PATHOLOGY (1/2/3) Flashcards
Outline the 4 components of diagnosis and managing early carious lesions.
- Impact on health
- Early caries diagnosis
- Early caries management- patient focused
- Early caries management - chair side
Define dental caries
Biofilm-mediated, diet-modulated, multifactorial, non-communicable dynamic disease resulting in net mineral loss of dental hard tissues.
It is determined by biological, psychological and environmental factors. Therefore, a caries lesion develops.
How do caries impact on quality of life?
- Eating
2.Sleeping - School attendance
- Family miss out on working
- Damage to underlying permanent teeth
- Ortho considerations of XLA teeth
What is the leading cause of dental caries in children aged 5-9 in the UK?
Dental caries
Explain the restorative escalator to a patient.
- Caries increases burden on child
- So we try to stop caries before we see it
- This reduces the need for LA
- And reduces the chance of needing a crown/XLA in the future.
What are the patient actions in reducing caries?
- OH
- Diet
- Fluoride
- Other - gum chewing, altered medication
What are the dental team actions in reducing caries?
- Seal lesions
- Infiltrate lesions
- Fill lesions
- Prevention
Why is it hard to control caries in one child in a family?
Families ‘share’ the bacteria so we need to try to change full family habits.
What are the 4 clinical factors influencing caries risk?
- Tooth surfaces (smooth, fissured, inter proximal)
- Enamel quality (normal, hypo mineralised, coated in plaque causes caries to happen quicker)
- Morphology (types of fissures - deep/plaque retentive)
- Caries in other teeth (caries in one surface may cause caries to arise on another surface)
What do teeth need for remineralisation?
Calcium and phosphate
How should we prepare teeth and check for caries?
- Dry clean teeth using reflected light
- Careful probing to feel texture
- Using separators but difficult to get patient back in after 2 days
- Transillumination using LED light
What are the different stages of the ICDAS scoring system?
- Sound
- First visual change in enamel (opacity/white/brown in dry environment)
- Distinct visual change in enamel (white/brown/opaque in wet environment)
- Localised enamel breakdown (surface integrity loss)
- Underlying dentine shadow (grey)
- Distinct cavity with visible dentine
- Extensive cavity with visible dentine.
What other diagnostic tools are used to detect caries? (usually in research than in practice)
- Laser fluorescence (blue light laser-> diagnodent as reading=demineralisation amount -> 25 or more=restore, less=monitor)
- Electrical impedance (probe to detect)
- Caries activity tests (microbiological -measures S.mutans level)
- Detection dyes - not that reliable
Difference in caries progress in permanent and primary teeth?
Progression takes years in permanent teeth but only months in primary teeth.
Serial radiographs are needed to determine activity and progression
What does an active carious lesion look like?
- Rough when end of perio probe ran across it
- Yellow/whiteish surface
- Opaque enamel
- Plaque covered
What does an inactive carious lesion look like?
- Smooth when end of perio probe ran across it
- Surface is white/black/brown
- Enamel is shiny
- No plaque
What is the bitewing frequency for:
1. High risk children and adults
2. Moderate-high risk children and adults
3. Low-risk children with mixed dentition
4. Low risk children and adults (permanent dentition)
- 6 months until no new/active lesions apparent
- 12 months until no new/active lesions apparent
- 12-18 months
- 2 years - consider extending interval if continued evidence of low caries activity
What colour is an arrested lesion and why?
May stain dark brown/black due to picking up protein/metal minerals
Darker=less likely lesion is progressing
What kind of diagnosis informed management do we take for:
- No detectable caries/initial lesion progressing and regressing/clinical lesions
- Caries just into dentine/Dentine lesions-seen radiographically
- Clinical dentine lesions/Pulpal lesions
- Preventative care
- Preventative and some operative care
- Preventative and operative care
Patient caries risk factors?
