Midterm 2 Flashcards
Loe and Silness Plaque Index
-assesses the amount of plaque at the gingival margin, examining the same anatomical units as the GI
-Plaque score range from {0} to {3}
-A probe is used to distinguish between scores {0} and {1}. Visible plaque is scored a {2} or {3}
-The Pl-I is computed for a tooth (4 surfaces), subject, or population
-It parallels the Gingival Index (GI) of Loe & Stilness
-First published by Silness & Loe
Problem with PI: very subjective, need a lot of training
Silness and Loe Gingival Index
- The severity of inflammation is assessed in 4 distinct gingival areas: distofacial papilla, facial margin, mesiofacial papilla, lingual gingival margin.
- Scores: 0 to 3; BLEEDING is considered. Presence of bleeding automatically leads to a score >=2
- Useful for the calculation of prevalence and severity in population and individual
- Score for tooth –> subject –> population
- frequently used index in clinical trials
- First published by Loe and Loe & Silness
increase PI, increase GI
If you have high GI but low PI – systemic issues?
PSR
- Purpose: periodontal screening and recording is a rapid and effective way to screen patients for periodontal diseases and summarizes necessary information with minimum documentation
- Endorsement: the ADA and the AAP support the use of PSR by dentists as a part of oral examinations
PSR Codes
0 - colored area visible, no calculus or defective margins, no BOP
1 - colored area visible, no calc/defective margins, + BOP
2 - colored area visible, + calc/defective margins, +/- BOP
3 - colored area partially visible, +/- calc/defective margins, +/- BOP
4 - colored area not visible, +/- Calc/defective margins, +/- BOP
PSR Benefits
- Early Detection: PSR includes evaluation of all sites. For this reason, it is highly sensitive technique for detecting deviations from periodontal health and a uniquely appropriate screening tool for periodontal diseases that are, by nature, site specific and episodic
- Speed: once learned, PSR takes only a few minutes to conduct for each patient
- Simplicity: PSR is easy to administer and comprehend. The simplicity of the scoring system aids in monitoring a patient’s periodontal status
- Cost-effectiveness: PSR utilizes a simple periodontal probe designed specifically for use with this screening system. It does not require the use of expensive equipment.
- Recording Ease: Documentation for PSR requires the recording of six numerical scores, one for each sextant of the mouth. It does not require extensive charting or lengthy narrative explanation
- Risk Management: Proper, consistent, and documented use of PSR shows that the dentist is evaluation a patient’s periodontal status
PSR Limitations
- PSR is a screening system designed to DETECT periodontal disease. It is not intended to replace comprehensive periodontal examination when indicated.
- Patients who have been treated for periodontal diseases and are in a maintenance phase of therapy required periodic COMPREHENSIVE periodontal examinations
- in addition, PSR is designed primarily for use with ADULT patients and has limited utility in screening children and adolescents
Papilla Marginal Attached Index (PMA)
- Background: “The number of units affected correlates with the severity of gingival inflammation”
- – not talking about bleeding or redness
- Facial gingival surface is divided in 3 scoring units P - M - A
- Gingival units affected with gingivitis are counted. Presence or absence of inflammation is counted as {1} and {0}, respectively
- Severity component can be considered
- Score computed for tooth –> subject –> population
- First published by Schour & Massler
incisors, canines, and premolars
NIDR Calculus Index
0 - calculus is absent
1 - supragingival calculus, but no subgingival calculus is present
