stage 2 severity: 3
stage 2 complexity: 3
severity:
- 3-4mm CAL
- 15-33% RBL
- no tooth loss due to perio
complexity:
- 5mm max PD
- horizontal bone loss
- furcation’s 2 or 3 would shift to a stage 3 or 4
stage 3 severity: 3
stage 3 complexity in addition to stage 2: 4
severity:
- 5mm CAL or more
- RBL middle third or above
- 1-4 teeth loss
complexity:
- takes ONE complexity factor to shift to a higher stage
- probing depth 6mm or higher
- class 2/3 furcations
- moderate ridge defects
stage 4 severity: 3
stage 4 complexity: 6
severity:
- 5mm or more CAL
- RBL mid or apical third
- 5 or more teeth lost
complexity; Need for complex rehabilitation due to:
- Masticatory dysfunction loss of teeth
- Secondary occlusal trauma
- (tooth mobility degree ≥2)
- Severe ridge defects (implant issues)
- Bite collapse, drifting, flaring
- <20 remaining teeth (10 opposing pairs
GRADING
Estimate ____Risk of periodontitis _______ and responsiveness to standard therapeutic principles, to guide intensity of therapy and monitoring
Estimate Potential _______ Periodontitis on systemic disease and the reverse, to guide systemic _____ and co‐therapy with medical colleagues
Estimate Future Risk of periodontitis progression and responsiveness to standard therapeutic principles, to guide intensity of therapy and monitoring
Estimate Potential Health Impact of Periodontitis on systemic disease and the reverse, to guide systemic monitoring and co‐therapy with medical colleagues
GRADING
________ to standard therapy
Potential impact on ________
A = _____
B = _______
C = ______
Clinicians should initially assume grade __ disease and seek specific evidence to shift to grade ___ or ___
risk/________
Responsiveness to standard therapy
Potential impact on systemic health
A slow
B moderate
C rapid
Clinicians should initially assume grade B disease and seek specific evidence to shift to grade A or C.
Risk/prognosis
GRADE A
characteristics (2)
modifiers (2)
characteristics:
- no additional bone loss or attachmetn loss over past 5 years
- low levels of destruction
modifiers:
- nonsmoker
- no history of diabete
GRADE B
characteristics 2
modifiers 2
characteristics
- less than 2mm additional bone loss or attachment loss over past 5 years
- destruction is in line with amount of plaque
modifiers
- smokes less than 10 cigs a day
- hba1c 7% or less
GRADE C
characteristics 2
modifiers 2
characteristics
- 2mm or more of bone/attachment loss over past 5 years
- tissue destruction exceeds expectations
modifiers
- smokes 10 or more cigs a day
- 7% or greater hba1c
grade A = slow rate
Primary criteria (direct or indirect- try to use direct most often)
example of direct evidence of progression (1)
examples of Indirect evidence of progression (2)
Primary criteria (whenever possible, direct evidence should be used)
Direct evidence of progression
No loss over 5 years on radiographic eval
Indirect evidence of progression
- <0.25 % bone loss/age
- Heavy biofilm deposits with low levels of destruction
how to calculate bone loss
Length of root from CEJ to apex; measure CEJ to height of bone (crest)
(CEJ to crest/CEJ to apex) x 100 = % then divide by age
EXAMPLE: 4mm (CEJ to crest)/ 13mm(CEJ to apex)= 30.7% divided by age 50 =.6 (grade B)
grade B = moderate
example of direct evidence
examples of indirect evidence
Direct evidence of progression
- <2 mm over 5 years (compare x-rays over time)
Indirect evidence of progression
- 0.25 to 1.0 % bone loss/age
- Destruction commensurate with biofilm deposits
grade C = rapid
example of direct evidence
examples of indirect evidence
Direct evidence of progression
- ≥2 mm over 5 years
Indirect evidence of progression
- >1.0 % bone loss/age
- Destruction exceeds expectations given biofilm deposits; specific clinical patterns suggestive of periods of rapid progression and/or early onset disease