- Diet - frequency of fermentable carbs
- Fluoride exposure - toothpaste/water
- OH - daily brushing/flossing
- Saliva - flow rate
- Habits - bedtime eating/drinking vessel/habitual eating
- Family caries - shared microbiome and environment
- Health - drugs reducing salivary flow / sugary meds
- Dental attendance - dentistry accessibility to monitor any lesions
Clinical caries risk factors?
- Type of surface - smooth surface/inter-proximal
- Enamel quality - normal or hypo-mineralised
- Morphology and type of fissures
- Caries in adjacent teeth
- Presence of plaque and composition
Indirect factors affecting caries?
- Environmental
- Socioeconomic factors
- Health
- Water fluoridation
Diet advice points
- Analyse diet diary at least 24 hours
- Explain how caries occur- use Stephan curve if possible
- Carb consumption frequency
- Avoid eating within 1hr before sleeping : golden hour
- 3 meals/ 2 snacks - 2hr gap between food and discuss eat well plate
- Foods with protective factors (diary)
- Xylitol gum
Important points to remember for infancy and preschool
- Establishing biofilm and influencing biofilm - sugar frequency
- Establish habits: sugar frequency/Dummy with honey or sugar/ cleaning asap/soft toothbrush/ dental check up by 1
How to assess OH
- Disclose tooth- where is the plaque?
- Is plaque associated with demineralisation
- When and how often are the teeth being brushed and who is helping?
- What type of brush is being used?
- Is floss being used?
OHI for children
- Brush as soon as teeth erupt
- Identify plaque with disclosing
- Brush 2x/day with fluoride toothpaste for 2 mins
- advise on brush - electric is better for reduced dexterity
- Teach parents how to floss kids teeth
- Parents should help brush until 7 years old / old enough to write name/ tie shoelaces.
Why is fluoride important in dentistry?
- Fluoride slows down demineralisation and enhances mineralisation
- Fluoride interferes with bacterial metabolism
- Fluoride is incorporated into developing enamel and strengthens it
- Ideally we want fluoride in saliva and at enamel surface, but in reality we want a low level of fluoride constantly in the mouth
Give fluoride toothpaste advice?
- Children up to 3yrs : at least 1000ppm toothpaste
- Children 3-6yrs (or high risk children) : 1350-1500ppm toothpaste
Advise pea sized amount, avoid swallowing and advise parent brushing
If considering extra fluoride:
1. Age 10 and over: 2800ppm fluoride toothpaste
2. Age 16 and over: 5000 ppm fluoride toothpaste
3. Age 8+: 0.05% NaF mouthwash
What is the use of fluoride varnish?
- 22600 ppm
- Duraphat: licensed for caries prevention
3.Colophony-free so good for those allergic
What fluoride product is used for desensitisation?
Sliver Diamine Fluoride
- colourless liquid
-silver = antibacterial
-44800ppm
When should we use fissure sealant?
Use in high risk areas
-If hypominersalised erupted tooth, better to use GIC fissure sealant because placing etch will cause sensitivity.
-Take radiographs if dark fissures in case of caries.
-Must maintain FS regularly - if broken, collects plaque=caries.
Compare and contrast resin sealants VS GIC sealants.
Resin Sealant:
1. Good caries reduction when sealant maintained
2. Around 75-80% retention two years later
3. Risk of fracture/leaks when resin wears
4. Must be fully erupted tooth and high cooperation from child
GIC sealants:
1. Caries reduction when sealants are partially lost
2. Around 40-60% retention at 2 years
3. Good for partially erupted teeth
4. Fluoride release
What is smooth surface sealing?
- Some lesions easily sealed by blocking with resin (better than cutting a tooth)
- Can use ortho separators interproximally and seal
-Helps in high risk teens with enamel lesions/erosion
-Good for children if good cooperation
-There is also whole tooth sealing=protecting whole tooth
-If tooth breaking down, could place SSC crown over
- Lots of options: restoration margin sealing, cavity sealing, hall technique.
What are the SDSEP guidelines for early interproximal and smooth surface caries?