2 - supragingival and subgingival, or subgingival calculus only is present
O’Leary Index
Percentage of tooth surfaces positive for plaque
- what we use in clinic
- disclose, rinse, then count red surfaces
Gingival Index Scores
[0=normal
1=mild inflam, slight color change, no bleeding, edema
2=BOP, moderate inflam, redness, edema 3=severe inflam, marked redness & edema, ulceration, spontaneous bleeding]
Plaque Index Scores
0 - No plaque
1 - a film of plaque adhering to the free gingival margin and adjacent area of the tooth. The plaque may be seen only by using the probe on the tooth surface
2 - moderate accumulation of soft deposits within the gingival pocket, or the tooth and gingival margin which can be seen with the naked eye
3 - abundance of soft matter within the gingival pocket and/or on the tooth and gingival margin
Reliability
an index to measure a condition in the same subject repeatedly and obtain the same score results each time
Validity
sensitivity and specificity of various diagnostic tools used to create an index
sensitivity
the probability that a test result will be positive when the test is administered to people who actually have the disease in question
- Pr(T+/D+) :: (+) –> (+)
specificity
the probability that a test will be negative when administered to people who are free of the disease in question
ex. no bleeding = healthy
exception = smokers – dont bleed as much
Specificity: Pr(T-/D-)
(-) —> (-)
Positive Predictive Value
the probability of disease in a subject with a positive test result
PVP =Pr(D+/T+)
Predictive Value Negative
The probability of not having the disease when the test is negative
PNV= Pr(D-/T-)
Gingival lesions of viral origin
- herpes simplex viruses type 1 and 2
- varicella-zoster virus
Herpes simplex 1 usually causes oral manifestation – main group
primary herpetic gingivostomatitis
through oral mucosal epithelium, virus penetrates a neural ending and travels to the trigeminal ganglion (comes back in stress/sickness/etc)
symptoms of primary herpetic gingivostomatitis
- painful severe gingivitis with redness
- ulcerations with SEROFIBRINOUS EXUDATE
- edema accompanied by STOMATITIS
Characteristics of primary herpetic gingivostomatitis
- incubation period is one week
- formation of vesicles, which rupture, coalesce and leave fibrin-coated ulcers
- healing within 10-14 days
areas where herpes virus can be found
gingivitis, necrotizing ulcerative diseases (NUG/NUP) and periodontitis
more primary infections occur at older ages in industrialized society
recurrent intraoral herpes infection
in 20-40% of individuals with primary infection
-vesicles will rupture and expose tissue
herpes labialis - recurrent HSV
-more than once a year
-recurrent herpes infection
-vermillion border and or the skin adjacent to it
-20-40% of individuals with primary infection
-trauma, UV light exposure, fever, menstruation (immune system down)
DIAGNOSIS:
intra oral lesions generally considered/mistaken for an APHTOUS ulceration (restricted to mouth)
differential diagnosis: aphthous ulcers do not affect keratinized mucosa
-ulcers in attached gingiva and hard palate
Gingival lesions of viral origin
- lifethreatening in immunocompromised patients
- if sampling is needed, aspiration from vesicle is the best way!!
- hand instruments, not cavitron because want to protect against exposure
- blood samples to determine increase Ab titer against virus [works better for primary infection]
- histopathology is not specific
treatment of gingival lesions of viral origin
-careful plaque removal to limit bacterial superinfection of the ulcerations
[have to prevent infection to yourself]
-systemic uptake of an antiviral medication such as aciclovir
— in immunocompromised patients
herpes zoster
-gingival lesion of viral origin
