Etiology of Periodontal Diseases Flashcards
Pathogenesis of Periodontal
Disease
- Pathogenesis of periodontal
disease is the series of
structure changes and
function within the
periodontium
microbial shift? vascular change? cellular change in gingiva? IS?
changes associated with perio dx
what is primary etiology of periodontitis
plaque in a susceptiable host resulting from dybiosis
What is Gingivitis?
only affects? counts as?
result of?
reversible?
precedes?
• Inflammatory response only affecting the gingiva, technically a perio dx
• Occurs as a results of biofilm (plaque) accumulation that is not removed
• Reversible
• Precedes periodontitis but does not always progress to periodontitis
how is gingivits reversible
no actual tissue loss, underlying tissue not affected
Gingivitis
Characterized by:
• Inflammation of gingival
margins and interdental papilla,
redness, bleeding on probing
• NO attachment loss=reversible
Periodontitis
Characterized by:
• Bone loss (alveolar)
• Apical migration of the Junctional Epithelium
What is
Periodontal
Disease??
• A chronic inflammatory disease affecting the periodontium
• Complex and multifactorial
• Initiated by a dysbiosis of biofilm (plaque) and modulated by the host response
Dysbiosis
Dysbiosis-an imbalance between the types of organism present in a person’s
natural microflora thought to contribute to a range of conditions of ill health.
main determinant of perio dx damage
immune response will cause damage
Differences between Gingivitis & Periodontitis
Histologic Stages of Gingivitis and Periodontitis
Key Features*
based on lesion types
initial, early, established and advanced lesions
- Initial Lesion of gingivitis
vascular-dialated cap/increased blood flow due to host immune response
some acute inflamm can be seen conn tissue
• Clinically healthy gingival tissues
• Develops within 2-4 days of the accumulation of plaque
- Early Lesion gingivitis
when? signs? cells?
• Early gingivitis that is clinically evident, overlap/ evolve from initial lesion
• Develops approximately 1 week of continued plaque accumulation, bleeding on probing, erythema
leukocyte infiltration in gingiva, beneath JE (lyphocytes, plasma cells, PMN, etc.)
- Established Lesion of gingivitis
2-3 weeks, predominance of plasma cells/ lymphocytes
blood vessels engorged/ congested= ischemia and cyanosis
• Established chronic gingivitis=some lesions are stable and do not progress
• Progression to this stage dependent on many factors= progression to periodontitis, tissues not responding to home care = perio therapy needed
progression into?
fibrosis?
cells in conn tisssue/JE?
- Advanced Lesions of gingivits
into alveolar bone=perio breakdown
fibrosis gingiva
plasma cells all over conn tissue
PMN in JE
* Transition from gingivitis to periodontitis only in susceptiable individuals
* Progression to this stage dependent on many factors
gingivitis epidemiology, correlation to adult perio?
82% adolescents, 42% adults have periodontitis
gingivitis epithelium
ulcerated, due to inflammatory response/mediators
regeneration depends on the epithelium
perio health flow chart
Stages of Gingivitis & Periodontitis
Radiographic Stages of Gingivitis &
Periodontitis
all interdental bone lose
can we know the bac spp responsible for perio dx
no, polymicrobial
sudden onset gingivitis
can have rapid onset and short duration due to many factors
chronic gingivits
longer duration with less pain unless complicate with acute exacerbations
typically flucuatine
usually with poor oral hygiene
localized/generalized gingivitis
30% or more than 30%
most common site of gingivitis
papilla
horizontal vs vertical bone loss
vertical bone loss usually single teeth horizontal more generalized
Gingival Pocket(pseudo-pocket/false pocket)
Pocket caused by hyperplasia;
coronal movement of the gingival margin
• No apical migration of the
junctional epithelium
• No bone loss
periodontal pocket, true pocket
bone loss, apical migration of JE
suprabony and infrabony related to the alveolar crest
tooth will be loosened
Necessary Information for a
Periodontal Diagnosis Complete Periodontal Assessment Requires:
• Description of the clinical appearance of the soft tissues
• Probing depths
• Plaque and bleeding index
• Recession/ Clinical Attachment Loss (CAL)
• Radiographs
Causative Factors of
Periodontal Disease can be:
Primary etiology: plaque in a
susceptible host
Secondary etiology:
local (calculus)/environmental factors
• Gingival diseases are initiated
primarily by?
