intro Flashcards
Reasons for Adult Tooth Loss
occurance rate of perio dx
“F”s in Periodontics
Failure to diagnosis
Failure to treat
Failure to refer
Failure to establish an appropriate maintenance schedule
Failure to accept treatment (patient)
phases of tx plans
Court Dictated Role of general dentists
Diagnose periodontal disease
Inform the patient of clinical findings
Refer patient to a Periodontist, or treat themselves
Treat to the current standard of care
Gingivitis
“Gingivitis is the inflammation of the gingival tissues without loss of connective tissue attachment.”
Periodontitis
“Periodontitis is the inflammation of
the gingival tissues with apical
migration of junctional epithelium
with concomitant loss of connective
tissue attachment and bone.
Probing Depth
“Probing depth is the distance from the soft tissue margin to the tip of the periodontal probe.”
Pockets are classified as:
Shallow (1-3mm); Moderate (4-6mm); Severe (≥ 7mm)
Clinical Attachment Level
“Clinical attachment level (CAL) is the distance from the cementoenamel junction (CEJ) to the tip of the periodontal probe during normal
probing.”
Chronic Periodontitis forms (1999)
mild, moderate, severe CAL
localized vs generalized?
Mild (Incipient): 1-2 mm CAL (Clinical Attachment Loss)
Moderate: 3-4 mm CAL
Severe: ≥ 5mm CAL
Localized: less than 30% teeth involved
Generalized: more than 30% teeth involved
Aggressive Periodontitis
Not classified as mild/moderate/severe
Assumed all aggressive cases are severe due to the high rate of destruction and/or the young age of onset
Localized: 1st molars and incisors (first to erupt)
Generalized: 1st molars, incisors, and ≥ 3 other
teeth
Periodontal Diseases and Conditions classes (2017)
Periodontal Health, Gingival Diseases and Conditions
Periodontitis
Other Conditions Affecting the Periodontium
Peri-Implant Diseases and Conditions
Peri-Implant Health
Peri-Implant Mucositis
Peri-Implantitis
Peri-Implant Soft and Hard Tissue Deficiencies
Periodontal Health, Gingival Diseases and Conditions
Periodontal Health and Gingival Health
Gingivitis: Dental Biofilm-Induced
Gingivitis Diseases: Non-Dental Biofilm-Induced
types of Periodontitis
Necrotizing Periodontal Diseases
Periodontitis
Periodontitis as a Manifestation of Systemic Disease
Other Conditions Affecting the Periodontium
Systemic Diseases or Conditions Affecting the Periodontium
Periodontal Abscesses and Endodontic-Periodontal Lesions
Mucogingival Deformities and Conditions
Traumatic Occlusal Forces
Tooth and Prosthesis Related Factors
Classification of Periodontitis
use staging and grading
STAGING periodontitis
- Based upon
- Severity of the case
- Complexity of the case
management - Consider
- CAL
- Amount and % of bone loss
- PD
- Presence/extent of ridge
defects - Furcation involvement
- Tooth mobility
- Tooth loss due to periodontitis
grading periodontitis
- Consider biologic features
- Rate of disease progression
- Risk of further advancement
- Potential threats to general
health (eg. smoking, diabetes) - Grade A, B, C
- A: low risk of progression
- B: moderate risk
- C: high risk
periodontitis stages chart
periodontitis grades chart
Peri-Implant Health
absence of inflammation
No BOP
Bone loss ≤ 2mm
Peri-Implant Mucositis
Signs of inflammation
BOP and/or SOP
Increased PD
Bone loss ≤ 2mm
Peri-Implantitis
Signs of inflammation
BOP and/or SOP
Increased PD (≥ 6mm)
Progressive Bone loss ≥ 3mm
New Vocabulary for:
perio biotype
excessive occ force
bio width
chronic/aggressive periodontitis
components of periodontium
Gingiva
PDL
Cementum
Alveolar Process
types of gingiva
- Marginal Gingiva
- Gingival Sulcus
- Attached Gingiva
- Interdental Gingiva
microscopic portions gingiva
- Gingival Epithelium
- Gingival Connective Tissue
Marginal Gingiva
Unattached or free
Sulcus epithelium adjacent to tooth
About 1 mm in depth
Up to 3 mm still considered normal
Free gingival groove
In 50% of cases, marginal gingiva is demarcated from
the attached gingiva by a free gingival groove
Gingival sulcus
Not attached to enamel or cementum
Bounded apically by the free gingival groove (50%
incidence) on the oral epithelium (if present)
If attachment loss occurs a sulcus is referred to as :
periodontal pocket
calculating attatched gingiva
attatched gingiva border
Bordered apically by the mucogingival junction
Bound to underlying periosteum of alveolar bone
attatched gingiva texture
firm, resilient
variable width attatched gingiva
vaires man and max
Interdental Gingiva
It occupies the embrasure
The interproximal space beneath the area of tooth
contact (Col)
Pyramidal or col shaped
Gingival Epithelium
|cellular/acellular? acts as? to protect? allows for?