-virocella-zoster virus causes varicella (chicken pox) [in later life = shingles]
-small ulcers usually on the tongue, palatal and gingiva
-latent in the DORSAL ROOT GANGLION
-skin lesions may be associated with intraoral lesions, or intraoral lesions may occur alone
-2nd and 3rd branch of the trigeminal ganglion
DIAGNOSIS: unilateral lesions associated with severe pain and paresthesia**
treatment of herpes zoster
soft diet, rest, atraumatic removal of plaque, and diluted chlorhexidine rinses
-this may be supplemented with antiviral drug therapy
Candidiasis
- gingival lesion of fungal origin
- candida species isolated from the mouth: C. albicans**, C. glabrata, C. krusei, C. tropicalis, C. parapsilosis, C. guilermondii
Oral carriage of C.albicans in healthy adults: 3-48%
- reduced host defense {immunosuppressed individuals, infant and adult who has been on Ab treatment for some time}
- C. albicans is frequently isolated from the SUBGINGIVAL flora of patients with severe periodontitis
Symptoms of Candidosis
Painless or slightly sensitive (burning)
- red and white lesions
- lesions can be scraped or separated from mucosa (culture or use color agent to test fungus)
patient susceptible to candidosis
- cancer patients receiving high dose radiation or chemotherapy –IMMUNOSUPPRESION
- patients who are using several different ANTIBIOTICS over a period of several weeks or months - lose regular oral flora
- DIABETESpatients
- MALNUTRITION
- HIV
- women who develop vaginal candidiasis
- pregnancy and use of contraceptives
Diagnosis of Candidosis
- a culture on nickersons medium at room temp (very old dentures = risk factor)
- MICROSCOPIC EXAMINATION of a smear of the material scraped from the lesion and stained
- culture can be misleading
treatment of candidosis
-use of the antimycotic/antifungal agents
[ex: nystatin given as a mouthrinse or systemically]
-flucanazole, nystatin, amphotericin B (IV)
clinical characteristics of candidosis
most clinical characteristic of gingival candidal infections is redness of the attached gingiva, often associated with granular surface
different types or oral mucosal manifestations of candidosis
- pseudomembranous (Whitish patches that can be wiped off)
- erythematous (red, associated with pain)
- plaque type (whitish plaque that cannot be removed; need to differentiate from oral leukoplakia)
- nodular (slightly elevated nodules of white or reddish color)
gingival lesions of systemic origin
Allergic and Traumatic reactions
allergic reactions
type I (immediate type) - mediated by IgE Type IV (delayed type) - mediated by T cells [12-48 hours following contact with allergen]
allergies to:
-dental restorative materials (type IV, contact allergy)
[mercury, nickel, gold, zinc, chromium, palladium, acrylics and others]
-oral hygiene products, chewing gum and food
[generally flavor additives or preservatives]
a diffuse fiery red edematous gingivitis sometimes with ulcerations or whitening
traumatic lesion
chemical
physical
thermal
chemical traumatic lesions
- surface etching by various chemical products with toxic properties
- ex. chlorhexidine-induced mucosal desquamation (sloughing with CT exposed), acetylsalicyclic acid burn, cocaine burn, alcohol content
incorrect use of caustics by the dentist
physical traumatic lesions
- hyperkeratosis, a white leukoplakia-like, frictional keratosis
- gingival laceration resulting in gingival recession
- traumatic ulcerative gingival lesion (brushing and flossing technique)
thermal injury
- minor burns from hot beverages
- mostly seen on palatal and labial mucosa
- painful, erythematous lesions
- vesicles may develop
foreign body reactions
- epithelial ulceration that allows entry of foreign material into gingival connective tissue
- foreign body can be generally detected via X-rays
- ex. amalgam tattoo, abrasives, toothpick etc.