• Gingival diseases are initiated
primarily by plaque on tooth and gingival surfaces
Plaque initiates ________-
which leads to ________
inflammation, which leads to pocket formation, and the pocket provides shelter
for more plaque
cornerstone of perio therapy
• Removal of subgingival plaque and calculus constitutes the cornerstone of periodontal
therapy
Local Contributing Factors of perio dx
- Calculus
- Carious lesions
- Overhangs
- Malpositioned teeth
- Xerostomia
- Furcations
- Food impaction
- Occlusal trauma
- Orthodontics
- Poor crown margins
Systemic Factors:
• Medication
• Stress
• Diabetes
• Obesity
• Cardiovascular disease
• Immuno-compromised
• Smoking
• Nutritional deficiencies
• Age
• Genetics
Primary Bacterium
Associated with
Periodontitis
• Aggregatibacter actinomysetemcomitan
(Aa)
• Porphyromonas gingivalis (Pg)
• Prevotella intermedia (Pi)
• Tannerella forsythia (T. forsythia)
• Treponema denticola (T. denticola)
interplay btwn? develops where? response to?
perio dx results from?
results from a complex interplay between the subgingival biofilm and the host immune-inflammatory events that develop in the gingival and periodontal tissues in response
to the challenge presented by the bacteria.
toxicity? results in?
as the subgingival biofilm matures:
as the biofilm matures, the bacteria become more toxic to the
periodontium, thus resulting in a change in the structure and function.
before periodontitis occurs what dx is present?
gingivitis is the gingival disease that will first affect the periodontium
is gingivitis considered a perio dx, why or why not?
gingivitis is considered a periodontal condition, because it takes place within
the periodontium, and the gingival sulcus.
where is ginigivitis confined to? perio dx confined to?
does gingivitis always lead to periodontitis?
Gingivitis does not always lead to periodontitis. In gingivitis, the inflammatory lesion is confined to the gingiva; however, with periodontitis, the inflammatory processes extend to additionally affect the periodontal ligament and the alveolar bone.
PDL? CAL? bone?
what is the nest result of ginivial and perio inflammation?
The net result of these inflammatory changes is the breakdown of the fibers of the periodontal ligament, resulting in clinical loss of attachment together with resorption of the alveolar bone.
The causative role of bacteria in the biofilm and inflammory responses?
The causative role of bacteria in the biofilm is clear in that the bacteria initiate and perpetuate the
inflammatory responses that develop in the gingival tissues.
The main determinant of
susceptibility to perio disease:
The nature of the immune-inflammatory responses themselves.
what causes most of the tissue damage of perio dx
host IS response
is perio dx an infection in the classic definition?
no
Days? state of lesions?
Histologic Stages of Gingivitis and Periodontitis
Stage I: Gingival Inflammation- The Initial Lesion (Days 2-4)
Stage II: Gingival Inflammation- The Early Lesion (Days 4-7)
Stage III: Gingival Inflammation-The Established Lesion (Days 14-21)
Stage IV: Gingival Inflammation- The Advanced Lesion
what is this change due to?
The first manifestations of gingival inflammation are:
vascular changes consisting of dilated capillaries and increased blood flow.