- Predominately cellular in nature
- As a mechanical/chemical/water/microbial barrier
- To protect the deep structures while allowing for a
selective interchange with the oral environment.
Gingival Connective Tissue
composed of mainly?
AKA? layers?
fibers arranged as?
- Composed primarily of collagen fibers and
ground substances - Also known as “lamina propria”. It consists of
a papillary layer and a reticular layer. - The gingival fibers are arranged in 3 groups
layers of gingival epithelium
ginigval epithelium areas
- Oral Epithelium
- Sulcular epithelium (~1 mm)
- Junctional Epithelium (~ 1mm)
oral epithelium
- Keratinized stratified squamous epithelium
- Turnover of 30 days
- Stratum corneum
- Stratum granulosum
- Stratum spinosum
- Stratum basale
sulcular epthelium
length?
attatched?
histo?
lacks what layers? unique cell found?
- Sulcular epithelium (~1 mm) * Unattached to enamel
- Non-keratinized stratified squamous epithelium
- Lacks stratum corneum and granulosum; Langerhans cells
- Junctional Epithelium
size?
histo?
TO rate?
attachment?
- Junctional Epithelium (~ 1mm)
- Non-keratinized stratified squamous epithelium
- High turnover rate (7-10 days)
- Attachment to the tooth surface via hemidesmosomes and non-collagenous proteins (proteoglycans & glysosaminoglycans)
Sulcular epithelium
Importance
it is a semi-permeable membrane against
bacterial products passing into underlying tissue
Development of Gingival Sulcus
Gingival Connective
Tissue composition
- 60% collagen fibers, 5% fibroblasts, 35% matrix, vessels and nerves.
- The gingival fibers are oriented with functions
orientation of gingival fibers purposes
- To brace the marginal gingiva against tooth
- To provide rigidity,
- To unite the marginal gingiva with the cementum and adjacent attached gingiva
gingival fiber groups
what contributes to bio width
Fibers that are in close proximity to the alveolar crest contribute to the connective tissue attachment component of the
“Biologic Width”.
bio width
2.04 mm total
0.97mm junctional epithelium
1.07mm connective tissue attachment
bio width AKA
Supracrestal Tissue Attachment
GCF
can be? main route? can serve as?
Can be represented as either a transudate (healthy) or an exudate (inflamed) from the gingival connective tissue and blood vessels.
* The main route: basement membrane -> JE intercellular space-> sulcus
* The biochemical factors (cytokines, enzymes, antibodies, etc.) in the GCF could potentially serve as diagnostic or prognostic biomarkers.
GCF functions
- Improve adhesion of the epithelium to the tooth through plasma proteins
- Possesses antimicrobial properties
cleanse sulcus
Stippling of attatched gingiva
- Represents the microscopic depressions and elevations created by the connective tissue projections within the gingival tissue
- Is a form of adaptive specialization or reinforcement for function
- ~ 40% of population
Mesenchymal-Epithelial
Interaction
The gene of the underlying connective tissue
determines the covering epithelium
PDL
A complex vascular and highly cellular connective tissue that surrounds the tooth root and connecting to the alveolar bone
* Periodontal fibers
* Cellular elements
* Ground substances
PDL Fibers
- Contains Collagen I, III and IV
- Sharpey’s fibers: the terminal portions of the collagen fibers embedded in the root cementum and the bundle bone
PDL fiber groups
- Alveolar crest
- Horizontal
- Oblique
- Apical
- Interradicular
- Alveolar crest PDL group
- Alveolar crest* Cementum → crest alveolar bone
- Prevents extrusion and lateral movements
- Horizontal PDL group
- Horizontal* Cementum → alveolar bone at 90º
- Opposes lateral forces
- Oblique PDL group
- Oblique *Largest group
- Cementum → alveolar bone coronal direction
- Resists vertical masticatory forces
- Apical PDL group
- Apical* Cementum → apical alveolar bone
- Resists tipping
- Interradicular PDL group
- Interradicular* Cementum → furcation bone
- Resist luxation and tipping
PDL Cells
PDL functions
physical, formative/remodeling, nutritional and sensory
PDL Physical functions
* Contains?
* Absorbs? transmits?
* mechanism?
* Maintains?