Mucocutaneous disorders
- lichen planus
- pemphigoid
- pemphigus vulgaris
- lupus erthematosus
Lichen Planus
-oral involvement alone is common
- can be seen as skin lesion also
-premalignant potential (0.5-2%)
-characteristic skin lesions (wickham striae)
-various clinical appearances [papular, reticular, plaque-like = generally asymptomatic
atrophic, ulcerative, bullous = generally symptomatic]
-any area of the oral mucosa
histopathology of lichen planus
- subepithelial band like accumulation of lymphocytes and macrophages characteristic of a type IV hypersensitivity reaction
- fibrin in the basement membrane (Ag-Ab response)
- deposits IgM, C3, C4 and C5
Oral Lichenoid Lesions
-an uncertain background
examples: lesions in contact with dental restorations
- lesions associated with various types of medications (NSAIDs, diuretics, beta blockers)
- a group of systemic disorders (liver disease)
treatment of lichen planus
- take biopsy (handling is different than regular biopsy)
- take sample for culture if questioning candida inf. (~ 38% of OLP causes have secondary inf)
- a traumatic dental plaque control
- topical corticosteroids to control pain, discomfort
pemphigoid
-a group of disorders in which autoantibodies towards components of the basement membrane result in DETACHMENT OF THE EPITHELIUM FROM THE CT
(a little more severe than lichen planus)
histopathology of pemphigoid
- autoantibody reactions against hemidesmosomes and lamina lucida components
- have sloughing of epithelium
- complement mediated cell destructive processes may be involved in the pathogenesis
- deposits C3, IgG and other Igs
Three types of pemphigoid
- bullous
- benign mucous membrane
- cicatrical (specific with eye and oral cavity – scar formation in eye leading to blindness)
-female predominance > 50 years old
Nicholsky sign
associated with pemphigoid
-rubbing of the gingiva creates bulla formation
treatment of pemphigoid
plaque removal with daily use of chlorhexidine and/or topical corticosteroid
pemphigus vulgaris
- formation of intraepithelial bullae in skin and mucous membranes
- strong genetic background (jewish and mediterranean)
- painful desquamative lesions, erosions or ulcerations
- chronic course with recurrent bulla formation
- typically in middle age or elderly
histology of pemphigus
ACANTHOLYSIS
- due to destruction of desmosomes
- pericellular epithelial deposits of IgG and C3
- circulating autoantibodies against interepithelial adhesion molecules = more severe form
kumars slide:
canthus layer - another name for stratum spinosum
why? because it has intercellular bridges or ‘canthae’
-acantholysis - breakdown of the spinous bridges
Lupus Erythematosus
autoimmune CT disorders in which autoAbs form to various CELLULAR constituents
-central atrophic area with SMALL WHITE DOTS surrounded by irradiating fine WHITE STRIAE with a periphery of TELANGIECTASIA (vascular lesion formed by dilation of a group of small blood vessels – blanching)
- lesions can be ulcerated and cannot be differentiated from leukoplakia or atrophic oral lichen planus
- Together with characteristic skin lesions (BUTTERFLY)
histology of lupus erythematosus
- degeneration of basal cells and increased width of the basement membrane
- deposits of Igs, C3 and fibrin along the basement membrane
2 forms of lupus erythematosus
discoid forms - mild chronic which affects skin and mucous membrane
systemic forms of the disease (can be fatal)
-4% turn systemically
Necrotizing Ulcerative Gingivitis (NUG)
NUG = bacterial origin
- adolescents or young adults, smokers and individuals often with psychological stress
- PAIN, ulceration and necrosis of the INTERDENTAL PAPILLAE (very specific), bleeding
- yellowish white plaque
duration: 1-2 days if treated
not contagious
- differential diagnosis with primary herpetic gingivostomatitis
- resolution of the disease is often required systemic Abs
predisposing factors of NUG
- systemic diseases like ulcerative colitis, blood dyscrasias and nutritional deficiency states
- abnormalities of white blood cell function
- patients suffering from AIDS
- associated with periodontal attachment loss
- may progress to Noma or cancrum oris
Treatment of NUG
- OHI
- mechanical debridement
- systemic Ab therapy
- surgical correction of gingival destruction
Reactive processes of periodontal soft tissue
- fibroma/fibrous hyperplasia
- pyogenic granuloma
- peripheral giant cell granuloma
reactive processes of periodontal hard tissue
-periapical cemental dysplasia
benign neoplasms of periodontal soft tissue
papillomas
malignant neoplasms of periodontal hard tissue
osteosarcoma
fibroma/fibrous hyperplasia
- reactive processes of periodontal soft tissues
- a focal fibrous hyperplasia causes by irritation
- sessile, well-circumscribed smooth-surfaced nodules
- cell poor, hyperplastic collagenous tissue
- may show hyperkeratinization
- very thick, fibrous tissue - VERY elastic = hard to cut
differential diagnosis of fibroma/fibrous hyperplasia
giant cell fibroma