Intro to perio Flashcards
What year are the new periodontal classifications from?
2017
What are the two states in healthy periodontium?
Intact periodontium
Reduced periodontium
What are the types of reduced periodontium?
- Reduced periodontium in a non-periodontitis patient
- Reduced periodontium in a successfully treated stable periodontitis patient
What is a reduced periodontium in a non-periodontitis patient?
- Clinical signs of periodontal health on a periodontium with pre-existing loss of connective tissue and/or loss of bone due to non-periodontitis (e.g. traumatic toothbrushing or crown lengthening)
What is reduced periodontium in a successfully treated periodontitis patient?
- Clinical signs of periodontal health on a periodontium with pre-existing loss of connective tissue and alveolar bone due to periodontitis, but had been successfully treated and is currently stable
Define periodontal health
- State free from inflammatory periodontal disease that allows an individual to function normally and avoid consequences due to current or past disease.
What are the clinical features of gingival health?
Absence of BOP (<10% of sites), erythema, edema and patient symptoms
What are the clinical INDICIES for gingivitis
> 10% bleeding sites
Probing depths <3mm
What are the two main categories of gingivitis
- Dental plaque biofilm induced gingivitis
- Non-dental plaque biofilm induced gingivitis
What is plaque biofilm induced gingivitis
An inflammatory lesion resulting from interactions between dental plaque biofilm and the hosts immune-inflammatory response
What is the treatment for plaque biofilm induced gingivitis
Removal of plaque
What are the local plaque retentive factors resulting in gingivitis?
- Overhangs
- Subgingival margins
- Surface irregularities
- Caries
- Intraoral appliance (ortho or dentures/clasps)
- Crowding
- Erupting teeth
- Calculus
How do systemic factors increase the risk of periodontal disease?
They alter the immune response, resulting in an exaggerated inflammatory response to plaque
List the main systemic risk factors for periodontal disease?
- Smoking
- Diabetes
- Drugs
- Vitamin C deficiency
What are the clinical signs of inflammation?
- Erythema, edema, pain, heat and loss of function
How do the clinical signs of inflammation manifest in gingivitis?
- Swelling (loss of knife edge appearance)
- BOP
- Redness
- Discomfort (brushing or probing)
List symptoms of gingivitis
- Bleeding gums
- Metallic taste
- Soreness
- Halitosis
- Difficulty eating
- Aesthetics
What are non-dental plaque biofilm induced gingival conditions?
Gingival abnormalities that are not caused by plaque and do not resolve following plaque removal, but likely a gingival manifestation of a systemic condition
List some causes of non-dental plaque biofilm induced gingivitis
- Genetics - hereditary gingival fibromatosis
- Infections - gonorrhea, tuberculosis, herpes
- Inflammatory - contact allaery, plasma cell gingivitis
- Pemphigus vulgaris, pemphigoid, LP, LE, crohns
- Vitamin C deficiency
- Neoplasms
What is the main marker for progression from gingivitis to periodontitis?
- Pathological apical migration of the junctional epithelium (indicates destruction of alveolar bone)
What are the signs of periodontitis?
- Continued inflammation (gingivitis signs BUT pockets >4mm are true and irreversible)
- CAL
- Migration of JE
- Destruction of bone and PDL
Staging criteria for periodontitis
Stage I = <15% or 1-2mm CAL
Stage II - 16-33% or 3-4mm CAL
Stage III - 34-66% or middle/apical third of root
Stage IV - >66% or middle/apical third of root
What does the staging and grading tell us about periodontits?
Stage - the severity
Grade - rate of progression
How to calculate the grade of periodontitis
Bone loss / age
What are the grades for periodontitis
Grade A - <0.5% bone loss/age or no evidence of bone loss over 5 years
Grade B - 0.5-1% bone loss/age or <2mm over 5 years
Grade C - >1% bone loss/age or >2mm over 5 years
What is the criteria for the extent and distribution of periodontitis
Localised - <30%
Generalise - >30%
Molar-incisor pattern
List the radiographic features of healthy bone levels
- At the CEJ (can be higher or lower with physiological bone loss)
- Good quality bone and stable lamina dura
- Crestal bone 2-3mm from CEJ
- Bone in the furcations
What is periodontal stability?
Successful treatment of local/systemic risk factors resulting in minimal bop (<10%), stable probing depths and lack of further periodontal destruction
What is the main indicator for periodontal stability?
Absence of inflammation/BOP
What makes up the periodontium?
Gingiva (free and attached) Alveolar mucosa Cementum Periodontal ligament Alveolar bone
What is the junctional epithelium?
Epithelial attachment between the connective tissue and tooth surface
Where is the junctional epithelium located?
Below the gingival sulcus (sucular epitheium)
How is JE attached to the enamel?
Via a basal lamina and intercellular hemidesmosome
What is the turnover of the JE?
4-6 days - this is rapid in comparison to the oral epithelium (6-12 days)
Difference between oral epithelium and JE/SE?
Oral epithelium is keratinised (resist mechanical forces)
JE and SE are non-keratinised
What is the periodontal ligament?
A group of specialised connective tissue fibres, which connects the tooth to the alveolar bone
What are the components of the pdl
Principal fibres Loose connective tissue Blasts and blast cells Oxytalan fibres Cell rests of Malassez
What are the three categories of principal fibres?
Dentoalveolar (around roots) Gingival fibres (around cervical portion of the tooth)
List the gingival principal fibres
Transseptal
Attached gingival
Free gingival
Circular
What are the roles of the gingival fibres?
Transseptal - resist tooth separation mesial and distally
The rest - resist gingival displacement
List the dentoalveolar principal fibres
Apical Oblique Horizontal Alveolar crest Interradicular
What are the two components of the alveolar bone?
- Alveolar process
- Alveolar bone proper
What is the role of the alveolar process
Provide structural support to the teeth
What is the role of the alveolar bone proper
Provide an attachment site for the PDL and the tooth
Where is the alveolar bone proper?
In the portion of bone lining the tooth socket
What are the histological lesions of periodontal disease?
Initial lesion
Early lesion
Established lesion
Advanced lesion
What occurs in the initial lesion?
- Vasodilation results in neutrophil migration, IGG, complement and fibrin
- Increase in permeability (increased GCF)
- Localised to gingival sulcus
What occurs in the early lesion?
- Localised epithelial proliferation of JE and SE
- Further vascular changes occur with increased GCF - Neutrophils dominate but there is local accumulation of lymphocytes (T cells)
What are the signs of epithelial proliferation in the early lesion?
- Rete peg hyperplasia
- Microulceration of the sucular epithelium (why it bleeds on probing)
What occurs in the established lesion?
- Further proliferation of JE and SE with some loss of collagen (no attachment loss)
- T cells dominate and plasma cells are found (mainly IgG and IgA)
- Maximum GCF
- Neutrophils persist
What occurs in the advanced lesion?
- Pocket formation, LOA, collagen and bone loss
- IgG, IgA and IgM present
- Dense infiltrate of lymphocytes, plasma cells and macrophages
- Bystander damage
- Neutrophils persist
What is bystander damae?
Breakdown of the epithelial barrier (pocket lining) allowing antigens direct access to periodontal tissues to activate immune cells
What is the key point of chronic inflammation?
There is persistent inflammation with attempts of repair
What are the roles of the B cells in periodontitis?
- Differentiate into plasma cells to form antibodies (neutralise, aggregate and opsonisation)
What are the roles of T cells in periodontitis?
- CD4 secrete cytokines to activate immune cells
What are the main cytokines?
- IL1 (pro-inflammatory)