- Contain blood vessels & nerves
- Absorbs occlusal forces and transmits occlusal force to the bone
- Suspensory mechanism attaching the teeth to the bone
- Maintains gingival tissue in the relationship to the teeth
- PDL Formative and remodeling functions
- Cells could respond to occlusal force and participate in the formation and resorption of cementum/bone/collagens
PDL Nutritional and sensory functions
supplies nutrients to?
transmits what sensations? through what CN?
- Supplies nutrients to cementum/bone/gingiva
- Transmits pressure and pain via trigeminal pathways
PDL Space
normal width? affected by? adaptions?
The normal width of PDL is approximately 0.2 mm
* Occlusal functions can affect PDL space
* Within physiologic limits, PDL accommodates increased force with an increased width, thickened fiber bundles, and
increased numbers of Sharpey’s fibers.
* When the force exceeds the adaptive capacity -> trauma from occlusion.
Cementum
- A specialized mineralized tissue
- Inorganic content (45-50%) is mainly hydroxyapatite, < bone/dentin/enamel
- Organic matrix (50-55%) is mainly composed of type I and type III collagen
cementum contains no/grows by?
- Contains no blood or lymph vessels, no nerves,
and grows by continuing deposition
cementum greatest growth rate/thickest area
- The highest rate of formation is in the apical regions
- The greatest thickness is in apical third and the furcation areas
Forms of Cementum
- Two main types of cementum
- Acellular (primary)* Found in coronal portion of root
- Cellular (secondary)* Found in apical portion of root
sources of cementum collagen fibers
Two major sources of collagen fibers
* Sharpey’s fiber* extrinsic - from fibroblasts
* Fibers that belong to cementum matrix * Intrinsic - from cementoblasts
Functions of Cementum
- Attaches the principal PDL fibers to the root (main function)
- Contributes to the process of repair after damage to the root surfaces
- Adjusts the tooth position to new requirements* It compensates for tooth eruption
- Protects dental pulp/dentin
potentail CEJ forms
Exposed Cementum issues
- Rough surface texture facilitates plaque adherence
- Porosities facilitate attachment of calculus
- Porosities facilitate absorption of bacterial enzymes
(i.e. endotoxin) - Smear layer inhibits attachment of connective tissue
Alveolar Process
- The portion of the maxilla and mandible that forms and supports the tooth sockets.
- A tooth dependent structure: It forms when the tooth erupts and disappears gradually after tooth extraction
- Contains blood or lymph vessels, and attachment of PDL fibers (Sharpey’s fibers)
- Nerves are not in the bone but in the periosteum
- Vascular pathways from gingiva into supporting alveolar bone
alveolar process shape
depends on?
anterior vs posterior?
distance from CEJ in health?
- Depends on interdental distance, tooth contours, root contours
- Anterior: Scalloped
- Posterior: Flattened Scallop
- Distance from CEJ in health
- 1 to 1.5 mm
- 1.5-2 mm in adult (taking into account the biologic width concept)
alveolar process components
- External plate: cortical bone
- Inner socket wall: thin cortical
bone - Alveolar bone proper
- Bundle bone
- Lamina dura:radiographic term
- Spongy bone: cancellous
trabeculae
*Basal bone is located apically but unrelated to the teeth.
Cancellous bone
found predominately in the interdental & interradicular areas (less in facially/lingually)
* In adult humans, more cancellous bone in the maxilla than in the mandible.
* Usually in the mandible, there is thicker cortical bone and less cancellous bone.
cancellous bone vs cortical bone for implants
cortical bone will produce more heat in preparation which can kill osteocytes=failure
F/L cortical plates
- Thin facial and lingual cortical plates overlying root surfaces
- Lack of cancellous bone (so no progenitor cells) overlying many facial root surfaces
fibrosis of marrow spaces in adults
- Increased fibrosis and lipid cell
content in marrow spaces (results
in a decrease in progenitor cells)
in adults > 40 years old
- Dehiscence:
- Dehiscence: lack of bone on
the facial/lingual of the tooth
but with interproximal bone
- Fenestration
- Fenestration: lack of bone
on the facial/lingual of the
tooth resembling a “window”
- Predisposing factors to Dehiscences & Fenestrations
prominent root contours, malposition and roots with labial protrusion in combination of thin bony plate
Periosteum
how can it bind bone?
- The periosteum is a fibrous sheath that lines the outer surface of bone.
- Bundles of periosteal collagen fibers penetrate the bone, binding the periosteum to the bone.
periosteum layers
- Composed of two layers:
Fibrous layer: a dense, fibrous, vascular layer
Osteogenic layer: a loose connective tissue inner layer, containing osteoprogenitor cells.