- Teeth with white spot lesions/enamel lesions on radiographs
- Anteriors with white spots
- May need separators 5 days before
- Site specific prevention
- Smooth surface sealant or infiltration
- Monitor
What are the SDSEP guidelines for early occlusal caries?
- Non-cavitation, white spot, no dentine is visible
- Caries may be in outer dentine 1/3
- Fissure seal- Resin if cooperative, GIC if not
- Careful monitoring- probing and radiographs
- Site specific prevention
- Consider Hall technique for primary molars
What is the significance of probiotics in caries?
- Naturally occurring bacteria that can alter the oral flora
- We can genetically engineer strains
eg. Lactobacilli - reduce S mutans - Not long term solution- need topping up
- Local and systemic factors include:
-Coaggregation and growth inhibition
-Bacteriocin and H202 production
-Competitive exclusion
-Immunomodulation - Delivered in milk, cheese, yogurt, tablets, lozenges, drops, powder
What is the significance of xylitol?
- Acidogenic bacteria cannot use them
- Causes diuresis (more peeing lol)
- Lots of preventative actions and has microbiological shift with regular use
- Infants with parents who chew xylitol gum have less caries.
What is the significance of casein phosphopeptide - amorphous calcium phosphate / MI paste/ tooth mousse?
- AKA tooth mousse or MI paste
- Supersaturation of calcium and phosphate ions at tooth surface in slow release form
- Neutralises acids, reduce enamel demineralisation, enhances remineralisation
-Synergistic with fluoride
-Good for low salivary flow patients. - Can get a formula with fluoride (MI paste) in UK - 900ppm F-
Summary Q- What are the key aspects of management of early caries?
- Accurate diagnosis
- OH, fluoride, floss!
- Professional fluoride
- Diet advice
- Sealing and other new materials
- Patient and family motivation
- Regular monitoring
- Filling lesions are the LAST RESORT
What are the 3 forms of Periodontitis according to the 2017 classification?
- Necrotizing Periodontal Diseases
- Periodontitis as Manifestation of Systemic Diseases
- Periodontitis (Stage/Grade)
Periodontitis stage is based on what?
Severity and Complexity of Management
Periodontitis Grade is based on what?
Disease progression
(Evidence or risk of rapid progression, anticipated treatment response)
Stage 1 Periodontitis means…..
<15% (or <2mm attachment loss from CEJ) interprox bone loss Early/Mild Periodontitis
Stage 2 Periodontitis means….
Coronal third of root interprox bone loss Moderate Periodontitis
Stage 3 Periodontitis means….
Mid third of root interprox bone loss Severe Periodontitis with potential for additional tooth loss
Stage 4 Periodontitis means….
Apical third of root interprox bone loss Severe Periodontitis with potential for loss of dentition
Grade A means….
Slow rate of progression
Grade B means…
Moderate rate of progression
Grade C means….
Rapid rate of progression
Periodontal health and gingival health includes what type of periodontium according to the classification?
Clinical gingival health on an Intact periodontium
Clinical gingival health on a Reduced periodontium
• Non periodontitis patient
• Periodontitis patient
Gingivitis- dental biofilm induced includes what categories according to the classification?
a) Associated with dental biofilm alone
b)Mediated by systemic or local risk factors
c)Drug-influenced gingival enlargement
Gingival diseases- non dental biofilm induced includes what categories according to the classification?
a)Genetic/developmental disorders
b)Specific Infections
c) Inflammatory and immune conditions
d) Reactive processes
e)Neoplasms
f)Endocrine, nutritional and
metabolic diseases
g)Traumatic lesions
h)Gingival pigmentation
What is the measurement of normal sulcus depth?
2mm
(between 1-3mm)
What is a false pocket?
deeper pocket + no attachment loss
Give some examples of local contributing factors of Gingivitis that is dental biofilm induced?
lack of saliva
tooth anatomic factors
dental restorations/appliances
NOTE: can occur on a periodontium with no attachment loss or on a periodontium with
attachment loss that is not progressing
Name 4 local risk factors of Gingivitis
High frenal attachments
Fixed orthodontic appliance
Incompetent lips, mouth breather, lack of saliva
Amelogenesis imperfecta- calculus
What are the systemic risk factors for Gingivitis dental biofilm induced?