These initial inflammatory changes occur in response to the host’s immune response as a result of bacterial invasion
is stage I of gingivitis and periodontitis clinically apparent
Clinically, this initial response of the gingiva to bacterial plaque
is not apparent.
histo? where?
what can be seen microscopically in stage I of gingivitis/periodontitis
some classic features of acute inflammation can be seen in the
connective tissue beneath the junctional epithelium.
how long does it take the initial lesion to develop into the early lesion
within about 1 week after the beginning of plaque
accumulation.
what can happen with progression?
clinical appearnce of the early lesion? (stage 2)
gingivitis
as time progresses, clinical signs of erythema may appear because of the proliferation of capillaries. Bleeding on probing may also be evident at this point in time.
cells? where?
microscopic appearence of stage 2/early lesion
the gingiva reveals leukocyte infiltration in the connective tissue beneath the junctional epithelium, which consists mostly of lymphocytes but also some migrating neutrophils as well as macrophages, plasma cells, and mast cells.
established lesion (stage 3) what cells become predominant
Predominance of plasma cells and B lymphocytes
what type of gingivitis in stage 3
chronic
when does this occur? blood vessels? results? tissue color?
chronic gingivitis
With chronic gingivitis, which occurs 2-3 weeks after the beginning of plaque
accumulation, the blood vessels become engorged and congested, venous return is impaired, and the
blood flow becomes sluggish. The result is a coloration change within the gingiva, causing a bluish hue
on the reddened gingiva.
progression of lesions seen with the established lesion/ stage 3
At this point of the established lesion there are two types that appear to exist; some lesions remain stable and do not progress for months or year, and others seem to become more active and convert to a progressively destructive lesion.
are establsihed lesions reversiable
The established lesions appear to be reversible, in that the sequence of events that occurs in the tissues as a result of successful periodontal therapy seems to be essentially the reverse of the sequence of events observed as gingivitis develops.
what characterizes stage 4 lesions/ advanced lesions
The extension of the lesion into alveolar bone characterized the fourth stage, which is also called phase of periodontal breakdown.
ginigiva? cells in conn tissue? cells in JE?
histology of stage 4 lesion
fibrosis of the gingiva is present and there is widespread manifestation of inflammatory and immunopathologic tissue damage. At the advance stage, the presence of plasma cells dominates the connective tissue, and neutrophils continue dominating the junctional epithelium.
*Gingivitis will progress to periodontitis only in:
*Gingivitis will progress to periodontitis only in individuals who are susceptible
how long does local inflammation persist? when does inflammation resolve?
local inflammation persists as long as the microbial biofilm is present adjacent to the gingival tissues and the inflammation resolves after meticulous removal of the biofilm.
Epidemiologic studies indicate more than __% of adolescents
in the US have gingivitis and signs of gingival bleeding
Epidemiologic studies indicate more than 82% of adolescents
in the US have gingivitis and signs of gingival bleeding
primary etiologic factor of gingivitis?
plaque, but other factors can affect the development of periodontal disease.
gingival tissue? BOP? contour? calculus/plaque? radio?
Clinical features of gingivitis can be characterized by any of the following clinical signs:
redness and sponginess of the gingival tissue
bleeding on probing,
changes in contour of gingiva
presence of calculus or plaque with no
radiographic evidence of crestal bone loss.
epithelium? inflammatory mediators effect? repair depends on?
histology of stage 4 lesion
Histologic examination of inflamed gingival tissue reveals ulcerated epithelium. Inflammatory mediators negatively affect epithelial function as a protective barrier.
Repair of the ulcerated epithelium depends on the proliferative or regenerative activity of the epithelial cells, and removal of the etiologic agents that triggered gingival breakdown is essential.
Gingivitis can develop with _____ onset and have a ______duration, and it can be ______
Gingivitis can develop with sudden onset and have a short duration, and it can be painful.
development? duration? pain? commonality?
chronic gingivitis
Chronic gingivitis develops slowly and has a long duration. It is painless, unless it is complicated by acute or subacute exacerbations, and it is the type that is most often encountered.
fluctuating? areas of inflamm?
chronic gingivitis
Chronic gingivitis is a
fluctuating disease in which inflammation persists or resolves and areas of inflammation may change
over time.
Localized gingivitis
Localized gingivitis is confined to the gingiva of a single tooth or group of teeth and affects less than 30%
of the remaining teeth.
Generalized gingivitis
eneralized gingivitis involves more than 30% of the remaining teeth.