◼ Smoking
◼ Metabolic factors (hyperglycaemia)
◼ Nutritional (Vitamin C)
◼ Pharmacological
◼ Sex hormones (puberty, pregnancy)
◼ Haematological conditions
In what trimester is the effects of plaque on gingiva exacerbated by progesterone?
Second and third trimester
For drug-influenced gingival enlargement as part of dental plaque induced gingival diseases, what is Phenytoin used for?
Phenytoin for epilepsy.
For drug-influenced gingival enlargement as part of dental plaque induced gingival diseases, what is Ciclosporin used for?
immunosuppressant for prevention of
organ rejection after transplants
Calcium channel blockers eg amlodipine,
nifedipine, diltiazem for heart problems (high blood
pressure, angina prophylaxis) are all in which category of the classification?
Dental Plaque induced Gingival diseases – Drug-influenced gingival enlargement
herpetic gingivostomatitis is gingivitis of which origin? and clinically what can you see?
viral origin
swollen lymph node
viral vesicles on gingiva (red, swollen)
Name some examples of viral gingival diseases non-dental biofilm induced…
Molluscum contagiosum, pox virus
Chicken pox, Varicella zoster
Viral ‘wart’ from child’s finger
Herpangina, Coxsackie virus
Name 2 examples of fungal gingival diseases non-dental biofilm induced…
Histoplasmosis
Linear gingival erythema
Gingival inflammation represents what….
Precursor of periodontitis AND
Clinically relevant risk factor for disease
progression and tooth loss
What is a prognostic indicator of tooth longevity?
Clinically healthy gingiva
Systemic diseases or conditions affecting the
periodontal supporting tissues is divided into 3 groups, name these 3 groups.
- Systemic disorders that have a major
impact on loss of periodontal tissue by
influencing periodontal inflammation - Other systemic disorders that influence the
pathogenesis of periodontal disease - Systemic disorders that can result in loss of
periodontal tissue independent of periodontitis:
neoplasms and other rare conditions
Name some diseases associated with immunologic disorders.
Downs syndrome
Leukocyte adhesion deficiency syndrome
Papillon-Lefevre syndrome
Chediak-Higashi syndrome
Severe neutropenia
Congenital neutropenia
Cyclic neutropenia
Trisomy chromosome 21 is what syndrome?
Down Syndrome
Down syndrome pts can have destructive periodontitis where primary and permanent dentitions are affected, what 2 possible clinical things can you also see?
Tendency for shortened roots
Early tooth loss possible
Papillon-Lefèvre Syndrome affects loss of function mutations in what gene?
Cathepsin C gene
What treatments may be provided for pt with Papillon-Lefèvre Syndrome with poor success rate?
Extract primary teeth before permanent teeth erupt
Antibiotic combinations (amoxycillin/clavulanic acid or metronidazole)
Give 2 examples of Periodontitis as manifestation of systemic disease
◼Hypophosphatasia - childhood
◼Ehlers-Danlos syndrome
Ehlers-Danlos syndrome Type IV & VIII associated with generalised
aggressive periodontitis can show what 3 clinical symptoms?
Skin hyperextensibility
Extensive joint mobility
Excess bruising due to fragile blood vessels
Necrotising gingivitis &
periodontitis can show what clinical signs….
Painful, bleeding gingivae,
punched out papillae
True/False:
Periodontal abscess can occur in a non-periodontitis patient
True
What are the causes of periodontal abscess in a non-periodontitis patient?
orthodontic factors, impaction,
harmful habit (e.g. nail biting, clenching)
What is recession?
Apical migration gingival tissues
(Recession) Apical migration gingival tissues With normal sulci, relates to what?
Anatomy (fenestration, dehiscence)
Tooth position
Orthodontic tooth movement
Trauma eg toothbrushing, habit
Plaque retention factors
(Recession) Apical migration gingival tissues With pockets, relates to what?
Periodontal disease
Smoking
If a pt has recession and a sugary diet, what are they prone to?
root caries
During Simplified BPE, which index teeth are used?
UR6, UR1, UL6
LR6, LL1, LL6
Ages 7-11yrs (mixed dentition stage) what BPE codes do you use?
BPE codes 0,1,2
Ages 12+ years
(permanent teeth erupted)
Full range BPE codes
0,1,2,3,4,*
What do the BPE codes mean in the simplified BPE?
0— Healthy
1—Bleeding after gentle
probing
2—Calculus or plaque
retention factor
3— Shallow pocket 4mm or
5mm
4— Deep pocket 6mm or
more
* — Furcation
Using the WHO probe what does the black band look like for:
Codes 0,1,2
Code 3
Code 4
Codes 0,1,2= Black band visible
Code 3= Black band
partially visible
Code 4 = Black band
disappears within pocket
What occurs in Initial Therapy for young patient?
Oral hygiene instruction
Toothbrush, interdental aids
Dentifrice, mouthrinse
Smoking cessation
Professional cleaning; remove overhangs
Extract teeth with hopeless prognosis; other dental work
Monitor response to initial therapy
What occurs in Corrective Therapy for young patient?
More non-surgical periodontal therapy
Periodontal surgery
Adjunctive antibiotics
Restorative work
Orthodontics
Restore function/ aesthetics
What occurs in Supportive Therapy for young patient?
Recall at interval appropriate to diagnosis
Monitor periodontal status
Re-motivate/re-educate child and parent
Repeat oral hygiene instruction
Re-treat disease
Monitor …..further recall
What type of radiographs are most common views in children and adolescents?
Bitewings or panoramic
What radiographic findings should you record?
Bone levels, type of bone loss, calculus, furcations, apical
pathology, caries, deficient or overhanging margins, widened pdl space
When should you perform Simplified BPE?
New child or adolescent patients;
Prior to
orthodontic or extensive restorative care
What should you do if
BPE = 0?
Screen again at routine recall or within 1 year, whichever sooner
Appropriate preventive care.
What should you do if
BPE = 1 or 2?
treat & screen again at routine recall or 6 m, whichever sooner.
BPE Code 1= Chart gingival bleeding. Disclose and chart plaque. Oral
hygiene instruction. Prophylaxis.
BPE Code 2 = Chart gingival bleeding. Disclose and chart plaque. Oral hygiene instruction. Remove defective margins, plaque
retention factors. Scale & prophylaxis.
What should you do if
BPE = 3?
Adult patients Code 3 would
mean initial therapy before recording pockets.
May be still appropriate to record pocket depths for Code 3 in a young patient.
Manage as for Code 2, plus record probing depths & bleeding on probing on affected index tooth (6 sites) – should also check if any other teeth in sextant are affected. Treatment will take longer and include scale & root surface debridement (RSD).
Consider referral if poor response.
What should you do if
BPE = 4 or *?
record full indices, consider refer
Code 4= Full periodontal charts. Oral hygiene instruction. Remove
defective margins, plaque retention factors. Scale & RSD as appropriate. Consider referral to specialist.
In what situations should GDP consider specialist referral?
-Diagnosis of periodontitis of advanced Grade or Stage
-Periodontitis not responding to treatment
-Systemic medical condition associated with periodontal destruction
-Medical history that significantly affects periodontal treatment or
requiring multi-disciplinary care
-Genetic conditions predisposing to periodontal destruction
-Root morphology adversely affecting prognosis
-Non-plaque-induced conditions requiring complex or specialist care
-Cases requiring diagnosis/management of rare/complex clinical
pathology
-Drug-induced gingival overgrowth needing surgery
-Cases requiring evaluation for periodontal surgery