Marginal
gingivitis
Marginal
gingivitis involves the gingival margin;
Papillary gingivitis involves? and it often extends?
apillary gingivitis involves the interdental papilla, and it often
extends into the adjacent portion of the gingival margin.
papilla and gingivitis
Papilla are involved more frequently than the gingival margin and the earliest signs of gingivitis often occur in the papilla
Diffuse gingivitis
iffuse gingivitis affects the
gingival margin, the attached gingiva, and the interdental papilla.
types of pockets based on deepening of sulcus
gingival pockets
periodontal pockets
also called? formed by?
-gingival pocket
-gingival pocket (also called ‘pseudo-pocket) is formed by gingival enlargement without destruction of
the underlying periodontal tissues. The sulcus is deepened because of the increased bulk of the gingiva.
results in? leads to?
-periodontal pocket
-periodontal pocket produces destruction of the supporting periodontal tissues, leading to the loosening and exfoliation of the teeth.
Deepening of the gingival sulcus may occur as a result of:
coronal movement (enlargement) of the
gingival margin, apical displacement of the gingival attachment, or a combination of the two processes.
Based on the location of the base of the pocket in relation to the underlying bone, periodontal pockets
can be classified into the following types:
suprabony and infrabony
suprabony pockets
ccurs when the bottom of the pocket is coronal to the
underlying alveolar bone
infrabony pocket
ccurs when the bottom of the pocket is apical to the
level of the adjacent alveolar bone. With this second type, the lateral pocket wall lies between the tooth
surface and the alveolar bone
different depths?
how many tooth surfaces can pockets involve
Pockets can involve one, two, or more tooth surfaces, and they can be of different depths and types on
different surfaces of the same tooth and on approximal surfaces of the same interdental space.
similar to? app of margin? blood? suppuration? pain? mobility?
Clinical features of periodontal pockets
Clinical features of periodontal pockets are similar to the clinical features of gingivitis presenting with a
bluish red thickened marginal gingiva, gingival bleeding and suppuration, and additionally, tooth mobility, diastema formation, and symptoms such as localized pain or pain ‘deep in the bone.’
The only reliable method of
locating periodontal pockets and determining their extent is:
The only reliable method of
locating periodontal pockets and determining their extent is careful periodontal probing of each tooth
surface.
it is sometimes difficult to differentiate between:
it is sometimes difficult to differentiate between a deep normal sulcus and shallow periodontal pocket.
why? apical to JE?
Periodontal pocket formation starts as:
Periodontal pocket formation starts as an inflammatory change in the connective tissue wall of the
gingival sulcus.
The cellular and fluid inflammatory exudate causes degeneration of the surrounding connective tissue, including the gingival fibers.
Just apical to the junctional epithelium, collagen fibers are destroyed and the area is occupied by inflammatory cells and edema.
Diseased gingiva is associated with an increased number of
what microbes?
increased number of spirochetes and motile rods.
what leads to collegen and bone destruction of perio dx
As the presence of bacteria appear around the periodontium, the host’s immunoinflammatory response
to the initial and persistent bacterial attached unleashes mechanisms that lead to collagen and bone
destruction.
Distinguishing between the effects of calculus and plaque on the gingiva
difficult, both are typically present with dx
does calculus directly contribute to gingival inflamm
Claculus does not contribute directly to gingival inflammation, but it provides a fixed nidus for the
continued accumulation of bacterial plaque and its retention in close proximity to the gingiva.
what microbes are found within the structural channels of supragingival and subgingival calculus.
Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, and
Treponema denticola
is subgingival calculus the cause of perio pockets
Subgingival calculus is likely to be the product rather than the cause of periodontal pockets
cornerstone of periodontal therapy.
the removal of subgingival plaque and calculus
Calculus plays an important role in maintaining and accentuating
periodontal disease how?
alculus plays an important role in maintaining and accentuating
periodontal disease by keeping plaque in close contact with the gingival tissue and by creating areas
where plaque removal is impossible.
